Course:KIN 500c 2018
|Advanced Concepts in Cardiovascular Physiology and Rehabilitation with Culturally Relevant Applications to Indigenous Health and Wellness|
|Instructor:||Dr. Darren Warburton|
|Sandy Yu-Shan Hsu|
|Important Course Pages|
- 1 Introduction: Present-Day Opportunities and Challenges in Indigenous Health and Wellness
- 2 Section A: Traditional Indigenous Healthy Lifestyle Behaviours, Diet and Foodways
- 2.1 Traditional Diets Among Indigenous Populations
- 2.2 Environmental Constraints on Dietary Intake Among Indigenous Populations
- 2.3 Globalization, Post-Colonization and Resources
- 2.4 Food Security and Successful Community Based Approaches
- 2.5 Tobacco and Smoking Cessation
- 3 Section B: Present-Day Challenges in Indigenous Health and Wellness
- 4 Section C: Physical Activity Across All Age Groups
- 4.1 Physical Activity in Canadian Aboriginal Populations: Stats, Preferred Activities and Barriers
- 4.2 Importance of Physical Activity and Physical Activity Initiatives
- 4.3 Current Canadian Physical Activity Guidelines and Why it May Not be Suitable for Aboriginal Populations
- 4.4 Recommendations for Effective Physical Activity Initiatives
- 4.5 Recommended Physical Activity Evaluation Tools and Fitness Measures
- 5 Section D: Community-Based and Indigenous-Led Healthy Lifestyle Approaches
- 5.1 Community-Based Approach to Address Physical Inactivity as a Modifiable Risk Factor
- 5.2 Community-Based Approaches Using Health Behavioural Modification Strategies
- 5.3 Importance of an Individualized Approach in Community-Based Initiatives
- 5.4 Participatory Action Research Approach in Community-Based Initiatives
- 6 Conclusion
Introduction: Present-Day Opportunities and Challenges in Indigenous Health and Wellness
Finding innovative and culturally relevant ways to increase physical activity participation in Indigenous peoples of Canada (First Nations, Métis, Inuit) is an important line of research. Physical activity is a primary and secondary preventative strategy against more than 25 chronic medical conditions including cancer, diabetes and cardiovascular disease (Warburton et al., 2006). Despite the health-related benefits of physical activity (Warburton et al., 2006), evidence suggests that traditional physical activity guidelines are ineffective in addressing the modifiable risk factors associated with physical inactivity due to their lack of cultural competency (Brooks-Cleator & Giles, 2016; Lavallée, 2007). In fact, Indigenous peoples of Canada are now amongst the highest risk for cardiometabolic diseases, stroke and secondary complications (Foulds et al., 2013), and have an earlier onset of these trends and complications (Foulds et al., 2011; Liu et al., 2006). In the context of Indigenous health and wellness, it is important to address these present-day challenges using a strengths-based approach, rather than a deficits-based approach (e.g., from the perspective of risks and diseases). A strengths-based approach focuses on empowering individuals to take ownership over their own health and wellness (Pattoni, 2012). This approach, which aligns with the concept of self-determination, uses a holistic lens to address healthy lifestyle behaviours, which recognizes the complex socioeconomic, sociocultural and historical barriers that can impact physical activity participation (Earle, 2011; Reading & Wien, 2009). A holistic approach considers not only the effects of physical activity on health, but also other factors impacting healthy lifestyle behaviours including dietary management, substance abuse, domestic violence and suicide (Goforth, 2007; Jacklin, 2009). These social determinants of health are associated with the historical and ongoing effects of residential schools and colonization, and recognizing this relationship is the first step towards understanding present-day opportunities and challenges in Indigenous health and wellness (Goforth, 2007). Recognizing the intergenerational trauma inflicted by residential schools and colonization can lead to the co-creation of culturally safe healthy lifestyle approaches to address contemporary issues in Indigenous health and wellness.
Section A: Traditional Indigenous Healthy Lifestyle Behaviours, Diet and Foodways
With the recent shift from traditional diets to more western type diets being consumed, this has greatly increased the amount of fats, simple carbohydrates and sugars in Indigenous Peoples’ diets (Johnson & Bordirsky, 2008). Currently, elders and older Aboriginal people consume more traditional foods than younger people (Redwood et al., 2008) and it has been found that the consumption of fruits and vegetables has become substantially lower compared to previous traditional diets (Kuhnlein, 2013).Current dietary surveys among Aboriginal people (including First Nations, American Indian and Alaska Native peoples) reveal that often diets are poor and do not meet dietary recommendations for saturated fat, fibre, sodium and fruit and vegetable intake (Earle, 2011). Poor dietary patterns have also been found among Aboriginal children, who tend to consume snack foods frequently and less than the recommended servings of milk, fruit and vegetables (Earle, 2011). There has also been a marked increase in physical inactivity among Aboriginal and Indigenous populations. This has been linked to the shift from traditional means of food acquisition through the process of hunting, gathering, fishing and growing (which is a very physically demanding task) (Kuhnlein, 2013) to more imported, processed foods bought from industrialized and globalized markets.
Traditional Diets Among Indigenous Populations
Traditional Indigenous diets are diverse, holistic and directly connected with Indigenous culture (Johnson and Bordirsky, 2008). Compared to Western diets, traditional diets have contain a lower carbohydrate content including simple sugars (Earle, 2011). This have been shown to be an important factor in conditions such as diabetes and obesity (Earle, 2011). They have also been found to be rich in micronutrients such as vitamin A, D, C, E and B-6 (Kuhnlein et al., 2004). Many Indigenous diets also contain rich sources of omega-3-fatty acids which are associated with a decreased risk of cardiovascular diseases (WHO, 2002). Food items in many traditional diets varies across Indigenous communities, geographic location and seasonality (McGrath-Hanna et al., 2003). Some common food items include wild game, sea mammals, fish berries, corn, beans, squash, corn, lye and wild rice. Most food items are associated with important meanings, lessons, ceremonies or medicines within Indigenous culture (Earle, 2011).
Environmental Constraints on Dietary Intake Among Indigenous Populations
Indigenous peoples highly value the health of the land and the community’s health (King et al., 2009). Their willingness to consume traditional food, has not only been affected by accessibility of resources and socio-economic barriers but there has also been some concerns about the contaminants in the food chain (Earle, 2011). Cadmium, mercury, PCBs and pesticides have been documented in traditional foods harvested by groups including the Cree peoples of eastern James Bay and Northern Manitoba, as well as the Ojibwa people of Grassy Narrows (Earle, 2011). This is a growing concern and although there is currently no clear evidence on the effects of these contaminants, future research may clarify how environmental toxins can increase risk factors for chronic diseases (Earle, 2011). While Western culture primarily goes by the principle of dominating the land, Aboriginal peoples believe that they are the least important creatures of the universe and are dependent on the four elements (fire, water, earth and air) and all of creation for survival Hamilton and Sinclair (1991) . It is believed that all four elements act together and if one or many of them are neglected, they get out of balance and their health will suffer in all areas (Malloch, 1989, p.106). It is evident that Aboriginal health is not only affected physically by environmental contamination, but it also imposes on their cultural well-being and values.
