Obesity Management with Indigenous Peoples
Exploring obesity within the context of multiple co-occurring health, socioeconomic, environmental and cultural factors, and situating these within policy/jurisdictional structures specific to Indigenous populations (e.g., federal versus provincial health funding), can facilitate emerging opportunities for obesity management. These contexts highlight a tension that providers must navigate, between drivers of obesity embedded in social- and system-level inequities and protective factors that promote healing through relationships and culturally contextualized approaches to care. Healthcare professionals should consider the following contextual factors when providing obesity care for Indigenous peoples:
- Structural inequities (i.e., social and systemic in origin) are embedded in health, education, social services and other systems, and they maintain social disadvantage for a large segment of the Indigenous population. These inequities influence food security, for example, through lower wages perpetuated by inaccessible education and high food costs in urban and remote areas, or through limited access to activity-based resources at individual and community levels. Indigenous people have experienced systemic disadvantage throughout their lifespan and those of their family members, producing a cumulative effect on obesity. In Indigenous contexts, obesity is therefore deeply affected by responses to pervasive stressors, as individuals navigate social and systemic barriers to meeting their goals.
- Overwhelming stress from social (e.g., discrimination) and systemic exclusion (e.g., poor or absent primary healthcare) can disempower Indigenous people in maintaining healthy behaviours. Patients may appear to be resistant to healthcare recommendations, where together with healthcare providers they may come to feel fatalistic toward their capacity to address obesity. Healthcare professionals often interpret such patient incongruity with recommendations in a deficit lens, labeling it as patient non-compliance or non-adherence. This non-concordance, or seeming apathy, may actually be a sense of paralysis in the face of overwhelming stress.
- Exploration of the patient’s social reality can open opportunities for contextualized approaches to obesity management.
- Reflection on assumptions about seeming apathy may contextualize patient motivations, where deep exploration of one’s own perceptions, attitudes and behaviours toward Indigenous patients may uncover anti-Indigenous sentiment implicit in healthcare practices or systems.
- Validation of a patient’s experiences of inequity can empower both patients and providers to identify steps to address social factors that influence health behaviours.
- Culture and relationships facilitate learning of complex knowledge. The interaction of obesity with co-occurring structural factors represents complex knowledge that is critical for patients to gain deep understanding of their health. Non-Indigenous healthcare providers may have ways of knowing and doing that are inconsistent with Indigenous patient perspectives on health knowledge and how it should be exchanged. Obesity management in this context requires a longitudinal, relationship-centred approach that engages and explores interactions with co-existing factors to build both knowledge and trust, in a manner aligned with Indigenous principles for communication.
- Connection: When patients connect with healthcare providers around their co-occurring health needs, there are complex linkages between wider structures and their health. The therapeutic relationship may be critically supportive when knowledge is delivered in a relevant way and makes sense to the patient.
- Trust-building: Healing of the therapeutic relationship is itself fundamental to engaging and supporting patients within contexts of multi-generational trauma to explore complex intersections in relation to health and health behaviour change.
- Differing worldviews: Western concepts of healthy behaviours related to obesity management, including preferences for body size, activity and food, may be discordant with Indigenous perspectives. Patients may not identify with provider perspectives, and providers must not assume that patients share provider worldviews or principles around how to communicate health knowledge. Discordant perspectives may involve a distinct sense of locus of control, self-efficacy and modes for speaking about the pathways into and out of obesity. An Indigenous approach to knowledge exchange includes contextualizing knowledge within the world of the patient and employing a narrative-based and indirect approach to sharing knowledge.
We suggest that healthcare providers for Indigenous people living with obesity:
- Engage with patient social realities.
- Validate the patient’s experiences of stress and systemic disadvantage influencing poor health and obesity, exploring elements of their environment where reduced stress could shift behaviours (Level 4, Grade D, Consensus).
- Advocate for access to obesity management resources within publicly funded healthcare systems, recognizing that resources beyond may be unaffordable and unattainable for many (Level 4, Grade D, Consensus).
- Help patients recognize that good health is attainable, and they are entitled to it (Level 4, Grade D, Consensus).
- Negotiate small attainable steps relevant to the patient’s context (Level 4, Grade D, Consensus).
- Address resistance, seeming apathy and paralysis in patients and providers (Level 4, Grade D (Consensus).
- Self-reflect on anti-Indigenous sentiment common within healthcare systems, exploring patient motivations and mental health (e.g., trauma, grief) as alternative understandings of causes and solutions to their health problems. Explore one’s own potential for bias influenced by systemic racism (Level 4, Grade D, Consensus).
- Expect patient mistrust in health systems; reposition yourself as a helper to the patient instead of as an expert, which may stir resistance and be a barrier to their wellness(Level 4, Grade D, Consensus).
- When resistance, seeming apathy and paralysis are encountered, explore patient mental and emotional health needs, which have unique drivers and presentations in many Indigenous contexts (Level 4, Grade D, Consensus).
- Build complex knowledge by healing relationships (Level 4, Grade D, Consensus).
- Build patient knowledge and capacity for obesity self-management through longitudinal explorations of co-occurring health, social, environmental and cultural factors. Strive to build relationships that incorporate healing from multi-generational trauma, which due to residential schools and child welfare system involvement may more frequently include sexual abuse (Level 4, Grade D, Consensus).
- Build your own knowledge regarding the health legacy of colonization—including ongoing experiences of anti-Indigenous discrimination within systems and wider society—to facilitate relationships built on mutual understanding (Level 4, Grade D, Consensus).
- Ensure knowledge provided is congruent with the patient’s perspectives and educational level, and is learner-centred, including potential for patient anticipation of racism or unequal treatment (Level 4, Grade D, Consensus).
- Connect to behaviour, the body and Indigenous ways of knowing, doing and being (Level 4, Grade D, Consensus).
- Elicit and incorporate the patient’s individual and community-based concepts of health and healthy behaviours in relationship to body size, activity and food preferences (e.g., preference for and/or scarce access to land-based foods and activities) (Level 4, Grade D, Consensus).
- Deeply engage in learning of common values and principles around communication and knowledge sharing in Indigenous contexts (e.g., relationalism, non-interference) (Level 4, Grade D, Consensus).
There is a strong relationship between stress, health, and obesity. Addressing stressors is an important part of being healthy.
- The causes of obesity are complex, with unique personal and historical factors that include colonization and residential school experiences affecting Indigenous people. Look for opportunities to speak with your healthcare providers, family, and wider community to build understanding of its causes and to reveal pathways to your health and wellness.
- Addressing stress and other emotional pain in your life can be protective of obesity. It is important for you to explore, identify, and address causes of stress in your life, at personal, social, and wider system levels. Seek out support from people you trust, including your healthcare providers. Doctors, nurses, dietitians, and social workers can be important resources for healing and accessing knowledge.
- Part of healing from the past is working on small, attainable steps that may best influence positive health and promote a healthier body weight.
- Community resources are important in this journey. Seek to connect with community activities that promote healthy behaviours (e.g., activity groups, traditional food preparation, community gardens).
- Due to colonization and social exclusion, Indigenous people experience significant stress that discourages overall mental and emotional wellness. Cultural and community disruption caused by colonization complicate the already-complex causes of obesity for Indigenous people. Learning about the causes and possible solutions to stressors at personal, social, and systemic levels is important to preventing and managing obesity, as this can allow you to connect to opportunities for support.