Assessing foods offered in the Food Distribution Program on Indian Reservations (FDPIR) using the Healthy Eating Index 2010

Associations of social determinants of health and childhood obesity: a cross-sectional analysis of the 2021 National Survey of Children's Health

CONTEXT

Childhood obesity is a growing health problem in the United States, with those affected having an increased likelihood of developing chronic diseases at a younger age. Social determinants of health (SDOH) are known to influence overall health. Families who are of low socioeconomic status (SES) have also been shown to be more likely to experience food insecurity.

OBJECTIVES

Our primary objective was to utilize the National Survey of Children's Health (NSCH) 2021 data to determine the current associations between childhood obesity and SDOH. Secondarily, we estimated the prevalence of select SDOH among children with obesity.

METHODS

We conducted a cross-sectional analysis of 2021 NSCH to extract data related to the SDOH domains. We extracted sociodemographic variables to utilize as controls and constructed logistic regression models to determine associations, via odds ratios, between SDOH and childhood obesity.

RESULTS

Within the binary regression models, children with obesity (≥95th percentile) were more likely than children without obesity to experience SDOH in all domains. After controlling for sociodemographic variables, children with obesity were significantly more likely to experience food insecurity when compared to children without obesity (adjusted odds ratio [AOR]=1.39; 95 % confidence interval [CI]: 1.13-1.17).

CONCLUSIONS

In line with the current American Academy of Pediatrics (AAP) Clinical Practice Guidelines (CPG), improving policies for nutrition programs and addressing the lack of access to nutritious foods may alleviate some food insecurity. Ensuring that children have access to sufficient nutritious foods is critical in addressing childhood obesity and thus decreasing risk of chronic disease.

Evaluation of US Department of Agriculture Foods Programs for Households Using Nutrition Guidelines for the Charitable Food System

BACKGROUND

US Department of Agriculture (USDA) Foods programs for households (ie, The Emergency Food Assistance Program, Food Distribution Program on Indian Reservations, and Commodity Supplemental Food Program) are designed to provide nutritious foods at no cost to income-eligible individuals in the United States.

OBJECTIVE

Our aim was to evaluate the nutritional quality of the foods available from 3 USDA Foods programs for households (ie, The Emergency Food Assistance Program, Food Distribution Program on Indian Reservations, and Commodity Supplemental Food Program) according to the Healthy Eating Research (HER) Guidelines for the Charitable Food System.

DESIGN

Review of the nutritional information of the foods available from USDA Foods programs for households was performed. Using the HER Guidelines, foods were categorized into a 3-tiered system (ie, choose often/green; choose sometimes/yellow; choose rarely/red) based on levels of saturated fat, sodium, and added sugar per serving, and presence of whole grains.

SETTING

All unique foods available from The Emergency Food Assistance Program, Food Distribution Program on Indian Reservations, and Commodity Supplemental Food Program (n = 152) for fiscal year 2022 were evaluated.

MAIN OUTCOME MEASURES

Nutritional quality of the foods available from USDA Foods programs for households according to the HER guidelines was measured. Foods were ranked green, yellow, red, or not ranked.

STATISTICAL ANALYSES PERFORMED

The proportion of foods in each HER Guidelines' rank was calculated across the 3 USDA Foods programs for households and by each program.

RESULTS

The majority of USDA Foods were ranked green (57.3%) or yellow (35.5%). A small number of items were ranked red (3.3%) or were unranked condiments or cooking staples (3.9%).

CONCLUSIONS

The USDA Foods available in the household programs were primarily fruits and vegetables; lean proteins; whole grains; and low-fat dairy products that were consistent with national dietary guidelines. There is some room for improvement, and adjustments in the specifications for certain items are recommended to strengthen the nutritional value of the foods provided through these important federal programs.

