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Sebai I, Deaconu A, Mobetty F, Nardocci M, Ing A, Batal M. Measurement of diet quality among First Nations peoples in Canada and associations with health: a scoping review. Nutr Rev 2024; 82:695-708. [PMID: 37421656 DOI: 10.1093/nutrit/nuad073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/10/2023] Open
Abstract
BACKGROUND Given the increasing number and the diversity of dietary quality indices used for research, and the differences between settings, there is a need to identify valid indices of dietary quality in different contexts and populations and to identify their associations with health-related outcomes. OBJECTIVES The primary objective of this scoping review is to identify the tools used in determining dietary quality among First Nations and to describe the changes in diet. The second objective is to describe the associations identified in studies that have measured the relationship between health and dietary quality among First Nations; and the third objective is to identify factors associated with diet quality. METHODS PubMed, Embase, CINAHL, Global Health, and Web of Science were searched from inception to June 2021 and updated in February 2022. Articles were included if the research subjects were First Nations, or if articles reported disaggregated subset data for First Nations. Eligible studies focused on nutrition and diet and were published in English or French. RESULTS A total of 151 articles were included in the analysis. Studies used several indicators to measure if individuals adhered to dietary guidelines. Traditional food consumption was frequently used as an indicator of diet quality (n = 96). The consumption of store-bought foods was used as an indicator in 28 studies. Some studies used other diet quality indicators such as the Healthy Eating Index (n = 5) and ultra-processed food "NOVA" classification (n = 6). A trend for decreasing traditional food intake over time was apparent, alongside an increase in store-bought food intake. This trend was accompanied with declining health status, including the increased prevalence of overweight and obesity, diabetes, metabolic diseases, and dental caries. CONCLUSION This scoping review showed that diet quality among First Nations is improved when traditional foods are consumed. Reduced diet quality was associated with increased risk of noncommunicable diseases.
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Affiliation(s)
- Ines Sebai
- Canada Research Chair in Nutrition and Health Inequalities (CIENS), Montreal, Canada
- TRANSNUT, Département de Nutrition, Faculté de Médecine, Université de Montréal, Montreal, Canada
- Centre de Recherche en Santé Publique, Université de Montréal et CIUSSS du Centre-Sud-de-l'Île-de-Montréal, Montreal, Canada
| | - Ana Deaconu
- Canada Research Chair in Nutrition and Health Inequalities (CIENS), Montreal, Canada
- TRANSNUT, Département de Nutrition, Faculté de Médecine, Université de Montréal, Montreal, Canada
| | - Fabrice Mobetty
- Canada Research Chair in Nutrition and Health Inequalities (CIENS), Montreal, Canada
- TRANSNUT, Département de Nutrition, Faculté de Médecine, Université de Montréal, Montreal, Canada
- Centre de Recherche en Santé Publique, Université de Montréal et CIUSSS du Centre-Sud-de-l'Île-de-Montréal, Montreal, Canada
| | - Milena Nardocci
- Canada Research Chair in Nutrition and Health Inequalities (CIENS), Montreal, Canada
- TRANSNUT, Département de Nutrition, Faculté de Médecine, Université de Montréal, Montreal, Canada
| | - Amy Ing
- Canada Research Chair in Nutrition and Health Inequalities (CIENS), Montreal, Canada
- TRANSNUT, Département de Nutrition, Faculté de Médecine, Université de Montréal, Montreal, Canada
| | - Malek Batal
- Canada Research Chair in Nutrition and Health Inequalities (CIENS), Montreal, Canada
- TRANSNUT, Département de Nutrition, Faculté de Médecine, Université de Montréal, Montreal, Canada
- Centre de Recherche en Santé Publique, Université de Montréal et CIUSSS du Centre-Sud-de-l'Île-de-Montréal, Montreal, Canada
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Vaillancourt C, Ahmed M, Kirk S, Labonté MÈ, Laar A, Mah CL, Minaker L, Olstad DL, Potvin Kent M, Provencher V, Prowse R, Raine KD, Schram A, Zavala-Mora D, Rancourt-Bouchard M, Vanderlee L. Food environment research in Canada: a rapid review of methodologies and measures deployed between 2010 and 2021. Int J Behav Nutr Phys Act 2024; 21:18. [PMID: 38373957 PMCID: PMC10875887 DOI: 10.1186/s12966-024-01558-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 01/03/2024] [Indexed: 02/21/2024] Open
