High levels of household food insecurity on the Navajo Nation

"We don't separate out these things. Everything is related": Partnerships with Indigenous Communities to Design, Implement, and Evaluate Multilevel Interventions to Reduce Health Disparities

Multilevel interventions (MLIs) are appropriate to reduce health disparities among Indigenous peoples because of their ability to address these communities' diverse histories, dynamics, cultures, politics, and environments. Intervention science has highlighted the importance of context-sensitive MLIs in Indigenous communities that can prioritize Indigenous and local knowledge systems and emphasize the collective versus the individual. This paradigm shift away from individual-level focus interventions to community-level focus interventions underscores the need for community engagement and diverse partnerships in MLI design, implementation, and evaluation. In this paper, we discuss three case studies addressing how Indigenous partners collaborated with researchers in each stage of the design, implementation, and evaluation of MLIs to reduce health disparities impacting their communities. We highlight the following: (1) collaborations with multiple, diverse tribal partners to carry out MLIs which require iterative, consistent conversations over time; (2) inclusion of qualitative and Indigenous research methods in MLIs as a way to honor Indigenous and local knowledge systems as well as a way to understand a health disparity phenomenon in a community; and (3) relationship building, maintenance, and mutual respect among MLI partners to reconcile past research abuses, prevent extractive research practices, decolonize research processes, and generate co-created knowledge between Indigenous and academic communities.

Relationship between food insecurity and a gestational diabetes risk reduction intervention: outcomes among American Indian and Alaska Native adolescent and young adult females

American Indian and Alaska Natives (AI/ANs) are disproportionately impacted by gestational diabetes mellitus (GDM), subsequent type 2 diabetes, and food insecurity. It is prudent to decrease risk of GDM prior to pregnancy to decrease the intergenerational cycle of diabetes in AI/AN communities. The purpose of this project is to describe and examine food insecurity, healthy eating self-efficacy, and healthy eating behaviors among AI/AN females (12-24 years old) as related to GDM risk reduction. Methods included: secondary analysis of healthy eating self-efficacy and behaviors, and household-level food insecurity measures from an randomized controlled trial that tested the effect of engagement in a GDM risk reduction educational intervention on knowledge, behavior, and self-efficacy for GDM risk reduction from baseline to 3-month follow-up. Participants were AI/AN daughters (12-24 years old) and their mothers (N = 149 dyads). Researchers found that more than one-third (38.1%) reported food insecurity. At baseline food insecurity was associated with higher levels of eating vegetables and fruit for the full sample (p = .045) and cohabitating dyads (p = .002). By 3 months healthy eating self-efficacy (p = .048) and limiting snacking between meals (p = .031) improved more in the control group than the intervention group only for cohabitating dyads. For the full sample, the intervention group had increases in times eating vegetables (p = .022) and fruit (p = .015), whereas the control group had declines. In the full sample, food insecurity did not moderate the group by time interaction for self-efficacy for healthy eating (p ≥ .05) but did moderate the group by time interaction for times drinking soda (p = .004) and days eating breakfast (p = .013). For cohabitating dyads, food insecurity did moderate self-efficacy for eating 3 meals a day (p = .024) and days eating breakfast (p = .012). These results suggest food insecurity is an important factor regarding the efficacy of interventions designed to reduce GDM risk and offer unique insight on "upstream causes" of GDM health disparities among AI/AN communities.

Cardiovascular Disease Burden and Outcomes Among American Indian and Alaska Native Medicare Beneficiaries

Importance

American Indian and Alaska Native persons face significant health disparities; however, data regarding the burden of cardiovascular disease in the current era is limited.

Objective

To determine the incidence and prevalence of cardiovascular disease, the burden of comorbid conditions, including cardiovascular disease risk factors, and associated mortality among American Indian and Alaska Native patients with Medicare insurance.

Design, Setting, and Participants

This was a population-based cohort study conducted from January 2015 to December 2019 using Medicare administrative data. Participants included American Indian and Alaska Native Medicare beneficiaries 65 years and older enrolled in both Medicare part A and B fee-for-service Medicare. Statistical analyses were performed from November 2022 to April 2023.

Main Outcomes and Measures

The annual incidence, prevalence, and mortality associated with coronary artery disease (CAD), heart failure (HF), atrial fibrillation/flutter (AF), and cerebrovascular disease (stroke or transient ischemic attack [TIA]).

Results

Among 220 598 American Indian and Alaska Native Medicare beneficiaries, the median (IQR) age was 72.5 (68.5-79.0) years, 127 402 were female (57.8%), 78 438 (38.8%) came from communities in the most economically distressed quintile in the Distressed Communities Index. In the cohort, 44.8% of patients (98 833) were diagnosed with diabetes, 61.3% (135 124) were diagnosed with hyperlipidemia, and 72.2% (159 365) were diagnosed with hypertension during the study period. The prevalence of CAD was 38.6% (61 125 patients) in 2015 and 36.7% (68 130 patients) in 2019 (P < .001). The incidence of acute myocardial infarction increased from 6.9 per 1000 person-years in 2015 to 7.7 per 1000 patient-years in 2019 (percentage change, 4.79%; P < .001). The prevalence of HF was 22.9% (36 288 patients) in 2015 and 21.4% (39 857 patients) in 2019 (P < .001). The incidence of HF increased from 26.1 per 1000 person-years in 2015 to 27.0 per 1000 person-years in 2019 (percentage change, 4.08%; P < .001). AF had a stable prevalence of 9% during the study period (2015: 9.4% [14 899 patients] vs 2019: 9.3% [25 175 patients]). The incidence of stroke or TIA decreased slightly throughout the study period (12.7 per 1000 person-years in 2015 and 12.1 per 1000 person-years in 2019; percentage change, 5.08; P = .004). Fifty percent of patients (110 244) had at least 1 severe cardiovascular condition (CAD, HF, AF, or cerebrovascular disease), and the overall mortality rate for the cohort was 19.8% (43 589 patients).

Conclusions and Relevance

In this large cohort study of American Indian and Alaska Native patients with Medicare insurance in the US, results suggest a significant burden of cardiovascular disease and cardiometabolic risk factors. These results highlight the critical need for future efforts to prioritize the cardiovascular health of this population.

Implementation of Indigenous Food Tax Policies in Stores on Navajo Nation

In 2014, the Navajo Nation Healthy Diné Nation Act (HDNA) was enacted and permanently approved in 2020; HDNA places a 2% surtax on unhealthy foods and beverages, while other 2014 legislation exempted healthy food items from the 6% regular sales tax. Little is known about Navajo Nation store manager/owner perspectives toward the HDNA and how best to support stores to implement the legislation. Purposive sampling was used to ensure a balanced sample of correct HDNA implementers, incorrect HDNA implementers, and stores which made healthy store changes over the past 6 years. Three community-based interviewers collected surveys by phone or in-person. Frequency of closed-ended questions was quantified, and open-ended responses were coded using thematic analysis. Of 29 identified sample stores, 20 were interviewed to reach saturation. Eleven of 20 stores made changes improving their healthy food environments. Barriers included lack of equipment (6/20) and low consumer demand (5/20). Facilitators included consumer awareness and increased produce supply options (5/20). Sixteen of 20 stores supported HDNA continuation. Facilitators to HDNA implementation included orientation and informational materials (6/20) and promotion of tax-free items (5/20). Barriers included confusion about the tax (6/20) and tax exemption (5/20). Suggestions for support included printed materials (6/20) and store training (5/20). HDNA benefits included greater awareness of healthy choices among staff (7/20) and customer-community members (2/20). Most managers and owners expressed receiving support for healthy store changes and HDNA, but also identified a need for added resources and support. Findings inform legislative action to promote timely and appropriate uptake of HDNA, and support equitable, healthy food systems.

