Scope of the problem

According to Statistics Canada, moderate FI is defined as inadequate quality and/or quantity of food consumed, and severe FI encompasses problems of missed meals, reduced food intake, and possibly whole days without food [11, 16, 17]. FI is a Canada wide-problem. However, it is at crisis levels for many Indigenous populations, specifically in areas of Canada’s North with high proportions of Indigenous Peoples [11, 16–19]. A direct comparison of the prevalence of FI within and among Indigenous groups, and with the overall Canadian population is challenging as the surveys vary in the study population (northern, urban, remote, on and off-reserve), age groups, criteria for FI, and methodology. The data show a disproportionately higher rate of moderate to severe FI in all Indigenous groups. Rural and remote Indigenous communities in the North are at a particularly high risk [20], although FI impacts Indigenous Peoples living on and off reserve including urban regions [14, 21–24]. Specific (FNIM) regions further illuminate the scope of FI among Indigenous children in Canada.

Inuit children

The Nunavut Inuit Child Health Survey in 2007–2008 assessed for FI preschool Inuit children aged 3–5 in 16 Arctic communities. Alarmingly 69.6% of households had FI (34.4% severe and 35.3% moderate) [7]. Of the severely food insecure homes, children skipped meals (75.8%) went hungry (90.4%) or did not eat for a full day (64.3%) in the past year due to insufficient money for food [10]. The 2012 Aboriginal Peoples’ Survey found that 53% of Inuit over the age of 15 in Inuit Nunangat (Inuit homelands) lived in households which experienced FI [25] and documented that 52% of Inuit older than 25 years of age living in the Arctic lived in households which experienced FI: Nunavut 55%, Nunavik 55%, Nunatsiavut 42% and Inuvialuit Settlement Region 33% [26]. In Iqaluit, the capital of Nunavut, FI was identified in 32.9% of households with children compared to 23.2% of households without [27]. The odds of FI among adolescents were higher in Nunavut (aOR 6.77), Northwest Territories (aOR 2.11) compared to Ontario [28]. Food security in Inuit Nunangat is a public action priority for ITK, Inuit land claims organizations, and governments, as indicated in the Inuit Nunangat Food Security Strategy [29].

First nations children

The National FN Regional Health Survey documented that over half of FN adults were moderately or severely FI. For those households with children, 43% were FI [30]. The First Nations Food, Nutrition and Environment Study (FNFNES) across-Canada participatory study of 92 on-reserve First Nations (south of 60° from 2008 to 2018) in partnership with the AFN, documented that 54% of households with children experienced FI vs 36% without children [23] and made recommendations to address FI [13]. In a FN Territory in Northern Ontario the prevalence of FI was 76% in households with children [20].

Métis children

There is a deficiency of data regarding FI for Métis children and more research is required. Métis children present a high prevalence of risk factors for food insecurity [31, 32]. Métis children are more likely to live in larger households, are twice as likely to live in a single parent household, and twice as likely to live in poverty compared to non-Aboriginal children, all risks factors for FI [14]. According to the Métis National Council (MNC), the lack of access to land (through historical dispossession) for harvesting traditional foods and agriculture, has been a long-standing issue for FI. The MNC’s Virtual Dialogue on Food Security and the Métis Nation in 2021 provided a summary of Métis FI issues and strategies [15].

While Indigenous populations in remote areas have a high prevalence of FI, it is an issue for urban Indigenous children as well. Métis and off-reserve FN youth in Saskatchewan and Ontario struggled to have healthy foods due to the unaffordability, availability, and lack of proximity without transportation [22, 33]. They resorted to energy dense market food (MF), as it was cheaper and lasted longer. The authors concluded that food insecurity manifested itself in different ways and suggest that obesity prevention strategies should take a family-targeted approach that consider the unique barriers facing urban Indigenous Peoples.

