Preventing diabetes and obesity in American Indian communities: the potential of environmental interventions

Development and implementation of a nutrition education programme for school-going adolescents in the context of double burden of malnutrition: a narrative essay

The early prevention of non-communicable diseases in Cameroon schools program was initiated in 2018 to address the alarming trend of obesity among adolescents through a nutrition education intervention aimed at increasing knowledge on nutrition and the benefits of healthy eating and physical activity. The program included: school surveys to document eating habits and health-risky behaviors in students, the development of a training curriculum, training and sensitization sessions for school staff, school vendors and students, and advocacy meetings with parliamentarians and mayors. We carried out a quasi-experimental study to assess the effect of the intervention on the student's knowledge and eating behavior three months after the training sessions. We compared the knowledge of a sample of students from five schools that were part of the program (IG) to that of students that were not (CG). The mean (±SD) score was 14.4/20 (±2.1) and 9.7/20 (±2.7) for IG and CG, respectively (p<0.001). Those who scored above 12/20 accounted for 89.8% of IG vs 23.8% of CG (p<0.001). Other significant achievements of this program are the amendment of the National School Hygiene Policy to include compulsory training in food hygiene and nutrition education for school canteen vendors and the integration of nutrition education sensitization sessions into the routine activities of school healthcare. The study showed that a well-structured multi-sectoral nutritional education program could be the bedrock to improve healthy nutrition among adolescents, thereby serving as a vehicle for non-communicable disease prevention.

Native opportunities to stop hypertension: study protocol for a randomized controlled trial among urban American Indian and Alaska Native adults with hypertension

Introduction

American Indian and Alaska Native (AI/AN) adults experience disproportionate cardiovascular disease (CVD) morbidity and mortality compared to other races, which may be partly attributable to higher burden of hypertension (HTN). Dietary Approaches to Stop Hypertension (DASH) is a high-impact therapeutic dietary intervention for primary and secondary prevention of CVD that can contribute to significant decreases in systolic blood pressure (BP). However, DASH-based interventions have not been tested with AI/AN adults, and unique social determinants of health warrant independent trials. This study will assess the effectiveness of a DASH-based intervention, called Native Opportunities to Stop Hypertension (NOSH), on systolic BP among AI/AN adults in three urban clinics.

Methods

NOSH is a randomized controlled trial to test the effectiveness of an adapted DASH intervention compared to a control condition. Participants will be aged ≥18 years old, self-identify as AI/AN, have physician-diagnosed HTN, and have elevated systolic BP (≥ 130 mmHg). The intervention includes eight weekly, tailored telenutrition counseling sessions with a registered dietitian on DASH eating goals. Intervention participants will be provided $30 weekly and will be encouraged to purchase DASH-aligned foods. Participants in the control group will receive printed educational materials with general information about a low-sodium diet and eight weekly $30 grocery orders. All participants will complete assessments at baseline, after the 8-week intervention, and again 12 weeks post-baseline. A sub-sample of intervention participants will complete an extended support pilot study with assessments at 6- and 9-months post-baseline. The primary outcome is systolic BP. Secondary outcomes include modifiable CVD risk factors, heart disease and stroke risk scores, and dietary intake.

Discussion

NOSH is among the first randomized controlled trials to test the impact of a diet-based intervention on HTN among urban AI/AN adults. If effective, NOSH has the potential to inform clinical strategies to reduce BP among AI/AN adults.

Clinical trials registration

https://clinicaltrials.gov/ct2/show/NCT02796313, Identifier NCT02796313.

Effect of Bitter-leaf (Vernonia amygdalina) Flavored Non-alcoholic Wheat Beer (NAWB) on, Insulin and GLUT-2 expression in Pancreas of High fat diet/Streptozotocin (HFD/STZ) Induced Diabetic Wistar Rats

Purpose

In the management of type 2 diabetes (T2D), dietary intervention has been proposed to be highly effective. This study, therefore, investigated the effect of bitter leaf-flavored non-alcoholic wheat beer (NAWB) on insulin secretion and GLUT-2 expression in the pancreas of STZ-induced diabetic rats.

Methods

In this study, the rats received a single intraperitoneal injection (i.p.) of STZ (35 mg/kg) after being fed a high-fat diet for 14 days to induce T2D. The rats were treated with bitter leaf flavored NAWB samples (100%HP- Hops only, 100%BL-Bitter leaf only, 75,25BL- 75% Hops, 25% Bitter Leaf, 50:50BL- 50% Hops:50% Bitter Leaf, and 25:75BL-25%Hops:75% Bitter Leaf) and Acarbose for 14 days. The superoxide dismutase, catalase, and glutathione peroxidase activity were also determined.

Results

The results from this study showed a correlation between GLUT-2 and Insulin expression. There was an upregulation of Insulin as GLUT-2 expression was upregulated. Furthermore, the treated groups showed better antioxidant activity when compared with the diabetic control.

Conclusion

Bitter leaf-flavored NAWB might thus be a good dietary intervention for type 2 diabetics.

School-based obesity prevention programs in rural communities: a scoping review

OBJECTIVE

The objective of this review was to examine existing literature and conceptually map the evidence for school-based obesity prevention programs implemented in rural communities, as well as identify current gaps in the literature.

INTRODUCTION

Pediatric obesity is a significant public health condition worldwide. Rural residency places children at increased risk of obesity. Schools have been identified as an avenue for obesity prevention in rural communities.

INCLUSION CRITERIA

We considered citations focused on children (5 to 18 years of age) enrolled in a rural educational setting. We included obesity prevention programs delivered in rural schools that focused on nutrition or dietary changes, physical activity or exercise, decreasing screen time, or combined nutrition and physical activity that aimed to prevent childhood obesity. We included all quantitative, qualitative, and mixed methods research designs, as well as text and opinion data.

METHODS

A search was conducted of published and unpublished studies in English from 1990 through April 2020 using PubMed, CINAHL Complete, ERIC, Embase, Scopus, Academic Search Premier, Cochrane Register of Controlled Trials, and ClinicalTrials.gov. Gray literature was also searched. After title and abstract review, potentially relevant citations were retrieved in full text. The full texts were assessed in detail against the inclusion criteria by 2 independent reviewers. Included citations were reviewed and data extracted by 2 independent reviewers and captured on a spreadsheet targeting the review objectives.

