Pilot study of a heart-healthy food box intervention for Native Americans with uncontrolled hypertension: methods and results from the Chickasaw Healthy Eating Environments Research Study.

We sought to evaluate the acceptability and feasibility of a culturally tailored food box intervention for improving blood pressure (BP), food security and Body Mass Index (BMI) among Chickasaw Nation adults with uncontrolled hypertension. As part of the Chickasaw Healthy Eating Environments Research Study (CHEERS), we administered a group randomized pilot study in four tribal communities (two intervention, two control). Participants in the intervention communities received six heart-healthy food boxes, culturally tailored to traditional Chickasaw diet and current food context. Outcomes were measured over 6 months. We enrolled 262 participants, and 204 with complete data on key variables were included in the analysis. The food boxes were very popular, and we achieved high retention for follow-up data collection. Intervention community participants had 2.6 mmHg lower mean systolic BP and improved diet quality and BMI compared with control participants, although, as expected for a pilot study, the differences were not statistically significant. The culturally tailored diet intervention and randomized trial study design were acceptable and feasible for Chickasaw Nation adults with uncontrolled hypertension. Our findings support the value of tribal-food bank partnerships as a potential approach for reducing food insecurity and hypertension-related disparities in Native American communities.

The Center for Indigenous Innovation and Health Equity: The Osage Nation's Mobile Market.

Over the last decade, the Osage Nation has actively worked to build Tribal food sovereignty within the reservation where rates of chronic disease and food insecurity are higher than the United States general population. In 2013, the Nation repurposed land toward the development of a Tribal farm with the aim of providing healthy foods to Osage citizens. Produce from the farm is distributed to elders groups, at Tribal Head Starts and schools, and to support the tribal food distribution program. These efforts have led to improved vegetable intake among Osage children, contributing to improved food security, but there is concern that tribal members who live in more remote areas of the Nation or have transportation or mobility issues are not able to access farm production. In partnership with the Center for Indigenous Health Equity (CIIHE), Osage Nation engaged in a community-based participatory research study to assess reservation areas with the greatest barriers to healthy foods and to identify community priorities for intervention. Guided by the principles of food sovereignty, which assert that intervention efforts must address the underlying structural issues of inequality, Osage has designed a mobile market initiative to expand the reach of the Harvest Land farm and deliver healthy, tribally produced meats, herbs, and fresh vegetables to areas with the highest rates of food insecurity. We describe the participatory research efforts and evaluation strategies that center Osage priorities for food security and food sovereignty.

The Choctaw Nation's Growing Hope Program.

The Choctaw Nation of Oklahoma's Historic Preservation Department (HPD) and the Center for Indigenous Health Equity (CIIHE) are partnering to implement and evaluate food sovereignty interventions to better understand the potential impact of such programs on individual and community health. The HPD's Growing Hope Program is a food sovereignty initiative that aims to restore traditional Choctaw gardens, which were once a physical, social, and cultural center of Choctaw life. The program combines heirloom seeds and the stories of their origins, gardening education and technical assistance, cooking classes, and a Choctaw youth internship program to support intergenerational knowledge and the restoration of culture and food security. Since its inception the program has provided Choctaw families with ancestral Choctaw cultivar seeds and provided the technical assistance to support the growing of sustainable, healthy, traditional Choctaw foods.

Food Security and Food Sovereignty: The Difference Between Surviving and Thriving.

Previous research in American Indian and Alaska Native (AI/AN) communities has documented high prevalence of food insecurity. Yet many AI/AN scholars and communities have expressed concerns that the dominant societal conceptions of food security are not reflective of the teachings, priorities, and values of AI/AN communities. Food security initiatives often focus on access to food and, at times, nutrition but little consideration is given to cultural foods, the spirituality carried through foods, and whether the food was stewarded in a way that promotes well-being not just for humans but also for plants, animals, land, and water. Despite the concerns of AI/AN communities that their needs are not centered in dominant societal food conceptualizations and food security programming, the food sovereignty efforts of AI/AN communities have captured national attention as a solution to modern food system inequities. Indigenous Food Sovereignty (IFS) is a holistic approach to food that incorporates values of relationality, reciprocity, and relationships. Fundamental differences exist between food security and food sovereignty, yet dominant society often reduces IFS as a solution to food security, rather than an entirely different food system that is predicated on values that contrast with that of dominant society. Despite calls to decolonize the definition and measurement of food security, we explore whether fixing the concept of food security is a worthy endeavor or whether efforts would be better spent supporting the resurgence and revitalization of AI/AN food values, food knowledge, and community food sovereignty initiatives.

