Best Practices for the Prevention and Management of Diabetes and Obesity-Related Chronic Disease among Indigenous Peoples in Canada: A Review

Open AccessPublished:April 07, 2016DOI:https://doi.org/10.1016/j.jcjd.2015.10.007

      Abstract

      Objectives

      To carry out a systematic review of interventions that have aimed at improving screening, treatment, prevention and management of type 2 diabetes and obesity-related chronic disease in Indigenous communities in Canada from 2008 to 2014, with the aim of identifying current best practices.

      Methods

      A comprehensive literature review was carried out through an electronic database search using Medline, EMBASE, PubMED and Google scholar.

      Results

      We identified 17 publications, comprising 13 evaluated interventions. Of them, 7 were school-based programs focused on children, 5 focused on adults, and 1 included both adults and children. Most interventions aimed at encouraging behaviour change, especially dietary change, but did little to address the underlying context of systemic marginalization and colonialism experienced in many Indigenous communities. Interventions focused on improving fitness were more effective than those aimed at dietary change. Overall, we found a range of successes among these interventions. Those that met with limited success reported that complex social issues and poverty presented challenges to effective intervention work in these communities. Participatory action research methods and community ownership of the intervention were found to be essential for project success.

      Conclusions

      Diabetes-focused intervention research in Indigenous communities appears to be a low priority for Canadian funders and policymakers. More intervention research is urgently needed in these communities. To be effective, this work must take an approach that is historically deep and sufficiently broad as to enable the ideologic, policy and institutional changes necessary in order to achieve true equity. This will involve addressing colonialism, racism and social exclusion as broader determinants of health.

      Résumé

      Objectifs

      Mener une revue systématique de la littérature à propos d'interventions qui ont visés à améliorer le dépistage, le traitement, la prévention et la gestion du diabète de type 2 et les maladies chroniques liées à l'obésité dans les communautés des Premières Nations au Canada entre 2008 et 2014, dans le but d'identifier les meilleures pratiques actuelles.

      Méthodes

      Un examen complet de la littérature a été réalisé en utilisant des bases de données électronique - Medline, Embase, PubMed et Google scholar.

      Résultats

      Nous avons identifié 17 publications, comprenant 13 interventions évaluées. Parmi eux, 7 visaient des programmes d'école axés sur les enfants, 5 étaient concentrés sur les adultes, et 1 comprenait les adultes et les enfants. La plupart des interventions visaient à encourager le changement de comportement, en particulier le changement de régime alimentaire, mais peu portaient attention au contexte sous-jacent de la marginalisation systémique et le colonialisme connu dans de nombreuses communautés autochtones. Les interventions axées sur l'amélioration d'état physique étaient plus efficaces que celles qui visaient des changements d'alimentation. Dans l'ensemble, nous avons trouvé une gamme de succès parmi ces interventions. Celles avec un succès limité, rapportaient des obstacles complexes au niveau social et de pauvreté qui ont présenté des défis pour travailler avec les communautés et mettre en place une intervention de façon efficace. Les méthodes de recherche participative et la possession communautaire de l'intervention ont été jugés essentielles pour la réussite du projet.

      Conclusions

      La recherche interventionnelle axée sur le diabète dans les communautés autochtones semble être une faible priorité pour les bailleurs de fonds et les décideurs politiques canadiens. Il y a un besoin urgent pour plus d'études avec intervention dans ces communautés. Pour être efficace, ce travail doit prendre une approche qui est historiquement profonde et suffisamment large pour permettre l'idéologie, la politique et les changements institutionnels nécessaires afin de parvenir à une véritable équité. Il faudra pour cela aborder le colonialisme, le racisme et l'exclusion sociale comme déterminants de la santé.

      Keywords

      Mots Clés

      Introduction

      Diabetes and obesity-related chronic disease have reached epidemic proportions among Indigenous peoples in Canada (
      • Public Health Agency of Canada
      Diabetes in Canada: Fact and figures from a public health perspective.
      ,
      • Young T.K.
      • Reading J.
      • Elias B.
      • O'Neil J.D.
      Type 2 diabetes mellitus in Canada's first nations: Status of an epidemic in progress.
      ,
      • Liu J.
      • Young T.K.
      • Zinman B.
      • et al.
      Lifestyle variables, non-traditional cardiovascular risk factors, and the metabolic syndrome in an Aboriginal Canadian population.
      ). The Public Health Agency of Canada has recently reported a diabetes prevalence rate of 17.2% among on-reserve First Nations people, 10.3% among off-reserve First Nations and 7.3% among Métis (
      • Public Health Agency of Canada
      Diabetes in Canada: Fact and figures from a public health perspective.
      ). The disparity between these figures and the prevalence rate of 5% among non-Indigenous Canadians illustrates the particular threat that obesity-related morbidities pose for Indigenous peoples in Canada.
      Genetic vulnerability plays a role in the development of diabetes, but the rates of diabetes and related chronic diseases among Indigenous peoples are widely considered to be due primarily to nonmedical factors. These nonmedical factors include sedentization and dietary change (
      • Public Health Agency of Canada
      Diabetes in Canada: Fact and figures from a public health perspective.
      ,
      • Sharma S.
      • Gittelsohn J.
      • Rosol R.
      • Beck L.
      Addressing the public health burden caused by the nutrition transition through the healthy foods north nutrition and lifestyle intervention program.
      ,
      • Kuhnlein H.V.
      • Receveur O.
      • Soueida R.
      • Egeland G.M.
      Arctic indigenous peoples experience the nutrition transition with changing dietary patterns and obesity.
      ), high cost and limited availability of healthful foods in many remote communities (
      • Willows N.D.
      • Hanley A.J.
      • Delormier T.
      A socioecological framework to understand weight-related issues in Aboriginal children in Canada.
      ,
      • Egeland G.M.
      • Pacey A.
      • Cao Z.
      • Sobol I.
      Food insecurity among Inuit preschoolers: Nunavut inuit child health survey, 2007–2008.
      ) as well as sociostructural barriers, such as high rates of poverty, poor infrastructure and limited opportunities for employment in many Indigenous communities (
      • Reading C.L.
      • Wien F.
      Health inequalities and social determinants of Aboriginal peoples' health.
      ). Furthermore, although the presence of walking trails and access to exercise equipment has been found to promote increased physical activity in Indigenous communities (
      • Wendel-Vos W.
      • Droomers M.
      • Kremers S.
      • et al.
      Potential environmental determinants of physical activity in adults: A systematic review.
      ), many nonurban communities lack both safe and all-weather places for walking, as well as facilities for specialized physical activity such as sports (
      • Joseph P.
      • Davis A.D.
      • Miller R.
      • et al.
      Contextual determinants of health behaviours in an aboriginal community in Canada: Pilot project.
      ,
      • Anand S.S.
      • Davis A.D.
      • Ahmed R.
      • et al.
      A family-based intervention to promote healthy lifestyles in an aboriginal community in Canada.
      ). Moreover, many Indigenous peoples face additional challenges in accessing appropriate healthcare, as many reside in rural and remote regions that lack comprehensive primary care and are often at great distances from specialized care (
      • Shubair M.M.
      • Tobin P.K.
      Type 2 diabetes in the first nations population: A case example of clinical practice guidelines.
      ). Stressful working conditions and isolation impede the retention of healthcare personnel in remote areas (
      • Andrews M.E.
      • Stewart N.J.
      • Pitblado J.R.
      • et al.
      Registered nurses working alone in rural and remote Canada.
      ,
      • Kulig J.C.
      • Stewart N.J.
      • Morgan D.
      • et al.
      Aboriginal nurses' insights from a national study.
      ).
      As with other health disparities between Indigenous and non-Indigenous peoples in Canada, the burden of diabetes and chronic disease are linked to the socioeconomic marginalization of Indigenous communities. Contemporary health disparities are part of the history of colonization that includes loss of land and livelihood, diminished community self-determination and policies that have undermined social and economic development such as the Residential School system (

      Vancouver Coastal Health, 2008–2011 Aboriginal Health and Wellness Plan. 2008.

      ,
      • Blackstock C.
      First Nations children count: Enveloping quantitative research in an Indigenous envelope.
      ). Any effort to address the health disparities between Indigenous peoples and other Canadians must therefore attend to the relationship between colonization, inequality and health. Moreover, such efforts must also attend to the loss of cultural continuity and identity due to active suppression of Indigenous culture and knowledge (

      Vancouver Coastal Health, 2008–2011 Aboriginal Health and Wellness Plan. 2008.

      ), including Indigenous concepts of health and wellness as well as severe social and economic disadvantage (

      Vancouver Coastal Health, 2008–2011 Aboriginal Health and Wellness Plan. 2008.

      ,
      • Blackstock C.
      First Nations children count: Enveloping quantitative research in an Indigenous envelope.
      ,
      • Chino M.
      • DeBruyen L.
      Building true capacity: Indigenous models for indigenous communities.
      ). Many interventions aimed at Indigenous communities have met limited success in part because they have failed to account for local conceptualizations of wellness (
      • Smylie J.
      • Kaplan-Myrth N.
      • McShane K.
      Metis Nation of Ontario-Ottawa Council, Pikwakanagan First Nation, Tungasuvvingat Inuit Family Resource Centre
      Indigenous knowledge translation: Baseline findings in a qualitative study of pathways of health knowledge in three Indigenous communities in Canada.
      ,
      • McNamarra B.J.
      • Sanson-Fisher R.
      • D'Este C.
      • Eades S.
      Type 2 diabetes in Indigenous populations: Quality of intervention research over 20 years.
      ).