Supporting the Health and Well-Being of Indigenous Communities: A Position Paper From the American College of Physicians

Indigenous peoples in the United States experience many health disparities and barriers to accessing health care services. In addition, Indigenous communities experience poor social drivers of health, including disproportionately high rates of food insecurity, violence, and poverty, among others. These challenges are unsurprising, given historical societal discrimination toward Indigenous peoples and government policies of violence, forced relocation with loss of ancestral home, and erasure of cultures and traditions. Indigenous peoples have displayed resilience that has sustained their communities through these hardships. Through treaties between the federal government and Indigenous nations, the federal government has assumed a trust responsibility to provide for the health and well-being of Indigenous populations through the direct provision of health care services and financial support of tribally operated health systems. However, despite serving a population that has endured substantial historical trauma and subsequent health issues, federal programs serving Indigenous peoples receive inadequate federal funding and substantially fewer resources compared with other federal health care programs. Access to care is further challenged by geographic isolation and health care workforce vacancies. Given the history of Indigenous peoples in the United States and their treatment by the federal government and society, the American College of Physicians (ACP) asserts the federal government must faithfully execute its trust responsibility through increased funding and resources directed toward Indigenous communities and the undertaking of concerted policy efforts to support the health and well-being of Indigenous people. ACP believes that these efforts must be community-driven, Indigenous-led, and culturally appropriate and accepted, and center values of respect and self-determination.

A pragmatic randomized trial of home-based testing for COVID-19 in rural Native American and Latino communities: Protocol for the "Protecting our Communities" study

BACKGROUND

Home-based testing for COVID-19 has potential to reduce existing health care disparities among underserved populations in the United States. However, implementation of home-based tests in these communities may face significant barriers. This study evaluates the acceptability, feasibility, and success of home-based testing and the potential added benefit of active support from trusted community health workers for Native Americans and Hispanic/Latino adults living in rural Montana and Washington states.

METHODS/DESIGN

The academic-community research team designed the trial to be responsive to community needs for understanding barriers and supports to home-based COVID-19 testing. The "Protecting Our Community" study is a two-arm pragmatic randomized controlled trial in which a total of 400 participants are randomized to active or passive arms. Participants of both study arms receive a commercially available home collection COVID-19 test kit, which is completed by mailing a self-collected nasal swab to a central laboratory. The primary study outcome is return of the kit to the central lab within 14 days. The cultural, social, behavioral, and economic barriers to home-based COVID-19 testing are also assessed by qualitative research methods. A survey and semi-structured interviews are conducted after the trial to evaluate perceptions and experience of home-based testing.

DISCUSSION

Implementing home-based testing in underserved populations, including among Native American and Hispanic/Latino communities, may require additional support to be successful. The Protecting Our Community trial examines the effect of trusted community health workers on use of home-based testing, which may be adaptable for community-driven models of home-based testing in other underserved populations.

Social determinants of obesity in American Indian and Alaska Native peoples aged ≥ 50 years

OBJECTIVE

American Indian and Alaska Native peoples (AI/ANs) have a disproportionately high rate of obesity, but little is known about the social determinants of obesity among older AI/ANs. Thus, our study assessed social determinants of obesity in AI/ANs aged ≥ 50 years.

DESIGN

We conducted a cross-sectional analysis using multivariate generalized linear mixed models to identify social determinants associated with the risk of being classified as obese (BMI ≥ 30.0 kg/m2). Analyses were conducted for the total study population and stratified by median county poverty level.

SETTING

Indian Health Service (IHS) data for AI/ANs who used IHS services in FY2013.

PARTICIPANTS

27,696 AI/ANs aged ≥ 50 years without diabetes.

RESULTS

Mean BMI was 29.8 ± 6.6 with 43% classified as obese. Women were more likely to be obese than men, and younger ages were associated with higher obesity risk. While having Medicaid coverage was associated with lower odds of obesity, private health insurance was associated with higher odds. Living in areas with lower rates of educational attainment and longer drive times to primary care services were associated with higher odds of obesity. Those who lived in a county where a larger percentage of people had low access to a grocery store were significantly less likely to be obese.

