Social Determinants Influencing Nutrition Behaviors and Cardiometabolic Health in Indigenous Populations: A Scoping Review of the Literature

Abstract

Nutrition behavior is influenced by a large number of factors, including social and cultural factors. This scoping review aims to summarize how social determinants of health (SDoH) influence nutrition behaviors in Indigenous populations affected by or at risk of cardiometabolic diseases. Following the PRISMA-ScR guidelines, we conducted a systematic search in six databases—PubMed, Web of Science, CINAHL, PsycINFO, Cochrane Library, and World Health Organization Global Index Medicus—limiting results to studies published in English up to 27 October 2023. A descriptive synthesis was conducted. We identified 1490 articles, and after screening, 31 of them met our inclusion criteria. We found that nutritional behavior is impacted by various SDoH domains, including economic stability, neighborhood and built environment, education, health and healthcare, and social and community context. The shift from traditional diets to Westernized diets and from subsistence-based food gathering to reliance on store-bought and processed foods reflects changes in SDoH, affecting both nutrition behaviors and health outcomes. Although not all included studies examined every SDoH domain in our review, future research should consider all domains to gain a comprehensive understanding of how they impact nutritional behavior. This approach will better inform interventions and policies, ultimately promoting health equity in Indigenous communities.

Full text

Citation: Gyawali, B.; Mkoma, G.F.;
Harsch, S. Social Determinants
Influencing Nutrition Behaviors and
Cardiometabolic Health in Indigenous
Populations: A Scoping Review of the
Literature. Nutrients 2024,16, 2750.
https://doi.org/10.3390/nu16162750
Academic Editor: Roberta Masella
Received: 16 July 2024
Revised: 8 August 2024
Accepted: 15 August 2024
Published: 17 August 2024
Copyright: © 2024 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
nutrients
Review
Social Determinants Influencing Nutrition Behaviors and
Cardiometabolic Health in Indigenous Populations: A Scoping
Review of the Literature
Bishal Gyawali 1, * , George Frederick Mkoma 2,3 and Stefanie Harsch 4
1
Global Health Section, Department of Public Health, University of Copenhagen, 1014 Copenhagen, Denmark
2Department of Epidemiology Research, Statens Serum Institut, 2300 Copenhagen, Denmark; gefm@ssi.dk
3Section of Health Services Research, Department of Public Health, University of Copenhagen,
1353 Copenhagen, Denmark
4Center for Medicine and Society, Albert-Ludwigs-Universität Freiburg, 79098 Freiburg, Germany;
stefanie.harsch@zmg.uni-freiburg.de
*Correspondence: bishalgyawali01@gmail.com; Tel.: +45-42348030
Abstract: Nutrition behavior is influenced by a large number of factors, including social and cultural
factors. This scoping review aims to summarize how social determinants of health (SDoH) influence
nutrition behaviors in Indigenous populations affected by or at risk of cardiometabolic diseases.
Following the PRISMA-ScR guidelines, we conducted a systematic search in six databases—PubMed,
Web of Science, CINAHL, PsycINFO, Cochrane Library, and World Health Organization Global
Index Medicus—limiting results to studies published in English up to 27 October 2023. A descriptive
synthesis was conducted. We identified 1490 articles, and after screening, 31 of them met our inclusion
criteria. We found that nutritional behavior is impacted by various SDoH domains, including
economic stability, neighborhood and built environment, education, health and healthcare, and
social and community context. The shift from traditional diets to Westernized diets and from
subsistence-based food gathering to reliance on store-bought and processed foods reflects changes in
SDoH, affecting both nutrition behaviors and health outcomes. Although not all included studies
examined every SDoH domain in our review, future research should consider all domains to gain a
comprehensive understanding of how they impact nutritional behavior. This approach will better
inform interventions and policies, ultimately promoting health equity in Indigenous communities.
Keywords: social determinants of health; sociohistorical factors; nutrition behaviors; cardiometabolic
health; indigenous populations
1. Introduction
Cardiometabolic diseases (CMDs), such as cardiovascular disease and type 2 dia-
betes, represent significant global health challenges in the 21st century [1]. These diseases
disproportionately impact specific groups, including ethnic minorities, low-income indi-
viduals, and residents of economically disadvantaged areas [
2
]. Indigenous populations,
characterized by their distinct cultural identities and strong ties to ancestral territories, are
particularly vulnerable to health disparities in cardiometabolic health [
3
,
4
]. Compared to
the general population, Indigenous people experience a higher burden of CMDs [5]. Poor
nutrition greatly contributes to CMDs among Indigenous people. Improving nutrition
quality can reduce these conditions by up to 50% [6].
Recent studies indicate that changes in nutritional behaviors have increased the bur-
den of CMDs, with poor nutrition quality contributing to over 11 million deaths globally
in 2017 [
7
]. Indigenous populations worldwide are undergoing a nutrition transition [
8
],
characterized by a decline in traditional food consumption (foods native to the local envi-
ronment) and a rise in the intake of market foods, including energy-dense and nutrient-poor
Nutrients 2024,16, 2750. https://doi.org/10.3390/nu16162750 https://www.mdpi.com/journal/nutrients

Nutrients 2024,16, 2750 2 of 28
products [
9
]. Research increasingly highlights that socioeconomic, cultural, and environ-
mental factor—collectively known as social determinants of health (SDoH)—are crucial for
understanding health disparities and promoting CMD prevention and management [
10
–
15
].
Since the seminal study on SDoH by Marmot et al., subsequent research has emphasized
their significant role in influencing lifestyle, risk factors, and disease outcomes [
16
]. These
determinants greatly influence nutritional habits, which are shaped by systemic factors,
such as racism and unequal resource distribution [
17
]. Certain population subgroups,
especially those who are vulnerable, marginalized, and disadvantaged, often live and work
in more deteriorated environments. They face greater exposure to disease risk factors and
experience physiological effects from chronic stress, leading to poorer health outcomes and
shorter lifespans. Powell-Wiley et al. identified several dimensions of social determinants
of health in marginalized populations, including economic stability, neighborhood and built
environment, education access and quality, healthcare access and quality, and social and
community context [
11
]. These determinants interact with cultural norms and traditions to
shape eating habits [18].
Studying Indigenous populations presents challenges due to their diversity; the United
Nations recognizes over 476 million Indigenous people across more than 5000 distinct
groups globally [
19
]. Living conditions, historical injustices, colonization, land dispos-
session, and restricted access to traditional foods have significantly impacted Indigenous
populations, influencing nutrition behaviors [20].
Considering the significant influence of SDoH on nutritional behavior and the gap
in synthesizing these determinants within Indigenous populations, this scoping review
aims to deepen our understanding of the social determinants of nutrition behavior among
Indigenous populations living with or at risk of CMDs by summarizing existing evidence.
The specific research question guiding this review was the following: ‘What are the social
determinants of nutrition behavior among Indigenous populations living with or at risk of
CMDs?’ Understanding these determinants is crucial for designing tailored interventions
and comprehensive strategies to improve nutritional behavior in Indigenous populations.
2. Materials and Methods
This study employed the scoping review methodology, adhering to Arksey and
O’Malley’s five-step process [
21
]. The methods are summarized according to the Pre-
ferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines: Extension
for Scoping Reviews (PRISMA-ScR) [
22
]. Following Arksey and O’Malley’s framework,
the review steps included the following: (1) defining the research question; (2) identifying
relevant studies; (3) selecting studies; (4) charting the data; and (5) collating, summarizing,
and reporting the findings [
21
]. The PCC model (Population, Concepts, and Context) was
used to construct the research question and develop the search strategy, following the
Johanna Briggs Institute’s recommendations [23].
2.1. Identifying Relevant Studies
To identify relevant studies, a comprehensive search of six databases—PubMed, Web
of Science, CINAHL, PsycINFO, Cochrane Library, and World Health Organization Global
Index Medicus—was conducted. The search strategy employed medical subject headings
and specific keywords (Supplementary File S1). Gray literature was also searched using
identical terms in Google and Google Scholar. Identified publications were managed using
EndNote 20 and screened for duplicates using Covidence (www.covidence.org). The search
was limited to studies published in English from the inception of each database up to 27
October 2023. The search strategy was developed through consultation with a university
librarian and discussions among the research team.