Globalization, Post-Colonization and Resources
Food is an inseparable from Indigenous identity, culture and ceremonial life but in recent years post-colonialism, has disrupted these strong relationships between the Indigenous culture, foodways and the land (Johnson and Bordirsky, 2008). There are a multitude of reasons why Indigenous populations have adapted a cultural shift in food sources from a traditional diet to a more western diet. Many of these reasons are due to the geographic location of the reserves and the political, economic or agricultural dependence burdened on Indigenous populations from the remnants of colonization (Johnson & Bordirsky, 2008). Since the implementation on the Indian Act, the residential schooling system and the reserves, the separation between the land and food has had a substantial impact on knowledge translation, as well as the health and wellness of Indigenous populations. Indigenous homeland has also been infringed upon due resource extraction, industrial developments, and toxic waste deposition which have left damaged environments and ecosystems which are inhabitable and expendable. For example, industries such as mining, logging and manufacturing has led many firsts nations reserves now incapable of supporting healthy fish, game, water and plants.
Food Security and Successful Community Based Approaches
The process of food acquisition provides benefits beyond health benefits such as the practice of cultural values like sharing and cooperation (Earle, 2011). The consumption of food provides Indigenous peoples a platform to converse in native languages, use traditional medicine and also participate in traditional events (Redwood et al., 2008). Traditional food consumption also connects people to their community, the land, and the past (Macgarth-Hanna et al., 2003). It has been widely established that a major challenge for Indigenous populations is food security and financial resources (First Nations Information Governance Centre, 2018). In Canada, 17.8% of First Nations adults in the age group of 25-39 years old reported being hungry but didn’t eat due to lack of money for food in the last year (First Nations Information Governance Centre, 2018). In addition, 16 % of adults from ages 40-54 reported being hungry and 13% of seniors skip or cut meals due to lack of financial resources. It has also been established that 46% of senior First nations will often skip meals due to lack of money almost every month.
Community garden initiatives have been introduced to many Aboriginal communities based on the premise of improving the connection between food, land and the community. The Tu'wusht Garden Project initiative launched by the Vancouver Health and Native Society and the xʷc̓ic̓əsəm garden created by University of British Columbia’s Faculty of Land and Food Systems was developed on the premise to improve the emotional, spiritual, physical and mental health of Indigenous peoples. Community garden initiatives can help encourage inter-generational food knowledge translation, improve self-autonomy in Indigenous communities, increase food security and encourage self-sustainability in Aboriginal communities. By improving consumption of traditional foods, it is also established that many nutrients in traditional diets can reduce the risk of certain chronic diseases (WHO, 2002).
Tobacco and Smoking Cessation
Significance of Tobacco in Indigenous and Aboriginal Cultures
For thousands of years, tobacco has been an integral part of many (but not all) First Nations and Aboriginal cultures in many parts of British Columbia and Canada (Alberta Health Services, 2014). For many, it is considered one of the sacred medicines given by the Creator, and is a central element to their spiritual and cultural beliefs. Traditional tobacco is intended to be used in small amounts for specific ceremonies, medicinal use, rituals, prayers and was considered a sacred plant (First Nations Health Authority, 2018). It is important to decipher the differences between commercial tobacco and traditional tobacco (Interior Health Authority, 2011). Commercial tobacco is highly addictive and full of noxious chemicals and carcinogens. According to elders using commercial tobacco recreationally, (whether smoking, chewing, or use through other means) is disrespectful to the spiritual and medicinal origins of traditional tobacco and has no connections to First Nations spirituality (Health Canada, 2001; Alberta Health Services, 2014).
Commercial Tobacco Use and Smoking Statistics across Indigenous populations:
Cigarette smoking has been linked with several factors associated with cardiac dysfunction and the development of multiple types of cancers including but not limited to lung, oral, face and neck, liver, kidney, bladder (Sasco, 2004). According to the First Nations Information Governance Centre (2018) based on the second Regional Health Survey, 43% of First Nations adults are daily smokers. Additionally, 13.7% self-identify as occasional smokers. In comparison, 17 % of the general Canadian population are daily smokers. It has also been established that younger First Nations adults, aged 18 to 29 years, have the highest proportion of daily smokers (51.5%). There has also been a noticeable significant decrease in the amount of daily smokers when comparing respondents with less than high school education to those with graduate studies (47% v.s 30.9%).
Smoking rates have markedly decreased over the last 30 years in the general population but has not been the same for Indigenous populations indicating that tobacco control strategies have not been universally effective (DiGiacomo, et al, 2011). This could be due to a number of reasons including the appropriateness and access to services and support. Based on the current finding, this may reflect some of the systematic barriers to improving health of Indigenous peoples (DiGiacomo, et al, 2011). High prevalence of smoking could also be related to factors such as the normalization of smoking in Indigenous communities (even at an early age), the historical role of tobacco or low-economic status (DiGiacomo, et al, 2011).
Success in Smoking Cessation
The efficacy of smoking cessation has been widely researched on general populations but very little research has been established on the efficacy of smoking cessation programs towards indigenous populations. As a potential solution, the World Health Organization (2008) recognizes strategies should be adapted to local contexts and tailored to individual preferences and needs of individuals.
DiGiacomo, et al (2011) provided examples of elements of access-promoting strategies. Some of these examples include through the workforce/organizational characteristics, cultural adaptations, support and follow-up, provision of instrumental support, self-determination/flexibility, and an integrative approach workforce such as complementary workplace policy, management support to run and attend, multidisciplinary team approach, community endorsed or community consultation, having councilors trained in cultural sensitivity, Aboriginal specific resources (video, flip charts, brochures, artwork), and increase the support and follow-up by the ongoing support.
The Interior Health Authority of British Columbia (2011) has proposed some meaningful suggestions in regards to community-based approached to reduce the use of commercial tobacco in Indigenous communities. Some of these suggestions include; creating a discussion within the community on how to reduce the use of commercial tobacco and increase use of traditional tobacco, advocate that elders act as mentors and potential role models for the younger Indigenous community members by teaching them the traditional uses of tobacco and other sacred plants, encourage communities to start community gardens to grow tobacco and other ceremonial plants to discourage reliance on commercial tobacco use, create more smoke-free spaces in communities and lastly, support those who wish to quit smoking with culturally appropriate programs and materials.