       Aims and objectives

      The objective of this study was to report the results of a systematic review of interventions that have focused on improving the screening, treatment, prevention and management of type 2 diabetes and obesity-related chronic disease in Indigenous communities in Canada between 2008 and 2014, with the aim of identifying current best practices. The review was carried out as a preliminary component of a study funded by the Canadian Institutes of Health Research to inform the design and the delivery and testing of a multisite intervention to be implemented in multiple Indigenous communities across Canada. The objective of the intervention is to develop an effective diabetes-care model that integrates with and extends existing diabetes prevention and treatment efforts in these communities by supporting their own efforts toward improvement in the delivery of care and in community programming.
      This review was deemed necessary because of previous calls for evidence-based programs aimed at reducing type 2 diabetes in Indigenous communities (
      • Smylie J.
      • Kaplan-Myrth N.
      • McShane K.
      Metis Nation of Ontario-Ottawa Council, Pikwakanagan First Nation, Tungasuvvingat Inuit Family Resource Centre
      Indigenous knowledge translation: Baseline findings in a qualitative study of pathways of health knowledge in three Indigenous communities in Canada.
      ,
      • McNamarra B.J.
      • Sanson-Fisher R.
      • D'Este C.
      • Eades S.
      Type 2 diabetes in Indigenous populations: Quality of intervention research over 20 years.
      ,
      • Saini M.
      • Quinn A.
      A systematic review of randomized controlled trials of health related issues within an Aboriginal context.
      ,
      • Edwards K.
      • Patchell B.
      State of the cience: A cultural view of Native Americans and diabetes prevention.
      ) and the paucity of formally evaluated, effective interventions that have aimed at improving screening, treatment, prevention and management of type 2 diabetes and obesity-related chronic disease in these communities, both in Canada and internationally. Indeed, a 2013 global systematic review of all randomized controlled trials (RCTs) carried out in Indigenous communities between 2000 and 2010 found only 22 studies that met their inclusion criteria, 6 of which were conducted in Canada (
      • Saini M.
      • Quinn A.
      A systematic review of randomized controlled trials of health related issues within an Aboriginal context.
      ). These low numbers represent a modest increase from the 13 studies that Morris (1999) found in his systematic review of RCT studies of Indigenous peoples between 1999 and the early 1970s, none of which were conducted Canada (
      • Morris P.S.
      Randomized control trials addressing Australian Aboriginal health needs: A systematic review of the literature.
      ).
      Canadian studies have also been included in a multicountry systematic review of type 2 diabetes interventions in Indigenous populations (
      • McNamarra B.J.
      • Sanson-Fisher R.
      • D'Este C.
      • Eades S.
      Type 2 diabetes in Indigenous populations: Quality of intervention research over 20 years.
      ) and in a systematic review of physical-activity interventions focused on Indigenous communities in the United States and Canada (
      • Teufel-Shone N.I.
      • Fitzgerald C.
      • Teufel-Shone L.
      • Gamber M.
      Systematic review of physical activity interventions implemented with American Indian and Alaska Native populations in the United States and Canada.
      ). McNamara and colleagues (
      • McNamarra B.J.
      • Sanson-Fisher R.
      • D'Este C.
      • Eades S.
      Type 2 diabetes in Indigenous populations: Quality of intervention research over 20 years.
      ) identified only 5 Canadian studies in their 20-year (1988–2008) review and report substantial limitations to the rigour of nearly all of the studies included in their review. Indeed, the limited quantity of useful material led the authors to conclude that “we have found an urgent need to increase the amount of high-quality intervention research in this field, which is currently at low levels” (
      • Joseph P.
      • Davis A.D.
      • Miller R.
      • et al.
      Contextual determinants of health behaviours in an aboriginal community in Canada: Pilot project.
      [pg. 7]). Furthermore, in their systematic review of physical-activity interventions, which spanned 1986 to 2006, Teufel-Shone and coauthors (
      • Teufel-Shone N.I.
      • Fitzgerald C.
      • Teufel-Shone L.
      • Gamber M.
      Systematic review of physical activity interventions implemented with American Indian and Alaska Native populations in the United States and Canada.
      ) identified very few Canadian studies and found that the majority of relevant interventions published during that period were implemented in the American Southwest. Finally, the authors of a 2010 multicountry review of successful cardiovascular health programs in Indigenous communities note that in the Canadian context they were “unable to find any cardiovascular treatment programs focused exclusively on the First Nations populations” (
      • Huffman M.D.
      • Galloway J.M.
      Cardiovascular health in Indigenous communities: Successful programs.
      [pg. 354]). Given the very limited available material with which to establish best practices for diabetes and obesity-related chronic disease in Indigenous communities in Canada prior to 2008, we focused our search on identifying recent Canadian material.

      Methods

      We carried out a comprehensive literature review of online databases to identify relevant Canadian intervention studies published between January 1, 2008, and December 31, 2014. We did not include studies that were published prior to 2008 because they have already been identified by McNamara and colleagues (
      • McNamarra B.J.
      • Sanson-Fisher R.
      • D'Este C.
      • Eades S.
      Type 2 diabetes in Indigenous populations: Quality of intervention research over 20 years.
      ).
      The literature review was carried out by KR using Medline, EMBASE, PubMED and Google scholar. RCTs were sought initially because they are widely considered to be the gold standard for evaluating the efficacy and effectiveness of health interventions (
      • Evans D.
      Hierarchy of evidence: A framework for ranking evidence evaluating healthcare interventions.
      ). However, the extremely low volume of articles necessitated a broadened review that included all studies with quantitative evaluative components, irrespective of the design. To be included in our review, interventions had to fulfill the following criteria: 1) have a baseline for comparison; 2) have incorporated an intervention aimed at reducing the incidence of diabetes, reducing rates of obesity and/or body mass index (BMI), improving blood sugar or blood pressure, or increasing physical activity or knowledge about fitness and/or healthful eating habits, or some combination of these; and 3) have evaluated the efficacy of that intervention. It was not necessary for there to be a control group, although particular effort was made to identify all controlled trials that fulfilled our selection criteria. Search terms were combined using and, and they included First Nations, Aboriginal, Indigenous, intervention, evaluation, prevention, Métis, Inuit, Inuvialuit, diabetes, hypertension, high blood pressure, chronic disease, chronic condition, obesity, diet, fitness, physical activity, best practice and randomized controlled trial. Initial citations were selected by title and abstract and were then reviewed by KR to ensure that they met our inclusion criteria.
      After identifying suitable studies, we systematically extracted data. These data included the goal of the study, the location of the intervention, information about the research participants, the duration of the intervention, the measured outcomes, the results of the evaluation and the limitations of the study (see Appendix 1).
      The literature we identified through our review was supplemented by a scoping review of wider literature relevant to best practices for diabetes and obesity-related chronic diseases among Indigenous people. These included qualitative, quantitative and mix-methods research, and our search focused on but also extended beyond Canada. In particular, we reviewed literature concerning intervention studies on which recent Canadian interventions have been modelled, notably Pima Pride (
      • Narayan K.M.
      • Hoskin M.
      • Kozak D.
      • et al.
      Randomized clinical trial of lifestyle interventions in Pima Indians: A pilot study.
      ) Kahnawake Schools Diabetes Prevention Project (
      • Macauley A.C.
      • Cargo M.
      • Bisset S.
      • et al.
      Community empowerment of the primary prevention of type 2 diabetes: Kanien'kekha:ka (Mohawk) ways for the Kahnawake schools diabetes prevention project.
      ,
      • Paradis G.
      • Levesque L.
      • Macaulay A.C.
      • et al.
      Impact of a diabetes prevention program on body size, physical activity, and diet among Kanien'keha:ka (Mohawk) children 6 to 11 years old: 8-year results of the Kahnawake schools diabetes prevention project.
      ,
      • Macaulay A.C.
      • Paradis H.
      • Potvin L.
      • et al.
      The Kahnawake schools diabetes prevention project: Intervention, evaluation, and baseline results of a diabetes primary prevention program with a Native community in Canada.
      ,
      • Potvin K.
      • Cargo M.
      • McComber A.M.
      • et al.
      Implementing participatory intervention and research in communities: Lessons from the Kahnawake schools diabetes prevention project in Canada.
      ), Sandy Lake Schools Diabetes Prevention Program (
      • Saksvig B.I.
      • Gittelsohn J.
      • Harris S.B.
      • et al.
      A pilot school-based healthy eating and physical activity intervention improves diet, food knowledge, and self-efficacy for Native Canadian children.
      ,
      • Hanley A.J.G.
      • Harris S.B.
      • Gittelsohn J.
      • et al.
      The Sandy Lake Health and Diabetes Project: Design, methods and lessons learned.
      ), Healthy Buddies (
      • Stock S.
      • Miranda C.
      • Evans S.
      • et al.
      Healthy buddies: A novel, peer-led health promotion program for the prevention of obesity and eating disorders in children in elementary school.
      ), Pathways (
      • Davis S.M.
      • Going S.B.
      • Helitzer D.L.
      • et al.
      Pathways: A culturally appropriate obesity-prevention program for American Indian schoolchildren.
      ) and Apache Healthy Stores (
      • Curran D.
      • Gittlesohn J.
      • Anliker J.
      • et al.
      Process evaluation of a store-based environmental obesity intervention on two American Indian Reservations.
      ,
      • Gittelsohn J.
      • Anliker J.
      • Ethelbach B.
      • et al.
      A food store intervention to reduce obesity in two American Indian communities: Impact on food choices and psychosocial indicators.
      ). We also carried out scoping reviews of relevant interventions carried out in Indigenous communities in contexts similar to those of Canada. Following earlier systematic reviews (
      • McNamarra B.J.
      • Sanson-Fisher R.
      • D'Este C.
      • Eades S.
      Type 2 diabetes in Indigenous populations: Quality of intervention research over 20 years.
      ,
      • Morris P.S.
      Randomized control trials addressing Australian Aboriginal health needs: A systematic review of the literature.
      ), we determined similar context to mean Native American, Native Hawaiian and American Samoan, Australian Aborigine and Torres Strait Islander, and Maori. Finally, although no exclusively qualitative studies met our inclusion criteria, we reviewed a large body of qualitative literature discussing best practices for healthcare provision, treatment and prevention in Indigenous communities in Canada. Several of the interventions included in our study involved interview components or ethnographic research as a component of the preliminary development of the intervention. This wider review was carried out in order to gain a more fulsome understanding of the body of knowledge upon which the reviewed interventions were designed and to better contextualize the limitations of and challenges incumbent on the reviewed interventions.

      Results

      We found very few recent evaluative studies of Canadian diabetes and chronic disease interventions. Our search produced a total of 17 publications that fit our inclusion criteria. These comprised 13 unique evaluated interventions; 4 interventions were discussed in multiple publications.

