Understanding Health Outcomes from Indigenous Perspectives: Systematic Review of the Influence of Indigenous Foodways on Health

ABSTRACT

Introduction: Indigenous food systems and foodways are understood to be nutritionally healthful for Indigenous communities. Yet, the aspects of how these foodways influence health outside of nutritional composition remain an understudied aspect of Indigenous health and wellbeing. The objective of this systematic review is to explore Indigenous food systems and Indigenous health utilizing a realist framework. Literature was reviewed and analyzed to explore how Indigenous foodways are understood to influence health from the perspective Indigenous peoples in North America. Methods: A systematic search of OVID Medline and Web of Science Core Collection was completed to identify studies relevant to Indigenous foodways, health, and knowledge/perspectives. Results:The systematic review revealed four main dimensions of health outcomes understood as influenced by Indigenous foodways: (1) physical, (2) mental, (3) social, and (4) cultural. These outcomes were thought to be interrelated and Indigenous foodways were a mechanism to promote health holistically. Discussion: Research found that Indigenous foodways are an important mechanism of holistic health, especially for addressing food insecurity. These findings suggest that to address health disparities, policy makers and community health practitioners should emphasize and support food diversity and cultural resurgence movements to promote Indigenous foodways. Additional research should explore the efficacy and effectiveness of existing policy promotion Indigenous foodways on improving health.

1 Mosby, I., & Galloway, T. (2017). ‘Hunger was never absent’: How residential school diets shaped current patterns of diabetes among Indigenous peoples in Canada. Canadian Medical Association Journal, 189(32), 1043–1045. INTRODUCTION

Indigenous food systems have, from the very start of colonization, been weaponized against Indigenous peoples as a tool of genocide and control. Settler-colonial states have long used systemic starvation policies as a part of their ongoing genocide of Indigenous peoples1. The policies include the deliberate destruction of ecosystems, pushing Indigenous peoples onto too small parcels of unproductive land, and mass slaughtering of animal food sources. In addition to directly destroying Indigenous food systems, the settler states also worked to disrupt “the transfer of food-related knowledge from one generation to the next” by forcing Indigenous youth into residential schools where they suffered unethical biomedical nutrition experimentations, starvation, and assimilation “forced to take on staples

2 Hoover, E. (2017)‘You can’t say you’re sovereign if you can’t feed yourself:’ Defining and Enacting Food Sovereignty in American Indian Community Gardening. American Indian Culture and Research Journal 41(3), 8.

3 Settee, P., & Shukla, S. (2020). Indigenous food systems: Concepts, cases, and conversations, 5.

4 Ibid

5 Settee, P., & Shukla, S. (2020). Indigenous food systems, 17.

6 Delormier, T., & Marquis, K. (2019) Building healthy community relationships through food security and food sovereignty. Current Developments in Nutrition, 3(Supplement 2), 26.

7 2017, 1045.

8 Maudrie, T., ColónRamos, U., Harper, K., Jock, B.W., & Gittelsohn, J. (2021). A Scoping Review of the Use of Indigenous Food Sovereignty Principles for Intervention and Future Directions. Current Developments in Nutrition, 5. of a standard diet that embodied Anglo ideals of foodways”2 . Today, Indigenous peoples in North America face a disproportionate and distinct burden of disease rooted in past and ongoing settler-colonialism. In Canada, the rate of diabetes is three to five times higher and life expectancy is 10 to 15 years shorter in Indigenous peoples than the general population3. Infant mortality, tuberculosis, obesity rates are all rising in Indigenous communities. Approximately 30 percent of Indigenous peoples in Canada experience food insecurity, a rate three times higher than the general population4. The health issues of Indigenous peoples are so dire as to be thought of as ‘fourth world’ conditions where Indigenous peoples “live in Third-world conditions within the First-world nation-state of Canada”5. Food related health issues, from non-communicable diseases such as diabetes to food insecurity, must be viewed in the context of settler-colonialism. Yet, from the very start of colonization, Indigenous peoples across North America have resisted settler-colonialism in all forms, including defending and upholding Indigenous food systems. This resistance is epitomized by Indigenous food sovereignty, defined as “the distinct responsibilities and abilities Indigenous communities possess to make decisions about the food they eat and continuing cultural food systems and practices through relationships with Indigenous territories”6. Not only is Indigenous food sovereignty resistance to colonization, it is resistance to disease. According to Mosby and Galloway, Indigenous food sovereignty is a direct move towards better health and wellness as it demands “the next generation of Indigenous children have access to the kinds of plentiful, healthy, seasonal and traditional foods that were denied to their parents and grandparents”7. At the center of the health goals of Indigenous food sovereignty are Indigenous food systems. The focus of this review, Indigenous food systems and foodways, have long been thought to be more healthful for Indigenous communities. Yet, they remain an understudied aspect of Indigenous health and wellbeing. Existing literature reviews on Indigenous foodways are generally focused on Indigenous food sovereignty or diet assessments. Reviews on Indigenous food sovereignty consider the theoretical and political foundations of the movement or policy and community action considerations8. The existing reviews on Indigenous food systems focus on diet aspects, specifically diet and consumption behavior of Indigenous peoples or micro-nutritional assessments of foodstuffs. Diet and consumption behavior reviews have documented the ‘nutritional transition’ of Indigenous peoples away from Indigenous food systems to Anglo-colonial market foods as well as ongoing health related issues related to diet including obesity and insecurity9. Scoping and systematic reviews on the micro-nutritional aspects of

