Preventing diabetes and obesity in American Indian communities: the potential of environmental interventions14

Joel Gittelsohn and Megan Rowan

ABSTRACT Obesity, diabetes, and other diet-related chronic diseases persist in American Indians at rates that are signicantly higher than those in other ethnic minority populations. Environmental interventions to improve diet and increase physical activity have the potential to improve these health outcomes, but relatively little work has taken place in American Indian communities. We reviewed the experiences and ndings of the following 3 case studies of intervention trials in American Indian communities: the Pathways trial, which was a school-based trial that focused on children; the Apache Healthy Stores program, which was a food-store program that focused on food preparers and shoppers; and the Zhiwaapenewin Akinomaagewin trial, which was a multiinstitutional trial for First Nations adults that worked with food stores, elementary schools, and health and social services agencies. All 3 trials showed mixed success. Important lessons were learned, including the need to focus on supply and demand, institutional and multilevel approaches, and the identication of institutional bases to sustain programs. Am J Clin Nutr 2011;93(suppl):1179S83S.

INTRODUCTION

American Indian and First and diabetes Nations peoples suffer from remarkably high rates of obesity and diabetes, and those rates have been steadily increasing (1, 2). From 1994 to 2004, rates doubled among American Indians aged <35 y (2). In American Indian adults, prevalence rates of overweight and obesity tend to be higher in women and certain tribal groups (3, 4). American Indian adults experience signicantly higher obesity rates than those of their minority and nonminority counterparts (4). Obesity is a potent risk factor for diabetes (5), cardiovascular disease, and hypertension (6). Signicant racial disparities illustrate increased risks for American Indian adults. Compared with the US general population, American Indians are 2.3 times more likely to be diagnosed with diabetes, and the prevalence of associated comorbities is 50% higher (5). Cardiovascular disease rates range from 16.7% in American Indian men to 9.1% in the general population of men (6). Similar discrepancies have been shown in American Indian women, who experience a median rate of 13.1 compared with the national rate of 6.8 (6). Median hypertension rates are also signicantly higher in American Indian men and women than in the general population (38.2 and 36.8 compared with 29.1 and 28.0, respectively) (6). Total energy and fat intake are associated with obesity and increased risk of many chronic diseases (7). Low fruit and vegetable consumption has also been associated with chronic

disease risk (8). Studies showed that adult American Indian diets are typically poor or need improvement, with low proportions meeting recommendations for consumption of fruit, vegetables, dairy, and micronutrient (9, 10). Conversely, there has been a documented shift to rened carbohydrates (eg, rened sugars) and high-fat and -sodium foods (9, 10). The external environment plays an important role in inuencing individual diets and risks for developing obesity and other chronic disease (11). Many minorities live in obesogenic food environments, which include an abundance of small food stores, carry outs, and fast-food restaurants and poor access to fruit and vegetables and other whole foods (12). Within food deserts, supermarkets are often scarce (13). High rates of obesity in North America have been associated with environmental factors that increase energy and fat intake and lead to decreased energy expenditure (14). The presence of supermarkets has been shown to have a positive effect on diet and rates of chronic disease (14). However, to our knowledge, these associations have not been assessed in American Indian communities. Most American Indian and First Nations communities are rural, with a high proportion of individuals living at or below the poverty level. Communities vary greatly in terms of access to roads, food stores, and traditional food sources. There is limited literature on the food environment in American Indian communities. According to the few studies available, large supermarkets are rare on most American Indian reservations, and the supermarkets that are present carry a limited range of foods (15). In lieu of supermarkets, most American Indians are dependent on gas-station stores, which primarily stock unhealthy foods (eg, sodas, chips, and candy) and rarely carry produce (15). Accessing affordable, high-quality healthy foods often requires off-reservation travel .30 miles (15). More studies are
1 From the Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. 2 Presented at the symposium Nutrition and Health Disparities: An Issue from Bench to Bedside and Community, held at Experimental Biology 2010, 27 April 2010. 3 Supported by the National Research Initiative of the US Department of Agriculture Cooperative State Research, Education and Extension Service (grant 2002-35200-12225) and an American Diabetes Association Clinical Research Award. 4 Address correspondence to J Gittelsohn, Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD 21205-2179. E-mail: jgittels@jhsph.edu. First published online March 16, 2011; doi: 10.3945/ajcn.110.003509.

