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Poor mental health among youth in Greenland is a major challenge, childhood conditions are critical for mental health later in life. The study aimed to examine the clustering of childhood conditions by considering risk and protective factors for mental health among youth and young adults in Greenland and to explore the relationship between these clusters and mental health outcomes in youth. The study included 565 participants aged 15–34 living in Greenland. Seven indicators including childhood adversities (ACEs), childhood residence, language, and cultural indicators (protective factors) were used to define clusters via latent class analysis (LCA). The associations between clusters and mental health outcomes (satisfaction with life (Cantrill’s ladder), self-esteem, self-efficacy, loneliness, psychological distress (General Health Questionnaire) and mental illness (Kessler 6)) were assessed by logistic regression. Four clusters were identified through LCA. While most participants reported positive childhoods, 40% (in two clusters) experienced ACEs. The two clusters differed as more participants in one cluster had experienced protective factors than the other. ACEs were associated with increased odds of negative aspects of mental health in youth. However, participants who faced high levels of adversity and few protective factors also had reduced odds of positive aspects of mental health in youth.

ABSTRACTSince 1993, dietary assessment has been carried out in Greenland as part of recurrent population health surveys. In preparation for the next survey in 2024, 91 participants from the survey in 2018 were selected for a validation study of the Food Frequency Questionnaire (FFQ). The 91 participants were reinterviewed 38–50 months after the first FFQ and invited to complete a food diary. As part of the 2018 survey, blood was analysed for mercury. The food diary was completed by 65 participants. The agreement between the two FFQ interviews was very good for macronutrients and fatty acids (p > 0.20), whereas the calculated intake of mercury was 22% higher in the second FFQ (p = 0.04) due to a higher intake of whale meat and muktuk (whale skin). The agreement between the second FFQ and the food diary was good for local food, imported meat and cakes/sweets/snacks but fruit and vegetables, dairy products, beverages and added sugar were significantly underreported in the food diary. Food items not included in the FFQ were identified from the food diaries. The correlation between the intake of marine mammals and blood mercury was moderate (Spearman’s rho = 0.41–0.50; p

ABSTRACTThe aim of this study was to examine the effect of diabetes and the diabetogenic TBC1D4 variant on kidney function in Greenland in a population-based setting. Health survey data and TBC1D4 genotypes from 5,336 Greenlanders were used to estimate odds ratios (ORs) of albuminuria (>30 mg/g creatinine) and chronic kidney disease (CKD, eGFR

ABSTRACTThe purpose was to analyse the association of muscular strength, muscle pain and reduced mobility in daily life with mental wellbeing among older Inuit men and women in Greenland. Data (N = 846) was collected as part of a countrywide cross-sectional health survey in 2018. Hand grip strength and 30-seconds chair stand test were measured according to established protocols. Mobility in daily life was assessed by five questions about the ability to perform specific activities of daily living. Mental wellbeing was assessed by questions about self-rated health, life satisfaction and Goldberg’s General Health Questionnaire. In binary multivariate logistic regression models adjusted for age and social position, muscular strength (OR 0.87–0.94) and muscle pain (OR 1.53–1.79) were associated with reduced mobility. In fully adjusted models, muscle pain (OR 0.68–0.83) and reduced mobility (OR 0.51–0.55) but were associated with mental wellbeing. Chair stand score was associated with life satisfaction (OR 1.05). With an increasingly sedentary lifestyle, increasing prevalence of obesity and increasing life expectancy the health consequences of musculoskeletal dysfunction are expected to grow. Prevention and clinical handling of poor mental health among older adults need to consider reduced muscle strength, muscle pain and reduced mobility as important determinants.

Abstract Background Between 1980 and 2018 Greenland has had one of the highest suicide rates in the world with an average rate of 96 suicides per 100,000 people annually. The aim of this study is to investigate suicide rates in Greenland according to age, birth cohort, period, sex, place of residence and suicide method from 1970 until 2018. Methods Suicide rates were examined using register and census data from 1970–2018 among Greenland Inuit. Rates were calculated by Poisson regression in Stata and by use of Excel. In analyses of the period trends, rates were standardized according to the World Standard Population 2000–2025. Results The suicide rate has been declining since a peak at 120 suicides per 100,000 people annually in the 1980s but remained high at a rate of 81.3 suicides per 100,000 people annually from 2015–2018. Descriptive analyses point to the decrease in male suicides as the primary factor for the overall decreasing rates while the rate among women has been increasing. Simultaneously, the proportion of women who used a violent suicide method increased from 60% in 1970–1979 to 90% in 2010–2018. The highest rates are seen among young people, especially young men aged 20–24 years and youth suicide rates increased with later birth cohorts. When the rates started to increase in the 1980s both the capital Nuuk and East Greenland had the highest rates. Since then, the rate in Nuuk has declined while the rate in East Greenland was three times the national rate from 2015–2018. Conclusions From 1970 to 1989 the suicide rate increased from 28.7 to 120.5 per 100,000 people mirroring a rapid societal transition in the post-colonial period. The rate has slowly declined from the peak in the 1980s but remains at a very high level. Young people in general are at risk, but the steady increase in the rate among women is worrying and there is a need to investigate underlying causes for this development.

Since 1993, regular population health surveys in Greenland have supported and monitored the public health strategy of Greenland and have monitored cardiometabolic and lung diseases. The most recent of these surveys included 2539 persons aged 15+ from 20 communities spread over the whole country. The survey instruments included personal interviews, self-administered questionnaires, blood sampling, anthropometric measurements, blood pressure, ECG, oral glucose test, pulmonary function, hand grip strength and chair stand test. Blood samples were analysed for glucose, glycated haemoglobin (HbA1c), insulin, incretin hormones, cholesterol, kidney function, fatty acids in erythrocyte membranes and mercury, urine for albumin-creatinine ratio, and aliquots were stored at −80°C for future use. Data were furthermore collected for studies of the gut microbiome and diabetes complications. Survey participants were followed up with register data. The potential of the study is to contribute to the continued monitoring of risk factors and health conditions as part of Greenland’s public health strategy and to study the epidemiology of cardiometabolic diseases and other chronic diseases and behavioural risk factors. The next population health survey is planned for 2024. The emphasis of the article is on the methods of the study and results will be presented in other publications.