Navajo Nation Stores Show Resilience During COVID-19 Pandemic

On April 8, 2020, the Navajo Nation issued an administrative order limiting business operations. Facing high coronavirus disease 2019 (COVID-19) rates and limited food infrastructure, a survey was conducted among Navajo Nation store managers to assess: (1) COVID-19 adaptations; (2) challenges; (3) changes in customer volume and purchasing; and (4) suggestions for additional support. Purposive sampling identified 29 stores in Navajo communities. Representatives from 20 stores (19 store managers/owners, 1 other; 7 grocery, and 13 convenience/other stores) were interviewed by phone or in-person to reach saturation (new information threshold < 5%). Responses were coded using frequencies and inductive thematic analysis. All 20 stores implemented COVID-19 guidelines (Centers for Disease Control and Prevention [CDC]/Navajo Nation) and most received orientation/support from local chapters, community organizations, or health centers. Stores implemented staff policies (50%, handwashing, vaccinations, protective personal equipment (PPE), sick leave, temperature checks), environmental changes (50%, hand sanitizer, checkout dividers), customer protocols (40%, limit customers, mask requirements, closed restrooms), and deep cleaning (40%). Most stores (65%) reported challenges including stress/anxiety, changing guidelines, supply chain and customer compliance; 30% reported infection or loss of staff. Weekday customer volume was slightly higher vs. pre-COVID, but weekend lower. Stores reported consistent or more healthy food purchases (50%), more nonfood essentials (20%), or shelf-stable foods (10%). Desired support included further orientation (30%), leadership support (20%), overtime/time to learn guidelines (20%), and signage/handouts (15%). Despite a high COVID-19 burden and limited food store infrastructure, Navajo Nation stores adapted by implementing staff, environmental and customer policies. Local support, staffing, and small store offerings were key factors in healthy food access.

Food Insecurity among American Indian and Alaska Native People: A Scoping Review to Inform Future Research and Policy Needs

Food insecurity, defined as insufficient access to nutritious foods, is a social determinant of health that may underpin health disparities in the US. American Indian and Alaska Native (AI/AN) individuals experience many health inequities that may be related to food insecurity, but no systematic analyses of the existing evidence have been published. Thus, the objective of this scoping review was to assess the literature on food insecurity among AI/AN individuals and communities, with a focus on the prevalence of food insecurity and its relations to sociodemographic, nutrition, and health characteristics. Systematic search and data extraction processes were used. Searches were conducted on PubMed as well as peer-reviewed journal and government websites. Of 3174 identified references, 34 publications describing 30 studies with predominantly AI/AN sample populations were included in the final narrative synthesis. Twenty-two studies (73%) were cross-sectional and the remaining 8 (27%) described interventions. The weighted average prevalence of food insecurity across the studies was 45.7%, although estimates varied from 16% to 80%. Most studies used some version of the USDA Food Security Survey Modules, although evidence supporting its validity in AI/AN respondents is limited. Based on the review, recommendations for future research were derived, which include fundamental validity testing, better representation of AI/AN individuals in federal or local food security reports, and consideration of cultural contexts when selecting methodological approaches. Advances in AI/AN food insecurity research could yield tangible benefits to ongoing initiatives aimed at increasing access to traditional foods, improving food environments on reservations and homelands, and supporting food sovereignty.

Driving Distance and Food Accessibility: A Geospatial Analysis of the Food Environment in the Navajo Nation and Border Towns

The Navajo Nation, an area home to approximately 173,000 people in the southwest United States, experiences the highest rates of food insecurity in the United States and is classified as a food desert. The present study assessed the accessibility to food outlets (grocery stores, convenience stores, and restaurants) as measured by driving time on the Navajo Nation and in selected surrounding border towns. Food outlets located in neighboring border towns were examined using network analysis tools in ArcGIS Pro to calculate driving distance and examine the potential impact of driving time within the Navajo Nation on accessibility to nutritious foods. There were 14 grocery stores, 21 convenience stores, and 65 restaurants identified in the Navajo Nation using Mergent Intellect, a proprietary database, as compared to border towns which had a total of 542 grocery stores, 762 convenience stores, and 3,329 restaurants equaling a ratio of about 50:1 (grocery, 39:1; convenience, 36:1; restaurants, 51:1) when comparing food outlets nearby versus on the Navajo Nation. This ecological study presents a visual representation of driving time and food accessibility, revealing geographic areas within the Navajo Nation where access to border town food stores is sparse, and food insecurity may be elevated.

Environmental and occupational health on the Navajo Nation: a scoping review

A scoping review was performed to answer: what environmental health concerns have been associated with adverse health outcomes in the Navajo Nation? The review focused on occupational and ambient environmental exposures associated with human industrial activities. The search strategy was implemented in PubMed, and two investigators screened the retrieved literature. Thirteen studies were included for review. Data were extracted using the matrix method. Six studies described associations between work in uranium mining and cancer. Six studies focused on environmental exposures to uranium mine waste and other metals, with outcomes that included biological markers, kidney disease, diabetes and hypertension, and adverse birth outcomes. One study explored occupational exposure to Sin Nombre Virus and infection. Most research has focused on the health effects of uranium, where occupational exposures occurred among miners and environmental exposures are a legacy of uranium mining and milling. Gaps exist with respect to health outcomes associated with current occupations and the psychosocial impact of environmental hazards. Other environmental exposures and hazards are known to exist on the Navajo Nation, which may warrant epidemiologic research.

Association of food security with cardiometabolic health during young adulthood: cross-sectional comparison of American Indian adults with other racial/ethnic groups

OBJECTIVES

Our aim was to assess the cross-sectional associations between food insecurity and cardiometabolic health indicators in American Indian young adults compared with non-Hispanic white, black, Asian or Pacific Islander and Hispanic young adults.

DESIGN

Data from the fourth wave of the National Longitudinal Study of Adolescent to Adult Health (Add Health) were used. Variables included a self-assessed measure of risk of food insecurity, indicators of cardiometabolic health (body mass index, haemoglobin A1c, blood pressure) and sociodemographic characteristics. Multivariable regression models were used to assess the association of risk of food insecurity with cardiometabolic health, while controlling for sociodemographic variables. All analyses were weighted and accounted for the complex survey design.

PARTICIPANTS

The analytical sample of n=12 799 included mostly non-Hispanic white respondents (n=7900), followed by n=2666 black, n=442 American Indian, n=848 Asian or Pacific Islander and n=943 Hispanic.

RESULTS

Risk of food insecurity was more common among respondents who were female, Black, American Indian, had lower educational attainment, and were classified as having obesity or diabetes. In unadjusted models, risk of food insecurity was significantly associated with greater odds of obesity (OR=1.39; 95% CI 1.20 to 1.60) and diabetes (OR=1.61; 95% CI 1.23 to 2.11). After adjusting for sociodemographic factors (age, sex, education, income, household size, tobacco smoking, alcohol intake and race/ethnicity), only the association between risk of food insecurity and obesity remained (OR=1.19; 95% CI 1.03 to 1.38). Relationships among risk of food insecurity, sociodemographic characteristics and diabetes varied across models stratified by race and ethnicity.

CONCLUSIONS

Results suggest that elevated risk of food insecurity is present in young American Indian adults, but its relationship with cardiometabolic health is unclear. Future work should capitalise on longitudinal data and the US Department of Agriculture's Food Security Survey Modules.

Shopper Purchasing Trends at Small Stores on the Navajo Nation since the Passage of the Healthy Diné Nation Act Tax: A Multi-Year Cross-sectional Survey

Background

In 2014, the Navajo Nation passed the Healthy Diné Nation Act (HDNA), which applies an additional 2% tax on unhealthy foods and beverages and a waiver of Navajo sales tax on healthy foods and beverages. However, the HDNA's impact on purchasing behavior has not been explored.

Objectives

We assessed beverage and produce purchasing trends among shoppers at small Navajo stores between 2017 and 2019, shopper characteristics associated with buying water, and whether HDNA awareness was associated with purchasing behaviors.