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necessary to investigate these key environmental antecedents to American Indian nutrition, obesity, and chronic disease. Moreover, interventions are necessary to improve food availability in these settings. There are several strategies that can be used to improve access (pricing and availability) to healthy foods in low-income minority settings. Within food stores, interventions can decrease the availability of unhealthy foods (eg, high fat and sugar), increase the availability of healthy foods (eg, low fat and sugar and high ber), alter physical features (eg, store layout, refrigeration units, storage, and shelving), change the setting for the provision of information (eg, point-of-purchase promotions), and manipulate prices (1619). Alone or in combination, food storebased strategies have the potential to affect access (ie, supply) and point-of-purchase decision making regarding food choices (ie, demand) and, thus, increase the likelihood of sustainability (16 19). However, the majority of store-intervention programs have been conducted within supermarkets in large US cities (20, 21). Few programs have worked with small convenience stores, which constitute the most common day-to-day food-purchase outlets for many rural American Indian populations. Environmental interventions can also change access to foods within neighborhoods by building new supermarkets, developing farmers markets, and improving transportation (21, 22). At the policy level, store standards (eg, limiting the provision of unhealthy foods and the promotion of those foods), pricing, menu labeling, and zoning policies have been tested in several high- and middle-income urban settings but have yet to be trialed in American Indian communities (2325). Other approaches, such as improving food networks (eg, distributors, producers, and retailers) and local production and increasing the content of foods could spur wideranging change that could reach American Indians. In short, little work has been done to change the food environment in American Indian communities. With the use of 3 case studies of intervention trials in American Indian communities, this article addressed the following key questions: 1) Who are the key stakeholders in environmental interventions in American Indian settings? How can they best be involved? 2) What approaches, or combination of approaches, to environmental change are likely to be most effective in American Indian communities? 3) What are some common lessons learned that can be applied to environmental intervention programs in other American Indian communities?

to provide a contextually rich description of each case to permit cross-case comparisons via pattern matching.
CASE STUDY 1: PATHWAYS TRIALCHANGING THE SCHOOL FOOD AND PHYSICAL ACTIVITY ENVIRONMENT

Stakeholder engagement The Pathways trial was a multicenter intervention trial funded by the National Heart, Lung, and Blood Institute that sought to reduce obesity and common psychosocial and behavioral risk factors in American Indian school children (2634). The trial took place in 7 American Indian communities from 1993 to 2001 (2634). Key stakeholders included tribal health departments, tribal administration and members, school administrators and staff, and school board members who provided approval and participated in program planning and implementation (2634). Substantial formative research was conducted to aid in the design of the intervention (26, 27).
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Approach to environmental change Pathways interventions were centered in elementary schools and include 4 main components as follows: a specially designed classroom curriculum for grades 35, changes to the school food service, an enhanced physical education program, and a family component (2830). The Pathways trial sought to change the school food environment by providing training and guidelines for school food-service workers on how to order, prepare, and serve foods that were lower in fat compared with usual foods offered (2830). In addition, teachers were given guidelines on nonfood rewards as a means of reducing competitive foods within schools (2830). Materials sent home with children and in-school events encouraged parents to provide healthy foods at home (2830). The Pathways trial also sought to change the school activity environment through an enhanced physical education program on the basis of the Sports, Play & Active Recreation for Kids (SPARK) curriculum and including additional noncompetitive American Indian games (30). The Pathways process evaluation showed that the program was implemented with different levels of success depending on the intervention component (31). The school curriculum and foodservice components were implemented with a high reach and dose, with improvement in implementation of the food-service guidelines from year to year of the intervention (31). The physical activity program was implemented with a high reach but only a moderate dose because most schools were able to meet target levels of 3 classes/student/wk but not the ideal dose of 5 classes/wk (31). The family component was weakly implemented with drops in rates of family pack return cards that came back and decreased attendance at school events from year to year as the study progressed (31). Program effect The Pathways trial saw positive changes in psychosocial measures and improvements in diet associated with the intervention (32, 33). However, no signicant improvements were seen in physical activity levels or in obesity, which was the primary outcome (32, 33). Although the Pathways trial was

METHODS

We addressed these questions by using a case-study approach (25). We selected 3 programs that were implemented in varied geographical settings and that sought to change the food and/or physical activity environment as a means of addressing the chronic-disease epidemic. The 3 case studies selected met the following criteria: 1) personal experience and familiarity of the lead author with the program, 2) peer-reviewed publications that detailed the formative research, process evaluation, and effect of intervention trials, and 3) signicant components of the intervention sought environmental changes. Our analyses sought

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successful in changing the school environment in American Indian communities, factors outside schools counter-balanced those within schools (33, 34). Therefore, changes in the home and community were not present to adequately support changes in schools.
CASE STUDY 2: APACHE HEALTHY STORES PROGRAMCHANGING THE COMMUNITY FOOD ENVIRONMENT