A drinking pattern characterised by occasional excessive drinking is a key challenge for public health in Greenland. The objective was to examine sex-specific time trends in drinking patterns among Greenland Inuit. Cross-sectional and cohort data from geographically representative health surveys in 1993, 2005–2010 and 2014 were included (n = 4,938). Drinking patterns were defined as abstainer, non-problematic and occasional binge drinking. Patterns were analysed by sex-specific crude proportions and logistical analyses according to age, birth cohort and calendar time, accounting for region and settlement type. More than half of the men and one-third of the women had an occasional binge drinking pattern, while 22.6% of females and 15.1% of men were abstainers. Abstention increased with increasing age, while occasional binge drinking decreased among men. Younger male birth cohorts were less likely to have an occasional binge drinking pattern, while the youngest females had the highest odds ratio. A drinking pattern characterised by occasional excessive use remains a key challenge for public health in Greenland with age as a strong predictor. A high prevalence of abstainers co-exists with a high prevalence of occasional binge drinking. The increased odds ratio for occasional binge drinking among younger females should be addressed further.

Abstract Background Amongst the indigenous Greenlandic Inuit, the experience of food insecurity has been attributed to a lack of money to buy enough food of sufficient quality to sustain a family, although a preference for alcohol and tobacco over food has also been cited. The purpose of the article was to compare dietary patterns and expenditure on food, alcoholic beverages and tobacco between survey participants who reported food insecurity and those who did not. Methods A countrywide cross-sectional health survey was carried out among 1886 adult Greenlandic Inuit in 2018. Diet was estimated by a food frequency questionnaire. Food insecurity status was based on the household hunger scale. Analyses were carried out by univariate general linear models adjusted for age, sex and social position. Results Nine percent of the participants reported food insecurity. Food insecurity was higher among younger participants, men and participants with low social position. Food insecure participants more often chose an unhealthy dietary pattern (43% vs. 32%) and they reported a higher energy intake. The food insecure spent the same amount of money on food as other participants but less on nutritious food and more on non-nutritious food. The cost per kilojoule (kJ) of the food of the food insecure was lower than that of the food secure (DKK 8.0 and 9.0 per 1000 kJ, respectively). The food insecure participants also spent considerably more on alcohol and tobacco. Conclusions The results suggest that it is not only unemployment and lack of money that creates food insecurity and unhealthy dietary patterns in Greenland. Food insecure participants gave higher priority to buying non-nutritious food, alcohol and tobacco than did food secure participants. There seems to be at least two population subgroups in Greenland with poverty and substance use, respectively, as the immediate determinants for food insecurity. The results are important for the design of interventions against food insecurity and unhealthy dietary patterns.

Abstract Cardiovascular disease (CVD) is a well-known complication of diabetes, but the association has not been studied among Inuit in Greenland. The aim was to examine the association between diabetes and incident CVD among Inuit in Greenland and determine if the common diabetogenic TBC1D4 variant confers increased risk of CVD. We followed an initial study population of 4127 adults in Greenland who had participated in at least one population-based health survey, in national registers. We used Poisson regression to calculate incidence rate ratios (IRR) of cardiovascular endpoints, comparing participants with and without diabetes and comparing homozygous TBC1D4 carriers with heterozygous carriers and non-carriers combined. Close to 10% had diabetes and age range was 18–96 years (45% male). Of the 3924 participants without prior CVD, 362 (~ 9%) had CVD events during a median follow-up of 10 years. Multivariate IRR for the effect of diabetes on CVD was 1.12 (95% CI: 0.80, 1.57) p = 0.50. Using a recessive genetic model, we compared homozygous TBC1D4 carriers with wildtype and heterozygous carriers combined, with a multivariate IRR of 1.20 (95% CI: 0.69, 2.11) p = 0.52. Neither diabetes nor the TBC1D4 variant significantly increased CVD risk among Inuit in Greenland in adjusted models.

The purpose of the article is to compare different indicators of social position as measures of social inequality in health in a population sample from an indigenous arctic people, the Inuit in Greenland. Data was collected during 2005–2015 and consisted of information from 3967 adult Inuit from towns and villages in all parts of Greenland. Social inequalities for smoking and central obesity were analysed in relation to seven indicators of social disparity in four dimensions, i.e. education and employment, economic status, sociocultural position, and place of residence. For each indicator we calculated age-adjusted prevalence by social group, rate ratio and the concentration index. The indicators were correlated with Pearson’s r ranging from 0.24 to 0.82. Concentration indices ranged from 0.01 to 0.17. We could not conclude that one indicator was superior to others. Most of the indicators were traditional socioeconomic indicators used extensively in research in western countries and these seemed to be useful among the Inuit too, in particular household assets and job. Two sociocultural indicators developed for use among the Inuit and which included parameters specific to the indigenous peoples in the transition from a traditional to a modern life style proved to be equally useful but not superior to the traditional socioeconomic indicators. The choice of indicator must depend on what it is realistic to collect in the actual research setting and the use of more than one indicator is recommended. It is suggested to further develop culture specific indicators of social position for indigenous peoples. Keywords: Social inequality, Socioeconomic conditions, Cultural transition, Smoking, Obesity, Inuit

Muscle strength is an important predictor for function and mortality among older adults. We measured hand grip strength among 1442 participants aged 15+ years and carried out a 30 second chair stand test among 786 participants aged 55+ years. Neither test has been carried out among the Inuit before. We present reference values for men and women as means with standard deviations and medians with 10th, 25th, 75th and 90th percentiles. Hand grip strength was higher among men than among women (means 45.2 kg and 25.8 kg; p

Alcohol is the single most important public health challenge in Greenland. We provide an overview of alcohol consumption, drinking patterns, and consequences of excessive use of alcohol in Greenland since 1950 through a synthesis of published results and analyses of population-based interview surveys. The import of alcohol fluctuated over the last 70 years with a peak in the 1980s at 22 litres 100% alcohol per person per year. In 1950 and 2015, the import of alcohol was similar at 8 litres. Several explanations have been put forward to explain the changes including restrictions, increased tax, demographic changes, treatment of alcohol disorders, and public health interventions. The proportion of abstainers increased from 1993 to 2018 while the proportion of participants with regular consumption decreased. About half of the population reported binge drinking at least monthly. Compared with Denmark, there were more abstainers and binge drinkers in Greenland, and fewer had a regular consumption. Although genetics may play a role for drinking patterns, social and cultural conditions are more important. Exposure to domestic alcohol problems and sexual abuse in childhood parallel the recorded import of alcohol and is a likely cause of transgenerational consequences such as youth suicides and alcohol problems.