RESULTS

Of the 105 studies selected for full-text review, 72 (68.6%) were included in the final study. Most of the studies (n = 50) were published between 2010 and 2019 and were conducted in the United States (n = 57). Most studies included children in rural elementary or middle schools (n = 57) and targeted obesity prevention (n = 67). Teachers implemented the programs in half of the studies (n = 36). Most studies included a combination of physical activity and nutrition components (n = 43). Other studies focused solely on nutrition (n = 9) or physical activity (n = 9), targeted obesity prevention policies (n = 9), or other components (n = 8). Programs ranged in length from weeks to years. Overall, weight-related, physical activity-specific, and nutrition-specific outcomes were most commonly examined in the included citations.

CONCLUSIONS

Obesity prevention programs that focused on a combination of physical activity and nutrition were the most common. Multiple outcomes were examined, but most programs included weight-specific and health behavior-specific outcomes. The length and intensity of rural school-based obesity prevention programs varied. More research examining scientific rigor and specific outcomes of rural school-based obesity prevention programs is needed.

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.

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.

Multilevel and Community-Level Interventions with Native Americans: Challenges and Opportunities

Multilevel and community-level interventions that target the social determinants of health and ultimately health disparities are seldom conducted in Native American communities. To contextualize the importance of multilevel and community-level interventions, major contributors to and causes of health disparities in Native communities are highlighted. Among the many documented socioeconomic factors influencing health are poverty, low educational attainment, and lack of insurance. Well-recognized health disparities include obesity, diabetes, and hypertension. Selected challenges of implementing community-level and multilevel interventions in Native communities are summarized such as the shortage of high-quality population health data and validated measurement tools. To address the lack of multilevel and community-level interventions, the National Institutes of Health created the Intervention Research to Improve Native American Health (IRINAH) program which solicits proposals that develop, adapt, and test strategies to address these challenges and create interventions appropriate for Native populations. A discussion of the strategies that four of the IRINAH grantees are implementing underscores the importance of community-based participatory policy work, the development of new partnerships, and reconnection with cultural traditions. Based on the work of the nearly 20 IRINAH grantees, ameliorating the complex social determinants of health disparities among Native people will require (1) support for community-level and multilevel interventions that examine contemporary and historical factors that shape current conditions; (2) sustainability plans; (3) forefronting the most challenging issues; (4) financial resources and time to collaborate with tribal leaders; and (5) a solid evidence base.

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.

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.

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.

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.

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.

Obesity risk factors in American Indians and Alaska Natives: a systematic review

OBJECTIVES

We systematically reviewed the literature on risk factors for obesity in American Indians (AIs) and Alaska Natives (ANs) of all ages.

STUDY DESIGN

We searched titles and abstracts in PubMed with combinations of the following terms: obesity, body mass index (BMI), American Indian, Alaska Native, and Native American.

METHODS

We limited our review to articles that provided an empirically testable claim about a variable associated with obesity, measured obesity as a dependent variable, and provided data specific to AI/ANs.

RESULTS

Our final sample included 31 articles; 20 examined AI/AN youth (<18 years), and 11 examined AI/AN adults (≥18 years). Risk factors for obesity varied by age. In infants, low birth weight, early termination of breastfeeding, and high maternal BMI, and maternal diabetes increased the risk of childhood obesity. In children and adolescents, parental obesity, sedentary behaviors, and limited access to fruits and vegetables were associated with obesity. In adulthood, sedentary behaviors, diets high in fats and carbohydrates, stress, verbal abuse in childhood, and the belief that health cannot be controlled were associated with obesity.

CONCLUSIONS

Extant studies have three limitations: they do not apply a life course perspective, they lack nationally representative data and have limited knowledge of the resilience, resistance and resourcefulness of AI/ANs. Future studies that avoid these shortcomings are needed to inform interventions to reduce the prevalence of obesity in AI/ANs across the life course.

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.

Diabetes and Obesity Associated with Poor Food Environments in American Indian Communities: the Tribal Health and Resilience in Vulnerable Environments (THRIVE) Study

BACKGROUND

American Indians (AIs) have significantly higher rates of diet-related chronic diseases than other racial/ethnic groups, and many live in environments with limited access to healthy food.

OBJECTIVE

As part of the Tribal Resilience in Vulnerable Environments (THRIVE) study, we examined the relations between the perceived food environment, utilization of food retailers, fruit and vegetable intake, and chronic diseases, including obesity, hypertension, and type 2 diabetes among AI adults.

METHODS

Through a community-based participatory research partnership, we surveyed a cross-sectional sample of 513 AIs living within the Chickasaw Nation and the Choctaw Nation of Oklahoma.

RESULTS

Only 57% of participants reported that it was easy to purchase fruits and vegetables in their town, and fewer (35%) reported that available fruits and vegetables were of high quality. Additionally, over half (56%) reported traveling ≥20 miles round trip to shop for food. Few participants met the recommended daily intake for fruit (44%) or vegetables (25%). Obesity (55%), hypertension (49%), and diabetes (25%) were commonly reported. Obesity was significantly higher among participants who reported that the price of fruits and vegetables were cost-prohibitive (prevalence proportion ratio (PPR): 1.24; 95% CI: 1.02, 1.50) and those who shopped frequently for food at nontraditional food retailers, such as Dollar Stores (PPR: 1.35; 95% CI: 1.08, 1.69) and small markets (PPR: 1.38; 95% CI: 1.02, 1.86). Diabetes was significantly higher among participants who frequently shopped at convenience stores/gas stations (PPR: 2.26; 95% CI: 1.22, 4.19).

CONCLUSIONS

Our study found that the use of nontraditional food retailers, including convenience stores, gas stations, and Dollar Stores, as a regular source of food was associated with obesity and diabetes. These results underscore the importance of interventions to improve rural Tribal food environments. Healthy retail interventions in nontraditional retail settings, such as those implemented through the THRIVE study, may contribute to reducing AI health disparities.