Section B: Present-Day Challenges in Indigenous Health and Wellness
Common Risk Factors Within Indigenous Communities:
Chronic Obstructive Pulmonary Disease (COPD) is a progressive condition that is noted by an inflammatory response within the lungs. (McIvor et al, 2011). COPD is characterized by airflow limitation due to the combination of emphysema and chronic bronchitis. Emphysema is defines as the abnormal enlargement of air spaces in combination with destruction of lung walls. While Bronchitis symptoms include chronic cough and mucous production (McIvor et al, 2011). Together, COPD leads to a decrease in lung function, exercise capacity, quality of life, and an increased risk of mortality (McIvor et al, 2011).
COPD has a higher prevalence within Indigenous populations (Anuk et al., 2017), such that one in two indigenous peoples within communities will have hospital diagnosed COPD within their lifetime (Wang & Hoy, 2014). Indigenous populations are also susceptible for common lower respiratory tract infections (LRI) (Basayke et al. 2017). Increased LRI have been suggested to increase the occurrence of bronchiectasis, a condition that is similar to COPD (Basayke et al., 2017). Bronchiectasis is the widening of bronchi and bronchioles within the lungs. This widening of the bronchi and bronchioles provides an increased risk for infection. Bronchiectasis and COPD, all though very similar, can co exist with one another (Basayake et al. 2017). Further, Anuk et al. (2017) suggests that COPD, smoking status, and bronchiectasis are most common within indigenous patients.
Stroke is caused by an acute injury of the central nervous system due to cerebral infarction or intracerebral hemorrhage (Sacco et al., 2013). Cerebral infarction is cellular death due to ischemia, while Intracerebral Hemmorrhage is characterized by a focal pooling of blood within the parenchyma or ventricular system of the brain (Sacco et al., 2013). Approximately 80 percent of strokes are due to cerebral infarction (Minnerup, 2013). Stroke and other cardiovascular diseases are a large health risk among many indigenous populations. For example, within the First Nations community, stroke and cardiovascular diseases are accountable for approximately 25% of all deaths (Health Canada, 2011).
Obesity and Diabetes
Obesity is defined as a medical condition at which excess fat has accumulated on the individual’s body. Diabetes is a metabolic condition associated with the body’s inability to produce insulin. Without producing insulin, this leads to abnormal metabolism of carbohydrates and heighted concentrations of glucose within an individual’s blood. Indigenous populations throughout Canada experience high rates of diabetes, obesity (Foulds et al. 2011). It is estimated that these rates are threefold higher than the general Canadian population (Heagle & Pollex 2005, Retnakaran et al., 2005). Studies report rates of obesity to be approximately 47% and obesity prevalence as high at 90% within indigenous populations (Vanasse et al 2006; MacMillan et al. 2006)
Long QT Syndrome
Long QT Syndrome (LQTS) is a disorder that is passed ancestrally. LQTS is characterized by a delayed ventricular repolarization following depolarization of the heart, and is confirmed on an electrocardiogram by having a prolonged QT interval (Yararbas & Pogun, 2010; Goldenberg & Moss, 2008). Common symptoms of LQTS include fainting due to ventricular arrhythmia's, which can lead to ventricular fibrillation and subsequently death (Yararbas & Pogun, 2010). LQTS has a significant prevalence in three different First Nations communities in Canada (Arbour et al., 2015). These three communities are at a disproportionately higher risk of congenital LQTS syndrome, arrhythmia and sudden cardiac death. The highest percent of LQTS is found within the Gitxsan First Nations in Northern British Columbia, where LQTS is fifteen times more prominent than other identified LQTS risk communities (Arbour et al., 2015).
Potential Predictors of Chronic Medical Conditions and Disease
According to Tupper et al. (2016), individuals who are exposed to tobacco smoke and have symptoms of sputum production; wheeze and shortness of breath are at higher risk of having COPD. This agrees with Ospina et al. (2015) which suggests that the most important etiologic factor for developing COPD is the individuals history with smoking.
Stroke and Cardiometabolic Diseases
Researchers have analyzed how simple measurements may predict and individuals outcome of health. These include body mass index (BMI) or weight to height ratio, and waist circumference. BMI is used to determine how much body fat is displaced throughout an individual’s frame. By using the BMI formula, a person can estimate if they are underweight, healthy, overweight, or obese. Similarly, waist circumference is also used as an indicator of health risk, however this is through the assessment of excess fat around the waist. BMI and waist circumference have been associated with risk of stroke in all race and ethnic groups (Chuive, et al. 2008; Um et al. 2003). Despite which measurements are available, both BMI and waist circumference are highly correlated and can be used to predict cardiovascular diseases. (Wang & Hoy, 2004). However, waist circumference is a better predictor for cardiometabolic diseases such as obesity, hypertension, and type two diabetes than BMI or other parameters in determining cardiovascular risk (Wang & Hoy, 2004).
Section C: Physical Activity Across All Age Groups
Physical Activity in Canadian Aboriginal Populations: Stats, Preferred Activities and Barriers
In 2012, it was reported that 40.9% of British Columbian First Nations adults were physically inactive (Foulds, Bredin & Warburton, 2012), which is lower than the 46.4% of First Nations adults on-reserve (First Nations Information Governance Centre, 2012) and the 44% of First Nations adults off-reserve across Canada (Gionet & Roshananfshar, 2013).
Additionally, for First Nations adults, Foulds et al. (2012) reported:
- 55.7% of female participants and 44.4% male participants as physically inactive.
- 24.3% of female participants and 17.1% of male participants met the Canadian physical activity guidelines
- No significant differences in physical activity levels between age groups.
- Individuals living on-reserve, in rural settings and in the interior region were more likely to be inactive compared to individuals living off-reserve, in urban settings and in the Vancouver-Lower Mainland region.
For children and youth, the First Nations Information Governance Centre, (2012) reported:
- 49.3% of First Nations youth as active.
- 17.9% of First Nations children (aged 6 to 11) as inactive.
Preferred Physical Activities of Aboriginal Canadians
According to the First Nations Information Governance Centre (2012), walking is the most frequently reported physical activity among Aboriginal peoples of all ages. Other preferred activities include gardening and fishing, especially among adults, and swimming, running, competitive sports, bicycling and food gathering in children and youth. According to Coble (2006), physical activity preferences among Aboriginal peoples have shifted towards more sport and lifestyle activities, and away from traditional activities (ie. powwow, traditional dancing etc.).