CONCLUSIONS

Our findings contribute to the understanding of social determinants of obesity among older AI/ANs and highlight the need to investigate AI/AN obesity, including longitudinal studies with a life course perspective to further examine social determinants of obesity in older AI/ANs.

Journey to Promoting Structural Change for Chronic Disease Prevention: Examining the Processes for Developing Policy, Systems, and Environmental Supports in Native American Nations

Background

Obesity and chronic disease rates continue to be disproportionally high among Native Americans (NAs) compared with the US general population. Policy, systems, and environmental (PSE) changes can address the root causes of these health inequalities by supporting access to healthy food and physical activity resources.

Objective

We aim to describe the actors and processes involved in developing PSE changes supporting obesity prevention in NA Nations.

Methods

As part of the Obesity Prevention Research and Evaluation of InterVention Effectiveness in NaTive North Americans 2 (OPREVENT2) trial (ClinicalTrials.gov registration: NCT02803853), we collected 46 in-depth interviews, 1 modified Talking Circle, 2 workshops, and 14 observations in 3 NA communities in the Midwest and Southwest regions of the United States. Participants included Tribal government representatives/staff, health staff/board members, store managers/staff, and school administrators/staff. We used a Grounded Theory analysis protocol to develop themes and conceptual framework based on our data.

Results

Health staff members were influential in identifying and developing PSE changes when there was a strong relationship between the Tribal Council and health department leaders. We found that Tribal Council members looked to health staff for their expertise and were involved in the approval and endorsement of PSE changes. Tribal grant writers worked across departments to leverage existing initiatives, funding, and approvals to achieve PSE changes. Participants emphasized that community engagement was a necessary input for developing PSE changes, suggesting an important role for grassroots collaboration with community members and staff. Relevant contextual factors impacting the PSE change development included historical trauma, perspectives of policy, and "tribal politics".

Conclusions

This article is the first to produce a conceptual framework using 3 different NA communities, which is an important gap to be addressed if structural changes are to be explored and enacted to promote NA health. The journey to change for these NA Nations provides insights for promoting future PSE change among NA Nations and communities.

Healthy Eating Index-2015 Scores Vary by Types of Food Outlets in the United States

Diet quality in the United States is improving over time but remains poor. Food outlets influence diet quality and represent the environments in which individuals make choices about food purchases and intake. The objective of this study was to use the Healthy Eating Index-2015 (HEI-2015) to evaluate the quality of foods consumed from the four major outlets where food is obtained—stores, full-service restaurants, quick-services restaurants, and schools—and to assess changes over time. This cross-sectional study used 24 h dietary recall data from eight cycles (2003–2004 to 2017–2018) of the National Health and Nutrition Examination Survey (NHANES). Linear trend estimation was used to test for changes in HEI scores over time, and balanced repeated replicate weighted linear regression was used to test for differences in total and component scores between types of food outlets. Overall, Americans are not consuming a mix of foods from any major category of food outlet that aligns with dietary guidelines. The total score for schools (65/100 points) and stores (62/100 points) was significantly higher than full-service (51/100 points) and quick-service (39/100 points) restaurants (p < 0.0001). HEI scores significantly improved over time for schools (p < 0.001), including an increase in whole grains from less than 1 point in 2003–2004 to 7 out of 10 points in 2017–2018. In 2017–2018, schools received the maximum score for total fruits, whole fruits, and dairy. Continued research on strategies for improving the quality of foods consumed from restaurants and stores is warranted.

