Overweight and obesity among North American Indian infants, children, and youth

Alaska Native Parents' Decision-Making About Food, Beverages, and Screen Time for Young Children: Formative Insights From the "Got Neqpiaq?" Project

With rising childhood obesity rates, ensuring children adopt healthy habits early is imperative. Given the unique context for Alaska Native families living in rural remote communities, who are concurrently experiencing changes in traditional practices, we investigated what impacts parents' decisions as they relate to daily living before revising a preschool curriculum focused on healthy habits. The objective of this study was to explore factors influencing parents' decisions about their children's foods, beverages, and activities. In focus group discussions with AN parents of young children across 12 communities, we asked about meals, traditional foods, beverages, physical activity, and screen time. All sessions were recorded, transcribed, and analyzed using open and selective coding to allow the most important themes to emerge. As parents discussed how they make decisions, several trends emerged related to adults' and children's food and beverage preferences; the impact of adult modeling on children; and how convenience, seasonality, access, and a reluctance to engage in conflict all impact decision-making. Parents and other community members shared important perspectives on exposing children to traditional subsistence foods and activities and passing important traditional knowledge to them at an early age. These perspectives will form the basis for preschool curricula in these communities.

American Indian Alaska Native (AIAN) adolescents and obesity: the influence of social determinants of health, mental health, and substance use

OBJECTIVE

To explore the prevalence of obesity among American Indian and Alaska Native (AIAN) adolescents aged 12-19 years in association with social determinants of health (SDOH), and mental health and substance use disorders.

METHODS

Guided by the World Health Organization's Social Determinants of Health Framework, we examined data from the Indian Health Service (IHS) Improving Health Care Delivery Data Project from Fiscal Year 2013, supplemented by county-level data from the U.S. Census and USDA. Our sample included 26,226 AIAN adolescents ages 12-19 years. We described obesity prevalence in relationship to SDOH and adolescents' mental health and substance use disorder status. We then fit a multivariable logit generalized linear mixed model to estimate the relationships after adjusting for other individual and county level characteristics.

RESULTS

We observed a prevalence of 32.5% for obesity, 13.8% for mental health disorders, and 5.5% for substance use disorders. Females had lower odds of obesity than males (OR = 0.76, p < 0.001), which decreased with age. Having Medicaid coverage (OR = 1.09, p < 0.01), residing in a county with lower education attainment (OR = 1.17, p < 0.05), and residing in a county with higher rates of poverty (OR = 1.51, p < 0.001) were each associated with higher odds of obesity. Residing in a county with high access to a grocery store (OR = 0.73, p < 0.001) and residing in a county with a higher proportion of AIANs (OR = 0.83, p < 0.01) were each associated with lower odds of obesity. Those with mental health disorders had higher odds of obesity (OR = 1.26, p < 0.001); substance use disorders were associated with decreased odds of obesity (OR = 0.73, p < 0.001).

CONCLUSIONS

Our findings inform future obesity prevention and treatment programs among AIAN youth; in particular, the need to consider mental health, substance use, and SDOH.

"He's a little skinny and he's a little wide.": a mixed design investigation of American Indian student perceptions of healthy bodies

BACKGROUND

Childhood is a critical developmental time of wellness patterns, yet little is known about what children know and believe. Even less is known about non-majority cultures like American Indian youth. The purpose of this study was to explore American Indian students' understandings of nutrition and physical activity.

METHODS

This mixed methods study took place in 10 schools in an American Indian community in the Southwestern U.S. Ninety American Indian students in grades 3-12 (8-19 years old) were interviewed. The interview included an 8-point body size chart. Numerical data were analyzed via t-test statistics while a constant comparison process and analysis was used for the interview data.

RESULTS

Students rated approximately 85% of students in Category 5 or smaller on the scale while placing 60% of adults at or above that size. There was a general trend of a larger body type for boys seen as healthy compared to that for girls. Students generally believed that their classmates were larger than the healthy body size. For students, a healthy body was the result of compliance with "eat right and exercise" rules. They exhibited little understanding of nutrition or physical activity and there were few developmental differences in understanding. Health was a corporeal concept and violators of the eat right and exercise rules were seen as lazy.