Determinants of FI

The contributing factors for FI in Indigenous populations are complex and include individual and community factors, historical, social and political factors. Batal described a paternalistic system that systematically provides inferior care, with a higher prevalence of malnutrition and obesity [34]. The Truth and Reconciliation Commission’s 2015 report [35] documented that trauma from residential schools and other discriminatory policies that have led to inter-generational trauma, addictions, underemployment and poverty for some individuals and communities, all of which contribute to FI [36]. Adults who attended or those with a parent or a grandparent who attended a residential school had a higher proportions of severe FI than those who did not (16.4%, 16.2% respectively verses 6.9%) [21]. The legacies of colonization, including many treaties, the Indian Act, and residential schools were strongly tied to policies focused on the assimilation and control of Indigenous People [37, 38]. Some of these policies impacted the availability and accessibility of food such as buffalo, and restricted hunting rights with confinements to reserve areas. Some cultural sharing practices involving feasts and ceremonies were outlawed, resulting in loss of inter-generational knowledge of traditional food procurement and preparation [38].

The pervasive driver for FI is poverty [11]: the high cost of market food (MF) which is commercially produced foods and is transported in, compared to the household income. Families more vulnerable to FI include those: with children, of larger size, single parent households headed by women, with lower education attainment, on income assistance or with limited income, limited knowledge of healthy MF, living in overcrowded conditions, and living in remote communities [8, 11, 24, 39]

Traditional foods and market foods

Over thousands of years, Indigenous populations have adapted to a diet suitable to their environment. Traditional (country) foods (TF) included any animals and plants harvested from the local environment [39]. The type of TF consumed reflected the local environment. For example, for coastal communities, fish and marine animals were a predominant part of the diet, berries and land animals in the interior. In Arctic regions above the tree line with a very short growing season, meats, fish, and marine animals have long been important TF [39].

TF were healthy and had all the nutrients required for a healthy active life, while food shortages occurred at times. TF tend to have higher amounts of protein, healthy fats, vitamins and minerals as well as lower amounts of saturated fat, carbohydrates, sugars and sodium [15] than most available MF. Along with the nutritional benefits of TF, hunting and gathering of TF is commonly a community activity that required physical activity and is deeply rooted in cultural traditions and identity, including networking and sharing [39].

Indigenous Peoples in Canada have gone through rapid change from traditional land-based food production to acculturation and participation in the wage economy where MF have become a greater part of the diet for many Indigenous communities [40]. The high cost of nutritious MF, especially in remote areas in comparison to household income, is a major contributor of FI. The 2017 Nunavut Food Price Survey compared the cost of staple food items demonstrated that the cost of food in Nunavut was at least double that of the rest of Canada [41]. Surveys through FNFNES also demonstrated FI across Canada where remoteness was correlated with food costs. In the most northern FN communities of Saskatchewan, a FNFNES survey revealed food costs almost triple those in the southern urban center [42].

With the social demographic changes in lifestyle, MF which are commercially produced foods have been transported in and are now a major portion of the diet [40]. The high cost of hunting including the cost of transportation, gasoline, ammunition, and lack of hunting equipment are major contributors to the demographic change [39, 43, 44]. Historically TF were shared with the extended households and the community, especially to those families who did not have a hunter, as having an active hunter in the family is associated with reduced FI [40, 45]. The sale of TF is an increasing trend in many areas. While potentially increasing access to TF for some, it risks limiting the exchange to those who can afford it, reproducing income-mediated patterns of access to healthy foods [39].

Environmental regulations and jurisdictional issues can also be barriers to the community’s ability to hunt on their traditional territories. Climate change, changing the migratory routes of animals, and declines in some animal populations such as caribou, walrus, changes the accessibility, availability and quality of TF and has significant dietary implications [40, 46]. Food safety concerns from naturally occurring or man-made contaminants have the potential of decreasing use of TF, and increasing FI, [47–49]. Persistent organic pollutants (POP) such as organochlorines, polychlorinated biphenyl (PCB)s and heavy metals, such as mercury and lead tend to accumulate in Arctic and sub-Arctic regions [40, 47, 48] and bioaccumulate in the food chain, especially in larger animals such as toothed whales, seal and walrus. Despite this, TF continues to be recognized by elders as healthier than MF, and important in the prevention of illness [39, 48, 49]. Traditional food consumption was associated with adequate nutrient intakes in Nunavut Inuit children aged 3–5 years [50]. Ideally a balance of TF and/or healthy MF needs to be optimized and combined to prevent FI, especially when TF is less available.