Barriers to Physical Activity
The most commonly reported barriers to physical activity among Aboriginal people include a lack of energy, time and access to transportation, low socioeconomic status, safety concerns, lack of facilities, equipment and programs, bad weather and poor infrastructure such as sidewalks (Coble and Rhodes, 2006; Findlay and Kohen, 2007). Other potential barriers include the lack of experienced trained staff for physical education, substance abuse, racism, gender roles and cost of sport participation (Mason & Koehli, 2012;Thompson et al., 2001)
Social environment can also act as a barrier or enabler to physical activity, especially for women (Thompson, Wolfe, Wilson, Pardilla & Perez, 2003). It has been found that individuals who knew or saw people who exercised were more likely to be active compared to those who did not know or see anyone who exercised (Thompson et al., 2003). Also, if physical activity is not valued or prioritized by the community, individuals were less likely to participate in physical activity (Thompson et al., 2002). The barriers to physical activity among Aboriginal populations suggests that effective community-based physical activity initiatives are needed and warranted, and should address the needs of families, children, parents and community leaders (Thompson et al., 2002; Warburton, Foulds, Charlesworth, Rhodes & Bredin, 2008).
Importance of Physical Activity and Physical Activity Initiatives
The concerning levels of chronic conditions such as obesity, cardiovascular disease, hypertension and diabetes among BC Aboriginal populations have highlighted the need for treatment and prevention programs in all geographic regions and areas of residence, especially rural, on-reserve and northern communities (Foulds et al., 2012). Physical activity can promote health and social connection between members of the family and community (Coble, 2006), and when done in adequate amounts, it can reduce the risk of chronic diseases and provide added health benefits such as improved cholesterol levels, blood pressure, body composition, bone density, cardiorespiratory and musculoskeletal fitness, and indicators of mental health (Tremblay et al., 2011; Warburton, Nicol, Bredin, 2006). Therefore, initiatives to increase physical activity levels in Aboriginal communities may lead to reduced incidents of chronic disease, and elevated health status, physically and socially.
Current Canadian Physical Activity Guidelines and Why it May Not be Suitable for Aboriginal Populations
For healthy growth and development, infants (aged < 1 year) should be physically active several times per day, especially through interactive floor-based play. . Meanwhile, toddlers (aged 1-2 years) and preschoolers (aged 3-4 years) should be active for at least 180 minutes spread throughout the day. Playing in different environments is recommended and various activities that help to develop fundamental motor skills should be included (Tremblay et al., 2012).
For health benefits, children (aged 5–11 years) and youth (aged 12–17 years) should be active for at least 60 minutes per day and participate in moderate- to vigorous-intensity activities. Vigorous-intensity and muscle and bone strengthening activities are recommended at least 3 days per week (Tremblay et al., 2011).
To achieve health benefits, adults aged 18–64 years should be physically active for at least 150 minutes per week, participating in moderate- to vigorous-intensity aerobic activities, in bouts of 10 minutes or more. It is also recommended to add muscle and bone strengthening activities that use major muscle groups, at least twice a week (Tremblay et al., 2011).
To achieve health benefits and improve functional abilities, adults aged 65 years and older are recommend to be physically active for at least 150 minutes per week, participating in moderate- to vigorous-intensity aerobic activities and balance enhancing exercises, in bouts of 10 minutes or more. Additionally, muscle and bone strengthening activities that use major muscle groups should be included at least twice a week (Tremblay et al., 2011).
The purpose of the national physical activity guideline is to help Canadians move towards healthier and more active lifestyles (Canada, 2011). However, researchers have argued that the current guidelines may not be suitable or culturally safe for the Aboriginal population because: 1) it only focuses on the physical or physiological benefits of physical activity and does not acknowledge the Aboriginal people’s unique cultural perspective of health and physical activity, which is based on the “medicine wheel”, an approach to health, wellness and healing by finding balance between the four dimensions of humanity: spiritual, emotional, mental and physical (Brooks-Cleator and Giles, 2016; Lavallée, 2007); 2) it fails to recognize Aboriginal peoples' view on health which encompasses not only the individual, but also the family, community and the environment (Levesque, Li, & Bohémier, 2013); 3) current methods of assessing physical activity among Aboriginal populations are inappropriate because the measurements are based on adaptations of leisure-time physical activity questionnaires designed for non-Aboriginal populations (Young & Katzmarzyk, 2007); 4) current physical activity assessment tools do not assess culturally based forms of physical activity and may underestimate activities spent in domestic care. For example, lower-intensity activities in forms of walking, child care and housework, all of which are relatively more difficult to assess than high-intensity activities such as participating in organized sports (Young & Katzmarzyk, 2007). Therefore, a holistic approach to developing physical activity initiatives is needed to ensure balance between the various aspects of health. The development of more culturally appropriate physical activity evaluation tools is also warranted. It is recommended that to create a culturally appropriate physical activity guideline, Aboriginal communities should be included in the process to help guide the development (Brooks-Cleator and Giles, 2016).
Recommendations for Effective Physical Activity Initiatives
Physical activity can play a significant role in improving emotional, mental, physical, and spiritual health for Aboriginal peoples (Lavallée, 2007). Previous strategies that have generated positive results in promoting and increasing physical activity levels in Aboriginal communities include Action Schools! BC, Zuni Diabetes Prevention program and Kahnawake School Diabetes Prevention Project levels (Naylor et al., 2010; Teufel-Shone, Fitzgerald, Teufel-Shone & Gamber, 2009; Tomlin et al., 2011). These initiatives are considered models of best practice because they: 1) were created, implemented and evaluated in a collaborative manner between members and the leader of the Aboriginal community, key stakeholders and outside public health professionals; 2) maintained cultural relevance and integrity of the targeted community; 3) provided learning and training opportunities for community members, school staff and students; 4) enhanced connection between members of the community; 5) demonstrated impact; 6) were sustainable; and 7) reshaped cultural perceptions of exercise and chronic disease prevention and created a culture of wellness (Teufel-Shone et al., 2009; Warburton et al., 2008). To increase the effectiveness of future physical activity initiatives, it is recommended that the development of programs should follow these seven key practices.
Recommended Physical Activity Evaluation Tools and Fitness Measures
Physical Activity Questionnaires
The Modifiable Activity Questionnaire (MAQ) was developed for easy modification to maximize its feasibility and appropriateness in a variety of minority populations (Kriska et al., 1990). The questionnaire is a comprehensive tool that measures current, past-week, past-year occupational and leisure activities, as well as extreme levels of inactivity as a result of disability (to view the original questionnaire, see Kriska et al., 1990).