Abstract
Numerous research methodologies have been used to examine food environments. Existing reviews synthesizing food environment measures have examined a limited number of domains or settings and none have specifically targeted Canada. This rapid review aimed to 1) map research methodologies and measures that have been used to assess food environments; 2) examine what food environment dimensions and equity related-factors have been assessed; and 3) identify research gaps and priorities to guide future research. A systematic search of primary articles evaluating the Canadian food environment in a real-world setting was conducted. Publications in English or French published in peer-reviewed journals between January 1 2010 and June 17 2021 and indexed in Web of Science, CAB Abstracts and Ovid MEDLINE were considered. The search strategy adapted an internationally-adopted food environment monitoring framework covering 7 domains (Food Marketing; Labelling; Prices; Provision; Composition; Retail; and Trade and Investment). The final sample included 220 articles. Overall, Trade and Investment (1%, n = 2), Labelling (7%, n = 15) and, to a lesser extent, Prices (14%, n = 30) were the least studied domains in Canada. Among Provision articles, healthcare (2%, n = 1) settings were underrepresented compared to school (67%, n = 28) and recreation and sport (24%, n = 10) settings, as was the food service industry (14%, n = 6) compared to grocery stores (86%, n = 36) in the Composition domain. The study identified a vast selection of measures employed in Canada overall and within single domains. Equity-related factors were only examined in half of articles (n = 108), mostly related to Retail (n = 81). A number of gaps remain that prevent a holistic and systems-level analysis of food environments in Canada. As Canada continues to implement policies to improve the quality of food environments in order to improve dietary patterns, targeted research to address identified gaps and harmonize methods across studies will help evaluate policy impact over time.
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Affiliation(s)
- Caroline Vaillancourt
- École de Nutrition, Centre de Nutrition, Santé et Société (NUTRISS), Université Laval, 2425 Rue de L'Agriculture, Québec, QC, G1V 0A6, Canada
| | - Mavra Ahmed
- Department of Nutritional Sciences, University of Toronto, 1 King's College Circle, Toronto, ON, M5S 1A8, Canada
| | - Sara Kirk
- School of Health and Human Performance, Dalhousie University, 6230 South Street, Kjipuktuk (Halifax), NS, B3H 4R2, Canada
| | - Marie-Ève Labonté
- École de Nutrition, Centre de Nutrition, Santé et Société (NUTRISS), Université Laval, 2425 Rue de L'Agriculture, Québec, QC, G1V 0A6, Canada
| | - Amos Laar
- Department of Population, Family and Reproductive Health, School of Public Health, University of Ghana, P. O. Box LG 13, Legon, Accra, Ghana
| | - Catherine L Mah
- School of Health Administration, Dalhousie University, 5850 College Street, Halifax, NS, B3H 4R2, Canada
| | - Leia Minaker
- School of Planning, University of Waterloo, 200 University Avenue West, Waterloo, ON, N2L 3T1, Canada
| | - Dana Lee Olstad
- Department of Community Health Sciences, University of Calgary, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
| | - Monique Potvin Kent
- School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Crescent, Ottawa, ON, K1G 5Z3, Canada
| | - Véronique Provencher
- École de Nutrition, Centre de Nutrition, Santé et Société (NUTRISS), Université Laval, 2425 Rue de L'Agriculture, Québec, QC, G1V 0A6, Canada
| | - Rachel Prowse
- Division of Community Health and Humanities, Faculty of Medicine, Memorial University of Newfoundland, 300 Prince Philip Drive, St. John's, NL, A1B 3V6, Canada
| | - Kim D Raine
- School of Public Health, University of Alberta, 11405 87 Ave Northwest, Edmonton, AB, T6G 1C9, Canada
| | - Ashley Schram
- School of Regulation and Global Governance (RegNet), ANU College of Asia & the Pacific, The Australian National University, 8 Fellows Road, Canberra, Australian Capital Territory, 2600, Australia
| | - Daniela Zavala-Mora
- Science Library, Université Laval, 1045 Avenue de La Médecine, Québec, QC, G1V 0A6, Canada
| | - Maryka Rancourt-Bouchard
- École de Nutrition, Centre de Nutrition, Santé et Société (NUTRISS), Université Laval, 2425 Rue de L'Agriculture, Québec, QC, G1V 0A6, Canada
| | - Lana Vanderlee
- École de Nutrition, Centre de Nutrition, Santé et Société (NUTRISS), Université Laval, 2425 Rue de L'Agriculture, Québec, QC, G1V 0A6, Canada.