This paper describes the extent and variation in health disparities between Indigenous and non-Indigenous people within Alaska, Greenland and the northern regions of Canada, Russia and the Nordic countries. We accessed official health statistics and reviewed research studies. We selected a few indicators of health status, health determinants and health care to demonstrate the health disparities that exist. For a large number of health indicators Indigenous people fare worse than non-Indigenous people in the same region or nationally, with the exception of the Sami in the Nordic countries whose health profiles are similar to their non-Sami neighbours. That we were unable to produce a uniform set of indicators applicable to all regions is indicative of the large knowledge gaps that exist. The need for ongoing health monitoring for Indigenous people is most acute for the Sami and Russia, less so for Canada, and least for Alaska, where health data specific to Alaska Natives are generally available. It is difficult to produce an overarching explanatory model for health disparities that is applicable to all regions. We need to seek explanation in the broader political, cultural and societal contexts within which Indigenous people live in their respective regions.

The genetic architecture of the small and isolated Greenlandic population is advantageous for identification of novel genetic variants associated with cardio-metabolic traits. We aimed to identify genetic loci associated with body mass index (BMI), to expand the knowledge of the genetic and biological mechanisms underlying obesity. Stage 1 BMI-association analyses were performed in 4,626 Greenlanders. Stage 2 replication and meta-analysis were performed in additional cohorts comprising 1,058 Yup'ik Alaska Native people, and 1,529 Greenlanders. Obesity-related traits were assessed in the stage 1 study population. We identified a common variant on chromosome 11, rs4936356, where the derived G-allele had a frequency of 24% in the stage 1 study population. The derived allele was genome-wide significantly associated with lower BMI (beta (SE), -0.14 SD (0.03), p = 3.2x10-8), corresponding to 0.64 kg/m2 lower BMI per G allele in the stage 1 study population. We observed a similar effect in the Yup'ik cohort (-0.09 SD, p = 0.038), and a non-significant effect in the same direction in the independent Greenlandic stage 2 cohort (-0.03 SD, p = 0.514). The association remained genome-wide significant in meta-analysis of the Arctic cohorts (-0.10 SD (0.02), p = 4.7x10-8). Moreover, the variant was associated with a leaner body type (weight, -1.68 (0.37) kg; waist circumference, -1.52 (0.33) cm; hip circumference, -0.85 (0.24) cm; lean mass, -0.84 (0.19) kg; fat mass and percent, -1.66 (0.33) kg and -1.39 (0.27) %; visceral adipose tissue, -0.30 (0.07) cm; subcutaneous adipose tissue, -0.16 (0.05) cm, all p

Background: During the last decades, social and life-style changes in Greenland have led to an increase in the incidence of several non-communicable diseases. Our aim is to present the cancer incidence and mortality in Greenland and compare the results with the other Nordic countries. Methods: The data stems from The Danish Cancer Registry and The Danish Register of Causes of Death. Comparable data on cancer incidence and mortality in Denmark, Finland, Iceland, Norway, Sweden, and Greenland are available through collaboration between Nordic Cancer Registries (NORDCAN). We included all individuals residing in Greenland and diagnosed with or died of a cancer from 1983 to 2014. Findings: The total number of cancer cases in Greenland for the study period was 4716 and there were 3231 cancer deaths. Respiratory and gastrointestinal cancers had the highest incidence as well as mortality in Greenland for the entire time period and for both sexes. Compared to the other Nordic countries, Greenland had significantly higher incidence and mortality rates for several cancers. Cancer of the lip, oral cavity, and pharynx, respiratory cancer, and cancer of unknown sites had the highest incidence rate ratios (2.3–3.9) and mortality rate ratios (2.7–9.9) for both sexes. The time trend from 1983 to 2014 showed a significant increase in cancer incidence in Greenland with nearly the same incidence level as the other Nordic countries. While the cancer mortality decreased in the other Nordic countries during the time period studied, there was no change in the cancer-specific mortality in Greenland. Interpretations: The trends in cancer incidence and mortality in Greenland compared to the other Nordic countries have not been reported earlier. These data underline a need to focus on cancer-specific mortality in Greenland and prevention of high-incidence cancers related to well-established risk factors. Keywords: Cancer incidence, Cancer mortality, Greenland, Inuit, Arctic, Cancer, Carcinoma, Nordic countries, Epidemiology

Abstract Greenland is a country in transition from a colonial past with subsistence hunting and fishing to an urban Nordic welfare state. Epidemiological transition from infectious to chronic diseases has been evident since the 1950s. Ninety percent of the population is Inuit. We studied three public health issues based on published literature, namely adverse childhood experiences, addictive behavior, and suicide; diet and obesity; and smoking. Alcohol consumption was high in the 1970s and 1980s with accompanying family and social disruption. This is still a cause of poor mental health and suicides in the generations most affected. The diet is changing from a traditional diet of fish and marine mammals to imported food including food items rich in sugar and fat from domestic animals, and the level of physical activity is decreasing with an ensuing epidemic rise in obesity. The prevalence of smoking is high at around 60% among both men and women and is only slowly decreasing. Smoking shows large social variation, and tobacco-related diseases are widespread. The diseases and conditions outlined above all contribute towards a low life expectancy at birth—69 years for men and 74 years for women in 2011–2015—compared with 78 and 84 years for men and women, respectively, on average in the European countries. The translation of government public health programs into local activities needs strengthening, and it must be realized that the improvement of public health is a long-term process.