Indigenous foodstuffs have definitively proven that Indigenous diets based on ‘traditional’ foods are healthier, with greater biodiversity, nutrient density in protein and essential micronutrient, and energy density10. However, these diet-centric reviews have been deeply criticized from Critical Indigenous perspectives. According to Neufeld, these reviews, and the studies they include focus either “exclusively on intake” or have “been almost exclusively deficit-based, with considerably less attention given to learning how larger food systems” influence health11. Additionally, these reviews fail to consider “Indigenous concepts of health, which are holistic, focus on language and place, and value relationships” instead centering on Western scientific knowledge regimes that reduce health to physical dietary metrics12 . The objective of this systematic review is to explore Indigenous food systems and Indigenous health from a holistic and critical perspective. In this paper, I systematically review literature to explore how Indigenous foodways are understood to influence health by Indigenous peoples in North America. What makes this review unique as well as necessary is that it focuses not on foodstuffs but foodways, not on diet health but on holistic wellness, and is based not on Western knowledge regimes but Indigenous knowledge and perspectives. Utilizing a realist conceptual framework, the research objective is to explore how the mechanisms of Indigenous foodways influence the outcome of holistic health in the context of Indigenous Communities in North America. First, I present the research methodologies, then I analyze the results of the systematic review, and finally I conclude by discussing the limitations and implications of this research.

METHODS

Statement of Positionality

The positions I hold inherently impact my perspective of Indigenous food sovereignty thus it is important to begin this work by accounting for those positions and addressing my reflexivity. I am a white settler. I was born and raised on Anishinaabe land belonging to the Ojibwe, Odawa, Potawatomi Nations in Waawiyatanong, the Anishinaabemowin name for Detroit. I currently occupy the lands belonging to the Haudenosaunee and Anishinaabe peoples. I am writing about Indigenous food sovereignty and food systems but my knowledge and experience on these issues is second-hand. My academic background is in the discipline of geography, specializing in urban studies and political geography. Geography has long been a field engaged in colonial violence,

9 Akande, V. O., Hendriks, A. M., Ruiter, R. A., & Kremers, S. P. (2015). Determinants of dietary behavior and physical activity among Canadian Inuit: a systematic review. International Journal of Behavioral Nutrition & Physical Activity, 12, 84; Batal, M., & Decelles, S. (2019). A Scoping Review of Obesity among Indigenous Peoples in Canada. Journal of Obesity, 2019; Gates, A., Skinner, K., & Gates, M. (2015). The diets of school-aged Aboriginal youths in Canada: a systematic review of the literature. Journal of Human Nutrition & Dietetics, 28(3), 246-261;McGrathHanna, N. K., Greene, D. M., Tavernier, R. J., & Bult-Ito, A. (2003). Diet and mental health in the Arctic: is diet an important risk factor for mental health in circumpolar peoples?--a review. International Journal of Circumpolar Health, 62(3), 228-241;Walch, A., Loring, P., Johnson, R., Tholl, M., & Bersamin, A. (2018). A scoping review of traditional food security in Alaska. International Journal of Circumpolar Health, 77(1)

10 Herrmann, T. M., Lamalice, A., & Coxam, V. (2020). Tackling the question of micronutrients intake as one of the main levers in terms of Inuit food security. Current Opinion in Clinical Nutrition & Metabolic Care, 23(1), 59-63; McCartan, J., van Burgel, E., McArthur, I., Testa, S., Thurn, E., Funston, S., Kho, A., McMahon, E., & Brimblecombe, J. (2020). Traditional Food Energy Intake among Indigenous Populations in Select HighIncome Settler-Colonized Countries: A Systematic Literature Review. Current Developments in Nutrition, 4(11), 26

11-12 See page 82.

11 Neufeld, H. T., Richmond, C., & Southwest Ontario Aboriginal, H. (2020). Exploring First Nation Elder Women’s Relationships with Food from Social, Ecological, and Historical Perspectives. Current Developments in Nutrition, 4(3), 11.

12 Ibid, 2.

13 Oswin, N. (2020). An other geography. Dialogues in Human Geography 10 (1), 10.

14 Kerpan, S. T., Humbert, M. L., & Henry, C. J. (2015). Determinants of diet for urban aboriginal youth: implications for health promotion. Health Promotion Practice, 16(3), 393

15 Ibid.

16 Pawson, R., Greenhalgh, T., Harvey, G., Walshe, K. ( 2005) Realist review –a new method of systematic review designed for complex policy interventions. Journal of Health Services Research and Policy, 10, 21.

17 Delormier, T., & Marquis, K. (2019) Building healthy community relationships through food security and food sovereignty. Current Developments in Nutrition, 3(Supplement 2), 30.

18 Pawson, R., Greenhalgh, T., Harvey, G., Walshe, K. ( 2005) founded upon and for the purpose of “overtly colonial knowledge production”13. These traditions are very much still in place and require active resistance in academic work. Thus, to engage with the topic of Indigenous food sovereignty and food systems, I seek to acknowledge my background and make a deliberate turn away from colonial knowledge regimes towards two-eyed seeing and critical Indigenous theory.

Conceptual Framework

Towards the end of two-eyed seeing and critical Indigenous theory, this review employs a realist conceptual framing. According to Kerpan, a major failing of Western scientific knowledge is that it “decontextualizes knowledge from its local context to make it more generalizable”14. This has resulted in health programming that has been “largely ineffective due to external strategies that do not take into consideration the local and cultural ways that Indigenous Peoples understand health”15. Realism, in contrast, demands contextualization and rejects positivist generalization. Realist reviews do not seek to make a definitive judgment but to discern “what works for whom, in what circumstances, in what respects and how”16 , allowing the space to unpack and engage with complex entanglements and contexts of Indigenous food systems. The context in which health is constructed among Indigenous peoples is vastly complex. In addition to the contexts of socioeconomic status, health gradient, gender, climate, is the context of colonization. As discussed above, this context cannot be ignored yet neither can ongoing decolonization efforts. Additionally, Indigenous foodways are not static or inert, rather foodways must be contextualized as “meaningful and significant, and symboliz[ing] the reciprocal caring relationship that Indigenous Peoples hold with the natural world, and that the earth is our mother who provides all that is needed… Food is a connection to the specific places and spaces wherein Indigenous Peoples draw their identity”17. Realist reviews are premised on a “systems-within-systems” approach to analyzing interventions and issues18. In reviewing literature on Indigenous food systems and holistic health, it is imperative to ground research within a framework where interdependent systems can be critically engaged with in their cultural, historical, and geographic contexts. In addition to the conceptual framing of the review, it is important to frame the topics at hand. First turning to the mechanisms of this review, Indigenous food systems are traditional harvested foods from the land or water as well as the “teachings of ancestral food knowledges, adaptive practices, and social-cultural values that shape a complex and layered