Nutrients 2024,16, 2750 3 of 28
2.2. Eligibility Criteria and Study Selection
For study selection, inclusion criteria focused on studies that (1) exclusively involved
Indigenous populations; (2) discussed CMDs; (3) examined SDoH domains, including
the economic, educational, neighborhood, health, and social factors influencing nutrition
behavior (Supplementary File S2); and (4) conducted primary (original) research. Studies
were excluded if they compared Indigenous with non-Indigenous groups, lumped different
populations together under the term ‘Indigenous’ (e.g., studies describing nutritional
transitions in a country), or focused solely on so-called tribal populations specifically
named as such, or targeted local populations (e.g., a tribe in India or Kenya) that do not
(self-)identify as Indigenous. Additionally, studies were excluded if they centered solely
on the gut microbiome or other biomedical markers, reported CMD prevalence without
linking it to nutrition, were not yet implemented (e.g., study protocols), or were review
papers, opinion pieces, or intervention studies (Table S1). Search execution and screening
were managed by one author (SH), with independent screening performed by two authors
(SH and BG) who independently screened all articles using Covidence. Any discrepancies
in article inclusion were resolved through consensus, with a third researcher (GFM) acting
as a referee where necessary.
2.3. Charting the Data
The eligible articles were thoroughly reviewed multiple times by two researchers (BG
and SH) to ensure familiarity with their content. Consensus was reached among researchers
on the categories for data extraction. BG and SH extracted data from selected articles and
then entered them into an Excel spreadsheet. The spreadsheet included the following
categories: author(s), year of publication, study title, country, Indigenous group, general
population or patients, study objectives, sample size and description, social determinants,
nutritional behavior, CMD and/or CMD risk factors, and main findings.
2.4. Collating, Summarizing, and Reporting Results
A comprehensive analysis of the selected articles was conducted using the extracted
data. A tabular summary of study details and outcomes was compiled. The extracted data
were descriptively synthesized, providing an overview of the included study characteristics,
settings, target group, and social determinants of nutritional behaviors. BG verified data
accuracy. Quality appraisal of the included studies or meta-analysis was not undertaken, as
this review aimed to provide an overview or mapping of relevant evidence on nutritional
behavior and SDoH [23].
3. Results
3.1. Literature Search
A total of 1474 articles were identified, primarily in the six electronic databases and
an additional 16 articles from the reference check that met our study criteria. Moreover,
576 duplicate articles were removed, and the remaining 913 were subjected to screening
according to the inclusion criteria. Following a review of the titles and abstracts, 337 were
included for the subsequent full-text screening in accordance with the inclusion criteria.
Finally, 31 articles met the inclusion criteria and were included in the current scoping
review. Details of the screening process are illustrated in Figure 1.

Nutrients 2024,16, 2750 4 of 28
Nutrients 2024, 16, 2750 4 of 27
Figure 1. PRISMA study flow chart.
3.2. Study Characteristics
This review included peer-reviewed articles from ten countries focusing on various
Indigenous populations. In the USA, the studies involved American Indian/Alaska Na-
tives [24–27], American Indians from the Chickasaw and Choctaw Nations [28–32], Native
Americans (Yup’ik) [33–35], and the Flathead Indian tribes [36]. Canadian studies covered
Figure 1. PRISMA study flow chart.

Nutrients 2024,16, 2750 5 of 28
3.2. Study Characteristics
This review included peer-reviewed articles from ten countries focusing on various
Indigenous populations. In the USA, the studies involved American Indian/Alaska Na-
tives [
24
–
27
], American Indians from the Chickasaw and Choctaw Nations [
28
–
32
], Native
Americans (Yup’ik) [
33
–
35
], and the Flathead Indian tribes [
36
]. Canadian studies covered
First Nation [
37
,
38
], FN Anishina, Ojibwe, Aji-Cree [
39
], the Inuit from Nunavut [
40
,
41
],
self-identified Indigenous populations [
42
], and the Woodland Cree [
43
]. Australian studies
included isolated communities [
44
], Aboriginal groups [
45
], and M
¯
aori [
14
]. Additionally,
this review included studies from Fiji (iTaukei) [
46
,
47
], Argentina (Toba and Wichí) [
48
],
French Guiana (Palikur/Parikwene) [
49
], Greenland (Greenland Inuit) [
50
], Guatemala
(Indigenous) [
51
], Mexico (Mayan) [
52
], and Russia (Yakutia) [
53
]. The geographical distri-
bution of Indigenous populations included in the study is shown in Figure 2.
Nutrients 2024, 16, 2750 5 of 27
First Nation [37,38], FN Anishina, Ojibwe, Aji-Cree [39], the Inuit from Nunavut [40,41],
self-identified Indigenous populations [42], and the Woodland Cree [43]. Australian stud-
ies included isolated communities [44], Aboriginal groups [45], and Māori [14]. Addition-
ally, this review included studies from Fiji (iTaukei) [46,47], Argentina (Toba and Wichí)
[48], French Guiana (Palikur/Parikwene) [49], Greenland (Greenland Inuit) [50], Guate-
mala (Indigenous) [51], Mexico (Mayan) [52], and Russia (Yakutia) [53]. The geographical
distribution of Indigenous populations included in the study is shown in Figure 2.
Figure 2. Geographical distribution of Indigenous populations included in this study. Please note
that numbers for certain countries, such as French Guiana, Guatemala, Mexico, and Fiji, are not
visible due to their small geographical size.
The publications ranged from 2005 to 2023, with the highest number in 2021 (seven
articles). The study design included two mixed-methods studies, 16 quantitative studies,
and 13 qualitative studies. The studies focused either on prevention for Indigenous com-
munities at risk of CMD (22 studies) [14,27–30,33–39,41–44,46–50,53] or on disease man-
agement for people with CMD (9 studies) [24–26,31,32,40,45,51,52]. The characteristics of
the included studies are detailed in Table 1, with full details in Table 2.
Figure 2. Geographical distribution of Indigenous populations included in this study. Please note that
numbers for certain countries, such as French Guiana, Guatemala, Mexico, and Fiji, are not visible
due to their small geographical size.
The publications ranged from 2005 to 2023, with the highest number in 2021 (seven
articles). The study design included two mixed-methods studies, 16 quantitative stud-
ies, and 13 qualitative studies. The studies focused either on prevention for Indigenous
communities at risk of CMD (22 studies) [
14
,
27
–
30
,
33
–
39
,
41
–
44
,
46
–
50
,
53
] or on disease
management for people with CMD (9 studies) [
24
–
26
,
31
,
32
,
40
,
45
,
51
,
52
]. The characteristics
of the included studies are detailed in Table 1, with full details in Table 2.