       Participant population

      Of the 13 interventions that met our review criteria, 7 were school-based programs that focused on children (
      • Eskicioglu P.
      • Halas J.
      • Sénéchal M.
      • et al.
      Peer mentoring for type 2 diabetes prevention in First Nations children.
      ,
      • Eskicioglu P.
      • Halas J.
      • Villeneuve S.
      • et al.
      The Aboriginal Youth Mentorship Program (AYMP): A peer-led healthy living after-school program for achieving healthy weights in First Nations children living in a northern remote setting.
      ,
      • Gates M.
      • Hanning R.M.
      • Gates A.
      • et al.
      A pilot comprehensive school nutrition program improves knowledge and intentions for intake of milk and milk alternatives among youth in a remote first nation.
      ,
      • Gates M.
      • Hanning R.M.
      • Gates A.
      • et al.
      Assessing the impact of pilot school snack programs on milk and alternatives intake in Northern Ontario, Canada.
      ,
      • Kakekagumick K.A.
      • Naqshbandi Hayward M.
      • Harris S.B.
      • et al.
      Sandy lake health and diabetes project: A community-based intervention targeting type 2 diabetes and its risk factors in a First Nations community.
      ,
      • Ronsley R.
      • Lee A.S.
      • Kuzeljevic B.
      • Panagiotopoulous C.
      Healthy buddies reduced body mass index score and waist circumference in aboriginal children living in remote coast communities.
      ,
      • Tomlin D.
      • Naylor P.J.
      • McKay H.
      • et al.
      The impact of action schools! BC on the health of Aboriginal children and youth living in rural and remote communities in British Columbia.
      ,
      • Naylor P.J.
      • Scott J.
      • Drummond J.
      • Panagiotopoulos C.
      Implementing a whole-school physical activity and healthy eating model in rural and remote first nations schools: A process evaluation of action schools! BC.
      ,
      • Toth E.
      Early trend towards improving fitness amongst children: A final project report to the Alberta Centre for Child, Family, and Community Research.
      ). Some of these studies had components aimed at the wider community (for instance, community walking trails, newsletters sent home to caregivers), but all 7 focused exclusively on children when measuring the success of their interventions. Another study included both children and adults (
      • Oster R.T.
      • Shade S.
      • Strong D.
      • Toth E.L.
      Improvements in indicators of diabetes-related health among first nations individuals enrolled in a community-driven diabetes complications mobile screening program in Alberta, Canada.
      ) (Oster et al, 2010), and the remaining 5 interventions (
      • Dreger L.C.
      • Mackenzie C.
      • McLoed B.
      Feasibility of a mindfulness-based intervention for Aboriginal adults with type 2 diabetes.
      ,
      • Foulds H.J.A.
      • Bredin S.S.D.
      • Warburton D.E.R.
      The effectiveness of community-based physical activity interventions with Aboriginal peoples.
      ,
      • Ho L.A.
      • Gittelsohn J.
      • Rimal R.
      • et al.
      An integrated multi-institutional diabetes prevention program improves knowledge and healthy food acquisition in Northwestern Ontario first nations.
      ,
      • Rosecrans A.M.
      • Gittelsohn K.
      • Ho L.S.
      • et al.
      Process evaluation of a multi-institutional community-based program for diabetes prevention among first nations.
      ,
      • Mead E.L.
      • Gittelsohn J.
      • Roache C.
      • et al.
      A community-based, environmental chronic disease prevention intervention to improve healthy eating psychosocial factors and the behaviors in indigenous populations in the Canadian arctic.
      ,
      • Sharma A.
      • Gittelsohn J.
      • Rosol R.
      • Beck L.
      Addressing the public health burden caused by the nutrition transition through the healthy foods north nutrition and lifestyle intervention program.
      ,
      • Tobe S.
      • Vincent L.
      • Wentworth J.
      • et al.
      Blood pressure 2 years after a chronic disease management intervention study.
      ) targeted adults exclusively.
      Of the studies, 2 (
      • Dreger L.C.
      • Mackenzie C.
      • McLoed B.
      Feasibility of a mindfulness-based intervention for Aboriginal adults with type 2 diabetes.
      ,
      • Foulds H.J.A.
      • Bredin S.S.D.
      • Warburton D.E.R.
      The effectiveness of community-based physical activity interventions with Aboriginal peoples.
      ) included both urban and rural communities, whereas the remaining interventions focused on rural and remote communities in all provinces and territories except the Yukon, New Brunswick, Prince Edward Island, Newfoundland and Labrador, Quebec and Nova Scotia. Three interventions (
      • Toth E.
      Early trend towards improving fitness amongst children: A final project report to the Alberta Centre for Child, Family, and Community Research.
      ,
      • Oster R.T.
      • Shade S.
      • Strong D.
      • Toth E.L.
      Improvements in indicators of diabetes-related health among first nations individuals enrolled in a community-driven diabetes complications mobile screening program in Alberta, Canada.
      ,
      • Dreger L.C.
      • Mackenzie C.
      • McLoed B.
      Feasibility of a mindfulness-based intervention for Aboriginal adults with type 2 diabetes.
      ) included First Nations participants both on and off reserve. Of the 13 interventions, 7 were implemented exclusively on reserve; 2 interventions (
      • Tomlin D.
      • Naylor P.J.
      • McKay H.
      • et al.
      The impact of action schools! BC on the health of Aboriginal children and youth living in rural and remote communities in British Columbia.
      ,
      • Ho L.A.
      • Gittelsohn J.
      • Rimal R.
      • et al.
      An integrated multi-institutional diabetes prevention program improves knowledge and healthy food acquisition in Northwestern Ontario first nations.
      ,
      • Rosecrans A.M.
      • Gittelsohn K.
      • Ho L.S.
      • et al.
      Process evaluation of a multi-institutional community-based program for diabetes prevention among first nations.
      ) were implemented in remote or semiremote regions, but it is unclear whether the First Nations participants resided on reserve, off reserve or some combination of both. Mead, Sharma and colleagues (
      • Mead E.L.
      • Gittelsohn J.
      • Roache C.
      • et al.
      A community-based, environmental chronic disease prevention intervention to improve healthy eating psychosocial factors and the behaviors in indigenous populations in the Canadian arctic.
      ,
      • Sharma A.
      • Gittelsohn J.
      • Rosol R.
      • Beck L.
      Addressing the public health burden caused by the nutrition transition through the healthy foods north nutrition and lifestyle intervention program.
      ) conducted the only intervention focused on Inuit communities.

