Harmony in Health: Wholistic Navigation of Type 2 Diabetes in Indigenous Communities - KIN 500C
| Harmony in Health: Wholistic Navigation of Type 2 Diabetes in Indigenous Communities | |
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| Course: | KIN 500C |
| Instructor: | Dr. Darren Warburton |
| Email: | darren.warbuton@ubc.ca |
| Contributors: | Daniel Lam
Mehrnaz Javadian Umar Ethof Hussain |
| Office: | Lower Mall Research Station |
Introduction
Authors' Positionality Statement
Before we start, there are a few things we would like to address. Firstly, we would like to acknowledge the rich history of the land that we reside on. We come to this paper with the recognition that we are guests on the land that has sustained Indigenous people since time immemorial. We have the privilege of living, learning, and working on the traditional, ancestral, and unceded territories of the xʷməθkʷəy ̓ əm (Musqueam), Skwxwú7mesh (Squamish) and səl ̓ilwətaɁɬ (Tsleil-Waututh) people.
Statement of Intent
This Wiki page aims to offer an exploration of type 2 diabetes from both western and Indigenous worldviews, including its multifaceted nature, screening, and management.
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Background
Pathophysiology and Mechanisms
Type 2 diabetes mellitus is a multifaceted endocrine and metabolic condition which operates via a complex interaction between genetic, lifestyle, and environmental factors, resulting in impaired glucose metabolism and eventual hyperglycaemia (high blood sugar) (Galicia-Garcia et al., 2020). The underlying mechanisms of type 2 diabetes involve insulin resistance, insufficient insulin secretion, and irregular liver glucose production, and adipose (fat) tissue dysfunction (Galicia-Garcia et al., 2020).
Insulin resistance
A key feature of type 2 diabetes is insulin resistance; insulin regulates and facilitates the uptake of glucose into cells, mainly muscle and fat tissue, where it is either used for energy or stored as glycogen. In type 2 diabetes, insulin resistance is characterized by a reduced metabolic reaction of insulin responsive cells, particularly in the pancreas, skeletal muscle, liver, and fat tissues, which leads to impaired glucose regulation and uptake causing elevated blood glucose levels (Czech, 2017).
Pancreatic beta cell dysfunction
The beta cells of the pancreas are specialized cells responsible for the production and release of insulin in response to elevated blood glucose levels (Marchetti et al., 2017). In individuals living with type 2 diabetes, the beta cells try to compensate for insulin resistance by increasing insulin production. However, long term exposure to elevated levels of glucose is toxic to beta cells (glucotoxicity) and can lead to beta cell dysfunction and damage ultimately leading to insufficient insulin secretion (Galicia-Garcia et al., 2020).
Hepatic glucose overproduction
The liver takes on a key role in regulating blood glucose levels via glycogenolysis (breakdown of glycogen into glucose) and gluconeogenesis (biosynthesis of glucose from non-carbohydrate sources). Due to insulin resistance and impaired insulin secretion, insulin sensitivity in the liver cells is diminished which leads to an increase in hepatic glycogenolysis and gluconeogenesis ultimately leading to hyperglycemia (Galicia-Garcia et al., 2020).
Adipose tissue dysfunction
Adipose tissue (fat tissue) is an important location for insulin activity and plays a crucial part in glucose and lipid metabolism (Gastaldelli, Gaggini, & DeFronzo, 2017). In type 2 diabetes, the fat tissue becomes insulin resistant thus impairing its ability of glucose and lipid uptake and storage and increases the breakdown of stored fat (triglycerides) into its component parts free fatty acids (FFAs) and glycerol; increased FFAs in circulation are toxic to pancreatic beta cells (lipotoxicity) further exacerbates systemic insulin resistance by impairing insulin activity in muscle and liver tissue (Galicia-Garcia et al., 2020). The fat tissue also secretes chemicals called adipokines which help regulate inflammation, metabolism, and insulin sensitivity. Due to adipose tissue dysfunction, adipokine secretion and production in fat tissue is also impaired which promotes further insulin resistance and inflammation.
Chronic low-grade inflammation
In type 2 diabetes the combination of insulin resistance, adipose tissue dysfunction and excess nutrient circulation in the blood (glucose and FFAs) exerts cellular stress and triggers the activation of inflammatory pathways which releases chemicals which promote inflammation such as cytokines, chemokines, and adipokines (Galicia-Garcia et al., 2020).
- Key Message: Understanding the intricate pathophysiology of type 2 diabetes highlights the importance of a proactive approach to healthcare, which focuses not only on managing symptoms but also on addressing the underlying physiological imbalances to prevent complications and improve overall well-being.
Symptoms
People living with type 2 diabetes often don’t recognise them and people can go years living with the condition without noticing (Mayo clinic, n.d.). Late diagnosis of type 2 diabetes shows a high prevalence of microvascular complications (Sosale et al., 2014). When present, symptoms may include:
Increased thirst and urination
Polydipsia (excessive thirst) and polyuria (frequent urination) are common symptoms of type 2 diabetes. The elevated blood sugar levels result in increased urination in order to remove excess glucose from the body which then results in dehydration leading to increased thirst.