Methods

A total of 332 shoppers at 34 stores in 2017 and 274 shoppers at 44 stores in 2019 were surveyed to assess HDNA awareness and same-day purchasing of water, sugar-sweetened beverages (SSBs), fruits, and vegetables. Hypotheses were tested using chi-square analyses and multivariate analysis.

Results

Water purchasing among respondents increased significantly from 2017 to 2019 (24.4% to 32.8%; P = 0.03). Shoppers in 2019 were 1.5 times more likely to purchase water compared with 2017 (adjusted P = 0.01). There was a trend toward reduced SSB purchasing (85.8% in 2017, 80.3% in 2019, P = 0.068), while produce purchasing remained unchanged over time, at approximately 17%. Shoppers were more likely to buy water if they relied on that store for the majority of their groceries (P = 0.006) and if they did not have their own transportation to get to the store (P = 0.004). Most shoppers (56.6%) were aware of the HDNA; of these, 35.6% attributed healthier habits to the HDNA, most commonly buying more healthy drinks (49.2%), fewer unhealthy drinks (37.7%), more healthy snacks (31.1%), and fewer unhealthy snacks (26.2%).

Conclusions

Shopper habits at small stores located on the Navajo Nation have shifted towards healthier purchasing from 2017 to 2019. Shoppers who were aware of the HDNA reported purchasing more healthy and fewer unhealthy food and drinks as a result of this legislation.

The Navajo Nation Healthy Diné Nation Act: A Description of Community Wellness Projects Funded by a 2% Tax on Minimal-to-No-Nutritious-Value Foods

CONTEXT

To promote the health of the Navajo people, the Navajo Nation passed the Healthy Diné Nation Act (HDNA) in 2014. The HDNA included a 2% tax on "minimal-to-no-nutritional-value" foods and waived 5% sales tax on healthy foods, the first such policy in the United States and any sovereign Tribal nation. Uniquely aligned with Tribal government structures, revenue was directly allocated to 110 small local government entities (Chapters) for self-determined wellness projects.

OBJECTIVE

To characterize HDNA-funded wellness projects, test for variation in project type, and funding amount over time by region and community size.

DESIGN

Longitudinal study assessing funded wellness projects from tax inception through 2019.

SETTING

The Navajo Nation.

PARTICIPANTS

One hundred ten Navajo Nation Chapters receiving funding for self-determined wellness projects.

OUTCOME MEASURES

The categories and specific types of wellness projects and funding over 4 years by region and community size.

RESULTS

Of revenue collected in 2015-2018, more than 99.1% was disbursed through 2019 ($4.6 million, $13 385 annually per community) across 1315 wellness projects (12 per community). The built recreational environment category received 38.6% of funds, equipment/supplies 16.5%, instruction 15.7%, food and water initiatives 14.0%, and social events 10.2%. Most common specific projects were walking trails ($648 470), exercise equipment ($585 675), food for events ($288 879), playgrounds ($287 471), and greenhouses ($275 554). Only the proportion allocated to instruction changed significantly over time (increased 2% annually, P = .02). Smaller communities (population <1000) allocated significantly higher proportions to traditional, agricultural, and intergenerational projects and less to the built environment.

CONCLUSIONS

Through 2019, more than 99% of HDNA revenue was successfully disbursed to 110 rural, Tribal communities. Communities chose projects related to promoting the built recreational environment, agriculture, and fitness/nutrition education, with smaller communities emphasizing cultural and intergenerational projects. These findings can inform other indigenous nations considering similar policies and funding distributions.

Healthy Eating Determinants and Food Security Resource Opportunities: Urban-Dwelling American Indian and Alaska Native Older Adults Perspectives

OBJECTIVE

To explore the perspectives of urban-dwelling American Indian and Alaska Native (AI/AN) older adults regarding determinants of healthy eating, food insecurity, and opportunities for an urban clinic to improve resources.

METHODS

Semistructured interviews (n = 24) with older adults (aged ≥ 60 years) at 1 urban AI/AN serving clinic. Telephone-based interviews were audio-recorded, professionally transcribed, and analyzed using thematic analysis.

RESULTS

Four overarching themes were revealed: (1) hunger-mitigating resources exist but do not necessarily lessen food insecurity; (2) multiple layers of challenges related to social determinants of health present barriers to healthy nutrition for AI/AN older adults; (3) unique facilitators rooted in AI/AN culture can help decrease food insecurity; and (4) many clinic-based opportunities for programs to improve food insecurity exist.

CONCLUSIONS AND IMPLICATIONS

Findings provide a foundation for urban-serving AI/AN clinics to develop healthy eating resources for their older adult patients. Greater benefit would result from resources that build on cultural strengths and address older adult-specific challenges to healthy eating.

Individual- and household-level factors associated with fruit, vegetable, and dietary fiber adequacy among Native American adults in 6 reservation communities

This study utilized baseline data collected in 2017 from the OPREVENT2 trial, which included 540 Native Americans in six Midwest and Southwest reservation communities. The objective was to identify correlates of fruit, vegetable, and dietary fiber adequacy among participants 18–75 years old who self-identified as the main food purchaser or preparer in their household. Mean daily servings of fruits and vegetables and grams of dietary fiber were quantified based on a 30-day semi-quantitative food frequency questionnaire.

Participants consumed an average of 0.5 (±0.4) cup-equivalent servings of fruit, 2.5 (±1.8) cup-equivalent servings of vegetables, and 15.5 (±8.9) grams of fiber per day. <2% of the study population met the 2015–2020 Dietary Guidelines for Americans recommendations for fruit consumption, while 12 and 42% met recommendations for dietary fiber and vegetable consumption, respectively.

Females had a prevalence ratio 1.4 times greater than males for adequate intakes of vegetables (p = 0.008) and over 6 times greater for dietary fiber (p < 0.001). Participants over the age of 30 were about twice as likely to meet dietary fiber recommendations (p = 0.031) compared to those 30 years and younger. Participants receiving food assistance from the USDA’s Food Distribution Program on Indian Reservations (FDPIR) were nearly twice as likely as non-FDPIR recipients to meet recommendations for dietary fiber (p = 0.008).

These findings can help guide the development of targeted interventions to improve diet quality; however, further work is needed to understand and address underlying reasons for low fruit consumption in these rural reservation communities.

Successful implementation of the Healthy Diné Nation Act in stores on the Navajo Nation

In 2014, the Navajo Nation Council passed the Healthy Diné Nation Act (HDNA), a 2% tax on unhealthy foods and beverages and a waiver of the 5% sales tax on healthy foods and water, to support health promotion and disease prevention among the Navajo people. Very little research has assessed implementation accuracy of food or beverage taxes and none were implemented within a sovereign Tribal nation. This study assessed the accuracy of HDNA tax implementation among 47 stores located on the Navajo Nation. A pair of tax-exempt items [e.g. a bottle of water and fresh fruit] and a pair of HDNA-tax eligible items [e.g. sugary beverage and candy bar] were purchased between July-December 2019. Receipts were retained to assess taxation. A total of 87.2% of stores accurately implemented the 2% tax on unhealthy items while 55.3% of the stores accurately implemented the 6% tax waiver on healthy items. In all, 51.1% of the stores accurately applied both taxes. There were no significant differences across store type (convenience or grocery stores and trading posts) or geographic region. In conclusion, almost all stores on the Navajo Nation accurately applied a 2% tax on unhealthy foods and beverages, while the proportion of stores applying a waiver on healthy foods was lower. Successful HDNA tax implementation among stores remains an important priority in achieving the goal to support health promotion and disease prevention among Navajo communities.

Changes in food pricing and availability on the Navajo Nation following a 2% tax on unhealthy foods: The Healthy Diné Nation Act of 2014

INTRODUCTION

In 2014, the Navajo Nation Healthy Diné Nation Act (HDNA) was passed, combining a 2% tax on foods of 'minimal-to-no-nutritional value' and waiver of 5% sales tax on healthy foods, the first-ever such tax in the U.S. and globally among a sovereign tribal nation. The aim of this study was to measure changes in pricing and food availability in stores on the Navajo Nation following the implementation of the HDNA.