       Outcome measures

      All studies but 1 used BMI and waist circumference as outcome measures. Of these 12 studies, only 5 studies (
      • Eskicioglu P.
      • Halas J.
      • Sénéchal M.
      • et al.
      Peer mentoring for type 2 diabetes prevention in First Nations children.
      ,
      • Eskicioglu P.
      • Halas J.
      • Villeneuve S.
      • et al.
      The Aboriginal Youth Mentorship Program (AYMP): A peer-led healthy living after-school program for achieving healthy weights in First Nations children living in a northern remote setting.
      ,
      • Ronsley R.
      • Lee A.S.
      • Kuzeljevic B.
      • Panagiotopoulous C.
      Healthy buddies reduced body mass index score and waist circumference in aboriginal children living in remote coast communities.
      ,
      • Oster R.T.
      • Shade S.
      • Strong D.
      • Toth E.L.
      Improvements in indicators of diabetes-related health among first nations individuals enrolled in a community-driven diabetes complications mobile screening program in Alberta, Canada.
      ,
      • Foulds H.J.A.
      • Bredin S.S.D.
      • Warburton D.E.R.
      The effectiveness of community-based physical activity interventions with Aboriginal peoples.
      ) reported reduced waist circumference, and only 4 (
      • Eskicioglu P.
      • Halas J.
      • Sénéchal M.
      • et al.
      Peer mentoring for type 2 diabetes prevention in First Nations children.
      ,
      • Eskicioglu P.
      • Halas J.
      • Villeneuve S.
      • et al.
      The Aboriginal Youth Mentorship Program (AYMP): A peer-led healthy living after-school program for achieving healthy weights in First Nations children living in a northern remote setting.
      ,
      • Ronsley R.
      • Lee A.S.
      • Kuzeljevic B.
      • Panagiotopoulous C.
      Healthy buddies reduced body mass index score and waist circumference in aboriginal children living in remote coast communities.
      ,
      • Oster R.T.
      • Shade S.
      • Strong D.
      • Toth E.L.
      Improvements in indicators of diabetes-related health among first nations individuals enrolled in a community-driven diabetes complications mobile screening program in Alberta, Canada.
      ) reported lowered BMIs. Five studies also measured blood pressure pre- and postintervention. Foulds and colleagues (
      • Foulds H.J.A.
      • Bredin S.S.D.
      • Warburton D.E.R.
      The effectiveness of community-based physical activity interventions with Aboriginal peoples.
      ), whose intervention was a walking and running fitness program, reported significant improvements for participants who had high blood pressure at baseline. Ronsely et al (
      • Ronsley R.
      • Lee A.S.
      • Kuzeljevic B.
      • Panagiotopoulous C.
      Healthy buddies reduced body mass index score and waist circumference in aboriginal children living in remote coast communities.
      ) recorded a modest 3% drop in blood pressure postintervention, alongside a 15% increase in high blood pressure in their control group. Tobe et al (
      • Tobe S.
      • Vincent L.
      • Wentworth J.
      • et al.
      Blood pressure 2 years after a chronic disease management intervention study.
      ) and Oster et al (
      • Oster R.T.
      • Shade S.
      • Strong D.
      • Toth E.L.
      Improvements in indicators of diabetes-related health among first nations individuals enrolled in a community-driven diabetes complications mobile screening program in Alberta, Canada.
      ) reported improvements in blood pressure. Toth (
      • Toth E.
      Early trend towards improving fitness amongst children: A final project report to the Alberta Centre for Child, Family, and Community Research.
      ) reported no improvement in blood pressure. Three studies (
      • Oster R.T.
      • Shade S.
      • Strong D.
      • Toth E.L.
      Improvements in indicators of diabetes-related health among first nations individuals enrolled in a community-driven diabetes complications mobile screening program in Alberta, Canada.
      ,
      • Dreger L.C.
      • Mackenzie C.
      • McLoed B.
      Feasibility of a mindfulness-based intervention for Aboriginal adults with type 2 diabetes.
      ,
      • Foulds H.J.A.
      • Bredin S.S.D.
      • Warburton D.E.R.
      The effectiveness of community-based physical activity interventions with Aboriginal peoples.
      ) measured cholesterol. Oster found improved cholesterol postintervention, while Foulds (
      • Foulds H.J.A.
      • Bredin S.S.D.
      • Warburton D.E.R.
      The effectiveness of community-based physical activity interventions with Aboriginal peoples.
      ) reported improved cholesterol only among female participants. Only Dredger et al (
      • Dreger L.C.
      • Mackenzie C.
      • McLoed B.
      Feasibility of a mindfulness-based intervention for Aboriginal adults with type 2 diabetes.
      ) measured blood glucose levels and reported significant reductions postintervention.
      Seven studies measured change in knowledge about healthful eating and/or active lifestyles (
      • Eskicioglu P.
      • Halas J.
      • Sénéchal M.
      • et al.
      Peer mentoring for type 2 diabetes prevention in First Nations children.
      ,
      • Eskicioglu P.
      • Halas J.
      • Villeneuve S.
      • et al.
      The Aboriginal Youth Mentorship Program (AYMP): A peer-led healthy living after-school program for achieving healthy weights in First Nations children living in a northern remote setting.
      ,
      • Gates M.
      • Hanning R.M.
      • Gates A.
      • et al.
      A pilot comprehensive school nutrition program improves knowledge and intentions for intake of milk and milk alternatives among youth in a remote first nation.
      ,
      • Gates M.
      • Hanning R.M.
      • Gates A.
      • et al.
      Assessing the impact of pilot school snack programs on milk and alternatives intake in Northern Ontario, Canada.
      ,
      • Kakekagumick K.A.
      • Naqshbandi Hayward M.
      • Harris S.B.
      • et al.
      Sandy lake health and diabetes project: A community-based intervention targeting type 2 diabetes and its risk factors in a First Nations community.
      ,
      • Mead E.L.
      • Gittelsohn J.
      • Roache C.
      • et al.
      A community-based, environmental chronic disease prevention intervention to improve healthy eating psychosocial factors and the behaviors in indigenous populations in the Canadian arctic.
      ,
      • Sharma A.
      • Gittelsohn J.
      • Rosol R.
      • Beck L.
      Addressing the public health burden caused by the nutrition transition through the healthy foods north nutrition and lifestyle intervention program.
      ), and all of them reported increased knowledge about healthful behaviours postintervention. However, authors concede that increased knowledge alone is of little use, especially if the target populations are children (who may have little control over the food they eat), or if healthful foods and safe areas for exercise are difficult to access. Moreover, moving knowledge into action may be a challenge for participants confronted on a daily basis with poverty (
      • McGibbons E.A.
      Oppression: A social determinant of health.
      ). The limited impact of this increased knowledge is evident in that although 6 interventions reported increased knowledge of healthful behaviours, only 3 (
      • Kakekagumick K.A.
      • Naqshbandi Hayward M.
      • Harris S.B.
      • et al.
      Sandy lake health and diabetes project: A community-based intervention targeting type 2 diabetes and its risk factors in a First Nations community.
      ,
      • Ho L.A.
      • Gittelsohn J.
      • Rimal R.
      • et al.
      An integrated multi-institutional diabetes prevention program improves knowledge and healthy food acquisition in Northwestern Ontario first nations.
      ,
      • Rosecrans A.M.
      • Gittelsohn K.
      • Ho L.S.
      • et al.
      Process evaluation of a multi-institutional community-based program for diabetes prevention among first nations.
      ) reported an actual increase in healthful behaviours. An example of such behaviour includes participants actively buying and cooking more foods that are low in fat and sugar.
      Of the 6 interventions that measured change in knowledge of healthy eating and lifestyle, 4 also measured self-efficacy (
      • Rimal R.N.
      Closing the knowledge-behaviour gap in health promotion: The mediating role of self-efficacy.
      ). In the context of these intervention studies, self-efficacy means participants' confidence in their ability to actually use their increased knowledge to live a healthier lifestyle in the future. Of the 4 interventions that measured self-efficacy, 1 found no change (
      • Gates M.
      • Hanning R.M.
      • Gates A.
      • et al.
      A pilot comprehensive school nutrition program improves knowledge and intentions for intake of milk and milk alternatives among youth in a remote first nation.
      ), and 3 (
      • Ho L.A.
      • Gittelsohn J.
      • Rimal R.
      • et al.
      An integrated multi-institutional diabetes prevention program improves knowledge and healthy food acquisition in Northwestern Ontario first nations.
      ,
      • Rosecrans A.M.
      • Gittelsohn K.
      • Ho L.S.
      • et al.
      Process evaluation of a multi-institutional community-based program for diabetes prevention among first nations.
      ,
      • Mead E.L.
      • Gittelsohn J.
      • Roache C.
      • et al.
      A community-based, environmental chronic disease prevention intervention to improve healthy eating psychosocial factors and the behaviors in indigenous populations in the Canadian arctic.
      ) found increased self-efficacy but also found that increased knowledge and self-efficacy did not lead to healthier behaviour. The 1 exception is Eskicioglu et al (
      • Eskicioglu P.
      • Halas J.
      • Sénéchal M.
      • et al.
      Peer mentoring for type 2 diabetes prevention in First Nations children.
      ), who report that increased self-efficacy was the best predictor of reduced waist circumference postintervention.
      The weakest area of outcome concerns increasing physical activity and fitness. Eleven studies (
      • Eskicioglu P.
      • Halas J.
      • Sénéchal M.
      • et al.
      Peer mentoring for type 2 diabetes prevention in First Nations children.
      ,
      • Eskicioglu P.
      • Halas J.
      • Villeneuve S.
      • et al.
      The Aboriginal Youth Mentorship Program (AYMP): A peer-led healthy living after-school program for achieving healthy weights in First Nations children living in a northern remote setting.
      ,
      • Kakekagumick K.A.
      • Naqshbandi Hayward M.
      • Harris S.B.
      • et al.
      Sandy lake health and diabetes project: A community-based intervention targeting type 2 diabetes and its risk factors in a First Nations community.
      ,
      • Ronsley R.
      • Lee A.S.
      • Kuzeljevic B.
      • Panagiotopoulous C.
      Healthy buddies reduced body mass index score and waist circumference in aboriginal children living in remote coast communities.
      ,
      • Tomlin D.
      • Naylor P.J.
      • McKay H.
      • et al.
      The impact of action schools! BC on the health of Aboriginal children and youth living in rural and remote communities in British Columbia.
      ,
      • Naylor P.J.
      • Scott J.
      • Drummond J.
      • Panagiotopoulos C.
      Implementing a whole-school physical activity and healthy eating model in rural and remote first nations schools: A process evaluation of action schools! BC.
      ,
      • Toth E.
      Early trend towards improving fitness amongst children: A final project report to the Alberta Centre for Child, Family, and Community Research.
      ,
      • Foulds H.J.A.
      • Bredin S.S.D.
      • Warburton D.E.R.
      The effectiveness of community-based physical activity interventions with Aboriginal peoples.
      ,
      • Ho L.A.
      • Gittelsohn J.
      • Rimal R.
      • et al.
      An integrated multi-institutional diabetes prevention program improves knowledge and healthy food acquisition in Northwestern Ontario first nations.
      ,
      • Mead E.L.
      • Gittelsohn J.
      • Roache C.
      • et al.
      A community-based, environmental chronic disease prevention intervention to improve healthy eating psychosocial factors and the behaviors in indigenous populations in the Canadian arctic.
      ,
      • Sharma A.
      • Gittelsohn J.
      • Rosol R.
      • Beck L.
      Addressing the public health burden caused by the nutrition transition through the healthy foods north nutrition and lifestyle intervention program.
      ) included physical activity components, yet only 3 studies (
      • Tomlin D.
      • Naylor P.J.
      • McKay H.
      • et al.
      The impact of action schools! BC on the health of Aboriginal children and youth living in rural and remote communities in British Columbia.
      ,
      • Toth E.
      Early trend towards improving fitness amongst children: A final project report to the Alberta Centre for Child, Family, and Community Research.
      ,
      • Foulds H.J.A.
      • Bredin S.S.D.
      • Warburton D.E.R.
      The effectiveness of community-based physical activity interventions with Aboriginal peoples.
      ) reported increases in either physical activity or fitness (measured as VO2max), while 2 studies reported decreases in physical activity following the intervention (
      • Toth E.
      Early trend towards improving fitness amongst children: A final project report to the Alberta Centre for Child, Family, and Community Research.
      ,
      • Ho L.A.
      • Gittelsohn J.
      • Rimal R.
      • et al.
      An integrated multi-institutional diabetes prevention program improves knowledge and healthy food acquisition in Northwestern Ontario first nations.
      ). Moreover, although Toth (
      • Toth E.
      Early trend towards improving fitness amongst children: A final project report to the Alberta Centre for Child, Family, and Community Research.
      ) found an increase in physical activity postintervention, the author acknowledges that a new physical activity program was launched in the local school concurrent with her intervention, and that the improvements in fitness were likely the result of this new curriculum rather than the intervention. Her results are also somewhat contradictory in that she found increased fitness but decreased physical activity. It appears that prioritizing fitness and physical activity in the intervention was important for success; of the 2 interventions that made improvements in activity and fitness, 1 study (
      • Foulds H.J.A.
      • Bredin S.S.D.
      • Warburton D.E.R.
      The effectiveness of community-based physical activity interventions with Aboriginal peoples.
      ) focused on them exclusively, and the others (
      • Tomlin D.
      • Naylor P.J.
      • McKay H.
      • et al.
      The impact of action schools! BC on the health of Aboriginal children and youth living in rural and remote communities in British Columbia.
      ,
      • Naylor P.J.
      • Scott J.
      • Drummond J.
      • Panagiotopoulos C.
      Implementing a whole-school physical activity and healthy eating model in rural and remote first nations schools: A process evaluation of action schools! BC.
      ) placed heavy emphasis on them in their school-based program.
      Seven interventions drew on participatory-action research methods, meaning that the interventions themselves were designed, implemented and evaluated as coconstructed projects between researchers and the community partners (
      • Jagosh J.
      • Maccaulay A.C.
      • Pluye P.
      • et al.
      Uncovering the benefits of participatory research: Implications of a realist review for health research and practice.
      ). Moreover, all interventions that met with even moderate success employed community-engagement strategies (
      • Cargo M.
      • Mercer S.L.
      The value and challenge of participatory research: Strengthening its practice.
      ). Most authors reported that long-term engagement and established relationships with communities were essential for the success of their interventions.
      Only 4 studies included a control group (
      • Eskicioglu P.
      • Halas J.
      • Sénéchal M.
      • et al.
      Peer mentoring for type 2 diabetes prevention in First Nations children.
      ,
      • Eskicioglu P.
      • Halas J.
      • Villeneuve S.
      • et al.
      The Aboriginal Youth Mentorship Program (AYMP): A peer-led healthy living after-school program for achieving healthy weights in First Nations children living in a northern remote setting.
      ,
      • Ronsley R.
      • Lee A.S.
      • Kuzeljevic B.
      • Panagiotopoulous C.
      Healthy buddies reduced body mass index score and waist circumference in aboriginal children living in remote coast communities.
      ,
      • Tobe S.
      • Vincent L.
      • Wentworth J.
      • et al.
      Blood pressure 2 years after a chronic disease management intervention study.
      ). Most of the interventions lasted less than 1 year, and in 1 case, evaluation of the intervention began only 1 week after implementation (
      • Gates M.
      • Hanning R.M.
      • Gates A.
      • et al.
      Assessing the impact of pilot school snack programs on milk and alternatives intake in Northern Ontario, Canada.
      ). Four studies were limited by small sample size (
      • Gates M.
      • Hanning R.M.
      • Gates A.
      • et al.
      A pilot comprehensive school nutrition program improves knowledge and intentions for intake of milk and milk alternatives among youth in a remote first nation.
      ,
      • Gates M.
      • Hanning R.M.
      • Gates A.
      • et al.
      Assessing the impact of pilot school snack programs on milk and alternatives intake in Northern Ontario, Canada.
      ,
      • Toth E.
      Early trend towards improving fitness amongst children: A final project report to the Alberta Centre for Child, Family, and Community Research.
      ,
      • Dreger L.C.
      • Mackenzie C.
      • McLoed B.
      Feasibility of a mindfulness-based intervention for Aboriginal adults with type 2 diabetes.
      ).

