Ann Ragnhild Broderstad

Indigenous and tribal peoples' health (The Lancet-Lowitja Institute Global Collaboration): a population study.

BACKGROUND International studies of the health of Indigenous and tribal peoples provide important public health insights. Reliable data are required for the development of policy and health services. Previous studies document poorer outcomes for Indigenous peoples compared with benchmark populations, but have been restricted in their coverage of countries or the range of health indicators. Our objective is to describe the health and social status of Indigenous and tribal peoples relative to benchmark populations from a sample of countries. METHODS Collaborators with expertise in Indigenous health data systems were identified for each country. Data were obtained for population, life expectancy at birth, infant mortality, low and high birthweight, maternal mortality, nutritional status, educational attainment, and economic status. Data sources consisted of governmental data, data from non-governmental organisations such as UNICEF, and other research. Absolute and relative differences were calculated. FINDINGS Our data (23 countries, 28 populations) provide evidence of poorer health and social outcomes for Indigenous peoples than for non-Indigenous populations. However, this is not uniformly the case, and the size of the rate difference varies. We document poorer outcomes for Indigenous populations for: life expectancy at birth for 16 of 18 populations with a difference greater than 1 year in 15 populations; infant mortality rate for 18 of 19 populations with a rate difference greater than one per 1000 livebirths in 16 populations; maternal mortality in ten populations; low birthweight with the rate difference greater than 2% in three populations; high birthweight with the rate difference greater than 2% in one population; child malnutrition for ten of 16 populations with a difference greater than 10% in five populations; child obesity for eight of 12 populations with a difference greater than 5% in four populations; adult obesity for seven of 13 populations with a difference greater than 10% in four populations; educational attainment for 26 of 27 populations with a difference greater than 1% in 24 populations; and economic status for 15 of 18 populations with a difference greater than 1% in 14 populations. INTERPRETATION We systematically collated data across a broader sample of countries and indicators than done in previous studies. Taking into account the UN Sustainable Development Goals, we recommend that national governments develop targeted policy responses to Indigenous health, improving access to health services, and Indigenous data within national surveillance systems. FUNDING The Lowitja Institute.

Population based study of health and living conditions in areas with both Sami and Norwegian populations--the SAMINOR study

Objectives. The overall aim of the SAMINOR project was to study health and diseases in relation to living conditions among the Sami population and to compare these with the Norwegian population in the same area. This article provides an overview of the background of the study and a description of the methods employed for the data collection. We give sample characteristics and elaborate on different definitions of ethnicity. Study Design. Cross-sectional, population-based study, including questionnaires, a clinical examination and analyses of blood samples. Methods. All individuals 30 or 36 to 79 years of age who were living in defined municipalities or specified local areas with a known Sami population were invited to a cardiovascular screening program. The data were collected during 2003–2004. The questionnaires focused on living conditions, health, Sami traditions and ethnicity. The eligible population consisted of 27,987 individuals and 16,865 (60.6%) participated by answering at least one questionnaire. Analyses were restricted to the 36 to 79 year-old age group which had 16,538 participants. The screening program comprised a blood sample, measurements of blood pressure, height, weight, and waist and hip ratio. Different definitions of Sami ethnicity were explored. Results. Of the sample, 35.6% reported Sami background, and 13.2% reported that they, their parents and their grandparents had Sami as their domestic language. This stringent definition of Sami produced clearer differences between Sami and Norwegians, as shown for some measures of socioeconomic status. Conclusions. The findings that are related to more strict definitions of Sami ethnicity have important implications for the interpretation of earlier works and for future studies.

