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An Indigenous Approach to Diabetes Research: Don't Just Tell Us We're Fat
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CANADIAN JOURNAL OF DIABETES
EDITORIAL COmmENTARy
An Indigenous Approach to Diabetes Research: Don’t Just Tell Us We’re Fat The prevalence of diabetes—particularly type 2 and gestational diabetes—is an increasing issue in certain ethnocultural groups, especially among Indigenous peoples (1). In this editorial commentary, the term Indigenous is capitalized to emphasize the importance of the collective group of peoples, and the term will be used when referring to Indigenous peoples globally. When referring to Indigenous peoples of Canada, the terms First Nations, Inuit and Métis will be used. When referring to a specific Nation of Indigenous peoples, the appropriate Nation term will be used (e.g. Anishnabek). Indigenous peoples are diagnosed with diabetes at a younger age, have a poorer quality of life, more complications and die earlier than their non-Indigenous counterparts with diabetes (2,3). The increased prevalence of diabetes in Indigenous populations has ignited research funding, and researchers are taking an interest in this topic. While epidemiological data are critical, the purpose of this editorial commentary is not to reiterate the statistics that are widely known amongst Indigenous peoples, researchers and practitioners. Rather, the purpose is to prompt researchers and practitioners to focus on decreasing the prevalence and increasing the quality of life of Indigenous people with diabetes. In doing so, it is suggested that the theoretical frameworks and epistemological positions of researchers may need to be more holistic and incorporate the knowledge and culture of Indigenous peoples when conducting research on diabetes. For instance, Iwasaki and Bartlett (4) explored the stress-coping of Aboriginal peoples with diabetes and concluded that “failing to take into account the cultural context of a particular group will lead to serious oversight in recognizing both the individual and collective aspects, which are essential to a broader and more culturally appropriate conceptualization.” This type of conceptualization of diabetes will allow for better assessment of the core reasons why Indigenous peoples have higher rates of and complications from diabetes. As a previously licensed athletic trainer/therapist, I would often encounter athletes with overuse injuries. Diagnosing the injury was the easy part. Determining the root cause or the true etiology of an injury was critical to help an athlete return to play rather than injury. While therapeutic interventions might help for a while, these are only band-aid solutions if the athlete returns to an activity without the proper understanding of the etiology of the injury. This prompted me to delve into the study of the psychology of athletic injury, because not all injuries could be explained purely
by looking at physical attributes. Much like an athlete who is treated for the symptoms of an injury vs. the root cause, looking at diabetes only through the physical realm (i.e. adiposity, poor diet or lack of exercise) while ignoring social and systemic factors will not get to the root of the problem. Delving deeper and asking, “Why is the diet poor?” or “Why is there lack of physical activity?” is a direction toward the root cause. This commentary implores researchers to consider how broader social determinants may be at play in the outcome of increased diabetes prevalence and poorer management. Dinca-Panaitescu and colleagues (5) explored these social determinants in an analysis of the Canadian Community Health Survey. They found that after adjusting for sociodemographics, housing, body mass index and physical activity, the prevalence of diabetes decreased steadily as income increased. While the increased prevalence of diabetes may often be attributed to behaviours and physical attributes, one cannot ignore the social determinants and— for many Indigenous peoples—the political determinants of health. The root cause of many illnesses in Indigenous peoples has been identified as the historical trauma of colonization (6-8). It is beyond the scope of this commentary to provide an extensive review of the historical trauma or intergenerational grief literature, but it behooves any researcher and practitioner wanting to work with Indigenous peoples to become familiar with the history and current political status of Indigenous peoples from the Indigenous perspective. Ongoing—colonization as we see in many First Nations, Inuit and Métis communities in Canada—defines health. For example, current colonial legislation such as the Indian Act needs to be understood from a health perspective. In conjunction with understanding these sociopolitical structures, multiple interventions are required at multiple levels (macro, meso and micro—individual, collective and political); however, those involved in these interventions must communicate with each other. For instance, communitybased physical activity and diet programs need to recognize, and perhaps even work with, other social service agencies that have an impact on poverty issues. If clean water is a dire issue or community is heavily immersed in land reclamation, implementing a physical activity program may not be a top priority. In order to have a better understanding of the lived experience of communities, researchers could actively engage with a Indigenous community, becoming advocates for