Enacting Treaty Rights through Restoring Shoshone Ancestral Foods on the Wind River Indian Reservation

Despite great loss in gathering and consumption of traditional foods among Indigenous communities, there is great hope for reclaiming and preserving knowledge. The Restoring Shoshone Ancestral Food Gathering (RSAFG) is a community group leading grassroots efforts on the Wind River reservation to reclaim Shoshone ancestral foods and promote food sovereignty. The story of the RSAFG promotes equitable, decolonized, and community empowered methods of reclaiming Indigenous foods by sharing three of RSAFG's acts of decolonization: 1) enacting treaty rights through gathering traditional plants, 2) demanding equitable partnerships in community-based research, and 3) sharing the story through radical authorship via layered narratives. A pesar de la gran pérdida en la recolección y el consumo de alimentos tradicionales entre las comunidades indígenas, existe una gran esperanza para recuperar y preservar el conocimiento. El Restoring Shoshone Ancestral Food Gathering (RSAFG) es un grupo comunitario que lidera los esfuerzos de base en la reserva wind river para recuperar los alimentos ancestrales shoshone y promover la soberanía alimentaria. La historia de la RSAFG promueve métodos equitativos, descolonizados y empoderados por la comunidad para recuperar los alimentos indígenas al compartir tres de los actos de descolonización de RSAFG: 1) promulgar los derechos de los tratados mediante la recolección de plantas tradicionales, 2) exigir asociaciones equitativas en la investigación basada en la comunidad, y 3) compartir la historia a través de la autoría radical a través de narrativas en capas.

The effects of foods available through the Food Distribution Program on Indian Reservations (FDPIR) on inflammation response, appetite and energy intake

OBJECTIVE

To compare the effects of a typical Food Distribution Program on Indian Reservations (FDPIR) diet with an FDPIR diet that meets Dietary Guidelines for Americans (DGA) on inflammation response, appetite and energy intake on a combination of American Indian (AI) and non-AI individuals.

DESIGN

A within-subjects, randomised, crossover design was used to compare two dietary conditions: (1) a FDPIR diet that met DGA and (2) a FDPIR diet that did not meet DGA. Each participant served as their own control and was exposed to both dietary conditions. Repeated-measures ANOVA and t tests assessed significance between the two dietary conditions.

SETTING

This took place in the Montana State University Nutrition Research Laboratory in the USA.

PARTICIPANTS

Female and male participants (n 13) aged 18-55 years from the university and local community.

RESULTS

There were no significant differences in inflammatory response and appetite sensations between the two dietary conditions. Findings indicated that participants ate 14 % more (P < 0·01) kcal on a typical FDPIR diet compared with a FDPIR diet that met DGA.

CONCLUSIONS

Higher energy intake during a typical FDPIR diet compared with a FDPIR diet that meets DGA may increase risk for obesity and nutrition-related diseases, including type 2 diabetes and other chronic inflammatory conditions.

Pilot Trial of Acceptance-Based Behavioral Weight Loss and Neurocognition Among American Indians

Acceptance-based behavioral therapies (ABTs) for obesity may be superior to standard behavioral therapies but have not been adequately tested with American Indians (AIs). Neurocognitive function is also unexamined in relation to behavioral weight loss among AIs despite findings that neurocognition predicts outcomes in general samples, may help explain some of the benefits of ABTs, and may be relevant to marginalized groups. The primary objective of this pilot was to examine the feasibility/acceptability of ABT in an AI sample. Exploratory analyses examined the relationship between neurocognition and weight loss. Forty-eight AI adults with overweight/obesity (ages 43.3 ± 10.3 years, 85% female; baseline body mass index = 36.8 ± 4.4 kg/m²) enrolled in a 6-month open ABT weight loss trial. Feasibility indices, including screening/enrollment, session attendance, retention rates for posttreatment assessments, and program acceptability were examined. Percent weight loss (%WL) was assessed as well as fluid and crystalized neurocognition (National Institutes of Health Toolbox Cognition Battery [NIHTB-CB]). We enrolled 79% of the eligible sample and retained 75% (N = 36) at posttreatment assessments. Program completers lost an average of 5.2 ± 4.9% of initial body weight (d_z = 1.14), whereas intent-to-treat analyses show a mean loss of 4.1 ± 4.7%. Participants reported high satisfaction, effectiveness, and cultural appropriateness. Exploratory analyses of neurocognitive domains suggested that crystalized cognition was higher among completers, and higher baseline cognitive flexibility predicted greater %WL (β = .34, p = .05). ABT resulted in clinically significant weight loss in an AI sample. A controlled trial of ABT in a larger, more diverse sample is warranted to determine whether (a) the findings are robust, generalizable, and/or superior to other treatments and (b) neurocognitive factors moderate outcomes.

