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Objectives: To determine among rural-dwelling on-reserve Saskatchewan First Nations people whether racial discrimination is associated with depression, and in turn, if this relationship is moderated by gender., Methods: As a component of a community-based participatory research project, a cross-sectional, interviewer-administered survey of 874 adults living on 2 Cree First Nation reserves in rural north-central Saskatchewan was conducted during May-August in 2012 and 2013. Self-reported, health-provider diagnosis of depression was the dependent variable and experiences of interpersonal racial discrimination was the primary exposure. Chi-square and multiple logistic regression were the main analytic techniques. Generalized estimating equations were applied to account for clustering within households., Results: Overall, 64% of participants reported being treated unfairly in 1 or more situations because of their ethnicity; 38% indicated discrimination occurring in 3 or more situations. Nineteen percent reported a diagnosis of depression. Adjusted analyses indicated that compared to those with no experience of racial discrimination, those reporting 1-2 and 3 or more situations were 1.77 times (95% CI: 1.06-2.95) and 1.91 times (95% CI: 1.19-3.04) more likely to have diagnosed depression respectively. The relationship between racial discrimination and depression was not modified by gender, although women were 1.85 times (95% CI: 1.24-2.76) more likely to report depression than men., Conclusion: Interpersonal racial discrimination was associated with depression among First Nations women and men in rural Saskatchewan. Research directed at identifying the most efficacious interventions, programs and policies to combat racism is required to advance the goal of health equity.

Background: Diabetes-related end stage renal disease (DM-ESRD) is a devastating consequence of the type 2 diabetes epidemic, both of which disproportionately affect Indigenous peoples. Projecting case numbers and costs into future decades would help to predict resource requirements, and simulating hypothetical interventions could guide the choice of best practices to mitigate current trends., Methods: An agent based model (ABM) was built to forecast First Nations and non-First Nations cases of DM-ESRD in Saskatchewan from 1980 to 2025 and to simulate two hypothetical interventions. The model was parameterized with data from the Canadian Institute for Health Information, Saskatchewan Health Administrative Databases, the Canadian Organ Replacement Register, published studies and expert judgement. Input parameters without data sources were estimated through model calibration. The model incorporated key patient characteristics, stages of diabetes and chronic kidney disease, renal replacement therapies, the kidney transplant assessment and waiting list processes, costs associated with treatment options, and death. We used this model to simulate two interventions: 1) No new cases of diabetes after 2005 and 2) Pre-emptive renal transplants carried out on all diabetic persons with new ESRD., Results: There was a close match between empirical data and model output. Going forward, both incidence and prevalence cases of DM-ESRD approximately doubled from 2010 to 2025, with 250-300 new cases per year and almost 1300 people requiring RRT by 2025. Prevalent cases of First Nations people with DM-ESRD increased from 19% to 27% of total DM-ESRD numbers from 1990 to 2025. The trend in yearly costs paralleled the prevalent DM-ESRD case count. For Scenario 1, despite eliminating diabetes incident cases after 2005, prevalent cases of DM-ESRD continued to rise until 2019 before slowly declining. When all DM-ESRD incident cases received a pre-emptive renal transplant (scenario 2), a substantial increase in DM-ESRD prevalence occurred reflecting higher survival, but total costs decreased reflecting the economic advantage of renal transplantation., Conclusions: This ABM can forecast numbers and costs of DM-ESRD in Saskatchewan and be modified for application in other jurisdictions. This can aid in resource planning and be used by policy makers to evaluate different interventions in a safe and economical manner.

Background: First Nations people are experiencing increasing rates of obesity and type 2 diabetes but no anthropometric information exists from before the 1950s to provide context to these epidemics., Objective: To compare anthropometric indices of First Nations children and youth on first entering residential schools with historical and contemporary reference groups., Methods: This observational cross-sectional study used archival records from the Department of Indian Affairs to calculate body mass index (BMI), height for age (HA) and weight for age (WA) of all known children and youth undergoing physical examinations on first entering residential schools in Saskatchewan and Manitoba from 1919 to 1953. Proportions of children and youth in each BMI category were determined by age, sex, time period and residential school. Z-scores for HA and WA were determined by age group and sex. Finally, median heights and weights were compared with a non-Indigenous cohort from the 1953 Canadian survey., Results: On admission to residential schools, 1,767 First Nations children and youth (847 boys, 920 girls) were more likely to have normal BMIs (79.8%) than Canadian children and youth today (66.5%), but lower rates of overweight/obesity (10.9% vs. 32.0%) and higher rates of underweight (9.3% vs. <2.0%). There was an overall trend of diminishing levels of underweight and increasing levels of overweight/obesity over time. Although 6.6% of boys and 7.9% of girls had HA Z-scores >-2, age-specific median heights tended to be higher than Canadian children and youth in 1953. Under 3% of children and youth had WA Z-scores of >-2., Conclusions: A large majority of First Nations children and youth exhibited normal anthropometric indices on first entering residential schools in Manitoba and Saskatchewan from 1919 to 1953. These historical findings provide an important context to the current epidemics of obesity and type 2 diabetes and suggest that the nutritional conditions in these First Nations children's communities were satisfactory during the residential school era.