Dietary intake of heme iron and risk of gastric cancer in the European prospective investigation into cancer and nutrition study

Even though recent studies suggest that a high intake of heme iron is associated with several types of cancer, epidemiological studies in relation to gastric cancer (GC) are lacking. Our previous results show a positive association between red and processed meat and non cardia gastric cancer, especially in Helicobacter pylori infected subjects. The aim of the study is to investigate the association between heme iron intake and GC risk in the European prospective investigation into cancer and nutrition (EURGAST‐EPIC). Dietary intake was assessed by validated center‐specific questionnaires. Heme iron was calculated as a type‐specific percentage of the total iron content in meat intake, derived from the literature. Antibodies of H. pylori infection and vitamin C levels were measured in a sub‐sample of cases and matched controls included in a nested case‐control study within the cohort. The study included 481,419 individuals and 444 incident cases of GC that occurred during an average of 8.7 years of followup. We observed a statistically significant association between heme iron intake and GC risk (HR 1.13 95% CI: 1.01–1.26 for a doubling of intake) adjusted by sex, age, BMI, education level, tobacco smoking and energy intake. The positive association between heme iron and the risk of GC was statistically significant in subjects with plasma vitamin C <39 mmol/l only (log2 HR 1.54 95% CI (1.01–2.35). We found a positive association between heme iron intake and gastric cancer risk.

Dietary intake of iron, heme-iron and magnesium and pancreatic cancer risk in the European prospective investigation into cancer and nutrition cohort

Several studies support a protective effect of dietary magnesium against type 2 diabetes, but a harmful effect for iron. As diabetes has been linked to pancreatic cancer, intake of these nutrients may be also associated with this cancer. We examined the association between dietary intake of magnesium, total iron and heme‐iron and pancreatic cancer risk in the European Prospective Investigation into Cancer and Nutrition (EPIC) cohort. In total, 142,203 men and 334,999 women, recruited between 1992 and 2000, were included. After an average follow‐up of 11.3 years, 396 men and 469 women developed exocrine pancreatic cancer. Hazard ratios and 95% confidence intervals (CIs) were obtained using Cox regression stratified by age and center, and adjusted for energy intake, smoking status, height, weight, and self‐reported diabetes status. Neither intake of magnesium, total iron nor heme‐iron was associated with pancreatic cancer risk. In stratified analyses, a borderline inverse association was observed among overweight men (body mass index, ≥25 kg/m2) with magnesium (HRper 100 mg/day increase = 0.79, 95% CI = 0.63–1.01) although this was less apparent using calibrated intake. In female smokers, a higher intake of heme‐iron was associated with a higher pancreatic cancer risk (HR per 1 mg/day increase = 1.38, 95% CI = 1.10–1.74). After calibration, this risk increased significantly to 2.5‐fold (95% CI = 1.22–5.28). Overall, dietary magnesium, total iron and heme‐iron were not associated with pancreatic cancer risk during the follow‐up period. Our observation that heme‐iron was associated with increased pancreatic cancer risk in female smokers warrants replication in additional study populations.

Iron status in a multiethnic population (age 36–80 yr) in northern Norway: the SAMINOR study

Objectives:  Northern Norway consists of a multiethnic population of Sámi and non‐Sámi. We evaluated iron status in these two groups with respect to gender, age and residence.

Iron stores in relation to dietary patterns in a multiethnic population: the SAMINOR study

OBJECTIVE We evaluated the association between serum ferritin (s-ferritin), transferrin saturation and dietary patterns, in connection with ethnicity, geographical settlement and lifestyle factors. DESIGN In 2003-2004, a cross-sectional study of health and living conditions was carried out in northern Norway. SETTING A questionnaire explored, among other factors, ethnicity and food consumption habits. Principal component analysis was used to assess the association between variables. Seven principal components were then used as input to a cluster analysis. To characterise food consumptions, five dietary patterns were identified and used to assess the effect of food consumption habits on Fe stores. SUBJECTS A total of 16 323 men and women between the ages of 36 and 79 years participated. RESULTS Participants who frequently consumed reindeer meat had higher levels of s-ferritin (P < 0.0001) than did individuals with other dietary patterns. This pattern was highly represented by subjects with three generations of Sami language (Sami I). Further, mean transferrin saturation in the reindeer group was higher compared with the other dietary clusters for men (P < 0.04) and women (P < 0.02). However, the reindeer pattern individuals also had the highest proportion of subjects with overweight and obesity. Obesity was positively associated with s-ferritin in both men and women (P < 0.0001). CONCLUSIONS The differences in Fe status described earlier between inland Sami and non-Sami can be explained by several factors such as food habits, age and obesity. High level of s-ferritin may reflect high intake of reindeer meat. Being overweight and obese is also associated with s-ferritin levels.