Increased hunger
In type 2 diabetes, some individuals may have polyphagia (increased hunger) as the body is unable to efficiently use glucose for energy due to insulin resistance.
Unexplained weight change
In type 2 diabetes because of insulin resistance and metabolic changes, some individuals may experience weight loss despite increased appetite via insulin resistance, increased urination, as well as inadequate calorie intake. Conversely other individuals may experience weight gain via lifestyle factors such as diet, physical activity, and medication.
Fatigue
Impaired uptake of glucose by active cells leads to lower energy levels. As a result, individuals with type 2 diabetes may experience persistent tiredness.
Frequent infections and slow wound healing
Elevated blood sugar levels cause dysfunction in the body’s immune system which leads to more frequent infections and slow wound healing.
Blurred vision
Elevated blood sugar levels can cause the lens of the eye to swell which changes the shape leading to blurred vision.
Numbness and tingling in hands and feet
Elevated blood sugar levels overtime can damage small blood vessels that supply nutrients and oxygen to nerves, which in turn damages nerves and leads to neuropathy.
Erectile dysfunction
People with type 2 diabetes that were assigned male at birth may experience erectile dysfunction due to damaged blood vessels and nerves associated with elevated blood sugar levels.
- Key Message: Type 2 diabetes symptoms consists of multiple clinical manifestations. However, many of these symptoms can go unnoticed thus recognizing these signs is important for early diagnosis and management of the condition.
Comorbidities
Type 2 diabetes often coexists with multiple additional medical conditions either alongside or as a result of type 2 diabetes. According to Iglay and collegues (2016) it is estimated that 97.5% of individuals diagnosed with type 2 diabetes also had at least one comorbidity and 88.5% had at least two comorbidities with the most common comorbidities being hypertension, obesity, dyslipidemia, chronic kidney disease, and cardiovascular disease.
Obesity
Obesity is a chronic multifactorial disease defined by excessive fat deposits and cahracterized by having a Body Mass Index (BMI) over 30 kg/m² and is a leading risk factor for type 2 diabetes with an estimated 62% of people living with type 2 diabetes having obesity and 90% considered overweight (BMI of 25-30 kg/m²) (Centers for Disease Control and Prevention [CDC], 2023). Obesity is a pro-inflammatory state; increased size and number of fat tissue means increased secretion of adipokines and cytokines which promote inflammation in fat tissue ultimately leading to insulin resistance which in turn causes increased breakdown of fat molecules into FFAs which in turn leads to pancreatic beta cell dysfunction (Garber, 2011). However, obesity is a modifiable risk factor with even moderate weight loss of up to 5-10% body weight leading to mitigated type 2 diabetes development which can be achieved through changes in lifestyle such as being more physically active and adhering to a healthy diet (Czech, 2017; Garber 2011).
Hypertension
Hypertension is defined as having higher blood pressure than normal. In type 2 diabetes, elevated blood sugar levels caused by insulin resistance increases the volume of blood which leads to elevated blood pressure (Ohishi, 2018). Over time this causes structural changes in the blood vessels and lead to an increase in resistance within arteries which further exacerbates systemic hypertension (Ohishi, 2018). Hypertension is one of the most common comorbidities found alongside type 2 diabetes with at least 50% of people with type 2 diabetes having hypertension in most regions globally (Colosia, Palencia, & Khan, 2013).
Dyslipidemia
Dyslipidemia is characterized by abnormal levels of lipids (fatty substances) in the blood such as elevated triglycerides (fat molecules) and low-density lipoproteins (LDL; bad cholesterol) as well as reduced levels high-density lipoproteins (HDL; good cholesterol) (Chehade, Gladysz, & Mooradian, 2013). This may cause cholesterol-rich deposits accumulating in the arterial walls leading to arterial narrowing and blood flow obstruction ultimately leading to the development of atherosclerosis (Chehade et al., 2013). Dyslipidemia is highly prevalent among people living with type 2 diabetes with an estimated 62% showing hypertrigliceridemia (excessive fat molecules in circulation) and and estimated 22% showing hypercholesterolemia (high blood cholesterol) (Shahwan, Jairoun, Farajallah, & Shanabli, 2019).
Cardiovascular Disease
Cardiovascular disease (CVD) is the most common cause of death in individuals with type 2 diabetes with approximately 50% of all deaths being attributed to CVD (Álvarez-Guisasola et al., 2024; Einarson, Acs, Ludwig, & Panton, 2018). Due to a combination of insulin resistance, hyperglycemia, hypertension and dyslipidemia, individuals with type 2 diabetes may develop CVD over time such as coronary artery disease, stroke, heart attacks, and peripheral artery disease (Rodriguez-Araujo & Nakagami, 2018).
