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

Individual- and household-level factors associated with fruit, vegetable, and dietary fiber adequacy among Native American adults in 6 reservation communities

This study utilized baseline data collected in 2017 from the OPREVENT2 trial, which included 540 Native Americans in six Midwest and Southwest reservation communities. The objective was to identify correlates of fruit, vegetable, and dietary fiber adequacy among participants 18–75 years old who self-identified as the main food purchaser or preparer in their household. Mean daily servings of fruits and vegetables and grams of dietary fiber were quantified based on a 30-day semi-quantitative food frequency questionnaire.

Participants consumed an average of 0.5 (±0.4) cup-equivalent servings of fruit, 2.5 (±1.8) cup-equivalent servings of vegetables, and 15.5 (±8.9) grams of fiber per day. <2% of the study population met the 2015–2020 Dietary Guidelines for Americans recommendations for fruit consumption, while 12 and 42% met recommendations for dietary fiber and vegetable consumption, respectively.

Females had a prevalence ratio 1.4 times greater than males for adequate intakes of vegetables (p = 0.008) and over 6 times greater for dietary fiber (p < 0.001). Participants over the age of 30 were about twice as likely to meet dietary fiber recommendations (p = 0.031) compared to those 30 years and younger. Participants receiving food assistance from the USDA’s Food Distribution Program on Indian Reservations (FDPIR) were nearly twice as likely as non-FDPIR recipients to meet recommendations for dietary fiber (p = 0.008).

These findings can help guide the development of targeted interventions to improve diet quality; however, further work is needed to understand and address underlying reasons for low fruit consumption in these rural reservation communities.

A Scoping Review of the Use of Indigenous Food Sovereignty Principles for Intervention and Future Directions

Indigenous food sovereignty (IFS) represents a community-led movement with potential to reduce health inequities, but no scoping review of the impact of taking an IFS approach on intervention research has been conducted. This review sought to: 1) describe intervention studies that employ IFS principles, and 2) describe the impact of studies using IFS principles on food access, eating patterns, diet quality, physical activity, and health. Through a literature review, 4 IFS principles were identified: 1) community ownership, 2) inclusion of traditional food knowledge, 3) inclusion and promotion of cultural foods, and 4) environmental/intervention sustainability. Twenty intervention studies published between January 1, 2000 and February 5, 2020 were included. Most of the studies that scored high in IFS principles saw a positive impact on diet. This review found evidence supporting the value of IFS principles in the development, implementation, and evaluation of health interventions for Indigenous communities.

Sociodemographic and Psychosocial Factors Associated With Diet Quality in 6 Rural Native American Communities

OBJECTIVE

To identify psychosocial and household environmental factors related to diet quality among Native Americans (NA).

DESIGN

Analysis of baseline data from a community-randomized obesity prevention trial.

SETTING

Six rural NA communities in the Midwest and the Southwestern US.

PARTICIPANTS

A total of 580 tribal members, aged 18-75 years old (mean 45 years), 74% female, self-identified as the main household food purchaser.

VARIABLES MEASURED

Diet quality (Healthy Eating Index-2015 [HEI]) was derived from a semiquantitative food frequency questionnaire. Sociodemographic, psychosocial, and home food environment factors were assessed via interviewer-administered questionnaires.

ANALYSIS

One-way ANOVA, linear regression models, and 2-tailed t tests compared HEI scores among sociodemographic categories. Multiple linear regression models assessed the relationship between psychosocial factors, home food environment, and HEI.

RESULTS

Prevalence of obesity was 59%. Mean HEI-2015 score was 49.3 (SD = 8.1). Average HEI scores were 3.0 points lower in smokers than nonsmokers (P < 0.001), and 2.2 points higher in females than males (P < 0.01). Higher self-efficacy (β = 0.97; P < 0.001) and healthier eating intentions (β = 0.78; P < 0.001) were positively associated with HEI. Healthier household food patterns score was associated with higher HEI (β = 0.48; P < 0.01).

CONCLUSIONS AND IMPLICATIONS

Psychosocial factors were associated with diet quality, a finding that supports the use of social-cognitive intervention approaches in rural NA communities in the Midwest and Southwest, and warrants evaluation in other locations. There remains a need to elucidate the association between the Food Distribution Program on Indian Reservations and diet quality.

The Retail Food Sector and Indigenous Peoples in High-Income Countries: A Systematic Scoping Review

Indigenous Peoples in high-income countries experience higher burdens of food insecurity, obesity, and diet-related health conditions compared to national averages. The objective of this systematic scoping review is to synthesize information from the published literature on the methods/approaches, findings, and scope for research and interventions on the retail food sector servicing Indigenous Peoples in high-income countries. A structured literature search in two major international databases yielded 139 relevant peer-reviewed articles from nine countries. Most research was conducted in Oceania and North America, and in rural and remote regions. Several convergent issues were identified across global regions including limited grocery store availability/access, heightened exposure to unhealthy food environments, inadequate market food supplies (i.e., high prices, limited availability, and poor quality), and common underlying structural factors including socio-economic inequality and colonialism. A list of actions that can modify the nature and structure of retailing systems to enhance the availability, accessibility, and quality of healthful foods is identified. While continuing to (re)align research with community priorities, international collaboration may foster enhanced opportunities to strengthen the evidence base for policy and practice and contribute to the amelioration of diet quality and health at the population level.

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.

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.