The Healthy Children, Strong Families 2 (HCSF2) Randomized Controlled Trial Improved Healthy Behaviors in American Indian Families with Young Children

BACKGROUND

American Indian (AI) families experience a disproportionate risk of obesity due to a number of complex reasons, including poverty, historic trauma, rural isolation or urban loss of community connections, lack of access to healthy foods and physical activity opportunities, and high stress. Home-based obesity prevention interventions are lacking for these families.

OBJECTIVE

Healthy Children, Strong Families 2 (HCSF2) was a randomized controlled trial of a healthy lifestyle promotion/obesity prevention intervention for AI families.

METHODS

Four hundred and fifty dyads consisting of an adult primary caregiver and a child ages 2 to 5 y from 5 AI communities were randomly assigned to a monthly mailed healthy lifestyle intervention toolkit (Wellness Journey) with social support or to a child safety control toolkit (Safety Journey) for 1 y. The Wellness Journey toolkit targeted increased fruit/vegetable (F/V) intake and physical activity, improved sleep, decreased added sugar intake and screen time, and improved stress management (adults only). Anthropometrics were collected, and health behaviors were assessed via survey at baseline and at the end of Year 1. Adults completed surveys for themselves and the participating child. Repeated measures analysis of variance was used to assess change over the intervention period.

RESULTS

Significant improvements to adult and child healthy diet patterns, adult F/V intake, adult moderate-to-vigorous physical activity, home nutrition environment, and adult self-efficacy for health behavior change were observed in Wellness Journey compared with Safety Journey families. No changes were observed in adult body mass index (BMI), child BMI z-score, adult stress measures, adult/child sleep and screen time, or child physical activity. Qualitative feedback suggests the intervention was extremely well-received by both the families and our community partners across the 5 participating sites.

CONCLUSIONS

This multi-site community-engaged intervention addressed key gaps regarding family home-based approaches for early obesity prevention in AI communities and showed several significant improvements in health behaviors. Multiple communities are working to sustain intervention efforts. This trial was registered at clinicaltrials.gov as NCT01776255.

Dietary Beliefs and Management of Older American Indians With Type 2 Diabetes

OBJECTIVES

This qualitative study examined dietary-related beliefs and self-management among older American Indians with type 2 diabetes mellitus (T2DM).

DESIGN

Semistructured in-person interviews were conducted and digitally recorded.

SETTING

Southeastern American Indian tribal community.

PARTICIPANTS

A total of 28 noninstitutionalized older tribal members aged >60 years.

PHENOMENON OF INTEREST

Study participants' beliefs and experiences with dietary practices and management related to T2DM.

ANALYSIS

Transcribed qualitative interviews were coded using an inductive content analysis approach.

RESULTS

Four themes regarding T2DM dietary beliefs and T2DM dietary management emerged from the analyses: diet changes, portion control, health care professional and family influence, and barriers to healthy eating. Study participants described how their beliefs, practices, and experiences in these 4 areas related to T2DM.

CONCLUSIONS AND IMPLICATIONS

American Indian older adults face a variety of challenges to dietary management of T2DM. Future research efforts can focus on assessing how social support can be leveraged to facilitate healthy diets for American Indians with T2DM. Clinicians and diabetes educators and Native communities have an instrumental role in identifying culturally appropriate messages and programs to help persons effectively manage T2DM.

A Pragmatic Review to Assist Planning and Practice in Delivering Nutrition Education to Indigenous Youth

Many health promotion campaigns have incorporated multi-component nutrition interventions to promote healthy diet-related behaviours among Indigenous communities, particularly children and adolescents. However, these campaigns show mixed results and while research often describes outcomes of approaches and interventions, it does not extensively describe implementation processes and best practices for nutrition education for Indigenous youth. To enhance knowledge and understanding of best processes in nutritional education approaches with Indigenous youth, we conducted a search using multiple databases including PubMed, Google Scholar, the Australian Indigenous HealthInfoNet and Australian government research databases to identify relevant peer-reviewed and grey literature as well as educational resources, such as websites and handbooks for teachers, parents, and students. We list and describe common features of successful nutritional interventions in Indigenous settings, steps for nutrition education targeting youth, school-based nutrition education for different ages, and general guidelines for teaching Indigenous students. Current best practice and knowledge gaps for the delivery of nutrition education to Indigenous youth are described.

Group Gardening in a Native American Community: A Collaborative Approach

Background. There is increasing awareness of the potential health benefits derived from gardening activities. Gardening practices are gaining momentum in Native American (NA) communities, yet no efforts have applied a community-based participatory research approach within a social-ecological model to understand opportunities and barriers for group gardening on an American Indian reservation. Objectives. The primary objective of this study was to identify influences across social-ecological levels that promote or hinder the implementation of community gardens and use of locally grown foods on the reservation; a secondary objective was to assess the feasibility of implementing a group gardening program for NA adults and potential of collecting health outcome measures. Method. Community members and academicians collaborated to develop and implement this study. The study (1) conducted interviews with key stakeholders to identify influences across social-ecological levels that promote or hinder the implementation of community gardens and using locally produced food and (2) assessed the physical and psychological well-being of NA adults participating in a group gardening feasibility study. Results. Major factors influencing using locally grown food and community gardens that emerged from nine interviews included knowledge/experience, self-efficacy, Elders, traditional ways, community values, generational gaps, and local tribal policies. Twenty NA adults with prediabetes or diabetes participated in the feasibility study. The Profile of Mood States Inventory showed consistently positive change in score for participants in the group gardening program versus the comparison group. Conclusions. This study identified key influences for growing locally grown food, and approaches for implementing group gardening programs for NA adults.

Work, worksites, and wellbeing among North American Indian women: a qualitative study

The purpose of this study was to understand what factors influenced work-family balance and related health behaviors among a sample of rural North American Indian women. We interviewed 89 women through both in-depth interviews and focus groups across four tribal communities in the American Southwest and Upper Midwest between July 2010 and August 2011. Interviews were transcribed, coded, and analyzed for emerging themes related to work- family demands placed on women and resources available to cope with those demands. Three prominent themes emerged: structural characteristics (the context of rural reservation life), role stressors (women's multiple and conflicting roles) and the influence of social support (communal nature of care in the family and institutional support in the workplace). We found that women in participating rural reservation communities often acted as primary caregivers for both immediate and extended family, and often placed the needs of others before themselves. The context of rural reservations, with high rates of unemployment, poverty, and chronic illnesses associated with the collective trauma of colonization, placed high demands on female caregivers. Social support from within the workplace, family, and cultural traditions helped some female caregivers balance the demands of home and work. Tribal worksites could be a resource for promoting health and work-life balance by being responsive to the particular demands placed on women that often interfere with engaging in positive health behaviors in general and tribal wellness programs in particular.