Dietary Quality Varies Among Adults on the Flathead Nation of the Confederated Salish and Kootenai Tribes in Montana

Diet-related chronic disease is among the most pressing public health issues and represents a health disparity among Native American communities. A community-based participatory approach was taken to evaluate dietary quality of adult residents of the Flathead Reservation of the Confederated Salish & Kootenai Tribes in Montana (the Flathead Nation). A survey was administered to collect basic demographic information and food security status (N = 80). Dietary quality was assessed using the 24-h dietary recall method with subsequent calculation of Healthy Eating Index 2010 (HEI-2010) scores, modified HEI without a dairy category, and the Dietary Diversity Scores (DDS). Participants included 80 adults from different households across eight communities (n = 10 per community) at the Flathead Nation. Approximately 50% of participants reported low or very low food security status while the remainder scored high or marginal food security. The mean total HEI-2010 score of study participants was 45.5 out of 100 points with a range between 20.0 and 78.1. The mean DDS of study participants was 4.6 (± 1.365) out of a total of 9 points. Participants with higher DDS had significantly higher intake of dietary fiber (p < 0.0003), potassium (0.0024), and cholesterol (p < 0.0048) compared to the lower DDS group. No significant correlations were found between HEI-2010 scores with DDS, demographic information, or food security status while significant differences were found between food security status and income (p < 0.01) and enrollment in nutrition assistance programs (p < 0.03). This study highlights the need to evaluate multiple parameters of dietary quality coupled with a community-based participatory approach in order for findings to be culturally relevant and support food and nutrition interventions.

Perceptions of food environments and nutrition among residents of the Flathead Indian Reservation

BACKGROUND

Indigenous food systems have been displaced with the emergence of colonization, industrialization, and cultural, economic, political, and environmental changes. This disruption can be seen in marked health and food environment disparities that contribute to high obesity and diabetes mellitus prevalence among Native American peoples.

METHODS

A Community-Based Participatory Research (CBPR) approach was used to document food environment experiences among residents of the Flathead Reservation in rural Montana. Participants were identified using purposive sampling techniques to participate in a survey and a semi-structured interview. Descriptive statistics helped to describe participant demographics, food access variables, and household food security status. Food environment perceptions were analyzed using the constant comparison method among trained researchers.

RESULTS

Participants completed surveys (n = 79) and interviews (n = 76). A large number participated in federal nutrition assistance programs. Many self-reported experiencing diet-related chronic diseases. Major themes included the community food environment, dietary norms, and food-health connections. Subthemes were represented by perceptions of food environment transitions and the important role of food in familial life. Further, opportunities and challenges were identified for improving community food environments.

CONCLUSIONS

Perceptions of the food environment were linked to strategies that could be targeted to improve dietary quality along a social-ecological model continuum. There is need for skill-based education that directly addresses the time and monetary constraints that were commonly experienced by residents. Coinciding food environment interventions to promote dietary quality that engage community members, store management, and government policy stakeholders are also needed to reestablish healthy Native American food systems and environments within this community.