Supporting Traditional Foodways Knowledge and Practices in Alaska Native Communities: The Elders Mentoring Elders Camp.

The transmission of generational knowledge in Alaska Native communities has been disrupted by colonization and led to declining health among Alaska Natives, as evidenced by the loss of knowledge regarding traditional foods and foodways and increasing rates of cardiometabolic disorders impacting Alaska Natives. Elders play a central role in passing down this generational knowledge, but emerging Elders may have difficulty in stepping into their roles as Elders due to the rapid social and cultural changes impacting their communities. The Center for Alaska Native Health Research (CANHR) and the Denakkanaaga Elders Program are partnering with the Center for Indigenous Innovation and Health Equity to uplift and support traditional food knowledge and practices to promote health in Alaska Native communities. Guided by a decolonizing and Indigenizing framework, researchers at CANHR are working with Athabascan Elders in the Interior of Alaska to strengthen and protect the intergenerational transmission of cultural knowledge and practices for emerging Elders. This community-academic partnership will implement and evaluate an Elders Mentoring Elders Camp to focus on repairing and nurturing relationships through the practice and preservation of cultural knowledge and practices, including traditional foodways. This initiative contributes to the intergenerational transmission of knowledge, which is necessary to keep culture alive and thriving.

The Development of a Community-Led Alaska Native Traditional Foods Gathering.

Traditional foods and foodways are a critical part of health and well-being for Alaska Native/American Indian (ANAI) peoples. However, many of these foods are being replaced by ultra-processed foods high in fat, sugar, and sodium. The cultural knowledge needed to gather, hunt, and fish to acquire these foods is not being passed down to younger generations, due to lingering effects of colonialism, leading to poor health outcomes among ANAI peoples. Southcentral Foundation (SCF) and the Center for Indigenous and Health Equity (CIIHE) are using community-based participatory research to identify and prioritize food sovereignty interventions to strengthen the transmission of cultural knowledge across generations and improve ANAI health. Through the implementation of a comprehensive landscape analysis and the development of a community advisory board, SCF has planned an Alaska Native Traditional Foods Gathering to highlight regional efforts to document, revitalize, and share cultural food knowledge and practices to build healthy communities.

Food Sovereignty and Health: A Conceptual Framework to Advance Research and Practice.

Settler colonialism disrupted traditional Indigenous foodways and practices and created high rates of diet-related disease among Indigenous peoples. Food sovereignty, the rights of Indigenous peoples to determine their own food systems, is a culturally centered movement rooted in traditional Indigenous knowledge. This approach directly intervenes upon systems-level barriers to health, making it an important strategy for health equity. While food sovereignty initiatives can be found within many Indigenous communities, the conceptual linkages between food sovereignty and health have not been well documented within the public health literature. We present a practice-informed conceptual framework developed as part of the Center for Indigenous Innovation and Health Equity (CIIHE) initiative, a community-academic partnership with the goal of strengthening Indigenous food systems and practices to promote health and well-being. The framework emphasizes connectedness, including the transmission of knowledge across generations and the restoration of relational responsibilities, as central to Indigenous concepts of health and wellness.

Framing an Indigenous Food Sovereignty Research Agenda.

Access to healthy and appealing food is essential for individuals to be able to live a healthy and quality life. For decades, food security has been a priority issue for public health professionals. Food sovereignty expands upon the concept of food insecurity (i.e., having access to nutritious and culturally relevant food) by incorporating people's rights to define their own food system. The expanded focus of food sovereignty on food systems prioritizes public health professionals' role in supporting environmental- and systems-level initiatives and evaluating their implications for health, economics, and the natural environment. Food sovereignty is of particular importance for Indigenous peoples (i.e., American Indian, Alaska Native, Native Hawaiian, and Pacific Islander communities). Colonization had demonstrable consequences, with many Indigenous communities being forcibly relocated from traditional lands, alongside the destruction of traditional food sources. Indigenous food sovereignty aligns with the sovereign nation status that American Indian tribes and Alaska Native communities have with the United States. Furthermore, the worldviews that incorporate Indigenous communities' relational responsibilities to care for their food systems, according to their traditional practices and beliefs (Coté, 2016; Morrison, 2011), uniquely positions Indigenous peoples to lead food sovereignty initiatives. In this article, we explore what is currently known regarding food sovereignty and health. We then discuss opportunities to expand the evidence on Indigenous food sovereignty's relationships with (1) health and well being, (2) economics, (3) the natural environment, and (4) programming facilitators and barriers.