CONCLUSIONS

Students held narrow and corporeal focused notions of health focused on simple rules. People who violated the rules were "lazy", a concept that seemed to underlie multiple constructs and a finding that holds true in other investigations. Students also reported few adult role models, a topic that should be explored with expanded family groups to better represent the multi-generational (e.g. grandparents, uncles, aunts) family housing common in the community. The findings are limited to a single American Indian community and a mixed design of relatively small numbers. This addition to the literature from a non-majority cultural group expands our knowledge of student perspectives on health. These findings can be used to create more effective curricula and interventions. Schools need more effective, but also alternately framed approaches that promote broader views of health.

Associations Between Rurality, pre-pregnancy Health Status, and Macrosomia in American Indian/Alaska Native Populations

OBJECTIVES

To examine the relationships between pre-pregnancy diabetes mellitus (DM), gestational diabetes mellitus (GDM), pre-pregnancy body mass index (BMI) and county-level social determinants of health, with infant macrosomia within a sample of American Indian/Alaska Native (AI/AN) women receiving Indian Health Service (IHS) care.

METHODS

The sample included women-infant dyads representing 1,136 singleton births from fiscal year 2011 (10/1/2019-9/30/2011). Data stemmed from the IHS Improving Health Care Delivery Data Project. Multivariate generalized linear mixed models were fitted to assess the association of macrosomia with pre-pregnancy health status and social determinants of health.

RESULTS

Nearly half of the women in the sample were under age 25 years (48.6%), and most had Medicaid health insurance coverage (76.7%). Of those with a pre-pregnancy BMI measure, 66.2% were overweight or obese. Although few women had pre-pregnancy DM (4.0%), GDM was present in 12.8% of women. Most women had a normal term delivery (85.4%). Overweight, obesity, pre-pregnancy DM, and county-level rurality were all significantly associated with higher odds of infant macrosomia.

Social Determinants of Health and Body Mass Index in American Indian/Alaska Native Children

Objective: To examine the associations between social determinants of health (SDOH) and prevalent overweight/obesity status and change in adiposity status among American Indian and Alaska Native (AI/AN) children. Methods: The study sample includes 23,950 AI/AN children 2-11 years of age, who used Indian Health Service (IHS) from 2010 to 2014. Multivariate generalized linear mixed models were used to examine the following: (1) cross-sectional associations between SDOH and prevalent overweight/obesity status and (2) longitudinal associations between SDOH and change in adiposity status over time. Results: Approximately 49% of children had prevalent overweight/obesity status; 18% had overweight status and 31% had obesity status. Prevalent severe obesity status was 20% in 6-11-year olds. In adjusted cross-sectional models, children living in counties with higher levels of poverty had 28% higher odds of prevalent overweight/obesity status. In adjusted longitudinal models, children 2-5 years old living in counties with more children eligible for free or reduced-priced lunch had 15% lower odds for transitioning from normal-weight status to overweight/obesity status. Conclusions: This work contributes to accumulating knowledge that economic instability, especially poverty, appears to play a large role in overweight/obesity status in AI/AN children. Research, clinical practice, and policy decisions should aim to address and eliminate economic instability in childhood.

Disparities in pancreatic cancer care and research in Native Americans: Righting a history of wrongs

Disparities in pancreatic cancer incidence and outcomes exist in Native American populations. These disparities are multifactorial, difficult to quantify, and are influenced by historical, socioeconomic, and health care structural factors. The objective of this article was to assess these factors and offer a call to action to overcome them. The authors reviewed published data on pancreatic cancer in Native American populations with a focus on disparities in incidence, outcomes, and research efforts. The historical context of the interactions between Native Americans and the United States health care system was also analyzed to form actionable items to build trust and collaboration. The incidence of pancreatic cancer in Native Americans is higher than that in the general US population and has the worst survival of any major racial or ethnic group. These outcomes are influenced by a patient population with often poor access to high-quality cancer care, historical trauma potentially leading to reduced care utilization, and a lack of research focused on etiologies and comorbid conditions that contribute to these disparities. A collaborative effort between nontribal and tribal leaders and cancer centers is key to addressing disparities in pancreatic cancer outcomes and research. More population-level studies are needed to better understand the incidence, etiologies, and comorbid conditions of pancreatic cancer in Native Americans. Finally, a concerted, focused effort should be undertaken between nontribal and tribal entities to increase the access of Native Americans to high-quality care for pancreatic cancer and other lethal malignancies.