Rural Counties With Majority Black Or Indigenous Populations Suffer The Highest Rates Of Premature Death In The US

Despite well-documented health disparities by rurality and race/ethnicity, research investigating racial/ethnic health differences among US rural residents is limited. We used county-level data to measure and compare premature death rates in rural counties by each county's majority racial/ethnic group. Premature death rates were significantly higher in rural counties with a majority of non-Hispanic black or American Indian/Alaska Native (AI/AN) residents than in rural counties with a majority of non-Hispanic white residents. After we adjusted for community-level covariates, differences in premature death remained significant in counties with a majority of AI/AN residents but not those with a majority of non-Hispanic black residents. This study highlights the particular vulnerability of non-Hispanic black and AI/AN rural communities to high rates of premature mortality. Policies to improve rural health should focus on these racially diverse communities, addressing economic vitality and current and historical political context to mitigate health inequities and the harmful health effects of neglecting social determinants of health.

Developing an Indigenous Goal-Setting Tool: Counting Coup

Chronic illness self-management best practices include goal-setting; however, the goal theory that many tools employ relies on individualistic principles of self-efficacy that are not culturally consonant within many Indigenous communities. During the creation of the Báa nnilah program, a chronic illness self-management intervention, we developed a goal-setting tool specific to the Apsáalooke Nation. Emerging from an Indigenous paradigm and methodology, Counting Coup serves as a goal-setting tool that promotes the Apsáalooke culture, connects individuals with their ancestors, and focuses on achievement of goals within relationships. Future research and practice should be grounded in the historical and cultural contexts of local communities when designing and implementing goal-setting tools. Limitations to Counting Coup as a goal-setting tool include the need for program facilitators to have a relationship with participants due to Counting Coup's foundation in relational accountability and that the environmental context may pose difficulties for participants in moving towards healthy behavior change.

The Retail Food Environment, Store Foods, and Diet and Health among Indigenous Populations: a Scoping Review

PURPOSE OF THE REVIEW

Describe the state of knowledge on how the retail food environment contributes to diet-related health and obesity among Indigenous populations, and assess how the literature incorporates Indigenous perspectives, methodologies and engagement throughout the research process. Outcomes included dietary behaviour (purchasing, intakes and diet quality) and diet-related health outcomes (weight-related outcomes, non-communicable diseases and holistic health or definitions of health as defined by Indigenous populations involved in the study).

RECENT FINDINGS

Of fifty included articles (1996-2019), the largest proportions described Indigenous communities in Canada (20 studies, 40%), the USA (16, 32%) and Australia (9, 18%). Among articles that specified the Indigenous population of focus (42 studies, 84%), the largest proportion (11 studies, 26%) took place in Inuit communities, followed by Aboriginal and Torres Strait Islander communities (8 studies, 19%). The included literature encompassed four main study designs: type A, dietary intakes of store foods (14 studies, 28%), and type B, store food environments (16, 32%), comprised the greatest proportion of articles; the remainder were type C, store food environments and diet (7, 14%), and type D, store food environment interventions (13, 26%). Of the studies that assessed diet or health outcomes (36, 72%), 22 (61%) assessed dietary intakes; 16 (44%) sales/purchasing; and 8 (22%) weight-related outcomes. Store foods tended to contribute the greatest amount of dietary energy to the diets of Indigenous peoples and increased non-communicable disease risk as compared to traditional foods. Multi-pronged interventions appeared to have positive impacts on dietary behaviours, food purchasing and nutrition knowledge; promotion and nutrition education alone had more mixed effects. Of the nine studies which were found to have strong engagement with Indigenous populations, eight had moderate or high methodological quality. Eighteen studies (36%) did not mention any engagement with Indigenous populations. The literature confirmed the importance of store foods to the total energy intake of the contemporary diets of Indigenous people, the gaps in accessing both retail food environments and traditional foods and the potential for both new dietary assessment research and retail food environment intervention strategies to better align with and privilege Indigenous Ways of Knowing.