Background: Aboriginal peoples in Canada (First Nations, Metis and Inuit) are experiencing an epidemic of diabetes and its complications but little is known about the influence of factors attributed to colonization. The purpose of this study was to investigate the possible role of discrimination, residential school attendance and cultural disruption on diabetes occurrence among First Nations adults., Methods: This 2012/13 cross sectional survey was conducted in two Saskatchewan First Nations communities comprising 580 households and 1570 adults. In addition to self-reported diabetes, interviewer-administered questionnaires collected information on possible diabetes determinants including widely recognized (e.g. age, sex, lifestyle, social determinants) and colonization-related factors. Clustering effect within households was adjusted using Generalized Estimating Equations., Results: Responses were obtained from 874 (55.7 %) men and women aged 18 and older living in 406 (70.0 %) households. Diabetes prevalence was 15.8 % among women and 9.7 % among men. In the final models, increasing age and adiposity were significant risk factors for diabetes (e.g. OR 8.72 [95 % CI 4.62; 16.46] for those 50+, and OR 8.97 [95 % CI 3.58; 22.52] for BMI 30+) as was spending most time on-reserve. Residential school attendance and cultural disruption were not predictive of diabetes at an individual level but those experiencing the most discrimination had a lower prevalence of diabetes compared to those who experienced little discrimination (2.4 % versus 13.6 %; OR 0.11 [95 % CI 0.02; 0.50]). Those experiencing the most discrimination were significantly more likely to be married and to have higher incomes., Conclusions: Known diabetes risk factors were important determinants of diabetes among First Nations people, but residential school attendance and cultural disruption were not predictive of diabetes on an individual level. In contrast, those experiencing the highest levels of discrimination had a low prevalence of diabetes. Although the reasons underlying this latter finding are unclear, it appears to relate to increased engagement with society off-reserve which may lead to an improvement in the social determinants of health. While this may have physical health benefits for First Nations people due to improved socio-economic status and other undefined influences, our findings suggest that this comes at a high emotional price.

Background: To date, determinants of respiratory health in First Nations people living on reserves and means of addressing and redressing those determinants have not been well established. Hence the Saskatchewan First Nations Lung Health Project (FNLHP) is a new prospective cohort study of aboriginal people being conducted in two First Nations reserves to evaluate potential health determinants associated with respiratory outcomes. Using the population health framework (PHF) of Health Canada, instruments designed with the communities, joint ownership of data, and based on the 4-phase concept of the First Nations Regional Longitudinal Health Survey, the project aims to evaluate individual factors, contextual factors, and principal covariates on respiratory outcomes. The objective of this report is to clearly describe the methodology of (i) the baseline survey that consists of two components, an interviewer-administered questionnaire and clinical assessment; and (ii) potential intervention programs; and present descriptive results of the baseline data of longitudinal FNLHP., Methods: The study is being conducted over 5 years (2012-2017) in two phases, baseline and longitudinal. Baseline survey has been completed and consisted of (i) an interviewer-administered questionnaire-based evaluation of individual and contextual factors of importance to respiratory health (with special focus on chronic bronchitis, chronic obstructive pulmonary disease, asthma and obstructive sleep apnea), and (ii) clinical lung function and allergy tests with the consent of study participants. The address-redress phase consists of potential intervention programs and is currently being rolled out to address-at community level (via green light program and environmental study), and redress-at policy level (via obesity reduction and improved diagnosis and treatment of obstructive sleep apnea) the issues that have been identified by the baseline data., Results: Interviewer-administered surveys were conducted in 2012-2013 and collected data on 874 individuals living in 406 households from two reserve communities located in Saskatchewan, Canada. Four hundred and forty six (51%) females and 428 (49%) males participated in the FNLHP., Conclusions: The information from this project will assist in addressing and redressing many of the issues involved including the provision of adequate housing, health lifestyle practices, and in planning for health service delivery.