Increased Adiposity and Low Height-for-Age in Early Childhood Are Associated With Later Metabolic Risks in American Indian Children and Adolescents

BACKGROUND

Growth abnormalities in childhood have been related to later cardiometabolic risks, but little is known about these associations in populations at high risk of type 2 diabetes.

OBJECTIVES

We examined the associations of patterns of growth, including weight and height at ages 1-59 months, with cardiometabolic risk factors at ages 5-16 years.

METHODS

We linked anthropometric data collected at ages 1-59 months to cardiometabolic data obtained from a longitudinal study in a southwestern American Indian population at high risk of diabetes. Analyses included 701 children with ≥1 follow-up examination at ages 5-16 years. We derived age- and sex-specific weight-for-height z-scores (WHZ) and height-for-age z-scores (HAZ) at ages 1-59 months. We selected the highest observed WHZ and the lowest observed HAZ at ages 1-59 months and analyzed associations of z-scores and categories of WHZ and HAZ with cardiometabolic outcomes at ages 5-16 years. We used linear mixed-effects models to account for repeated measures.

RESULTS

Overweight/obesity (WHZ >2) at ages 1-59 months was significantly associated with increased BMI, fasting and 2-hour postload plasma glucose, fasting and 2-hour insulin, triglycerides, systolic blood pressure, diastolic blood pressure, and decreased HDL cholesterol at ages 5-16 years relative to normal weight (WHZ ≤1). For example, at ages 5-9 years, 2-hour glucose was 10.4 mg/dL higher (95% CI: 5.6-15.3 mg/dL) and fasting insulin was 4.29 μU/mL higher (95% CI: 2.96-5.71 μU/mL) in those with overweight/obesity in early childhood. Associations were attenuated and no longer significant when adjusted for concurrent BMI. A low height-for-age (HAZ < -2) at ages 1-59 months was associated with 5.37 mg/dL lower HDL (95% CI: 2.57-8.17 mg/dL) and 27.5 μU/mL higher 2-hour insulin (95% CI: 3.41-57.6 μU/mL) at ages 10-16 years relative to an HAZ ≥0.

CONCLUSIONS

In this American Indian population, findings suggest a strong contribution of overweight/obesity in early childhood to cardiometabolic risks in later childhood and adolescence, mediated through persistent overweight/obesity into later ages. Findings also suggest potential adverse effects of low height-for-age, which require confirmation.

Alaska Native Elders' perspectives on dietary patterns in rural, remote communities

BACKGROUND

Given the increasing rates of childhood obesity in Alaska Native children and the understanding that the most effective interventions are informed by and reflect the cultural knowledge of the community in which they are implemented, this project sought to gather the wisdom of local Yup'ik and Cup'ik Elders in the Yukon-Kuskokwim region of Alaska around how to maintain a healthy diet and active lifestyle.

METHODS

Perspectives were sought through the use of semi-structured focus groups, which were completed in person in twelve communities. All conversations were recorded, translated, transcribed, and analyzed using a qualitative approach, where key themes were identified.

RESULTS

Elders provided a clear and consistent recollection of what their life looked like when they were young and expressed their perspectives related to maintaining a healthy and traditional lifestyle. The key themes the Elders discussed included an emphasis on the nutritional and cultural benefits of traditional foods; concerns around changing dietary patterns such as the consumption of processed foods and sugar sweetened beverages; and concerns on the time and use of screens. Elders also expressed a desire to help younger generations learn traditional subsistence practices.