Chronic Kidney Disease
In individuals with type 2 diabetes, prolonged exposure to elevated blood sugar and hypertension may damage the blood vessels and nephrons in the kidneys leading to impaired kidney function leading to a build up of fluid and waste in the bloodstream (CDC, 2019). It is estimated that the overall prevalence of chronic kidney disease (CKD) in people living with type 2 diabetes is 24% with the highest prevalence being in older adults aged 75+ years old (61%) and people with haemoglobin A1C of over 8.0% (38.6%) (Jitraknatee, Ruengorn, & Nochaiwong, 2020).
Mental Health
Individuals with type 2 diabetes are often more susceptible to experiencing mental health complications such as depression, stress, and anxiety than the general population due to the added burden of self-managing a chronic medical condition (Robinson et al., 2018). It is estimated that 19% of people living with type 2 diabetes have some form of mental health comorbidity with depression (13.6%) and anxiety (3.17%) being the most prevalent (Guerrero Fernández de Alba et al., 2020).
- Key Message: Type 2 diabetes frequently coexists with multiple comorbidities which highlights the importance of comprehensive and holistic management strategies addressing both diabetes and its associated conditions for better health outcomes.
Evaluation
Diagnosis
There are 3 standard tests for diagnosing type 2 diabetes (Goyal, Singhal, & Jialal, 2023).
Fasting Plasma Glucose (FPG) Test
The Fasting Plasma Glucose (FPG) Test is an essential diagnosis tool for Type 2 diabetes. This test measures the blood glucose level after an overnight fast. A reading of 126 mg/dL (7.0 mmol/L) or above suggests the presence of diabetes. The FPG test is highly regarded for its convenience, affordability, and widespread accessibility, rendering it a common screening method in clinical settings. By swiftly administering and conducting straightforward procedures of the test, it enables efficient screening in a diverse healthcare environment (American Diabetes Association, 2022). Furthermore, a full fasting lipid panel may be needed because people with T2D have elevated triglycerides, which will affect management (BC Guideline, 2023). The limitations of the test include sample instability, high day-to-day variability, the inconvenience of fasting conditions, and reflecting glucose homeostasis at a single point in time (BC Guideline, 2023).
Oral Glucose Tolerance Test (OGTT)
The requirement of the Oral Glucose Tolerance Test is to stay fasted overnight and follow with the ingestion of a sugary solution. The blood glucose levels will be measured before and two hours post-consumption. According to the guideline, a level of 200 mg/dL (11.1 mmol/L) or higher two hours post-consumption confirms diabetes (American Diabetes Association, 2022). Compared to the FPG test, the OGTT is more time-consuming and less convenient, but it provides critical insight into glucose processes in the body and has the ability to detect abnormalities that other tests might fail to capture (BC Guideline, 2023). The limitations of this test include sample instability, high day-to-day variability, high cost, unappetizing nature, and inconvenience (BC Guideline, 2023).
Hemoglobin A1c (HbA1c) Test
By measuring the percentage of glycated hemoglobin, the Hemoglobin A1c (HbA1c) test evaluates average blood sugar levels over the previous two to three months. An HbA1c level of 6.5% or higher is diagnosed as diabetes. The HbA1c test does not require fasting and is indispensable for long-term glucose monitoring and the evaluation of the risk of diabetes-related complications over a longer period of time. However, patients with certain medical conditions, such as hemoglobinopathies, very low eGFR, hematologic malignancies, or anemia, might receive inaccurate results (BC Guideline, 2023). The HbA1c test has several limitations: the cost of the test is high, there are many misleading medical conditions, the test requires a standard and validated assay, and results can be altered by ethnicity and aging (BC Guideline, 2023).
Table 2. Classifications of type 2 diabetes based on glucose test results according to Diabetes Canada (Punthakee, Goldenberg, & Katz, 2018).
| Test | |||
|---|---|---|---|
| Condition | Hb A1C (%) | FPG (mmol/L) | 2-H OGTT |
| Normal | ≤ 5.4 | ≤ 5.5 | ≤ 7.7 |
| At Risk | 5.5 - 5.9 | 5.6 - 6.0 | n/a |
| Prediabetes | 6.0 - 6.4 | 6.1 - 6.9 | 7.8 - 11.0 |
| Diabetes | ≥ 6.5 | ≥ 7.0 | ≥ 11.1 |
Screening
Risk Assessment Questionnaires
Other than the direct measure of blood glucose levels in the body, risk assessment questionnaires as non-diagnostic tools can also play a role in evaluating the Type 2 diabetes risk factors of individuals. Risk assessment questionnaires are pivotal in identifying high-risk individuals who may benefit from further testing. The questionnaires include questions that ask about the background of the individuals, such as age, weight, degree of physical activity engagement, and family history (Canadian Diabetes Association, 2018).
Community-based Screening Program
This program focuses on the population that might lack regular healthcare services by enhancing the accessibility of diabetes screening. By implementing health fairs, mobile clinics, and other outreach activities in deprived areas, it helps with the early detection and intervention of T2D (Canadian Diabetes Association, 2018).