Intended and Unintended Consequences of a Community-Based Fresh Fruit and Vegetable Dietary Intervention on the Flathead Reservation of the Confederated Salish and Kootenai Tribes

Tribal communities in the United States face disparities to accessing healthy foods including high-quality produce. A six-week fresh fruit and vegetable (FV) dietary intervention, Eat Fresh, was co-designed with a Community Advisory Board of local food and nutrition stakeholders on the Flathead Reservation of the Confederated Salish and Kootenai Tribes in Montana. Eat Fresh was implemented as a pilot study with low-income participants (n = 19) enrolled in the Food Distribution Program on Indian Reservations toward improving dietary quality and perceptions of well-being. We evaluated Eat Fresh at pre- and post-intervention on the basis on food procurement practices, dietary quality using the Healthy Eating Index (HEI), Body Mass Index (BMI), blood pressure, and participant perceptions of health. Participants reported consuming a greater number of types of FVs daily during the intervention (p < 0.005 for fruits and p > 0.19 for vegetables). Overall, participants found Eat Fresh moderately challenging to adhere to with the main barriers being access to ingredients in recipes (39.51% of responses), time constraints to cook (35.80%), and lack of financial resources (33.33%). Dietary quality improved during the intervention from a mean HEI score of 48.82 (± 11.88) out of 100-56.92 (± 11.88; (p > 0.12). HEI scores for fruit consumption significantly increased (p < 0.05) from 1.69 (out of 5 points) during the pre-intervention to 2.96 during the post-intervention. BMI and blood pressure increased for several participants, highlighting an unintended consequence. Most participants responded that FV consumption made them feel either very good (51.16%) or good about their health (43.02%) with the majority (83%) perceiving an improvement in energy. Findings of this pilot study highlight both intended and unintended consequences of a dietary intervention that provide lessons in co-designing community-based programs.

Food Environment Typology: Advancing an Expanded Definition, Framework, and Methodological Approach for Improved Characterization of Wild, Cultivated, and Built Food Environments toward Sustainable Diets

The food environment is a critical place in the food system to implement interventions to support sustainable diets and address the global syndemic of obesity, undernutrition, and climate change, because it contains the total scope of options within which consumers make decisions about which foods to acquire and consume. In this paper, we build on existing definitions of the food environment, and provide an expanded definition that includes the parameter of sustainability properties of foods and beverages, in order to integrate linkages between food environments and sustainable diets. We further provide a graphical representation of the food environment using a socio-ecological framework. Next, we provide a typology with descriptions of the different types of food environments that consumers have access to in low-, middle-, and high-income countries including wild, cultivated, and built food environments. We characterize the availability, affordability, convenience, promotion and quality (previously termed desirability), and sustainability properties of food and beverages for each food environment type. Lastly, we identify a methodological approach with potential objective and subjective tools and metrics for measuring the different properties of various types of food environments. The definition, framework, typology, and methodological toolbox presented here are intended to facilitate scholars and practitioners to identify entry points in the food environment for implementing and evaluating interventions that support sustainable diets for enhancing human and planetary health.

Latent Class Analysis Offers Insight into the Complex Food Environments of Native American Communities: Findings from the Randomly Selected OPREVENT2 Trial Baseline Sample

Native Americans (NAs) experience a high burden of obesity and diabetes, yet previous research has not holistically described the unique food environments of NA communities. The objective of this paper is to describe the subgroups and demographic characteristics related to NA household food environments. Surveys collected food getting, food assistance, and sociodemographic variables from randomly selected adults from three NA communities (n = 300) in the Midwest and Southwest. Exploratory latent class analysis (LCA) identified the appropriate number of subgroups based on indicator responses. After assigning participants to classes, demographic differences were examined using bivariate analyses. NA household food environments could be described using two subgroups (“lower” and “higher access household food environments”). The “lower access” group had significantly higher age, smaller household size, and fewer children per household than the “higher access” group, while body mass index (BMI) did not significantly vary. This is the first LCA of NA household food environments and highlights the need for approaches that characterize the complexity of these environments. Findings demonstrate that NA household food environments can be described by developing subgroups based on patterns of market and traditional food getting, and food assistance utilization. Understanding NA household food environments could identify tailored individual and community-level approaches to promoting healthy eating for NA Nations.