Food Systems, Food Sovereignty, and Health: Conference Shares Linkages to Support Indigenous Community Health.

The Center for Indigenous Innovation and Health Equity (CIIHE) at Oklahoma State University Center for Health Sciences (OSU-CHS) is a community-academic partnership with Indigenous peoples from Alaska, Hawai'i, and Oklahoma. The CIIHE supports communities to strengthen traditional food practices and food sovereignty and evaluate the impact of those efforts on health. In February 2022, the CIIHE sponsored and hosted a virtual conference to better understand how food sovereignty initiatives can improve health. More than 600 participants gathered to hear the latest research and practice in the areas of public health and agriculture, nutrition, community-based and Indigenous knowledge, and health economics. Community-led food sovereignty initiatives being implemented as part of the CIIHE were featured along with other Indigenous initiatives in urban, rural, and reservation communities. A survey was administered to conference participants to assess food sovereignty topics and priorities for future research. In this Practice Note, we describe innovative community-led initiatives presented as part of the conference and recommendations for action emerging from qualitative and quantitative data collected from conference participants.

The effect of food prescription programs on chronic disease management in primarily low-income populations: A systematic review and meta-analysis.

Background: Having low-income limits one's ability to purchase foods that are high in nutritional value (e.g. vegetables and fruits (V/F)). Higher V/F intake is associated with less diet-related chronic disease. Food pharmacy programs are potential solutions to providing V/F to low-income populations with or at-risk for chronic disease. Aim: This systematic review aimed to determine the effect of food pharmacy programs, including interventions targeting populations at-risk for chronic disease. Methods: We searched Pubmed and Google Scholar databases for studies reporting on food pharmacy interventions and outcomes (hemoglobin A1c, body mass index (BMI), V/F intake, and blood pressure). We calculated pooled mean differences using a random-effects model. Seventeen studies met our inclusion criteria; 13 studies used a pre/post study design, three used a randomized controlled trial, and one was a post-survey only. Results: We found that the pooled mean daily servings of V/F (0.77; 95% CI: 0.30 to 1.24) was higher and BMI (-0.40; 95% CI: -0.50 to -0.31) was lower with food pharmacy interventions We did not find any differences in the pooled mean differences for hemoglobin A1c or systolic blood pressure. Conclusion: Findings posit that food pharmacy programs delivered to primarily low-income individuals with comorbidities may be a promising solution to improving V/F intake and possibly overall diet in these populations.

Impact of a Healthy Retail Intervention on Fruits and Vegetables and Total Sales in Tribally Owned Convenience Stores: Findings From the THRIVE Study.

BACKGROUND: Healthy retail interventions are a recommended intervention strategy to address diet-related diseases, such as obesity and diabetes; however, retail managers are concerned about their bottom line. This study's aim was to assess the impact of a healthy retail intervention on fruits and vegetables (FV) sales, as well as total sales, in tribally owned convenience stores where grocery stores are scarce. METHOD: We analyzed weekly sales data over the first 6 months of a healthy retail intervention. We assessed the proportion of sales from two FV baskets. The FV basket included all fresh, canned, and dried FV sold at stores; while the fruits, vegetables, and salads (FVS) basket included all FV items as well as all salads sold. We compared mean weekly sales rates in intervention and control stores over the 6-month period using generalized estimating equations models to account for repeated measures. RESULTS: Mean weekly FV basket sales rates were higher in intervention stores than control stores in both Nations. Mean weekly FVS baskets sales were significantly higher in intervention stores than control stores in one Nation and were higher, but not statistically significant, in intervention stores in the other Nation. Total sales remained steady throughout the intervention period. CONCLUSIONS: The THRIVE (Tribal Health and Resilience in Vulnerable Environments) intervention increased FV sales without negatively affecting total sales. Policy and Practice Implications. Healthy retail interventions in tribal convenience stores, where many Native Americans living in rural areas shop due to scarcity of grocery stores, could improve diet-related disparities without reducing total sales.