Background: Despite abundant evidence that socio-economic status (SES) is a fundamental determinant of health, there is a dearth of research examining association between SES, measured at the individual and community levels, and cardiovascular risk factors and morbidity among indigenous populations. Objectives: To examine the influence of individual-level and community-level SES on systolic and diastolic blood pressure among Greenlandic Inuit. Methods: Multilevel analysis of cross-sectional data from the Inuit Health in Transition – Greenland Survey, to which 3,108 Greenlandic Inuit aged 18 years and older participated. Blood pressure is measured using an automatic device, according to standardized protocol. Individual SES is measured by education. Community socio-economic conditions are measured using combined information on average disposable household income and settlement type. Results: Education was not significantly associated with blood pressure. There was an inverse U-shape association between community socio-economic conditions and blood pressure with significantly lower SBP and DBP among participants living in remote traditional villages characterized by lower average disposable household income and in affluent more urbanized towns. Sex-stratified analyses demonstrate the salience of community conditions for men. Conclusions: The association observed between blood pressure and community-level socio-economic conditions suggests that public health and social policies, programmes and interventions aiming to improve living conditions might improve cardiovascular health in Greenland. Studies are required to further examine social gradients in cardiovascular risk factors and morbidity among indigenous populations using different measures of SES.

Background: Previous studies of Greenlandic children’s disease pattern and contacts to the health care system are sparse and have focused on the primary health care sector. Objective: We aimed to identify the disease pattern and use of health care facilities of children aged 0–10 in two Greenlandic cohorts. Methods and design: In a retrospective, descriptive follow-up of the Ivaaq (The Greenland Child Cohort) and the CLEAR (climate changes, environmental contaminants and reproductive health) birth cohorts (total n=1,000), we reviewed medical records of children aged 6–10 in 2012 with residence in Nuuk or Ilulissat (n=332). Data on diseases and health care system contacts were extracted. Diagnoses were validated retrospectively. Primary health care contacts were reviewed for a random sample of 1:6. Results: In 311 children with valid social security number, the total number of health care system contacts was 12,471 equalling 4.6 contacts per child per year. The annual incidence rate of hospital admissions was 1:10 children (total n=266, 1,220 days, 4.6 days/admission), outpatient contacts 2:10 children and primary care 3.6 per child. Contacts were overall more frequent in boys compared with girls, 39.5 versus 34.6 during the study period, p=0.02. The highest annual contact rates for diseases were: hospitalisations/acute respiratory diseases 13.9:1,000; outpatient contacts/otitis media 5.1:1,000; primary care/conjunctivitis or nasopharyngitis 410:1,000 children. Outpatient screening for respiratory tuberculosis accounted 6.2:1,000, primary care non-disease (Z-diagnosis) 2,081:1,000 annually. Complete adherence to the child vaccination programme was seen in 40%, while 5% did not receive any vaccinations. Conclusions: In this first study of its kind, the health care contact pattern in Greenlandic children showed a relatively high hospitalisation rate and duration per admission, and a low primary health care contact rate. The overall contact rate and disease pattern resembled those in Denmark, except for tuberculosis screening. Adherence to the vaccination programme was low. These findings may be helpful for the organisation and dimensioning of the Greenlandic health care system for children.

This article gives an overview of the ongoing cohort and dietary studies underlying the assessment of population health in the Arctic. The emphasis here is on a description of the material, methods and results or preliminary results for each study. Detailed exposure information is available in an article in this journal, whereas another paper describes the effects associated with contaminant exposure in the Arctic. The cohort descriptions have been arranged geographically, beginning in Norway and moving east to Finland, Sweden, Russia and the other Arctic countries and ultimately to the Faroe Islands. No cohort studies have been reported for Alaska or Iceland.

The objective of this study was to identify geographic, dietary, and other predictors for childhood exposure to perfluoroalkyl substances (PFASs), polychlorinated biphenyls (PCBs), and methylmercury in Greenlandic children. The study includes cross-sectional data from 367 Greenlandic children aged 7 to 12 years examined during 2012–2015. A parent or guardian participated in a structured interview, and a blood sample from the child was analysed for PFASs, PCBs and total mercury. Predictors for the environmental exposures were identified using linear regression. Area of residence was found to have the strongest explanatory power, accounting for 24% to 68% of the variance in the serum concentrations. Information about diet was available for two-thirds of the children, and among these, consumption of traditional Greenlandic food accounted for 2% to 10% of the variance in the biomarker concentrations. Models including all predictors associated with at least one of the environmental chemicals explained 19% to 54% of the total variance. In conclusion, area is a likely proxy for a traditional marine diet, and together area and diet constitute the most important predictors of exposure to methylmercury, PCBs and PFASs among Greenlandic children.

Despite the importance of indigenous people in the Arctic, there is no accurate estimate of their size and distribution. We defined indigenous people as those groups represented by the “permanent participants” of the Arctic Council. The census in Canada, Russia and the United States records status as an indigenous person. In Greenland, a proxy measure is place of birth supplemented by other information. For the Nordic countries we utilized a variety of sources including registered voters’ lists of the various Sami parliaments and research studies that established Sami cohorts. Overall, we estimated that there were about 1.13 million indigenous people in the northern regions of the 8 Member States of the Arctic Council. There were 8,100 Aleuts in Alaska and the Russian North; 32,400 Athabaskans in Alaska and northern Canada; 145,900 Inuit in Alaska, northern Canada and Greenland; 76,300 Sami in northern Norway, Sweden, Finland and Russia; and 866,400 people in northern Russia belonging to other indigenous groups. Different degrees and types of methodological problems are associated with estimates from different regions. Our study highlights the complexity and difficulty of the task and the considerable gaps in knowledge. We hope to spur discussion of this important issue which could ultimately affect strategies to improve the health of circumpolar peoples.

