C

ItIJ

TCdSotPlo(AstbtfiutNtfiALO

NAAr

JlSC

RMmO5

A

1

RESEARCH

ommentary

mproving Health among American Indianshrough Environmentally-Focused Nutritionnterventions

AMIE STANG, PhD, MPH, RD, LN

cUaar7g3edjrhAr2(bINa

nvliatcIaifcd

Itivlirralp(d

here are currently 562 federally recognized Ameri-can Indian or Alaskan Native tribes or villages in theUnited States (1). According to data from the US

ensus Bureau, 4.5 million US citizens of American In-ian or Alaskan Native ethnicity reside in the Unitedtates, including individuals who recognize more thanne heritage (2). This constitutes approximately 1.5% ofhe US population. The 2005 Bureau of Indian Affairsopulation and Labor Force reports approximately 2 mil-

ion individuals who are recognized or enrolled membersf Alaskan Native or American Indian tribes or villages1). Requirements for recognition of American Indian orlaskan Native heritage vary greatly and there is noingle definition or criterion for federal or tribal recogni-ion. In general, blood quantum (the degree of Nativelood of an individual), knowledge of tribal cultural prac-ices and beliefs, language, religious or spiritual beliefs,amilial kinship, and the degree to which an individualdentifies as a member of a tribe or village are criteriased to determine tribal recognition or enrollment. Fewerhan half (44%) of the American Indian and Alaskanative population currently reside on Indian reserva-

ions or lands (2,3). According to the 2000 US Census, theve largest urban populations of American Indians andlaskan Natives resided in the cities of New York, NY;os Angeles, CA; Phoenix, AZ; Anchorage, AK; and Tulsa,K (2).

UTRITION-RELATED HEALTH ISSUES EXPERIENCED BY NATIVEMERICANS AND ALASKAN NATIVESmerican Indian and Alaskan Native populations expe-

ience considerable nutrition-related health disparities

. Stang is an assistant professor and chair of the Pub-ic Health Nutrition Program, University of Minnesota,chool of Public Health, Division of Epidemiology andommunity Health, Minneapolis.Address correspondence to: Jamie Stang, PhD, MPH,D, LN, Public Health Nutrition Program, University ofinnesota, School of Public Health, Division of Epide-iology and Community Health, Suite 300, West Bankffice Building, 1300 S 2nd St, Minneapolis, MN5454. E-mail: stang002@umn.eduManuscript accepted: June 5, 2009.Copyright © 2009 by the American Dietetic

ssociation.0002-8223/09/10909-0001$36.00/0

odoi: 10.1016/j.jada.2009.06.371

528 Journal of the AMERICAN DIETETIC ASSOCIATION

ompared with other racial and ethnic groups within thenited States. American Indian adults have the highestge-adjusted rates for cardiovascular disease, diabetes,nd obesity of any racial or ethnic group (4). Age-adjustedates of diabetes among Native people vary from 14% to2%, which are 2.4 to more than 6 times the rate of theeneral US population (4-6). More than a third (up to9%) of American Indians and Alaskan Natives havelevated triglycerides and as many as 46% have low high-ensity lipoprotein cholesterol levels (7,8). The age-ad-usted prevalence of overweight (but not obese) statusanges from 24% to 43%, and the prevalence of obesityas been estimated at 34% to 67% of Native adults (4,7,9).bdominal obesity, a recognized risk factor for insulinesistance and type 2 diabetes mellitus, has been noted in3% to 85% of American Indians and Alaskan Natives7,9). Hypertension is present in 30% to 46% and meta-olic syndrome in as many as 55% of adult Americanndians and Alaskan Natives (4,8,9). More than 40% ofative adults report functional limitations as a result oft least one chronic health condition (4).In the United States it is estimated that during the

ext few decades, morbidity and mortality from cardio-ascular disease and diabetes will nearly double, with theargest increases experienced by minority populations,ncluding American Indians (10,11). Obesity, which isffected by both the quality and quantity of dietary in-ake, is a significant mediator in the development of thesehronic diseases that disproportionately affect Americanndians. Lifestyle interventions focusing on weight lossnd reduction in waist circumference with a concomitantmprovement in insulin sensitivity may be the most ef-ective prevention and treatment option to treat thesehronic diseases (12,13). Nutrition intervention will un-oubtedly play a substantial role in these efforts.Data on dietary intake from 13 different American