The Godin-Shephard Leisure-Time Physical Activity Questionnaire (GSLTPAQ) is another validated physical activity evaluation tool (Amireault & Godin, 2015) that may be suitable for Aboriginal communities (to view the original questionnaire, see Godin & Shephard, 1985). The questionnaire is used to determine activity levels (ie. active, moderately active, insufficiently active) of participants based on self-reported leisure-time physical activity during a 7-day period (Godin, 2011). Weekly leisure-time activity scores are calculated by multiplying the frequency of mild, moderate, and strenuous leisure-time physical activity per week by 3, 5 and 9 METs respectively. A score of 24 units or more is classified as active; a score of 14 to 23 units is classified as moderately active and; a score of less than 14 is classified as insufficiently active (Godin, 2011). A strength of the questionnaire is that it does not require participants to provide an estimated average of time spent being physically active, which reduces the likelihood of measurement error (Altschuler et al., 2009; Amireault & Godin, 2015). Additionally, the physical activities listed in the GSLTPAQ may be adapted to various populations and communities as long as the new activities match the appropriate MET categories (Godin, 2011).
Fitness Measures: Field Testing Options
Maximal oxygen uptake (VO2max) is a widely accepted measure of the working capacity of the cardiorespiratory and cardiovascular systems that reflects the maximum rate of oxygen transport to exercising muscles or maximal aerobic power, and is influenced by ventilation, cardiac output, vascularization and the ability of muscles to utilize oxygen (Burr, Bred, Faktor & Warburton, 2011; Siconolfi, Garber, Lasater & Carleton, 1985). However, VO2max is a difficult measure to obtain due to the demanding nature of the exercise and the instrumentation which is not widely accessible (Bohannon, Bubela, Wang, Magasi & Gershon, 2015). Therefore, submaximal functional tests have been developed as alternatives to maximal testing. Two suitable submaximal tests that are feasible in various settings include the six-minute walk test and the three-minute step test. Both tests have demonstrated reliable and valid results in individuals of various ages (Bohannon et al., 2015).
The Six-minute walk test (SMWT) measures the total distance a person can walk at a constant, uninterrupted, unhurried pace in 6-minutes. The method assesses exercise capacity at a submaximal level, and is feasible and practical for individuals of all ages, as well as patients with cardiovascular or pulmonary disease (Gibbons, Fruchter, Sloan & Levy, 2001; Hamilton & Haennel, 2000; Lammers, Hislop, Flynn & Haworth, 2007). Additionally, the SMWT is simple to perform, brief and low at cost (Bohannon et al., 2015; Lammers et al., 2007). Participant characteristics (ie. height, weight, gender, resting heart rate and age) can be used to predict an individual's SMWT distance and VO2max with the following equations developed by Burr et al., (2011):
- 6MWT distance (m) = –60.697 + (5.181 × height [cm]) – (1.906 × body weight [kg])
- VO2max (mL⋅kg–1⋅min–1) = 70.161 + (0.023 × 6MWT [m]) – (0.276 × weight [kg]) – (6.79 × sex, where m = 0, f = 1) – (0.193 × resting HR [bpm]) − (0.191 × age [y])
The YMCA Three-minute step test (TMST) protocol requires individuals to step on and off a 12-inch step 24 times per minute for 3-minutes. The strengths of the TMST include its feasibility for healthy individuals across a wide age ranges (19-70 years) and low cost. Furthermore, it is a quick test and is portable, and requires less space (Bohannon et al., 2015; Siconolfi et al., 1985). However, there are some limitations associated with TMST. For example, the nature of the exercise is more demanding, and thus, it may not be suitable for young children, older adults, individuals who are overweight or obese and/or patients with cardiopulmonary disease or limitations such as knee pain (Bohannon et al., 2015).
Section D: Community-Based and Indigenous-Led Healthy Lifestyle Approaches
Community-Based Approach to Address Physical Inactivity as a Modifiable Risk Factor
Community-Based Approaches Using Health Behavioural Modification Strategies
Importance of an Individualized Approach in Community-Based Initiatives
Participatory Action Research Approach in Community-Based Initiatives
Because Indigenous peoples view the concepts of health and wellness from a holistic perspective, traditional healthy lifestyle guidelines are ineffective in addressing Indigenous health and wellness. Evidence suggests that community-based and Indigenous-led healthy lifestyle initiatives are effective ways to empower Indigenous peoples in making self-determined goals towards health and wellness. These approaches are effective because they address health and wellness using a holistic perspective, which considers the interconnectedness and balance between physical, mental, emotional and spiritual wellbeing. These determinants of wellness relate strongly to a balance of the mind, body and spirit with both the community and environment (National Aboriginal Health Organization, 2011). Reconnecting with the environment through land-based activities, reclaiming traditional Indigenous foodways, and revitalizing Indigenous languages are examples of ways in which traditional healthy lifestyle guidelines can be modified to enhance cultural safety. Cultural safety is also an important focus in research with Indigenous communities. Health and wellness research with Indigenous communities should decolonize traditional approaches by making the necessary adaptations in research design to reflect cultural competency (e.g., modifications to physical activity questionnaires and field test options). Making cultural adaptations to current best practices can be achieved through participatory action research, which involves the collaboration among Indigenous Elders, knowledge brokers, cultural competency experts, and community-based researchers. Such collaboration embodies the "Two-Eyed Seeing" approach (Iwama et al., 2009), which decolonizes traditional research approaches and fosters a strengths-based perspective to address present-day opportunities and challenges in Indigenous health and wellness. The evidence presented in this Wiki page can be used to assist in the co-creation of inclusive, sustainable and culturally relevant healthy lifestyle approaches to empower Indigenous peoples of Canada in reaping the health-related benefits of physical activity.
Alberta Health Services.(2011) First Nations People and Tobacco Misuse. Tobacco Information Series. (2014, July 30).Retrieved from https://www.albertaquits.ca/files/AB/files/library/Tobacco_Misuse_FINAL.pdf
Altschuler, A., Picchi, T., Nelson, M., Rogers, J. D., Hart, J., & Sternfeld, B. (2009). Physical activity questionnaire comprehension-lessons from cognitive interviews. Medicine and science in sports and exercise, 41(2), 336. doi: 10.1249/MSS.0b013e318186b1b1
Amireault, S., & Godin, G. (2015). The Godin-Shephard leisure-time physical activity questionnaire: validity evidence supporting its use for classifying healthy adults into active and insufficiently active categories. Perceptual and motor skills, 120(2), 604-622. doi: 10.2466/03.27.PMS.120v19x7
Anuk, K., Melissa, F., Rebecca, P., & Subash, H. (2017). Chronic respiratory disease in the regional and remote population of the northern territory top end: A perspective from the specialist respiratory outreach service. Australian Journal of Rural Health, 25(5), 275-284.
Arbour, L., Asuri, S., Whittome, B., Polanco, F., & Hegele, R. A. (2015). The genetics of cardiovascular disease in canadian and international aboriginal populations doi:https://doi.org/10.1016/j.cjca.2015.07.005
Basnayake, T. L., Morgan, L. C., & Chang, A. B. (2017). The global burden of respiratory infections in indigenous children and adults: A review. Respirology, 22(8), 1518-1528.