METHODS

Store observations were conducted in 2013 and 2019 using the Nutrition Environment Measurement Survey-Stores (NEMS-S) adapted for the Navajo Nation. Observations included store location, type, whether healthy foods or HDNA were promoted, and availability and pricing of fresh fruits and vegetables, canned items, beverages, water, snacks and traditional foods. Differences between 2013 and 2019 and by store type and location were tested.

RESULTS

The matched sample included 71 stores (51 in the Navajo Nation and 20 in border towns). In 2019, fresh produce was available in the majority of Navajo stores, with 71% selling at least 3 types of fruit and 65% selling at least 3 types of vegetables. Compared with border town convenience stores, Navajo convenience stores had greater availability of fresh vegetables and comparable availability of fresh fruit in 2019. The average cost per item of fresh fruit decreased by 13% in Navajo stores (from $0.88 to $0.76) and increased in border stores (from $0.63 to $0.73), resulting in comparable prices in Navajo and border stores in 2019. While more Navajo stores offered mutton, blue corn and wild plants in 2019 compared to 2013, these changes were not statistically significant.

DISCUSSION

The findings suggest modest improvements in the Navajo store environment and high availability of fruits and vegetables. Navajo stores play an important role in the local food system and provide access to local, healthy foods for individuals living in this rural, tribal community.

Food Insecurity and Associated Challenges to Healthy Eating Among American Indians and Alaska Natives With Type 2 Diabetes: Multiple Stakeholder Perspectives

Objective: To examine stakeholder perspectives on food insecurity and associated challenges to healthy eating among American Indian and Alaska Native (AI/AN) adults with type 2 diabetes (T2D). Methods: Focus groups and interviews were conducted with purposively selected stakeholders: AI/ANs with T2D, their family members, healthcare administrators, nutrition and diabetes educators, and national content experts on AI/AN health. Two coders analyzed transcripts using the constant-comparison method. Results: Key themes included (1) rural- and urban-dwelling AI/ANs experience different primary food security and associated challenges; (2) factors contributing to food insecurity extend beyond cost of healthy food; and (3) barriers to consuming fresh, healthy food include cost, preparation time, limited cooking knowledge, and challenges with gardening. Discussion: Resources for AI/ANs with T2D who experience food insecurity and associated challenges to healthy eating should be tailored based on urban versus rural location and should address cost and other barriers to consumption of fresh fruits and vegetables.

A Scoping Review of the Use of Indigenous Food Sovereignty Principles for Intervention and Future Directions

Indigenous food sovereignty (IFS) represents a community-led movement with potential to reduce health inequities, but no scoping review of the impact of taking an IFS approach on intervention research has been conducted. This review sought to: 1) describe intervention studies that employ IFS principles, and 2) describe the impact of studies using IFS principles on food access, eating patterns, diet quality, physical activity, and health. Through a literature review, 4 IFS principles were identified: 1) community ownership, 2) inclusion of traditional food knowledge, 3) inclusion and promotion of cultural foods, and 4) environmental/intervention sustainability. Twenty intervention studies published between January 1, 2000 and February 5, 2020 were included. Most of the studies that scored high in IFS principles saw a positive impact on diet. This review found evidence supporting the value of IFS principles in the development, implementation, and evaluation of health interventions for Indigenous communities.

Facilitators and Barriers to Healthy Eating Among American Indian and Alaska Native Adults with Type 2 Diabetes: Stakeholder Perspectives

BACKGROUND

American Indian and Alaska Native (AI/AN) adults have a higher prevalence of type 2 diabetes (T2D) and related complications than non-AI/AN adults. As healthy eating is a cornerstone of diabetes self-management, nutrition education plays an important role in diabetes self-management education.

OBJECTIVE

To understand stakeholder perspectives on facilitators and barriers to healthy eating for AI/AN adults with T2D in order to inform the cultural adaptation of an existing diabetes nutrition education curriculum.

METHODS

Individual interviews were conducted with 9 national content experts in diabetes nutrition education (e.g. registered dietitians, diabetes educators, experts on AI/AN food insecurity) and 10 community-based key informants, including tribal health administrators, nutrition/diabetes educators, Native elders, and tribal leaders. Four focus groups were conducted with AI/AN adults with T2D (n = 29) and 4 focus groups were conducted with their family members (n = 22). Focus groups and community-based key informant interviews were conducted at 4 urban and reservation sites in the USA. Focus groups and interviews were recorded and transcribed verbatim. We employed the constant comparison method for data analysis and used Atlas.ti (Mac version 8.0) to digitalize the analytic process.

RESULTS

Three key themes emerged. First, a diabetes nutrition education program for AI/ANs should accommodate diversity across AI/AN communities. Second, it is important to build on AI/AN strengths and facilitators to healthy eating (e.g. strong community and family support systems, traditional foods, and food acquisition and preparation practices). Third, it is important to address barriers to healthy eating (e.g. food insecurity, challenges to preparation of home-cooked meals, excessive access to processed and fast food, competing priorities and stressors, loss of access to traditional foods, and traditional food-acquisition practices and preparation) and provide resources and strategies for mitigating these barriers.

CONCLUSIONS

Findings were used to inform the cultural adaptation of a nutrition education program for AI/AN adults with T2D.

Stopping Gestational Diabetes in American Indian and Alaska Native Girls: Nutrition as a Key Component to Gestational Diabetes Risk Reduction

BACKGROUND

American Indian and Alaska Native (AI/AN) women have a higher risk of gestational diabetes mellitus (GDM) and subsequent diagnosis of diabetes than do non-Hispanic White women. Healthy eating is key to weight management both prior to pregnancy and between pregnancies and can reduce the risk of developing GDM. Our research team developed an innovative preconception counseling and diabetes risk-reduction program, which includes nutrition and weight-management principles and is culturally tailored for adolescent AI/AN women. The program is entitled Stopping Gestational Diabetes Mellitus (SGDM).

OBJECTIVE

The purpose of this article is to examine nutrition-related information collected as a part of the formative qualitative research conducted for the development of a preconception counseling and gestational diabetes risk-reduction program, SGDM.

METHODS

This in-depth secondary analysis explored the original qualitative data from the needs assessment for SGDM program development. Participants included AI/AN women with a history of GDM (n = 5); AI/AN girls at risk of GDM (n = 14), and their mothers (n = 11), health care providers, and health administrators who care for AI/AN girls (n = 16); AI/AN elected leaders; and Indian health system administrators (n = 12). All focus groups and interviews were reanalyzed utilizing the following research question: "How do key stakeholders discuss food and/or nutrition in terms of gestational diabetes risk reduction for AI/AN adolescent girls?"

RESULTS

Three primary nutrition themes emerged: 1) AI/AN women were aware of healthy nutrition, healthy weight gainduring pregnancy, and healthy nutrition for people with type 2 diabetes, but these principles were not linked to reducing the risk of GDM; 2) participants expressed the need for education on the role of nutrition and weight management in GDM risk reduction; 3) participants shared challenges of healthful eating during and before pregnancy for AI/AN women.

CONCLUSIONS

These stakeholders' comments informed the development of the nutrition components of SGDM.

Nutritional Education and Its Effects on Household Food Insecurity in Southeastern Iran

Background:

Food insecurity can affect health directly or indirectly through its impact on nutritional status. We aimed at determining the effects of nutrition education intervention on household food insecurity in Zahedan, southeast Iran.

Methods:

The study was conducted using multi-stage sampling method. The first stage was a cross-sectional investigation whereby 2,160 households were studied in Zahedan in 2015. The prevalence of food insecurity was determined and food-insecure households were identified. Household food security status was assessed through the 18-item US Household Food Security Survey Module. In the second stage, based on the determined sample size of 150 households in each group, eligible households were randomly divided into the intervention and control groups. Before the educational intervention, questionnaires including demographic and socioeconomic information were completed for both groups. Then, data analysis was performed and the intervention was conducted on the intervention group. Six months post-intervention, a final assessment was made by interviewing the two groups to complete demographic, socioeconomic, and household food security questionnaires.

