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

"We have to … work for wholeness no matter what": Family and culture promoting wellness, resilience, and transcendence

Sociocultural, mental, behavioral, and physical factors are interrelated associates of chronic health conditions-such as diabetes, obesity, and cardiovascular disease-all of which are disproportionally high and drive much of the mortality and morbidity for Indigenous peoples. Indigenous worldviews conceptualize health holistically, with inseparability across social, spiritual, cultural, familial, mental, behavioral, physical, and social dimensions of wellness. Food, family, and culture are fundamental to Indigenous wellness. The purpose of this article is to use the Framework of Historical Oppression, Resilience, and Transcendence (FHORT) conceptualization of relational wellness to honor urban and rural U.S. Indigenous perspectives that highlight the intersections of family, culture, physical health, spiritual, and mental health to promote resilience and wellness. This research focused on interconnections between wellness, culture, health, and family. Thirty-one critical ethnographic interviews used a life-history approach with methodology following an Indigenous toolkit for ethical and culturally sensitive research strategies, such as building upon cultural strengths, engaging in long-term, relational commitments with communities, incorporating storytelling and oral history traditions, centering Indigenous methodologies and preferences, working with cultural insiders, and prioritizing the perspectives of Indigenous peoples. Emergent themes included: (a) roots of Indigenous wellness: cultural values promoting balance and connection; (b) practicing resilience: family transmission of health information; and (c) wholistic mental wellness and resilience, with the subtheme culture and wellness. Interventions can be developed in collaboration with tribes for optimum efficacy and cultural relevancy and can approach wellness holistically in culturally relevant ways that center foodways, culture, family, and spirituality.

"Take care of your families, take care of one another": Indigenist families and foodways

Objective

The purpose of this research was to examine how families and foodways have evolved over time and how they may present promising promotive factors for resilience, health, and wellness.

Background

Because food is central to family, social relationships, and healthy living, Indigenist foodways may promote family resilience and offset inequities.

Method

Pragmatic horizon analysis of data drawn from 31 critical ethnographic interviews on food and family in the Southeast and Northwest, including both urban and rural reservation tribal contexts, resulted in emergent themes related to food and families.

Results

Themes included (a) foodways fostering family connectedness: "The fresh vegetable is how I remember my grandpa"; (b) tight-knit extended families and communities: "The community where I grew up … everybody knew each other, so everybody … pitched in"; (c) family and community celebrations nurturing cohesion: "The family I have, I can always count on. I can trust each one of them"; and (d) families fostering healing: "Sit down and talk to somebody … that you can trust."

Conclusion

Participants explained how foodways promoted family resilience by bringing families and communities together. Indigenist foodways fostered continuity and healing through food preparation and processing and through feasts and gatherings.

Implications

Foodways were described as fundamental to family resilience and community connectedness. Subsistence fostered exercise, eating locally sourced foods, and family resilience. Interventions are needed to promote Indigenist foodway sovereignty while first understanding how culture, history, and food inform wellness and community well-being.

Cardiometabolic risk among rural Native American adults in a large multilevel multicomponent intervention trial

This cross-sectional analysis of the baseline evaluation sample of the Obesity Prevention and Evaluation of InterVention Effectiveness in Native Americans 2 (OPREVENT2) study included 601 Native American adults ages 18-75 living in rural reservation communities in the Midwest and Southwest United States. Participants completed a self-report questionnaire for individual and family history of hypertension, heart disease, diabetes and obestiy. Body mass index (BMI), percent body fat, and blood pressure were measured by trained research staff. About 60% of respondents had a BMI >30 kg/m2. Approximately 80% had a waist-to-hip ratio and percent body fat classified as high risk, and nearly 64% had a high-risk blood pressure measurement. Although a large proportion of participants reported a family history of chronic disease and had measurements that indicated elevated risk, relatively few had a self-reported diagnosis of any chronic disease. Future studies should examine potential connections between healthcare access and discordance in self-reported versus measured disease risks and diagnoses.

A Qualitative Evaluation of a Community-Based Intervention on Health-Related Behaviors in Disadvantaged Women

Purpose: Grounded in social ecological model and self-determination theory, the aim of this study was to qualitatively evaluate the first and second year follow-ups of a community-based healthy lifestyle programme on health-related behaviors, and outcomes in disadvantaged adult women. Methods: Eleven disadvantaged adult women (M = 37.72; SD = 8.34) (seven of them from the Roma population) participated in this community-based participatory action research. Discussion groups, semi-structured interviews, and field notes were used to assess the effects of the intervention programme on health-related behaviors and health outcomes through thematic analysis. Results: Women perceived improvements in PA-related variables, healthy eating, and other health-related outcomes throughout two years. Most women mentioned these behavior changes in the first year, while others perceived them in the second year. Conclusions: These findings highlight the importance of developing contextual and culturally tailored interventions that address the specific problems and needs that emerge from ethnic groups. Given that some of these behavior changes were only mentioned by most of these women in the second year, long-term interventions seem to be ideally required in this population.