Nutrients 2024,16, 2750 6 of 28
Table 1. Characteristics of included studies.
Sample Description
Indicators Data Number of Studies
Country
Indigenous group
USA 13
American Indian/Alaska Natives 4
American Indians (Chickasaw Nation,
Choctaw Nation)
5
3
Native American (Yup’ik) 1
Flathead Indian 1
Canada 7
First Nation 2
FN Anishina, Ojibwe, Aji-Cree 1
Indigenous Population (self-identified) 1
Inuit (Nunavut Inuit) 2
Woodland Cree 1
Australia 3
Isolated Australian Communities 1
Aboriginal 1
M¯
aori 1
Fiji; iTaukei 2
Argentina: Toba and Wichí1
French Guiana: Palikur/Parikwene 1
Greenland: Greenland Inuit 1
Guatemala: Indigenous 1
Mexico: Mayan 1
Russia: Yakutia 1
Year
2005–2009 4
2010–2014 3
2017 2
2018 2
2019 5
2020 4
2021 7
2022 1
2023 3
Study Design
Mixed-methods study 2
Quantitative study 16
Qualitative study 13
Target Group People with disease 9
General population at risk 22

Nutrients 2024,16, 2750 7 of 28
Table 2. Detailed characteristics of included studies.
Author
Study
Year Country Indigenous
Group
Study
Population
Sample Size and
Description Study Design Study Aim Results/Findings Related to Nutrition Behavior
Indigenous populations potentially at risk of CMDs
(Akande
et al., 2021)
[41]
2021 Canada
Inuit
(Nunavut
Inuit)
General
population,
possibly at risk
16 adults
(10 women,
six men)
Qualitative
study
involving
semi-
structured
photo-
elicitation
interviews
To explore the
perspectives of
Nunavut Inuit on the
barriers and enablers
of healthy diets and
physical activity
participation in the
community of Iqaluit
-Work-related changes, from hunting to a wage
economy, influence food availability, impacting
dietary choices.
-Affordability is the main perceived barrier to
healthy food choices, affecting traditional and
non-traditional healthy foods.
-Unhealthy junk foods are cheaper, while traditional
foods have become more expensive due to the rising
cost of hunting equipment and skilled hunters.
-The availability of funds for purchasing healthy
food is limited by spending choices such as
smoking, drug use, and alcohol consumption.
-The availability of healthy food options (including
traditional foods) is a major barrier to
eating healthily.
-Political restriction on the number of specific wild
animals allowed to be hunted reduces the
consumption of healthy hunted meat.
-Colonization and sociocultural assimilation have
influenced food consumption practices, making
former ‘food sharing’ practices less common.
(Bell et al.,
2017) [14]2017 Australia M¯
aori
General
population,
possibly at risk
15 Indigenous
(M¯
aori) people
Qualitative
study
involving
narrative
interviews
To identify the
intrinsic mechanisms
that specifically relate
to Indigenous
people’s interpretation
of obesity
-Western models of calorie counting, diet and
exercises were perceived as not sensitive to the
needs and unrelatable concepts in the context
of obesity.
-The perceived association of biomedical health care
with colonization causes feelings of alienation and
reduces the acceptance of the health professional’s
advice regarding a healthy diet.

Nutrients 2024,16, 2750 8 of 28
Table 2. Cont.
Author
Study
Year Country Indigenous
Group
Study
Population
Sample Size and
Description Study Design Study Aim Results/Findings Related to Nutrition Behavior
(Berg et al.,
2012) [28]2012
United
States of
America
American
Indians
General
population,
possibly at risk
998 American
Indians
Quantitative
study
To examine factors
related to engaging in
at least four days of
physical activity per
week and factors
related to consuming
at least five fruits and
vegetables per day
among a sample of
American Indians in
the Midwest
Education, knowledge, and perceptions are critical
factors in improving nutrition behaviors.
(Bjerregaard
and Larsen,
2021) [50]
2021 Greenland Greenland
Inuit
General
population,
possibly at risk
2436 Inuit aged
15+ years
Quantitative
study
To explore the role of
social position in
dietary patterns and
expenditures on food
and other
commodities
-Low social position associated with the selection of
unhealthy food patterns.

Nutrients 2024,16, 2750 9 of 28
Table 2. Cont.
Author
Study
Year Country Indigenous
Group
Study
Population
Sample Size and
Description Study Design Study Aim Results/Findings Related to Nutrition Behavior
(Bruner and
Chad, 2014)
[43]
2014 Canada Woodland
Cree
General
population,
possibly at risk
279 (females
15 years and
older), 19 for
interviews
Mixed-
methods study
To explore the social,
cultural, behavioral,
and environmental
factors influencing
diet intake from a
trans-generational
perspective and to
characterize the
dietary practices
among Woodland
Cree women
-Shifts in the consumption of food associated with
their Indian culture and an increase in ‘store-bought’
fast foods and overeating contributed to
unhealthy bodies.
-Younger community members prefer store-bought
foods which are less healthy than hunting.
-High costs to travel a long distance (145 km) to
purchase food in the closest marketplaces influence
food choices (e.g., fresh food would be spoiled).
-Availability of healthy food options is limited
locally, leading to the high frequency of purchasing
packaged processed foods.
-Environmental changes (e.g., deforestation)
negatively influence hunting and thus make
obtaining traditional foods more difficult.
-A health center routinely supplies fruits and
vegetables to individuals/programs, which is well
received, yet this is not often possible due to
long-distance traveling (300 km) to acquire
these items.
-Shifts in the consumption of food associated with
their Indian culture and an increase in ‘store-bought’
fast foods and overeating contributed to
unhealthy bodies.
-Younger community members prefer store-bought
foods which are less healthy than hunting.
(Buksh et al.,
2022) [46]2022
Pacific
Island
countries,
Fiji
iTaukei
mothers
General
population,
possibly at risk
15 Indigenous
women
Qualitative
study
involving
in-depth
interviews
To explore
sociocultural factors
that contribute to
overeating and
unhealthy eating
behaviors in an urban
Indigenous
community in Fiji
-Families with lower SES cannot afford meat and
opt for cheaper processed meat options (canned
meat, fish, sausages), thus eating less healthily.
-Cultural norms, beliefs, expectations, and pressures
contribute to overeating, unhealthy eating, and
nutrition transitions among Indigenous populations
in urban areas.

Nutrients 2024,16, 2750 10 of 28
Table 2. Cont.
Author
Study
Year Country Indigenous
Group
Study
Population
Sample Size and
Description Study Design Study Aim Results/Findings Related to Nutrition Behavior
(Buksh et al.,
2023) [47]2023
Pacific
Island
countries,
Fiji
iTaukei
mothers
(urban
Indigenous
Fijian
mothers)
General
population,
possibly at risk
15 Indigenous
women
Qualitative
study
involving
in-depth
interviews
To explore how urban
indigenous Fijian
mothers perceive
healthy eating and
how these perceptions
impact the food
decisions they make
for their families
Multifaceted perceptions on healthy
eating positively and negatively impacted the
family food choices.
(Byker
Shanks et al.,
2020) [36]
2020
United
States of
America
Flathead
Indian
General
population,
possibly at risk
Surveyed 79
residents and
conducted 76
semi-structured
interviews
Quantitative
and qualitative
multi-
methods study
To document food
environment
experiences among
residents of the
Flathead Reservation
in rural Montana
Perceptions of the food environment were linked to
strategies that could be targeted to improve
dietary quality.
(Domingo
et al., 2021)
[37]
2021 Canada First Nations
communities
General
population,
possibly at risk
3681 (2370
women/1311 men)
First Nations
people aged >=
19 years
Quantitative
study
To examine the
pattern of household
food insecurity in First
Nations communities
and its association
with obesity
Low income is linked to changes in unhealthy
dietary practices.
Receiving income support linked to healthy
dietary practices.
(Estradé
et al., 2021)
[35]
2021
United
States of
America
Native
American
General
population,
possibly at risk
580 tribal
members,
self-identified as
the main
household food
purchaser (74%
female)
Quantitative
study
To identify
psychosocial and
household
environmental factors
related to diet quality
among Native
Americans (NA)
-Healthier household-level food patterns associated
with higher diet quality.
-High educational level associated with higher
diet quality.