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social change driven by the community. One might say, “I’m a researcher, not a social worker or politician.” However, when it comes to working with Indigenous communities, particularly within Canada, researchers in academic institutions are guided by the Tri-Council Policy Statement 2 (TCPS2) (9), which emphasizes the importance of engaging with the community as well as ensuring the mutual benefits in research. It states that research “should have the potential to produce valued outcomes from the perspective of the community.” As an example, the TCPS2 provides a scenario for diabetes research, stating “genetic research on diabetes ... is unlikely to benefit the community in the short term, but collaboration may facilitate increased knowledge of the condition, and what changes can be made to improve health outcomes.” But if the research only looks at genetics and fails to consider the social and political experiences in a community it will not improve health outcomes. As an Anishnabek Métis, I am inherently politically and personally tied to all Indigenous communities in which I choose to do research. My professional responsibilities and those of my non-Indigenous counterparts are now detailed in the TCPS2 (9). In article 9.12, the importance of collaborative research and the issue of reciprocity are discussed: What are you giving back and what is the research giving back to the community? From a purely positivist epistemological view, this type of engagement may not coincide with the notion of objectivity. However, from an Anishnabek epistemology, the physical, intellectual/mental, emotional and spiritual is interconnected and cannot be separated. We cannot view the world purely from an intellectual viewpoint. Therefore, the positivist notion of objectivity is impossible, and an epistemological shift is necessary (10). In closing, the prevalence of diabetes in Indigenous peoples has sparked a needed emphasis on research and programming in these communities. Looking beyond the physical and taking a holistic approach to research is critical in attempting to have a positive impact on prevalence and outcomes of
diabetes in Indigenous communities. Finally, researchers need to consider what their research is giving back, and not just because this is stated in the TCPS2. Researchers must ask, “How will or can these research results help the community?” And equally important, “Can these results harm the community, particularly if interpreted with an epistemological lens that is not inclusive of knowledge of the community?” Lynn F. Lavallée PhD Ryerson University Toronto, Canada
REFERENCES 1.
Dyck R, Osgood N, Lin TH, et al. Epidemiology of diabetes mellitus among First Nations and non-First nations adults. CMAJ. 2010; 182:249-256. 2. Davis TMJ, McAullay D, Davis WA, et al. Characteristics and outcome of type 2 diabetes in urban Aboriginal people: the Fremantle Diabetes Study. Int Med J. 2007;37:59-63. 3. Daniel M, Green LW, Marion SA, et al. Effectiveness of communitydirected diabetes prevention and control in a rural Aboriginal population in British Columbia, Canada. Soc Sci Med. 1999;48:815-832. 4. Iwasaki Y, Barlett J. Stress-coping among Aboriginal individuals with diabetes in an urban Canadian context: from woundedness to resilience. J Aboriginal Health. 2006;3:15-25. 5. Dinca-Panaitescu S, Dinca-Panaitescub M, Bryant TC, et al. Likelihood of diabetes increases as income level decreases: results of the Canadian Community Health Survey. J Health Pol. 2010;99:116-123. 6. Brave Heart MYH. The return to the sacred path: healing the historical trauma and historical unresolved grief response among Lakota through a psychoeducational group intervention. Smith Coll Stud Soc Work. 1998; 68:287-305. 7. Whitbeck LB, Adams GW, Hoyt DR, et al. Conceptualizing and measuring historical trauma among American Indian people. Amer J Comm Psych. 2004;33:119-130. 8. Fast E, Collin-Vezina D. Historical trauma, race-based trauma and resilience of Indigenous peoples: a literature review. First Peoples Child Fam Rev. 2010;5:126-136. 9. Canadian Institutes of Health Research, Natural Sciences and Engineering Research Council of Canada, Social Science and Humanities Research Council of Canada. Tri-Council Policy Statement: Ethical Conduct for Research Involvement Humans. December 2010. 10. Lavallée L. Practical application of an Indigenous research framework and Indigenous research methods: sharing circles and Anishnaabe symbol-based reflection. Int J Qual Methods. 2009;8:21-40.
A Resource for the South Asian Population is Now Available! Are you working with clients from a multicultural background? Are you looking for a management resource that connects with this population? The Canadian Diabetes Association proudly presents its tool in diabetes nutrition management Just the Basics for the South Asian population.
Features: Culturally appropriate: • healthy eating tips • portion guides • meal ideas • physical activity tips • healthy lifestyle choices
Available in four languages: • English • French • Punjabi • Hindi • Tamil
Download yours now by visiting diabetes.ca or request printed copies through the literature order desk at orders.diabetes.ca.
