DIETARY INTAKE, PHYSICAL ACTIVITY, FOOD SECURITY and NUTRITIONAL STATUS of NEWCOMER CHILDREN in SASKATCHEWAN a Thesis Submitted
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DIETARY INTAKE, PHYSICAL ACTIVITY, FOOD SECURITY AND NUTRITIONAL STATUS OF NEWCOMER CHILDREN IN SASKATCHEWAN A Thesis Submitted To the College of Graduate Studies and Research in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy in the College of Pharmacy and Nutrition University of Saskatchewan Saskatoon, Saskatchewan by Virginia Lane © Copyright Virginia Lane, March, 2017. All rights reserved. PERMISSION TO USE In presenting this thesis in partial fulfillment of the requirements for a postgraduate degree from the University of Saskatchewan, I agree that the Libraries of this University may make it freely available for inspection. I further agree that permission for copying of this thesis in any manner, in whole or a part, for scholarly purposes may be granted by the professor who supervised my thesis work: Dr. Hassanali Vatanparast College of Pharmacy and Nutrition In his absence, permission may be granted by the Dean of the College of Pharmacy and Nutrition. It is understood that any copying or publication or use of this thesis or parts thereof for financial gain shall not be allowed without my written permission. It is also understood that due recognition should be given to the researcher and to the University of Saskatchewan in any scholarly use which may be made of any material in my thesis. Requests for permission to copy or to make other use of material in this thesis in whole or part should be addressed to: Dean College of Pharmacy and Nutrition University of Saskatchewan 104 Clinic Place Saskatoon, Saskatchewan S7N 2Z4 i ABSTRACT Newcomers are usually healthy when they arrive in Canada, but subsequently experience health declines shortly thereafter. It is important to understand the health and nutrition issues of newcomer children, as well as healthcare access issues, as poor dietary and physical activity patterns established early in childhood combined with poor healthcare access can impact the development of chronic disease. This study evaluates the health/nutritional status of newcomer children through a cross-sectional analysis of 300 participants aged 3 to 13 years who have been in Canada for less than 5 years and currently live in Regina or Saskatoon. Questionnaires evaluate socio-demographics, food security, and physical activity. Participants’ diets were assessed through 24 hour recalls. Physical measurements included total body bone mineral content (TBBMC), blood pressure, serum vitamin D, total cholesterol, and glucose. In-depth interviews were also completed with 19 families and 24 service providers to understand lifestyle changes and barriers and supports to healthcare access in the Regina Qu'Appelle and Saskatoon Health Regions. Sixty-two percent of refugees and 43% of immigrants experienced food insecurity. Recent newcomer families and families that included parents with lower education levels were at higher risk for household food insecurity. Older children, those with better educated parents, and those who consumed a poorer quality diet were at higher risk for being overweight/obese. Although immigration status was not a significant risk factor for overweight/obesity, older immigrants (11-13 yrs) were at significantly higher risk of having waist circumference ≥90th percentile (55%) compared to refugees (20%). Significantly more refugees (23%) had stunted growth compared to immigrants (5%). Refugees, and especially refugee children from Asia, appeared to be at greater risk for lower percentile heights. Participants had low intakes of vitamin D (91%) and calcium (80%). Seventy-two percent of refugee ii and 53% of immigrant children had insufficient serum vitamin D levels. Sixty percent of refugees and 42% of immigrants had high blood cholesterol. Participants were sufficiently active (71.5%); however, a high proportion also engaged in too much sedentary activity (58.4%). Parents indicated interest in having their children involved in sports and activities that are typical in their cultures. Barriers to participation in physical activities included: recreational physical activity being a foreign concept, cultural limits to women’s and girls’ participation, lack of awareness of available activities, transportation difficulties, busy schedules, limited financial resources, safety concerns, and children’s preference for screen time. Overall, the greatest barrier to accessing healthcare services was health system navigation difficulties; understanding how to access care that resulted in service delays. Service providers experienced difficulties with making appointments with newcomers and having good communication to facilitate shared understanding of health issues. Participants mentioned difficulties with accessing appropriate interpretations services. Changes to interim federal health benefits created confusion around eligibility so some healthcare providers were reluctant to provide care. Newcomers frequently spoke about concerns with high drug costs that would be covered by provincial health benefits programs, but they lacked awareness of these programs. Service providers perceived that gender and cultural concerns were a barrier to care. Overall newcomer children are at high risk for inadequate consumption of milk products, which puts them at risk for low intakes of vitamin D and calcium, and subsequently low levels of serum vitamin D. Health concerns for refugee children include food insecurity, poor diet, stunting and high blood cholesterol levels. Older immigrant children are more at risk for overweight, obesity, as indicated by at-risk waist circumferences. The study results also indicate the need to evaluate how the health system can be adjusted to be more responsive to the healthcare needs of newcomer children and their iii families. Provincially we need to ensure that all newcomers are aware of provincial health benefit programs. Health regions may give consideration to refining services to better meet the needs of newcomers by providing training to increase the cultural competency of staff and embedding the use of available interpretation services into standard work processes. iv ACKNOWLEDGEMENTS I would like to take this opportunity to thank all the people who provided support and encouragement for my research endeavours. My family deserves thanks for supporting me over the years I have devoted to educational pursuits. I would like to recognize and thank my supervisor Dr. Hassan Vatanparast who always provided me with guidance to successfully complete all stages of the research. I appreciated his balanced approach to providing enough information to set me in the right direction to discover more. In addition, I would like to express my gratitude to my committee chair Dr. Susan Whiting, and committee members Dr. Judy White, Dr. Phil Chillibeck, Dr. Shanthi Johnson and Dr. Marwa Farag who provided insightful advice and direction. I am grateful to all research participants and key informants who brought the research to life and really opened my eyes to their lived experiences. v DEDICATION Dedicated to Gayatri Nepal, Lili Htoo and Jaw Na Thar, interpreters who are more than interpreters. They provided culturally sensitive liaison services to their respective community members that ensured good participation. vi TABLE OF CONTENTS PERMISSION TO USE ............................................................................................................................. i ABSTRACT ............................................................................................................................................... ii ACKNOWLEDGMENTS .........................................................................................................................v DEDICATION .......................................................................................................................................... vi TABLE OF CONTENTS ........................................................................................................................ vii LIST OF TABLES .................................................................................................................................. xvi LIST OF FIGURES .............................................................................................................................. xvii LIST OF ABBREVIATIONS .............................................................................................................. xviii DEFINITIONS ....................................................................................................................................... xix CHAPTER 1: INTRODUCTION .............................................................................................................1 1.1 Statement of Problem .........................................................................................................................1 1.2. Background to Problem .....................................................................................................................2 1.3 Purpose of the Study ...........................................................................................................................5 1.4 Research Questions ............................................................................................................................5 1.5 Scope of the Study ..............................................................................................................................6 1.6 Significance of the Study ...................................................................................................................6