Nutrients 2024,16, 2750 11 of 28
Table 2. Cont.
Author
Study
Year Country Indigenous
Group
Study
Population
Sample Size and
Description Study Design Study Aim Results/Findings Related to Nutrition Behavior
(Ho et al.,
2008) [39]2008 Canada
First Nations
(Anishi-
naabe
(Ojibwe and
Oji-Cree)
General
population,
possibly at risk
129 First Nations
adults
Descriptive
quantitative
study
To describe
determinants of
diet-related behavior
and physical activity
in First Nations for the
development of
culturally appropriate
diabetes prevention
programs
Larger households in remote communities tend to
have higher scores for acquiring healthy food.
(Jock et al.,
2020) [34]2020
USA
(Midwest,
Southwest)
Native
American
General
population,
possibly at risk
300 adults, three
NA communities
Quantitative
study
To describe the
subgroups and
demographic
characteristics related
to NA household food
environments
There was low fruit and vegetable access among
both the higher and lower access household food
environments. Wild or brown rice and game meats
were frequently obtained from higher access groups.
(Keith et al.,
2018) [29]2018
United
States of
America
American
Indians
General
population,
possibly at risk
20 participants
who were newly
enrolled,
academically
underprepared
tribal college
students enrolled
in life skills course
A nonexperi-
mental cohort
design used
for qualitative
descriptive
analysis
To build an
understanding of
factors that influence
healthy food choices
among tribal college
students at increased
risk for college
attrition
-Lack of income as students limit the acquisition of
healthy foods.
-Transportation challenges and high food costs are
linked to difficulties in making healthy food choices.
-Lack of nutrition knowledge linked with unhealthy
food choices.
-Difficulty accessing the store influences the
likeliness to buy healthy foods.
-Lack of exposure and positive role models for
food choices.
-A busy schedule is a barrier to preparing healthy
meals at home.
-Cultural traditions and practices are linked with
healthy eating choices.

Nutrients 2024,16, 2750 12 of 28
Table 2. Cont.
Author
Study
Year Country Indigenous
Group
Study
Population
Sample Size and
Description Study Design Study Aim Results/Findings Related to Nutrition Behavior
(Keshavarz
et al., 2023)
[42]
2023 Canada
Self-
identified
Indigenous
people
General
population,
possibly at risk
1528 individuals
in 2004 and 950
individuals in
2015
Quantitative
study
To identify the dietary
patterns of off-reserve
Indigenous Peoples in
Canada and their
association with
chronic conditions
High income positively correlated with higher
adherence to healthy dietary patterns.
(Love et al.,
2019) [30]2019
United
States,
Oklahoma
American
Indian Com-
munities,
Chickasaw
Nation and
the Choctaw
Nation
General
population,
possibly at risk
513 American
Indians
Quantitative
study
To examine the
relations between the
perceived food
environment,
utilization of food
retailers, fruit and
vegetable intake, and
chronic diseases,
including obesity,
hypertension, and
type 2 diabetes among
AI adults
57% of participants reported that it was easy to
purchase fruits and vegetables in their town, and
fewer (35%) reported that the available fruits and
vegetables were of high quality. Additionally, over
half (56%) reported traveling ≥20 miles round trip
to shop for food.
(Philip et al.,
2017) [33]2017
United
States,
Alaska
Native
population
(Alaska)
(Yup’ik)
General
population,
possibly at risk
486 Yup’ik adults Quantitative
study
To assess the
relationships between
socioeconomic,
behavioral, and
cardiometabolic risk
factors among Yup’ik
people of
southwestern Alaska,
with a focus on the
role of the
socioeconomic and
cultural components
-Access to enough and appropriate foods is linked
with better dietary practices.
-Western culture is associated with higher
consumption of processed foods and lower
consumption of subsistence foods.
-Western culture was associated with higher
consumption of processed foods and lower
consumption of subsistence foods.

Nutrients 2024,16, 2750 13 of 28
Table 2. Cont.
Author
Study
Year Country Indigenous
Group
Study
Population
Sample Size and
Description Study Design Study Aim Results/Findings Related to Nutrition Behavior
(Rapinski
et al., 2023)
[49]
2023 French
Guiana
Palikur/
Parikwene
People
General
population,
possibly at risk
75 community
members, elders,
healthcare
professionals,
administrators
Qualitative
study,
including
ethnographic
research and
interviews
To identify the dietary
patterns of off-reserve
Indigenous men,
women, and children
in Canada and their
association with
chronic conditions in
2004 and 2015 while
considering related
sociodemographic
and socioeconomic
conditions
The income level among adults was recognized as
an important factor that may be associated with the
dietary intake of the off-reserve Indigenous
population.
(Rosella
et al., 2020)
[38]
2020 Canada,
Ontario
First Nations
communities
General
population,
possibly at risk
993 adults Cohort study
To predict 10-year
diabetes risk and
describe the factors
that contribute to
diabetes risk in First
Nations adults living
in Ontario First
Nations communities
Factors included food insecurity, low income, and
eating traditional vegetative foods.
(Setiono
et al., 2019)
[27]
2019
United
States of
America
American
Indian Com-
munities
General
population,
possibly at risk
580 adults from
each of the six
communities
Descriptive
quantitative
study
To characterize
common dietary
patterns among adults
from 6 AI
communities (N = 580)
and assess their
relationship with BMI,
percentage body fat,
waist-to-hip ratio,
hypertension, and
self-reported T2DM
and cardiovascular
disease
Five main dietary patterns: meat and fried foods,
processed foods, fruits and vegetables, sugary
snacks, and meat alternatives and high-protein
foods. Those consuming more meat and fried foods
had higher waist-to-hip ratios (0.03; 95% CI: 0.01,
0.04), BMI (2.45 kg/m2; 95% CI: 0.83, 4.07), and
odds of being overweight or obese (OR: 2.63; 95%
CI: 1.10, 6.31). Higher intake of processed foods was
associated with increased odds of self-reported
T2DM (OR: 3.41; 95% CI: 1.31, 8.90).

Nutrients 2024,16, 2750 14 of 28
Table 2. Cont.
Author
Study
Year Country Indigenous
Group
Study
Population
Sample Size and
Description Study Design Study Aim Results/Findings Related to Nutrition Behavior
(Sorensen
et al., 2005)
[53]
2005
Russia,
Northeast-
ern Siberia
Yakutia
General
population,
possibly at risk
201 people in three
urbanized towns
and three rural
communities
Descriptive
quantitative
study
To investigate diet and
lifestyle determinants
of plasma lipids in the
Yakut, an Indigenous
Siberian herding
population
Modern lifestyles (often associated with higher
incomes) correlated positively with market and
mixed diets, while subsistence lifestyles (often
associated with lower incomes) negatively
correlated with market diets but positively
correlated with mixed and subsistence diets.
(Stotz et al.,
2021a) [25]2021
United
States of
America
American
Indian,
Alaska
Natives
General
population,
possibly at risk,
possibly at risk
29 AI/AN with
T2DM, 22 family
members, 10
community-based
key informants
Qualitative
study
involving
focus groups
and key
informants’
interviews
To examine
stakeholder
perspectives on food
insecurity and
associated challenges
to healthy eating
among American
Indian and Alaska
Native Adults with
T2DM
-Food insecurity was reported as a barrier to healthy
eating practices.
-High cost of healthy food and limited income
linked with unhealthy food choices.
-Living in rural areas is linked to a lack of access to
healthful foods such as fruits and vegetables,
supermarkets, and full-scale grocery stores, and to
the higher availability of fast and processed foods.
-Lack of fresh fruits and vegetables at grocery stores
and non-availability of traditional foods and
food-acquisition habits are barriers to healthy eating.
-Strong community and family support systems,
traditional foods, and food acquisition and
preparation practices facilitate healthy eating.
(Stotz et al.,
2021b) [26]2021
United
States of
America
American
Indian,
Alaska
Native
Adults
General
population,
possibly at risk,
possibly at risk
Nine experts in
diabetes
education, 20
community-based
key informants, 29
AI/AN and 22
family members
Qualitative
study
involving
key-informant
interviews and
focus groups
To understand
stakeholder
perspectives on
facilitators and
barriers to healthy
eating for AI/AN
adults with T2D to
inform the cultural
adaptation of an
existing diabetes
nutrition education
curriculum
-Low cost associated with barriers to consuming
fresh healthy food
Urban dwellers experience barriers to healthy
eating compared to rural dwellers.
-Challenges with gardening are associated with
barriers to consuming fresh healthy food.
-Both individual factors (e.g., comorbidities and
chronic diseases) and societal factors (e.g., trauma
related to colonization) influence the ability to eat
healthfully.