worldview that includes one’s sacred relationships with, and responsibility to, the environment, other humans, animals, land and water”19. Though it is often referred to as ‘traditional food’, I use the term ‘Indigenous foodways’ throughout this paper to refer to all aspects produced through Indigenous food systems. According to Settee and Shukla, “calling the diet ‘traditional’ is problematic when conveying the present-day and ongoing nature of the subsistence mode of production and consumption of bush food”20. Additionally, this can contribute to the historical relegation of Indigenous peoples and the ‘freezing’ of practices and ways of life in history. Importantly, the use of foodways instead of foods is intentional as Indigenous foodways are “not simply what we eat but how and why we eat it, and more importantly, what it means”21. These foodways are protected and upheld through Indigenous food sovereignty. At its simplest conception, Indigenous food sovereignty consists of four pillars, “(1) sacred or divine sovereignty, (2) participation, (3) self-determination, and (4) legislation and policy”22 . The outcome of these pillars/practices is that Indigenous food sovereignty “inherently asserts Indigenous Peoples’ self-determination of their own culturally suitable food systems and promotes revitalization of Indigenous food systems”23 . Turning now to the outcomes of this review, Indigenous health and wellness must be conceptualized holistically and in context. Throughout this review, health and wellness refer generally to holistic conceptions of health at all levels, physical, mental, spiritual, communal, based in Indigenous knowledge and epistemologically different from Western systems24. This conception is grounded in the understanding that “Indigenous Peoples possess unique determinants of health and wellness, such as jurisdictional issues related to community self-control and determination [and] historical factors, such as colonization, dispossession of traditional lands, and assimilation policies”25 . Importantly, there is no one pan-Indigenous conception of wellness and health. This diversity and variance require holistic health to be conceptualized as inclusive of all aspects considered as wellness for the various nations represented in this review. A limit to the realist framework is the expansiveness allowed by it in reviews. Thus, an essential foregrounding choice is where to draw the ‘boundary’ of what contexts and aspects are included. For this review, the boundary was to limit research to Indigenous knowledge and understandings of the influence of foodways on health. This choice was based on the demand “to include Indigenous knowledge, values of interconnectedness, and relationality to replace the colonial dysfunctionalities with strength”26. The focus on Indigenous perspectives and understandings is based on the valuing of Indigenous peoples as experts on their own health and foodways by treating “Indigenous peoples’ knowledge not just

19 Settee, P., & Shukla, S. (2020),4.

20 Ibid, 63.

21 Ibid, 85.

22 Ibid, 4.

23 Ibid.

24 Kerpan, S. T., Humbert, M. L., & Henry, C. J. (2015). Determinants of diet for urban aboriginal youth: implications for health promotion.

25 Neufeld, H. T., Richmond, C., & Southwest Ontario Aboriginal, H. (2020). Exploring First Nation Elder Women’s Relationships with Food from Social, Ecological, and Historical Perspectives. Current Developments in Nutrition, 4(3), 9.

26 Settee, P., & Shukla, S. (2020),223.

27 Ibid.

28 Ibid, 88. as data points to prove a larger learning, but as vital knowledge sources”27. Indigenous ways of knowing, while diverse and varied, generally are “embedded in the cumulative experiences and teachings of people, are transmitted orally through storytelling from generation to generation, and involve a connection to the land through ceremony”28 .

Systematic Search Methods

In an attempt to find as many relevant studies as possible, the database search strategy was designed “to err on the side of over-inclusion during this first stage”29. A systematic search of OVID Medline and Web of Science Core Collection was completed to identify initial studies. The central concepts for the search were Indigenous food systems and Indigenous peoples. For OVID, Indigenous food systems were targeted with the MeSH terms of “food supply” or “diet”. Indigenous peoples were targeted with the MeSH terms of “Indigenous Peoples” or “Indians, North American (exploded)” in order to return as many studies on Indigenous peoples in North America as possible. In addition to the MeSH terms, “traditional food*” was included in the search as a keyword to focus results on studies that looked at Indigenous foodways. Initial searching prior to the inclusion of this keyword returned mainly studies on food security or consumption patterns that did not look at Indigenous foodways at all. For Web of Science, Indigenous food systems were searched with the keywords of “traditional food system”, or “Indigenous food system”, or “food system”. In parity with OVID, Indigenous peoples were searched with the keyword of “Indigenous Peoples” or “Native American”. In addition, the keyword “health” was included as initial searches returned mostly articles or reviews on the politics or policies of Indigenous food systems, not the health impacts. OVID Medline returned 140 papers and Web of Science returned 50 papers. Papers were then imported into EndNote and duplicates were removed resulting in an initial 187 papers. Following a sensitive initial search phase, the screening phase was more discerning to exclude irrelevant studies. In order to mitigate bias and conduct the screening in a reproducible manner, the following criteria were established to determine inclusion in the systematic review. First, included studies must be set in the area of study, North America, resulting in 19 studies being excluded. This criterion was established to limit the review to a similar area in terms of politics and colonial experiences. Second, included studies must be written in English. All studies met this criterion. Third, included studies must be empirical research. This criterion was established as part of the review guidelines and papers could be any form of empirical research. 38 studies did not meet this

