Telemedicine and a Nutrition North update

This past week I was able to experience counselling through telemedicine, which is basically talking to someone through video/webcam, for the first time. Telemedicine allows consults to occur in outlying communities without the practitioner having to travel to their location.

Telemedicine reduces barriers to accessing care, as it allows for more frequent and flexible scheduling compared to site visits alone. Since nurses are the only permanent staff at the health clinics outside of Moose Factory, this is especially valuable for any "specialized" service. Dietetics, physio, and any appropriate medical consults can use telemedicine to consult clients. That is not to say that telemedecine is a replacement for visiting communities, but with limited health care resources it is a valuable complementary service. 

Where telemedicine lacks, is the difficulty in connecting with clients over a pixelated video screen. What I expected was somethign similar to skype, where you are basically face to face with the individual, but in reality it is closer to speaking to someone on the opposite side of a room. Since there is often multiple people involved in a consult, the cameras and screens are positioned some distance away from the person, and while you can zoom in, it still makes for an interesting dynamic. 

The most difficult issue is sharing resources with clients. Holding food models to the camera, to show what a healthy plate of food looks like or to gain a sense of their pop intake, is far from ideal. In this sense the quality of care suffers when compared to an in person consult, but overall care is improved by greater access. 

There is no doubt that telemedicine needs to be balanced with adequate in person care, but I wonder what the future of telemedicine looks like? Will we one day be able to do "home" visits via telemedicine, or maybe consults on smartphones, that would surely improve show rates!

Nutrition North update:

Olivier De Schutter the United Nations special representative on the right to food included a specific section on the Nutrition North Canada program. A couple of sections in paticular caught my eye:

Nutrition North Canada provides subsidies to retailers operating in NNC-eligible communities and to food suppliers operating in southern Canada. The subsidies are intended to be passed on to consumers through lower retail prices for eligible items. However, in the absence of adequate monitoring by those it is intended to benefit, it is unclear whether the programme is achieving its desired outcome.

Nutrition North Canada currently publishes the subsidy per kilogram for each eligible community, but it does not require retailers to inform Aboriginal Affairs and Northern Development Canada or the public of their airfreight costs. As such, the federal Government has no way of verifying if the subsidy is being passed on...

While monitoring of the program has been a huge critisicm from Northern food activists, other concerns surrounding implementation and efficacy of the program were also raised in the special rapporteur's report.

 The Special Rapporteur recognizes that neither Nutrition North Canada nor the Food Mail Program could address other factors responsible for the high food costs in northern communities, such as the high cost of energy for heating and refrigeration, electricity generation, building construction, equipment maintenance, etc. Food costs remain higher in the North than elsewhere in Canada for legitimate reasons, but more needs to be done to improve the effectiveness of Nutrition North Canada. 

Now that  Canada has been investigated by an international organization, I wonder if the government of Canada will take note?

JK

Comparing the cost of food.

Coming to Moose Factory I knew I would be spending significantly more on food than when I was in Nova Scotia, but it wasn't until I took part in a food costing activity this past week that I realized just how much more. As part of an online course, I was to cost a weeks worth of healthy food for a family of 3 (2 adults, 1 child), and compare with other students located across Canada/World. The values that came out were simply astounding.

While the food plan we used is far from a rigorous research study, the cost comparison is very interesting. For Moose Factory a healthy diet for a family of 3 according to our meal plan is $190.11, while in Ottawa and Montreal the cost came out to ~$104.25. Prices that are nearly double! The fact that this comes as a surprise for me after 5 weeks also shows how poor I am at paying attention to my expenses.

To give these values more context we can match it to social assistance and minimum wage:

 A) The family is receiving Ontario Works (OW) social assistance (for a couple and 1 child under the age of 17):

Annual income: $9,948.00

Monthly income: $829.00

Allows for distribution of a weekly income of: $190.00

It almost seems silly to implement the food values into this number, as clearly it is unaffordable. But if a family receiving social assistance in Ontario were to eat healthy according to our meal plan:

Weekly income: 190.00

Cost of healthy food basket in Montreal/Ottawa: $104.25

% of income spent on food: ~55%

Cost of healthy food basket in Moose Factory: $190.11

% of income spent on food: 100%

And if one parent is working a full-time (40 hours/week), minimum wage job ($10.25/hr):

Annual income: $19, 680.00

Monthly: $1,640.00

Weekly income: $379.00

% of income spent on food in Montreal/Ottawa: ~28%

% of income spent on food in Moose Factory: ~50%

It is pretty clear from these values that support for people is too low to allow them to eat a healthy diet. I think spending half of your pay check on food is pretty unrealistic, and food tends to be an “elastic” component of the household budget, in the sense that people can be more flexible with food than they can with housing and related expenses such as heat, power etc.

  The sad part is that Moosonee and Moose Factory actually have the lowest prices for the area,  people from up the coast drive down the winter ice road to shop in Moosonee. The cost of some items can be double in the communities up the coast. Though I haven't traveled to any of the coastal communities yet, I've heard horror stories of people placing locks on their fridge, because of the high price, food is sometimes stolen. It is hard to imagine this happening in Canada today, and even harder to accept! 