Sustaining obesity prevention in communities: a systematic narrative synthesis review

Obesity is a global problem for which sustainable solutions are yet to be realized. Community-based interventions have improved obesity-related behaviours and obesity in the short term. Few papers have explored how to make the interventions and their intended outcomes sustainable. The aim of this paper is to identify factors that contribute to the sustainability of community-based obesity prevention interventions and their intended outcomes. A systematic narrative synthesis review was conducted of published community-based obesity prevention interventions to identify factors contributing to intervention sustainability. Data extracted were included study authors' perspectives of intervention success and sustainability. Eighty-one papers met the inclusion criteria, and from these we identified ten factors that contribute to sustainability: resourcing, leadership, workforce development, community engagement, partnerships, policy, communications, adaptability, evaluation and governance. This review of community-based obesity prevention interventions gives rise to optimism that sustainable change is possible. We propose a framework to help practitioners build sustainability into their interventions and report on them so that others can also benefit.

Education, Income, and Employment and Prevalence of Chronic Disease Among American Indian/Alaska Native Elders

INTRODUCTION

Chronic disease studies have omitted analyses of the American Indian/Alaska Native (AI/AN) population, relied on small samples of AI/ANs, or focused on a single disease among AI/ANs. We measured the influence of income, employment status, and education level on the prevalence of chronic disease among 14,632 AI/AN elders from 2011 through 2014.

METHODS

We conducted a national survey of AI/AN elders (≥55 y) to identify health and social needs. Using these data, we computed cross-tabulations for each independent variable (annual personal income, employment status, education level), 2 covariates (age, sex), and presence of any chronic disease. We also compared differences in values and used a binary logistic regression model to control for age and sex.

RESULTS

Most AI/AN elders (89.7%) had been diagnosed with at least one chronic disease. AI/AN elders were also more than twice as likely to have diabetes and more likely to have arthritis. AI/AN elders with middle-to-low income levels and who were unemployed were more likely to have a chronic disease than were high-income and employed AI/AN elders.

CONCLUSION

Addressing disparities in chronic disease prevalence requires focus on more than access to and cost of health care. Economic development and job creation for all age cohorts in tribal communities may decrease the prevalence of long-term chronic diseases and may improve the financial status of the tribe. An opportunity exists to address health disparities through social and economic equity among tribal populations.

Patient-provider relationship and perceived provider weight bias among American Indians and Alaska Natives

Objective

The objective of this study was to examine patient-provider relationships among American Indians and Alaska Native (AI/AN) patients by examining associations between patient activation, perceived provider weight bias and working alliance. Patient activation is generally defined as having the knowledge, skills and confidence to manage one's health.

Methods

Among a sample of 87 AI/AN adults presenting for general medical care at an urban clinic in the north-west region of the USA, ordinary least squares regression analysis was completed to examine associations.

Results

Better working alliance scores were associated with increased patient activation, while perceived provider weight bias was associated with reduced patient activation. In addition, those with class II obesity had decreased patient activation.

Conclusion

These findings point to the importance of a positive patient-provider relationship in AI/ANs. Optimal patient engagement and subsequent health outcomes warrant additional consideration of patients' perceptions of provider weight bias within the context of health promotion and interventions.

OPREVENT2: Design of a multi-institutional intervention for obesity control and prevention for American Indian adults

Background

Obesity and other nutrition-related chronic disease rates are high in American Indian (AI) populations, and an urgent need exists to identify evidence-based strategies for prevention and treatment. Multi-level, multi-component (MLMC) interventions are needed, but there are significant knowledge gaps on how to deliver these types of interventions in low-income rural AI communities.

Methods

OPREVENT2 is a MLMC intervention targeting AI adults living in six rural reservations in New Mexico and Wisconsin. Aiming to prevent and reduce obesity in adults by working at multiple levels of the food and physical activity (PA) environments, OPREVENT2 focuses on evidence-based strategies known to increase access to, demand for, and consumption of healthier foods and beverages, and increase worksite and home-based opportunities for PA. OPREVENT2 works to create systems-level change by partnering with tribal stakeholders, multiple levels of the food and PA environment (food stores, worksites, schools), and the social environment (children as change agents, families, social media). Extensive evaluation will be conducted at each level of the intervention to assess effectiveness via process and impact measures.

Discussion

Novel aspects of OPREVENT2 include: active engagement with stakeholders at many levels (policy, institutional, and at multiple levels of the food and PA system); use of community-based strategies to engage policymakers and other key stakeholders (community workshops, action committees); emphasis on both the built environment (intervening with retail food sources) and the social environment. This paper describes the design of the intervention and the evaluation plan of the OPREVENT2.

Trial registration

Clinical Trial Registration: NCT02803853 (June 10, 2016)

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.

Store owners as potential agents of change: energy drinks in the interior of Alaska

Childhood obesity disproportionately impacts disadvantaged communities, including Alaska Native children. In part, lack of access to fresh fruits and vegetables and over consumption of sugar sweetened beverages including energy drinks contribute to excessive weight gain in Alaska Native youth. This commentary reports the possibility of storeowners and workers partnering with community members to limit sales of nutrient-poor energy drinks through point-of-sale counselling in rural communities in the interior of Alaska. This model of intervention may be useful to implement in areas where there are limited health workers or others that can serve as health educators. This study reports preliminary evidence from rural Alaska and from other Arctic communities that store workers may effectively improve community health status by limiting or promoting specific products. Storeowners or workers may be helpful partners in the fight against childhood obesity as they are present at the point of sale of high-risk beverages to Alaska Native youth.