criterion, the majority of which were theory or opinion papers. The 47 combined papers that did not meet these criteria were excluded through abstract screening. 130 studies remained to be screened based on the fourth criterion. Fourth, included studies must be relevant to all three core concepts being reviewed: Indigenous food systems, health, and knowledge/ perspectives. 103 studies were excluded through abstract screening and an additional 13 were excluded through full text screening based on this criterion. 14 studies were excluded because they did not address any of the three concepts. 24 studies were excluded because they did not address Indigenous peoples or health, only looking at environmental contamination of sources of Indigenous foodways. 24 studies were excluded because they did not include health, focusing mainly on consumption amounts and dietary patterns of both market and Indigenous foodways. 54 studies, including all 13 full-text screened studies, were excluded because they did not include Indigenous peoples’ knowledge or perspective on health. Broadly, these papers tended to focus on micro nutritional assessment of Indigenous foodstuffs rather than understanding of foodways and their influence on health. 14 out of 187 studies generated through the initial search met all criteria and were included in the review. An additional three papers were identified through citation snowballing: Elliott et.al. (2012) was identified from Delormier et.al. (2017), and Gilpin and Hayes (2020) and Powlowska-Mainville (2020) were both identified from Neufeld (2020). Figure 1 presents a summary table of the 17 studies to be reviewed.

Data Analysis Methods

Following a realist framework, data extraction occurred by reading each paper with the aim of identifying the mechanisms through which Indigenous foodways are understood to influence health outcomes. This review process resulted in a data extraction table where mechanisms and outcomes were of central focus. This table is available as a supplemental appendix. Additionally, a major aspect of this review was critical appraisal of the included studies. To this end, methodologies and notes on quality were captured in the data extraction table. Thematic synthesis is useful to evaluate the perceived appropriateness, acceptability, and, especially, effectiveness of Indigenous foodways as a health intervention. Based on the qualitative methods of all 17 of the included studies, the purpose of thematic synthesis analysis was “aggregative, that is, findings are accumulated and summarised rather than ‘transformed’… [as] a way of producing a ‘map’ of the contents of qualitative studies”30 . Grounded in a realist approach which

29 Centre for Reviews and Dissemination. (2009) Systematic Reviews: CRD’s guidance for undertaking reviews in health care. York: CRD, University of York, 23.

30 Barnett-Page, E., & Thomas, J. (2009). Methods for the synthesis of qualitative research: a critical review. BMC medical research methodology, 9, 5.

Figure 1 Summary table of the 17 studies included for systematic review.

emphasises contextualization, the themes identified were organised to ‘map’ how and where Indigenous foodways were understood to influence health. The four themes identified through data extraction and iterative review were that Indigenous foodways influence: physical, mental, social, and cultural.

RESULTS

Before turning to the thematic synthesis of the included studies, it is important to first synthesise their characteristics, as presented in Figure 1. Three of the 17 studies were on Indigenous peoples located in the United States. 14 were based in Canada, of which three studies were located in the Arctic and an additional three located in cities, broadly focused on urban Indigenous peoples rather than one specific nation. The cities were Vancouver, London, and one that was unnamed. Turning to methodologies, all studies employed qualitative methods in some ways. 14 studies utilised interviews or focus group sessions. Of those, four additionally used some surveying in tandem with open ended interviews. Two studies employed photo voice methodologies and two studies employed storytelling methodologies. An additional four used some ethnographic methods as well. From the resulting data, 15 out of 17 studies conducted some form of thematic analysis. Three studies also incorporated statistical analysis. The two studies that did not use thematic analysis utilised storytelling analysis where the results produced, and the analysis were in the form of stories in line with Indigenous ways of teaching. In terms of quality of methodologies, it is not constructive to compare sample size or length of study given the wide range in local contexts. Sample sizes range from a low of only five participants to a high of 1,711. But quality or rigour is not obvious just from the number in a sample given how small some target populations included were; Genius et.al. (2015) for example had a sample of 26 student interviewees out of a total of only 40 students in the entire school. Many studies utilised community-based participatory research (CBPR) methodologies throughout, one measure for quality of the inclusion of Indigenous communities. Eleven out of 17 explicitly stated that they employed CBPR methods, though again this does not provide a complete picture. Some of the studies which did not explicitly state they used CBPR, like Gilpin and Hayes (2020), were authored by Indigenous scholars on and for their own community. Yet, CBPR is not always an assurance of engaged and critical research. Bhawra et. al. (2015), for example, stated their research was community-based yet perpetuated colonial tropes around the ‘nutritional transition’ as a matter of personal preference or choice rather than consequence of acculturation and forced assimilation. Additionally, normative determinants of academic quality do not always translate to quality of Critical Indigenous research. In Arthur and Porter (2019), for example, the lead author explicitly states that his positionality affects his research and his work is conducted out of anger and in opposition to settler-colonialism in his community. This could be considered a ‘conflict of interest’ by

31 Settee, P., & Shukla, S.,9.

Figure 2 The four themes are modeled as spheres of health outcome, which together form holistic health. normative standards but is a clear example of strong, engaged research carried out critically and ethically for and with an Indigenous community. Though the included studies took place across a wide geographic range, utilised different data collection methods, from the studies arose four themes related to the principal research question of how Indigenous foodways are understood to influence health by Indigenous peoples in North America. These four themes organise the findings of the studies into spheres of health outcome influence, where foodways are perceived to have positive influence over physical, mental, social, and cultural health outcomes. These spheres of health outcomes are aligned with Indigenous understandings of holistic health conceptualised as health across “physical, emotional, spiritual, and mental spheres which relate to the spirit, family, and community worlds”31. For each of these different themes, there are a series of mechanisms identified throughout the studies as pathways by which traditional food influences health. These themes are represented in Figure 2, which highlights interconnection between the spheres conceptualised as holistic health.

