Breanna Anderson

NUTR 640 Assessment Paper

November 28, 2017

Childhood Obesity in Native American Populations

The epidemiological transition is characterized by a shift from infectious disease to

chronic disease as a populations primary public health problem. This describes recent
trends in Native American communities. Among Native American populations,
undernutrition and infectious disease were the primary concerns prior to 1970, but
alongside the transition away from traditional foods towards high-energy alternatives (e.g.
processed foods and convenience foods), obesity and its associated outcomes, including
type II diabetes mellitus, cardiovascular disease, and cancer have outpaced these concerns
in morbidity and mortality1. This shift in the food environment and its associated health
consequences coincide with a transition from a subsistence to cash economy as well as the
foods available as a result of government rations and commodities2. Food insecurity, due to
a lack of access to healthful and nutritious food options, is another risk factor that puts
Native American communities at risk for developing obesity. A study assessing food
security, specifically in four southwestern reservation communities in the states of Arizona
and New Mexico, found that 45% of adults and 29% of children included in the survey were
classified as food insecure, and only 28% reported that they frequently had healthy food
available in their homes3. The most common barriers to food access for these families
included cost and transportation, that those that were most likely to become food insecure
were those with a higher number of children and families living in rural communities3.
Food insecurity rates among the study population were three times the national average,
and fast food consumption was also common, as was consumption of convenience foods3.
These shifts in the food environment through shifting economies, the nature of government
commodity foods, readily available fast foods and processed convenience foods, and high
rates of food insecurity among Native American populations may increase risk of obesity,
including obesity rates in children. As a vulnerable population still growing and developing,
youth with high adiposity at this stage of life may experience increased risk for health
complications later in life, and it is necessary to address the obesity epidemic among this
population.

Childhood obesity rates among American Indian(AI) and Alaska Native(AN) children
are higher than the national average rates found via the National Health and Nutrition
Examination Survey (NHANES), and despite slight changes among some age groups, these
rates have remained relatively stable between 2006-20144. The prevalence of overweight
BMI for AI/AN children ages 2-19 is 18.5%, and the obesity prevalence for this age group is
29.7%4. Although prevalence of obesity is highest among adolescents, those in the 12-19
year old age group (19.7% and 33.8% for overweight and obesity, respectively)4, obesity
rates are still of significant concern for children in younger age categories. For the 2-5 year
old age group, 17.5% of children are overweight and 20.7% were obese4. For children ages
11-17, the prevalence of overweight BMI and obese BMI are 17.9% and 31.7%, respectively4.
The purpose of this assessment is to address these childhood obesity rates among Native
Americans aged 2-5 years old. Food Frequency Questionnaires (FFQ) and Bioelectrical
Impedance Analysis are the suggested methods to address this high obesity prevalence in
Native American children.

Although the Food Frequency Questionnaire (FFQ) will not directly measure
obesity, assessing the diet of these populations is necessary for understanding what dietary
factors may contribute to obesity rates and where interventions may be necessary. The
Food Frequency Questionnaire requires individuals to report their usual consumption for
each food item on a list in a specific time period, often in terms of a weeks, months, or even
a year. This can also include documentation of portion size5. This provides data on usual
intake over an extended period of time, in terms of nutrient content, food groups, and
energy intake. FFQs are useful for large epidemiological studies5, which is crucial for
assessing Native American communities spanning across the United States. Because FFQs
can be used to rank subjects5, ranking the overweight and obese children alongside normal
weight children may be useful in understanding diet vs. outcome. FFQs can be used to
assess diet and disease risk, which can be important in assessing risks associated with
obesity, for example, diabetes and cardiometabolic risk factors. To build upon food records,
a Dietary Quality Index for children has been developed based on FFQs. This included
dietary diversity, dietary quality, dietary equilibrium: adequacy and moderation, and a
meal index6. Creating such a scale may be useful in assessing the healthfulness of the diet to
find associations between diet quality and obesity rates within this population.

When using an FFQ, it is important to consider culturally appropriate foods. In

working with Native American populations, for example, it is necessary to ensure a
validated FFQ includes traditional foods and dishes, so that diet can be accurately reported.
When implementing a Food Frequency Questionnaire to this age group in children, the test
will be administered to the parents or guardians who can more accurately assess the
dietary patterns of their child based on meals they prepare and serve. Because children
ages 2-5 years old will generally be eating under parental supervision, this method may be
more accurate than if children were school-aged and eating out of the home. A reference
database such as the USDA Food and Nutrient Database will be used to calculate nutrient
and energy consumption based on the food list, and traditional foods assessed by the FFQ
will need to be calculated via an algorithm combining reference foods and recipes to obtain
the average nutrient composition.