Nutrients 2024,16, 2750 15 of 28
Table 2. Cont.
Author
Study
Year Country Indigenous
Group
Study
Population
Sample Size and
Description Study Design Study Aim Results/Findings Related to Nutrition Behavior
(Valeggia
et al., 2010)
[48]
2010 Argentina
Two
Indigenous
populations
of the
Argentine
Gran Chaco:
the Toba and
Wichı
General
population,
possibly at risk
541 adults Quantitative
study
To evaluate the
association between
socioeconomic and
nutritional statuses in
adults of two
Indigenous
populations of the
Argentine Gran
Chaco: the Toba and
Wichı’ of the province
of Formosa
-Higher socioeconomic status linked to high
consumption of marketed foods.
(Wycherley
et al., 2019)
[44]
2019 Australia
Indigenous
Australians
living in
remote areas
General
population,
possibly at risk
13 remote
Indigenous
Australian
communities, with
populations
ranging from
139–1079 persons
Quantitative
study
To explore the
modifiable
environmental-level
factors associated with
the features of dietary
intake that underpin
cardiometabolic
disease risk in this
population group
-Unemployment linked to lower dietary
intake quality.
-Lower household income is associated with poorer
dietary intake quality.
-Lesser household crowding and shorter distances
to neighboring stores are associated with lower
dietary intake quality.
Indigenous populations living with CMDs
(Bird et al.,
2008) [40]2008 Canada Inuit Adults with
T2DM
Four ethnographic
and informal
interviews
Qualitative
multi-case
study,
including
ethnographic
research, as
well as
informal
interviews and
field
observations
To explore the
experience of adult
members of a small
Arctic community
who are living with
diabetes as well as
factors that influence
their food choices and
perceptions of
diabetes and health
management
-Lack of education and uncertainty about the proper
carbohydrate choices and meal spacing.
-Adaptability of T2DM patients to respond to their
health condition is increased by learning about
coping strategies, including healthy eating, and
sharing knowledge to improve healthy eating.
-Mixed sentiments about experiences with the
‘Southern’ style of healthcare, e.g., distrust,
skepticism, trust, and respect, which influence the
following of the healthcare providers’ instruction on
a healthy diet.

Nutrients 2024,16, 2750 16 of 28
Table 2. Cont.
Author
Study
Year Country Indigenous
Group
Study
Population
Sample Size and
Description Study Design Study Aim Results/Findings Related to Nutrition Behavior
(Dussart,
2009) [45]2009 Australia Aboriginal Adults with
T2DM
84 Aboriginal
diabetic sufferers,
kin and
medical staff
Qualitative
semi-
structured
interviews
To better understand
how diabetes sufferers
cope with their illness
in everyday life for
creating more
culturally sensitive
health promotion
initiatives
-Biomedical imperatives (about an appropriate diet
for the management of diabetes) are clashing with
Indigenous forms of sociality.
-Due to social expectations of generosity and sharing
food, store-bought prepared food relieves the stress.
-Initiatives to introduce dietary changes must find a
balance between personal autonomy and
social obligations.
(Goins et al.,
2020) [31]2020
United
States of
America
American
Indians
Adults with
T2DM
28 participants,
57% women
Qualitative
study using a
low-inference
descriptive
design with
semi-
structured
in-depth
interviews
To examine the beliefs,
attitudes, and
practices of older
American Indians
regarding their T2DM
management
-Higher costs of foods linked with unhealthy
food choices.
-Difficulty of grocery shopping in terms of reading
labels linked to determining the best food choices.
-T2DM management influenced by
sociocultural factors, Native culture, southern
Appalachian culture, spirituality, traditional Native
foods, southern Appalachian foods and foodways;
social aspects of food, historical trauma, and
financial circumstances related to food.
(Juárez-
Ramírez
et al., 2019)
[52]
2019 Mexico Mayan
people
Adults with
T2DM
195 adults with
T2DM
Mixed-
methods study
To understand
non-adherence to
medically
recommended diets
among Mayans with
diabetes
- Cultural beliefs and not nutrition explain the
origin of diabetes; therefore the relevance of food is
overlooked.
-High-calorie foods (corn, pork, sugar-based foods)
are part of traditional ceremonies and make it
difficult to follow dietary regimens.
(Schure et al.,
2019) [32]2019
United
States of
America
American
Indians
Adults with
T2DM
28 noninstitution-
alized older tribal
members aged
>60 years
Qualitative
study
involving
semi-
structured
in-person
interviews
To examine
dietary-related beliefs
and self-management
among older
American Indians
with T2DM
-Cultural upbringing of not wasting food hinders
diabetic patients from eating healthily.
-Social support, motivation, community dinners,
healthcare professional and family influence, and
personal beliefs (e.g., distaste for wasting food)
facilitate adherence to a healthy diet.

Nutrients 2024,16, 2750 17 of 28
Table 2. Cont.
Author
Study
Year Country Indigenous
Group
Study
Population
Sample Size and
Description Study Design Study Aim Results/Findings Related to Nutrition Behavior
(Teufel-
Shone et al.,
2018) [24]
2018
United
States of
America
Several
American
Indian,
Alaska
Natives
Adults with
T2DM
2484 AI/AN with
T2DM
Quantitative
study
To examine the
association between
food choice and
distress in a large
national sample of
American
Indians/Alaska
Natives with T2DM
Both males (34.9%) and females (65.1%) had higher
healthy food scores than unhealthy scores.
Unhealthy food scores showed significant positive
relationships with distress for both genders
(females: β= 0.078, p= 0.0007; males: β= 0.139,
p< 0.0001).
(Wilson et al.,
2021) [51]2021 Guatemala
Indigenous
Guatemalan
community
Adults with
T2DM
32 adults with
T2DM
Qualitative
structured
interviews
To assess barriers to
making dietary
modifications for
people living with
T2DM in a rural
Indigenous
Guatemalan
population
-A healthful diet is too costly.
-Fluctuation of income level in ‘off-season’ times
affects money available for healthy food.
-Travel time and travel costs to the next market (5 to
30 km away) limit a healthy diet.
-Lack of refrigerators limits the amount of
perishable, fresh food that can be bought at
a distance.
-Challenges exist in the necessity to prepare food
differently for diabetic patients than family
members (incompatibility with family and
traditional diet).