Stakeholder engagement The Apache Healthy Stores (AHS) program was a communitybased environmental intervention trial funded by the US Department of Agriculture that sought to increase the availability of healthy food options in local food stores and increase the purchase and consumption of these foods (3537). The trial took place in the White Mountain and San Carlos Apache reservations from 2003 to 2005 (3537). Key stakeholders included tribal administration and members, store owners and managers, and tribal health departments, particularly the diabetes prevention programs (35). Stakeholders contributed to program planning and assisted in the implementation of the program. The intervention was developed through formative research and an engagement process that centered on community workshops (35). Approach to environmental change The AHS program sought to change the food environment by working with small and large food stores to increase the range of healthy options and to promote these foods at the point of purchase and through community media (36). Trained staff worked with local stores owners and managers to increase the stocking of healthy foods that were selected through the community workshop process (36). These foods were promoted in stores through interactive sessions, posters, yers, and small promotional giveaways (eg, water bottles and food clips) (36). Community media reinforced key messages through radio announcements, newspaper articles, and cartoons (36). At the store level, the program was implemented with a high level of dose and reach and a moderate to high level of delity (36). At the community level, the AHS program was implemented with a moderate degree of delity and dose (36). At the individual level, cooking demonstrations and taste tests reached a large number of community members with a high dose (36). Implementing the AHS program on multiple levels (store, community, and individual) was challenging and differed between levels (36). Overall, improvements were seen from start to nish as program staff monitored, documented, and responded to barriers to implementation (36, 37). Program effect The AHS program was successful in showing improvements in food-related knowledge, healthy food intentions, and the frequency of healthy food purchasing among the main food preparer or shopper of studied households (37). Modest improvements in gram intakes of promoted healthy foods and decreases in less healthful high-fat, high-sugar foods, were shown in association with the highest levels of exposure to the intervention (37). The combination of mass-media activities, in-store signage at the

point of purchase, interactive sessions, and the increased availability of healthy food options in local stores were responsible for the success of the intervention (37). The study results conrmed that trials that seek to change the food environment have the potential to favorably affect various psychosocial factors, food consumption, and food-related behaviors that would reduce risk of obesity and other diet-related chronic diseases. On the other hand, potential improvements in health outcomes were not assessed. Therefore, it is possible that improvements in diet were marginal and not associated with measurable health benets. Interventions that engage multiple community settings are likely to show a broader range of benets. Finally, the AHS program was sustained and still continues to operate in one of the 2 American Indian communities by the local diabetes prevention program.

CASE STUDY 3: ZHIWAAPENEWIN AKINOMAAGEWIN TRIALCHANGING THE FOOD AND PHYSICAL ACTIVITY ENVIRONMENT
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Stakeholder engagement The Zhiwaapenewin Akinomaagewin (ZA) trial was a communitybased environmental intervention trial funded by the American Diabetes Association that combined a food-store intervention similar to that of the AHS program with a school program similar to that in the Pathways trial and worked in partnership with staff of the local health and social services (3842). The trial took place in 7 First Nations reserves from 2004 to 2006 (3842). Key stakeholders included band administration, store owners and managers, school administrators and teachers, and staff of health and social services (38). The ZA intervention was developed through formative research and community workshops (38) in which stakeholders contributed ideas and strategies. Approach to environmental change Similar to the AHS intervention, the ZA intervention sought to change the food environment by working with local food stores to increase the range of healthy options and to promote these foods at the point of purchase and through community media (38, 39). Promotions emphasized interactive sessions in stores, community centers, and at school events and emphasized taste testing and healthy cooking demonstrations (38, 39). A key difference between the ZA and AHS interventions was that, in addition to these changes in local food stores, a locally developed health curricula was introduced to students in grades 35 (38, 39). The school curriculum, which was adapted from a previously successful program (17), reinforced key messages introduced in stores. Family packs were sent home with students (38, 39). Physical activity and dietary changes were promoted through the school program and community activities, including walking groups (38, 39). School-curricula implementation had moderate delity with 63% of lessons delivered as planned. Store activities had moderate delity; the availability of all promoted foods was 70%, and appropriate shelf labels were posted 60% of the time (39). Cooking demonstrations were performed with a 71% delity and high dose (39). A total of 156 posters were placed in community locations; radio, cable television, and newsletters were used (39).