Blodgett, A. T., Schinke, R. J., Peltier, D., Fisher, L. A., Watson, J., & Wabano, M. J. (2011). May the circle be unbroken: The research recommendations of aboriginal community members engaged in participatory action research with university academics. Journal of Sport and Social Issues, 35(3), 264-283. doi:10.1177/0193723511416984
Bohannon, R. W., Bubela, D. J., Wang, Y. C., Magasi, S. S., & Gershon, R. C. (2015). Six-minute walk test versus three-minute step test for measuring functional endurance (Alternative measures of functional endurance). Journal of strength and conditioning research/National Strength & Conditioning Association'', 29(11), 3240. doi: 10.1519/JSC.0000000000000253
Brooks-Cleator, L. A., & Giles, A. R. (2016). Physical activity for older Aboriginal adults: A call for cultural safety. Revue phénEPS/PHEnex Journal, 7(3). Retrieved from http://ojs.acadiau.ca/index.php/phenex/article/viewFile/1615/1339
Burr, J. F., Bredin, S. S., Faktor, M. D., & Warburton, D. E. (2011). The 6-minute walk test as a predictor of objectively measured aerobic fitness in healthy working-aged adults. The Physician and sports medicine, 39(2), 133-139.
Canada. (2011, May 23). Physical Activity. Retrieved from https://www.canada.ca/en/public-health/services/health-promotion/healthy-living/physical-activity.html
Chiuve SE, Rexrode KM, Spiegelman D, Logrocino G, Manson JE, Rimm EB. Primary prevention of stroke by healthy lifestyle. Circulation2008;118:947–54.
Coble, J. D. (2006). Physical activity behaviors and motivations in an adult First Nation population (Doctoral dissertation).
Coble, J. D., & Rhodes, R. E. (2006). Physical activity and Native Americans: a review. American Journal of Preventive Medicine, 31(1), 36-46. doi: 10.1016/j.amepre.2006.03.004
DiGiacomo, M., Davidson. P.M., Penelope, A. A., Davison, J., Moore, L., Thompson. S. Smoking Cessation in Indigenous Populations of Australia, New Zealand, Canada, and the United States: Elements of Effective Interventions. Int. J. Environ. Res. Public Health. 2011, 8(2), 388-410; doi:10.3390/ijerph8020388
Earle, L. (2011). Traditional Aboriginal Diets and Health. National Collaborating Centre for Aboriginal Health. pp.1-8. Retrieved from https://www.ccnsa-nccah.ca/docs/emerging/FS-TraditionalDietsHealth-Earle-EN.pdf
First Nations Information Governance Centre (2012). First Nations regional health survey (RHS) 2008/10: National report on adults, youth and children living in First Nations communities. Ottawa ON: FNIGC. Retrieved from https://fnigc.ca/sites/default/files/docs/first_nations_regional_health_survey_rhs_2008-
Findlay, L. C., & Kohen, D. E. (2007). Aboriginal children's sport participation in Canada. Pimatisiwin: A Journal of Aboriginal & Indigenous Community Health, 5(1).
Foulds, H. J., Bredin, S. S. D, & Warburton, D. E. R. (2012). An evaluation of the physical activity and health status of British Columbian Aboriginal populations. Applied Physiology, Nutrition, and Metabolism, 37(1), 127-137. doi: 10.1139/h11-138
Foulds, H. J., Bredin, S. S. D., & Warburton, D. E. R. (2011). The effectiveness of community based physical activity interventions with Aboriginal peoples. Preventive Medicine, 53(6), 411-416. doi:10.1016/j.ypmed.2011.09.008
Foulds H. J., Bredin S.S.D, Warburton D. E. R. The prevalence of overweight and obesity in British Columbian Aboriginal adults. Obesity Reviews. 2011;12(5):e4-e11.
Foulds H. J., Shubair M. M., Warburton D. E. A review of the cardiometabolic risk experience among Canadian Métis populations. Canadian Journal of Cardiology. 2013;29(8):1006-13.
Gibbons, W. J., Fruchter, N., Sloan, S., & Levy, R. D. (2001). Reference values for a multiple repetition 6-minute walk test in healthy adults older than 20 years. Journal of Cardiopulmonary Rehabilitation and Prevention, 21(2), 87-93.
Gionet, L., & Roshanafshar, S. (2013). Select health indicators of First Nations people living off reserve, Métis and Inuit. Statistics Canada.
Godin, G. (2011). The Godin-Shephard leisure-time physical activity questionnaire. Health & Fitness Journal of Canada, 4(1), 18-22.
Godin, G., & Shephard, R. J. (1985). A simple method to assess exercise behavior in the community. Can J Appl Sport Sci, 10(3), 141-146.
Goforth, S. (2007). Aboriginal healing methods for residential school abuse and intergenerational effects: A review of the literature. Journal of Native Social Work, 6(1), 11-32.
Goldenberg, I., Zareba, W., & Moss, A. J. (2008). Long QT syndrome doi:https://doi.org/10.1016/j.cpcardiol.2008.07.002
Hatala, A. R. (2008). Spirituality and Aboriginal mental health: An examination of the relationship between Aboriginal spirituality and mental health. Advances in Mind-Body Medicine, 23(1), 6-12. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/20664135
Hamilton, D. M., & Haennel, R. G. (2000). Validity and reliability of the 6-minute walk test in a cardiac rehabilitation population. Journal of Cardiopulmonary Rehabilitation and Prevention, 20(3), 156-164.
Health Canada. A statistical profile on the health of First Nations in Canada: vital statistics for Atlantic and Western Canada, 2001/02. Ottawa: Health Canada; 2011. Available from: www.hc-sc.gc.ca/fniah-spnia/alt_formats/pdf/pubs/aborig-autoch/stats-profil-atlant/vital-statistics-eng.pdf
Health Canada. Diabetes among Aboriginal (First Nations, Inuit and Métis) people in Canada: the evidence: Health Canada; 2005.
Hegele, R. A., & Pollex, R. L. (2005). Genetic and physiological insights into the metabolic syndrome. American Journal of Physiology - Regulatory, Integrative and Comparative Physiology, 289(3), 663-669. doi:10.1152/ajpregu.00275.2005
Hupin, D., Roche, F., Gremeaux, V., Chatard, J. C., Oriol, M., Gaspoz, J. M., Barthélémy, J. C., & Edouard, P. (2015). Even a low-dose of moderate-to-vigorous physical activity reduces mortality by 22% in adults aged ≥60 years: A systematic review and meta-analysis. British Journal of Sports Medicine, 49(19): 1262-1267. doi:10.1136/bjsports-2014-094306
Interior Health Authority. Traditional Tobacco Use. Draft. Interior Health Authority. 2011, Jan 6. Retrieved from https://www.interiorhealth.ca/YourHealth/HealthyLiving/TobaccoReduction/Documents/Traditional Tobacco Use.docx
Iwama, M., Marshall, M., Marshall, A., & Bartlett, C. (2009). Two-eyed seeing and the language of healing in community-based research. Canadian Journal of Native Education, 32(2), 3-23.