CONCLUSIONS

The risk of obesity in Alaska Native children is high and intervention efforts should be grounded in local knowledge and values. The perspectives from Yup'ik and Cup'ik Elders in the Yukon-Kuskokwim Delta area of Alaska provide a better understanding on local views of how to maintain a healthy diet, physical activities, and traditional values.

Storekeeper perspectives on improving dietary intake in 12 rural remote western Alaska communities: the "Got Neqpiaq?" project

Low intake of fruits and vegetables and high intake of sugar-sweetened beverages persists as a public health concern in rural remote Alaska Native (AN) communities. Conducting key informant interviews with 22 storekeepers in 12 communities in the Yukon-Kuskokwim region of Alaska, we explored potential factors impeding or facilitating dietary change towards healthier food choices. We selected these sites as part of a multi-level intervention aimed at introducing more traditional AN subsistence foods, increasing fruit and vegetable intake, and decreasing SSB consumption among young children enrolled in Head Start (preschool) programmes (Clinicaltrials.gov #NCT03601299). Storekeepers in these communities agreed that seasonality and flight schedules were primary factors determining commercial foods’ availability. Several storekeepers noted that federal food assistance programmes that specify which food items may be purchased with funds received from the programme and community policies that set limits on less healthy items promote customer purchases of healthier products. The fact that storekeepers are comfortable enforcing government assistance programme guidelines, company policies, and tribal resolutions suggests an important role storekeepers play in improving nutritional intake in their communities.

California and federal school nutrition policies and obesity among children of Pacific Islander, American Indian/Alaska Native, and Filipino origins: Interrupted time series analysis

BACKGROUND

Obesity prevalence remains high among children of Pacific Islander (PI) origin, Filipino (FI), and American Indian/Alaska Native (AIAN) origins in the United States. While school nutrition policies may help prevent and reduce childhood obesity, their influences specifically among PI, FI, and AIAN children remain understudied. We evaluated the association of the California (CA) state school nutrition policies for competitive food and beverages and the federal policy for school meals (Healthy, Hunger-Free Kids Act of 2010 (HHFKA 2010)) with overweight/obesity among PI, FI, and AIAN students.

METHODS AND FINDINGS

We used an interrupted time series (ITS) design with FitnessGram data from 2002 to 2016 for PI (78,841), FI (328,667), AIAN (97,129), and White (3,309,982) students in fifth and seventh grades who attended CA public schools. Multilevel logistic regression models estimated the associations of the CA school nutrition policies (in effect beginning in academic year 2004 to 2005) and HHFKA 2010 (from academic year 2012 to 2013) with overweight/obesity prevalence (above the 85 percentile of the age- and sex-specific body mass index (BMI) distribution). The models were constructed separately for each grade and sex combination and adjusted for school district-, school-, and student-level characteristics such as percentage of students eligible for free and reduced price meals, neighborhood income and education levels, and age. Across the study period, the crude prevalence of overweight/obesity was higher among PI (39.5% to 52.5%), FI (32.9% to 36.7%), and AIAN (37.7% to 45.6%) children, compared to White (26.8% to 30.2%) students. The results generally showed favorable association of the CA nutrition policies with overweight/obesity prevalence trends, although the magnitudes of associations and strengths of evidence varied among racial/ethnic subgroups. Before the CA policies went into effect (2002 to 2004), overweight/obesity prevalence increased for White, PI, and AIAN students in both grades and sex groups as well as FI girls in seventh grade. After the CA policies took place (2005 to 2012), the overweight/obesity rates decreased for almost all subgroups who experienced increasing trends before the policies, with the largest decrease seen among PI girls in fifth grade (before: log odds ratio = 0.149 (95% CI 0.108 to 0.189; p < 0.001); after: 0.010 (-0.005 to 0.025; 0.178)). When both the CA nutrition policies and HHFKA 2010 were in effect (2013 to 2016), declines in the overweight/obesity prevalence were seen among White girls and FI boys in fifth grade. Despite the evidence of the favorable association of the school nutrition policies with overweight/obesity prevalence trends, disparities between PI and AIAN students and their White peers remained large after the policies took place. As these policies went into effect for all public schools in CA, without a clear comparison group, we cannot conclude that the changes in prevalence trends were solely attributable to these policies.