The Harvard Service Food Frequency Questionnaire (HFFQ) has been validated in
Native American children ages 1 to 5 years old, though specifically those participating in
the North Dakota WIC program7. The HFFQ was administered to parents, and three 24-
hour dietary recalls on these children were also collected over a one month period7.
Average nutrient intakes from the series of 24-hour dietary recalls and the HFFQ were
compared, and Pearson correlation coefficients were calculated. Of the twenty nutrients
studies, all but protein, zinc, and fiber had correlations of .47 or higher, and after adjusting
the model, the average correlation for nutrients between the two assessment tools was
.527. It was found that the HFFQ has similar validity for children ages 1-5 as it does for
adults populations7. Although this study assesses Native American children in the same age
group as this assessment, it is very limited in scope due to only assessing Native Americans
receiving WIC benefits in one geographic region. Reliance on WIC benefits and only being
able to use those benefits on selected foods may limit the diet. Repeating this process
among a more representative cohort (individuals from multiple Native American
Communities across the United States) as well as beyond individuals on government
assistance programs like WIC may be key to understanding validity of the HFFQ for the
purposes of this assessment. Additionally, building upon the HFFQ which has shown to be
valid to include traditional Native American foods may be useful for future validation
studies in this population. A study in Singapore used three day food records and focus
groups to develop a list of culturally appropriate foods for the purpose of developing a
new, culturally appropriate FFQ, and even included bowl sizes to ensure proper
documentation of portion sizes on the proposed FFQ8. This could be a method to consider
for developing a culturally appropriate food list for other populations, including
developing and FFQ or building upon an existing FFQ to contain traditional dishes.

The second assessment tool to be used in the assessment of childhood obesity

among Native Americans ages 2-5 will be Bioelectrical Impedance Analysis(BIA). This
method assesses body composition, defined as body fat in relation to lean body mass, by
placing two electrodes on the body, generally the right hand and foot, and sending an
electric current throughout the body. Resistance of the currents flow is measured and used
to calculate body water, which can then be used in calculations to measure body fat 9.
Assessing body composition may be more accurate for assessing risk factors than use of
BMI calculations due to variation in body fatness, and body composition is correlated with
chronic disease risk9,10. Although chronic disease tends to be a health concern later in life,
increased adiposity in children can still suggest increased risk for developing
cardiometabolic risk factors later in life11.

This process is quick and noninvasive, and ethnicity specific calculations for body
impedance analysis(BIA) have been developed11. In terms of the reference values that will
be used for this assessment, looking at data in terms of percentiles may be useful. A study
derived reference values for a white population and propose percentiles as a reference to
evaluate BIA12. Similar methods may be able to be used to devise a reference standard for
Native American populations. Different ethnicities differ in body fat content that may not
be fully assessed in BMI calculations, which only consider weight and height, so the use of
this data assists in quantifying adiposity and disease risk among children in Native
American communities.

Bioelectrical impedance has been validated and equations for calculation of body
composition have been derived for Native American populations. Looking at Native
American women ages 18-60 in New Mexico, a study assessed height and weight, total bone
mineral content (BMC) and bone mineral density (BMD) via dual-energy x-ray
absorptiometry (DEXA), hydrostatic weighing (HW) at residual lung volume (RV), and
bioelectrical impedance analysis (BIA)13. Upon the analysis, a new equation for calculating
body composition for Native Americans was developed and was shown to be valid for use
in this population13. Although this is meant to be a race-specific equation, it may need to
be studied for validity in children, specifically, as children have different body fatness than
adult women. Repeating this process in a child cohort, especially one 2-5 years of age, is not
feasible. Some assessments done on this population to develop the equation, including
hydrostatic weighing and other elaborate procedures, may be complex for this children
that are so young. Despite this, comparing the equation developed for body composition
alongside other validated equations or using a different set of test practices as a reference,
may be useful for assessing and validating body composition equations for Native
American children, specifically.

Because childhood obesity is not directly related to nutrient levels in the body, a
biochemical or laboratory assessment may not be as relevant for this assessment. One
laboratory assessment that may be relevant is doubly labeled water, as it assesses energy
expenditure through calculating metabolic rate based on the rate of CO2 elimination from
ones body14. Given the goals of this study, metabolic rate may not provide adequate
information without information on physical activity, as lack of physical activity is a risk
factor that contributes to obesity. For this population and the health concern in question, it
may not be necessary to use a method to precisely quantify metabolic rate. A questionnaire
on physical activity levels would be sufficient and will better match the goals of the
assessment, and could include questions on playing outside or participation in games that
require activity for the 2-5 year old age group. Additionally, using the doubly labeled water
procedure is more invasive and time consuming that simply using a physical activity
questionnaire, and injection may not be warranted for this study population. A quantified
total energy expenditure (TEE) may not be necessary as healthy lifestyle patterns through
physical activity are more relevant to the assessment goals.