Results:

The prevalence of food insecurity in the 2,160 households was 58.8%. After the intervention, the number of food-insecure households diminished by 22% in the intervention group, and these households were assigned to the food secure category. After controlling the confounding variables, the educational intervention was significantly effective in reducing food insecurity score (P<0.001).

Conclusion:

The findings demonstrated the beneficial role of nutritional education and the skills of resource management in modifying nutritional behaviors and improving food security in the study population.

A Cluster Randomized Controlled Trial of a Home-Delivered Food Box on Food Security in Chickasaw Nation

BACKGROUND

The 2010 Child Nutrition reauthorization called for the independent evaluation of innovative strategies to reduce the risk of childhood hunger or improve the food security status of households with children.

OBJECTIVE

The research question was whether the Packed Promise intervention reduces child food insecurity (FI-C) among low-income households with children.

DESIGN

This study was a cluster randomized controlled trial of 40 school districts and 4,750 eligible, consented households within treatment and control schools.

PARTICIPANTS/SETTING

Data were collected at baseline (n = 2,859) and 2 follow-ups (n = 2,852; n = 2,790) from households with children eligible for free school meals in participating schools in 12 rural counties within the Chickasaw Nation territory in south central Oklahoma in 2016 to 2018.

INTERVENTION

Each month of the 25-month intervention, for each eligible child, enrolled households could choose from 5 types of food boxes that contained shelf-stable, nutritious foods ($38 food value) and a $15 check for purchasing fruits and vegetables.

MAIN OUTCOME MEASURES

The primary outcome was FI-C. Other outcomes included household and adult food security, very low food security among children, and food expenditures.

STATISTICAL ANALYSES PERFORMED

Differences between the treatment and control groups were estimated by a regression model controlling for baseline characteristics.

RESULTS

The Packed Promise project did not significantly reduce FI-C at 12 months (29.3% prevalence in the treatment group compared with 30.1% in the control group; P = 0.123) or at 18 months (28.2% vs 28.7%; P = 0.276), but reduced food insecurity for adults by 3 percentage points at 12 months (P = 0.002) but not at 18 months (P = 0.354). The intervention led to a $27 and a $16 decline in median household monthly out-of-pocket food expenditures at 12 and 18 months, respectively.

CONCLUSIONS

An innovative intervention successfully delivered nutritious food boxes to low-income households with children in rural Oklahoma, but did not significantly reduce FI-C. Improving economic conditions in the demonstration area and participation in other nutrition assistance programs among treatment and control groups might explain the lack of impact.ClinicalTrials.gov ID: NCT04316819 (http://www.clinicaltrials.gov).

FUNDING/SUPPORT

This article is published as part of a supplement supported by the US Department of Agriculture, Food and Nutrition Service.

Systemic Disease and Ocular Comorbidity Analysis of Geographically Isolated Federally Recognized American Indian Tribes of the Intermountain West

BACKGROUND

The American Indian Navajo and Goshute peoples are underserved patient populations residing in the Four Corners area of the United States and Ibupah, Utah, respectively.

METHODS

We conducted a cross-sectional study of epidemiological factors and lipid biomarkers that may be associated with type II diabetes, hypertension and retinal manifestations in tribal and non-tribal members in the study areas (n = 146 participants). We performed multivariate analyses to determine which, if any, risk factors were unique at the tribal level. Fundus photos and epidemiological data through standardized questionnaires were collected. Blood samples were collected to analyze lipid biomarkers. Univariate analyses were conducted and statistically significant factors at p < 0.10 were entered into a multivariate regression.

RESULTS

Of 51 participants for whom phenotyping was available, from the Four Corners region, 31 had type II diabetes (DM), 26 had hypertension and 6 had diabetic retinopathy (DR). Of the 64 participants from Ibupah with phenotyping available, 20 had diabetes, 19 had hypertension and 6 had DR. Navajo participants were less likely to have any type of retinopathy as compared to Goshute participants (odds ratio (OR) = 0.059; 95% confidence interval (CI) = 0.016-0.223; p < 0.001). Associations were found between diabetes and hypertension in both populations. Older age was associated with hypertension in the Four Corners, and the Navajo that reside there on the reservation, but not within the Goshute and Ibupah populations. Combining both the Ibupah, Utah and Four Corners study populations, being American Indian (p = 0.022), residing in the Four Corners (p = 0.027) and having hypertension (p < 0.001) increased the risk of DM. DM (p < 0.001) and age (p = 0.002) were significantly associated with hypertension in both populations examined. When retinopathy was evaluated for both populations combined, hypertension (p = 0.037) and living in Ibupah (p < 0.001) were associated with greater risk of retinopathy. When combining both American Indian populations from the Four Corners and Ibupah, those with hypertension were more likely to have DM (p < 0.001). No lipid biomarkers were found to be significantly associated with any disease state.

CONCLUSIONS

We found different comorbid factors with retinal disease outcome between the two tribes that reside within the Intermountain West. This is indicated by the association of tribe and with the type of retinopathy outcome when we combined the populations of American Indians. Overall, the Navajo peoples and the Four Corners had a higher prevalence of chronic disease that included diabetes and hypertension than the Goshutes and Ibupah. To the best of our knowledge, this is the first study to conduct an analysis for disease outcomes exclusively including the Navajo and Goshute tribe of the Intermountain West.

Impact of a Fruit and Vegetable Prescription Program on Health Outcomes and Behaviors in Young Navajo Children

BACKGROUND

Rates of childhood obesity are higher in American Indian and Alaska Native populations, and food insecurity plays a major role in diet-related disparities. To address this need, local healthcare providers and a local nonprofit launched the Navajo Fruit and Vegetable Prescription (FVRx) Program in 2015. Children up to 6 y of age and their caregivers are enrolled in the 6-mo program by healthcare providers. Families attend monthly health coaching sessions where they receive vouchers redeemable for fruits, vegetables, and healthy traditional foods at retailers participating in the FVRx program.

OBJECTIVES

We assessed the impact of a fruit and vegetable prescription program on the health outcomes and behaviors of participating children.

METHODS

Caregivers completed voluntary surveys to assess food security, fruit and vegetable consumption, hours of sleep, and minutes of physical activity; healthcare providers also measured children's body mass index [BMI (kg/m2)] z score at initiation and completion of the program. We calculated changes in health behaviors, BMI, and food security at the end of the program, compared with baseline values.

RESULTS

A total of 243 Navajo children enrolled in Navajo FVRx between May 2015 and September 2018. Fruit and vegetable consumption significantly increased from 5.2 to 6.8 servings per day between initiation and program completion (P < 0.001). The proportion of participant households reporting food insecurity significantly decreased from 82% to 65% (P < 0.001). Among children classified as overweight or obese at baseline, 38% achieved a healthy BMI z score at program completion (P < 0.001). Sixty-five percent of children were retained in the program.

CONCLUSIONS

The Navajo FVRx program improves fruit and vegetable consumption among young children. Children who are obese or overweight may benefit most from the program.

Diet quality among pregnant women in the Navajo Birth Cohort Study

Proper nutrition during pregnancy is vital to maternal health and fetal development and may be challenging for Navajo Nation residents because access to affordable and healthy foods is limited. It has been several decades since reported diet quality during pregnancy was examined on Navajo Nation. We present the first study to estimate iodine intake and use the Healthy Eating Index (HEI-2015) to assess maternal diet quality among pregnant women in the Navajo Birth Cohort Study (NBCS). Based on dietary intake data derived from food frequency questionnaires, overall estimated micronutrient intake has remained similar since the last assessment in 1981, with potential improvements evident for folate and niacin. A high proportion of women (>50%) had micronutrient intakes from dietary sources below the Estimated Average Requirements during pregnancy. The median urinary iodine concentration for NBCS women (90.8 μg/L; 95% CI [80, 103.5]) was less than adequate and lower than concentrations reported for pregnant women that participated in the National Health and Nutrition Examination Survey (NHANES) between 2011 and 2014. Overall, average diet quality of NBCS women estimated using the HEI-2015 (62.4; 95% CI [60.7, 64.0]) was similar to that reported for women of child-bearing age and pregnant women in NHANES. Although, NBCS women had diets high in added sugar, with sugar-sweetened beverages as the primary contributors. Our study provides updated insights on maternal diet quality that can inform health and nutrition initiatives in Navajo communities emphasizing nutrition education and access to prenatal vitamins and calcium, iodine, and vitamin E dense foods.