      Discussion

      Given the widespread acknowledgment of the health disparities between Indigenous people and the wider Canadian populace, it is both surprising and disappointing that we found only 13 studied interventions that met our inclusion criteria. However, this small number is larger than the number found in previous reviews—which spanned much longer time periods—indicating a likely rise in the number of intervention studies conducted in Indigenous communities. The existence of 13 interventions indicates, nevertheless, a very small number of interventions, suggesting that Indigenous health is a low priority in the context of current research and policy.
      In terms of improved outcomes, the interventions in our review that met with the most success were those that collaborated closely with local communities at all stages of the research process and drew on local human resources as key actors in their interventions. For example, Foulds and coauthors (
      • Foulds H.J.A.
      • Bredin S.S.D.
      • Warburton D.E.R.
      The effectiveness of community-based physical activity interventions with Aboriginal peoples.
      ) trained and then employed members of local First Nations communities as fitness trainers, while Ronsley et al (
      • Ronsley R.
      • Lee A.S.
      • Kuzeljevic B.
      • Panagiotopoulous C.
      Healthy buddies reduced body mass index score and waist circumference in aboriginal children living in remote coast communities.
      ) and Eskicioglu et al (
      • Eskicioglu P.
      • Halas J.
      • Sénéchal M.
      • et al.
      Peer mentoring for type 2 diabetes prevention in First Nations children.
      ,
      • Eskicioglu P.
      • Halas J.
      • Villeneuve S.
      • et al.
      The Aboriginal Youth Mentorship Program (AYMP): A peer-led healthy living after-school program for achieving healthy weights in First Nations children living in a northern remote setting.
      ) attribute much of their program's success to expressed desire for a diabetes-focused intervention on the part of the communities they worked with and to a mentorship/buddy system among local children and youth.
      The number of interventions targeting school children is of interest. It may occur because children are seen as valuable foci for intervention research because their participation in a study is more easily achieved in a school-based intervention. The success of several studies included in our review (
      • Ronsley R.
      • Lee A.S.
      • Kuzeljevic B.
      • Panagiotopoulous C.
      Healthy buddies reduced body mass index score and waist circumference in aboriginal children living in remote coast communities.
      ,
      • Tomlin D.
      • Naylor P.J.
      • McKay H.
      • et al.
      The impact of action schools! BC on the health of Aboriginal children and youth living in rural and remote communities in British Columbia.
      ,
      • Naylor P.J.
      • Scott J.
      • Drummond J.
      • Panagiotopoulos C.
      Implementing a whole-school physical activity and healthy eating model in rural and remote first nations schools: A process evaluation of action schools! BC.
      ), notably the effective Healthy Buddies First Nations and the Aboriginal Youth Mentorship Program, add further evidence to indicate the potential of child-focused school-based interventions. Importantly, the most effective school-based interventions (
      • Eskicioglu P.
      • Halas J.
      • Sénéchal M.
      • et al.
      Peer mentoring for type 2 diabetes prevention in First Nations children.
      ,
      • Eskicioglu P.
      • Halas J.
      • Villeneuve S.
      • et al.
      The Aboriginal Youth Mentorship Program (AYMP): A peer-led healthy living after-school program for achieving healthy weights in First Nations children living in a northern remote setting.
      ,
      • Ronsley R.
      • Lee A.S.
      • Kuzeljevic B.
      • Panagiotopoulous C.
      Healthy buddies reduced body mass index score and waist circumference in aboriginal children living in remote coast communities.
      ) involved peer-mentoring, a strategy not reflected in earlier school-based interventions. The success of the interventions that used peer mentorship as a pedagogic strategy suggests that this may be a best practice for future intervention research focusing on Indigenous children.
      A number of studies had control arms that received the intervention at staggered times, but the search identified only 1 randomized controlled trial (DREAM3) (
      • Tobe S.
      • Vincent L.
      • Wentworth J.
      • et al.
      Blood pressure 2 years after a chronic disease management intervention study.
      ). Ronsley et al (
      • Ronsley R.
      • Lee A.S.
      • Kuzeljevic B.
      • Panagiotopoulous C.
      Healthy buddies reduced body mass index score and waist circumference in aboriginal children living in remote coast communities.
      ) state that an RCT would not have been acceptable to the community because of the longstanding relationship that had been established between the researchers and the community. However, although an RCT was evidently unacceptable in the case of Ronsley et al, RCTs may be appropriate in some contexts. As Saini and Quinn (
      • Saini M.
      • Quinn A.
      A systematic review of randomized controlled trials of health related issues within an Aboriginal context.
      ) note in a systematic review of RCTs in Indigenous contexts, “not including these communities in effectiveness-based interventions to assess health outcomes limits the transferability of knowledge gained from these studies and further marginalizes Aboriginal communities from the knowledge regarding the benefits and limitations of health-based interventions” (pg. 7). Indeed, the authors of several interventions included in our review indicated that they hoped to implement modified versions of their interventions as RCTs in the future. Furthermore, BRAID (Believing we can Reduce Aboriginal Incidence of Diabetes)-Kids (
      • Toth E.
      Early trend towards improving fitness amongst children: A final project report to the Alberta Centre for Child, Family, and Community Research.
      ) was originally designed as an RCT, but this never materialized. Nevertheless, Toth reports that the community members were open to the idea of an RCT because they understood that an RCT would offer the best means of identifying whether the outcomes measured were indeed results of the intervention. Rather, the failure to develop an RCT, and the overall limited success of the intervention in its final form, was attributed to barriers such as high turnover of necessary staff in local schools and other crises in the community. As Toth found with BRAID-Kids, conventional research methodologies such as RCTs may be ill-equipped to cope with the larger context of marginalization and oppression that Indigenous communities continue to confront. Although excluding Indigenous communities from effectiveness-based interventions serves to perpetuate their marginalization, addressing the larger forces of oppression is a prior imperative.
      Interventions, such as BRAID-Kids, indicate that evaluative health interventions, including RCTs, encounter particular problems in many Indigenous communities. As Toth notes, multiple complex social problems and more immediate needs in many Indigenous communities mean limited local energies can be devoted to interventions, so spending these energies in evaluation may detract from the success of the programs. Moreover, Ronsley et al (
      • Ronsley R.
      • Lee A.S.
      • Kuzeljevic B.
      • Panagiotopoulous C.
      Healthy buddies reduced body mass index score and waist circumference in aboriginal children living in remote coast communities.
      ) note that they were able to implement their intervention only due to a longstanding relationship with the 3 intervention communities and that it would not have been possible to appoint 1 of these communities as a control group because they all wanted to benefit from the intervention. This is a difficult balance because evaluation is generally perceived as a way to increase the chances of scale-up and sustained resource inputs from political decision makers. Mead et al (
      • Mead E.L.
      • Gittelsohn J.
      • Roache C.
      • et al.
      A community-based, environmental chronic disease prevention intervention to improve healthy eating psychosocial factors and the behaviors in indigenous populations in the Canadian arctic.
      ) struggled with high staff turnover in the remote northern communities in which they implemented Healthy Foods North and with logistic barriers to stocking the local store with healthful food. Staff turnover was also a challenge for Naylor et al (
      • Naylor P.J.
      • Scott J.
      • Drummond J.
      • Panagiotopoulos C.
      Implementing a whole-school physical activity and healthy eating model in rural and remote first nations schools: A process evaluation of action schools! BC.
      ), whereas storage of dairy products at remote schools consisting entirely of portables was a challenge for Gates (
      • Gates M.
      • Hanning R.M.
      • Gates A.
      • et al.
      A pilot comprehensive school nutrition program improves knowledge and intentions for intake of milk and milk alternatives among youth in a remote first nation.
      ) and her colleagues.
      With the exception of Oster et al, (
      • Oster R.T.
      • Shade S.
      • Strong D.
      • Toth E.L.
      Improvements in indicators of diabetes-related health among first nations individuals enrolled in a community-driven diabetes complications mobile screening program in Alberta, Canada.
      ), all the interventions we identified made explicit reference to the historical and social context of discrimination and colonization that implicate Indigenous healthcare, and they used participatory research methodologies as part of their study designs. These included Indigenous communities as key players at all stages of the interventions, from design to evaluation. In some cases (e.g. Ronsley et al [
      • Ronsley R.
      • Lee A.S.
      • Kuzeljevic B.
      • Panagiotopoulous C.
      Healthy buddies reduced body mass index score and waist circumference in aboriginal children living in remote coast communities.
      ]), the community had themselves requested the involvement of researchers in response to a perceived local need. The studies reviewed suggest that community-based participatory research is a necessary component for effective interventions and that this is now standard practice for intervention studies of diabetes among Indigenous peoples. Nevertheless, in focusing on evaluated interventions, our inclusion criteria may have failed to capture some important non-evaluated interventions. Our findings indicate that more interventions focused on achieving dietary changes as opposed to physical activity and fitness. The majority of the interventions have focused on improving diet through greater knowledge about healthful eating and, to a lesser extent, by augmenting the availability of healthful foods. However, the few studies that improved physical activity and fitness were among those with the most significant improvements in health postintervention (
      • Ronsley R.
      • Lee A.S.
      • Kuzeljevic B.
      • Panagiotopoulous C.
      Healthy buddies reduced body mass index score and waist circumference in aboriginal children living in remote coast communities.
      ,
      • Tomlin D.
      • Naylor P.J.
      • McKay H.
      • et al.
      The impact of action schools! BC on the health of Aboriginal children and youth living in rural and remote communities in British Columbia.
      ,
      • Naylor P.J.
      • Scott J.
      • Drummond J.
      • Panagiotopoulos C.
      Implementing a whole-school physical activity and healthy eating model in rural and remote first nations schools: A process evaluation of action schools! BC.
      ,
      • Foulds H.J.A.
      • Bredin S.S.D.
      • Warburton D.E.R.
      The effectiveness of community-based physical activity interventions with Aboriginal peoples.
      ). Moreover, the only intervention (
      • Foulds H.J.A.
      • Bredin S.S.D.
      • Warburton D.E.R.
      The effectiveness of community-based physical activity interventions with Aboriginal peoples.
      ) that focused exclusively on physical activity and fitness found significant improvements in overall health for nearly all of their measured indicators, especially among participants who were in the poorest health at baseline. Although this represents only 1 intervention, the encouraging results of this physical activity-focused intervention may indicate that physical activity is a fruitful focus for future disease-focused interventions.
      The interventions reviewed suffer from a number of limitations, the most significant of which is the absence of a control group in all but 4 of the studies. Moreover, although school-based initiatives aimed at peer mentoring met with some success, focusing on changing children's eating habits does little to address the underlying issues of food access and availability in Indigenous communities, thus reflecting a very superficial and depoliticized approach to ensuring that nutritious foods are available to Indigenous children. Some of the interventions in our study were very fairly short term—in one case only 1 week long—and 4 studies were limited by small sample size. Longer-term interventions with larger cohorts of participants would better inform best practices for future interventions targeting diabetes and chronic disease among Indigenous peoples in Canada.
      Overall, the vast majority of intervention research we examined looked to change personal lifestyle choices, such as enhancing nutrition knowledge in order to enable healthful eating choices. This should continue, but we feel it was out of proportion to the need for improvements in healthcare delivery and the socially constructed determinants of health. For health research to make long-term and significant inroads into Indigenous health inequality, social inequality must also improve. This will entail accepting that colonialism, racism and social exclusion are themselves fundamental, ongoing social determinants of health. As Czyzewski (
      • Czyzweski K.
      Colonialism as a broader social determinant of health.
      ) states:Colonialism is the guiding force that manipulated the historic, political, social, and economic contexts shaping Indigenous/state/non-Indigenous relations and account for the public erasure of political and economic marginalization, and racism today. These combined components shape the health of Indigenous peoples. At the intermediate level, this occurs via the funding and organization of the health care, education, and labour systems; as well as the extent to which Indigenous peoples can operate their environmental stewardship and maintain cultural continuity. Along with these intermediate determinants, proximal determinants are also subsumed under this larger structural reality: that the root of these determinants is colonial relations; relations that have produced and reproduce unfavourable conditions and environments (p. 4).
      Thus, Indigenous health research that fails to recognize and address how these root causes shape Indigenous health will fail to achieve Indigenous health equity and may also reproduce health inequity for Indigenous peoples. Indeed, health institutions, programs or services that fail to promote Indigenous health equity may serve to perpetuate ongoing disparities between the well-being of Indigenous peoples and other Canadians, rendering them tools of oppression rather than wellness.