In conclusion, a culturally adapted FFQ and use of bioelectric impedance analysis

(BIA) may be useful for addressing childhood obesity rates for Native American children
ages 2-5 years. With the epidemiologic transition that has occurred in this population
leading to a shift in the food environment, assessing weight-related risks at a young age
and intervening early in life is key. By using an FFQ to further understand dietary influence
of these obesity rates, and using BIA to assess risks due to adiposity and body composition,
it will be possible to increase our understanding on this public health issue, assess the
severity of the problem for this age group, and develop interventions to reduce childhood
obesity rates. Prior to completing these goals, further validation studies may be necessary
to ensure use of these methods is appropriate for this study population.

References
1. Compher C. The Nutrition Transition in American Indians. Journal of Transcultural
Nursing. 2006;17(3):217-223. doi:10.1177/1043659606288376.
2. Wiedman D. Native American Embodiment of the Chronicities of Modernity:
Reservation Food, Diabetes, and the Metabolic Syndrome among the Kiowa,
Comanche, and Apache. Medical Anthropology Quarterly. 2012;26(4):595-612.
doi:10.1111/maq.12009.
3. Mullany B, Neault N, Tsingine D, et al. Food insecurity and household eating patterns
among vulnerable American-Indian families: associations with caregiver and food
consumption characteristics. Public Health Nutrition. 2012;16(04):752-760.
doi:10.1017/s136898001200300x.
4. Bullock A, M.D., Sheff K, M.S., Moore K, M.D., Manson S, PhD. Obesity and overweight
in american indian and alaska native children, 20062015. Am J Public Health.
2017;107(9):1502-1507.
https://search.proquest.com/docview/1938529219?accountid=35396. doi:
http://dx.doi.org/10.2105/AJPH.2017.303904.
5. Thompson FE, Subar AF. Nutrition in the Prevention and Treatment of Disease.
(Monsen ER, Rock C, Coulston AM, eds.). Academic Press; 2001.
6. Huybrechts I, Vereecken C, Bacquer DD, et al. Reproducibility and validity of a diet
quality index for children assessed using a FFQ. British Journal of Nutrition.
2010;104(01):135-144. doi:10.1017/s0007114510000231.
7. Blum RE, Wei EK, Rockett HRH et al. Validation of a Food Frequency Questionnaire
in Native American and Caucasian Children 1 to 5 Years of Age. Matern Child Health
Journal. 1999;3(3):167-172. https://doi.org/10.1023/A:1022350023163
8. Mubarik F, Bhaskaran K, Kho S, et al. Development of food lists as a first step to
develop a food frequency questionnaire for toddlers in a multi-ethnic population.
Nutrition & Dietetics. 2016;74(1):11-17. doi:10.1111/1747-0080.12323.
9. Bio-Electrical Impedance Analysis (BIA) - Body Mass Analysis. Doylestown Health.
https://www.doylestownhealth.org/medical-services/nutrition-
counseling/bioelectrical-impedance-analysis-bia--body-mass-analysis. Accessed
November 28, 2017.
10. Dehghan M, Merchant AT. Is bioelectrical impedance accurate for use in large
epidemiological studies? Nutrition Journal. 2008;7(1). doi:10.1186/1475-2891-7-
26.
11. Weber DR, Leonard MB, Zemel BS. Body Composition Analysis in the Pediatric
Population. Pediatric endocrinology reviews: PER. 2012;10(1):130-139.
12. Pichard C, Kyle UG, Bracco D, Slosman DO, Morabia A, Schutz Y. Reference values of
fat-free and fat masses by bioelectrical impedance analysis in 3393 healthy subjects.
Nutrition. 2000;16(4):245-254. doi:10.1016/s0899-9007(00)00256-2.
13. Stolarcyzk LM, Heyward VH, Hicks VL, Baumgartner RN. Predictive accuracy of
bioelectrical impedance in estimating body composition of Native American women.
The American Journal of Clinical Nutrition. 1994;59:964-70.
14. Buchowski MS. Doubly Labeled Water Is a Validated and Verified Reference
Standard in Nutrition Research. The Journal of Nutrition. 2014;144(5):573-574.
doi:10.3945/jn.114.191361.