Working as a dietitian in these communities is especially challenging, while you try to offer suggestions for healthy low cost meal alternatives, you can tell that people have tried every way they can to save money on food. At that point it becomes more about assuring they take their multivitamin on a regular basis, not exactly ideal.

JK

  

A nature hike and country food

Yesterday I was able to go on a hike to another island on the Moose River, just across from Moose Factory. Even though I was assured it was normal and safe, I must admit that the giant cracks on the ice were a little unnerving. But after making it across the river the hike was great, and we had beautiful weather.

The most interesting part of the hike was learning about the different animals that reside in the area, and which are used as food or trapped for their fur. It was interesting to see traps for beaver and pine marten, as people in the area still rely on animals to supplement their income and diet. As well as berries still ripe for picking in the winter.

 The top of a beaver trap, you must chisel through the ice to see if you have caught anything.

Moose berries, growing all over the place had a mild ciitrus flavour.

Country foods are still on the plate of people in Moose Factory, it is not uncommon for someone to list moose or rabbit when doing a diet recall during a counseling session. For myself I believe it's important to learn more about the role of country foods in peoples diet and what amounts are appropriate.

While Canada's food guide for aboriginal people has been adapted to include country foods it is still based on "European" Canadian research. The First Nations people of North America lived on a diet consisting primarily of protein and fat, and their bodies have in turn adapted to this diet, so that the recent shocks to their dietary patterns have caused major health issues (Young et al., 2000). Studies have shown that people of First Nation descent who eat higher amounts of country food have a reduced risk of developing obesity and other chronic disease.  First Nations people have been affected by a rapidly changing food culture that has caused a diabetes epidemic, due to drastic sociocultural changes and a history of colonization (Young et al., 2000).

 The "Westernization" of their diet, has no doubt been a major factor. It is the same reason why we see obesity and non-communicable chronic disease flourishing world wide. Easily accessible energy dense nutrient poor food, coupled with the destruction of a way of life, has paved the way for chronic illness to take hold of indigenous communities in Canada.

Most people that come for diet counseling require basic teaching on how to eat healthy, reduce processed foods, and strategies on how to eat on a budget. There have been a few cases where an elder, who's diet contains country foods, has been referred for diet counseling. While I have no problem suggesting they reduce the amount of sugar and cream in their tea, or reduce their portion sizes, I still do not feel totally comfortable suggesting they make half their plate contain fruits and vegetables and to select lean meats.

I'm still trying to understand the role of traditional food, and while I realize that especially among young people in the area country foods make up a very small part of their diet, I wonder if diet recommendations for First Nations people should better reflect their history and physical anthropology.

JK


Young K., Reading J., Elias B. & O'Neil J. (2000). Type 2 diabetes mellitus in Canada's First Nations: Status of an epidemic in progress. Canadian Medical Association Journal. 163(5).

A day in the life

So I haven't had too much to reflect on this week. I just finished up two days of hospital orientation, in which I learned proper hand washing technique and that I probably don't need to worry about what happens in a bomb threat because "those may happen down South, but we've never had them up here".

I thought I would do a photo blog this week to give an idea of what things look like up here. I'm also going on a nature hike on Saturday so I'll post some photos from that as well. 

So one thing I was quite excited about when I came here was the opportunity to work out in an old ambulance garage. I successfully found a gym grungier then the YMCA in Saskatoon, though I definitely feel more comfortable working out in Moose Factory, as there aren't 5 guys that look like they just got out on parole giving me dirty looks. Plus it doesn't get much more Canadian than working out in an old ambulance garage when it's -40 out!

I haven't took many photos since being up here, which I regret, but I thought I'd share a few more from around the island and a couple from the train ride up from Cochrane to Moosonee.

Linking the community and clinical settings

Coming into my clinical nutrition placement I did not expect to find many connections with my other interests of community development and food security. In my previous clinical experience, working in a large hospital, it seemed half the time I was figuring out how much to give someone in their tube feed. One thing I knew for sure was that this calculating side of dietetics is not for me, incredibly important, but not something I enjoyed doing on a regular basis.

What I'm realizing in this current setting is how deeply rooted food security is in  the dietetics profession.  Food security isn't just about the affordability of a nutritious diet, but is also about health literacy, participation, and the availability of nutritious food.

When counselling a client who knows what to eat, but just can't afford to buy food to keep her family healthy, this is a food security issue. As is when an individual does not know how to cook anything but kraft dinner and hotdogs, or someone that is reliant on others for transportation and can't go out to the store to get food on a regular basis.

Of course as a new graduate who's been trained to give diet advice, helping a client come up with solutions is quite challenging. Canada's food guide will only get you so far.

As an outpatient or inpatient dietitian you are working on food security issues at the individual level. I am developing a better understanding of food issues in Moose Factory, but understanding is not always enough. It gets frustrating having to work through limitations imposed by the political, social, and economic environment.