      Conclusion

      More diabetes intervention research in Indigenous communities is strongly recommended. We believe that the lack of research into diabetes and obesity-related chronic disease in Indigenous communities in Canada is wholly insufficient and fails to reflect the need for reducing the gross inequality that exists between Indigenous and non-Indigenous Canadians. In particular, off-reserve First Nations, Métis and Inuit communities have been overlooked in the diabetes and obesity-focused interventions we examined. Although the successes in the research that worked with children should continue, further research to improve outcomes for adults is also needed.
      We also recommend the continuation of intervention research that works with communities as equal partners who are able to take ownership by engaging in and undertaking research on their own terms. For example, we identified peer mentorship as 1 possible expression of enhanced control and ownership of health at the community level. Indigenous control and ownership must remain a priority to advance intervention research and working with communities to harness their strengths may offer additional support to overcome the challenges alluded to previously.
      The interventions included in our review focused on behavioural and lifestyle modifications. These interventions are thus insufficiently attentive to the relationship between social inequality, ongoing colonialism, social determinants of health and poor health delivery in many Indigenous communities. These areas must also be addressed in the interest of effectively addressing Indigenous health inequality. Therefore, we recommend that intervention research take an approach that is historically deep and sufficiently broad to enable the ideologic, policy and institutional changes necessary to achieve true equity.

       Limitations

      The small number of studies in our review implies that our findings and recommendations are intended to be exploratory. Given the need to improve the rates and impact of diabetes in Indigenous communities, we hope our discussion and recommendations promote conversation and engagement among health researchers and communities about how to expand and improve diabetes and chronic-disease research. Despite our use of multiple search engines, it is possible that our search terms failed to capture all studies that would have fulfilled our selection criteria. Moreover, some intervention studies may not have been published, and many community-level activities and interventions may be effective yet are never documented online. Researchers are less likely to publish studies with poor outcomes, which may suggest that interventions have achieved less than the moderate success indicated (
      • Curran D.
      • Gittlesohn J.
      • Anliker J.
      • et al.
      Process evaluation of a store-based environmental obesity intervention on two American Indian Reservations.
      ). Finally, although we have aimed to carry out this study in a manner that acknowledges and attends to the historical and contemporary context of marginalization, racism and colonialism faced by Indigenous communities, the colonial heritage of health research and practice in Canada may be impossible to entirely supersede within the confines of contemporary intervention research. We recognize that our efforts in this regard are likely incomplete.

      Author Contributions

      KR collected the data, contributed to data analysis, drafted portions of the text, revised it critically for intellectual content and gave final approval of the version to be published; BT, MZ, BL, DEB and SH contributed to data analysis, drafted portions of the text, revised it critically for intellectual content and gave final approval of the version to be published.

      Acknowledgments

      This work was supported by the Canadian Institutes of Health Research (funding reference number # MCO 117675 , # 297910 , # PME-133824 ) and by The Lawson Foundation . The FORGE Ahead Project was funded with support from AstraZeneca (Table 1).
      Table 1FORGE AHEAD Program Team
      NameInstitution/organization affiliation
      Principal investigator
      Stewart Harris, MD, MPH, FCFP, FACPMWestern University, London, ON
      Co-investigators
      Ed Barre, PhDCape Breton University, Sydney, NS
      Onil Bhattacharyya, MD, PhDWomen's College Research Institute, University of Toronto, Toronto, ON
      David Dannenbaum, MDCree Board of Health & Social Services of James Bay, Montreal, QC
      Keith Dawson, MD, PhDUniversity of British Columbia, Vancouver, BC
      Roland Dyck, MD, FRCPCUniversity of Saskatchewan, Saskatoon, SK
      Jo-Ann Episkenew, PhDUniversity of Saskatchewan, Regina, SK
      Michael Green, MD, MSc, FCFPQueen's University, Kingston, ON
      Anthony Hanley, PhDUniversity of Toronto, Toronto, ON
      Barry Lavallee, MD, CCFP, FCFP, MCIScUniversity of Manitoba, Winnipeg, MB
      Ann Macaulay, CM, MD, FCFP, FRCPC (Hon)McGill University, Montreal, QC
      Alex McComber, MEdKahnawake Mohawk Territory, Montreal, QC
      Monica Parry, RN, MEd, MSc, PhDUniversity of Toronto, Toronto, ON
      Sonja Reichert, MD, MSc, CCFPWestern University, London, ON
      Jon Salsberg, MA, PHD (c.)McGill University, Montreal, QC
      Amardeep Thind, MD, PhDWestern University, London, ON
      Sheldon Tobe, MD, MScCH (HPTE), FRCPC, FACP, FASHSunnybrook Research Institute, University of Toronto, Toronto, ON
      Ellen Toth, MDUniversity of Alberta, Edmonton, AB
      Audrey Walsh, RN, PhDCape Breton University, Sydney, NS
      Jay Wortman, MDUniversity of British Columbia, Vancouver, BC
      Lloy Wylie, PhDWestern University, London, ON
      Merrick Zwarenstein, MBBCh, MSc, PhDWestern University, London, ON
      COLLABORATORS
      Ross Bailie, MD, PhDMenzies School of Health Research, Brisbane, QLD Australia
      Kayla Collins, PhDNewfoundland and Labrador Centre for Health Information, St. John's, NL
      Valeria Rac, MD, PhDToronto Health Economics and Technology Assessment (THETA) Collaborative, University of Toronto, Toronto, ON
      Claire de Oliveira, MA, PhDCentre for Addiction and Mental Health (CAMH), Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, ON
      Michael Hindmarsh, BASc, MA, PhD (ABD)Hindsight Healthcare Strategies, Toronto, ON
      Linda Stanley, BS,MS,PhDTri-Ethnic Research Center, Colorado State University, Colorado, CO, USA
      Policy maker and knowledge user organizations
      Gina DoxtaterAssembly of First Nations, Ottawa, ON
      Joanne LewisCanadian Diabetes Association, Toronto, ON
      Marlene NoséHealth Canada, FNIHB, Ottawa, ON
      Brigitte ParentAssembly of First Nations, Ottawa, ON
      Stephen SundquistOntario Stroke Network (also on behalf of the Heart & Stroke Foundation), Toronto, ON
      Wave 1: Partnering communities
      Lillian Houle

      Phyllis Racette

      Amber Houle
      Ebb and Flow First Nation, Ebb and Flow, MB
      Dawn Montour-Lazare

      Alexandra Audi

      Jessica Jacobs
      Kahnawake Mohawk, Montreal, QC
      Randy Littlechild

      Ingrid Ekomiak

      Tina Littlechild
      Maskwacis Health, Hobbema, AB
      Theresa O'Keefe

      Ada Roberts

      Maggie Organ
      Miawpukek First Nations, Conne River, NL
      Kelsey Bigplume-Kahnapace

      Chalsea Onespot
      Tsuu T'ina Nation, Calgary, AB
      Ivan Kimble McComb

      Emilie Dufour

      Verna Jolly

      Charlene Diamond
      Waskaganish First Nations, Eastern James Bay, QC
      Western research staff
      Mariam Naqshbandi Hayward, BA, MScWestern University, London, ON
      Selam Mequanint, BSc, MTechWestern University, London, ON
      Jann Paquette-Warren, MScWestern University, London, ON
      Jordan Tompkins, BSc, MAWestern University, London, ON
      Susan Webster-Bogaert, BSc (KIN), MAWestern University, London, ON
      Braden Te Hiwi, MHKWestern University, London, ON
      Jim Esler, MAWestern University, London, ON
      Meghan Fournie, BAWestern University, London, ON
      Marie Tyler, MScWestern University, London, ON
      Jackie McLellanWestern University, London, ON

      Appendix. 1

       Summary of interventions

      Tabled 1
      TitleStudy typeLocationDurationParticipantsInterventionOutcomeLimitations
      Dreger LC, Mackenzie C, McLoed B. Feasibility of a mindfulness-based intervention for Aboriginal adults with type 2 diabetes. Mindfulness 2013;4:264-80Quasi-experimental pre/post interventionManitoba (urban and rural sites)3 separate 8-week sessions18+, self-identified as Aboriginal, type 2 diabetes, no substance abuse, suicidal ideation or active psychosis2 two-hour-long weekly mindfulness meditation sessions, instruction to practice mindfulness at home for 20–30 min/day, 5 days/weekSignificant improvement in blood sugar regulation

      Significant improvement in emotional well-being

      Participants liked program
      Small sample size, low numbers of male participants

      Medications were not monitored; some participants may have been taking medications that influenced the results

      No control group
      Eskicioglu P, Halas J, Sénéchal M, Wood L, McKay E, Villeneuve S, Shen GX, Dean H, McGavock JM. Peer Mentoring for type 2 diabetes prevention in First Nations children. Pediatrics 2014;133:e1624-31

      Eskicioglu P, Halas J, Villeneuve S, Monias C, McKay E, Wood L, McGaock J. The Aboriginal Youth Mentorship Program (AYMP): A peer-led healthy living after-school program for achieving healthy weights in First Nations children living in a northern remote setting. Abstracts/Can J Diabetes 2013;73:S217-89
      Pre/post evaluation with control armRemote: northern Manitoba5-month intervention, offered twice237 grade 4 studentsWeekly 90-minute peer-led after-school program for grade 4 students, led by volunteer peer-mentors grades 7–12

      Included healthful snack, physical activity, and an educational game
      Significant decrease in WC and zBMI in intervention arm

      Significant improvement in knowledge of healthful eating and self-esteem in intervention arm
      Risk of selection bias due to self-selection to the intervention

      Study arms differed in age at baseline

      Ratio of female-to-male participants in intervention arm was 3:1, while the ratio was 1:1 in the control arm

      Risk of carry-over of students who received the intervention into the control arm in year 2
      Foulds HJA, Bredin SSD, Warburton DER. The effectiveness of community-based physical activity interventions with Aboriginal peoples. Preve Med 2011;53:411-6Non-randomized pre/post evaluation21 Indigenous communities in British Columbia (urban, rural, on and off-reserve)13 week session, offered annually 2007–20105925 people age 18–75, at risk for cardiovascular disease. 273 pre and post-screening sessionsWeekly group training plus 2 weekly personal-training sessions, in preparation for the 10 km Vancouver Sun Run Participants trained to walk, walk and run, or run

      Trainers were Indigenous
      Significant improvements in WC, significant improvements in cholesterol in females, improved physical activity scoresSelf-selected participants, no control group
      Gates M, Hanning RM, Gates A, Isogai A, Tsuji LJS, Metatawabin JA. Pilot comprehensive school nutrition program improves knowledge and intentions for intake of milk and milk alternatives among youth in a remote First Nation. J Nutr Educ Behav 2013;45:455-9Pilot pre/post evaluationFly-in remote reserve on James Bay5 weeksKindergart-en to grade 12 school childrenSchool-based program focused on milk and milk alternatives, taught by visiting university students; each class received one 30-minute class on nutrition

      Healthful breakfasts and snacks were provided
      Significant improvement in knowledge about milk and milk alternatives, and intentions to consume in the futureShort duration, difficult to establish cause and effect without control group.
      Gates M, Hanning RM, Gates A, McCarthey DD, Tsuhi LJS. Assessing the Impact of pilot school snack programs on milk and alternatives intake in northern Ontario, Canada. J School Health 2013;83:69–76Pilot pre/post evaluation2 remote, isolated communities on James Bay, Ontario1 school yearSchoolchildren grades 6–8A daily school snack program was initiated in 1 community In the other, milk and alternatives were added to an existing school snack program Snacks consisted of one fruit or vegetable item and 1 milk or milk alternative item

      The research team facilitated the program for 1 week, and collected data both at baseline and after 1 week The program was then handed over to a local volunteer Research team returned to collect data after 1 year
      Community 1: short-term increase in consumption of milk and alternatives, no long-term Community 2: Significant improvement in consumption in short and long term.Data collected after 1 week, with follow-up after 1 year.