"I don't remember any of us … having diabetes or cancer": How historical oppression undermines indigenous foodways, health, and wellness

Past and present structures of settler colonial historical oppression aimed to erase and replace Indigenous peoples have profoundly disrupted U.S. Indigenous foodways. The purpose of this article is to use the Indigenous Framework of Historical Oppression, Resilience, and Transcendence (FHORT) to understand U.S. Indigenous peoples' experiences and perceptions of how (a) foodways have changed within the context of settler colonial historical oppression and (b) these changes have affected wellness and cultures of Indigenous peoples. Critical ethnographic analysis focused on data from 31 interviews with participants from a rural Southeast reservation and a Northwest urban context. Results revealed participants' descriptions of changing foodways situated in a system of historical oppression, with themes including (a) historical oppression and changing values and foodway practices; (b) settler colonial governmental programs interrupting foodways through commodities and rations; and (c) changing foodway practices: from homegrown and homemade to fast food and premade. Participants described the aftermath of settler colonial governmental policies and programs undermined foodways, connectedness, cultural knowledge, family and interpersonal relationships, ceremonies, and outdoor activities-all of which promote health and wellness. To redress historical oppression, including settler colonial governmental policies, decolonized decision-making, foodways, and Indigenous food sovereignty are recommended as approaches to inform policy and programming that affirms Indigenous values and worldviews.

The prevalence and socio-demographic associations of household food insecurity in seven slum sites across Nigeria, Kenya, Pakistan, and Bangladesh. A cross-sectional study

Although the proportion of people living in slums is increasing in low- and middle-income countries and food insecurity is considered a severe hazard for health, there is little research on this topic. This study investigated and compared the prevalence and socio-demographic associations of household food insecurity in seven slum settings across Nigeria, Kenya, Pakistan, and Bangladesh. Data were taken from a cross-sectional, household-based, spatially referenced survey conducted between December 2018 and June 2020. Household characteristics and the extent and distribution of food insecurity across sites was established using descriptive statistics. Multivariable logistic regression of data in a pooled model including all slums (adjusting for slum site) and site-specific analyses were conducted. In total, a sample of 6,111 households were included. Forty-one per cent (2,671) of all households reported food insecurity, with varying levels between the different slums (9-69%). Household head working status and national wealth quintiles were consistently found to be associated with household food security in the pooled analysis (OR: 0·82; CI: 0·69-0·98 & OR: 0·65; CI: 0·57-0·75) and in the individual sites. Households which owned agricultural land (OR: 0·80; CI: 0·69-0·94) were less likely to report food insecurity. The association of the household head's migration status with food insecurity varied considerably between sites. We found a high prevalence of household food insecurity which varied across slum sites and household characteristics. Food security in slum settings needs context-specific interventions and further causal clarification.

"We were always doing something outside. … I had a wonderful, wonderful life": U.S. Indigenous peoples' subsistence, physical activity, and the natural world

Obesity tends to be higher, whereas physical activity (PA) tends to be lower for U.S. Indigenous peoples, which drives chronic health problems and mortality. Historical oppression and nutritional colonialism have disrupted Indigenous peoples' subsistence and concomitant PA. The purpose of this research is to use the framework of historical oppression, resilience, and transcendence (FHORT) with 31 participants in a critical ethnography identifying past and present forms of PA. By examining universal themes across two tribal contexts-a Southeast reservation tribal context and an urban Northwestern context-important knowledge about promising forms of PA can inform culturally relevant and effective interventions to promote health and prevent obesity and chronic health problems. Reconstructive thematic qualitative analysis resulted in the following themes: (a) Family-Centered Physical Activity: "The Kids Would … Follow Along, Dropping Seeds and Covering it … the Seeds Grew"; (b) Staying Active in the Natural World: "When I Would Go Home [from boarding school] in the Summertime, That's When … We'll Be Back Being an Indian"; (c) Staying Active through Culture: "The Traditional Dancing … [is] a Form of Exercise"; (d) Mental Wellness in Nature: "It Seemed Like Just Sitting Out There Makes You Feel Better"; and (e) Sports and Competitions Fostering PA: "A lot … Prefer Playing Softball, Basketball, Volleyball, Nowadays". Results highlighted how participants preferred and participated in subsistence and PA growing up, how this had evolved over time, and how being outside in nature contributed to a sense of wellness and overall health.