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Shafiee M, Keshavarz P, Lane G, Pahwa P, Szafron M, Jennings D, Vatanparast H. Food Security Status of Indigenous Peoples in Canada According to the 4 Pillars of Food Security: A Scoping Review. Adv Nutr 2022; 13:2537-2558. [PMID: 35876642 PMCID: PMC9776675 DOI: 10.1093/advances/nmac081] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 06/27/2022] [Accepted: 07/08/2022] [Indexed: 01/29/2023] Open
Abstract
Food insecurity is a significant public health problem for Indigenous peoples in Canada. A comprehensive literature review is needed to organize the evidence according to the 4 pillars of food security (i.e., availability, access, utilization, and stability) and identify gaps in the published literature on this topic. Therefore, in this scoping review we aimed to summarize the published research discussing any of the 4 pillars of food security among Indigenous peoples in Canada. We conducted a literature search of the following databases: Ovid Medline, EMBASE, Web of Science (Web of Knowledge), and CINAHL, as well as the Indigenous Studies Portal (up to June 19, 2021). Population-based studies of any design were included, except for review-style articles. Articles published in languages other than English were also excluded. Of the 4687 studies identified by the database searches, 91 met our inclusion criteria. Evidence from these studies indicates that all dimensions of food security among Indigenous peoples in Canada have been impacted. Lack of availability of both traditional and market foods is highlighted among Inuit and First Nation communities. Economic disadvantages, high food prices, and lack of access to transportation are major factors affecting the accessibility pillar of food security. Major factors affecting the utilization pillar of food security are the loss of traditional knowledge and skills, lack of knowledge on market foods, low quality of market foods, and food safety issues. Climate change has affected all 4 pillars of food security among Indigenous peoples. These findings suggest that resolving food insecurity issues among Indigenous peoples in Canada, especially those living in remote communities, requires a culturally specific integrated approach targeting food availability, food cost, food knowledge, food safety, and food quality.
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Affiliation(s)
- Mojtaba Shafiee
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Pardis Keshavarz
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Ginny Lane
- Margaret Ritchie School of Family and Consumer Sciences, University of Idaho, Moscow, ID, USA
| | - Punam Pahwa
- Department of Community Health and Epidemiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.,Canadian Centre for Health and Safety in Agriculture, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Michael Szafron
- School of Public Health, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Derek Jennings
- Department of Community Health and Epidemiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Hassan Vatanparast
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.,School of Public Health, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
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Keith JF, Stastny S, Brunt A, Agnew W. Barriers and Strategies for Healthy Food Choices among American Indian Tribal College Students: A Qualitative Analysis. J Acad Nutr Diet 2018; 118:1017-1026. [PMID: 29066177 DOI: 10.1016/j.jand.2017.08.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 08/02/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND American Indian and Alaskan Native individuals experience disproportionate levels of chronic health conditions such as type 2 diabetes and overweight and obesity that are influenced by dietary patterns and food choices. Understanding factors that influence healthy food choices among tribal college students can enrich education and programs that target dietary intake. OBJECTIVE To build an understanding of factors that influence healthy food choices among tribal college students at increased risk for college attrition. DESIGN A nonexperimental cohort design was used for qualitative descriptive analysis. PARTICIPANTS/SETTING Participants (N=20) were purposively sampled, newly enrolled, academically underprepared tribal college students enrolled in a culturally relevant life skills course at an upper Midwest tribal college between September 2013 and May 2015. Participant demographic characteristics included various tribal affiliations, ages, and number of dependents. MAIN OUTCOME MEASURES Participant responses to qualitative research questions about dietary intake, food choices, self-efficacy for healthy food choices, psychosocial determinants, and barriers to healthy food choices during telephone interviews were used as measures. ANALYSIS Qualitative analysis included prestudy identification of researcher bias/assumptions, audiorecording and transcription, initial analysis (coding), secondary analysis (sorting and identifying meaning), and verification (comparative pattern analysis). RESULTS Qualitative analysis revealed a variety of themes and subthemes about healthy food choices. Main themes related to barriers included taste, food gathering and preparation, and difficulty clarifying healthy food choices. Main themes related to strategies included taste, cultural traditions and practices, and personal motivation factors. CONCLUSIONS Qualitative analysis identified barrier and strategy themes that may assist nutrition and dietetics practitioners working with tribal/indigenous communities, tribal college educators and health specialists, and tribal community health workers who target health and dietary intake of American Indian and Alaskan Native students.