Prevention Research with Indigenous Communities to Expedite Dissemination and Implementation Efforts.

Effectively translating evidence-based interventions into clinic and community settings is an increasing priority for health researchers. The successful dissemination and implementation (D&I) of interventions found efficacious ensures that major health funders such as the National Institutes of Health can demonstrate a return on investment in biomedical and behavioral research and that all populations receive maximum benefit from scientific discoveries. However, the products of research efficacy trials, the evidence-based interventions, are rarely designed with D&I in mind, rendering these interventions fundamentally misaligned with real-world settings. Further, while some evidence-based interventions have been successfully adapted for implementation in indigenous communities, few such examples have been published. Literature regarding the adoption and implementation of evidence-based interventions in indigenous communities is scarce, and the feasibility of scaling up successful interventions is poorly understood, potentially widening health disparities. The Intervention Research to Improve Native American Health (IRINAH) partners are generating efficacy data on community-responsive and engaged interventions that are also designed to facilitate D&I efforts, reducing the time between research to practice to benefit indigenous communities, should these interventions prove effective. In this manuscript, we provide an overview and key challenges of D&I science with indigenous communities. We then use IRINAH case studies to highlight strategies that IRINAH partners are using to plan for the scale-up and implementation of the studies. We conclude with recommendations to inform the next phase of IRINAH research efforts.

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.

Building Capacity for Productive Indigenous Community-University Partnerships.

This paper describes capacity development as a key aspect of community-based research with indigenous communities. University research engagement with indigenous communities includes extensive, and often negative, historical antecedents. We discuss strategies for developing effective, egalitarian, and balanced indigenous community-university relationships to build research capacity of these communities, and to create sustainable partnerships to improve health and wellness, and to reduce health disparities. We draw on the experience of eight investigators conducting research with indigenous communities to assess effective strategies for building and enhancing partnerships, including (1) supporting indigenous investigator development; (2) developing university policies and practices sensitive and responsive to Indigenous community settings and resources, and training for research; (3) developing community and scientifically acceptable research designs and practices; (4) aligning indigenous community and university review boards to enhance community as well as individual protection (e.g., new human subjects training for Indigenous research, joint research oversight, adaptation of shorter consent forms, appropriate incentives, etc.); (5) determining appropriate forms of dissemination (i.e., Indian Health Services provider presentation, community reports, digital stories, etc.); (6) best practices for sharing credit; and (7) reducing systematic discrimination in promotion and tenure of indigenous investigators and allies working in indigenous communities.

A Nutrition Environment Measure to Assess Tribal Convenience Stores: The THRIVE Study.

In rural American Indian (AI) communities, where supermarkets are rare, tribally owned and operated convenience stores are an important food source. Food environment measures for these settings are needed to understand and address the significant diet-related disparities among AIs. Through a tribal-university partnership that included tribal health and commerce representatives from two Native Nations in rural southeastern Oklahoma, we developed the Nutrition Environment Measures Survey for Tribal Convenience Stores (NEMS-TCS) to inform the development and evaluation of a healthy food retail intervention. The NEMS-TCS assessed four scored domains of the rural convenience store food environment-food availability, pricing, quality, and placement-and included 11 food categories that emphasized ready-to-eat food items. Trained raters administered the NEMS-TCS using a sample of 18 rural convenience stores (primarily ranging between 2,400 and 3,600 square feet). We assessed interrater reliability with kappa statistics for dichotomized variables and intraclass correlation coefficients (ICC) for continuous variables. NEMS-TCS demonstrated high inter-rater reliability for all food categories (>85% agreement), subscores (ICC = 0.73-1.00), and the total score (ICC = 0.99). The NEMS-TCS responds to recent calls for reliable measures for rural food environments and may be valuable for studying food environments of large convenience stores in other Native Nations as well as other rural settings.

A Healthy Retail Intervention in Native American Convenience Stores: The THRIVE Community-Based Participatory Research Study.