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Interviews revealed that the program was culturally acceptable and relevant, and suggestions for improvement were made (39). Program effect Baseline and follow-up data were collected before and after the 9-mo intervention program in schools, stores, and communities that aimed to improve diet and increase physical activity in adults (41). Regression analyses indicated a signicant change in the knowledge of respondents in intervention communities (P , 0.019) (41, 42). There was also signicant increase in the frequency of healthy food acquisition in respondents in the intervention communities (P , 0.003) (41, 42). However, there were no signicant changes in the physical activity or body mass index in either the intervention or comparison groups (41, 42). The ZA program was expanded to additional First Nations reserves after completion of the trial.
DISCUSSION AND CONCLUSIONS

As we examined our 3 environmental intervention case studies, several key common patterns emerged. First, American Indian chronic diseaseprevention strategies appeared to be successful when they functioned at multiple levels, including environmental and individual levels. An additional pattern was that such programs sought to change the food and physical activity environments by partnering with key local stakeholders such as food retailers, schools, and other community organizations. With the use of these strategies, institutional-level intervention components promoted healthy dietary and behaviors in a way that inuenced household (eg, food purchasing) and individual foodrelated psychosocial factors and behaviors, which ultimately affected obesity and other diet-related chronic disease. Also, the interventions directly inuenced individual-level behaviors such as food choices. Second, complementary supply-and-demand approaches were important components of environmental interventions. Multilevel approaches were successful in changing diabetes- and obesityrelated psychosocial factors and dietary risk behaviors in each of the rural Native North American settings addressed in our case studies. As illustrated by the Pathways trial, the success of environmental changes in schools hinged on changes, support, and reinforcement at household and community levels. A change in any single institution should be complemented by reinforcing strategies in other institutions or at other levels. The AHS program successfully integrated each level of the food environment in its strategy, and by doing so, the program addressed the supply and demand needed to produce a signicant effect. The introduction of key foods addressed the supply, whereas workshops, interactive sessions, community media, and pointof-purchase marketing spurred the demand needed to sustain food supplies without subsidies or external reinforcements. However, despite this evidence, the majority of food-intervention programs operated at the store-level only. Other programs sought to increase demand through nutrition education but did little to affect availability or supply. Third, it was important to work in multiple institutions to achieve high exposure. Other programs have addressed demand through the media, point-of-purchase displays, and structural adjustments within stores but failed to extend their communi-

cations efforts to the greater community. The AHS and ZA programs achieved a high exposure by working with community leaders, such as local health services and community organizations. These leaders contributed to the design of a settingappropriate strategy and helped to extend the program reach through intertribal dissemination. By working in multiple institutions, such as schools, food stores, and community events, the AHS and ZA programs also increased the likelihood of interpersonal contact and reinforced messaging. Finally, it was important to nd an appropriate institutional base to sustain activities. Although addressing demand and working in multiple institutions provided the necessary mechanisms to produce a program effect, the long-term sustainability was dependent on the involvement of community partners. This was especially important in the American Indian communities in which tribal and local health-service agencies played a signicant role in the health and wellness of community members. As shown by the AHS and ZA programs, staff of health and social services could be useful collaborators because they had a vested interest in changing health behaviors. By engaging staff at the start of the program, ownership and capacity can be increased, which can be sustained post-intervention. This review had several limitations: 1) We considered interventions that took place in different settings and used varying approaches with a varying emphasis on changing the food environment, which made direct comparisons complex. We considered our ndings suggestive and provocative but not conclusive. 2) Our analyses were limited to retail food-store interventions. Environmental interventions could also include the provision of new supermarkets and farmers markets and improved transportation. 3) The cases selected did not address other variables within the food environment that affected the availability and consumption of retail store food in American Indian settings. Local hunting, farming, and food production and the external food-distribution chain needed to be analyzed to determine the sourcing variables that affected food access (availability and pricing). 4) As noted in our analysis of the Pathways trial, more research was needed to address the factors within the community that affected food choices. Those community factors and the associated organizations need to be included in future interventions and analyzed for effect. The environmental intervention showed great promise as a means to address the high rates of obesity and chronic disease in American Indian communities. Environmental interventions provided opportunities for improved diet and increased physical activity. Much future work remains. Often, behavior-change theories do not adequately address the inclusion of environmental factors as modiable elements of intervention strategies. We need rened approaches for modifying the food environment on the basis of solid evidence. There has been a lack of food-store interventions in urban American Indian settings where there is a greater dependence on small stores that lack access to local food producers. Future work should consider the role of prepared foods and the prepared-food environment (eg, menus, foodpreparation methods, and pricing) in the American Indian diet and develop and test pilot interventions that address these

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concerns. Future interventions should also place greater emphasis on the involvement of community members and organizational leaders in the development and implementation of interventions. A community-based approach is key to sustainability and acceptability. Long-term sustainability is also dependent on supportive policies. However, policy-makers are typically interested in health outcomes as a measure of the program success. Future work needs to show the benets of these programs by including long-term-effect health assessments.
The authors responsibilities were as followsJG: was the primary investigator or coinvestigator on all studies reviewed and assisted with the preparation and review of the manuscript; and MR: performed the literature review and drafted the manuscript. Neither of the authors had a conict of interest.

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