ndian nations throughout the United States suggesthat, similar to the general US population, many Amer-can Indians consume diets high in processed meats, sa-ory snacks, sweetened beverages, and fried foods withow intakes of fruits, vegetables, and whole grains. Stud-es of food and beverage intake among American Indiansesiding in various regions in the United States haveevealed that soft drinks, coffee, white bread, processednd cured meats, chips, butter/margarine, fried bread,ard, eggs, whole milk, ground beef, mutton, and friedotatoes are among the most commonly consumed foods14-18). Surveys of dietary intake among American In-ian adults have found that, on average, the percentage

f energy from fat ranges from 34% to 37%, with 12% to

© 2009 by the American Dietetic Association

1Waatttemf

TNIvdpbCemcft(tomeaciswta(bwbdtiecits

m(dtfutnisrtta

Fictipieaopaapgsewtnt

meegbattkphptitc

ItRipnoaitpA

itolcpclct

3% of energy consumed as saturated fat (16,19,20).hen the nutritional content of diets consumed by Native

dults is compared with the American Heart Associationnd American Diabetes Association dietary guidelines andhe Dietary Reference Intakes, there are several differenceshat suggest a need for nutrition intervention. Dietary in-akes of cholesterol, sodium, protein, and proportion of en-rgy from total and saturated fat are more than recom-ended levels, and intakes of fiber and vitamins A, C, and

olate are less than recommended levels (19,20).

HE NEED FOR HEALTHFUL ENVIRONMENTS TO SUPPORTUTRITION INTERVENTIONSnterviews with Native community members have re-ealed that they are aware of the need to eat a healthfuliet, and most understand the role that dietary intakelays in the development and prevention of obesity, dia-etes, hypertension, and cardiovascular disease (5,18,21).oncurrently, these interviews have also revealed barri-rs that American Indians experience in attempting toake more healthful food choices. Limited access to gro-

ery stores that offer low-fat, low-sugar, or whole-grainood products and a variety of fruits and vegetables ishe most frequently cited barrier to healthful eating5,15,18,21). For American Indians living on reserva-ions, the distance to travel to stores limits the frequencyf visiting large stores where more healthful food optionsay be available (18). The lack of a reliable supply of

lectricity and facilities to store perishable food items islso cited as a barrier to healthful eating among Ameri-an Indians living on reservations (18). The loss of hunt-ng and fishing rights, unavailability of traditional foodsuch as wild game, loss of traditional agriculture due toater scarcity and poor soil conditions, and loss of

raditional ways of procuring and preparing foods havelso been identified as reasons for poor food choices5,15,18,21). Many urban American Indians live in neigh-orhoods that lack large well-stocked grocery stores,hich limits the availability of healthful foods (18). Thesearriers suggest that environmental strategies that ad-ress limited access to healthful food choices and loss ofraditional eating habits must be addressed along withndividual behavior change methods to truly affect di-tary change among Native populations. Even the mostulturally competent, evidence-based programs cannotmprove eating behaviors among individuals or popula-ions who live and work in an environment that does notupport or provide healthful food choices.Environmental strategies build on the social-ecologicalodel of intervention, which is multilevel in nature

22,23). This model provides a structure for relating in-ividual determinants of behavior change within the con-ext of social factors that may prevent or promote health-ul eating behaviors. The social-ecological model has beensed extensively to plan, implement, and evaluate mul-ilevel health behavior interventions. The model recog-izes differing levels of influence on health behaviors,

ncluding those distal to the individual (national andtate-level policies and food systems, community-levelegulations, community organizations, and local food sys-ems), as well as those proximal to the individual (ex-ended and immediate family; peers and social networks;

nd individual knowledge, attitudes, and beliefs) (22,23). w

S

actors such as genetic disposition, health beliefs, cook-ng skills, language proficiency, literacy, and lifestylehoices are categorized as personal influences. Social fac-ors include family, peers, and social networks that cannfluence eating behaviors through role modeling, peerressure, and social support. Community-level factorsnclude physical settings in which people purchase andat food, local policies that affect food quality and avail-bility, and the culture and traditions that influence localrganizations. Community-level factors govern many as-ects of daily life and can serve as both opportunities fornd barriers to healthful eating. The most distal factorsre those enacted at the national and state levels such asublic health policies and programs, national and re-ional food systems, and food marketing. According to theocial-ecological model, nutrition interventions are mostffective and behavior changes most likely to be sustainedhen all relevant levels of influence are addressed simul-

aneously. A proposed social-ecological model to guideutrition interventions for American Indians is shown inhe Figure.