This diagram from the Ryerson University food security program provides a good depiction of how individual nutritional outcomes are shaped by the environment. It is important to have an understanding of how each level impacts nutrition status and eating habits, in order to help someone come up with ideas to overcome these barriers.

While it can be frustrating when you realize the difficulties people face to eat healthy. These limitations, imposed on us by our environment, force people to become creative problem solvers, and aiding a client navigate these challenges can be a rewarding experience.

The importance of advocating for clients, and developing programs in the community is important. To move forward as a profession, and affect healthy change, dietitians need to blur the line between the "clinical" and "community" settings. This will foster creative solutions to the complex issues we face in our food environment.

JK

Stress, trauma, and recovery

This past weekend I was able to attend a community workshop called "Pathways to Healing". The workshop brought speakers, from a variety of backgrounds, both from Canada and the U.S, to Moose Factory. The workshop is held annually and is intended to help the community overcome past struggles and increase its resiliency.

I was fortunate enough to hear Darryl Tonemah speak. Darryl is an aboriginal health psychologist from the Tucarosa reserve in New York. Along with three undergraduate degrees, he has a master's in community counseling, and a Ph.D in counselling Psychology and cultural studies.

What grabbed my attention immediately about Darryl was his incredible story telling ability. I've only experienced a few times in my life someone who is able to engage you so deep in story that you find your palms sweating, and you are ready to jump out of your seat. Darryl was one of those story tellers.

Darryl's talk focused on stress and trauma, and its impact through the life cycle.

He presented stress as something that forces you to act, it is not necessarily a negative, but it just means you can't do nothing. Looking at stress in this way, it can actually be viewed as a very positive thing. You can't grow, learn, or love without it!

He then defined trauma as an event that overwhelms our ability to act. It is an event where we have no control over the situation, and is so difficult to process that the brain and body protects itself by shutting down. The problem with this response is you don't always return to normal afterwards.

Darryl began his discussion of trauma looking at its impact on pregnant mothers. He talked about a study that followed the children of mothers who were pregnant in the New York City area during the Sept. 11, 2011 terrorist attacks. The study followed the children 10 years  following the event and found they experienced worse physical and emotional health outcomes, than children who weren't in utero during the attacks. The trauma felt by the mother is turn felt by the fetus, through the various chemical changes that occur. The mind-body relationship is an amazing thing.

What I learned most from Darryl's talk was how difficult it is to recover from a traumatic event, and when you don't have adequate support to help you process, then trauma can last a lifetime.

If trauma can perpetuate from one generation to the next, how do you try to recover as a community?

It is certainly not something that will fade in time. That is what Pathways to Healing is trying to address, and I feel very grateful to have had the opportunity to attend Darryl's presentation.

 JK

 





 

Nutrition North and the high cost of food

One issue I wanted to explore during my time in Moose Factory, was the high price of food in remote communities. Moose Factory itself is not included in the Nutrition North subsidy program, although food in Moose Factory/Moosonee is significantly higher than down South. However, many other communities in the health district do partake in the subsidy program.

A little on the Nutrition North program...   

The Nutrition North subsidy is a federal program that provides retailers and food processors located in Northern communities, with no year round surface transportation ( no permanent road, rail, or marine access), subsidies on perishable foods (fruits, vegetables, eggs, meat, milk, and cheese). The program is a market driven model, so retailers apply to the program, and if accepted the subsidy is transferred directly to the store. Businesses are then accountable to pass on the subsidy to the consumer. Restaurants and social institutions, such as day cares or schools, are also eligible for this subsidy.  

Fruits, vegetables, meat, milk, and eggs are eligible for a higher subsidy rate than combination foods such as pizza or lasagna.

The main question, which has drawn criticism of the program, is how much of the subsidy finds its way to the citizens of these communities? A “market driven model” such as the Nutrition North program, encourages business growth in these communities by making them more profitable. It does not guarantee nutritious and affordable food will be available in Northern communities. This is not to say that business is bad, and that the government should fully control the food entering these communities. It is just to say that without proper oversight and transparency, these businesses providing the service could profit at the expense of the communities. It comes as no surprise then that the most successful initiatives for providing food to remote communities have been generated from within.

As the Wawatay news reported in September 2011, Fort Albany is a good example of a community who organized to fill a hole in the subsidy program. The community started up a food security committee in January 2011, with concern of affordable nutritious food as its focal point. The community partnered with Nishnawbe Aski Nation’s True North Community Cooperative, which provides remote communities with nutritious food boxes, subsidized through Nutrition North Canada. The program is like a bulk buying club for the community, which cuts out the retailer, and most of the food comes from stores in Cochrane or Timmins. The food is then sold, in the style of a farmer’s market, at cost to the community. 

It is creative ideas such as this that are needed to provide remote communities with accessible nutritious food. The community took advantage of the subsidy to better fulfill the needs of its people, instead of going through a retailer like the Northern store.   

A discussion thread for anyone interested in learning more about how Northern Nutrition Canada has impacted communities can be found here: 
https://groups.google.com/forum/?fromgroups#!topic/northern_food/Pdkgrd-xYXg