Maternal correlates of body mass index in American Indian/Alaska Native and White adolescents: Differences between mother/son and mother/daughter pairs

INTRODUCTION

Obesity rates for American Indian and Alaska Native (AI/AN) adolescents are among the highest in the US. However, little is known about the influence of maternal correlates on adolescent body mass index (BMI), and the extent to which the size and significance of these correlates vary by adolescent sex and race.

METHODS

We conducted a cross-sectional analysis with a sample of 531 AI/AN and 8896 White mother/adolescent pairs from Wave 1 of the National Longitudinal Study of Adolescent to Adult Health. We used generalized estimating equations to measure the association of maternal educational attainment, marital status, employment status, obesity status, and adolescent BMI of AI/AN and White adolescents, while controlling for adolescents' demographic and behavioral covariates. We sought to determine whether the size and statistical significance of maternal correlates differed by race, and between mother/son and mother/daughter pairs.

RESULTS

The strength and statistical significance of maternal correlates varied between mother/son and mother/daughter pairs in both races. However, we did not find effect modification by race. Maternal obesity showed the strongest effect on adolescent BMI in all mother/adolescent pairs.

CONCLUSION

Our findings suggest that maternal factors are critical in the transmission of obesogenic behaviors from one generation to the next, and their effects vary between mother/son and mother/daughter pairs, and are similar for AI/ANs and Whites. We encourage future work aimed at preventing adolescent obesity to investigate causal pathways between maternal correlates and adolescent BMI.

Self-Reported Physical Activity Among American Indian Adults From Two Diverse Regions

PURPOSE

Physical activity may be a protective factor against the disproportionate rates of chronic diseases faced by American Indians. Nevertheless, few studies report any cultural adoptions made to capture physical activity behaviors among this hard-to-reach population. Existing studies reporting the prevalence of physical activity among American Indians are often aggregated and tend to obscure regional, local, and tribal-level variations. This study examines the prevalence of physical activity and inactivity levels, along with associated factors, among rural dwelling American Indian adults from 2 distinct regions.

METHODS

Baseline self-reported data were collected using a culturally modified version of the International Physical Activity Questionnaire (IPAQ) short form during the Obesity Research Prevention and Evaluation of Intervention Effectiveness in Native North Americans trial (OPREVENT) among rural American Indian adults (aged 18-75 years) from 5 tribal communities in Michigan and New Mexico.

FINDINGS

Most participants were classified as moderately physically active (43.5%), and the majority reported access to physical activity facilities (83.5%). Michigan participants reported engaging in more moderate and total physical activity than those in New Mexico (P < .001) and reported spending less time sitting (P < .001).

CONCLUSIONS

Differences in physical activity among the American Indian communities may be due to regional variations in occupations, climate, and tribal and community support and infrastructure. The unexpected high level of activity evokes uncertainty in the accuracy and appropriateness of the data collection instrument. Research is needed to understand culturally appropriate approaches to measure physical activity and inactivity among rural American Indians.

American Indians' Family Health Concern on a Northern Plains Reservation: "Diabetes Runs Rampant Here"

OBJECTIVES

The objective was to identify significant family health concerns from the perspective of adult tribal members residing in a reservation setting on the Northern Plains of the United States. Findings were used to cocreate culturally appropriate strategies to address the most significant family health concern.

DESIGN AND SAMPLE

A focused ethnography within a participatory framework was employed. An advisory council, comprised of seven tribal members, guided the research team. A purposive sampling technique with a snowball process was used. Twenty-one adult tribal members volunteered to participate.

MEASURES

Face-to-face, audio-recorded, semi-structured interviews were conducted and transcribed verbatim. Other data sources included field notes of approximately 100 hours of field work, windshield surveys, and a focus group. Data were analyzed using Spradley's guidelines.

RESULTS

The significant family health concern was "diabetes runs rampant here" with inter-related cognitive, emotional, and behavioral responses. These responses were compounded by accumulated emotional trauma from witnessing premature deaths and severe comorbidities associated with diabetes. Contextual factors shaping "diabetes runs rampant here" were identified.

CONCLUSION

Holistic approaches are urgently needed in diabetes prevention and management programs. Implications for public health nurses are discussed and recommendations are provided for future research.

"We're Changing Our Ways": Women's Coping Strategies for Obesity Risk-reducing Behaviors in American Indian Households

This article reveals women caregivers' perceptions and coping strategies to improve households' food and physical activity habits. Results emerged from the pre-intervention formative research phase of a multi-site, multi-level obesity prevention pilot intervention on American Indian (AI) reservations. Using purposive sampling, 250 adults and children participated in qualitative research. Results reveal that having local institutional support was a key structural facilitator. 'Family connectedness' emerged as a key relational facilitator. Hegemony of systems, food deserts, transportation, and weather were key structural barriers; Childcare needs and time constraints were key relational barriers. Women's coping strategies included planning ahead, maximizing, apportioning, tempting healthy, and social support. Findings informed the development and implementation of a novel obesity prevention pilot intervention tailored for each participating AI community addressing culturally relevant messages, institutional policies, and programs. We conclude with future consideration for comparative, ethnicity-based, class-based, and gender-specific studies on women's coping strategies for household health behaviors.

Barriers and facilitators to following the Dietary Guidelines for Americans reported by rural, Northern Plains American-Indian children

OBJECTIVE

The Dietary Guidelines for Americans (DGA) promote healthy dietary choices for all Americans aged 2 years and older; however, the majority of Americans do not meet recommendations. The goal of the present study was to identify both barriers and facilitators to adherence to DGA recommendations for consumption of five recommended food groups: grains (specifically whole grains), vegetables, fruits, meat/beans and milk (specifically reduced-fat/non-fat), among American-Indian children.

DESIGN

Nominal group technique sessions were conducted to identify and prioritize children's perceived barriers and facilitators to following the DGA, as presented in the 'MyPyramid' consumer education icon. After response generation to a single question about each food group (e.g. 'What sorts of things make it harder (or easier) for kids to follow the MyPyramid recommendation for vegetables?'), children individually ranked their top five most salient responses. Ranked responses are presented verbatim.

SETTING

A rural Northern Plains American-Indian reservation, USA.

SUBJECTS

Sixty-one self-selected fifth-grade children.