CONCLUSIONS

The current study found evidence of favorable associations of the state and federal school nutrition policies with overweight/obesity prevalence trends. However, the prevalence of overweight/obesity continued to be high among PI and AIAN students and FI boys. There remain wide racial/ethnic disparities between these racial/ethnic minority subgroups and their White peers. Additional strategies are needed to reduce childhood obesity and related disparities among these understudied racial/ethnic populations.

Caring for American Indian and Alaska Native Children and Adolescents

American Indian and Alaska Native (AI/AN) populations have substantial health inequities, and most of their disease entities begin in childhood. In addition, AI/AN children and adolescents have excessive disease rates compared with the general pediatric population. Because of this, providers of pediatric care are in a unique position not only to attenuate disease incidence during childhood but also to improve the health status of this special population as a whole. This policy statement examines the inequitable disease burden observed in AI/AN youth, with a focus on toxic stress, mental health, and issues related to suicide and substance use disorder, risk of and exposure to injury and violence in childhood, obesity and obesity-related cardiovascular risk factors and disease, foster care, and the intersection of lesbian, gay, bisexual, transgender, queer, and Two-Spirit and AI/AN youth. Opportunities for advocacy in policy making also are presented.

Native Youth Participating in the Together on Diabetes 12-Month Home-Visiting Program Reported Improvements in Alternative Healthy Eating Index-2010 Diet Quality Domains Likely to Be Associated With Blood Pressure and Glycemic Control

BACKGROUND

The Together on Diabetes (TOD) intervention was a home-visiting diabetes prevention and management program for Native youth.

OBJECTIVES

(1) Examine the impact of the TOD program on diet quality using the Alternative Healthy Eating Index (AHEI-2010); (2) determine association between diet quality and cardiometabolic health.

DESIGN

The TOD program was conducted from October 2012 to June 2014 and was evaluated using a pretest-posttest study design from baseline to 12 months. Dietary intake was assessed using a food frequency questionnaire.

PARTICIPANTS/SETTING

There were 240 participants between 10 and 19 years of age from 4 reservation-based, rural tribal communities in the southwestern United States that had been diagnosed with T2DM or prediabetes or were identified as at risk based on body mass index and a qualifying laboratory test.

INTERVENTION

Youth were taught a 12-lesson curriculum on goal setting, nutrition, and life skills education.

MAIN OUTCOME MEASURES

Behavioral and physiologic outcomes related to diabetes.

STATISTICAL ANALYSIS

Changes in AHEI-2010 score and associations with cardiometabolic measures were tested, over time, using adjusted longitudinal linear mixed-effects models.

RESULTS

The study sample reported an average energy intake of 2016 kcal/d (±1260) and AHEI-2010 score of 47.4 (±7.4) (range: 0-110, higher = better diet quality), indicating low diet quality at baseline. At 12 months' follow-up, there was a reduction in kilocalories (mean = -346 kcal/d; P < .001), sugar-sweetened beverages (mean = -2 fluid oz/d; P = .032), red/processed meat (mean = -1.5 oz/d; P = .008), and sodium (mean = -650 mg/d; P < .001) but no change in AHEI-2010 score (P = .600). The change in systolic blood pressure from baseline to 12 months for participants within the highest AHEI-2010 quartile group was significantly larger than the change in participants within the lowest quartile group (mean = -5.90 mm Hg; P = .036).

CONCLUSIONS

Despite stable AHEI-2010 scores during follow-up, there were improvements in diet quality domains likely to be associated with cardiometabolic health. Home-visiting programs like TOD are promising interventions for decreasing dietary intake of poor-quality foods.