Theme One: Physical Health Influence

Community Advisor, Anishinaabe: “Food is medicine. If you’re sick and have a cold, you don’t take vitamin C capsules, you boil a light batch of cedar tea.” (Domingo et.al.:2021:7)

Of the four themes, the physical health influence of Indigenous foodways was the most evident and ubiquitous. In all but one paper (Arthur & Porter:2019 which focused exclusively on mental health), the influence and importance of Indigenous foodways to improve and better health was clear. The most noted health influence was that Indigenous foodways were an essential component for food security. The mechanism by which this outcome occurs was understood to be straightforward: bodily health improved when participants could access needed food and Indigenous foodways were an essential strategy to access food. Specifically, in evaluations of food security status, Chan et.al. (2006), Kerpan et.al. (2015), Lambden et.al. (2007), Skinner et.al. (2013), and Sowerwine et.al. (2019) all found either the majority or all of their participants engaged in harvesting as a strategy for food security.

Two additional physical health outcomes found were nutrition and physical activity promotion from Indigenous foodways. Indigenous foodways were understood across the studies to better physical health because of the nutritional and medicinal character of the foodstuffs as compared to market-based foods. The outcomes were seen as a decrease in diet-related illness and obesity from a more nutritious diet. However, more than nutritional makeup, these foodstuffs were understood to better physical health because “food is medicine”32 . Physical activity promotion was the least mentioned way that foodways influenced physical health, but several studies which looked at harvesting practices33 highlight that the actions of harvesting Indigenous foods are a mechanism of health promotion, getting out into the bush and working to hunt or grow foods.

Theme Two: Mental Health Influence

Participant, Tsartlip First Nation, BC: “It’s meditative and physical and allows for real contact with the earth…There is a deep satisfaction and amidst the life distractions it balances me. This is where I feel peace.”(Gilpin & Hayes:2020:112)

Bonnie, Oneida, ON: “The venison and the corn soup is good. It makes you feel better. I don’t know if it’s good for you, but it makes you feel good to eat it.” (Neufeld et.al.:2020:8)

Mental and physical health outcomes are deeply intertwined and many of the mechanisms through which foodways influence mental health are similar to that of physical health, but there are some distinct and important understandings of how mental health can improve from Indigenous foodways. Overall, fewer of the studies addressed mental health outcomes, only seven broaching the topic directly34. Just as with physical health, the most discussed influence was Indigenous foodways providing food security. In the case of mental health, the outcome is seen as decreased stress and worry and improved general mood as the weight of food insecurity is lifted by Indigenous foodways. A major coping strategy to access Indigenous foodways and thus improve security was through family. Gilpin and Hayes (2020) and Kerpan et.al. (2015) note that practices of sharing intrinsic to foodways additionally improve mental wellbeing by strengthening support ties and de-stressing home environments. A major aspect of improved mental health outcomes come from the emotional influence of these foodways. As highlighted in the pull quotes, emotional health is influenced through harvesting as well as eating. Powlowska-Mainville (2020) and Gilpin and Hayes (2020) emphasise the emotional impact of harvesting, where food security as well

32 Domingo, A., Charles, K. A., Jacobs, M., Brooker, D., & Hanning, R. M. (2021). Indigenous Community Perspectives of Food Security, Sustainable Food Systems and Strategies to Enhance Access to Local and Traditional Healthy Food for Partnering Williams Treaties First Nations (Ontario, Canada). International Journal of Environmental Research and Public Health, 18(9), 15, Article 4404, 7.

33 Lambden, J., Receveur, O., & Kuhnlein, H. V. (2007). Traditional food attributes must be included in studies of food security in the Canadian Arctic. International Journal of Circumpolar Health, 66(4), 308-319; Gilpin, M., Hayes, M. (2020). A Collection of Voices: Land-based leadership, community wellness, and food knowledge revitalization of the WJOLELP Tsartlip First Nation garden project. In Settee, P., & Shukla, S. (Eds). Indigenous Food Systems: Concepts, Cases, and Conversations, Toronto, Ontario: Canadian Scholars. Chapter 6, 101118; Pawlowska-Mainville, A. (2020). Aki Miijim (Land Food) and the Sovereignty of the Asatiwisipe Anishinaabeg Boreal Forest Food System. In Settee, P., & Shukla, S. (Eds). Indigenous Food Systems: Concepts, Cases, and Conversations, Toronto, Ontario: Canadian Scholars. Chapter 4, 57-82.

34 See page 90.

34 Arthur, M. L., & Porter, C. M. (2019). Restorying Northern Arapaho food sovereignty. Journal of Agriculture Food Systems and Community Development, 9, 69-84; Domingo, A. et al. (2021). Indigenous Community Perspectives of Food Security, Sustainable Food Systems and Strategies to Enhance Access to Local and Traditional Healthy Food for Partnering Williams Treaties First Nations (Ontario, Canada); Elliott, B., Jayatilaka, D., Brown, C., Varley, L., & Corbett, K. K. (2012). “We are not being heard”: Aboriginal perspectives on traditional foods access and food security. Journal of environmental and public health, 2012, 130945; Gilpin, M., Hayes, M. (2020). A Collection of Voices: Land-based leadership, community wellness, and food knowledge revitalization of the WJOLELP Tsartlip First Nation garden project. In Settee, P., & Shukla, S. (Eds). Indigenous Food Systems: Concepts, Cases, and Conversations, Toronto, Ontario: Canadian Scholars. Chapter 6, 101-118; Kerpan, S. et al.(2015) Determinants of diet for urban aboriginal youth: implications for health promotion; Neufeld, H. (2020). Exploring First Nation Elder Women’s Relationships with Food from Social, Ecological, and Historical Perspectives; PawlowskaMainville, A. (2020). Aki Miijim (Land Food) and the Sovereignty of the Asatiwisipe Anishinaabeg Boreal Forest Food System.