CANADIAN JOURNAL OF DIABETES
EDITORIAL COmmENTARy
An Indigenous Approach to Diabetes Research: Don’t Just Tell Us We’re Fat The prevalence of diabetes—particularly type 2 and gestational diabetes—is an increasing issue in certain ethnocultural groups, especially among Indigenous peoples (1). In this editorial commentary, the term Indigenous is capitalized to emphasize the importance of the collective group of peoples, and the term will be used when referring to Indigenous peoples globally. When referring to Indigenous peoples of Canada, the terms First Nations, Inuit and Métis will be used. When referring to a specific Nation of Indigenous peoples, the appropriate Nation term will be used (e.g. Anishnabek). Indigenous peoples are diagnosed with diabetes at a younger age, have a poorer quality of life, more complications and die earlier than their non-Indigenous counterparts with diabetes (2,3). The increased prevalence of diabetes in Indigenous populations has ignited research funding, and researchers are taking an interest in this topic. While epidemiological data are critical, the purpose of this editorial commentary is not to reiterate the statistics that are widely known amongst Indigenous peoples, researchers and practitioners. Rather, the purpose is to prompt researchers and practitioners to focus on decreasing the prevalence and increasing the quality of life of Indigenous people with diabetes. In doing so, it is suggested that the theoretical frameworks and epistemological positions of researchers may need to be more holistic and incorporate the knowledge and culture of Indigenous peoples when conducting research on diabetes. For instance, Iwasaki and Bartlett (4) explored the stress-coping of Aboriginal peoples with diabetes and concluded that “failing to take into account the cultural context of a particular group will lead to serious oversight in recognizing both the individual and collective aspects, which are essential to a broader and more culturally appropriate conceptualization.” This type of conceptualization of diabetes will allow for better assessment of the core reasons why Indigenous peoples have higher rates of and complications from diabetes. As a previously licensed athletic trainer/therapist, I would often encounter athletes with overuse injuries. Diagnosing the injury was the easy part. Determining the root cause or the true etiology of an injury was critical to help an athlete return to play rather than injury. While therapeutic interventions might help for a while, these are only band-aid solutions if the athlete returns to an activity without the proper understanding of the etiology of the injury. This prompted me to delve into the study of the psychology of athletic injury, because not all injuries could be explained purely
by looking at physical attributes. Much like an athlete who is treated for the symptoms of an injury vs. the root cause, looking at diabetes only through the physical realm (i.e. adiposity, poor diet or lack of exercise) while ignoring social and systemic factors will not get to the root of the problem. Delving deeper and asking, “Why is the diet poor?” or “Why is there lack of physical activity?” is a direction toward the root cause. This commentary implores researchers to consider how broader social determinants may be at play in the outcome of increased diabetes prevalence and poorer management. Dinca-Panaitescu and colleagues (5) explored these social determinants in an analysis of the Canadian Community Health Survey. They found that after adjusting for sociodemographics, housing, body mass index and physical activity, the prevalence of diabetes decreased steadily as income increased. While the increased prevalence of diabetes may often be attributed to behaviours and physical attributes, one cannot ignore the social determinants and— for many Indigenous peoples—the political determinants of health. The root cause of many illnesses in Indigenous peoples has been identified as the historical trauma of colonization (6-8). It is beyond the scope of this commentary to provide an extensive review of the historical trauma or intergenerational grief literature, but it behooves any researcher and practitioner wanting to work with Indigenous peoples to become familiar with the history and current political status of Indigenous peoples from the Indigenous perspective. Ongoing—colonization as we see in many First Nations, Inuit and Métis communities in Canada—defines health. For example, current colonial legislation such as the Indian Act needs to be understood from a health perspective. In conjunction with understanding these sociopolitical structures, multiple interventions are required at multiple levels (macro, meso and micro—individual, collective and political); however, those involved in these interventions must communicate with each other. For instance, communitybased physical activity and diet programs need to recognize, and perhaps even work with, other social service agencies that have an impact on poverty issues. If clean water is a dire issue or community is heavily immersed in land reclamation, implementing a physical activity program may not be a top priority. In order to have a better understanding of the lived experience of communities, researchers could actively engage with a Indigenous community, becoming advocates for