Associations Between Rurality, pre-pregnancy Health Status, and Macrosomia in American Indian/Alaska Native Populations

OBJECTIVES

To examine the relationships between pre-pregnancy diabetes mellitus (DM), gestational diabetes mellitus (GDM), pre-pregnancy body mass index (BMI) and county-level social determinants of health, with infant macrosomia within a sample of American Indian/Alaska Native (AI/AN) women receiving Indian Health Service (IHS) care.

METHODS

The sample included women-infant dyads representing 1,136 singleton births from fiscal year 2011 (10/1/2019-9/30/2011). Data stemmed from the IHS Improving Health Care Delivery Data Project. Multivariate generalized linear mixed models were fitted to assess the association of macrosomia with pre-pregnancy health status and social determinants of health.

RESULTS

Nearly half of the women in the sample were under age 25 years (48.6%), and most had Medicaid health insurance coverage (76.7%). Of those with a pre-pregnancy BMI measure, 66.2% were overweight or obese. Although few women had pre-pregnancy DM (4.0%), GDM was present in 12.8% of women. Most women had a normal term delivery (85.4%). Overweight, obesity, pre-pregnancy DM, and county-level rurality were all significantly associated with higher odds of infant macrosomia.

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.

Physical Activity Interventions Among American Indian and Alaska Native Persons: A Systematic Review

OBJECTIVE

The purpose of this review was to identify and describe physical activity (PA) interventions that have been implemented with American Indian and Alaska Natives (AIANs) in the U.S. and Canada since 2006.

DATA SOURCE

Searches were conducted in 8 databases plus grey literature sources.

STUDY INCLUSION AND EXCLUSION CRITERIA

Eligible studies: (a) described an intervention designed to increase PA; (b) targeted AIANs residing in the U.S. or Canada, or if a multiethnic population, contained an AIAN subanalysis; (c) were published in 2006 or later; and (d) reported a PA outcome.

DATA EXTRACTION

Two reviewers independently extracted data, with conflicts resolved through discussion.

DATA SYNTHESIS

Data were synthesized by participant characteristics, intervention strategies, PA outcomes, and impact.

RESULTS

We identified 25 eligible studies, most targeting children and youth. Intergenerational, environmental policy, cultural adaptation, and curriculum-based approaches were used. Twenty studies used self-reported PA measures. 80% of studies used an element of cultural adaptation, mostly considering cultural needs in design, not program or outcome evaluation. Sedentary behavior and leisure-time PA were rarely assessed. Significant changes in PA outcomes were achieved post-intervention in 13 studies (52%).

CONCLUSION

Future interventions should target AIAN adults to evaluate sedentary behavior and leisure-time PA. Interventions should incorporate psychometrically tested objective measures and prioritize the Native perspective from intervention design through project evaluation.

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.

A multi-level, multi-component obesity intervention (Obesity Prevention and Evaluation of InterVention Effectiveness in NaTive North Americans) decreases soda intake in Native American adults

OBJECTIVE

To evaluate the impact of a multi-level, multi-component (MLMC) adult obesity intervention on beverage intake in Native American adults living in five geographically and culturally diverse tribal communities.

DESIGN

A 14-month, community-randomised, MLMC design was utilised, with three communities randomised to Intervention and two communities randomised to Comparison. FFQ were administered pre- and post-interventions, and difference-in-differences (DiD) analysis was used to assess intervention impact on beverage intake.

SETTING

The intervention took place within food stores, worksites, schools and selected media outlets located in the five communities. Key activities included working with store owners to stock healthy beverages, display and dispersal of educational materials, support of policies that discouraged unhealthy beverage consumption at worksites and schools and taste tests.

PARTICIPANTS

Data were collected from 422 respondents between the ages of 18 and 75 living in the five communities pre-intervention; of those, 299 completed post-intervention surveys. Only respondents completing both pre- and post-intervention surveys were included in the current analysis.

RESULTS

The DiD for daily servings of regular, sugar-sweetened soda from pre- to post-intervention was significant, indicating a significant decrease in Intervention communities (P < 0·05). No other changes to beverage intake were observed.

CONCLUSIONS

Large, MLMC obesity interventions can successfully reduce the intake of regular, sugar-sweetened soda in Native American adults. This is important within modern food environments where sugar-sweetened beverages are a primary source of added sugars in Native American diets.

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.

Cultural adaptation of health interventions including a nutrition component in Indigenous peoples: a systematic scoping review

BACKGROUND

Indigenous populations throughout the world experience poorer health outcomes than non-indigenous people. The reasons for the health disparities are complex and due in part to historical treatment of Indigenous groups through colonisation. Evidence-based interventions aimed at improving health in this population need to be culturally safe. However, the extent to which cultural adaptation strategies are incorporated into the design and implementation of nutrition interventions designed for Indigenous peoples is unknown. The aim of this scoping review was to explore the cultural adaptation strategies used in the delivery of nutrition interventions for Indigenous populations worldwide.