Indigenous people are often diagnosed at a younger age and with a higher severity of T2D, as well as a series of complications developing more rapidly than in non-Indigenous populations. To increase the effectiveness of screening for Indigenous people, it is crucial that the strategies align with the perspectives of community-specific cultural, social, and health services contexts (Crowshoe et al., 2018).
Screening Recommendations for Indigenous People (Crowshoe et al., 2018):
- Adults: With additional risk factors such as obesity or a strong family history of diabetes, diabetes screening is recommended to be conducted every 6 to 12 months.
- Women of Childbearing Age: With the high risks associated with gestational diabetes and its implications for future generations, Indigenous women should be screened for T2D with an A1C test after the first antenatal visit. Those with negative early screening should be re-screened for gestational diabetes mellitus (GDM) between 24 to 28 weeks of gestation. Postpartum screening should be conducted between 6 weeks and 6 months postpartum, especially after GDM.
- Children and Adolescents: Starting from age 10 or puberty onset, Indigenous children who have additional risk factors like obesity, a family member with T2D, signs of insulin resistance, prediabetes, or exposure to hyperglycemia in utero are recommended to receive T2D screening every 2 years as being a high risk ethnic group.
Community-Based Approaches
By involving local leaders and integrating culturally appropriate education, screening initiatives will become most successful. In order to foster a supportive environment, Holistic approach is beneficial for utilizing points of care instruments that provide immediate results, facilitating timely intervention in the community (Crowshoe et al, 2018).
Epidemiology and Statistics
Estimated prevalence and cost of diabetes in Canada
According to Diabetes Canada (n.d.):
- 5.88million cases are diagnosed in 2023 with the majority of type 2 diagnosed
- 1 in 3 Canadians within 11 million people have diabetes or prediabetes today
- In Canada, every 24 hours,
- More than 20 Canadians die of diabetes-related complications
- 480 more Canadians are diagnosed with this devastating disease
- 14 Canadians have a lower limb amputation
- Our health care system spends $75 million treating diabetes
- 90% of Canadians with diabetes are living with type 2 diabetes.
- 1.7 million Canadians who have type 2 diabetes and do not know about it
- Diabetes complications can lead to early mortality, potentially reducing lifespan by 5-15 years.
- People diagnosed with depression have a heightened risk, ranging from 40%-60%, of developing type 2 diabetes.
- Individuals managing type 2 diabetes may allocate as much as 16% of their gross annual income toward medication and devices, with costs ranging from $76 to $10,014
- Populations at elevated risk for type 2 diabetes include African, Arab, Asian, Hispanic, Indigenous, and South Asian groups, along with older individuals, those with lower income or educational levels, physical inactivity, and overweight and obesity.
- Adult men are more at risk of type 2 disease compared to adult woman
Prevalence of Diabetes in First Nations Populations in Canada
The prevalence of self-reported diabetes among adults varies across different Indigenous groups (Indigenous communities and diabetes, 2024). Specifically, First Nations individuals living on reserve, First Nation individuals living off reserve, Metis and Inuit report diabetes at a rate of 17.2%, 12.7%, 9.9%, and 4.7%, respectively. Indigenous people are often diagnosed with diabetes at a younger age, have increased symptom severity at diagnosis, face increased complication rates, and face worse treatment outcomes (Indigenous communities and diabetes, 2024).
Pharmacological Management of T2D
Pharmacological strategies such as achieving glycemic control, minimizing the risk of hypoglycemia, and managing associated risks such as cardiovascular and renal complications are crucial in a comprehensive approach for the management of T2D (Diabetes Canada, 2020).
Adjustments in Anti-hyperglycemic Medication
According to Diabetes Canada (2020), adjustments should be made when the glycemic targets are not met with current antihyperglycemic medications, or if the patient’s clinical status changes. To improve glycemic control and reduce cardiorenal impacts, it is essential to include the addition of new classes of agents or the replacement of existing ones. On the other hand, reassessment of glycemic targets should be carried out if the medications do not achieve the desired effect for the individuals. Some other specific medication recommendations from Diabetes Canada (2020) include reducing hypoglycemia risk and weight management, which involves taking DPP-4 inhibitors, GLP-1 receptor agonists, and SGLT2 inhibitors if the risk of hypoglycemia is a priority, while taking GLP1-RA and SGLT2i if losing weight is a priority for the patients, respectively. Last but not least, insulin therapy such as a basal insulin regimen should be initiated if glycemic targets are not achieved through oral medication alone. Insulins such as glargine U-300, insulin detemir, or insulin degludec are preferred, especially for individuals with multiple risk factors for hypoglycemia, because they contain long-acting insulin analogues. Furthermore, bolus insulin as rapid-acting analogues are better at managing blood glucose spikes post meals compared to regular insulin. Additional agents such as GLP1-RA, SGLT2i, or DPP4i may also be added in the modification if insulin therapy does not meet the glycemic targets, in order to enhance the therapeutic effect.