Traditionally, nutrition interventions have focused pri-arily on levels proximal to the individual. Common

xamples of these efforts include individualized nutritionducation and counseling, group nutrition education pro-rams and classes, peer education initiatives, and family-ased education programs designed to change knowledge,ttitudes, and beliefs about healthful eating. Althoughhese efforts have been found to be successful in the shorterm, follow-up data suggest that individual and groupnowledge and education improvements are not reliablyredictive of long-term changes in dietary intake orealth status (24). This phenomenon may be explained inart by the lack of concurrent environmental initiativeso support individualized efforts to change eating behav-ors. Individuals must have access to an environmenthat supports healthful eating if they are to successfullyhange their behaviors.The barriers to healthful eating identified by American

ndians speak to the need to address the larger context ofhe food environment in which individuals live and work.ecent legislation to require labeling of trans-fatty acids

s a national-level intervention, whereas efforts to im-rove the nutrition environment of schools are a commu-ity-level change. Although there is an increasing recordf the implementation of community-based interventionsimed at American Indian youth, there are few suchnterventions aimed at American Indian adults. Data onhe design, implementation, or evaluation of worksite andlace of worship–based health promotion programs formerican Indians are absent in the published literature.Because of their strong sense of family and tribal affil-

ation, American Indian communities present an oppor-unity to focus substantial nutrition intervention effortsn community-level influences. Elders and communityeaders are influential members of Native societies whoan influence the beliefs and practices of large groups ofeople. Like many cultures, American Indian communi-ation is based on an oral tradition rather than on writtenanguage. The use of group storytelling and talking cir-les led by community elders are means of health educa-ion that enable health professionals to impart knowledge

hile also honoring the traditions of Native people. Talk-

eptember 2009 ● Journal of the AMERICAN DIETETIC ASSOCIATION 1529

icpimpamlttl

ffeiapNotm

GwNm(hitoa

FTaiIrmapisEhttf

ica

F reven

1

ng circles are a customary way in which Native peopleommunicate important information to one other; theyrovide a forum in which a recognized group leader canmpart information to others in a reciprocal, respectful

anner. There is a strong belief that a talking circlerovides an opportunity for the “right time, right place,nd right people to hear right things” (25). Thus, infor-ation presented within a talking circle carries particu-

ar importance to those who participate. The use of theseraditional communication methods provides a founda-ion on which strong, culturally sensitive, community-evel interventions can be built.

The inaccessibility of grocery stores, lack of healthfulood choices in local food venues, and loss of traditionalood-procurement methods cited as barriers to healthfulating demonstrate the need to change public policy andmprove infrastructure. Urban planning initiatives, suchs setting aside land specifically for gardening, have beenroposed as a means of improving the dietary intake ofative people in both urban and rural areas (26). The use

f traditional gardening methods such as the Three Sis-ers* could help promote traditional food-procurementethods while also improving access to fresh produce.

*Three Sisters: Beans, corn, and squash are plantedn one mound; corn provides a “pole” for the beans tolimb, while squash leaves provide shade for the corn

igure. A social-ecological model for health promotion and disease p

pnd beans.

530 September 2009 Volume 109 Number 9

ardening may also increase levels of physical activity,hich may also have positive effects on the health ofative people. It has also been proposed that gardeningay become a means of gaining income for Native people

26). The incorporation of community greenhouses oroop houses in northern climates and irrigation methods

n the Southwest could help to assure a steady supply ofraditional healthful food options. Such activities wouldnly be achievable through a collaborative effort by tribalnd municipal leaders and policymakers.