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White M, Addison C, Jenkins BWC, Henderson F, McGill D, Payton M, Antoine-LaVigne D. Factors Affecting Dietary Practices in a Mississippi African American Community. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2017; 14:E718. [PMID: 28671637 PMCID: PMC5551156 DOI: 10.3390/ijerph14070718] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 06/28/2017] [Accepted: 06/29/2017] [Indexed: 12/14/2022]
Abstract
This study examined the practices, personal motivation, and barriers of African American communities in Mississippi regarding their dietary practices. We selected the Metro Jackson Area comprised of Hinds, Madison and Rankin Counties because it is a combination of urban and rural communities. The sample consisted of 70 participants from seven sites. A total of seven focus groups responded to six questions to assess practices, personal motivation, and barriers to dietary practices: (1) Where in your community can you access fresh fruits and vegetables? (2) How many meals a day should a person eat? (3) What would you consider to be a healthy breakfast, lunch and dinner? (4) What would you consider to be a healthy snack? (5) What do you consider to be your motivations for eating healthy? (6) What do you consider to be your barriers to eating healthy? Each of the seven focus groups consisted of 6 to 12 participants and provided details of their dietary practices. The focus group interviews were digitally-recorded. The recorded interviews were transcribed. The majority of the participants stated that there is a limited availability of fresh fruits/vegetables in rural areas because of a shortage of grocery stores. When they do find fruits, they are priced very high and are unaffordable. Even though health conditions dictate food frequency and portion size, community members feel that individuals should eat three good balanced meals per day with snacks, and they should adhere to small portion sizes. While the desire to attain overall good health and eliminate associative risks for heart disease (e.g., diabetes, obesity) are personal motivations, the cost of food, transportation, age, and time required for food preparation were seen as barriers to healthy eating. Decisions regarding meal choice and meal frequency can have an impact on long-term health outcomes. Health promotion programs should become an integral part of academic- community collaborative agreements.
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Affiliation(s)
- Monique White
- Center of Excellence in Minority Health and Health Disparities, School of Public Health, Jackson State University, 350 West Woodrow Wilson Drive, Suite, 2900B, Jackson, MS 39213, USA.
- Jackson Heart Study Community Outreach Center, School of Public Health, Jackson State University, 350 West Woodrow Wilson Drive, Suite, 2900B, Jackson, MS 39213, USA.
| | - Clifton Addison
- Center of Excellence in Minority Health and Health Disparities, School of Public Health, Jackson State University, 350 West Woodrow Wilson Drive, Suite, 2900B, Jackson, MS 39213, USA.
- Jackson Heart Study Community Outreach Center, School of Public Health, Jackson State University, 350 West Woodrow Wilson Drive, Suite, 2900B, Jackson, MS 39213, USA.
- Jackson Heart Study Graduate Training and Education Center, School of Public Health, Jackson State University, 350 West Woodrow Wilson Drive, Suite, 2900B, Jackson, MS 39213, USA.
| | - Brenda W Campbell Jenkins
- Center of Excellence in Minority Health and Health Disparities, School of Public Health, Jackson State University, 350 West Woodrow Wilson Drive, Suite, 2900B, Jackson, MS 39213, USA.
- Jackson Heart Study Graduate Training and Education Center, School of Public Health, Jackson State University, 350 West Woodrow Wilson Drive, Suite, 2900B, Jackson, MS 39213, USA.
| | - Frances Henderson
- Center of Excellence in Minority Health and Health Disparities, School of Public Health, Jackson State University, 350 West Woodrow Wilson Drive, Suite, 2900B, Jackson, MS 39213, USA.
| | - Dorothy McGill
- Center of Excellence in Minority Health and Health Disparities, School of Public Health, Jackson State University, 350 West Woodrow Wilson Drive, Suite, 2900B, Jackson, MS 39213, USA.
| | - Marinelle Payton
- Center of Excellence in Minority Health and Health Disparities, School of Public Health, Jackson State University, 350 West Woodrow Wilson Drive, Suite, 2900B, Jackson, MS 39213, USA.
- Jackson Heart Study Graduate Training and Education Center, School of Public Health, Jackson State University, 350 West Woodrow Wilson Drive, Suite, 2900B, Jackson, MS 39213, USA.
| | - Donna Antoine-LaVigne
- Center of Excellence in Minority Health and Health Disparities, School of Public Health, Jackson State University, 350 West Woodrow Wilson Drive, Suite, 2900B, Jackson, MS 39213, USA.
- Jackson Heart Study Community Outreach Center, School of Public Health, Jackson State University, 350 West Woodrow Wilson Drive, Suite, 2900B, Jackson, MS 39213, USA.