Jacklin, K. (2009). Diversity within: Deconstructing Indigenous community health in Wikwemikong unceded indian reserve. Social Science and Medicine, 68(5), 980-989. doc: 10.1016/j.socscimed.2008.12.035.
Johnson, J., Bodirsky, M. (2008). Decolonizing diet: Healing by reclaiming traditional indigenous foodways. Cuisine: The Journal of Canadian Food Cultures, 1(1)
Kahn, C. B., Reinschmidt, K., Teufel-Shone, N. I., Oré, C. E., Henson, M., & Attakai, A. (2016). American Indian Elders’ resilience: Sources of strength for building a healthy future for youth. American Indian and Alaska Native Mental Health Research (Online), 23(3), 117–133.
Katzmarzyk, P. T. (2008). Obesity and physical activity among Aboriginal Canadians. Obesity, 16(1), 184-190.
King, M., Smith, A., Michael, G. Indigenous health part 2: the underlying causes of the health gap. The Lancet. (2009); 374 (9683).
Kirkness, V., & Barnhardt, R. (2001). First Nations and higher education: The four R’s—respect, relevance, reciprocity, responsibility. Journal of American Indian Education, 30, 1–15.
Kriska, A. M., Knowler, W. C., LaPorte, R. E., Drash, A. L., Wing, R. R., Blair, S. N., ... & Kuller, L. H. (1990). Development of questionnaire to examine relationship of physical activity and diabetes in Pima Indians. Diabetes care, 13(4), 401-411.
Kuhnlein, H.V., Erasmus, B., Spigelski, D., Burlingame, B. Indigenous Peoples’ Food systems & Well-being: Interventions & policies for healthy communities. Rome, Italy: Nutrition Division, Food and Agriculture Organization of the United Nations: 2013. Retrieved from: http://www.fao.org/docrep/018/i3144e/i3144e.pdf
Lai, H. P. H., & Warburton, D. E. R. (2017). Health benefits of physical activity across the adult lifespan: Knowledge translation of “more is better, but every little bit counts”. Health and Fitness Journal of Canada, 9(4), 18-21. Retrieved from http://new-hfjc.library.ubc.ca/index.php/html/article/view/223/194
Lammers, A. E., Hislop, A. A., Flynn, Y., & Haworth, S. G. (2008). The 6-minute walk test: normal values for children of 4–11 years of age. Archives of disease in childhood, 93(6), 464-468. doi: 10.1136/adc.2007.123653
Lavallée, L. (2007). Physical activity and healing through the medicine wheel. Pimatisiwin, 5(1), 127-153.
Levesque, A., Li, H. Z., & Bohémier, M. (2013). Cultural variations in health conceptions: A qualitative approach. Pimatisiwin, 11(2), 215-229.
Liu J, Hanley AJ, Young TK, Harris SB, Zinman B. Characteristics and prevalence of the metabolic syndrome among three ethnic groups in Canada. Int J Obes (Lond). 2006;30: 669-676.
MacMillan, H. L., MacMillan, A. B., Offord, D. R., & Dingle, J. L. (1996). Aboriginal health. Canadian Medical Association Journal, 155(11), 1569-1578.
Malloch, L. (1989). Indian medicine, Indian health: Study between red and white medicine. Canadian Women Studies, 10, Summer/Fall, Nos. 2 & 3 105-113.
Marsh, T. N., Coholic, D., Cote-Meek, S., & Najavits, L. M. (2015). Blending Aboriginal and Western healing methods to treat intergenerational trauma with substance use disorder in Aboriginal peoples who live in northeastern Ontario, Canada. Harm Reduction Journal, 12, 1-12. doi: 10.1186/s12954-015-0046-1
Mason, C., & Koehli, J. (2012). Barriers to physical activity for Aboriginal youth: Implications for community health, policy, and culture. Pimatisiwin, 10(1), 97-108.
McGrath-Hanna, N.K., Greene, D.M., Tavernier, R.J., and BultIto, A. (2003). Diet and mental health in the Arctic: Is diet an important risk factor for mental health in circumpolar peoples?—a review. International Journal of Circumpolar Health 62(3):228–241.
McIvor, R. A., Tunks, M., & Todd, D. C. (2011). COPD. BMJ Clinical Evidence, 2011, 1502.
Minnerup, J. (2013). Stroke : Pathophysiology and therapy Morgan & Claypool Life Sciences.
Murdoch-Flowers, J., Tremblay, M. C., Hovey, R., Delormier, T., Gray-Donald, K., Delaronde, E., Macaulay, A. C. (2017). Understanding how Indigenous culturally-based interventions can improve participants’ health in Canada. Health Promotion International. doi: 10.1093/heapro/dax059
Myers J. E., Sweeney, T. J., & Witmer, J. M. (2000). The wheel of wellness counselling for wellness: A holistic model for treatment planning. Journal of Counseling and Development, 78(3), 251-266. doi: 10.1002/j.1556-6676.2000.tb01906.x
National Aboriginal Health Organization. (2015). Holistic Health and Traditional Knowledge. Retrieved from http://www.naho.ca/blog/2011/07/25/holistic-health-and-traditional-knowledge/
Naylor, P. J., Scott, J., Drummond, J., Bridgewater, L., McKay, H. A., & Panagiotopoulos, C. (2010). Implementing a whole school physical activity and healthy eating model in rural and remote First Nations schools: a process evaluation of Action Schools! BC. Rural Remote Health, 10(2), 1296.
Ospina, M. B., Voaklander, D., Senthilselvan, A., Stickland, M. K., King, M., Harris, A. W., & Rowe, B. H. (2015). Incidence and prevalence of chronic obstructive pulmonary disease among aboriginal peoples in alberta, canada. PloS One, 10(4), e0123204. doi:10.1371/journal.pone.0123204
Pattoni, L. (2012). Strenghts-based approaches for working with individuals. Retrieved from https://www.iriss.org.uk/sites/default/files/iriss-insight-16.pdf
Pelletier, C. A., Smith-Forrester, J., & Klassen-Ross, T. (2017). A systematic review of physical activity interventions to improve physical fitness and health outcomes among Indigenous adults living in Canada. Preventive Medicine Reports, 8, 242-249 doi:10.1016/j.pmedr.2017.11.002
Reading, C. L., & Wien, F. (2009). Health inequalities and social determinants of Aboriginal People’s health. Prince George, BC: National Collaborating Centre for Aboriginal Health.