| 325
social change driven by the community. One might say, “I’m a researcher, not a social worker or politician.” However, when it comes to working with Indigenous communities, particularly within Canada, researchers in academic institutions are guided by the Tri-Council Policy Statement 2 (TCPS2) (9), which emphasizes the importance of engaging with the community as well as ensuring the mutual benefits in research. It states that research “should have the potential to produce valued outcomes from the perspective of the community.” As an example, the TCPS2 provides a scenario for diabetes research, stating “genetic research on diabetes ... is unlikely to benefit the community in the short term, but collaboration may facilitate increased knowledge of the condition, and what changes can be made to improve health outcomes.” But if the research only looks at genetics and fails to consider the social and political experiences in a community it will not improve health outcomes. As an Anishnabek Métis, I am inherently politically and personally tied to all Indigenous communities in which I choose to do research. My professional responsibilities and those of my non-Indigenous counterparts are now detailed in the TCPS2 (9). In article 9.12, the importance of collaborative research and the issue of reciprocity are discussed: What are you giving back and what is the research giving back to the community? From a purely positivist epistemological view, this type of engagement may not coincide with the notion of objectivity. However, from an Anishnabek epistemology, the physical, intellectual/mental, emotional and spiritual is interconnected and cannot be separated. We cannot view the world purely from an intellectual viewpoint. Therefore, the positivist notion of objectivity is impossible, and an epistemological shift is necessary (10). In closing, the prevalence of diabetes in Indigenous peoples has sparked a needed emphasis on research and programming in these communities. Looking beyond the physical and taking a holistic approach to research is critical in attempting to have a positive impact on prevalence and outcomes of
diabetes in Indigenous communities. Finally, researchers need to consider what their research is giving back, and not just because this is stated in the TCPS2. Researchers must ask, “How will or can these research results help the community?” And equally important, “Can these results harm the community, particularly if interpreted with an epistemological lens that is not inclusive of knowledge of the community?” Lynn F. Lavallée PhD Ryerson University Toronto, Canada
REFERENCES 1.
Dyck R, Osgood N, Lin TH, et al. Epidemiology of diabetes mellitus among First Nations and non-First nations adults. CMAJ. 2010; 182:249-256. 2. Davis TMJ, McAullay D, Davis WA, et al. Characteristics and outcome of type 2 diabetes in urban Aboriginal people: the Fremantle Diabetes Study. Int Med J. 2007;37:59-63. 3. Daniel M, Green LW, Marion SA, et al. Effectiveness of communitydirected diabetes prevention and control in a rural Aboriginal population in British Columbia, Canada. Soc Sci Med. 1999;48:815-832. 4. Iwasaki Y, Barlett J. Stress-coping among Aboriginal individuals with diabetes in an urban Canadian context: from woundedness to resilience. J Aboriginal Health. 2006;3:15-25. 5. Dinca-Panaitescu S, Dinca-Panaitescub M, Bryant TC, et al. Likelihood of diabetes increases as income level decreases: results of the Canadian Community Health Survey. J Health Pol. 2010;99:116-123. 6. Brave Heart MYH. The return to the sacred path: healing the historical trauma and historical unresolved grief response among Lakota through a psychoeducational group intervention. Smith Coll Stud Soc Work. 1998; 68:287-305. 7. Whitbeck LB, Adams GW, Hoyt DR, et al. Conceptualizing and measuring historical trauma among American Indian people. Amer J Comm Psych. 2004;33:119-130. 8. Fast E, Collin-Vezina D. Historical trauma, race-based trauma and resilience of Indigenous peoples: a literature review. First Peoples Child Fam Rev. 2010;5:126-136. 9. Canadian Institutes of Health Research, Natural Sciences and Engineering Research Council of Canada, Social Science and Humanities Research Council of Canada. Tri-Council Policy Statement: Ethical Conduct for Research Involvement Humans. December 2010. 10. Lavallée L. Practical application of an Indigenous research framework and Indigenous research methods: sharing circles and Anishnaabe symbol-based reflection. Int J Qual Methods. 2009;8:21-40.
A Resource for the South Asian Population is Now Available! Are you working with clients from a multicultural background? Are you looking for a management resource that connects with this population? The Canadian Diabetes Association proudly presents its tool in diabetes nutrition management Just the Basics for the South Asian population.
Features: Culturally appropriate: • healthy eating tips • portion guides • meal ideas • physical activity tips • healthy lifestyle choices
Available in four languages: • English • French • Punjabi • Hindi • Tamil
Download yours now by visiting diabetes.ca or request printed copies through the literature order desk at orders.diabetes.ca.