Returning to Our Roots: Tribal Health and Wellness through Land-Based Healing

(1) Background: Settler colonialism has severely disrupted Indigenous ancestral ways of healing and being, contributing to an onslaught of health disparities. In particular, the United Houma Nation (UHN) has faced large land loss and trauma, dispossession, and marginalization. Given the paucity of research addressing health for Indigenous individuals living in Louisiana, this study sought to co-identify a United Houma Nation health framework, by co-developing a community land-based healing approach in order to inform future community-based health prevention programs. (2) Methods: This pilot tested, co-designed and implemented a land-based healing pilot study among Houma women utilizing a health promotion leadership approach and utilized semi-structured interviews among 20 UHN women to identify a UHN health framework to guide future results. (3) Results: The findings indicated that RTOR was a feasible pilot project. The initial themes were (1.) place, (2.) environmental/land trauma, (3.) ancestors, (4.) spirituality/mindfulness, (5.) cultural continuity, and (6.) environment and health. The reconnection to land was deemed feasible and seen as central to renewing relationships with ancestors (aihalia asanochi taha), others, and body. This mindful, re-engagement with the land contributed to subthemes of developing stronger tribal identities, recreating ceremonies, and increased cultural continuity, and transforming narratives of trauma into hope and resilience. Based on these findings a Houma Health (Uma Hochokma) Framework was developed and presented. (4) Conclusions: Overall, this study found that land can serve as a feasible therapeutic site for healing through reconnecting Houma tribal citizens to both ancestral knowledges and stories of resilience, as well as viewing self as part of a larger collective. These findings also imply that revisiting historically traumatic places encouraged renewed commitment to cultural continuity and health behaviors—particularly when these places are approached relationally, with ceremony, and traumatic events tied to these places, including climate change and environmental/land trauma, are acknowledged along with the love the ancestors held for future generations.

Dietary Intake of Upper Midwest and Southwest Native American Adults

Limited information on current dietary patterns of Native American (NA) adults exists. This paper describes the dietary intake of 582 NA adults, aged 19-75 years, living in six communities in New Mexico and Wisconsin in 2016-2017 and compares macronutrient and micronutrient intakes, estimated via a semi-quantitative 30-day Block Food Frequency Questionnaire, among different age and sex groups. NA adults consumed a diet high in % energy from total fat, saturated fat, added sugars, and sodium. A general trend of lower micronutrient intakes with increasing age was observed. Health professionals can apply this information to develop effective and culturally relevant nutrition interventions. Abbreviations: NA = Native American; CVD = Cardiovascular diseases; IOM = Institute of Medicine; IRB = Institutional Review Board; AIQ = Adult Impact Questionnaire; FFQ = Food Frequency Questionnaire; NHANES = National Health and Nutrition Examination Survey; NHNS: Navajo Health and Nutrition Survey.

Malnutrition prevalence among children and women of reproductive age in Mexico by wealth, education level, urban/rural area and indigenous ethnicity

OBJECTIVE

To compare the prevalence of malnutrition (undernutrition and excess weight) by wealth, education level, ethnicity and urban/rural areas in Mexican children and women of reproductive age.

DESIGN

We compared the prevalence of overweight, obesity, wasting/underweight, stunting/short stature and anaemia by socioeconomic and ethnic indicators. For each indicator, we estimated prevalence ratios (PR) adjusted by all other socioeconomic and ethnic indicators. We analysed if results differed by urban/rural areas.

SETTING

Mexican National Health and Nutrition Survey 2012.

PARTICIPANTS

Children <5 years, non-pregnant women 11-19 years and non-pregnant women 20-49 years (n 33 244).

RESULTS

In most age groups, belonging to non-indigenous households, with high wealth, high education and in urban areas were inversely associated with stunting or short stature (PR ranging from 0·40 to 0·83), and wealth and education were inversely associated with anaemia (PR ranging from 0·53 to 0·78). The prevalence of overweight was similar across subgroups among children <5 years; however, among women 11-19 years, wealth, non-indigenous household and urban areas were positively associated (PR ranging from 1·16 to 1·33); and among women 20-49 years, education was inversely associated (PR 0·83).

CONCLUSIONS

Socially disadvantaged populations have a higher prevalence of undernutrition, whereas the prevalence of excess weight is either equal (children <5 years), slightly lower (women 11-19 years) or even higher (women 20-49 years) with lower education. These results highlight the need for specific actions to address social inequalities in malnutrition in the Mexican population.