      Small sample size, no control group.
      Ho LA, Gittelsohn J, Rimal R, Treuth MA, Sharma S, Rosecrans A, Harris SB. An integrated multi-institutional diabetes prevention program improves knowledge and healthy food acquisition in Northwestern Ontario First Nations. Health Educ Behav 2008;35:561-73

      Rosecrans AM, Gittelsohn K, Ho LS, Harris SB, Naqshbani M, Sharma S. Process evaluation of a multi-institutional community-based program for diabetes prevention among First Nations. Health Educ Res 2008;23:272-86
      Quasi-experimental pretest/post-test evaluation4 communities (2 remote, 2 semiremote) in Northwestern Ontario

      2 sites received the intervention in the first year, and the other 2 in the second year
      9 monthsRandomly selected adultsMulti-institutional program with school, store and community componentsGreater acquisition of healthful food following intervention

      Greater knowledge of healthful lifestyles following interventions
      Relatively short time period for such extensive intervention Components not well integrated

      Communities were not randomly assigned, no control group
      Mead EL, Gittelsohn J, Roache C, Corriveau A, Sharma S. A community-based, environmental chronic disease prevention intervention to improve healthy eating, psychosocial factors and the behaviors in Indigenous populations in the Canadian arctic. Health Educ Behav 2012;40:592–602

      Sharma A, Gittelsohn J, Rosol R, Beck L. Addressing the public health burden caused by the nutrition transition through the Healthy Foods North nutrition and lifestyle intervention program. J Human Nutr Dietet 2010;23(Suppl 1):120-7
      Quasi-experimental pre/post-evaluation3 Inuit and 3 Inuvialuit intervention communities in Nunavut and the Northwest Territories, all above the Arctic circle. One additional Inuit and 1 additional Inuvialuit community received a delayed intervention, and served as a comparison Communities ranged from 800 to 3500 residents.12 months246 (intervention communities) and 133 (comparison communities) randomly-selected adults who were not breastfeeding and were long-term residents of these communities7 phases (tea/coffee/healthful breakfast; healthy snacks; healthy home eating/traditional foods; healthy beverages; healthier cooking/meal planning; consuming sufficient vitamins and minerals)

      Stocked local store with healthier items, offering tastings and cooking demonstrations, and point-of-purchase advertising of healthy foods

      Worked with local community to identify local ways of being active

      Radio and television media, community-wide activities in red centres, schools, and so forth

      Activities included taste tests, community feats, walking clubs, pedometer challenges and cooking classes
      Intervention communities showed significant improvements in food-related self-efficacy and intentions but not with healthy food acquisition frequency.

      Greatest improvements were seen in overweight and obese participants, and participants of with high socioeconomic status
      No follow-up after the intervention ended, therefore unable to determine whether the intervention had any lasting effect

      Low numbers of male participants.
      Kakekagumick KA, Naqshbandi Hayward M, Harris S, Saksvig B, Gittelsohn J, Manokeesic G, Goodman S, Hanley AJ. Sandy Lake Health and Diabetes Project: A community-based intervention targeting type 2 diabetes and its risk factors in a First Nations community. Front Endocrinol 2013;4:1–9Review of interventions over 22 years, including 2 pre/post-test evaluationsSandy Lake First Nation (remote, fly-in community in Sub-Arctic Ontario)22 years (many different phases):

      Phase 1 (Formative research studies): 1991–1996

      Phase 2 (Community baseline survey, Northern Store Program): 1993–1995

      Phase 3 (Home visit program, launch of radio show and school curriculum): 1996–1997

      Phase 4 (School program evaluation 1): 1998–1999

      Phase 5: (School program evaluation 2) 2005–2006

      Community walking trail
      Children in grade 3 and 4 were evaluated at the end of the school year in 3 consecutive years.Component of the Sandy Lake Health and Diabetes Project (SLHDP). Intervention included a radio show, a Northern Store program, a home visit program, a diabetes radio show, a community walking trail, promotional activities such as distribution of pamphlets, and a school-based diabetes curriculum All program components aimed to encourage physical activity and healthy lifestyle promotion The program explicitly aims to encourage culturally appropriate activities and lifestylesImprovement in self-efficacy and health knowledge,

      increase in milk consumption and decrease in sugar consumption
      Limitations of the various stages of the intervention are unclear.
      Oster RT, Shade S, Strong D, Toth EL. Improvements in indicators of diabetes-related health among First Nations individuals enrolled in a community-driven diabetes complications mobile screening program in Alberta, Canada. Revue Canadienne de Santé Publique 2010;101:410-4Pre/post screening of diabetes-related health indicators43 on-reserve communities in AlbertaBiannual visits between 2001 and 2007People aged 9 to 84 who were diagnosed with diabetes and who either self-enrolled in response to advertising, or were enrolled by community health workers. This comprised 64% percent of eligible Indigenous people in Alberta2 mobile clinics staffed by healthcare personnel who were either First Nations or had Aboriginal-specific training visited local communities Local community health personnel facilitated in each communitySignificant improvements in BMI, blood pressure, total cholesterol and A1C levelsWith no control group, it is impossible to know whether the improvements are due to the intervention

      Participants self-selected

      Information on medications that could have impacted the findings were not reliably collected
      Ronsley R, Lee AS, Kuzeljevic B, Panagiotopoulous C. Healthy Buddies reduced body mass index score and waist circumference in Aboriginal children living in remote coast communities. J School Health 2013;83:605-13Pilot pre- and postanalysis with control groupThree remote communities in coastal northern British Columbia10 monthsStudents in grades K-12 at two schools, third school dropped out (naturalistic control group)School-based program based on a BC Ministry of Education program, adapted for FN communities. Includes 3 components (physical activity, healthful eating, healthy body image) Comprises 21 lessons and 6 fitness loops

      Peer mentoring is central to the program
      Significant decrease in zBMI, WC in intervention groups

      BP increased in control group but not in intervention group

      Linear model analysis showed significant interaction between zBMI, weight, nutritious beverage knowledge, healthy living, and self-esteem
      Limited data on individual schools' adherence to the program, not an RCT
      Tobe S, Vincent L, Wentworth J, Hildebrandt D, Kiss A, Perkins N, Hartman S, Ironstand L, Hoppe J, Hunter K, Pylypchuk G. Blood Pressure 2 years after a chronic disease management intervention study. Int J Circumpolar Health 2010;69:50–60Prospective single-arm observational study of an RCTAll over Alberta2 years96 on-reserve adults (18+) with Indian status, all of whom had completed DREAM3, an RCT study of blood pressure controlBlood pressure measurements every 6 months over 2 yearsBlood pressure control was maintained 2 years after the completion of DREAM3Not all participants completed all measurements.
      Tomlin D, Naylor PJ, McKay H, Zorzi A, Mitchell M, Panagiotopoulous C. The impact of Action Schools! BC on the health of Aboriginal children and youth living in rural and remote communities in British Columbia. Int J Circumpolar Health 2012;71:179-99

      Naylor PJ, Scott J, Drummond J, Bridgewater L, McKay HA, Panagiotopoulous C. 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 2010;10:2:1296
      Pre-experimental pre/post designThree remote communities in coastal northern British Columbia7 monthsAll school children grades 4–12School-based program including classroom-based healthy eating education and physical activity (150 mins per week, plus 15 extra minutes per day in-class) Includes family and community elementsWC increase, increase in variety of vegetables consumed, substantial increase in aerobic fitness

      Teacher evaluations of program indicate that it is feasible and appropriate for First Nations schools
      Short duration, no control group.
      Toth E. Early trend towards improving fitness amongst children: A final project report to the Alberta Centre for Child, Family, and Community Research, July 2012Pilot pre-postanalysis1 FN community in northern Alberta1 yearSchool-childrenSchool-based diabetes and obesity prevention curriculum, tradition-based “Cree Pride” intervention for familiesFitness improved, physical activity decreased Males less active than femalesImprovements in fitness drawn from 25 children, very low sample size, high turn-over of staff in the school and high number of community deaths due to addictions diverted focus from the intervention No control group

      References

        • Public Health Agency of Canada
        Diabetes in Canada: Fact and figures from a public health perspective.
        (Ottawa)2011
        • Young T.K.
        • Reading J.
        • Elias B.
        • O'Neil J.D.
        Type 2 diabetes mellitus in Canada's first nations: Status of an epidemic in progress.
        CMAJ. 2000; 163: 561-566
        • Liu J.
        • Young T.K.
        • Zinman B.
        • et al.
        Lifestyle variables, non-traditional cardiovascular risk factors, and the metabolic syndrome in an Aboriginal Canadian population.
        Obesity. 2006; 14: 500-508
        • Sharma S.
        • Gittelsohn J.
        • Rosol R.
        • Beck L.
        Addressing the public health burden caused by the nutrition transition through the healthy foods north nutrition and lifestyle intervention program.
        J Hum Nutr Diet. 2010; 23: 120-127
        • Kuhnlein H.V.
        • Receveur O.
        • Soueida R.
        • Egeland G.M.
        Arctic indigenous peoples experience the nutrition transition with changing dietary patterns and obesity.
        J Nutr. 2004; 134: 1447-1453
        • Willows N.D.
        • Hanley A.J.
        • Delormier T.
        A socioecological framework to understand weight-related issues in Aboriginal children in Canada.
        Appl Physiol Nutr Metab. 2012; 37: 1-13
        • Egeland G.M.
        • Pacey A.
        • Cao Z.
        • Sobol I.
        Food insecurity among Inuit preschoolers: Nunavut inuit child health survey, 2007–2008.
        CMAJ. 2010; 182: 243-248
        • Reading C.L.
        • Wien F.
        Health inequalities and social determinants of Aboriginal peoples' health.
        National Collaborating Centre for Aboriginal Health, Prince George, BC2009
        • Wendel-Vos W.
        • Droomers M.
        • Kremers S.
        • et al.
        Potential environmental determinants of physical activity in adults: A systematic review.
        Obesity Rev. 2007; 8: 425-440
        • Joseph P.
        • Davis A.D.
        • Miller R.
        • et al.
        Contextual determinants of health behaviours in an aboriginal community in Canada: Pilot project.
        BMC Pub Health. 2012; 12: 952-960
        • Anand S.S.
        • Davis A.D.
        • Ahmed R.
        • et al.
        A family-based intervention to promote healthy lifestyles in an aboriginal community in Canada.
        Can J Pub Health. 2007; 8: 447-452
        • Shubair M.M.
        • Tobin P.K.
        Type 2 diabetes in the first nations population: A case example of clinical practice guidelines.
        Rural Remote Health. 2010; : 1505
        • Andrews M.E.
        • Stewart N.J.
        • Pitblado J.R.
        • et al.
        Registered nurses working alone in rural and remote Canada.
        Can J Nurs Res. 2005; 37: 14-33
        • Kulig J.C.
        • Stewart N.J.
        • Morgan D.
        • et al.
        Aboriginal nurses' insights from a national study.
        Can Nurse. 2006; 102: 16-20
      1. Vancouver Coastal Health, 2008–2011 Aboriginal Health and Wellness Plan. 2008.