Cardiovascular disease (CVD) is one of the leading causes of death worldwide. In Greenland, valid estimates of prevalence and incidence of CVD do not exist and can only be calculated if diagnoses of CVD in the Greenlandic Hospital Discharge Register (GHDR) are correct. Diagnoses of CVD in GHDR have not previously been validated specifically. The objective of the study was to validate diagnoses of CVD in GHDR. The study was conducted as a validation study with primary investigator comparing information in GHDR with information in medical records. Diagnoses in GHDR were considered correct and thus valid if they matched the diagnoses or the medical information in the medical records. A total of 432 online accessible medical records with a cardiovascular diagnosis according to GHDR from Queen Ingrid’s Hospital from 2001 to 2013 (n=291) and from local health care centres from 2007 to 2013 (n=141) were reviewed. Ninety-nine and ninety-two percent of discharge diagnosis in GHDR from Queen Ingrid’s Hospital and local health care centres were correct in comparison with diagnoses in the medical record indicating valid registration practice. The correctness of cardiovascular diagnoses in GHDR was considered high in terms of acceptable agreement between medical records and diagnoses in GHDR. Cardiovascular diagnoses are valid for epidemiological use.

Background: The eight Arctic States exhibit substantial health disparities between their remote northernmost regions and the rest of the country. This study reports on the trends and patterns in the supply and distribution of physicians, dentists and nurses in these 8 countries and 25 regions and addresses issues of comparability, data gaps and policy implications Methods: We accessed publicly available databases and performed three types of comparisons: (1) among the 8 Arctic States; (2) within each Arctic State, between the northern regions and the rest of the country; (3) among the 25 northern regions. The unit of comparison was density of health workers per 100,000 inhabitants, and the means of three 5-year periods from 2000 to 2014 were computed. Results: The Nordic countries consistently exceed North America in the density of all three categories of health professionals, whereas Russia reports the highest density of physicians but among the lowest in terms of dentists and nurses. The largest disparities between “north” and “south” are observed in the Northwest Territories and Nunavut of Canada for physicians, and in Greenland for all three categories. The disparity is much less pronounced in the northern regions of Nordic countries, while Arctic Russia tends to be oversupplied in all categories. Conclusions: Despite efforts and standardisation of definitions by international organisations such as OECD, it is difficult to obtain an accurate and comparable estimate of the health workforce even in the basic categories of physicians, dentists and nurses . The use of head counts is particularly problematic in jurisdictions that rely on short-term visiting staff. Comparing statistics also needs to take into account the health care system, especially where primary health care is nurse-based. List of Abbreviations ADA: American Dental Association; AHRF: Area Health Resource File; AMA: American Medical Association; AO: Autonomous Okrug; AVI: Aluehallintovirasto; CHA: Community Health Aide; CHR: Community Health Representative; CHW: Community Health Worker; CIHI: Canadian Institute for Health Information; DO: Doctor of Osteopathic Medicine; FTE: Full Time Equivalent; HPDB: Health Personnel Database; MD: Doctor of Medicine; NOMESCO: Nordic Medico-Statistical Committee; NOSOSCO: Nordic Social Statistical Committee; NOWBASE: Nordic Welfare Database; NWT: Northwest Territories; OECD: Organization for Economic Co-operation and Development; RN: Registered Nurse; SMDB: Scott’s Medical Database; WHO: World Health Organization

Background: Suicide is a serious public health challenge in circumpolar regions, especially among Indigenous youth. Indigenous communities, government agencies and health care providers are making concerted efforts to reduce the burden of suicide and strengthen protective factors for individuals, families and communities. The persistence of suicide has made it clear that more needs to be done. Objective: Our aim was to undertake a scoping review of the peer-reviewed literature on suicide prevention and interventions in Indigenous communities across the circumpolar north. Our objective was to determine the extent and types of interventions that have been reported during past decade. We want to use this knowledge to support community initiative and inform intervention development and evaluation. Design: We conducted a scoping review of online databases to identify studies published between 2004 and 2014. We included articles that described interventions in differentiated circumpolar Indigenous populations and provided evaluation data. We retained grey literature publications for comparative reference. Results: Our search identified 95 articles that focused on suicide in distinct circumpolar Indigenous populations; 19 articles discussed specific suicide-related interventions and 7 of these described program evaluation methods and results in detail. The majority of publications on specific interventions were found in North American countries. The majority of prevention or intervention documentation was found in supporting grey literature sources. Conclusion: Despite widespread concern about suicide in the circumpolar world and active community efforts to promote resilience and mental well-being, we found few recorded programs or initiatives documented in the peer-reviewed literature, and even fewer focusing specifically on youth intervention. The interventions described in the studies we found had diverse program designs and content, and used varied evaluation methods and outcomes. The studies we included consistently reported that it was important to use community-based and culturally guided interventions and evaluations. This article summarizes the current climate of Indigenous circumpolar suicide research in the context of intervention and highlights how intervention-based outcomes have largely remained outside of peer-reviewed sources in this region of the world.

Background: Suicides remain a major public health problem in Greenland. Their increase coincides with the modernization since 1950. Serious suicidal thoughts are reported by a significant proportion of participants in countrywide surveys. Objective: To analyze the time trend by region of suicides and suicidal thoughts among the Inuit in Greenland. Design: Data included the Greenland registry of causes of death for 1970–2011 and 2 cross-sectional health surveys carried out in 1993–1994 and 2005–2010 with 1,580 and 3,102 Inuit participants, respectively. Results: Suicide rates were higher among men than women while the prevalence of suicidal thoughts was higher among women. Suicide rates for men and women together increased from 1960 to 1980 and have remained around 100 per 100,000 person-years since then. The regional pattern of time trend for suicide rates varied with an early peak in the capital, a continued increase to very high rates in remote East and North Greenland and a slow increase in villages relative to towns on the West Coast. Suicidal thoughts followed the regional pattern for completed suicides. Especially for women there was a noticeable increasing trend in the villages. The relative risk for suicide was highest among those who reported suicidal thoughts, but most suicides happened outside this high-risk group. Conclusion: Suicide rates and the prevalence of suicidal thoughts remain high in Greenland but different regional trends point towards an increased marginalization between towns on the central West Coast, villages and East and North Greenland. Different temporal patterns call for different regional strategies of prevention.