Incorporation of Information-Seeking Behavior Into Food Insecurity Research

INTRODUCTION

Limited or uncertain availability of nutritionally adequate and safe foods affects the health of individuals. Because of its association with chronic health conditions, addressing food insecurity may improve health outcomes and decrease health-related costs. This study explores whether and how information seeking as captured by calls made to United Way 2-1-1 can be used to identify food-insecure areas and information deserts-communities with low proportions of residents accessing government food resources but with high rates of 2-1-1 calls for emergency food resources.

METHODS

Details regarding calls made to United Way of Salt Lake 2-1-1 for emergency food resources between 2014 and 2018 (n=63,221) were analyzed in 2019. Using GIS methods, areas with the highest number of calls for emergency food resources (hot spots) were identified; multinomial logistic regression was used to identify community-level sociodemographic predictors of food insecurity.

RESULTS

Areas with a smaller proportion of the population aged <18 years, more female householders, and more African Americans are associated with higher odds of being food-insecure.

CONCLUSIONS

Patterns of information seeking about emergency food resources suggest that, despite statewide access to federal means-tested food programs, significant food needs remain. This novel approach in food insecurity research can help public health officials and health systems address an important social determinant of health by identifying areas vulnerable to food insecurity. In addition, this work may be useful in benchmarking food needs, information seeking, and replicating analyses where similar data are available.

Implementation of the Navajo fruit and vegetable prescription programme to improve access to healthy foods in a rural food desert

OBJECTIVE

To utilise a community-based participatory approach in the design and implementation of an intervention targeting diet-related health problems on Navajo Nation.

DESIGN

A dual strategy approach of community needs/assets assessment and engagement of cross-sectorial partners in programme design with systematic cyclical feedback for programme modifications.

SETTING

Navajo Nation, USA.

PARTICIPANTS

Navajo families with individuals meeting criteria for programme enrolment. Participant enrolment increased with iterative cycles.

RESULTS

The Navajo Fruit and Vegetable Prescription (FVRx) Programme.

CONCLUSIONS

A broad, community-driven and culturally relevant programme design has resulted in a programme able to maintain core programmatic principles, while also allowing for flexible adaptation to changing needs.

School Nutrition Policies and Practices on an American Indian Reservation: Research and Policy Considerations

Navajo (Diné) and other American Indian children are more affected by overweight and obesity than their U.S. counterparts. In this descriptive study, the authors combined a socioecological and Navajo cultural framework to analyze the various factors that influence food choices available to children in schools. The Healthy Hunger-Free Kids Act of 2010 updated nutrition standards for school meals and all other foods and beverages sold in schools. Some studies have shown that improved nutrition standards were not favorably received by students and school food programs. To better understand these broader trends in a Navajo context, the researcher administered in-person surveys to 6 principals and 14 food service workers from a sample of 6 schools and performed on-site observations of two schools. Data were analyzed using a combination of descriptive statistics, matrix analysis, and thematic analysis techniques. Results showed that schools were offering more healthy food options in school lunches and that some schools were still serving unhealthy foods, such as pizza, tater tots, and French fries. Classroom and fundraising events provided other sources for low-nutrient foods and beverages. Participants had mixed responses about the updated nutrition standards, and food waste of healthy foods was a major concern. This study proposes opportunities for nurses to engage in research and advance stronger policies that increase healthy food options and limit access to less healthy foods.

Healthy Stores Initiative Associated with Produce Purchasing on Navajo Nation

BACKGROUND

American Indians and Alaska Natives experience diet-related health disparities compared with non-Hispanic whites. Navajo Nation's colonial history and remote setting present unique challenges for healthy food access.

OBJECTIVE

This study aims to understand the impact of the Healthy Navajo Stores Initiative (HNSI) on fruit and vegetable purchasing on Navajo Nation.

METHODS

We conducted a cross-sectional survey of 692 customers shopping at 28 convenience stores, trading posts, and grocery stores on Navajo Nation. Individual- and household-level sociodemographic data and food purchasing behaviors were collected. Descriptive and bivariate analyses for customers' individual- and household-level characteristics were conducted using chi-squared tests. The impact of individual-, household-, and store-level factors on fruit and vegetable purchasing was assessed using multiple logistic regression modeling.

RESULTS

Store participation in the HNSI was significantly associated with customers' purchase of produce. Customers experienced 150% higher odds of purchasing produce if they shopped in participating stores, compared with nonparticipating stores (P < 0.001). Store type was strongly associated with customers' purchase of fruits or vegetables. Customers shopping at a grocery store had 520% higher odds of purchasing produce than did customers shopping at convenience stores (P < 0.001). Customers shopping at trading posts had 120% higher odds of purchasing fruits or vegetables than did customers shopping at convenience stores (P = 0.001).

CONCLUSIONS

Our findings reveal increased produce purchasing at stores participating in the HNSI. Customers were significantly more likely to purchase fruits or vegetables in stores enrolled in a healthy store intervention than in nonenrolled stores, after controlling for quantity of produce stocked and store type. Customers shopping in grocery stores and trading posts were significantly more likely to purchase produce than customers shopping in convenience stores. These findings have implications for food access in rural tribal communities.

Adolescent food insecurity: the special case of Marshallese youth in north-west Arkansas, USA

OBJECTIVE

Food insecurity is not randomly dispersed throughout the population; rather, there are a number of risk and protective factors shaping both the prevalence and severity of food insecurity across households and sociodemographic populations. The present study examines some of these factors and the role that race and ethnicity among adolescent individuals in north-west Arkansas might play, paying specific attention to a subgroup of Pacific Islanders: the Marshallese.

DESIGN

The study uses cross-sectional survey data collected from a self-administered questionnaire of 10th-12th grade students.

SETTING

A city in north-west Arkansas, USA.

PARTICIPANTS

The number of enrolled students in the selected high school at the time of the survey was 2148. Ten classrooms (116 students) were unable to participate at the time of the survey, making 2032 students eligible to be surveyed. Approximately 22% refused to participate and 105 students were absent from school, yielding a response rate of approximately 78% (n 1493).

RESULTS

Marshallese students had a higher prevalence of food insecurity than all other racial and ethnic groups in the study. After controlling for other sociodemographic, risk and protective factors, their odds of food insecurity remained significantly higher than both non-Hispanic White and Hispanic or Latinx students.

CONCLUSIONS

Adolescent food insecurity among Marshallese students must be made sense of in relation to structural-level determinants that shape the distribution of vital resources such as food across racial, ethnic and foreign-born lines.

The Association between Food Insecurity and Diet Quality Varies by Race/Ethnicity: An Analysis of National Health and Nutrition Examination Survey 2011-2014 Results

BACKGROUND

Food insecurity is believed to influence the quality and quantity of foods consumed; however, studies examining food insecurity and diet quality have been inconclusive and few studies have explored variability in these associations by sex and race/ethnicity.

OBJECTIVE

This study examined associations between food insecurity and diet quality, and variations by sex and race/ethnicity.

DESIGN

Cross-sectional analysis of data from the 2011-2014 National Health and Nutrition Examination Surveys.

PARTICIPANTS

The study population was composed of 4,393 adults (aged 20 to 65 years) with family incomes ≤300% of the federal poverty level with complete data on household food security and dietary intake via two 24-hour dietary recalls.