Objective: To compare the long-term risks of end stage renal disease and death among First Nations and non-First Nations people with youth-onset diabetes., Methods: Using Saskatchewan Ministry of Health administrative databases covering the period between 1980 and 2005, we conducted a retrospective cohort study of end stage renal disease and death among youth with diabetes diagnosed before age 20. We developed Fine and Gray sub-distribution hazards models and cumulative incidence functions for the 2 outcomes by First Nations status and duration of diabetes., Results: Incident cases of youth-onset diabetes were diagnosed in 352 First Nations and 2288 non-First Nations people. Mean ages at diabetes diagnoses were 11.7 and 11.2 years, respectively (p=0.13). Adjusted for sex and age at diabetes diagnosis, the risk for end stage renal disease was 2.59 (95% CI, 1.11-6.04) times higher, and the risk for death 2.64 (95% CI, 1.44-4.87) times higher for First Nations compared to non-First Nations people. After 25 years, the cumulative incidence of end stage renal disease was 12.3% for First Nations people compared to 4.3% in their non-First Nations counterparts. Corresponding mortality rates were 14.6% and 7.2%, respectively., Conclusions: First Nations people with youth-onset diabetes experience higher long-term risks for end stage renal disease and death than their non-First Nations counterparts. Early identification of type 2 diabetes and secondary prevention of diabetic nephropathy are feasible short-term goals for this high-risk group. More effective primary prevention initiatives and programs to delay diabetes onset are imperative to reverse current trends., (Copyright © 2014 Canadian Diabetes Association. Published by Elsevier Inc. All rights reserved.)

Background: Diabetes-related end-stage renal disease disproportionately affects indigenous peoples. We explored the role of differential mortality in this disparity., Methods: In this retrospective cohort study, we examined the competing risks of end-stage renal disease and death without end-stage renal disease among Saskatchewan adults with diabetes mellitus, both First Nations and non-First Nations, from 1980 to 2005. Using administrative databases of the Saskatchewan Ministry of Health, we developed Fine and Gray subdistribution hazards models and cumulative incidence functions., Results: Of the 90 429 incident cases of diabetes, 8254 (8.9%) occurred among First Nations adults and 82,175 (90.9%) among non-First Nations adults. Mean age at the time that diabetes was diagnosed was 47.2 and 61.6 years, respectively (p<0.001). After adjustment for sex and age at the time of diabetes diagnosis, the risk of end-stage renal disease was 2.66 times higher for First Nations than non-First Nations adults (95% confidence interval [CI] 2.24-3.16). Multivariable analysis with adjustment for sex showed a higher risk of death among First Nations adults, which declined with increasing age at the time of diabetes diagnosis. Cumulative incidence function curves stratified by age at the time of diabetes diagnosis showed greatest risk for end-stage renal disease among those with onset of diabetes at younger ages and greatest risk of death among those with onset of diabetes at older ages., Interpretation: Because they are typically younger when diabetes is diagnosed, First Nations adults with this condition are more likely than their non-First Nations counterparts to survive long enough for end-stage renal disease to develop. Differential mortality contributes substantially to ethnicity-based disparities in diabetes-related end-stage renal disease and possibly to chronic diabetes complications. Understanding the mechanisms underlying these disparities is vital in developing more effective prevention and management initiatives.

Background: Indigenous peoples worldwide are experiencing elevated rates of type 2 diabetes and its complications. To better understand the disproportionate burden of diabetic end stage renal disease (ESRD) among Canadian First Nations people (FN), we examined prevalence, determinants, and co-morbidities of chronic kidney disease (CKD) within this population., Methods: The 2007 Canadian FN Diabetes Clinical Management and Epidemiologic (CIRCLE) study conducted a cross-sectional national medical chart audit of 885 FN adults with type 2 diabetes to assess quality of diabetes care. In this sub-study, participants were divided by estimated glomerular filtration rate (eGFR in ml/min/1.73 m2), as well as by albuminuria level in those with eGFRs = > 60. Those with eGFRs = > 60 and negative albuminuria were considered to have normal/near normal kidney function (non-CKD). Using univariate and logistic regression analysis, they were compared with participants having eGFRs = > 60 plus albuminuria (CKD-alb) and with participants having eGFRs <60 (CKD-eGFR <60)., Results: While 84.5% of total CIRCLE participants had eGFRs = > 60, almost 60% of the latter had CKD-alb. Of the 15.5% of total participants with CKD-eGFR <60, 80% had eGFRs 30-60 (Stage 3 CKD) but over 10% (1.6% of total participants) had ESRD. Independent determinants of CKD-alb were male gender and increasing diabetes duration, systolic BP, A1C and total cholesterol. These plus smoking rates also discriminated between FN with micro- and macro-albuminuria. Independent determinants of CKD-eGFR <60 were increasing age at diabetes diagnosis, diabetes duration, total cholesterol and systolic BP. However, participants with CKD-eGFR <60 also displayed a decreasing mean age of diabetes diagnosis as eGFR declined. Micro-vascular co-morbidities were significantly associated with CKD-alb but both micro- and macro-vascular co-morbidities were associated with CKD-eGFR <60. Only 35-40% of participants with CKD used insulin., Conclusions: High prevalences of CKD-alb and early CKD-eGFR <60 among diabetic FN were largely related to modifiable and treatable risk factors. However, an earlier age of diabetes diagnosis and longer duration of diabetes characterized those with ESRD. These findings suggest that a failure to meet current standards of diabetes care interacting with an age-related survival benefit contribute to the disproportionate burden of ESRD among FN and possibly other Indigenous peoples.