UTURE RESEARCH NEEDShere are few published data on using a social-ecologicalpproach to support nutrition-related behavior change tomprove the health and nutritional status of Americanndian adults (18,21,27). The incorporation of both envi-onmental and individual behavior-change strategies in aultilevel nutrition intervention is absent from the liter-

ture. The paucity of environmental strategies used toromote healthful eating may be a result of the difficultyn obtaining funding for these efforts as well as the con-iderable timeframe required to complete such efforts.nvironmental strategies involve many individuals whoold various roles within a multitude of organizations;hus, they can be substantially more complex and difficulto implement than traditional individual or peer- andamily-based strategies. The process of changing public

tion efforts in American Indian communities.

olicy or community rules and regulations can be pro-

tc

hbTewasedaaatwrAwt

SNt

t

R

1

1

1

1

1

1

1

1

1

1

2

2

2

2

2

2

2

2

2

racted, requiring years of intervention efforts before ahange can be implemented or an effect can be evaluated.

Despite these drawbacks, environmental strategiesave the potential to have pervasive, enduring effects onoth the treatment and prevention of chronic diseases.hese long-term strategies are necessary to provide annvironment that supports healthful food choices inhich culturally-specific, evidence-based, individualizedpproaches to health promotion and disease preventionuch as the Medicine Wheel, a culturally-based nutritionducation program designed to reduce risk factors foriabetes and cardiovascular disease, can succeed (28). Anssessment of the impact of environmental changes (suchs increased availability of healthful, affordable foods) ondherence to individual or group-level nutrition interven-ions merits serious investigation. It is unlikely that weill succeed in reversing the trajectory toward increased

ates of chronic disease and health disparities amongmerican Indians, and the US population in general,ithout multilevel, environmentally focused nutrition in-

erventions.

TATEMENT OF POTENTIAL CONFLICT OF INTEREST:o potential conflict of interest was reported by the au-

hor.FUNDING/SUPPORT: The author received no funding

o write this commentary.

eferences1. US Department of the Interior, Indian Affairs. http://www.doi.gov/

bia/. Accessed May 5, 2009.2. US Census Bureau. Profile of General Demographic Characteristics.

U.S., Inside Metropolitan Areas, Outside Metropolitan Areas. TableDP1. Washington, DC: US Census Bureau, Department of Commerce,2001.

3. Urban Indian Health. Issue Brief No. 6006. Menlo Park, CA: Kaiser JFamily Foundation; 2001.

4. Barnes PM, Adams PF, Powell-Griner E. Health characteristics of theAmerican Indian and Alaska Native adult population: United States,1999-2003. Advance data from Vital and Health Statistics. No. 356.Hyattsville, MD: National Center for Health Statistics; 2005.

5. Taylor C, Keim KS, Sparrer A, Van Delinder J, Parker S. Social andcultural barriers to diabetes prevention in Oklahoma American In-dian women. Prev Chronic Dis. 2004;1:A06. http://www.cdc.gov/pcd/issues/2004/apr/03_0017.htm. Accessed May 12, 2009.

6. Lee ET, Howard BV, Savage PJ, Cowan LD, Fabsitz RR, Oopik AJ,Yeh JL, Go O, Robbins DC, Welty TK. Diabetes and impaired glucosetolerance in three American Indian populations aged 45-74 years: TheStrongHeart Study. Diabetes Care. 1995;18:599-610.

7. Welty TK, Rhoades DA, Yeh F, Lee ET, Cowan LD, Fabsitz RR,Robbins DC, Devereau RB, Henderson JA, Howard BV. Changes incardiovascular disease risk factors among American Indians: TheStrong Heart Study. Ann Epidemiol. 2002;12:97-106.

8. Resnick HE, Strong Heart Study Investigators. Metabolic syndromein American Indians. Diabetes Care. 2002;25:1246-1247.

9. Schumacher C, Ferucci ED, Lanier AP, Slattery ML, Schraer C,

Raymer T, Dillard D, Murtaugh MA, Tom-Orme L. Metabolic syn-drome: Prevalence among American Indian and Alaska native people

S

living in the southwestern United States and in Alaska. Metab SyndrRelat Disord. 2008;6:267-273.

0. Hennekens CH. Increasing burden of cardiovascular disease: Currentknowledge and future directions for research on risk factors. Circu-lation. 1998;97:1095-1102.

1. Boyle JP, Honeycutt AA, Narayan KM, Hoerger TJ, Geiss LS, ChenH. Projection of diabetes burden through 2050: Impact of changingdemography and disease prevalence in the US. Diabetes Care. 2001;24:1936-1940.