35 Neufeld, H. (2020), 8.

36 Delormier, T., & Marquis, K. (2019) Building healthy community relationships through food security and food sovereignty. as connection to land and culture engaged feelings of pride, wealth, self-reliance, and empowerment. All of the authors discuss how participants attach positive feelings of joy, peace, and goodness to Indigenous foodways. As Bonnie, cited by Neufeld et.al. 35, emphasises it does not necessarily matter if these foods are physically or ‘nutritiously’ good for you, there is a genuine health influence from the fact that they make you feel good. It is important to understand the outcomes of food security and emotional well-being as co-created, where feeling secure is a mechanism to improve emotional well-being as well.

Theme Three: Social Health Influence

Participant, Klamath Nation, CA-OR:“I know that this last winter we were pretty scarce on food, and my uncle went and got deer for us. We survived a lot off that.” (Sowerwine et.al.:2019:594)

Aside from physical health outcomes, the most noted influence was on social health outcomes. 12 out of 17 studies discussed the social health benefits brought about by Indigenous foodways. Even with the amount of discussion on social health, there was very little variance in how it was discussed. There were two main mechanisms and two main outcomes of social health across the 12 papers. The mechanisms were understood to be the sharing of or the time together harvesting or making Indigenous foods. The outcomes, influenced by both mechanisms, were understood to be increased food security as a social health benefit and strengthened social ties. Social health outcomes are very related to mental health outcomes, with security and support being identified in both spheres of health but the descriptions of these health outcomes were different for the different spheres. Sharing was identified in the bulk of studies as a major characteristic of Indigenous foodways, where foodway practices were tied to the sharing and redistribution of food to family and those in need36. According to Settee and Shukla (2020), reciprocity, relationality, and responsibilities to share are integral to not only Indigenous foodways but holistic conceptions of health as well, where the health of these social networks and relationships are deeply important to overall wellness. These foodway networks and relationships are a main facilitator of food security, influencing physical and mental health as previously discussed but also influencing the health of social relationships. Additionally, food security influences overall societal health where strong communities are fed communities. As the pull quote highlights, sharing networks and social ties are a means of survival and secu-

rity for communities. Similarly, another mechanism by which foodways influence social health is through strengthening social relationships during the time together preparing and harvesting Indigenous foods. Domingo et.al. (2021), Genius et.al.(2015), Hanemaayer et.al.(2020), Kerpan et.al.(2015), and Neufeld et.al.(2020) all emphasise the theme of foodway practices -- harvesting, preparing, sharing, and eating- as important times for strengthening social ties. Neufeld, in particular, explores this relationship between foodways and social health in the extreme circumstances of residential school survivors, noting that the “reciprocal relationships or shared roles in the maintenance of traditional foodways have also been described as ‘intimate and spiritual’” spaces for intergenerational bonding37 .

Theme Four: Cultural Health Influence

Participant, Klamath Nation, CA-OR:“[Indigenous foods] are just a part of my culture and even my religion and my history. Those are things that are very important to me to hold onto and pass on to my own future children and my nieces and nephews. It’s just a part of who I am. I couldn’t imagine myself without those things that are important to me and to my family.” (Sowerwine et.al.:2019:580)

The final theme emerging from analysis is the influence of Indigenous foodways on cultural health. Though interrelated to social health, cultural health is generally conceptualized as when good health and wellbeing are supported culturally. An important component of cultural health is the vibrancy and strength of the culture itself as a mechanism of overall wellness. Eleven out of the 17 studies addressed influences on cultural health, all related to the cultural resurgence and sovereignty inherent in Indigenous foodways. Encompassed in Indigenous foodways are traditional ecological knowledge, spirituality/religion, language, value systems, ceremonies, relationships to land, family, and identity. In engaging in foodway practices, participants highlighted the reconnection to all these elements of culture. As the pull quote highlights, foodways are not just what is being eaten but representative of culture, generally. In and of itself, reconnecting to culture is an important health outcome, but from doing so stems several other health outcomes included in the studies. Participants noted the influence of foodways on political and personal empowerment as well as establishing a sense of identity. But perhaps most significantly and most evident across studies was the outcome of Indigenous sovereignty through the mechanism of Indigenous foodways.38 Sovereignty was identified by participants as

37 Neufeld, H. (2020), 8.

38 Arthur & Porter (2019). ; Delormier et.al (2017). ; Elliott et.al (2020); Gilpin & Hayes (2020); Neufeld et.al (2020); Powlowska-Mainville (2020); Sowerwine, J., Mucioki, M., SarnaWojcicki, D., & Hillman, L. (2019). Reframing food security by and for Native American communities: a case study among tribes in the Klamath River basin of Oregon and California. Food Security, 11(3), 579-607. the pinnacle state of a healthy culture. These sentiments were summed up by Arthur, “many participants explained that during [nutritional transition] they “just got away from that” referring to things like language, sustainability, sharing, tribalism, culture, and happiness” and through resurgence of foodways they could get back to that, get back to sovereignty (2019:79). Importantly, Indigenous foodways were thought of as a mechanism on the way to sovereignty, it being the most important influence on health, not an end in and of itself.

DISCUSSION

Health Outcomes in Colonial Context

As sovereignty is the ultimate mechanism understood to influence health, it is important to highlight the overall colonial context in which health occurs. Throughout the studies, the impact of colonialism as a barrier to Indigenous foodways was addressed. My question and my research focus are strength based, looking at the understood influence of Indigenous foodways. But it is important not to dismiss the context of settler-colonialism in which this research occurs. It is from this context that the systematic theme of the loss and absence of Indigenous foodways emerges. All but two of 17 studies discussed the context of colonialism for foodways. I present a context-mechanism-outcome configuration to synthesize the understandings of settler-colonialism from the studies. Colonialism and colonial-capitalism can be understood as the upstream causes/contexts of Indigenous foodway loss and health disparities for Indigenous peoples. These flow down to the mechanisms. The major perceived mechanisms identified in the studies were dispossession and forced assimilation, including genocidal policies like forced removal and residential schools as well as cultural assimilation into the market economy. These mechanisms represent the dramatic and violent theft of people, land, and culture carried out to the end of colonialism. From the studies, the most commonly noted outcomes were poverty, food insecurity, cultural knowledge loss, environmental degradation, displacement, and intergenerational trauma. At all levels, these CMOs are the contexts within which Indigenous foodways currently exist and the mechanisms barring access to such foodways.