Design and methods in a survey of living conditions in the Arctic – the SLiCA study

Objectives: The main objective of this study is to describe the methods and design of the survey of living conditions in the Arctic (SLiCA), relevant participation rates and the distribution of participants, as applicable to the survey data in Alaska, Greenland and Norway. This article briefly addresses possible selection bias in the data and also the ways to tackle it in future studies. Study design: Population-based cross-sectional survey. Methods: Indigenous individuals aged 16 years and older, living in Greenland, Alaska and in traditional settlement areas in Norway, were invited to participate. Random sampling methods were applied in Alaska and Greenland, while non-probability sampling methods were applied in Norway. Data were collected in 3 periods: in Alaska, from January 2002 to February 2003; in Greenland, from December 2003 to August 2006; and in Norway, in 2003 and from June 2006 to June 2008. The principal method in SLiCA was standardised face-to-face interviews using a questionnaire. Results: A total of 663, 1,197 and 445 individuals were interviewed in Alaska, Greenland and Norway, respectively. Very high overall participation rates of 83% were obtained in Greenland and Alaska, while a more conventional rate of 57% was achieved in Norway. A predominance of female respondents was obtained in Alaska. Overall, the Sami cohort is older than the cohorts from Greenland and Alaska. Conclusions: Preliminary assessments suggest that selection bias in the Sami sample is plausible but not a major threat. Few or no threats to validity are detected in the data from Alaska and Greenland. Despite different sampling and recruitment methods, and sociocultural differences, a unique database has been generated, which shall be used to explore relationships between health and other living conditions variables.OBJECTIVES The main objective of this study is to describe the methods and design of the survey of living conditions in the Arctic (SLiCA), relevant participation rates and the distribution of participants, as applicable to the survey data in Alaska, Greenland and Norway. This article briefly addresses possible selection bias in the data and also the ways to tackle it in future studies. STUDY DESIGN Population-based cross-sectional survey. METHODS Indigenous individuals aged 16 years and older, living in Greenland, Alaska and in traditional settlement areas in Norway, were invited to participate. Random sampling methods were applied in Alaska and Greenland, while non-probability sampling methods were applied in Norway. Data were collected in 3 periods: in Alaska, from January 2002 to February 2003; in Greenland, from December 2003 to August 2006; and in Norway, in 2003 and from June 2006 to June 2008. The principal method in SLiCA was standardised face-to-face interviews using a questionnaire. RESULTS A total of 663, 1,197 and 445 individuals were interviewed in Alaska, Greenland and Norway, respectively. Very high overall participation rates of 83% were obtained in Greenland and Alaska, while a more conventional rate of 57% was achieved in Norway. A predominance of female respondents was obtained in Alaska. Overall, the Sami cohort is older than the cohorts from Greenland and Alaska. CONCLUSIONS Preliminary assessments suggest that selection bias in the Sami sample is plausible but not a major threat. Few or no threats to validity are detected in the data from Alaska and Greenland. Despite different sampling and recruitment methods, and sociocultural differences, a unique database has been generated, which shall be used to explore relationships between health and other living conditions variables.

Prevalence of metabolic syndrome and diabetes mellitus in Sami and Norwegian populations. The SAMINOR—a cross-sectional study