RESULTS

Core barriers for all food groups studied included personal preference (i.e. 'don't like') and environmental (i.e. 'cost too much'; 'store is too far to get them'; 'grandma don't have'). Core facilitators included suggestions, i.e. 'make a garden and plant vegetables'; 'tell your friends to eat healthy'.

CONCLUSIONS

Barriers and facilitators are dissimilar for individual food groups, suggesting that dietary interventions should target reduction of barriers and promotion of facilitators specific to individual food groups recommended by the DGA.

Systematic review of health disparities for cardiovascular diseases and associated factors among American Indian and Alaska Native populations

BACKGROUND

American Indians and Alaska Native (AI/AN) populations experience significant health disparities compared to non-Hispanic white populations. Cardiovascular disease and related risk factors are increasingly recognized as growing indicators of global health disparities. However, comparative reports on disparities among this constellation of diseases for AI/AN populations have not been systematically reviewed.

OBJECTIVES

We performed a literature review on the prevalence of diabetes, metabolic syndrome, dyslipidemia, obesity, hypertension, and cardiovascular disease; and associated morbidity and mortality among AI/AN.

DATA SOURCES

A total of 203 articles were reviewed, of which 31 met study criteria for inclusion. Searches were performed on PUBMED, MEDLINE, the CDC MMWR, and the Indian Health Services.

STUDY ELIGIBILITY CRITERIA

Published literature that were published within the last fifteen years and provided direct comparisons between AI/AN to non-AI/AN populations were included.

STUDY APPRAISAL AND SYNTHESIS METHODS

We abstracted data on study design, data source, AI/AN population, comparison group, and. outcome measures. A descriptive synthesis of primary findings is included.

RESULTS

Rates of obesity, diabetes, cardiovascular disease, and metabolic syndrome are clearly higher for AI/AN populations. Hypertension and hyperlipidemia differences are more equivocal. Our analysis also revealed that there are likely regional and gender differences in the degree of disparities observed.

LIMITATIONS

Studies using BRFSS telephone surveys administered in English may underestimate disparities. Many AI/AN do not have telephones and/or speak English. Regional variability makes national surveys difficult to interpret. Finally, studies using self-reported data may not be accurate.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Profound health disparities in cardiovascular diseases and associated risk factors for AI/AN populations persist, perhaps due to low socioeconomic status and access to quality healthcare. Successful programs will address social determinants and increase healthcare access. Community-based outreach to bring health services to the most vulnerable may also be very helpful in this effort.

SYSTEMATIC REVIEW REGISTRATION NUMBER

N/A.

Association between Obesity and History of Abuse among American Indians in Rural California

OBJECTIVES

To explore factors associated with obesity among American Indians.

METHODS

A cross-sectional survey of American Indian adults (N=459) was conducted at 13 rural reservation sites in California. Participants responded to a survey about their health and wellness perceptions. The Body Mass Index (BMI) was used to assess obesity. A predictive model for BMI was built using a generalized regression model.

RESULTS

Having high blood pressure and having a history of verbal abuse in childhood were significant predictors of higher BMI. Participants with high blood pressure were likely to have 3.2 units of BMI higher on average than those who do not have high blood pressure (p-value <0.0001). Similarly, those with a history of childhood verbal abuse were likely to have 1.9 units higher BMI on average compared to those with no such history. Having a history of diabetes or sexual abuse in childhood trend towards increased BMI, although not statistically significant.

CONCLUSION

Identifying childhood trauma and its impact on adult obesity rates among American Indians provides new avenues for intervention. Efforts to reduce over weight and obesity should include culturally sensitive interventions to ameliorate and repair what is lost through personal violations of stigma, abuse or neglect.

High levels of household food insecurity on the Navajo Nation

OBJECTIVE

To assess levels of and identify factors associated with food insecurity on the Navajo Nation.

DESIGN

A cross-sectional study was conducted utilizing the ten-item Radimer/Cornell food insecurity instrument. Sociodemographic, psychosocial and anthropometric data were collected.

SETTING

Navajo Nation, USA.

SUBJECTS

Two hundred and seventy-six members of the Navajo Nation were randomly selected at food stores and other community locations.

RESULTS

Of the sample, 76·7% had some level of food insecurity. Less education (mean years of schooling: P = 0·0001; non-completion of higher education: P = 0·0003), lower full-time employment rates (P = 0·01), and lower material style of life (P = 0·0001), food knowledge (P = 0·001) and healthy eating self-efficacy (P < 0·0001) scores were all positively associated with food insecurity. Perceived expensiveness (P < 0·0001) and perceived inconvenience (P = 0·0001) of healthy choices were also positively associated with food insecurity.

CONCLUSIONS

Food insecurity rates on the Navajo Nation are the highest reported to date in the USA and are likely attributable to the extremely high rates of poverty and unemployment. Reducing food insecurity on the Navajo Nation will require increasing the availability of affordable healthy foods, addressing poverty and unemployment, and providing nutrition programmes to increase demand.

Food Insecurity and Obesity Among American Indians and Alaska Natives and Whites in California

Food insecurity is linked to obesity among some, but not all, racial and ethnic populations. We examined the prevalence of food insecurity and the association between food insecurity and obesity among American Indians (AIs) and Alaska Natives (ANs) and a comparison group of whites. Using the 2009 California Health Interview Survey, we analyzed responses from 592 AIs/ANs and 7371 white adults with household incomes at or below 200% of the federal poverty level. Food insecurity was measured using a standard 6-item scale. Sociodemographics, exercise, and obesity were all obtained using self-reported survey data. Logistic regression was used to estimate associations. The prevalence of food insecurity was similar among AIs/ANs and whites (38.7% vs 39.3%). Food insecurity was not associated with obesity in either group in analyses adjusted for sociodemographics and exercise. The ability to afford high-quality foods is extremely limited for low-income Californians regardless of race. Health policy discussions must include increased attention on healthy food access among the poor, including AIs/ANs, for whom little data exist.