Limitations

limitation of this review is the complexity and entanglements of the concepts of interest. One aspect of foodways may be a mechanism or an outcome at the same time; food security, for example, was widely discussed as a physical health outcome but also as a mechanism influencing additional mental and social health outcomes. When exploring holistic systems of Indigenous health and foodways, the linearity of realism and the context-mechanism-outcome configuration is not always applicable to Indigenous ways of knowing. While this review is strength based and stands out among related reviews from that perspective, this framing could be interpreted as downplaying the influence and harm of settler-colonialism. However, this review was never supposed to be about the influence of settler-colonialism on health; rather, it turns towards examining Indigenous foodways influence on health. Additionally, the limitations of realism, while significant, can be overcome by highlighting the co-creation and interdependency of the systems explored. The limited applicability and scope of this review could also be seen as a weakness; it purposefully does not seek to provide a widely applicable understanding of foodways and is narrowly focused on the Nations included in the studies and in the specific context of North American Anglo-settler-colonialism. I contend that this is not a limitation but a reality of studying diverse and complex minority populations and decontextualized or generalized findings lose relevancy.

Implications

The myriad and positive influences of foodways on health were made very clear through review. While the results of this study do not apply broadly to Indigenous peoples or foodways around the world, for researchers and policy practitioners in North America and from the participating Nations, there are two major important implications. First, these results highlight the necessity of policy based on promoting and protecting Indigenous foodways, policies which do so should be conceptualized as part of food sovereignty not just food security. Throughout the studies, the importance of food sovereignty to both foodways and health was emphasized. The pervasive sentiment, summed up by a Klamath Nation participant, is that health disparities are the result of colonialism and solutions rest not in Wester-colonial practices but Indigenous sovereignty and cultural resurgence: “I believe that Native Americans should be able to harvest their foods wherever, within their ancestral territories. We always have since time immemorial. The government itself is basically tying our hands to being able to live off the lands”.39 Second, these results highlight the necessity of research based on Indigenous knowl-

39 Sowerwine et.al (2019), 600

40 Neufeld et.al (2020), 15 edge which treats Indigenous participants not as subjects but experts on their own health, foodways, and needs. Many of the health outcomes influenced by Indigenous foodways come not from objective diet or nutritional measures but the subjective connections to culture, family, and mental wellbeing promoted through foodways. To support food sovereignty and protect Indigenous foodways requires “understanding Indigenous food systems from the communities’ perspectives and their contexts. This is a first step to decolonizing our overall understanding of the importance of Indigenous food systems”.40

CONCLUSION

Though a small portion of the Indigenous foodways scholarships, these studies that center on Indigenous knowledge and perspectives on foodways are an essential contribution to the overall understanding of Indigenous health. From the 17 studies systematically reviewed emerged four main themes answering how Indigenous foodways are understood to influence health: physical, mental, social, and cultural health. These outcomes are interrelated and Indigenous foodways as a whole influence health holistically. Research found that Indigenous foodways are an important mechanism of holistic health, especially for addressing food insecurity. These findings suggest that to address health disparities, policy makers and community health practitioners should emphasize and support food diversity and cultural resurgence movements to promote Indigenous foodways. Importantly, this research highlights the need to look beyond micro nutritional or dietary assessment to understand the influence of Indigenous foodways. Foodways are more than foodstuffs and their influence on health extends beyond just physical health to mental, social, cultural, and ultimately the health of the sovereignty movements and decolonization of Indigenous peoples. 

BIBLIOGRAPHY

Akande, V. O., Hendriks, A. M., Ruiter, R. A., & Kremers, S. P. (2015). Determinants of dietary behavior and physical activity among Canadian Inuit: a systematic review. International Journal of Behavioral Nutrition & Physical Activity, 12, 84.

Arthur, M. L., & Porter, C. M. (2019). Restorying Northern Arapaho food sovereignty. Journal of Agriculture Food Systems and Community Development, 9, 69-84.

Barnett-Page, E., & Thomas, J. (2009). Methods for the synthesis of qualitative research: a critical review. BMC medical research methodology, 9, 59.

Batal, M., & Decelles, S. (2019). A Scoping Review of Obesity among Indigenous Peoples in Canada. Journal of Obesity, 2019.

Bhawra, J., Cooke, M. J., Hanning, R., Wilk, P., & Gonneville, S. L. (2015). Community perspectives on food insecurity and obesity: Focus groups with caregivers of metis and Off-reserve first nations children. International Journal for Equity in Health, 14, 96.

Centre for Reviews and Dissemination. (2009) Systematic Reviews: CRD’s guidance for undertaking reviews in health care. York: CRD, University of York

Chan, H. M., Fediuk, K., Hamilton, S., Rostas, L., Caughey, A., Kuhnlein, H., Egeland, G., & Loring, E. (2006). Food security in Nunavut, Canada: barriers and recommendations. International Journal of Circumpolar Health, 65(5), 416-431.

Delormier, T., Horn-Miller, K., McComber, A. M., & Marquis, K. (2017). Reclaiming food security in the Mohawk community of Kahnawa:ke through Haudenosaunee responsibilities. Maternal & Child Nutrition, 13(3), 11.