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Charlton K, Probst Y, Kiene G. Dietary Iodine Intake of the Australian Population after Introduction of a Mandatory Iodine Fortification Programme. Nutrients 2016; 8:nu8110701. [PMID: 27827915 PMCID: PMC5133088 DOI: 10.3390/nu8110701] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 10/14/2016] [Accepted: 10/26/2016] [Indexed: 11/26/2022] Open
Abstract
To address mild iodine deficiency in Australia, a mandatory fortification program of iodised salt in bread was implemented in 2009. This study aimed to determine factors associated with achieving an adequate dietary iodine intake in the Australian population post-fortification, and to assess whether bread consumption patterns affect iodine intake in high-risk groups. Using nationally representative data of repeated 24-h dietary recalls from the 2011–2012 Australian National Nutrition and Physical Activity Survey, dietary iodine intakes and food group contributions were compared by age, socioeconomic status (SES), and geographical remoteness (N = 7735). The association between fortified bread intake and adequacy of iodine intake (meeting age and sex-specific Estimated Average Requirements) was investigated using logistic regression models in women of childbearing age 14–50 years (n = 3496) and children aged 2–18 years (n = 1772). The effect of SES on bread consumption was further investigated in a sub group of children aged 5–9 years (n = 488). Main sources of iodine intake at the time of the survey were cereal and cereal products, followed by milk products and dishes. Differences in iodine intake and dietary iodine habits according to age, SES and location were found (p < 0.001) for women of child-bearing age. Fortified bread consumption at ≥100 g/day was associated with five times greater odds of achieving an adequate iodine intake (OR 5.0, 95% CI 4.96–5.13; p < 0.001) compared to lower bread consumption in women and 12 times in children (OR 12.34, 95% CI 1.71–89.26; p < 0.001). Disparities in dietary iodine intake exist within sectors of the Australian population, even after mandatory fortification of a staple food. On-going monitoring and surveillance of iodine status is required.
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Affiliation(s)
- Karen Charlton
- School of Medicine, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong 2522, NSW, Australia.
- Illawarra Health and Medical Research Institute, Wollongong 2522, NSW, Australia.
| | - Yasmine Probst
- Illawarra Health and Medical Research Institute, Wollongong 2522, NSW, Australia.
- Smart Foods Centre, School of Medicine, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong 2522, NSW, Australia.
| | - Gabriella Kiene
- School of Medicine, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong 2522, NSW, Australia.
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Okoro CS, Musonda I, Agumba J. Evaluating the Influence of Nutrition Determinants on Construction Workers' Food Choices. Am J Mens Health 2016; 11:1713-1727. [PMID: 26821794 DOI: 10.1177/1557988315625775] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Nutritional knowledge as well as economic, social, biological, and cultural factors have been known to determine an individual's food choices. Despite the existence of research on the factors which influence nutrition globally, there is little known about the extent to which these factors influence the food choices of construction workers, which in turn influence their health and safety during construction activities. The present article investigates the extent to which construction workers' nutrition is influenced by nutritional knowledge, as well as economic, environmental, social, psychological, and physiological factors. A field questionnaire survey was conducted on site construction workers in the Gauteng Province of South Africa. Principal components analysis and multiple regression analysis were used to analyze the data. Findings revealed that consumption of foods termed alternative foods including dairy products, eggs, nuts, fish, and cereals, was influenced by nutritional knowledge and resources. Foods termed traditional core foods were influenced by cultural background; foods termed secondary core foods comprising fruits and vegetables were influenced by economic factors, resources, and cultural background; while foods termed core foods were mostly influenced by nutritional knowledge. By providing evidence of the factors which most influence selection and consumption of certain foods by construction workers, relevant nutrition interventions will be designed and implemented, taking cognizance of these factors.
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Affiliation(s)
| | | | - Justus Agumba
- 1 University of Johannesburg, Johannesburg, South Africa
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Gates A, Skinner K, Gates M. The diets of school-aged Aboriginal youths in Canada: a systematic review of the literature. J Hum Nutr Diet 2014; 28:246-61. [DOI: 10.1111/jhn.12246] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- A. Gates
- School of Public Health & Health Systems; University of Waterloo; Waterloo ON Canada
| | - K. Skinner
- Faculty of Health & Behavioural Sciences; Lakehead University; Thunder Bay ON Canada
| | - M. Gates
- School of Public Health & Health Systems; University of Waterloo; Waterloo ON Canada
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