Background: Since the 1990s, research has been carried out to monitor environmental contaminants and their effects on human health in the Arctic. Although evidence shows that Arctic indigenous peoples are exposed to higher levels of contaminants and do worse on several dimensions of health compared with other populations, the contribution of such exposures on adverse outcomes is unclear. Objective: The purpose of this review is to provide a synopsis of the published epidemiological literature that has examined association between environmental contaminants and health outcomes in Arctic indigenous populations. Design: A literature search was conducted in OVID Medline (1946-January 2014) using search terms that combined concepts of contaminant and indigenous populations in the Arctic. No language or date restrictions were applied. The reference lists of review articles were hand-searched. Results: Of 559 citations, 60 studies were relevant. The studies fell under the following categories: paediatric (n=18), reproductive health (n=18), obstetrics and gynaecology (n=9), cardiology (n=7), bone health (n=2), oncology (n=2), endocrinology (n=2) and other (n=2). All studies, except one from Arctic Finland, were either from Nunavik or Greenland. Most studies assessed polychlorinated biphenyls (n=43) and organochlorine pesticides (n=29). Fewer studies examined heavy metals, perfluorinated compounds, or polybrominated diphenyl ethers. Details of study results for each health category are provided. Conclusions: It is difficult to make conclusive statements about the effects of environmental contaminants on health due to mixed results, small number of studies and studies being restricted to a small number of regions. Meta-analytical synthesis of the evidence should be considered for priority contaminants and health outcomes. The following research gaps should be addressed in future studies: association of contaminants and health in other Arctic regions (i.e. Inuvialuit Settlement Region, Nunavut, Nunatsiavut, Alaska, European North and Russian North); assessment of contaminants on chronic diseases; inclusion of clinical endpoints in assessments; and assessment of the emerging contaminants of perfluorinated compounds and polybrominated diphenyl ethers.

Background and objectives. Public health research has pointed to alcohol and substance abuse as the most significant public health challenges in Greenland with the negative impact on families and communities that entail, but few studies have investigated the role of problem gambling as addictive behaviour among Inuit. The objectives of the present study were to investigate (a) the association between lifetime problem gambling and harmful alcohol use as well as frequent use of marijuana and (b) the prevalence of cross-addictive behaviour among Greenland Inuit. Design. A representative cross-sectional study among Greenland Inuit (n=2,189). Data was collected among adults (18+) in 8 towns and 13 villages in Greenland from 2006–2010. Lifetime problem gambling, harmful alcohol use and frequent use of marijuana were measured through a self-administered questionnaire. Results. The odds ratio for harmful alcohol use and frequent use of marijuana was significantly higher among lifetime problem gamblers compared to non-problem gamblers/non-gamblers. One or more addictive behaviours were present among more than half of the men (53%) and one third of the women (37%), and the co-occurrence of lifetime problem gambling with either harmful alcohol use, frequent use of marijuana or both was found among 12.2% of men and 3.7% of women. The prevalence of one or more addictive behaviours was 44% in households with children. Conclusions. For lifetime problem gamblers, the gambling problems were more often than not combined with harmful alcohol use, frequent use of marijuana or both – especially among men. The high prevalence of addictive behaviours in households with children indicates that many families are presently affected negatively by alcohol, gambling and marijuana. This suggests that pathological gambling should be included systematically in future public health strategies, treatment programs and interventions in Greenland.

Background. Questionnaires are widely used to obtain information on health-related behaviour, and they are more often than not the only method that can be used to assess the distribution of behaviour in subgroups of the population. No validation studies of reported consumption of tobacco or alcohol have been published from circumpolar indigenous communities. Objective. The purpose of the study is to compare information on the consumption of tobacco and alcohol obtained from 3 population surveys in Greenland with import statistics. Design. Estimates of consumption of cigarettes and alcohol using several different survey instruments in cross-sectional population studies from 1993–1994, 1999–2001 and 2005–2010 were compared with import statistics from the same years. Results. For cigarettes, survey results accounted for virtually the total import. Alcohol consumption was significantly under-reported with reporting completeness ranging from 40% to 51% for different estimates of habitual weekly consumption in the 3 study periods. Including an estimate of binge drinking increased the estimated total consumption to 78% of the import. Conclusion. Compared with import statistics, questionnaire-based population surveys capture the consumption of cigarettes well in Greenland. Consumption of alcohol is under-reported, but asking about binge episodes in addition to the usual intake considerably increased the reported intake in this population and made it more in agreement with import statistics. It is unknown to what extent these findings at the population level can be inferred to population subgroups.

Objectives. Self-rated health (SRH) and associated risk and protective correlates were investigated among two indigenous adolescent populations, Greenlandic Inuit and Norwegian Sami. Design. Cross-sectional data were collected from “Well-being among Youth in Greenland” (WBYG) and “The Norwegian Arctic Adolescent Health Study” (NAAHS), conducted during 2003–2005 and comprising 10th and 11th graders, 378 Inuit and 350 Sami. Methods. SRH was assessed by one single item, using a 4-point and 5-point scale for NAAHS and WBYG, respectively. Logistic regressions were performed separately for each indigenous group using a dichotomous measure with “very good” (NAAHS) and “very good/good” (WBYG) as reference categories. We simultaneously controlled for various socio-demographics, risk correlates (drinking, smoking, violence and suicidal behaviour) and protective correlates (physical activity, well-being in school, number of close friends and adolescent–parent relationship). Results. A majority of both Inuit (62%) and Sami (89%) youth reported “good” or “very good” SRH. The proportion of “poor/fair/not so good” SRH was three times higher among Inuit than Sami (38% vs. 11%, p≤0.001). Significantly more Inuit females than males reported “poor/fair” SRH (44% vs. 29%, p≤0.05), while no gender differences occurred among Sami (12% vs. 9%, p≤0.08). In both indigenous groups, suicidal thoughts (risk) and physical activity (protective) were associated with poor and good SRH, respectively. Conclusions. In accordance with other studies of indigenous adolescents, suicidal thoughts were strongly associated with poorer SRH among Sami and Inuit. The Inuit–Sami differences in SRH could partly be due to higher “risk” and lower “protective” correlates among Inuit than Sami. The positive impact of physical activity on SRH needs to be targeted in future intervention programs.