A food store-based environmental intervention is associated with reduced BMI and improved psychosocial factors and food-related behaviors on the Navajo nation

The prevalence of obesity is significantly higher among American Indians (AIs) and is associated with increased rates of diabetes, hypertension, and cardiovascular disease. We implemented a 14-mo intervention trial (Navajo Healthy Stores) on the Navajo Nation that sought to increase availability of healthier foods in local food stores and to promote these foods at the point of purchase and through community media. We divided the Navajo Nation into 10 store regions, half of which were randomized to intervention and half to comparison. We evaluated the program by using a pre-post sample of systematically sampled adult Navajo consumers (baseline, n = 276; postintervention, n = 145). Intervention impact was examined by analyzing pre-post differences by intervention group and by intervention exposure level. When intervention and comparison groups were compared, only body mass index (BMI) showed a trend toward impact of the intervention (P = 0.06). However, greater exposure to the intervention was associated with significantly reduced BMI (P ≤ 0.05) and improved healthy food intentions (P ≤ 0.01), healthy cooking methods (P ≤ 0.05), and healthy food getting (P ≤ 0.01). With increasing exposure, the odds of improving overweight or obese status was 5.02 (95% CI: 1.48, 16.99; P ≤ 0.01) times the odds of maintaining or worsening overweight or obese status. In summary, a food store intervention was associated with reduced overweight/obesity and improved obesity-related psychosocial and behavioral factors among those persons most exposed to the intervention on an AI reservation.

A pilot comprehensive school nutrition program improves knowledge and intentions for intake of milk and milk alternatives among youth in a remote first nation

OBJECTIVE

To evaluate the impact of a pilot comprehensive school nutrition program modeled on Social Cognitive Theory on knowledge, intentions, self-efficacy, and intake of milk and milk alternatives (MMA) in First Nations youth.

METHODS

A pilot school nutrition program was implemented at Peetabeck Academy in Fort Albany, Ontario in May, 2010. The Knowledge, Self-Efficacy, and Intentions Questionnaire (KSIQ) and Waterloo Web-based Eating Behavior Questionnaire (WEB-Q) were used to assess change in attitudes and behavior from pre- to postprogram.

RESULTS

The KSIQ preprogram (n = 26), postprogram (n = 19); WEB-Q preprogram (n = 30), postprogram (n = 10). Improved knowledge (6.0 ± 1.5 vs. 6.9 ± 1.5, P = .05) and intention scores (9.6 ± 4.4 vs. 11.3 ± 4.1, P = .01) were observed.

CONCLUSIONS AND IMPLICATIONS

A comprehensive school nutrition program can improve knowledge and intentions for intake of MMA in First Nations youth. Environmental constraints beyond the school environment need to be addressed.

Reducing Alaska Native paediatric oral health disparities: a systematic review of oral health interventions and a case study on multilevel strategies to reduce sugar-sweetened beverage intake

BACKGROUND

Tooth decay is the most common paediatric disease and there is a serious paediatric tooth decay epidemic in Alaska Native communities. When untreated, tooth decay can lead to pain, infection, systemic health problems, hospitalisations and in rare cases death, as well as school absenteeism, poor grades and low quality-of-life. The extent to which population-based oral health interventions have been conducted in Alaska Native paediatric populations is unknown.

OBJECTIVE

To conduct a systematic review of oral health interventions aimed at Alaska Native children below age 18 and to present a case study and conceptual model on multilevel intervention strategies aimed at reducing sugar-sweetened beverage (SSB) intake among Alaska Native children.

DESIGN

Based on the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) Statement, the terms "Alaska Native", "children" and "oral health" were used to search Medline, Embase, Web of Science, GoogleScholar and health foundation websites (1970-2012) for relevant clinical trials and evaluation studies.

RESULTS

Eighty-five studies were found in Medline, Embase and Web of Science databases and there were 663 hits in GoogleScholar. A total of 9 publications were included in the qualitative review. These publications describe 3 interventions that focused on: reducing paediatric tooth decay by educating families and communities; providing dental chemotherapeutics to pregnant women; and training mid-level dental care providers. While these approaches have the potential to improve the oral health of Alaska Native children, there are unique challenges regarding intervention acceptability, reach and sustainability. A case study and conceptual model are presented on multilevel strategies to reduce SSB intake among Alaska Native children.

CONCLUSIONS

Few oral health interventions have been tested within Alaska Native communities. Community-centred multilevel interventions are promising approaches to improve the oral and systemic health of Alaska Native children. Future investigators should evaluate the feasibility of implementing multilevel interventions and policies within Alaska Native communities as a way to reduce children's health disparities.

Healthy gardens/healthy lives: Navajo perceptions of growing food locally to prevent diabetes and cancer

Poor access to nutritious foods, departure from traditional diets, and reduced physical activity are associated with a rise in type 2 diabetes and certain types of cancers among the Navajo. Diabetes in particular is of concern because of its increased prevalence among Navajo youth. Gardening can successfully address issues of poor availability of fruits and vegetables and offer many other social and health benefits. Our assessment aimed to determine Navajo attitudes about gardening and health in San Juan County, New Mexico. We conducted seven focus groups (including 31 people) to assess knowledge and attitudes related to gardening and uncover barriers and facilitators to participation in a garden project. Each group session was moderated by two Navajo students. Transcripts revealed that many Navajo are aware of adverse health issues that occur on the reservation, predominantly obesity and diabetes. Participants expressed a preference for educational approaches that incorporated cultural traditions, respect for elders, use of visual aids, and experiential learning. Several social and agronomic barriers to gardening were also mentioned. Results suggested a broad interest in promoting gardening especially to reduce the risk of diabetes with the added value of enhancing social capital in Navajo communities.

A community-based intervention to prevent obesity beginning at birth among American Indian children: study design and rationale for the PTOTS study

Eating and physical activity behaviors associated with adult obesity have early antecedents, yet few studies have focused on obesity prevention interventions targeting very young children. Efforts to prevent obesity beginning at birth seem particularly important in populations at risk for early-onset obesity. National estimates indicate that American Indian (AI) children have higher rates of overweight and obesity than children of other races/ethnicities. The Prevention of Toddler Obesity and Teeth Health Study (PTOTS) is a community-partnered randomized controlled trial designed to prevent obesity beginning at birth in AI children. PTOTS was developed to test the effectiveness of a multi-component intervention designed to: promote breastfeeding, reduce sugar-sweetened beverage consumption, appropriately time the introduction of healthy solid foods, and counsel parents to reduce sedentary lifestyles in their children. A birth cohort of 577 children from five AI tribes is randomized by tribe to either the intervention (three tribes) or the comparison condition (two tribes). The strengths and weaknesses of PTOTS include a focus on a critical growth phase, placement in the community, and intervention at many levels, using a variety of approaches.