Non-Pharmacological Management of T2D
Healthy Behaviour Interventions and Holistic Health Approaches
Exercise and Physical Activity
According to Warburton & Bredin, 'Physical activity is any bodily movement produced by skeletal muscles that result in energy expenditure above resting levels. It encompasses a wide range of activities, including those done as part of daily living, occupation, leisure, and active transport' (2016). This indicates any kind of movement, even walking, can be potentially beneficial for T2D patients. For example, simply minimizing sedentary time such as interrupting sitting every 20 to 30 minutes will have a positive effect on the body as a self-monitor physical activity levels strategy (Warburton & Bredin, 2016).
Aerobic Exercise Guidelines for Individuals with T2D
Aerobic exercise consists of sustained rhythmic motions, such as walking, cycling, swimming, or running, which involves large muscle groups and is typically lasting at least 10 minutes consecutively (Sigal et al., 2018). The guideline recommends 150 minutes of moderate-to-vigorous-intensity aerobic exercise each week, with higher intensity exercise showing greater benefits for glucose control (Sigal et al., 2018). However, it is important for individuals to engage in aerobic exercise progressively with its duration, frequency, and intensity, in order to minimize injury risk and improve adherence. Walking does not require a lot of energy expenditure; however, it has been shown that walking at least 2 hours weekly has been associated with a substantial reduction in the incidence of premature death from any cause among patients with diabetes (Warburton, Nicol & Bredin, 2006). Participating in aerobic exercise will reduce glycosylated hemoglobin in the body of T2D patients, thus enhancing the control of blood glucose level by improving glucose homeostasis (Warburton, Nicol & Bredin, 2006). Also, by contributing to regular aerobic exercise, it will improve body composition, lipid profiles, blood pressure, and reduction in systemic inflammation, which is crucial in managing T2D as well (Warburton, Nicol & Bredin, 2006). Last but not least, by engaging in aerobic exercise, patients with T2D also show improvement in psychological well-being, which is significant for the prevention and management of T2D.
Resistance Exercise Guidelines for Individuals with T2D
Resistance exercises aim to increase muscle strength and endurance by involving brief repetitive exercises with weights or even one's own body weight (Sigal et al., 2018). The guideline recommends that resistance training should be performed at least twice a week, ideally three times a week on nonconsecutive days (Colberg et al., 2010). When it comes to intensity, a moderate (50% of 1 repetition maximum) or vigorous (75-80% of 1RM) are recommended as it is best to enhance insulin action and achieve gains in muscle strength (Colberg et al., 2010). The duration of the exercise is an important part as well; it is recommended that each session should include 5-10 exercises that target the major muscle groups with 10-15 repetitions per set (Colberg et al., 2010). Supervision by a qualified trainer is recommended, especially for beginners in the weight room, thus to optimize the gains and minimize the risk of injury (Colberg et al., 2010). By engaging in resistance exercise, it will bring tremendous benefits to the T2D patients. First, resistance training enhances insulin sensitivity by increasing muscle mass. By having bigger muscle mass, the muscle's ability to uptake glucose will enhance, thus reducing glucose levels (Colberg et al., 2010). Second, glucose uptake independently of insulin during muscle contraction, which is especially beneficial for individuals with T2D who often have impaired insulin signaling (Colberg et al., 2010). Last but not least, insulin sensitivity and glucose control are associated with lower body fat, and resistance training helps in reducing body fat by increasing muscle mass and improving metabolic rate (Colberg et al., 2010).
PAR-Q+
Before participating in physical activity, it is essential for participants to fill out the PAR-Q+ to keep them safe in the program. The PAR-Q+ aims to pinpoint individuals for whom engaging in physical activity could pose risks or those who should seek medical guidance regarding the most appropriate types of activity for them. By covering a wide spectrum of physical conditions, it should be effective enough to advise against specific types of physical activity or levels of intensity (Warburton et al., 2011). According to Warburton et al., the PAR-Q+ provides four benefits to the participants which include identifying existing health concerns, assessing fitness level, ensuring safety, and facilitating communication with healthcare providers (2011).
Indigenous Perspectives
Then and Now
Before European settlers arrived, the land now known as North America was home to Indigenous peoples (Miles & Huguenin, 2023). These communities had developed sophisticated social, political, and cultural systems over thousands of years. Their ways of life were deeply connected to the land and were adaptive to their environment. They led physically active lives that were sustained with nutritious and traditional foods (Miles & Huguenin, 2023). Therefore, prior to colonization, Indigenous people enjoyed high quality health and rarely experienced conditions such as T2D (Burnside et al., 2023; Miles & Huguenin, 2023).
Currently, Indigenous populations worldwide experience disproportionately high rates of diseases, including diabetes and obesity (Burnside et al., 2023; Kurtz et al., 2022). The rise in diabetes can be attributed to multiple factors, primarily historical and ongoing colonization (Burnside et al., 2023; Gracey & King, 2009; Kurtz et al., 2022). These colonial impacts have had profound impacts on Indigenous people and their health by causing social, economic and cultural disruptions (Gracey & King, 2009; Kurtz et al., 2022).