2. McLaughlin T, Abbasi F, Kim H-S, Lamendola C, Schaaf P, Reaven G.Relationship between insulin resistance, weight loss, and coronaryheart disease risk in healthy, obese women. Metabolism. 2001;50:795-800.

3. Hamman RF, Wing R, Edelstein SL, Lachin JM, Bray GA, DelahantyL, Hoski M, Kriska AM, Mayer-Davis EJ, Pi-Sunyer X, RegensteinerJ, Venditti B, Wylie-Rosett J. Effect of weight loss with lifestyleintervention on risk of diabetes. Diabetes Care. 2006;29:2102-2107.

4. Costacou T, Levin S, Mayer-Davis EJ. Dietary patterns among mem-bers of the Catawba Indian nation. J Am Diet Assoc. 2000;100:833-835.

5. Harnack L, Story M, Holy Rock B. Diet and physical activity patternsof Lakota Indian adults. J Am Diet Assoc. 1999;7:829-835.

6. Taylor CA, Keim KS, Gilmore A. Impact of core and secondary foodson nutritional composition of diets in Native-American women. J AmDiet Assoc. 2005;105:413-419.

7. Balew C, White LL, Strauss KF, Benson LJ, Mendlein JM, MokdadAH. Intake of nutrients and food sources of nutrients among theNavajo: Findings from the Navajo Health and Nutrition ExaminationSurvey. J Nutr. 1997;127(suppl 10):S2085-S2093.

8. Vastine A, Gittelsohn J, Ethelbah B, Anliker J, Caballero B. Forma-tive research and stakeholder participation in intervention develop-ment. Am J Health Behav. 2005;29:57-69.

9. Stang JS, Zephier EM, Story M, Himes JH, Yeh JL, Welty R, HowardBV. Dietary intakes of nutrients thought to modify cardiovasculardisease risk from three groups of American Indians: The Strong HeartDietary Study, Phase II. J Am Diet Assoc. 2005;105:1895-1903.

0. Eilat-Adar S, Xu J, Zephier E, O’Leary V, Howard BV, Resnick HE.Adherence to dietary recommendations for saturated fat, fiber andsodium is low in American Indians and other US adults with diabetes.J Nutr. 2008;138:1699-1704.

1. Ho LS, Gittelsohn J, Harris SB, Ford E. Development of an integrateddiabetes prevention program with First Nations in Canada. HealthPromot Int. 2006;21:88-97.

2. McLeroy KR, Bibeau D, Steckler A, Glanz K. An ecological perspectiveon health promotion programs. Health Educ Q. 1988;15:351-377.

3. Story M, Kaphingst KM, Robinson-O’Brien R, Glanz K. Creatinghealth food and eating environments: Policy and environmental ap-proaches. Annu Rev Public Health. 2008;29:253-272.

4. Dansinger ML, Tatsioni A, Wong JB, Chung M, Balk EM. Meta-analysis: The effect of dietary counseling for weight loss. Ann InternMed. 2007;147:41-50.

5. Share Your Vision Community Outreach Kit. US Department of Healthand Human Service, Office of Population Affairs; 2008. 4Parents.govWeb site. http://www.4parents.gov/shareyourvision/documents/community_outreach_kit.pdf. Accessed May 12, 2009.

6. Lombard KA, Forster-Cox S, Smeal D, O’Neill MK. Diabetes on theNavajo nation: What role can gardening and agriculture extensionplay to reduce it? Rural Remote Health. 2006;6:640-656.

7. Yancey AK, Kumanyika SK, Ponce NA, McCarthy WJ, Fielding JE,Leslie JP, Akbar J. Population-based interventions engaging commu-nities of color in healthy eating and active living: A review. PrevChronic Dis. 2004;1:A09. http://www.cdc.gov/pcd/issues/2004/jan/03_0012.htm. Accessed May 12, 2009.

8. Kattelmann KK, Conti K, Ren C. The Medicine Wheel Nutrition

Intervention: A diabetes education study with the Cheyenne RiverSioux Tribe. J Am Diet Assoc. 2009;109:1532-1539.

eptember 2009 ● Journal of the AMERICAN DIETETIC ASSOCIATION 1531