Objectives. To assess a healthy retail intervention in Tribal convenience stores in Oklahoma.Methods. We adapted healthy retail strategies to the context of 8 Tribally owned stores. We assessed individual- and store-level outcomes in a cluster-controlled intervention trial (April 2016-June 2017). We measured fruit and vegetable intake, store environment perceptions, and purchases before and after the intervention among a cohort of 1637 Native American shoppers. We used mixed-effects linear regression to estimate pre- to postintervention changes in and between groups.Results. We followed 74% of participants (n = 1204) 9 to 12 months. Intervention and control participants perceived healthier stores after intervention. Higher shopping frequency was related to purchases of fruits, vegetables, and healthy items.Conclusions. Intervention exposure was associated with healthy purchasing but not fruit and vegetable intake. Research is needed to further assess impacts of environmental interventions on intake.Public Health Implications. As the first healthy retail intervention in Tribally owned stores, our results contribute evidence for environmental and policy interventions to address obesity in Tribal Nations. Multicomponent interventions, led by Tribal leaders from diverse sectors, are needed to create healthy environments and sustainable improvements in Native American health.

Food choice considerations among American Indians living in rural Oklahoma: The THRIVE study.

In rural American Indian (AI) communities, access to affordable, healthy foods is often limited. Understanding AI food choice considerations when selecting foods, such as sensory appeal, cost, or health, is an important yet understudied topic for eliminating persistent AI health disparities. In partnership with the Chickasaw Nation and Choctaw Nation of Oklahoma, we administered a modified version of the Food Choice Values (FCV) Questionnaire to a cross-sectional sample of 83 AI patrons shopping at tribally-owned convenience stores ≥3 times per week. The FCV Questionnaire uses 25 items to assess eight FCV subscales related to buying and eating food, including sensory appeal; safety; accessibility; convenience; health/weight control; organic; tradition; and comfort. We compared mean scores for each FCV subscale by demographic groups using t-tests and ANOVA. We used confirmatory factor analysis (CFA) to examine how well the data from this population fit FCV subscale constructs. We then used cluster analysis, MANOVA, and discriminant analysis to characterize distinct segments of the population based on patterns of FCV endorsement. Appeal, safety, and access FCVs were most strongly endorsed across the sample. Prioritization of FCVs varied by age, gender, income, and education. Our cluster analysis identified four groups, or segments, each with distinct patterns of FCV endorsement: limited endorsement of any FCVs (23.3%); safety and sensory appeal (32.9%); health/weight control (17.8%); and broad endorsement of FCVs (26.0%). These groups varied by age and employment status. Findings from this analysis informed the design and implementation of a healthy retail intervention comprised of new healthful foods and beverages, product placement and marketing strategies within four tribally-owned and operated convenience stores. Public health interventions aimed at reducing nutrition-related disparities in rural AI populations may benefit from assessing food choice considerations.

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

OBJECTIVES: To examine food insecurity and cardiovascular disease-related health outcomes among American Indians (AIs) in rural Oklahoma. METHODS: We surveyed a cross-sectional sample of 513 AI adults to assess food insecurity domains (i.e., food quality and quantity) and obesity, diabetes, and hypertension. RESULTS: Among AIs surveyed, 56% reported inadequate food quantity and 62% reported inadequate food quality. The unadjusted prevalence of diabetes (28.4% vs 18.4%), obesity (60.0% vs 48.3%), and hypertension (54.1% vs 41.6%) was higher among participants with inadequate food quantity than among those with adequate food quantity. These associations did not reach statistical significance after adjustment for age, gender, study site, education, and income. The unadjusted prevalence of obesity (60.7% vs 45.8%), diabetes (27.3% vs 18.8%), and hypertension (52.5% vs 42.5%) was higher among those with inadequate food quality than among those with adequate food quality, even after adjustment for age, gender, study site, education, and income. CONCLUSIONS: Tribal, federal, and state policymakers, as well as businesses and nonprofit organizations, must collaboratively take aggressive action to address food insecurity and its underlying causes, including improving tribal food environments, reducing barriers to healthy foods, and increasing living wages.

The adaptation and implementation of a community-based participatory research curriculum to build tribal research capacity.

We studied community-based participatory research in American Indian/Alaska Native communities. We have presented a case study describing a community-clinic-academic partnership with the goal of building tribal capacity and infrastructure to conduct health disparities research. The 2-year intensive training was guided by the framework of an evidence- and community-based participatory research curriculum, adapted and implemented with practice-based data collection activities and seminars to address issues specific to community-based participatory research with sovereign tribal nations. The initiative highlighted important challenges and opportunities in transdisciplinary partnerships; identified gaps in conducting health disparities research at the tribal, clinical, and university levels; and led to important policy change initiatives in all the partner settings.