Nutritional Issues in Aboriginal Children

by Lylee Williams

Dr. Michael Moffatt is a Pediatrician, an
Epidemiologist and a Professor in
the Departments of Community Health
Sciences and Pediatrics and Child
Health, Faculty of Medicine, University
of Manitoba. His research interests
in the area of nutrition include the effect
of iron deficiency on child development,
the dietary intake of the Inuit in the Keewatin
Region, NWT, and primary tooth dental caries in Aboriginal children. He is a visiting pediatrician to Norway House,
Manitoba, Coral Harbour and Repulse Bay, NWT.

Nutritional Issues in Aboriginal Children

Dr. Moffatt began his presentation by stating that he was
presenting an opinion piece rather than a systematic review.
He explained that part of the problem is the shortage
of accurate and adequate data on nutritional issues.
However, he believes that an abundant amount of issues
affect Aboriginal people in many parts of Canada.
Three of these issues were the topic of his presentation:
Iron Deficiency, Vitamin D and Calcium Deficiency, and Obesity.

Iron Deficiency:
Iron is the mineral found in the largest amounts in the blood.
Important for growth, it is also required for a healthy immune
system and for energy production. Iron deficiency is most often
caused by insufficient intake.²

Overview of existing data:

Data from health studies and surveys carried out in
Canadian Aboriginal populations during the 1970s to the
1990s suggested the following:

Nutrition surveys in the 1970s suggested that 40 per cent
of Aboriginal children between 1-4 years old were iron deficient.

A 1970s Cross Lake, Manitoba study showed 20 per cent
of preschool children having significant anaemia.

Studies in the mid-1980s in Norway House, Manitoba
found that more than 50 per cent of the children between 6-24 months old had iron deficiency as marked by anaemia. It is probable that a larger portion had iron deficiency without anaemia.

In the late 1980s-early 1990s, surveys done in the Mackenzie Valley, NWT showed infants whose mothers had not received iron supplements in pregnancy had low levels of iron at 4 1/2 months old.

In the 1990s, a health survey in the Keewatin region, NWT found a 27 per cent incidence of anaemia in children from the ages of 9 months to 2 years old.

In the early 1990s, 53 per cent of urban Aboriginal children in Winnipeg not assigned to a iron-supplemented treatment group had low levels of iron between the age of 6-15 months.

Anaemia is a condition in which there are too few red blood cells in the blood stream, resulting in a decrease in the amount of oxygen that the blood is able to carry. As a result, they have less energy available to perform their normal functions. Important processes, such as muscular activity and cell building and repair, slow down and become less efficient. The most common cause of anaemia is iron deficiency.2

Risk factors:

Dr. Moffatt stated: "The clinical conclusion is that iron
deficiency almost certainly affects many Aboriginal infants,
toddlers and children in Canada, both urban and rural."

He identified the following risk factors:

Poverty.

Low parental education.

Poor access to iron-fortified formulas.

A dependence on evaporated milk as a formula, which has arisen because of decreased access to Native traditional foods that may be used for weaning.

In-the-womb exposure to gestational diabetes can result in low transfer of iron from the mother to the fetus.

Consequences of iron deficiency:

There is evidence that iron deficiency leads to "iron deficiency
anaemia" and studies show a link to motor and cognitive effects. Dr. Moffatt pointed out, "There's not proof at this point" and
added that a cognitive effect of iron deficiency is probable but unproven at the present time.

Characteristic features of iron deficiency anaemia in children include
failure to thrive (grow) and increased infections. Dietary deficiencies,
especially of iron, folic acid and vitamins B6 and B12, can lead to anaemia.3
Cognition is the mental process of knowing, thinking, learning and judging.4

Suggestions for intervention:

Dr. Moffatt made the following suggestions to reduce iron
deficiency in children:

Encourage breastfeeding.

Promote the use of iron-fortified formulas for infants.

Discourage the use of evaporated milk even though it is
much cheaper in many economically depressed areas.

In communities where the prevalence of iron deficiency may
be in the 20-25 per cent range, to screen babies at 9 months of age and make appropriate interventions when iron deficiency is discovered.

Adequate iron intake may be accomplished through a well-balanced
diet or iron supplements as well as the provision of iron-fortified formula
for bottle-fed infants.5

Vitamin D and Calcium:

Rickets still exists in some Aboriginal communities.
Dr. Moffatt reported that deficiencies in vitamin D
and calcium are very prevalent in Manitoba and announced
that rickets still exists.