        • Blackstock C.
        First Nations children count: Enveloping quantitative research in an Indigenous envelope.
        First Peoples Child Fam Rev. 2009; 4: 135-143
        • Chino M.
        • DeBruyen L.
        Building true capacity: Indigenous models for indigenous communities.
        Am J Pub Health. 2006; 96: 596-599
        • Smylie J.
        • Kaplan-Myrth N.
        • McShane K.
        • Metis Nation of Ontario-Ottawa Council, Pikwakanagan First Nation, Tungasuvvingat Inuit Family Resource Centre
        Indigenous knowledge translation: Baseline findings in a qualitative study of pathways of health knowledge in three Indigenous communities in Canada.
        Health Promot Prac. 2009; 10: 436-446
        • McNamarra B.J.
        • Sanson-Fisher R.
        • D'Este C.
        • Eades S.
        Type 2 diabetes in Indigenous populations: Quality of intervention research over 20 years.
        Prev Med. 2011; 52: 3-9
        • Saini M.
        • Quinn A.
        A systematic review of randomized controlled trials of health related issues within an Aboriginal context.
        National Collaborating Centre for Aboriginal Health, Prince George2013
        • Edwards K.
        • Patchell B.
        State of the cience: A cultural view of Native Americans and diabetes prevention.
        J Cult Divers. 2009; 16: 32-35
        • Morris P.S.
        Randomized control trials addressing Australian Aboriginal health needs: A systematic review of the literature.
        J Pediatr Health Care. 1999; 35: 130-135
        • Teufel-Shone N.I.
        • Fitzgerald C.
        • Teufel-Shone L.
        • Gamber M.
        Systematic review of physical activity interventions implemented with American Indian and Alaska Native populations in the United States and Canada.
        Am J Health Promot. 2009; 26: S8-32
        • Huffman M.D.
        • Galloway J.M.
        Cardiovascular health in Indigenous communities: Successful programs.
        Heart Lung Circ. 2010; 19: 351-360
        • Evans D.
        Hierarchy of evidence: A framework for ranking evidence evaluating healthcare interventions.
        J Clin Nurs. 2003; 12: 77-84
        • Narayan K.M.
        • Hoskin M.
        • Kozak D.
        • et al.
        Randomized clinical trial of lifestyle interventions in Pima Indians: A pilot study.
        Diabetic Med. 1998; 15: 660-672
        • Macauley A.C.
        • Cargo M.
        • Bisset S.
        • et al.
        Community empowerment of the primary prevention of type 2 diabetes: Kanien'kekha:ka (Mohawk) ways for the Kahnawake schools diabetes prevention project.
        in: Ferreira M.L. Lang G.C. Indigenous peoples and diabetes: Community empowerment and wellness. Carolina Academic Press, Durham2006: 407-458
        • Paradis G.
        • Levesque L.
        • Macaulay A.C.
        • et al.
        Impact of a diabetes prevention program on body size, physical activity, and diet among Kanien'keha:ka (Mohawk) children 6 to 11 years old: 8-year results of the Kahnawake schools diabetes prevention project.
        Pediatrics. 2005; 111: 333-339
        • Macaulay A.C.
        • Paradis H.
        • Potvin L.
        • et al.
        The Kahnawake schools diabetes prevention project: Intervention, evaluation, and baseline results of a diabetes primary prevention program with a Native community in Canada.
        Prev Med. 1997; 26: 779-790
        • Potvin K.
        • Cargo M.
        • McComber A.M.
        • et al.
        Implementing participatory intervention and research in communities: Lessons from the Kahnawake schools diabetes prevention project in Canada.
        Soc Sci Med. 2003; 56: 1295-1305
        • Saksvig B.I.
        • Gittelsohn J.
        • Harris S.B.
        • et al.
        A pilot school-based healthy eating and physical activity intervention improves diet, food knowledge, and self-efficacy for Native Canadian children.
        J Nutr. 2005; 135: 2392-2398
        • Hanley A.J.G.
        • Harris S.B.
        • Gittelsohn J.
        • et al.
        The Sandy Lake Health and Diabetes Project: Design, methods and lessons learned.
        Chron Dis Canada. 1995; 16: 149-156
        • Stock S.
        • Miranda C.
        • Evans S.
        • et al.
        Healthy buddies: A novel, peer-led health promotion program for the prevention of obesity and eating disorders in children in elementary school.
        Pediatrics. 2007; 120: e1059-68
        • Davis S.M.
        • Going S.B.
        • Helitzer D.L.
        • et al.
        Pathways: A culturally appropriate obesity-prevention program for American Indian schoolchildren.
        Am J Clin Nutr. 1999; 69: 796S-802S
        • Curran D.
        • Gittlesohn J.
        • Anliker J.
        • et al.
        Process evaluation of a store-based environmental obesity intervention on two American Indian Reservations.
        Health Educ Res. 2005; 20: 719-729
        • Gittelsohn J.
        • Anliker J.
        • Ethelbach B.
        • et al.
        A food store intervention to reduce obesity in two American Indian communities: Impact on food choices and psychosocial indicators.
        FASEB J. 2005; 19: AS94.11
        • Eskicioglu P.
        • Halas J.
        • Sénéchal M.
        • et al.
        Peer mentoring for type 2 diabetes prevention in First Nations children.
        Pediatrics. 2014; 133: e1624-31
        • Eskicioglu P.
        • Halas J.
        • Villeneuve S.
        • et al.
        The Aboriginal Youth Mentorship Program (AYMP): A peer-led healthy living after-school program for achieving healthy weights in First Nations children living in a northern remote setting.
        Can J Diabetes. 2013; 73: S217-89
        • Gates M.
        • Hanning R.M.
        • Gates A.
        • et al.
        A pilot comprehensive school nutrition program improves knowledge and intentions for intake of milk and milk alternatives among youth in a remote first nation.
        J Nutr Educ Behav. 2013; 45: 455-459
        • Gates M.
        • Hanning R.M.
        • Gates A.
        • et al.
        Assessing the impact of pilot school snack programs on milk and alternatives intake in Northern Ontario, Canada.
        J School Health. 2013; 83: 69-76
        • Kakekagumick K.A.
        • Naqshbandi Hayward M.
        • Harris S.B.
        • et al.
        Sandy lake health and diabetes project: A community-based intervention targeting type 2 diabetes and its risk factors in a First Nations community.
        Front Neuroendocrinol. 2013; 4: 1-9
        • Ronsley R.
        • Lee A.S.
        • Kuzeljevic B.
        • Panagiotopoulous C.
        Healthy buddies reduced body mass index score and waist circumference in aboriginal children living in remote coast communities.
        J School Health. 2013; 83: 605-613
        • Tomlin D.
        • Naylor P.J.
        • McKay H.
        • et al.
        The impact of action schools! BC on the health of Aboriginal children and youth living in rural and remote communities in British Columbia.
        Int J Circumpolar Health. 2012; 71: 179-199
        • Naylor P.J.
        • Scott J.
        • Drummond J.
        • Panagiotopoulos C.
        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. 2010; 10: 1296
        • Toth E.
        Early trend towards improving fitness amongst children: A final project report to the Alberta Centre for Child, Family, and Community Research.
        2012
        • Oster R.T.
        • Shade S.
        • Strong D.
        • Toth E.L.
        Improvements in indicators of diabetes-related health among first nations individuals enrolled in a community-driven diabetes complications mobile screening program in Alberta, Canada.
        Rev Can Santé Pub. 2010; 101: 410-414
        • Dreger L.C.
        • Mackenzie C.
        • McLoed B.
        Feasibility of a mindfulness-based intervention for Aboriginal adults with type 2 diabetes.
        Mindfulness. 2013; 4: 264-280
        • Foulds H.J.A.
        • Bredin S.S.D.
        • Warburton D.E.R.
        The effectiveness of community-based physical activity interventions with Aboriginal peoples.
        Prev Med. 2011; 53: 411-416
        • Ho L.A.
        • Gittelsohn J.
        • Rimal R.
        • et al.
        An integrated multi-institutional diabetes prevention program improves knowledge and healthy food acquisition in Northwestern Ontario first nations.
        Health Educ Behav. 2008; 35: 561-573
        • Rosecrans A.M.
        • Gittelsohn K.
        • Ho L.S.
        • et al.
        Process evaluation of a multi-institutional community-based program for diabetes prevention among first nations.
        Health Educ Res. 2008; 23: 272-286
        • Mead E.L.
        • Gittelsohn J.
        • Roache C.
        • et al.
        A community-based, environmental chronic disease prevention intervention to improve healthy eating psychosocial factors and the behaviors in indigenous populations in the Canadian arctic.
        Health Educ Behav. 2012; 40: 592-602
        • Sharma A.
        • Gittelsohn J.
        • Rosol R.
        • Beck L.
        Addressing the public health burden caused by the nutrition transition through the healthy foods north nutrition and lifestyle intervention program.
        J Hum Nutr Diet. 2010; 23: 120-127
        • Tobe S.
        • Vincent L.
        • Wentworth J.
        • et al.
        Blood pressure 2 years after a chronic disease management intervention study.
        Int J Circumpolar Health. 2010; 69: 50-60
        • McGibbons E.A.
        Oppression: A social determinant of health.
        Fernwood Publishing, Black Point2012
        • Rimal R.N.
        Closing the knowledge-behaviour gap in health promotion: The mediating role of self-efficacy.
        Health Com. 2000; 12: 219-237
        • Jagosh J.
        • Maccaulay A.C.
        • Pluye P.
        • et al.
        Uncovering the benefits of participatory research: Implications of a realist review for health research and practice.
        Milbank Q. 2012; 90: 1-41
        • Cargo M.
        • Mercer S.L.
        The value and challenge of participatory research: Strengthening its practice.
        Annu Rev Public Health. 2008; 29: 325-350
        • Czyzweski K.
        Colonialism as a broader social determinant of health.
        Int Indigenous Policy J. 2011; 2: 1-14