Nutrients 2024,16, 2750 18 of 28
3.3. Factors Influencing Nutrition Behaviors
3.3.1. Sociohistorical Embedding of the Studies
Few included studies have examined how sociohistorical factors influence the social
determinants of CMDs and their risk factors among Indigenous populations. These in-
clude nutritional changes prompted by diagnosed health conditions [
34
], shifts in dietary
habits such as reduced consumption of traditional foods and increased intake of sugary
beverages and non-nutritious foods [
50
], and lifestyle changes such as decreased traditional
food gathering and increased adoption of Western diets [
43
]. Additionally, the contact
with European societies in the 20th century accelerated these changes, leading to greater
reliance on store-bought and processed foods [
49
]. The rapid expansion of the global food
industry further altered food availability [
52
]. Historical factors such as trauma from colo-
nization contribute to health disparities and poorer outcomes in nutrition-related chronic
diseases [
26
]. Discrimination and limited access to culturally competent health services also
impact health outcomes among populations [
51
], compounded by factors such as poverty
and underfunded health programs [29].
3.3.2. Dietary Characteristics
The included studies highlight diverse dietary patterns among Indigenous popu-
lations, which can be categorized by ecological and cultural distinctions. Geographical
location plays a significant role in shaping traditional diets among Indigenous populations,
which vary across distinct ecospheres: the cold, resource-limited north (Canada, Greenland,
and Russia), hot temperature zones in Latin America, Fiji, and Australia, and semi-hot
areas in the USA. Each climate zone dictates food availability; for instance, the northern
regions traditionally include seal meat, arctic char, caribou meat, pasteurized milk, berries
and spinach, often consumed fresh or preserved [
40
,
41
]. Woodland Cree communities
in Canada also incorporate land animals, fish, berries, fats, mixed foods, grains, fruits,
vegetables, and dairy products into their diets [
43
], while Yakutia in Russia relies on a
subsistence diet rich in meat and dairy [53].
Despite traditional fare, the studies report widespread consumption of nutritionally
poor, industrially processed foods among Indigenous communities. These include potato
chips, frozen pizzas, refined flour products, cookies, and sugary beverages [
41
]. Similarly,
Greenland Inuit have been observed consuming unhealthy options such as candy, cakes,
and fast food [
50
]. Up to 80% of some diets consist of imported food items, reflecting a
blend of traditional and store-bought products rather than a distinct categorization [42].
Traditional Indigenous diets in warmer ecological zones such as Argentina feature
hunted game, wild honey, fruits, low-maintenance horticultural products, and store-bought
items such as eggs and cheese [
44
,
48
]. Indigenous Australians in remote areas incorporate
discretionary foods and sugary drinks alongside some fruits and vegetables, often resulting
in a diet that is low in dietary fiber but high in fats and sugars [
45
]. Similar shifts from
traditional diets to market foods have been observed among Indigenous groups in French
Guiana and Mexico, resulting in increased consumption of sweet and fatty items [49,52].
Traditional foods of American Indians in the USA include Sochan, bean bread, and
southern Appalachian foodways [
31
]. However, many American Indians and Alaska
Natives frequently include less healthy options in their diets, such as processed meats,
flour products, baked goods, soft drinks, fried potatoes, and fast foods [
24
]. Some studies
report cultural practices contributing to dietary habits, including sweet tea consumption,
cooking with fatback, and eating fried foods, reflecting both traditional and contemporary
influences [28,29].
3.3.3. Nutritional Behavior Outcomes
The included studies reported different nutritional behavior outcomes, including
the following: (1) marketed and foraged food consumption [
48
], (2) dietary intake qual-
ity
[35,44],
(3) food or dietary intake [
33
,
37
,
39
,
43
,
53
], (4) food choices [
24
,
28
,
29
,
31
,
32
,
40
,
41
,
49
], (5) dietary patterns [
27
,
42
,
50
], (6) nutrition transitions (overconsumption and un-

Nutrients 2024,16, 2750 19 of 28
healthy eating) [
46
], (7) dietary regimens [
52
], (8) dietary modifications [
51
], (9) caloric
restriction [
14
], (10) healthy eating practices [
25
,
26
,
47
], (11) dietary quality [
36
], (12) house-
hold food environment [
34
], (13) fruit and vegetable intake [
30
], (14) traditional food
consumption [38], and (15) bush and store-bought food intake [45].
3.3.4. Overview of Dietary Assessment Methods Used in Quantitative Studies
In this review, various quantitative studies utilized different methods to assess dietary
intake. The dietary assessment methods included the 24 h food recall method, which
was reported by four studies [
39
,
42
,
43
,
48
]. Additionally, four studies employed the Food
Frequency Questionnaire (FFQ) method [
24
,
33
,
35
,
50
]. One study used the Harvard Food
Frequency Questionnaire [53].
3.3.5. SDoH Influencing Nutrition Behaviors
The most studied SDoH influencing nutrition behaviors was economic stability (n = 16),
followed by social and community context (n = 15), neighborhood and built environment
(n = 10), education (n = 5), and health and healthcare (n = 4) (Tables S2 and S3).
SDoH Influencing Nutrition Behaviors for Indigenous Populations Potentially at Risk
Economic stability as a determinant of nutrition behaviors among the general pop-
ulation at risk of CMD was reported by five quantitative studies [
37
,
42
,
44
,
48
,
53
], four
qualitative studies [
29
,
33
,
41
,
46
], and one mixed-methods study [
43
]. Education as a factor
affecting nutrition behavior was mentioned in one qualitative study [
29
]. Neighborhood
and built environment were explored in two quantitative studies [
39
,
44
], two qualitative
studies [
29
,
41
], and one mixed-methods study [
43
]. Health and healthcare were discussed
in one qualitative study [
14
] and one mixed-methods study [
43
]. Social and community con-
text was reported by two quantitative studies [
33
,
50
], four qualitative studies [
29
,
33
,
41
,
46
],
and one mixed-methods study [43].
Several specific findings were noted. Higher socioeconomic status was found to cor-
relate with increased consumption of marketed foods, suggesting that those with greater
financial resources are more likely to purchase commercially available food items [
48
].
Unemployment was linked to lower dietary intake quality, indicating that lack of employ-
ment negatively affects food choices and overall diet [
44
]. Lower household income was
consistently associated with poorer dietary intake quality and unhealthy dietary practices,
highlighting the financial barriers to maintaining a healthy diet [
37
,
44
]. Modern lifestyle
linked with higher income was positively associated with market and mixed diets, showing
that increased income facilitates the adoption of diverse dietary patterns [
53
]. Shifts from
traditional hunting-based economies to wage-based employment significantly impacted
food availability and dietary choices, leading to reduced access to traditional, nutritious
food [
41
]. Individuals in lower socioeconomic groups faced restricted access to nutritious
foods, often relying on cheaper, processed options due to financial constraints [
29
,
46
]. Addi-
tionally, transportation challenges and high food costs impeded the ability of these groups
to make healthy food choices [29]. Proximity to stores and household crowding were also
influential, with closer proximity to stores generally correlating with healthier diets, while
limited access to healthy food options and difficulties in reaching stores posed significant
barriers [
29
,
39
,
41
,
44
]. Human-enforced environmental changes, such as deforestation, dis-
rupted traditional food sources and affected dietary patterns, further complicating the
efforts to maintain healthy eating habits [
43
]. A lack of nutrition knowledge was linked to
unhealthy food choices [
29
]. Cultural perceptions of biomedical healthcare also influenced
dietary adherence, with historical factors complicating the acceptance of health advice [
14
].
Social factors, such as low social position, significantly influenced dietary patterns [
50
].
Societal pressures and cultural norms often promote food consumption as a symbol of
love and affluence and a shared belief that food should not be wasted [
29
,
46
]. Finally, colo-
nization and socio-cultural assimilation profoundly impacted food consumption choices,