Advancing healthy and sustainable food environments: The Flathead Reservation case study

This case study describes a methodological approach to evaluating and improving food environments in an indigenous community in the United States of America. A community-research partnership was developed to support healthy diets from sustainable food systems. Our team implemented complementary methodologies to evaluate multiple dimensions of the food environment, including food availability, convenience, affordability and desirability. Our findings were used to design and implement multiphase food-environment interventions that elucidated the following: (1) food-environment measurements should be multifaceted and context-specific; (2) food desirability, including sensory attributes, diversity and phytonutrient quality, are important but overlooked aspects of the food environment; (3) successful food-environment interventions are community-based and incremental; (4) food-environment interventions should seek to forge links with existing institutional structures to influence policy; and (5) findings from food-environment interventions should be disseminated in various ways to diverse stakeholders.

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.

Social Determinants of American Indian Nutritional Health

The American Indian (AI) population suffers from significant health disparities, including nutrition-related chronic diseases (diabetes, cancer, and heart disease). Several risk factors for disease and social determinants of health have unique histories in the AI population, including historical trauma, boarding schools, adverse childhood experiences, poverty, federal food programs, and food deserts. To effectively address these disparities, a multipronged approach in collaboration with stakeholders is needed to address the upstream social determinants of health and to increase access to healthier foods. Promising practices and strategies can be considered in several focus areas, including 1) improving existing food programs, 2) promoting breastfeeding and early childhood nutrition, 3) promoting food sovereignty and access to traditional foods, 4) expanding locally cultivated foods, and 5) taxing unhealthy foods and subsidizing healthier options. As these strategies are implemented, it is vital that they are studied, evaluated, and reported to expand tribally specific evidence-based practices.

Diet Quality of Pregnant American Indian Women in the Northern Plains

INTRODUCTION

We examined diet quality and intake of pregnancy-specific micronutrients among pregnant American Indian women in the Northern Plains.

METHODS

We conducted an analysis of nutrition data from the Prenatal Alcohol and SIDS and Stillbirth (PASS) Network Safe Passage Study and the PASS Diet Screener study (N = 170). Diet intake, including dietary supplementation, was assessed by using three 24-hour recalls conducted on randomly selected, nonconsecutive days. Diet intake data were averaged across the participant's recalls and scored for 2 dietary indices: the Healthy Eating Index 2010 (HEI-2010) and the Alternate Healthy Eating Index for Pregnancy (AHEI-P). We also assessed nutrient adequacy with Dietary Reference Intakes for pregnancy.

RESULTS

On average, participants were aged 26.9 (standard deviation [SD], 5.5) years with a pre-pregnancy body mass index of 29.8 (SD, 7.5) kg/m2. Mean AHEI-P and HEI-2010 scores (52.0 [SD, 9.0] and 49.2 [SD, 11.1], respectively) indicated inadequate adherence to dietary recommendations. Micronutrient intake for vitamins D and K, choline, calcium, and potassium were lower than recommended, and sodium intake was higher than recommended.

CONCLUSION

Our findings that pregnant American Indian women are not adhering to dietary recommendations is consistent with studies in other US populations. Identifying opportunities to partner with American Indian communities is necessary to ensure effective and sustainable interventions to promote access to and consumption of foods and beverages that support the adherence to recommended dietary guidelines during pregnancy.

The Impact of Individual and Parental American Indian Boarding School Attendance on Chronic Physical Health of Northern Plains Tribes

This study investigated the relationship of American Indian boarding school attendance and chronic physical health. We hypothesized boarding school attendance would be associated with an increased number of chronic physical health problems. We also examined the relationship between boarding school attendance and the 15 chronic health problems that formed the count of the chronic health conditions. American Indian attendees had a greater count of chronic physical health problems compared with nonattendees. Father's attendance was independently associated with chronic physical health problems. Attendees were more likely to have tuberculosis, arthritis, diabetes, anemia, high cholesterol, gall bladder disease, and cancer than nonattendees.