Displacing TF with high energy and nutrient poor MF, such as sweetened drinks or chips, tends to increase excess calories, especially from fat and carbohydrates, contributing fewer vitamins and minerals [51]; however, MF is more affordable. Long transportation distances and delays often result in perishables being of poor quality, expired, expensive or unavailable [43]. In Inuit communities in Nunavut, non-nutrient-dense foods were acquired three times more frequently than more nutrient-dense foods [52]. Studies in Indigenous communities including Inuit, Dene and Métis communities found that the younger generation preferred MF over TF with diets that had higher carbohydrate intake mostly in the form of sucrose and a trend towards greater saturated fats [53] but were inadequate in calcium, Vitamin A, folic acid and fiber.

Consequences of FI

FI in a child can have numerous adverse short-term and potential life-long consequences on their health, education and future employment. FI emerges as a predictor of multiple forms of malnutrition such as undernutrition, being overweight and obesity [54]. Malnourished children are more likely to subsequently develop acute and chronic illnesses including cardiac disease, diabetes and cancer [11, 55, 56]. FI in young children is associated with lower cognitive development outcomes and behavioral problems [2, 3]. Hunger also impedes learning as children have difficulty trying to learn while hungry and can experience reduced academic achievements [2]. FI in childhood has also been associated with future unemployment, and can perpetuate the vicious cycle of poverty [2, 3]. It can create stress in the family environment and contributes to anxiety and depression [3, 57]. FI has been associated with poor general and mental health, high stress levels, and life dissatisfaction [58] and an increased risk of dysthymia and thoughts of suicide in adolescents [59]. Severe household FI in Nunavik in childhood and adolescence was associated with persistent psychological distress in adolescence [57]. For youth living in Inuit Nunangat from 1994 to 2008, the mortality rate in Inuit children was 5 times, and suicide rate 30 times higher than the national Canadian average respectively [60].

Micronutrient deficiencies in Indigenous children, related to FI have been associated with numerous adverse health outcomes. FI in Nunavik was associated with nutritional deficiencies especially iron deficiency anemia (IDA), and FI children were an average of 2 cm shorter than food secure children [61]. IDA was identified in 36% of children in a surveillance of Indigenous children in the James Bay area [62]. Vitamin D-deficient rickets which is associated with FI (55) disproportionately impacts Indigenous and northern children in Canada with an incidence of rickets in 1 and 2 year old children in the three Canadian territories equal to 6–12 times higher than the rest of Canada [63, 64].

Dental caries surveys in Inuit and FN, reported very high rates in children: from 69 to 90%, with an average of 6–8 teeth with dental decay by 12–19 years [65]. The risk was associated with increased consumption of soda pop (sweetened beverages), and the lack nutritional supplements containing Vitamin D, calcium or fluoride, and not drinking milk [51]. This was all compounded by poor access to oral healthcare [65, 66]. Poor diet prior to conception can have lasting effects on the infant’s health. In eastern James Bay, Northern Quebec, in an area with low levels of maternal dietary folate, there is a high prevalence of spinal bifida [67].

Obesity can be a significant consequence of FI along with its related health issues [68]. FI was associated with an elevated BMI in Inuit households in the Arctic [11]. Indigenous children are twice as likely to be classified as obese [69]. From the Aboriginal People’s Survey assessing youth ages 6 to 17, 22% of Métis and FN were overweight and 15% obese [69]. Households with very high FI were at higher risk of being overweight or obese. In 18 Canadian Inuit communities, there was a significant decrease in TF and increase in MF, with an increase in BMI over a decade from 1998 [70]. In Cree children grades 4–6 in northern Quebec, 29.9% were overweight and 34.4% were obese and Cree children aged 9–18, 67.6% of were overweight where the majority of the diet consisted of high energy dense MF such as sweetened beverages and snack foods with intakes of zinc, calcium and vitamin D below the recommended intake [71]. The lack of clean water in many Indigenous communities has resulted in the substitution of water with sugary drinks (soda, juice) contributing to the obesity issue [72]. One of the most serious consequences of obesity is the epidemic of type 2 diabetes in many FN communities [73, 74] as well as cardiac disease.

Recommendations

Food security is a Human Right [1]. In view of the many specific risk factors and the highest prevalence in Canada, FI must be addressed as an urgent public health crisis for Indigenous Peoples in Canada. In addition, we must respect and incorporate the United Nations Declaration on the Rights of Indigenous Peoples (UNDRIP) which acknowledges the rights of Indigenous Peoples “to engage freely in all their traditional and other economic activities”, including traditional hunting and harvesting [79].