MAIN OUTCOME MEASURES

Diet quality was assessed using the Healthy Eating Index-2015.

STATISTICAL ANALYSES PERFORMED

Associations between food insecurity and Healthy Eating Index-2015 total and component scores were examined using linear regression models and generalized linear models. Models adjusted for sociodemographic and health covariates.

RESULTS

Compared with food-secure adults, food-insecure adults reported a 2.22-unit lower Healthy Eating Index-2015 score (95% CI -3.35 to -1.08). This association was most pronounced among non-Hispanic whites and adults of Asian or other races/ethnicities. There were no associations among non-Hispanic black or Hispanic adults, and no differences by sex. Among non-Hispanic whites, food insecurity was associated with lower scores for total protein foods, seafood and plant proteins, and added sugar. Among Asians, food insecurity was associated with lower scores for whole fruit.

CONCLUSIONS

Food insecurity was associated with lower diet quality primarily among non-Hispanic whites; Asians; and other adults, a group composed of American Indian or Alaska Natives, Native Hawaiian or Other Pacific Islanders, and multiracial adults. Further research is needed to better understand the nature of this association among understudied racial/ethnic groups.

Gardening for Health: Patterns of Gardening and Fruit and Vegetable Consumption Among the Navajo

American Indians, including Navajo, are disproportionately affected by obesity and diabetes, in part due to diet-related health behaviors. The purpose of this study was to assess the patterns of gardening and fruit and vegetable (FV) consumption among residents in two communities on the Navajo Nation in order to inform a community gardening intervention. We analyzed survey data collected from participants in the Yéego Gardening study conducted in two communities in the Navajo Nation (N = 169). We found that 51% of the sample gardened, and on average participants gardened 8.9 times per month. Lack of time (53%) and financial barriers, such as gas for transportation or irrigation (51 and 49%, respectively), were reported as barriers to gardening. Most participants reported low levels of self-efficacy (80%) and behavioral capability (82%) related to gardening. Those with higher levels of gardening self-efficacy and behavioral capability reported more frequent gardening. Average daily FV consumption was 2.5 servings. Most participants reported high levels of self-efficacy to eat FV daily (64%) and high behavioral capability to prepare FV (66%). There was a positive association between FV consumption and gardening, with those gardening more than 4 times per month eating about 1 more serving of FV per day than those gardening 4 or fewer times per month. Further research is needed to better understand how gardening can increase fruit and vegetable availability and consumption among residents of the Navajo Nation.

OPREVENT (Obesity Prevention and Evaluation of InterVention Effectiveness in NaTive North Americans): Design of a Multilevel, Multicomponent Obesity Intervention for Native American Adults and Households

Obesity prevalence is high in Native American (NA) adults, and there is a critical need to establish and implement evidence-based social, behavioral, and policy interventions that are theoretically informed. The use of multilevel, multicomponent (MLMC) interventions has been shown to be an effective strategy for comprehensive health behavior change; however, there is little guidance available in the literature to facilitate implementation in this underserved and understudied population. To decrease obesity and related comorbidities in NA adults, an MLMC intervention called OPREVENT (Obesity Prevention and Evaluation of InterVention Effectiveness in NaTive North Americans) was implemented in 5 rural NA communities to modify the food-purchasing environment, improve diet, and increase physical activity (PA). Five NA communities across the Upper Midwest and Southwest United States were randomly assigned to Immediate (n = 3) or Delayed (n = 2) Intervention. OPREVENT was implemented in Immediate Intervention community food stores, worksites, schools, and media over 1 y. A community-randomized controlled trial was used to evaluate intervention impact in adults at the individual and institutional levels, with individual-level data being collected on diet, PA, and psychosocial variables at baseline and follow-up; and institutional-level data being collected on food stores, worksites, and schools, media, and process measures. The OPREVENT intervention was one of the first MLMC obesity interventions in this population and provides evidence-based practices for future program development. The purpose of this article is to describe the design, implementation, and evaluation of OPREVENT. This trial was registered at isrctn.com as ISRCTN76144389.

Associations between Food Consumption Patterns and Chronic Diseases and Self-Reported Morbidities in 6 American Indian Communities

Background

American Indian (AI) have the highest rates of diet-related chronic diseases in the country. Yet, the relation between dietary patterns and chronic diseases in this population has not been well explored.

Objective

We aimed to characterize common dietary patterns among adults from 6 AI communities (N = 580) and assess their relation with BMI, percentage body fat, waist-to-hip ratio, hypertension, and self-reported type 2 diabetes and cardiovascular disease.

Methods

We conducted a baseline assessment of an obesity prevention study (N = 580). Dietary intake data were collected using a modified Block FFQ. Exploratory factor analysis was used to characterize dietary patterns. We used multivariate linear and logistic regression analyses to assess associations between dietary patterns and health outcomes, controlling for age, sex, employment status, smoking status, geographic region, and energy intake.

Results

Five dietary patterns, explaining 81.8% of variance in reported food consumption, were identified: “meat and fried foods,” “processed foods,” “fruits and vegetables,” “sugary snacks,” and “meat alternatives and high-protein foods.” “Those with higher consumption of “meat and fried foods” were associated with higher mean waist-to-hip ratio (0.03; 95% CI: 0.01, 0.04), higher mean BMI (2.45 kg/m2; 95% CI: 0.83, 4.07), and increased odds of being overweight or obese (OR: 2.63; 95% CI: 1.10, 6.31) compared to those with lower consumption of “meat and fried foods.” Higher consumption of “processed foods” was associated with increased odds of self-reported type 2 diabetes (OR: 3.41; 95% CI: 1.31, 8.90). No protective effect of consumption of “fruits and vegetables” was observed, although average consumption was below national recommendation levels.

Conclusions

AI dietary patterns corroborate nutritional concerns previously reported among AI populations. Future interventions should discourage overconsumption of meat, fried foods, and processed foods, and promote consumption of fruits and vegetables to reduce chronic disease burden in this population.

Nutritional aspects of people affected by leprosy, between 2001 and 2014, in semi-arid Brazilian municipalities

The study aimed to characterize food insecurity, nutritional status, and eating habits of people affected by leprosy. This is a descriptive cross-sectional study based on a census population. We evaluated 276 cases, reported in the Notifiable Diseases Information System, between 2001 and 2014, in the municipalities of Vitória da Conquista and Tremedal, in the state of Bahia. Food insecurity was estimated according to the Brazilian Food Insecurity Scale. We collected weight and height measurements, meal frequency, and household, socioeconomic, psychosocial and clinical variables. The prevalence of food insecurity was 41.0% among the study population - 28.3% mild, 8.0% moderate and 4.7% severe. Overweight/obesity was estimated in 60.1% of the study participants, and excessive salt intake was reported by 8.6%. Beans and red meat were the most regularly consumed foods; there was low consumption of milk, raw and cooked vegetables, and fruits. This population presented high food insecurity prevalence, inadequate eating habits and nutritional status, reflecting nutritional vulnerability. The insertion of nutritional assistance in the leprosy control programmes is recommended, to improve health care.

Nontargeted Diabetes Screening in a Navajo Nation Emergency Department

We developed a nontargeted diabetes screening program in a rural Indian Health Service emergency department in Shiprock, New Mexico to measure the proportion of previously undiagnosed diabetes and prediabetes, and to assess glycemic control among patients with known disease. Of 924 patients screened in the emergency department between May and July 2017, 28.8% screened positive for previously undiagnosed diabetes or prediabetes; among patients with known disease, the median hemoglobin A1c was 8.2%. Of the newly identified patients, 54.9% attended follow-up.