Nutrients 2024,16, 2750 20 of 28
displacing traditional food practices that emphasized food sharing and social cohesion [
41
].
Detailed factors are also reported in Table S2.
SDoH Influencing Nutrition Behaviors for Indigenous Populations Living with CMDs
Five qualitative studies [
25
,
26
,
31
,
32
,
51
] and one mixed-methods study [
52
] identified
economic stability, specifically poverty and cost of living, as factors influencing nutrition
behaviors among patients with CMD. Education, both as formal education but also as
informally acquired knowledge about a healthy diet, was reported as a factor by one
quantitative study [
35
] and three qualitative studies [
25
,
26
,
40
]. Neighborhood and built
environment were characterized by access to food, environmental conditions, and the
missing availability of consumer information and were noted in one quantitative study [
35
]
and four qualitative studies [
25
,
26
,
31
,
51
]. Health and healthcare in terms of dominating
worldviews were discussed in three qualitative studies [
26
,
40
,
45
]. Seven qualitative stud-
ies [
14
,
26
,
31
,
32
,
45
,
47
,
51
] and one mixed-methods study reported social and community
context as factors affecting nutrition behaviors [52].
Several notable findings were observed. Food insecurity and the high cost of healthy
foods due to limited income emerged as significant barriers to adopting healthy eating
practices [
25
]. The studies highlighted affordability issues associated with fresh, healthy
foods and the higher costs of nutritious options, influencing dietary choices negatively
across different communities [
26
,
31
,
32
,
51
]. Additionally, poverty-related food cultures
were identified as barriers to maintaining consistent dietary regimens among patients [
52
].
Educational attainment was found to be positively correlated with better diet quality among
patients, emphasizing the role of education in promoting healthier eating habits [
35
].
Limited cooking knowledge and inadequate health education services were identified
as barriers to consuming fresh, healthy foods [
25
,
26
,
40
]. Specific gaps in knowledge
regarding dietary choices, carbohydrate selections, and meal spacing were noted among
patients [
40
]. Moreover, household food patterns were found to influence diet quality, with
healthier household food environments correlating with improved dietary habits among
patients [
35
]. Urban–rural disparities in access to healthful foods, such as fresh fruits and
vegetables, were reported, along with challenges related to travel time and costs to markets,
further complicating efforts to maintain a healthy diet [
25
,
26
,
51
]. Environmental conditions,
including gardening challenges and lack of refrigeration, posed barriers to consuming
fresh, healthy foods, illustrating the broader impact of environmental factors on dietary
choices [
25
,
26
,
51
]. Societal and individual factors, such as cultural trauma and chronic
diseases, were also identified as influencers of healthy eating behaviors, highlighting the
complex interplay of social determinants on dietary practices [
26
,
40
,
45
]. Cultural beliefs
and practices significantly influenced dietary management approaches and the acceptance
of healthcare advice among patients, emphasizing the importance of cultural competency
in healthcare settings [
14
,
45
,
52
]. Social and cultural factors played a crucial role in dietary
adherence among patients, with community support systems and traditional food practices
facilitating healthier eating habits [
32
,
47
,
51
]. Challenges related to balancing cultural
dietary practices with health recommendations were noted, reflecting the need for culturally
sensitive healthcare interventions [
51
]. Cultural beliefs regarding the origins of certain
health conditions and the incorporation of high-calorie foods in traditional ceremonies
were identified as specific barriers to dietary adherence, highlighting the complexity of
integrating cultural practices with modern health advice [
52
]. For further details, please
refer to Table S3.
4. Discussion
4.1. Summary of Findings
This scoping review is among the first to map evidence of SDoH affecting nutrition
behavior and cardiometabolic health among Indigenous populations. Our review reported
various transitioning processes, such as from pastoral to more urbanized lifestyles, from
traditional to Westernized diets, and from subsistence-based food gathering to reliance on

Nutrients 2024,16, 2750 21 of 28
store-bought and processed foods. These transitions reflect changes in economic situations,
cultural practices, and access to resources, all of which significantly influence nutrition
behaviors and health outcomes. Similarly, factors such as economic stability, education,
neighborhood and built environment, health and health care, and social and community
contexts significantly influence nutrition behavior among Indigenous populations at risk
and those with CMDs, with multiple studies having identified various overlapping factors.
Figure 3illustrates the SDoH-CMD causation pathways suggested by Powell-Wiley
et al. [
11
] and complements it with the findings derived from the studies on Indigenous
populations. The SDoH-related topics that emerged addressed questions regarding the
availability and affordability of food, its nutritious value and quality, and its cultural
acceptability. The thickness of the line corresponds to the proportion of studies reporting
on the influence of this SDoH on diet and dietary behavior. Some included studies even
provide explanations for this influence of SDoH on nutritional behavior, including social
and power structures, as well as environmental changes. Furthermore, the studies report
on five transitions linked to changes in the SDoH, including lifestyle, capitalism, migration,
life course, and health changes.
Nutrients 2024, 16, 2750 20 of 27
4. Discussion
4.1. Summary of Findings
This scoping review is among the first to map evidence of SDoH affecting nutrition
behavior and cardiometabolic health among Indigenous populations. Our review re-
ported various transitioning processes, such as from pastoral to more urbanized lifestyles,
from traditional to Westernized diets, and from subsistence-based food gathering to reli-
ance on store-bought and processed foods. These transitions reflect changes in economic
situations, cultural practices, and access to resources, all of which significantly influence
nutrition behaviors and health outcomes. Similarly, factors such as economic stability, ed-
ucation, neighborhood and built environment, health and health care, and social and com-
munity contexts significantly influence nutrition behavior among Indigenous populations
at risk and those with CMDs, with multiple studies having identified various overlapping
factors.
Figure 3 illustrates the SDoH-CMD causation pathways suggested by Powell-Wiley
et al. [11] and complements it with the findings derived from the studies on Indigenous
populations. The SDoH-related topics that emerged addressed questions regarding the
availability and affordability of food, its nutritious value and quality, and its cultural ac-
ceptability. The thickness of the line corresponds to the proportion of studies reporting on
the influence of this SDoH on diet and dietary behavior. Some included studies even pro-
vide explanations for this influence of SDoH on nutritional behavior, including social and
power structures, as well as environmental changes. Furthermore, the studies report on
five transitions linked to changes in the SDoH, including lifestyle, capitalism, migration,
life course, and health changes.
Figure 3. Concretizing the CMD causation pathway based on the empirical evidence found in the
studies on Indigenous populations.
Figure 3. Concretizing the CMD causation pathway based on the empirical evidence found in the
studies on Indigenous populations.
4.2. Dietary Characteristics
Our review revealed that Indigenous populations exhibit diverse dietary character-
istics, particularly traditional diets, which vary significantly across different ecospheres.
Each ecosphere has its seasonality, which crucially affects the availability of traditional
foods and consequently their contribution to dietary energy and intake estimation [
54
].
Importantly, our review underscores the benefits of traditional diets, including locally
harvested animal and plant species, in maintaining a high-quality diet and promoting
good health, as supported by other research [
55
]. However, our review also found a notice-
able shift from traditional, nutrient-dense diets—high in fiber and low in fat and refined

Nutrients 2024,16, 2750 22 of 28
carbohydrates—to Westernized diets that are energy-dense and high in fat and refined
sugars. The literature indicates that energy-dense, nutrient-poor foods are convenient and
affordable, while healthy foods are often in limited supply and costly [
56
,
57
]. This shift has
resulted in persistently poor dietary patterns and has significantly increased the prevalence
of health conditions such as obesity, type 2 diabetes, and cardiovascular diseases, which
were previously uncommon in Indigenous populations [
9
]. Our review underscores the
vital role of traditional foods in Indigenous cultures, contributing to social, emotional,
spiritual, and physical health [
58
]. Policy interventions developed with Indigenous people
to increase access to traditional foods could help reduce these diet-related chronic diseases,
such as CMDs and promote overall well-being.
4.3. SDoH Influencing Nutrition Behaviors for Indigenous Populations Potentially at Risk
of CMDs
Our review revealed that economic factors such as low income, unemployment, and
limited education are linked to a preference for cheaper, processed foods among the In-
digenous populations at risk of CMDs. Research in Nunavut and Inuvialuit communities
also supports this, showing that Inuit households with lower education and income levels,
combined with limited access to nutrition education, consume fewer fruits and vegetables
and rely more on energy-dense store-bought foods [
59
,
60
]. Addressing these economic
disparities is crucial for improving dietary outcomes. The neighborhood and built envi-
ronment also play significant roles in nutrition behavior. Proximity to stores affects access
to fresh produce, with low-income neighborhoods often lacking access to fresh fruits and
vegetables, preventing residents from meeting the recommended nutritional standards and
highlighting a deficiency in local resources [
61
]. Colonization has had a profound impact
on sociocultural assimilation and political activities, such as a ban on hunting, leading to a
decline in traditional food practices among Indigenous populations. This decline negatively
affects dietary habits. For instance, in the Nunavut community, restrictions on hunting
caribou have limited access to sufficient traditional foods [
62
]. Malli et al. highlight how
colonization has disrupted Indigenous food systems through capitalism, legal changes
and sociocultural shifts [
63
]. The authors stress the importance of traditional knowledge
sharing and authentic Indigenous inclusion in policymaking. Additionally, our review
underscores the significant influence of cultural norms on dietary patterns. Research shows
that Indigenous communities engage in food-sharing networks where surplus traditional
foods are distributed to those in need, improving food access, especially in rural areas [
64
].
The erosion of these cultural practices may exacerbate mental health challenges and induce
distress, both of which are risk factors for CMDs [
65
]. Empowering communities and
adapting policies to ensure access to traditional foods are essential for promoting healthier
dietary habits and fostering overall well-being in Indigenous populations and beyond.
4.4. SDoH Influencing Nutrition Behaviors for Indigenous Populations Living with CMDs
This scoping review found several SDoH that influence the nutrition behaviors of
Indigenous people living with CMDs. The high cost of healthy foods, including fruits,
vegetables, and diabetes-friendly products, was commonly reported as a barrier to healthy
eating. Similar findings were reported in other studies, which indicated that these high
costs led individuals to make food choices based on affordability rather than nutritional
value, thereby impacting their ability to adhere to recommended diets [
66
]. Education
also emerged as a crucial factor influencing nutrition behavior. In our review, higher
educational levels were associated with better diet quality. Other literature confirms this
finding, highlighting that the patients’ nutritional behavior improved with education on
therapeutic diets, provided by clinicians [
67
]. Additionally, studies consistently reported
that individuals with higher education levels understood nutritional information better
than those with lower education levels [
68
,
69
]. Historical trauma from colonization also
affected trust in healthcare providers, with mixed sentiments of distrust, skepticism, and
respect influencing the willingness to follow dietary instructions. Similar findings were