CHILE: an evidence-based preschool intervention for obesity prevention in Head Start

BACKGROUND

Obesity is a major concern among American Indians and Hispanics. The Child Health Initiative for Lifelong Eating and Exercise (CHILE) is an evidence-based intervention to prevent obesity in children enrolled in 16 Head Start (HS) Centers in rural communities. The design and implementation of CHILE are described.

METHODS

CHILE uses a socioecological approach to improve dietary intake and increase physical activity. The intervention includes: a classroom curriculum; teacher and food service training; family engagement; grocery store participation; and health care provider support.

RESULTS

Lessons learned from CHILE include the need to consider availability of recommended foods; the necessity of multiple training sessions for teachers and food service; the need to tailor the family events to local needs; consideration of the profit needs of grocery stores; and sensitivity to the time constraints of health care providers.

CONCLUSIONS

HS can play an important role in preventing obesity in children. CHILE is an example of a feasible intervention that addresses nutrition and physical activity for preschool children that can be incorporated into HS curricula and aligns with HS national performance standards.

Trends of overweight and obesity among white and American Indian school children in South Dakota, 1998-2010

OBJECTIVE

To investigate the prevalence of overweight and obesity among white and American Indian children in a predominantly rural state.

DESIGN AND METHODS

Using a repeated, cross-sectional design of school children's height and weight, the study sample included 361,352 measures of children who were 5.0-19.9 years, attending school across 13 academic calendar years. Trained staff measured height, weight, and recorded gender, age, and race. Data were voluntarily reported to the State Department of Health.

RESULTS

American Indian children consistently had higher rates of overweight and obesity compared to white children. Across the years, 16.3% of white students were overweight, whereas 19.3% of American Indian students were overweight. In addition, 14.5% of white children were obese and 25.9% of American Indian children were obese. Examining by rural versus urban schools, prevalence of overweight had been increasing among white male and female students and American Indian female students living in rural areas. Obesity is also increasing among rural white females and male and female American Indian children.

CONCLUSIONS

The findings here suggest that although American Indian children are at higher risk, in general, compared to white children, rural populations in general are experiencing increases in childhood overweight and obesity. Targeted rural interventions beginning at an early age are necessary to improve the health of rural children, especially in American Indian communities.

A Community-Based, Environmental Chronic Disease Prevention Intervention to Improve Healthy Eating Psychosocial Factors and Behaviors in Indigenous Populations in the Canadian Arctic

Diet-related chronic diseases are highly prevalent among indigenous populations in the Canadian Arctic. A community-based, multi-institutional nutritional and lifestyle intervention—Healthy Foods North—was implemented to improve food-related psychosocial factors and behaviors among Inuit and Inuvialuit in four intervention communities (with two comparison communities) in Nunavut and the Northwest Territories, Canada, in 2008. The 12-month program was developed from theory (social cognitive theory and social ecological models), formative research, and a community participatory process. It included an environmental component to increase healthy food availability in local stores and activities consisting of community-wide and point-of-purchase interactive educational taste tests and cooking demonstrations, media (e.g., radio ads, posters, shelf labels), and events held in multiple venues, including recreation centers and schools. The intervention was evaluated using pre- and postassessments with 246 adults from intervention and 133 from comparison communities (311 women, 68 men; mean age 42.4 years; 78.3% retention rate). Outcomes included psychosocial constructs (healthy eating knowledge, self-efficacy, and behavioral intentions), frequency of healthy and unhealthy food acquisition, healthiness of commonly used food preparation methods, and body mass index (kg/m2). After adjustment for demographic, socioeconomic status, and body mass index variables, respondents living in intervention communities showed significant improvements in food-related self-efficacy (β = 0.15, p = .003) and intentions (β = 0.16, p = .001) compared with comparison communities. More improvements from the intervention were seen in overweight, obese, and high socioeconomic status respondents. A community-based, multilevel intervention is an effective strategy to improve psychosocial factors for healthy nutritional behavior change to reduce chronic disease in indigenous Arctic populations.

Evidence for validity of five secondary data sources for enumerating retail food outlets in seven American Indian communities in North Carolina

Background

Most studies on the local food environment have used secondary sources to describe the food environment, such as government food registries or commercial listings (e.g., Reference USA). Most of the studies exploring evidence for validity of secondary retail food data have used on-site verification and have not conducted analysis by data source (e.g., sensitivity of Reference USA) or by food outlet type (e.g., sensitivity of Reference USA for convenience stores). Few studies have explored the food environment in American Indian communities. To advance the science on measuring the food environment, we conducted direct, on-site observations of a wide range of food outlets in multiple American Indian communities, without a list guiding the field observations, and then compared our findings to several types of secondary data.

Methods

Food outlets located within seven State Designated Tribal Statistical Areas in North Carolina (NC) were gathered from online Yellow Pages, Reference USA, Dun & Bradstreet, local health departments, and the NC Department of Agriculture and Consumer Services. All TIGER/Line 2009 roads (>1,500 miles) were driven in six of the more rural tribal areas and, for the largest tribe, all roads in two of its cities were driven. Sensitivity, positive predictive value, concordance, and kappa statistics were calculated to compare secondary data sources to primary data.

Results

699 food outlets were identified during primary data collection. Match rate for primary data and secondary data differed by type of food outlet observed, with the highest match rates found for grocery stores (97%), general merchandise stores (96%), and restaurants (91%). Reference USA exhibited almost perfect sensitivity (0.89). Local health department data had substantial sensitivity (0.66) and was almost perfect when focusing only on restaurants (0.91). Positive predictive value was substantial for Reference USA (0.67) and moderate for local health department data (0.49). Evidence for validity was comparatively lower for Dun & Bradstreet, online Yellow Pages, and the NC Department of Agriculture.

Conclusions

Secondary data sources both over- and under-represented the food environment; they were particularly problematic for identifying convenience stores and specialty markets. More attention is needed to improve the validity of existing data sources, especially for rural local food environments.