Rickets is a bone disease of children that is caused by a lack of vitamin D.
Symptoms include poor growth of skull bones, delayed teething, deformed
chest, potbelly, bow legs, and swollen wrists and ankles. Giving a concentrated supply of vitamin D in addition to an adequate diet is a standard treatment for
rickets. Calcium supplements may also be prescribed to help restore the
normal calcium. Any deformities usually disappear if the condition is treated in the early stages. 6

In 1986, 48 rickets cases were reported in Manitoba over a 15-year period. Forty of these were from Aboriginal communities with almost half coming from the Island Lake area. In the 1990s, studies of calcium intake of northern populations showed an intake of 50 per cent or less of the recommended amounts. These findings are not surprising because dairy products, which are a good source of calcium, are not widely used and not very available there.

Dietary calcium is needed during growth for bone development
and for maintenance of skeletal integrity later in life to prevent
osteoporosis, which is the loss of normal bone density, mass
and strength, leading to increased porousness and vulnerability
to fracture.7

The community of Garden Hill in the Island Lake area has a
particular problem with rickets. In the 1980s, a survey in two
of the communities in this area showed that the majority of children had vitamin D levels well below the normal range.
In 1993-94, the incidence appears to have been in a range of
85 per 1,000. Dr. Moffatt concluded that this is a community whose members have very low vitamin D stores in the body.

Treating rickets:

To treat the problem of rickets, "Stoss Therapy" was
introduced in Garden Hill, in which mothers were given
100,000 units of vitamin D at the diagnosis of pregnancy.
Babies were given 100,000 units at the age of 1 month
and again at 4 months. The result of that program actually
has been the virtual elimination of rickets from this community.
The only cases seen have been in children whose mothers either missed the program or refused to take part in it. As a result, since
1995 there haven't been rickets cases in this community, since 1995. To determine community and risk factors that might be responsive to change, three Manitoba Aboriginal communities were recently looked at and compared:

Garden Hill (high incidence of rickets)
St. Theresa Point (lower incidence)
Norway House (no rickets cases)

Surprisingly, the percentage of women in Norway House
with blood levels of vitamin D below accepted standards
was almost 80 per cent. This was in the summer, when the level
should have been the highest due to increased exposure
to sunlight.

The body produces Vitamin D, the sunshine vitamin,
when exposed to the sun's ultraviolet light.8

Dr. Moffatt thinks that what is probably happening in these
two communities, one with high incidence and the other
with none, is common to other northern communities:
high geographic latitude with decreased exposure to sunlight
and therefore few external sources of vitamin D and calcium.

He speculated, "The curve is shifted just enough in Norway
House to avoid seeing rickets. The breastfeeding rates are
lower in that community and that is almost certainly a risk
factor as well." He added that in many other northern
communities, there might be vitamin D deficiency in many people,
including pregnant women who may be passing on very
low supplies to their infants.

Consequences of low vitamin D levels:

The following have been linked to vitamin D deficiency:

Osteoporosis results in the long term, because of the
small bone masses accumulated prior to birth and early in childhood.

Vitamin D may play a role in resistance to infection.

There is potential of baby bottle tooth decay.

There is scientific evidence that decreased insulin production may exist in the presence of low vitamin D stores.

Some cancers have been potentially associated with vitamin D definciency.

In regard to baby bottle tooth decay, a low level of calcium
in the blood can cause both tetany and poor tooth development. At birth, even a short period of calcium deficiency, called
hypocalcemia, can affect the development of tooth enamel.

Hypocalcemia is a condition in which abnormally low amounts of calcium in the blood. It is extremely serious in newborn babies; particularly those fed on cow's milk. In babies, hypocalcemia causes vomiting and breathing problems. In severe hypocalcemia, the patient may suffer a seizure, or tetany, with muscular spasms of the hands, feet and jaw. 9

There is a high rate of tooth decay in northern Aboriginal communities. Noting that educational programs have not been very successful in reducing this problem, Dr. Moffatt stressed the need for a method of prevention.

He believes that the problem is related to deficiencies of
vitamin D and calcium and that improvement will be seen
with better nutrition. He concluded that such deficiencies
in these communities are probably widespread.

Effecting Change:

In the past, a lot of the calcium intake in these northern
Aboriginal communities was obtained from the traditional diet.
Boiling bones and eating organ meats are just two examples
of likely external sources of vitamin D and calcium. Dr. Moffatt commented, "Most of those traditions have gone by the wayside and access to country foods is less than it used to be."

He suggested the following:

Encourage the use of dairy products.
Introduce public marketing strategies to promote dairy
product use in the north.