Objectives Metabolic syndrome (MetS) is recognised as a reliable long-term predictor of adverse health outcomes. Elevated prevalence rates of MetS and chronic lifestyle diseases have been documented in different indigenous groups. We aimed to evaluate the prevalence of MetS and diabetes mellitus in relation to ethnicity in Northern Norway. In addition, we discussed different cut-off values for waist circumference (WC) and what impact this has on the prevalence of MetS. Materials and methods SAMINOR is a population-based study of health and living conditions in areas home to Sami and non-Sami populations. The survey was carried out in 2003–2004. All eligible residents in specific age groups were invited. In total, 16 538 males and females aged 36–79 years participated and gave informed consent for medical research. Results This study involved a total of 7822 female and 7290 male participants. Sami affiliation was reported by 5141 participants (34%). The prevalence of MetS was high in both ethnic groups independent of which WC cut-off value was used. No ethnic differences in prevalence of diabetes mellitus were demonstrated. However, ethnicity appeared to affect diabetes treatment, which was more prevalent among Sami than non-Sami women. Conclusions In this study, there was no ethnic difference in diabetes prevalence, but ethnicity appeared to affect diabetes treatment. Tablet treatment was more commonly in use among Sami women than among non-Sami women. We demonstrated a high share of negative metabolic components. These metabolic components have important health implications. Therefore, determining preventive initiatives is important in the primary and specialist healthcare system. These initiatives must be made culture and linguistic specific, in order to reduce differences and improve health status in the whole population.

A population-based study on health and living conditions in areas with mixed Sami and Norwegian settlements - the SAMINOR 2 questionnaire study.

Objectives To describe the method, data collection procedure and participation in The Population-based Study on Health and Living Conditions in Areas with both Sami and Norwegian Settlements – the SAMINOR 2 questionnaire study. Study design Cross-sectional and semi-longitudinal. Methods In 2012, all inhabitants aged 18–69 and living in selected municipalities with both Sami and Norwegian settlements in Mid and Northern Norway were posted an invitation to participate in a questionnaire survey covering several topics related to health and living conditions. The geographical area was similar to the area where the SAMINOR 1 study was conducted in 2003/2004 with the exception of one additional municipality. Participants could alternatively use a web-based questionnaire with identical question and answer categories as the posted paper version. Results In total, 11,600 (27%) participated (16% used the web-based questionnaire), with a higher participation rate among those over 50 (37% for women and 32% for men). Some geographical variation in participation rates was found. In addition, for those invited who also participated in the SAMINOR 1 study, we found that the participation rates increased with the level of education and income, while there was little difference in participation rates across ethnic groups. Conclusion The knowledge generated from future theme-specific research utilizing the SAMINOR 2 database has the potential to benefit the general population in this geographical area of Norway, and the Sami people in particular, by providing knowledge-based insight into the health and living conditions of the multi-ethnic population in these parts of Norway.

Marginalisation and cardiovascular disease among rural Sami in Northern Norway: a population-based cross-sectional study

BackgroundLike other indigenous peoples, the Sami have been exposed to the huge pressures of colonisation, rapid modernisation and subsequent marginalisation. Previous studies among indigenous peoples show that colonialism, rapid modernisation and marginalisation is accompanied by increased stress, an unhealthy cardiovascular risk factor profile and disease burden. Updated data on the general burden of cardiovascular disease among the Sami is lacking. The primary objective of this study was to assess the relationship between marginalisation and self-reported lifetime cardiovascular disease (CVD) by minority/majority status in the rural Sami population of Norway.MethodsA cross-sectional population-based study (the SAMINOR study) was carried out in 2003-2004. The overall participation rate was 60.9% and a total of 4027 Sami individuals aged 36-79 years were included in the analyses. Data was collected by self-administrated questionnaires and a clinical examination.ResultsThe logistic regression showed that marginalised Sami living in Norwegian dominated areas were more than twice as likely to report CVD as non-marginalised Sami living in Sami majority areas (OR 2.10, 95% CI: 1.40-3.14). No sex difference was found in the effects of marginalisation on self-reported life-time cardiovascular disease. Moderate to no intermediate effects were seen after including established CVD risk factors.ConclusionsThis study showed that marginalised Sami living in Norwegian dominated areas were more than twice as likely as non-marginalised Sami from Sami majority areas to report lifetime cardiovascular disease (CVD). Moderate to no intermediate effects were seen after including established CVD risk factors, which suggest little difference in lifestyle related factors. Chronic stress exposure following marginalisation may however be a plausible explanation for some of the observed excess of CVD.