Retnakaran, R., Hanley, A. J. G., Connelly, P. W., Harris, S. B., & Zinman, B. (2005). Cigarette smoking and cardiovascular risk factors among aboriginal canadian youths. Canadian Medical Association Journal, 173(8), 885-889. doi:10.1503/cmaj.045159
Sacco, R. L., Kasner, S. E., Broderick, J. P., Caplan, L. R., Connors, J. J. (., Culebras, A., . . . Council on Cardiovascular and Stroke Nursing. (2013). An updated definition of stroke for the 21st century: A statement for healthcare professionals from the american heart Association/American stroke association. Stroke, 44(7), 2064-2089. doi:10.1161/STR.0b013e318296aeca
Sasco, A.J., Secretan, M.B., Straif, K. (2004). Tobacco and cancer: a brief review of recent epidemiological evidence. Lung Cancer: 45(2), S3-S9.
Siconolfi, S. F., Garber, C. E., Lasater, T. M., & Carleton, R. A. (1985). A simple, valid step test for estimating maximal oxygen uptake in epidemiologic studies. American journal of epidemiology, 121(3), 382-390. doi: 10.1093/oxfordjournals.aje.a114010
Teufel-Shone, N. I., Fitzgerald, C., Teufel-Shone, L., & Gamber, M. (2009). Systematic review of physical activity interventions implemented with American Indian and Alaska Native populations in the United States and Canada. American Journal of Health Promotion, 23(6_suppl), S8-S32. doi:10.4278/ajhp.07053151
Thompson, J. L., Allen, P., Cunningham-Sabo, L., Yazzie, D. A., Curtis, M., & Davis, S. M. (2002). Environmental, policy, and cultural factors related to physical activity in sedentary American Indian women. Women & health, 36(2), 57-72. doi: 10.1300/J013v36n02_05
Thompson, J. L., Davis, S. M., Gittelsohn, J., Going, S., Becenti, A., Metcalfe, L., ... & Ring, K. (2001). Patterns of physical activity among American Indian children: an assessment of barriers and support. Journal of community health, 26(6), 423-445. doi: 10.1023/A:1012507323784
Thompson, J. L., Wolfe, V. K., Wilson, N., Pardilla, M. N., & Perez, G. (2003). Personal, social, and environmental correlates of physical activity in Native American women. American Journal of Preventive Medicine, 25(3), 53-60. doi: 10.1016/S0749-3797(03)00165-X
Tomlin, D., Naylor, P. J., McKay, H., Zorzi, A., Mitchell, M., & Panagiotopoulos, C. (2012). The impact of Action Schools! BC on the health of Aboriginal children and youth living in rural and remote communities in British Columbia. International journal of circumpolar health, 71(1), 17999. doi: 10.3402/ijch.v71i0.17999
Tremblay, M. S., LeBlanc, A. G., Carson, V., Choquette, L., Connor Gorber, S., Dillman, C., ... & Kho, M. E. (2012). Canadian physical activity guidelines for the early years (aged 0–4 years). Applied Physiology, Nutrition, and Metabolism, 37(2), 345-356. doi: 10.1139/h2012-018
Tremblay, M. S., Warburton, D. E., Janssen, I., Paterson, D. H., Latimer, A. E., Rhodes, R. E., ... & Murumets, K. (2011). New Canadian physical activity guidelines. Applied Physiology, Nutrition, and Metabolism, 36(1), 36-46. doi: 10.1139/H11-009
Tupper, O., Kjeldgaard, P., Løkke, A., & Suppli Ulrik, C. (2016). Predictors of COPD in high risk individuals seen in primary care. European Respiratory Journal, 48(suppl 60), PA1125. doi:10.1183/13993003.congress-2016.PA1125
Um, J., Mun, K., An, N., Kim, P., Kim, S., Kim, H., . . . You, Y. (2003). Polymorphism of angiotensin-converting enzyme gene and BMI in obese korean women. Clinica Chimica Acta, 328(1), 173-178. doi:10.1016/S0009-8981(02)00428-X
Vanasse, A., Demers, M., Hemiari, A., & Courteau, J. (2006). Obesity in canada: Where and how many? International Journal of Obesity, 30(4), 677-683. doi:10.1038/sj.ijo.080316
Walker, M., Fredericks, B., Mills, K., & Anderson, D. (2014). “Yarning” as a method for community-based health research with indigenous women: The indigenous women’s wellness research program. Health Care for Women International, 35(10), 1216-1226. doi:10.1080/07399332.2013.81575
Warburton, D. E. R., & Bredin, S. S. D. (2016). Reflections on physical activity and health: What should we recommend? Canadian Journal of Cardiology, 32(4), 495-504. doi:10.1016/j.cjca.2016.01.024
Warburton, D. E. R., Charlesworth, S., Ivey, A., Nettlefold, L., & Bredin, S. S. D. (2010). A systematic review of the evidence for Canada’s physical activity guidelines for adults. International Journal of Behavioural Nutrition and Physical Activity, 7(39), 1-220. doi: 10.1186/1479-5868-7-39
Warburton, D. E., Foulds, H. J., Charlesworth, S., Rhodes, R. E., & Bredin, S. S. (2008). The importance of physical activity interventions in Aboriginal children. Health & Fitness Journal, 1(1), 9-13.
Wang, Z., & Hoy, W. E. (2004). Waist circumference, body mass index, hip circumference and waist-to-hip ratio as predictors of cardiovascular disease in aboriginal people. European Journal of Clinical Nutrition, 58(6), 888-93. doi:http://dx.doi.org.ezproxy.library.ubc.ca/10.1038/sj.ejcn.1601891
Wang, Z., & Hoy, W. E. (2014). Lifetime risk of hospital diagnosed chronic obstructive pulmonary disease in remote Aboriginal people: a cohort study. Australian And New Zealand Journal Of Public Health, 38(4), 340-343. doi:10.1111/1753-6405.12233
WHO Report on the Global Tobacco Epidemic, 2008 (The MPOWER Package); World Health Organization: Geneva, Switzerland, 2008.
Yararbas, G., & Pogum, S. (2010). Encyclopedia of psychopharmacology (Stolerman, Ian P. ed.) Springer Berlin Heidelberg.
Young, T. K., & Katzmarzyk, P. T. (2007). Physical activity of Aboriginal people in Canada. Applied Physiology, Nutrition, and Metabolism, 32(S2E), S148-S160. doi: 10.1139/H07-110
Sectional Contributions: Introduction: Henry Lai, Section A: Megan Merrick, Section B: Emily Gerson, Section C: Sandy Yu-Shan Hsu, Section D: Henry Lai, Conclusion: Henry Lai