Fatty acids (FAs) are involved in cellular processes important for normal body function, and perturbation of FA balance has been linked to metabolic disturbances, including type 2 diabetes. An individual's level of FAs is affected by diet, lifestyle, and genetic variation. We aimed to improve the understanding of the mechanisms and pathways involved in regulation of FA tissue levels, by identifying genetic loci associated with inter-individual differences in erythrocyte membrane FA levels. We assessed the levels of 22 FAs in the phospholipid fraction of erythrocyte membranes from 2,626 Greenlanders in relation to single nucleotide polymorphisms genotyped on the MetaboChip or imputed. We identified six independent association signals. Novel loci were identified on chromosomes 5 and 11 showing strongest association with oleic acid (rs76430747 in ACSL6, beta (SE): -0.386% (0.034), p = 1.8x10-28) and docosahexaenoic acid (rs6035106 in DTD1, 0.137% (0.025), p = 6.4x10-8), respectively. For a missense variant (rs80356779) in CPT1A, we identified a number of novel FA associations, the strongest with 11-eicosenoic acid (0.473% (0.035), p = 2.6x10-38), and for variants in FADS2 (rs174570), LPCAT3 (rs2110073), and CERS4 (rs11881630) we replicated known FA associations. Moreover, we observed metabolic implications of the ACSL6 (rs76430747) and CPT1A (rs80356779) variants, which both were associated with altered HbA1c (0.051% (0.013), p = 5.6x10-6 and -0.034% (0.016), p = 3.1x10-4, respectively). The latter variant was also associated with reduced insulin resistance (HOMA-IR, -0.193 (0.050), p = 3.8x10-6), as well as measures of smaller body size, including weight (-2.676 kg (0.523), p = 2.4x10-7), lean mass (-1.200 kg (0.271), p = 1.7x10-6), height (-0.966 cm (0.230), p = 2.0x10-5), and BMI (-0.638 kg/m2 (0.181), p = 2.8x10-4). In conclusion, we have identified novel genetic determinants of FA composition in phospholipids in erythrocyte membranes, and have shown examples of links between genetic variants associated with altered FA membrane levels and changes in metabolic traits.

OBJECTIVE:Epidemiological studies have provided evidence of an association between vitamin D insufficiency and type 2 diabetes. Vitamin D levels have decreased among Inuit in Greenland, and type 2 diabetes is increasing. We hypothesized that the decline in vitamin D could have contributed to the increase in type 2 diabetes, and therefore investigated associations between serum 25(OH)D3 as a measure of vitamin D status and glucose homeostasis and glucose intolerance in an adult Inuit population. METHODS:2877 Inuit (≥18 years) randomly selected for participation in the Inuit Health in Transition study were included. Fasting- and 2hour plasma glucose and insulin, C-peptide and HbA1c were measured, and associations with serum 25(OH)D3 were analysed using linear and logistic regression. A subsample of 330 individuals who also donated a blood sample in 1987, were furthermore included. RESULTS:After adjustment, increasing serum 25(OH)D3 (per 10 nmol/L) was associated with higher fasting plasma glucose (0.02 mmol/L, p = 0.004), 2hour plasma glucose (0.05 nmol/L, p = 0.002) and HbA1c (0.39%, p

The traditional diet in Greenland consists to a large extent of meat and organs of seal and other marine mammals, which is polluted by POPs and mercury. These substances are present in the blood of Greenlanders in concentrations well above international guidelines, and as these contaminants are suspected of having negative impacts on health, some action should be taken. On the other hand, traditional food is also an important source of health promoting micronutrients that are not provided by imported food in sufficient quantities, for example vitamin D, long chain n-3 fatty acids, and selenium, not to mention the traditional diet's function as a social glue that is perceived as important for Inuit identity in Greenland. The proportion of the total diet that comes from marine mammals is on a constant decrease, and especially children and young adults consume rather little seal and whale. The traditional food items are consequently being replaced by imported food, and among the imported food items several rather unhealthy items are popular, that is carbonated soft drinks with sugar, sweets, chips and farmed (red) meat with a high content of saturated fat. Together with a decrease in physical activity, this dietary transition has resulted in a severe epidemic of overweight and diabetes. In giving advice to the public, the Greenland Board of Nutrition was therefore faced with the challenge to retain the benefits of the traditional diet while minimizing the contaminant exposure, and at the same time to counteract the effects of poor quality imported food. The Board tried to balance the known and suspected positive and negative aspects of the total diet in relation not only to physical health but to general wellbeing, and decided on 10 simple recommendations. As the consumption of traditional food becomes less prominent and as the consumption of food rich in empty calories increases, the guidelines are continuously revised and updated.