Historical policies that displaced Indigenous people from their lands and suppressed their culture—including their diet and physical activities—have significantly contributed to current health challenges (Gracey & King, 2009; Kurtz et al., 2022). The transition to Western diets and sedentary lifestyles has led to increased rates of obesity and diabetes. Moreover, the intergenerational emotional and social trauma from residential schools and forced assimilation compounds these health issues (Gracey & King, 2009; Kurtz et al., 2022). These factors are intertwined with poverty, loss of cultural identity, crowded living conditions, and strained relationships, all of which hinder access to nutritious foods and escalate the risk of chronic diseases such as T2D (Gracey & King, 2009; Kurtz et al., 2022).
Culture is Important
Mainstream Western health systems often fail to serve Indigenous people effectively (Burnside et al., 2023; Kurtz et al., 2022). These systems overlook the foundational issues and structure factors that lead to the previously mentioned socioeconomic disparities, health care gaps, and increased mortality rates (Burnside et al., 2023; Kurtz et al., 2022). This is because current health practices are mostly influenced by Western worldviews, hindering the integration of Indigenous worldviews necessary for culturally safe practices for Indigenous populations (Josewski et al., 2023).
The impacts of this disconnection can be seen from the practices of Indigenous people living with T2D in terms of how they manage their condition. These individuals often postpone or avoid medical care due to past negative encounters with healthcare (Institute of Health Economics & Craig, 2017). They typically seek care when they encounter severe symptoms caused by chronic hyperglycemia. Furthermore, community healthcare providers are already providing services at full capacity and cannot expand programs or accept more patients due to limited resources (Institute of Health Economics & Craig, 2017). When combined with other barriers, such as geographical isolation of many rural and remote communities, these factors create obstacles to timely care for many Indigenous people thereby preventing effective disease prevention, support and treatment to ensure continuity in T2D management (Institute of Health Economics & Craig, 2017).
Effectively managing T2D in Indigenous communities requires methods that respect their cultural values and worldviews (Bonin et al., 2022; Burnside et al., 2023; Halseth & Murdock, 2020; Kurtz et al., 2022). Such approaches should integrate Indigenous knowledge, languages, traditional healing practices, self-determination, and governance (Halseth & Murdock, 2020; Warburton & Bredin, 2019). T2D management efforts are more successful when they are community-led and conducted in culturally significant settings. Successful examples include the use of traditional foods, storytelling, and engagement in physical activities like traditional dancing and hunting (Bonin et al., 2022; Kurtz et al., 2022; Miles, Bredin, et al., 2023; Warburton & Bredin, 2019). This approach provides Indigenous people living with T2D with wholistic support and care to effectively manage their symptoms.
Additionally, understanding and embracing the Truth and Reconciliation Commission of Canada's calls to action is crucial for the effective provision and co-construction of healthcare that meets the aspirations of Indigenous people. Specifically, the Truth and Reconciliation Commission of Canada (TRC) (2015) emphasizes in Call to Action 18 that health issues among Indigenous people stem from colonization and previous government policies and cultural genocide, while Call to Action 22 highlights traditional healing and cultural practices as effective ways to address inequalities. Call to Action 19 also calls for addressing the gaps that exist within Indigenous health, including chronic diseases and available appropriate health services (Truth and Reconciliation Commission of Canada, 2015). This is further backed by international declarations such as Article 24 of the United Nations Declaration on the Rights of Indigenous Peoples (UNDRIP) which states that Indigenous communities have the right to use traditional medicines and health practices (United Nations, 2007).
- Key Message: It is vital for Indigenous people living with T2D to have access to culturally-based care and management practices (Burnside et al., 2023; Kurtz et al., 2022; Warburton & Bredin, 2019). That is not to say that Western practices are ineffective in nature but rather using cultural initiatives that fit the local context work better for Indigenous people. When used to supplement these wholistic and culturally-based approaches, Western medicine can be used effectively as well (Kurtz et al., 2022; Warburton & Bredin, 2019).
The following subsections will explore the definition and dimensions of wellness in Indigenous cultures followed by introducing examples of strengths-based and cultural management practices that can help improve the health and wellbeing of individuals living with T2D.
Wholistic Management of T2D
What is Wellness?
Indigenous cultures across Canada and the world are diverse. However, wellness, according to many Indigenous people, is a wholistic idea that is constantly evolving (Bonin et al., 2022). Wellbeing often means achieving harmony across spiritual, physical, mental, and emotional dimensions of health (Bonin et al., 2022; First Nations Health Authority, 2008; Miles & Huguenin, 2023). This includes aspects such as family, community, land and a sense of belonging to the environment one lives in (Bonin et al., 2022; Miles & Huguenin, 2023). Therefore, the term “wholistic” has been purposefully used throughout this resource, as opposed to the term “holistic”, to highlight the interconnectedness of these dimensions (Absolon, 2010; Miles, Chow, et al., 2023).