Objectives: We investigated the contribution of gestational diabetes mellitus (GDM) to the historic epidemic of type 2 diabetes mellitus (T2DM) in Saskatchewan., Methods: We constructed a population-level simulation model of the inter- and intragenerational interaction of GDM and T2DM for the period 1956 to 2006. The model was stratified by gender, ethnicity, and age; parameterized with primary and secondary data; and calibrated to match historic time series. Risk of diabetes was sigmoidally trended to capture exogenous factors., Results: Best-fit calibrations suggested GDM may be responsible for 19% to 30% of the cases of T2DM among Saskatchewan First Nations people, but only for approximately 6% of cases among other persons living in Saskatchewan. The estimated contribution of GDM to the growth in T2DM was highly sensitive to assumptions concerning the post-GDM risk of developing T2DM., Conclusions: GDM may be an important driver for the T2DM epidemic in many subpopulations. Because GDM is a readily identifiable, preventable, and treatable condition, investments in prevention, rapid diagnosis, and evidence-based treatment of GDM in at-risk populations may offer substantial benefit in lowering the T2DM burden over many generations. Model-informed data collection can aid in assessing intervention tradeoffs.

Background: Saskatchewan Aboriginal people are experiencing epidemics of both type 2 diabetes (T2DM) and tuberculosis (TB). The purpose of this study was to determine if a relationship exists between diabetes and TB in Saskatchewan and to establish whether there is a difference in the degree of any association between Aboriginal and non-Aboriginal people., Methods: Utilizing Saskatchewan Health databases, TB incidence (cases identified from 1986-2001) was compared between four subpopulations identified from 1991-1995: Registered Indians (RI) with and without diabetes, and other Saskatchewan people (OSKP) with and without diabetes., Results: Diabetic women aged 20-59 years had higher average annual incidence rates of TB than non-diabetic women, but within-population rate ratios of TB in diabetic versus non-diabetic women were only significant in those aged 50-59 (2.7 [CI 1.28, 5.72] in RI and 3.9 [CI 1.58, 9.67] in OSKP). No other within-population diabetic subgroup had significantly higher rates of TB. The only male diabetic group that had a higher rate of TB were RI plus OSKP men aged 50-59 years. Overall, diabetes preceded TB in 87/111 individuals with both diseases (p < 0.0001)., Conclusions: Our results suggest that T2DM is a predictor for TB in Saskatchewan women aged 20-59 but particularly in RI and OSKP women aged 50-59 years. This has implications for TB screening and prevention initiatives.

Background: Saskatchewan aboriginal people are experiencing an epidemic of type 2 diabetes (T2DM) and diabetic end-stage renal disease (DESRD). The purpose of these investigations was to study the role of the intrauterine environment in the emergence of these diseases., Methods: Epidemiologic studies were carried out using data from the Provincial Department of Health databases, the Saskatoon Health Region obstetrical unit, the Saskatchewan Renal Transplant Program, surveys of Saskatchewan aboriginal communities, and the Canadian Organ Replacement Registry. Parameters analyzed included rates, risk factors, and outcomes of T2DM, gestational diabetes (GDM), and DESRD; birth registration information; anthropometric measurements; and human leukocyte antigen profiles., Results: Aboriginal ethnicity is an independent predictor of GDM. High rates of GDM appear in remote aboriginal communities before the significant appearance of T2DM and are associated with increasing rates of high birth weight. A significant relationship between high-birth-weight rates and T2DM has strengthened over several decades. Finally, higher birth weights and older mother's age (both associated with GDM), and increased frequencies of the human leukocyte antigen-A2/DR4 and A2/DR8 haplotypes are associated with DESRD among aboriginal people., Conclusion: It is likely that diabetic pregnancies play a key role in the initiation, progression, and perpetuation of the T2DM epidemic among Canadian aboriginal peoples, and may additionally increase the risk for DESRD. We speculate that an ancient survival advantage that promoted caloric conservation in young women and their unborn children is now a risk factor for prepregnancy obesity, GDM, and excess fetal nutrition. Infants are often large and have an increased risk for T2DM and its complications (hefty fetal-type hypothesis).