Food Insecurity among Older Aboriginal and Torres Strait Islanders

It is well established that Indigenous populations are at a heightened risk of food insecurity. Yet, although populations (both Indigenous and non-Indigenous) are ageing, little is understood about the levels of food insecurity experienced by older Indigenous peoples. Using Australian data, this study examined the prevalence and correlates of food insecurity among older Aboriginal and Torres Strait Islanders. Using nationally representative data, we employed ordinal logistic regression models to investigate the association between socio-demographic characteristics and food insecurity. We found that 21% of the older Aboriginal and Torres Strait Islander population were food insecure, with 40% of this group exposed to food insecurity with food depletion and inadequate intake. This places this population at a 5 to 7-fold risk of experiencing food insecurity relative to their older non-Indigenous peers. Measures of geography, language and low socio-economic status were highly associated with exposure to food insecurity. Addressing food insecurity offers one pathway to reduce the disparity in health outcomes between Aboriginal and Torres Strait Islanders and non-Indigenous Australians. Policies that consider both remote and non-remote Australia, as well as those that involve Aboriginal people in their design and implementation are needed to reduce food insecurity.

Household food insecurity and dietary patterns in rural and urban American Indian families with young children

BACKGROUND

High food insecurity has been demonstrated in rural American Indian households, but little is known about American Indian families in urban settings or the association of food insecurity with diet for these families. The purpose of this study was to examine the prevalence of food insecurity in American Indian households by urban-rural status, correlates of food insecurity in these households, and the relationship between food insecurity and diet in these households.

METHODS

Dyads consisting of an adult caregiver and a child (2-5 years old) from the same household in five urban and rural American Indian communities were included. Demographic information was collected, and food insecurity was assessed using two validated items from the USDA Household Food Security Survey. Factors associated with food insecurity were examined using logistic regression. Child and adult diets were assessed using food screeners. Coping strategies were assessed through focus group discussions. These cross-sectional baseline data were collected from 2/2013 through 4/2015 for the Healthy Children, Strong Families 2 randomized controlled trial of a healthy lifestyles intervention for American Indian families.

RESULTS

A high prevalence of food insecurity was determined (61%) and was associated with American Indian ethnicity, lower educational level, single adult households, WIC participation, and urban settings (p = 0.05). Food insecure adults had significantly lower intake of vegetables (p < 0.05) and higher intakes of fruit juice (<0.001), other sugar-sweetened beverages (p < 0.05), and fried potatoes (p < 0.001) than food secure adults. Food insecure children had significantly higher intakes of fried potatoes (p < 0.05), soda (p = 0.01), and sports drinks (p < 0.05). Focus group participants indicated different strategies were used by urban and rural households to address food insecurity.

CONCLUSIONS

The prevalence of food insecurity in American Indian households in our sample is extremely high, and geographic designation may be an important contributing factor. Moreover, food insecurity had a significant negative influence on dietary intake for families. Understanding strategies employed by households may help inform future interventions to address food insecurity.

TRIAL REGISTRATION

( NCT01776255 ). Registered: January 16, 2013. Date of enrollment: February 6, 2013.

Food Insecurity and Chronic Diseases Among American Indians in Rural Oklahoma: The THRIVE Study

OBJECTIVES

To examine food insecurity and cardiovascular disease-related health outcomes among American Indians (AIs) in rural Oklahoma.

METHODS

We surveyed a cross-sectional sample of 513 AI adults to assess food insecurity domains (i.e., food quality and quantity) and obesity, diabetes, and hypertension.

RESULTS

Among AIs surveyed, 56% reported inadequate food quantity and 62% reported inadequate food quality. The unadjusted prevalence of diabetes (28.4% vs 18.4%), obesity (60.0% vs 48.3%), and hypertension (54.1% vs 41.6%) was higher among participants with inadequate food quantity than among those with adequate food quantity. These associations did not reach statistical significance after adjustment for age, gender, study site, education, and income. The unadjusted prevalence of obesity (60.7% vs 45.8%), diabetes (27.3% vs 18.8%), and hypertension (52.5% vs 42.5%) was higher among those with inadequate food quality than among those with adequate food quality, even after adjustment for age, gender, study site, education, and income.

CONCLUSIONS

Tribal, federal, and state policymakers, as well as businesses and nonprofit organizations, must collaboratively take aggressive action to address food insecurity and its underlying causes, including improving tribal food environments, reducing barriers to healthy foods, and increasing living wages.

Yéego Gardening! A Community Garden Intervention to Promote Health on the Navajo Nation

BACKGROUND

Yéego Gardening! is a community garden intervention to increase gardening behavior, increase access to low-cost fruit and vegetables, and ultimately increase consumption in Navajo communities.

OBJECTIVES

To design a theory-based, culturally relevant intervention with three components: a community garden, monthly workshops on gardening and healthy eating, and community outreach.

METHODS

Gardens were constructed and maintained in collaboration with community-based organizations in two Navajo communities. Monthly workshops were held throughout the growing season and incorporated aspects of Navajo culture and opportunities to build confidence and skills in gardening and healthy eating behaviors. In addition, program staff attended community events to promote gardening and healthy eating.

CONCLUSIONS

Community input was essential throughout the planning and implementation of the intervention. If effective, community gardens may be a way to increase fruit and vegetable availability and intake, and ultimately reduce risk of obesity and diabetes.

Food insecurity, overweight and obesity among low-income African-American families in Baltimore City: associations with food-related perceptions

OBJECTIVE

To examine associations between food insecurity, excess body weight, psychosocial factors and food behaviours among low-income African-American families.

DESIGN

Cross-sectional survey of participants in the baseline evaluation of the B'More Healthy Communities for Kids (BHCK) obesity prevention trial. We collected data on socio-economic factors, food source destinations, acquiring food, preparation methods, psychosocial factors, beliefs and attitudes, participation in food assistance programmes, anthropometry and food security. We used principal component analysis to identify patterns of food source destinations and logistic regression to examine associations.

SETTING

Fourteen low-income, predominantly African-American neighbourhoods in Baltimore City, MD, USA.

SUBJECTS

Two hundred and ninety-eight adult caregiver-child (10-14 years old) dyads.

RESULTS

Of households, 41·6 % had some level of food insecurity and 12·4 % experienced some level of hunger. Food-insecure participants with hunger were significantly more likely to be unemployed and to have lower incomes. We found high rates of excess body weight (overweight and obesity) among adults and children (82·8 % and 37·9 % among food insecure without hunger, 89·2 % and 45·9 % among food insecure with hunger, respectively), although there were no significant differences by food security status. Food source usage patterns, food acquisition, preparation, knowledge, self-efficacy and intentions did not differ by food security. Food security was associated with perceptions that healthy foods are affordable and convenient. Greater caregiver body satisfaction was associated with food insecurity and excess body weight.

CONCLUSIONS

In this setting, obesity and food insecurity are major problems. For many food-insecure families, perceptions of healthy foods may serve as additional barriers to their purchase and consumption.

Nutrition-based interventions to address metabolic syndrome in the Navajo: a systematic review

AIMS AND OBJECTIVES

The objective of this systematic review is to identify nutrition-based interventions that may be effective for the prevention and treatment of metabolic syndrome in the Navajo.

BACKGROUND

Metabolic syndrome, a major risk factor for cardiovascular disease, affects almost half of the Navajo population. The diet of the Navajo, heavy in fat and refined carbohydrates, has been identified as an important contributing factor to the high rates of metabolic syndrome in this population.

DESIGN

A search was conducted on PubMed, EMBASE and CINAHL to identify studies published before October, 2013, involving nutrition-based interventions in adult populations similar to the Navajo targeting at least one measure of metabolic syndrome.

METHODS

Data on efficacy and participation were gathered and synthesised qualitatively.

RESULTS

Out of 19 studies included in this systematic review, 11 interventions were identified to be effective at improving at least one measure of metabolic syndrome. Level of exposure to the intervention, frequency of intervention activities, family and social support, cultural adaptation and case management were identified as factors that may improve the efficacy of an intervention.

CONCLUSIONS

Multiple nutrition-based interventions have been found to be effective in populations similar to the Navajo.

RELEVANCE TO CLINICAL PRACTICE

Development of a strategy to address metabolic syndrome in the Navajo may involve aspects from multiple interventions to increase efficacy and maximise participation.