Delormier, T., & Marquis, K. (2019) Building healthy community relationships through food security and food sovereignty. Current Developments in Nutrition, 3(Supplement 2), 25–31

Domingo, A., Charles, K. A., Jacobs, M., Brooker, D., & Hanning, R. M. (2021). Indigenous Community Perspectives of Food Security, Sustainable Food Systems and Strategies to Enhance Access to Local and Traditional Healthy Food for Partnering Williams Treaties First Nations (Ontario, Canada). International Journal of Environmental Research and Public Health, 18(9), 15, Article 4404.

Elliott, B., Jayatilaka, D., Brown, C., Varley, L., & Corbett, K. K. (2012). "We are not being heard": Aboriginal perspectives on traditional foods access and food security. Journal of environmental and public health, 2012, 130945.

Gates, A., Skinner, K., & Gates, M. (2015). The diets of school-aged Aboriginal youths in Canada: a systematic review of the literature. Journal of Human Nutrition &

Dietetics, 28(3), 246-261.

Genius, S. K., Willows, N., Alexander First, N., & Jardine, C. (2015). Through the lens of our cameras: children's lived experience with food security in a Canadian Indigenous community. Child: Care, Health & Development, 41(4), 600-610.

Gilpin, M., Hayes, M. (2020). A Collection of Voices: Land-based leadership, community wellness, and food knowledge revitalization of the WJOLELP Tsartlip First Nation garden project. In Settee, P., & Shukla, S. (Eds). Indigenous Food

Systems: Concepts, Cases, and Conversations, Toronto, Ontario: Canadian Scholars. Chapter 6, 101-118

Hanemaayer, R., Anderson, K., Haines, J., Lickers, K. R., Xavier, A. L., Gordon, K., & Neufeld, H. T. (2020). Exploring the Perceptions of and Experiences with Traditional Foods among First Nations Female Youth: A Participatory Photovoice Study. International Journal of Environmental Research and Public Health, 17(7), 16, Article 2214.

Herrmann, T. M., Lamalice, A., & Coxam, V. (2020). Tackling the question of micronutrients intake as one of the main levers in terms of Inuit food security. Current

Opinion in Clinical Nutrition & Metabolic Care, 23(1), 59-63.

Hoover, E. (2017)‘You can’t say you’re sovereign if you can’t feed yourself:’ Defining and Enacting Food Sovereignty in American Indian Community Gardening.

American Indian Culture and Research Journal 41(3), 31-70.

Kerpan, S. T., Humbert, M. L., & Henry, C. J. (2015). Determinants of diet for urban aboriginal youth: implications for health promotion. Health Promotion Practice, 16(3), 392-400.

Lambden, J., Receveur, O., & Kuhnlein, H. V. (2007). Traditional food attributes must be included in studies of food security in the Canadian Arctic. International

Journal of Circumpolar Health, 66(4), 308-319.

Maudrie, T., Colón-Ramos, U., Harper, K., Jock, B.W., & Gittelsohn, J. (2021). A Scoping Review of the Use of Indigenous Food Sovereignty Principles for Intervention and Future Directions. Current Developments in Nutrition, 5.

McCartan, J., van Burgel, E., McArthur, I., Testa, S., Thurn, E., Funston, S., Kho, A., McMahon, E., & Brimblecombe, J. (2020). Traditional Food Energy Intake among Indigenous Populations in Select High-Income Settler-Colonized Countries: A Systematic Literature Review. Current Developments in Nutrition, 4(11), 26

McGrath-Hanna, N. K., Greene, D. M., Tavernier, R. J., & Bult-Ito, A. (2003). Diet and mental health in the Arctic: is diet an important risk factor for mental health in circumpolar peoples?--a review. International Journal of Circumpolar Health, 62(3), 228-241.

Mead, E., Gittelsohn, J., Kratzmann, M., Roache, C., & Sharma, S. (2010). Impact of the changing food environment on dietary practices of an Inuit population in Arctic Canada. Journal of Human Nutrition & Dietetics, 23 Suppl 1, 18-26.

Mosby, I., & Galloway, T. (2017). ‘Hunger was never absent’: How residential school diets shaped current patterns of diabetes among Indigenous peoples in Canada.

Canadian Medical Association Journal, 189(32), 1043–1045.

Oswin, N. (2020). Another geography. Dialogues in Human Geography 10 (1): 9-18.

Neufeld, H. T., Richmond, C., & Southwest Ontario Aboriginal, H. (2020). Exploring First Nation Elder Women's Relationships with Food from Social, Ecological, and Historical Perspectives. Current Developments in Nutrition, 4(3), 11, Article nzaa011.

Pawlowska-Mainville, A. (2020). Aki Miijim (Land Food) and the Sovereignty of the Asatiwisipe Anishinaabeg Boreal Forest Food System. In Settee, P., & Shukla, S. (Eds). Indigenous Food Systems: Concepts, Cases, and Conversations, Toronto, Ontario: Canadian Scholars. Chapter 4, 57-82.

Pawson, R., Greenhalgh, T., Harvey, G., Walshe, K. ( 2005) Realist review –a new method of systematic review designed for complex policy interventions. Journal of Health Services Research and Policy, 10, 21-34

Settee, P., & Shukla, S. (2020). Indigenous food systems: Concepts, cases, and conversations.

Shanks, C. B., Ahmed, S., Dupuis, V., Houghtaling, B., Crane, M. A. R., Tryon, M., & Pierre, M. (2020). Perceptions of food environments and nutrition among residents of the Flathead Indian Reservation. Bmc Public Health, 20(1), 15, Article 1536.

Skinner, K., Hanning, R. M., Desjardins, E., & Tsuji, L. J. (2013). Giving voice to food insecurity in a remote indigenous community in subarctic Ontario, Canada: traditional ways, ways to cope, ways forward. Bmc Public Health, 13, 427.

Sowerwine, J., Mucioki, M., Sarna-Wojcicki, D., & Hillman, L. (2019). Reframing food security by and for Native American communities: a case study among tribes in the Klamath River basin of Oregon and California. Food Security, 11(3), 579-607.