These dimensions of health can also be represented using the Medicine Wheel, which is a traditional Anishinaabe teaching tool. This wholistic framework for health is applied in various ways across different Indigenous communities (Burnside et al., 2023; Lavallée, 2009). While not all Indigenous nations use the Medicine Wheel, those that do often adapt its colors and teachings to their specific cultural contexts (Lavallée, 2009). Generally, the Medicine Wheel includes four quadrants representing physical, emotional, spiritual and mental aspects of wellness and health (Burnside et al., 2023). Promoting balance and connection among various aspects of health makes the Medicine Wheel a powerful model in managing chronic conditions such as T2D in Indigenous communities.
Understanding and Addressing Dimensions of Wellness within T2D
Successful management efforts in Indigenous communities have to be rooted in Indigenous cultural practices and worldviews (Burnside et al., 2023; Kurtz et al., 2022; Warburton & Bredin, 2019). This means incorporating the multiple dimensions of wellness: physical, emotional, mental and spiritual. While the following activities are organized under specific categories below, their classification can shift depending on the aspect of wellness being emphasized, demonstrating their wholistic and multifaceted nature.
Table 3. Definition and examples of the four dimensions of wholistic wellness.
| Dimension of Wholistic Wellness | Definition | Example Activities
*These activities are each wholistic in nature meaning they incorporate multiple dimension of wellness.* |
|---|---|---|
| Physical | The physical component of wellness refers to developing skills, maintaining a healthy diet, engaging in physical activity, and wellness practices and behaviors (Burnside et al., 2023). |
(Bonin et al., 2022; Kurtz et al., 2022; Miles & Huguenin, 2023; Native Women’s Association of Canada, 2012, n.d.; Salloum & Warburton, 2019) |
| Mental | The mental component of wellness refers to understanding diabetes, awareness and showing capacity for learning about T2D (Burnside et al., 2023). |
(Bonin et al., 2022; Kurtz et al., 2022; Miles & Huguenin, 2023; Native Women’s Association of Canada, n.d.; Salloum & Warburton, 2019) |
| Emotional | The emotional component of wellness refers to building confidence, empowerment, forming relationships with healthcare, and having aspirations as well as challenges (Burnside et al., 2023). |
(Bonin et al., 2022; Kurtz et al., 2022; Miles & Huguenin, 2023; Native Women’s Association of Canada, n.d.) |
| Spiritual | The spiritual component of wellness refers to incorporation of Indigenous values and worldviews, traditional healing and medicine, as well as embracing the Indigenous culture (Burnside et al., 2023). |
(Bonin et al., 2022; Crowshoe et al., 2018; Kurtz et al., 2022; Miles & Huguenin, 2023; Salloum & Warburton, 2019) |
Staying Active
Physical activity and exercise are important factors in helping prevent and manage T2D (Bonin et al., 2022; Kurtz et al., 2022) Warburton, Nicol & Bredin, 2006). Understanding one's physical body is also deeply intertwined with spiritual reverence, linking present existence to past and future generations (Miles & Huguenin, 2023). Traditional Indigenous lifestyles naturally integrate physical activities such as hunting, farming, gathering, and fishing into daily life, fostering a wholistic health approach (Miles & Huguenin, 2023). Encouraging physical activity within these communities should adopt a wholistic approach, emphasizing land-based activities that leverage existing community strengths and practices (Warburton & Bredin, 2019). This method not only promotes physical health but also supports cultural preservation and self-determination by integrating cultural and traditional knowledge into health and wellness strategies (Miles & Huguenin, 2023; Warburton & Bredin, 2019). Having such initiatives that align with cultural values enhance community identity and the effectiveness of health outcomes (Miles & Huguenin, 2023; Native Women’s Association of Canada, n.d.).
- Key Message: Physical activity prescription is not a one-size fits all approach, but rather requires an individualized approach to provide the individual with a culturally safe and appropriate physical activity plan. This plan needs to be aligned with the individual’s aspirations and strengths (Warburton & Bredin, 2018, 2019).
Eating Well
Traditional foods serve a holistic purpose, providing nourishment not just physically but also mentally, emotionally, and spiritually (Earle, 2013; First Nations Health Authority, 2014; Government of British Columbia, n.d.). Indigenous diets, rich in nutritional value and cultural importance, consist mainly of locally sourced plants and animals (Earle, 2013; Native Women's Association of Canada, 2012). These diets are typically high in protein—especially from animal sources—and nutrients but low in fats. When fats are present, they usually derive from marine sources rich in omega-3 fatty acids, beneficial for cardiovascular health. Furthermore, these diets are characterized by low carbohydrate and simple sugar content, aiding in the management and prevention of conditions such as diabetes and obesity (Earle, 2013; Native Women's Association of Canada, 2012).
