Design and Methods of a Participatory Healthy Eating Intervention for Indigenous Children: The FRESH Study.

Objective: To increase vegetable and fruit intake, reduce body mass index (BMI), and improve parental blood pressure among American Indian families. Design: Randomized, wait-list controlled trial testing a multi-level (environmental, community, family, and individual) multi-component intervention with data collection at baseline and 6 months post-intervention. Setting: Tribally owned and operated Early Childhood Education (ECE) programs in the Osage Nation in Oklahoma. Participants: American Indian families (at least one adult and one child in a ECE program). A sample size of 168 per group will provide power to detect differences in fruit and vegetable intake. Intervention: The 6-month intervention consisted of a (1) ECE-based nutrition and gardening curriculum; (2) nutrition education and food sovereignty curriculum for adults; and (3) ECE program menu modifications. Main Outcome Measures: The primary outcome is increase in fruit and vegetable intake, assessed with a 24-h recall for adults and plate weight assessments for children. Secondary outcomes included objective measures of BMI among adults and children and blood pressure among adults.

Methods for Assessing Willingness to Try and Vegetable Consumption among Children in Indigenous Early Childcare Settings: The FRESH Study.

Food preferences begin in early childhood, and a child's willingness to try (WTT) new vegetables is an important determinant of vegetable intake. Young children living in rural communities are at increased risk for food insecurity, which may limit exposure to and consumption opportunities for vegetables. This manuscript describes the validation of the Farfan-Ramirez WTT (FR-WTT) measure using baseline data from the FRESH study, a gardening intervention for Native American families with preschool-aged children in Osage Nation, Oklahoma. Individually weighed vegetable containers were prepared with six types of vegetables and ranch dip. Researchers presented children (n = 164; M = 4.3 years, SD = 0.8) with these vegetables preceding a snack- or lunch time and recorded the child's FR-WTT for each vegetable using a 5-point scale, ranging from "did not remove food (0)" to "put food in mouth and swallowed (4)". After the presentation period, contents were re-weighed to calculate vegetable consumption. Household parents/guardians completed the Child Food Neophobia Scale (CFNS) for their child. FR-WTT scores were positively correlated with consumption weights of all vegetables (r = 0.7613, p < 0.0001) and each vegetable individually (r = 0.2016-0.7664). The total FR-WTT score was inversely correlated with the CFNS score (r = 0.3268, p < 0.0001). Sensitivity analyses demonstrated similar relationships by BMI, food security, and age. In conclusion, the FR-WTT is a valid method for assessing young children's vegetable eating behavior and intake.

Process Evaluation Tool Development and Fidelity of Healthy Retail Interventions in American Indian Tribally Owned Convenience Stores: the Tribal Health Resilience in Vulnerable Environments (THRIVE) Study.

BACKGROUND: The Tribal Health Resilience in Vulnerable Environments (THRIVE) study aimed to increase healthy food access in 2 rural American Indian communities. The intervention sought to increase fruit and vegetable availability, variety, and convenience through placement, promotion, and pricing of healthy foods and beverages in tribal convenience stores. OBJECTIVE: The aim of this study was to describe the development and implementation of the study process evaluation tool to assess intervention fidelity as part of this cluster-controlled trial. METHODS: Eight stores (2 intervention and 2 control stores per Nation) participated in the study, implemented from May 2016 to May 2017. A web-based survey tailored to store layouts and intervention components assessed how often intervention items were available, approximate quantity available, and whether placement of healthier food items and promotional materials were implemented as designed. After pilot testing the survey, tribal staff members implemented it to collect process evaluation data in the 8 stores during a period of 9-12 mo, assessing study implementation and potential changes in control stores. RESULTS: Promotional materials were available ≥75% of the time for most intervention locations. Fruit availability was similar in Nation A and Nation B intervention stores (79-100% compared with 70-100%), whereas fresh vegetable availability was higher in Nation B compared with Nation A (95-96% compared with 55-75%). Both control stores in Nation A and 1 control store in Nation B had moderate fruit and vegetable availability, ranging from 45% to 52%. No control stores in either Nation used intervention promotional materials. CONCLUSIONS: Process evaluation data indicate that the study was implemented with moderate to high fidelity. The development and implementation of the tool can inform future healthy retail interventions that aim to improve rural and tribal food environments.

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.