METHODS

Five health and medical databases were searched to January 2020. Interventions that included a nutrition component aimed at improving health outcomes among Indigenous populations that described strategies to enhance cultural relevance were included. The level of each cultural adaptation was categorised as evidential, visual, linguistic, constituent involving and/or socio-cultural with further classification related to cultural sensitivity (surface or deep).

RESULTS

Of the 1745 unique records screened, 98 articles describing 66 unique interventions met the inclusion criteria, and were included in the synthesis. The majority of articles reported on interventions conducted in the USA, Canada and Australia, were conducted in the previous 10 years (n = 36) and focused on type 2 diabetes prevention (n = 19) or management (n = 7). Of the 66 interventions, the majority included more than one strategy to culturally tailor the intervention, combining surface and deep level adaptation approaches (n = 51), however, less than half involved Indigenous constituents at a deep level (n = 31). Visual adaptation strategies were the most commonly reported (n = 57).

CONCLUSION

This paper is the first to characterise cultural adaptation strategies used in health interventions with a nutrition component for Indigenous peoples. While the majority used multiple cultural adaptation strategies, few focused on involving Indigenous constituents at a deep level. Future research should evaluate the effectiveness of cultural adaptation strategies for specific health outcomes. This could be used to inform co-design planning and implementation, ensuring more culturally appropriate methods are employed.

The Retail Food Sector and Indigenous Peoples in High-Income Countries: A Systematic Scoping Review

Indigenous Peoples in high-income countries experience higher burdens of food insecurity, obesity, and diet-related health conditions compared to national averages. The objective of this systematic scoping review is to synthesize information from the published literature on the methods/approaches, findings, and scope for research and interventions on the retail food sector servicing Indigenous Peoples in high-income countries. A structured literature search in two major international databases yielded 139 relevant peer-reviewed articles from nine countries. Most research was conducted in Oceania and North America, and in rural and remote regions. Several convergent issues were identified across global regions including limited grocery store availability/access, heightened exposure to unhealthy food environments, inadequate market food supplies (i.e., high prices, limited availability, and poor quality), and common underlying structural factors including socio-economic inequality and colonialism. A list of actions that can modify the nature and structure of retailing systems to enhance the availability, accessibility, and quality of healthful foods is identified. While continuing to (re)align research with community priorities, international collaboration may foster enhanced opportunities to strengthen the evidence base for policy and practice and contribute to the amelioration of diet quality and health at the population level.

A Model Depicting the Retail Food Environment and Customer Interactions: Components, Outcomes, and Future Directions

The retail food environment (RFE) has important implications for dietary intake and health, and dramatic changes in RFEs have been observed over the past few decades and years. Prior conceptual models of the RFE and its relationships with health and behavior have played an important role in guiding research; yet, the convergence of RFE changes and scientific advances in the field suggest the time is ripe to revisit this conceptualization. In this paper, we propose the Retail Food Environment and Customer Interaction Model to convey the evolving variety of factors and relationships that convene to influence food choice at the point of purchase. The model details specific components of the RFE, including business approaches, actors, sources, and the customer retail experience; describes individual, interpersonal, and household characteristics that affect customer purchasing; highlights the macro-level contexts (e.g., communities and nations) in which the RFE and customers behave; and addresses the wide-ranging outcomes produced by RFEs and customers, including: population health, food security, food justice, environmental sustainability, and business sustainability. We believe the proposed conceptualization helps to (1) provide broad implications for future research and (2) further highlight the need for transdisciplinary collaborations to ultimately improve a range of critical population outcomes.

Implementation of a multilevel, multicomponent intervention for obesity control in Native American communities (OPREVENT2): challenges and lessons learned

OPREVENT2 was a multilevel, multicomponent (MLMC) adult obesity prevention that sought to improve access and demand for healthier food and physical activity opportunities in six Native American communities in the Southwest and Midwest. OPREVENT2 worked with worksites, food stores, schools (grades 2-6), through social media and mailings, and with a local community action committee (CAC), in each of the three intervention communities, and was implemented in six phases. We conducted a process evaluation to assess implementation of each intervention component in terms of reach, dose delivered and fidelity. Implementation of each component was classified as high, medium or low according to set standards, and reported back at the end of each phase, allowing for improvements. The school and worksite components were implemented with high reach, dose delivered and fidelity, with improvement over time. The school program had only moderate reach and dose delivered, as did the social media component. The CAC achieved high reach and dose delivered. Overall, study reach and dose delivered reached a high implementation level, whereas fidelity was medium. Great challenges exist in the consistent implementation of MLMC interventions. The detailed process evaluation of the OPREVENT2 trial allowed us to carefully assess the relative strengths and limitations of each intervention component.