Background. Among circumpolar populations, recent research has documented a significant increase in risk factors which are commonly associated with chronic disease, notably obesity. Objective. The present study undertakes a scoping review of research on obesity in the circumpolar Inuit to determine the extent obesity research has been undertaken, how well all subpopulations and geographic areas are represented, the methodologies used and whether they are sufficient in describing risk factors, and the prevalence and health outcomes associated with obesity. Design. Online databases were used to identify papers published 1992–2011, from which we selected 38 publications from Canada, the United States, and Greenland that used obesity as a primary or secondary outcome variable in 30 or more non-pregnant Inuit (“Eskimo”) participants aged 2 years or older. Results. The majority of publications (92%) reported cross-sectional studies while 8% examined retrospective cohorts. All but one of the studies collected measured data. Overall 84% of the publications examined obesity in adults. Those examining obesity in children focused on early childhood or adolescence. While most (66%) reported 1 or more anthropometric indices, none incorporated direct measures of adiposity. Evaluated using a customized quality assessment instrument, 26% of studies achieved an “A” quality ranking, while 18 and 39% achieved quality rankings of “B” and “C”, respectively. Conclusions. While the quality of studies is generally high, research on obesity among Inuit would benefit from careful selection of methods and reference standards, direct measures of adiposity in adults and children, studies of preadolescent children, and prospective cohort studies linking early childhood exposures with obesity outcomes throughout childhood and adolescence.

Objectives. We studied the association and agreement between questionnaire data and biomarkers of marine food among Greenland Inuit. Design. Cross sectional study. Methods. The study population comprised 2,224 Inuit, age 18+ (43% men); data collected 2005–2008 in Greenland. Using a food frequency questionnaire (FFQ), we calculated consumption of seal, whale, and fish (g/day) and as meals/month, intake of eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA), total N3, and mercury. We measured erythrocyte membrane fatty acids (FA) and whole blood mercury (Hg). Associations were assessed by Pearson correlation and agreement between the 2 methods was assessed by Bland–Altman plots depicting mean difference between the methods. Using multiple linear regressions, the associations were studied between whole blood mercury, erythrocyte FA and frequency or gram per day of seal, whale, and fish. Results. Partial correlations ranged from r=0.16, p

Carnitine palmitoyltransferase IA, encoded by CPT1A, is a key regulator of fatty acid metabolism. Previously, a loss-of-function mutation, namely, c.1436 C→T (p.P479L), was reported in CPT1A in the homozygous state in Canadian aboriginal male with presumed CPT1A deficiency. To determine the population frequency of this variant, we determined CPT1A p.P479L genotypes in 1111 Greenland Inuit. Associations between genotype and variation in plasma total cholesterol, triglycerides, LDL, HDL, apolipoprotein (apo) B, and apoA-I was also investigated. We found the L479 allele occurs at a high frequency in this sample (0.73), while it was completely absent in 285 nonaboriginal samples. This suggests that the original proband’s symptoms were not likely due to the CPT1A p.P479L mutation because it is very common in Inuit and because symptoms suggesting CPT1A deficiency have not been reported in any carrier subsequently studied. However, CPT1A p.P479L was associated with elevated plasma HDL and apoA-I levels. The association with increased levels of HDL and apoA-I suggest that the polymorphism might protect against atherosclerosis.

BACKGROUND:Low vitamin D status may be pronounced in Arctic populations due to limited sun exposure and decreasing intake of traditional food. OBJECTIVE:To investigate serum 25(OH)D3 as a measure of vitamin D status among adult Inuit in Greenland, predictors of low serum 25(OH)D3 concentrations and the trend from 1987 to 2005-2010. DESIGN:A total of 2877 randomly selected Inuit (≥ 18 years) from the Inuit Health in Transition study were included. A sub-sample (n = 330) donated a blood sample in 1987 which allowed assessment of time trends in vitamin D status. RESULTS:The geometric mean serum 25(OH)D3 (25[OH]D2 concentrations were negligible and not reported) in 2005-2010 was lowest among the 18-29 year old individuals (30.7 nmol/L; 95% CI: 29.7; 31.7) and increased with age. In all age-groups it decreased from 1987 to 2005-2010 (32%-58%). Low 25(OH)D3 concentrations (

OBJECTIVE:The Inuit population in Greenland has undergone rapid socioeconomic and nutritional changes simultaneously with an increasing prevalence of obesity. Therefore, the objective was to examine fetal programming as part of the aetiology of obesity among Inuit in Greenland by investigating the association between birth weight and measures of body composition and fat distribution in adulthood. METHODS:The study was based on cross-sectional data from a total of 1,473 adults aged 18-61 years in two population-based surveys conducted in Greenland between 1999-2001 and 2005-2010. Information on birth weight was collected from birth records. Adiposity was assessed by anthropometry, fat mass index (FMI), fat-free mass index (FFMI), and visceral (VAT) and subcutaneous adipose tissue (SAT) estimated by ultrasound. The associations to birth weight were analyzed using linear regression models and quadratic splines. Analyses were stratified by sex, and adjusted for age, birthplace, ancestry and family history of obesity. RESULTS:Spline analyses showed linear relations between birth weight and adult adiposity. In multiple regression analyses, birth weight was positively associated with BMI, waist circumference, FMI, FFMI and SAT with generally weaker associations among women compared to men. Birth weight was only associated with VAT after additional adjustment for waist circumference and appeared to be specific and inverse for men only. CONCLUSIONS:Higher birth weight among Inuit was associated with adiposity in adulthood. More studies are needed to explore a potential inverse association between birth size and VAT.

The INSIG2 rs7566605 polymorphism was identified for obesity (BMI> or =30 kg/m(2)) in one of the first genome-wide association studies, but replications were inconsistent. We collected statistics from 34 studies (n = 74,345), including general population (GP) studies, population-based studies with subjects selected for conditions related to a better health status ('healthy population', HP), and obesity studies (OB). We tested five hypotheses to explore potential sources of heterogeneity. The meta-analysis of 27 studies on Caucasian adults (n = 66,213) combining the different study designs did not support overall association of the CC-genotype with obesity, yielding an odds ratio (OR) of 1.05 (p-value = 0.27). The I(2) measure of 41% (p-value = 0.015) indicated between-study heterogeneity. Restricting to GP studies resulted in a declined I(2) measure of 11% (p-value = 0.33) and an OR of 1.10 (p-value = 0.015). Regarding the five hypotheses, our data showed (a) some difference between GP and HP studies (p-value = 0.012) and (b) an association in extreme comparisons (BMI> or =32.5, 35.0, 37.5, 40.0 kg/m(2) versus BMI