Strategies and policies

Taking into considerations that Indigenous Peoples and their children in Canada are overrepresented amongst those affected by FI, the specificities relating to the consequences of the colonialism, a National Indigenous Food Strategy Program within a food sovereignty framework are required. Key components include involvement of community leadership, recognizing community and individual food preference, and increasing the availability and quality of TF and healthy MF. It must be resourced to ameliorate, monitor, and evaluate FI strategies [19].

a) Addressing poverty

As the primary driver for FI is poverty, especially in relation to the high cost of healthy MF and the ability to obtain TF, poverty reduction programs are critical to reducing FI in Indigenous populations in Canada [11]. Coordinated poverty reduction strategies involving Indigenous organizations, territorial, provincial and federal governments [11] need to be developed. This includes income support to reflect the real cost of living and increasing funding for programs supporting FNIM employment. Prioritizing a reform of the Nutrition North Program into an evidence-based food security program, increasing community eligibility, subsidizing healthy foods, hunting and harvesting, with adequate oversight and accountability will help to ensure subsidies result in better access and quality of MF and TF.

b) Translation into practice: FNIM-led food strategies

Translational science research to practice is very important. It is imperative to support and implement the recommendations of FNIM-led food security strategies, including the FNFNES (2021), MNC’s report on Food Security & the Métis Nation (2021), and ITK’s Inuit Nunangat Food Security Strategy (2021) [12–14] which outline clear objectives and actions for improving food security and poverty reduction strategies. Other measures include:

• Enabling the acquisition of healthy TF by subsidizing ammunition, and gas for hunters, and support community harvesting and storage community freezers, school and traditional harvesting programs [12, 13, 19].
• Maintaining and improving harvester support programs support community wellness and intergenerational knowledge sharing and include land-based education and healing as well as sustainable wildlife management [13, 14, 19].
• Ensuring universal child access to healthy foods through federal funding for established school-based and early childhood nutrition and education programs serving Indigenous communities need to be continued and expanded to communities where they do not yet exist [80].
• Promoting food production enterprise opportunities within Indigenous communities, increase self-sufficiency and increase employment opportunities, and innovations such as greenhouses which grow fresh produce (Table 1).

c) Surveillance, monitoring and research

There is an urgent need to address the many gaps in knowledge with high quality research especially where there is a paucity of data, in areas such as urban Indigenous and Métis children, food safety and contamination and and others identified by the Indigenous organizations. Continued research in the fields of FI, food sovereignty, and their relationship to co-occurring conditions related to healthy eating and beverage consumption, and monitoring food safety with respect to environmental toxins in the food chain, are vastly important to the health of Indigenous Peoples. Continued evaluation of FI towards sustainable healthy food programs are important for communities to initiate track, evaluate, and grow robust community-based programs to counter-balance FI. There must be adequate funding for the high-quality, multi-year surveillance data for FI and monitoring FI reduction programs, especially in vulnerable communities in Canada and in particlar for training of Indigenous scholars. Quality Improvement interventions with community leadership, and partership with qualified research teams, are desirable, and could led to more rapid changes and improvements [81].

d) For the clinicians

Clinicians should consider early screening for food insecurity in communities or families at risk. Validated evaluation tools for food insecurity in children are available to the clinicians and require basic clinical communication skills [68, 82]. However, these would need to be validated culturally with the different Nations. The clinician should also be aware of resources available to access quality food in sufficient quantity (such as community organizations, food banks and others). Collaboration with a dietician and/or a traditional knowledge keeper are also excellent resources to have at the clinic, community health center, or hospital. Vitamins and micronutrients supplementation should be provided as needed, when documented or at risk of deficiency in pregnant mother and/or in children. Beyond the immediate health needs, clinicians are well advised to collaborate upstream with the community leaders and public health.

e) Honoring indigenous knowledge

Lastly and most important, is the transition away from deficit-based models such as “Food Insecurity “towards strength-based models, such as Indigenous Knowledge. By doing so, it embraces culturally focused strength-based food sovereignty programs which incorporate and honor ancestral ways of life, language, governance, and traditions. These are all part of many Indigenous connection to the earth, through food source, the maintenance of health through ancestral ways of living, set in the premise of looking forward multiple generations towards the continued resiliency through food, diet, relationship, and sovereignty.