Nutrients 2024,16, 2750 23 of 28
noted in other studies [
70
]. Urban–rural disparities in access to healthy foods were another
barrier to nutrition behavior. Accessibility issues significantly influenced dietary patterns,
with the rural areas facing greater challenges compared to the urban areas in our review.
The studies included in our review further indicated that lack of transportation, long travel
distances, and physical impairments hindered access to shopping centers and healthy
foods, especially in rural areas. These findings were consistent with other studies, which
highlighted physical barriers to healthy food among patients, compounded by poor health
status and mobility impairments [
66
]. Contrary to other findings, one study in our review
highlighted that urban dweller also faced barriers to healthy eating [
25
]. This was because
urban-dwelling patients had less physical access and proximity to the lands where their
traditional foods were fished, hunted, gathered, and grown. These neighborhoods and
built environmental constraints call for innovative solutions, such as mobile food markets
and community gardens, to improve food access among these groups of patients. Our
review highlighted that cultural beliefs and social support significantly influenced dietary
behaviors. Family members and caregivers played a vital role in promoting healthy eating
habits, with traditional cuisine and home-farmed foods being often associated with good
nutritional behavior. Similar findings were reported in other studies, which emphasized the
strong influence of the family environment on food knowledge and preferences, particularly
highlighting the roles of mothers and grandmothers [
71
]. Reduced social networks made
participants particularly vulnerable to food insecurity and poor dietary intake. Additionally,
evidence indicated that family involvement in meal preparation was associated with better
disease management, including type 2 diabetes [
72
]. Reorienting health services to better
consider Indigenous groups’ social organization and cultural values better could improve
nutritional behavior and overall care. This might involve integrating family members into
care models and developing approaches that align with the needs and preferences of these
patient groups [73].
4.5. Limitations of This Review
This review has several limitations. Firstly, relying solely on published literature
is prone to publication bias and overlooks valuable unpublished studies. Additionally,
restricting this review to English-language articles could exclude important research in
other languages, limiting the inclusivity of the findings. The preponderance of cross-
sectional studies in the reviewed literature could affect the depth and generalizability of
the synthesized evidence. However, as this was a scoping review, our primary aim was
to identify the existing evidence, describe its scope and extent, and highlight the gaps in
the topic. There was also a lack of mechanistic studies that manipulated SDoH related
to nutrition behaviors among Indigenous populations, resulting in their exclusion from
our review. Furthermore, focusing on Indigenous populations means the findings cannot
be generalized to the broader population at risk or living with CMDs, though it provides
important empirical evidence relevant for Indigenous populations. Definitional challenges
regarding the criteria for identifying Indigenous populations (see the UN decision on
self-definition) [
3
] and the complexity of defining nutritional behavior [
74
] add further
limitations. The heterogeneity in study designs and outcome measures across the included
studies necessitates a cautious interpretation of the findings. Additionally, the individual
studies included did not comprehensively address all domains of SDoH, and some studies
did not explicitly explore their association with nutrition behaviors. This complexity
hindered the precise identification of the SDoH factors influencing nutritional behaviors.
This complexity has made it challenging to accurately identify and describe the exact
strength of individual SDoH factors that influence nutritional behaviors.
Despite these limitations, this review’s strength lies in its comprehensive synthesis
of diverse studies from various databases, making it the first of its kind. This approach
provides valuable insights into the SDoH affecting nutritional behavior among Indigenous
populations. The rigorous screening and consultation processes enhance the validity and

Nutrients 2024,16, 2750 24 of 28
reliability of the findings, reinforcing the relevance of the conclusions and recommendations
drawn from the included studies.
4.6. Implications and Recommendations for Future Studies
Our review highlights the significant relevance of social determinants—specifically
economic stability, neighborhood and built environment, education, health and health-
care, and social and community context—in influencing the nutritional behavior and
cardiometabolic health among Indigenous populations. The scope of our work enabled us
to identify knowledge gaps in areas that are critical for developing targeted interventions to
improve nutritional behavior in these communities. However, a cautious interpretation of
our work is needed due to variations in methodologies, definitions of SDoH domains and
Indigenous populations, as well as differences in the socioeconomic and cultural context of
where the research was conducted.
Future research, including mechanistic studies, should thoroughly examine all SDoH
domains to gain a comprehensive understanding and better inform interventions and poli-
cies, ultimately promoting health equity in Indigenous communities. Future quantitative
and qualitative studies should clearly define outcome measures and report the direction of
associations between the examined factors and nutritional behaviors, as this was lacking
in the studies included in our review. Additionally, this review underscores the need
for robust mixed-methods studies to gain a deeper understanding of the various SDoH
pathways influencing dietary behaviors, particularly concerning cardiometabolic health
in Indigenous populations, given that only two mixed-methods studies were found in
our review.
5. Conclusions
This scoping review summarizes comprehensive evidence to examine SDoH that
influence nutritional behaviors in Indigenous populations affected by or at risk of car-
diometabolic diseases. Nutritional behavior is impacted by various SDoH domains, in-
cluding economic stability, neighborhood and built environment, education, health and
healthcare, and social and community context. The shift from traditional diets to West-
ernized diets and from subsistence-based food gathering to reliance on store-bought and
processed foods reflects changes in SDoH, affecting nutritional behaviors and health out-
comes. Although not all included studies examined every SDoH domain, future research
should consider all domains to gain a comprehensive understanding of how they con-
cretely impact nutritional behavior and the interrelationships among different factors. This
approach will better inform interventions and policies, ultimately promoting health equity
in Indigenous communities.
Supplementary Materials: The following supporting information can be downloaded at: https:
//www.mdpi.com/article/10.3390/nu16162750/s1, File S1: Example search strategy PubMed; File S2:
Key themes of Social Determinants of Health; Table S1: Inclusion and exclusion criteria; Table S2:
SDoH influencing nutrition behaviors for Indigenous population potentially at risk of CMDs [
14
,
29
,
33
,
37
,
39
,
41
–
44
,
46
,
48
,
50
,
53
,
56
]; Table S3: SDoH influencing nutrition behaviors for Indigenous people
living with CMDs [14,25,26,31,32,35,40,45,46,51,52].
Author Contributions: Conceptualization, B.G. and S.H.; methodology, B.G. and S.H.; formal analysis,
B.G. and S.H.; writing—original draft preparation, B.G. and S.H.; writing—review and editing, S.H.,
G.F.M. and B.G. All authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: Not applicable.

Nutrients 2024,16, 2750 25 of 28
Conflicts of Interest: The authors declare no conflicts of interest that are relevant to the content of
this article. B.G. is a guest editor for the Nutrients journal’s special issue on ‘Food and Nutrient Intake
and Cardio-Metabolic Health in Indigenous Populations’.
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