Engagement in traditional food procurement activities such as hunting, fishing, and gathering not only involves physical exertion that supports physical health but also reinforces social bonds and cultural practices (Earle, 2013). These activities facilitate the sharing of resources and cooperative social structures, enhancing community cohesion and individual social well-being (Miles & Huguenin, 2023). Traditional foods also carry spiritual meanings, as they are often used in ceremonies and rituals and are seen as gifts from the land (Government of British Columbia, n.d.; Native Women's Association of Canada, 2012).
However, there has been a significant shift from these traditional diets to more modern dietary patterns that are high in processed fats and sugars (Earle, 2013). This shift, coupled with a more sedentary lifestyle, has contributed to an increase in chronic diseases among Indigenous populations. The transition involves a move away from nutrient-dense traditional foods towards more readily available market foods that often do not meet nutritional needs and are less beneficial for health (Crowshoe et al., 2018; Earle, 2013).
In response to these changes, there is a need for the revival of traditional diets (Earle, 2013). The reintegration of traditional foods into daily life can help combat chronic diseases and maintain the health and cultural heritage of Indigenous communities. This approach not only addresses physical health but also supports the cultural and social frameworks integral to Indigenous identities (Earle, 2013).
Another important reason for this revitalization process is to address the long history food has played in oppressive and colonial practices in Canada (Bodirsky & Johnson, 2008; Government of British Columbia, n.d.). Historically, tactics like forced relocations to reservations with limited resources, restrictions on fishing and hunting, and conducting nutritional experiments in residential schools illustrate a pattern of food-related injustices in Canada against Indigenous people (Bodirsky & Johnson, 2008; Government of British Columbia, n.d.). Supporting the integration of traditional Indigenous foods, systems, and knowledge into public institutions also represents a step towards reconciliation (Bodirsky & Johnson, 2008; Government of British Columbia, n.d.).
- Key Message: It is important for all Indigenous people, including those living with T2D, to (re)integrate traditional and healthy foods into their diet and learn about healthy nutrition from culturally appropriate resources which have been developed by and in collaboration with Indigenous people. There are a few resources included at the end of this wiki page.
Table 4. Snapshot of Eating Well With Canada's Food Guide - First Nations, Inuit and Métis (Health Canada, 2007). This guide has been developed in collaboration with Indigenous people.
| Food Groups | Recommended Number of Daily Servings for Teens (13-18) and Adults (+19) | What is one serving? | Notes |
|---|---|---|---|
| Vegetables and Fruits | Females: 7-8
Males: 7-10 |
Leafy vegetables and wild plants:
Dark greens and orange vegetables: 125mL = 1/2 cup Other vegetables (including canned and frozen): 125mL = 1/2 cup Berries: 125mL = 1/2 cup Fruit: 1 fruit = 125mL = 1/2 cup 100% juice: 125mL = 1/2 cup |
Choose fruits and vegetables that have been prepared with little or no added fat, salt or sugar. Have more fruits and vegetables than juice. Consume at least one dark green and one orange vegetable daily. |
| Meat and Alternatives | Females: 2
Males: 3 |
Cooked traditional meats and wild game: 75g =125mL = 1/2 cup
Cooked lean meat and poultry: 75g = 125mL = 1/2 cup Cooked fish and Shellfish: 75g = 125mL = 1/2 cup Eggs: 2 eggs Cooked beans: 175mL = 3/4 cup Peanut butter = 30mL = 2 Tbsp |
Try to consume at least two servings of fish per week. Choose lean meat and alternatives prepared with little or no added salt or fat. Try to have meat alternatives such as tofu, beans and lentils often. |
| Grain Products | Females: 6-7
Males: 7-8 |
Bread: 1 slice or 35g
Bannock: 35 g Cereal:
Cooked pasta: 125mL = 1/2 cup Cooked rice (wild, brown, white): 125mL = 1/2 cup |
Consume grain products that are lower in sugar, salt and fat. Make half of daily grain product intake whole grain. |
| Milk and Alternatives | Females:
|
Milk (including powdered and mixed): 250mL = 1 cup
Canned milk = 125mL = 1/2 cup Fortified soy beverage: 250mL = 1 cup Yogurt: 175mL = 3/4cup Cheese: 50g = 1 1/2oz |
Consume 500mL or 2 cups of skim, 1% or 2% milk per day. Choose lower fat milk alternatives. Drink fortified soy beverages if you do not consume milk. |
Integrating all Dimensions of the Medicine Wheel through Community Gardens
Further Resources
- Diabetes Canada which has many resources including Diabetes Education Video Library and A Snapshot of Diabetes Management in Canada.
- National Indigenous Diabetes Association
- Diabetes factsheets for Indigenous People
Staying Active
- Diabetes Canada's Benefits of Physical Activity
Eating Well
- Eating Well with Canada’s Food Guide - First Nations, Inuit and Métis
- Healthy Food Guidelines for First Nations Communities
- Feed BC's Resource for Indigenous Cookbooks provided by Chef Andrew George.
- Native Women's Association of Canada's Diabetes Self Management Tool for Aboriginal Women
- Food is Medicine: The Cooking Show alongside with the Recipe Book for all the meals seen in throughout the season.
References
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