He then spoke about lactose intolerance and the fact that
milk is not a traditional food for Aboriginal people.

Lactose intolerance is the inability to digest milk sugar. It is caused by a
lack or deficiency of lactase, an enzyme manufactured in the small intestine. When a person with lactose intolerance consumes milk or other dairy products, some or all of the lactose they contain remains undigested, retains fluid and
ferments in the colon, resulting in diarrhea, gas and abdominal cramps.
Being lactose intolerant is not a serious threat to health and can easily be
managed through dietary modification.10

Surveys in Island Lake found that despite this fact, almost
everyone said that they would use more dairy products
if they could get them or if they could afford them.

Currently in Garden Hill, mothers who participate in the
dental caries study comparing the children of mothers
who did and did not get the "Stoss Therapy" dietary
regimen, are given a brick of cheese as a token reward for
their involvement. Dr. Moffatt remarked, "It has been
absolutely astounding how well that's been received.
Everybody wants the cheese and so, it can be
observed that they're not as resistant to dairy products
as might be thought."

To reduce the problem of vitamin D and calcium deficiency,
he suggested the following approaches:

Make dairy products more accessible.

Encourage the use of high calcium foods.

Deliver nutrition education.

Provide adequate supplementation during pregnancy
and perhaps in infancy.

Encourage traditional ways like eating soups
made from boiled bones for increased calcium as well
as eating organ meats for some vitamin D.

Obesity:

A study carried out in Manitoba and northwestern Ontario
in the 1990s showed that obesity was present in 40 per cent of
girls and 34 per cent of boys. Measurements were taken using
a technique called BMI.

BMI refers to Body Mass Index. It is one of the anthropometric
measures of body mass; anthropometric being the technique that
deals with the measurement of the size, weight and proportions
of the human body.11

"This is not good news," Dr. Moffatt commented in reference
to these findings, "because there is clear evidence that it is a
predictor of diabetes." He added that Type 2 Diabetes in
Aboriginal youth is on the upswing in Canada, and in Manitoba
alone, there are 20 new cases a year and the numbers just
keep on growing. He reported a child in Manitoba has already died, only ten years after being diagnosed. Death occurred after complications of renal failure and blindness. As well, another young person in her twenties who has been diagnosed about 10 years earlier is on dialysis right now.

Chronic renal failure represents a slow decline in kidney function
over time. It may be caused by a number of disorders, that including
long-standing diabetes. If renal function declines to a low enough
level (end-stage kidney disease), kidney dialysis may be necessary.
Kidney dialysis is a method of filtering unwanted substances from the
blood using a machine that acts as an artificial kidney.12

Approaches to combat obesity:

Dr. Moffatt reported that there is evidence that some approaches are effective, such as:

The American Pathways Program.

The Kahnawake Schools Diabetes Prevention Program,
that has a great focus on promotion, encouragement and support of good nutrition and physical activities for community members.

Recent evidence from California suggests that just concentrating on decreasing television watching and video games actually results in a stabilization of weight or a decrease in weight.

He pointed out the strong evidence that if obesity is present
in preschoolers and there is an obese parent, it almost certainly predicts obesity in adulthood.

Dr. Moffatt added that nutritional deficiencies are common even before symptoms of illness show up and doctors are just scratching the surface in finding out what the possible health problems are.

In closing, he commented, "We have to remember not to blame the victim but keep in mind that these are almost all the result of poverty. Many, if not most Aboriginal children are actually happy and healthy. They may have some nutritional deficiencies that we can help them with, but there are still a lot of positive things in these communities. None of these families want to intentionally under-nourish their children."

1.Balch, James F., M.D. and Phyllis A. Balch, C.N.C. (1997).
"Prescription for Nutritional Healing". New York, Avery Publishing Group., p. 25.
2 Balch and Balch: 1997:128.
3 Balch and Balch: 1997:128.
4 On-Line Medical Dictionary.
5 Griffith, H. Winter, M.D. (1985). "Symptoms, Illness and Surgery".
California, The Body Press., p. 143.
6 World Book Illustrated Home Medical Encyclopedia. (1984).
Chicago, World Book Encyclopedia, Inc., p. 406.
7 On-Line Medical Dictionary.
8 On-Line Medical Dictionary.
9 McClure, Nicola, Dr. et al. (1983). "The Canadian Family Health Encyclopedia".
Ontario, Libraries Classics Bookshops., p. 278.
10 Balch and Balch: 1997: 361
11 On-Line Medical Dictionary.
12 On-Line Medical Dictionary.