Obesity Education among American Indians: Evaluating a Culturally Appropriate Approach to Health Awareness

This research focused on a key health issue that significantly affects American Indian community - obesity. We sought to understand how American Indians perceive culturally appropriate an ethnic identity education about obesity as compared with the generic education that is not sensitive to the ethnic identity of American Indians. The project utilizes a survey based observational design where a sample of American Indians is measured for their preference of educational flyers showing American Indian imagery versus generic/Caucasian imagery. The perceived obesity among American Indians was compared with actual bodyweight levels. The American Indian community strongly prefers education that is supported by culturally appropriate imagery. This result provides support to the hypothesis that cultural identity plays a vital role in health education among American Indians and can be an effective strategy in future efforts.

Impact of the 2017 Child and Adult Care Food Program Meal Pattern Requirement Change on Menu Quality in Tribal Early Care Environments: The Food Resource Equity and Sustainability for Health Study

BACKGROUND

Native American (NA) children have a high prevalence of obesity contributing to lifespan health disparities. Dietary intake is important to promote healthy weight gain, growth, and development. In 2017, the USDA enforced changes to the Child and Adult Care Food Program (CACFP). The CACFP provides reimbursement to qualifying Early Care and Education (ECE) programs that serve foods that uphold the program's nutrition requirements.

OBJECTIVE

This study had the following 2 objectives: 1) Describe a novel index to evaluate ECE menus based on revised CACFP requirements (accounting for food substitutions) and best practices for 3- to-5-y-old children, and 2) analyze CACFP requirement and best practice compliance and nutrient changes in 9 NA ECE programs before and after enforcement of the revised CACFP requirements.

METHODS

This longitudinal study is within a larger community-based participatory research study. Menus and meals served were evaluated for 1 wk at each of 9 programs before and after enforcement of the revised meal patterns. Nutrient analysis, CACFP requirement and best practice compliance, and substitution quality were evaluated. Differences were determined using a paired t-test or Wilcoxon matched test. This trial was registered at clinicaltrials.gov as NCT03251950.

RESULTS

Total grams of fiber consumed increased (5.0 ± 1.2 compared with 5.9 ± 0.8 g, P = 0.04) and total grams of sugar consumed decreased (53.8 ± 12.6 compared with 48.4 ± 7.9 g, P = 0.024), although room for further improvement exists. Although total grams of fat remained unchanged, grams of saturated fat significantly increased (7.8 ± 1.4 compared with 10.5 ± 3.4, P = 0.041). Other nutrients remained unchanged. Overall CACFP requirement and best practice compliance scores improved, although this finding was not statistically significant. No significant changes in food quality associated with substitutions occurred.

CONCLUSIONS

This study provides early evidence to support the beneficial impact of the revised CACFP requirements. Understanding barriers to compliance within rural NA communities would be an important next step in enhancing the health of vulnerable children.

[Excess weight in Xukuru indigenous children in Ororubá, Pernambuco State, Brazil: magnitude and associated factors]

The few studies on health and nutrition in indigenous peoples in Northeast Brazil point to some differences with indigenous peoples in the North and Central of the country. This study estimated the prevalence rates and risk of overweight and excess weight in Xukuru children in the village of Ororubá, Pernambuco State, and assessed the socioeconomic and demographic factors potentially associated with these conditions. This cross-sectional study analyzed the associations between adequate weight, excess weight (overweight and obesity), and risk of overweight according to the indices and cutoff points of the World Health Organization for children and the explanatory variables, using multinomial logistic regression. Prevalence of excess weight was 7.7% and risk of overweight was 24.2%. The odds of risk of overweight and excess weight were higher in children < 2 years. Children of obese mothers showed higher odds of excess weight. Prevalence of risk of overweight was 97% higher when compared to households with fixed income. The findings suggest that the Xukuru are experiencing an accelerated nutritional transition, with a paradoxical situation to which other indigenous peoples in Brazil are also exposed.

Associations between Food Consumption Patterns and Chronic Diseases and Self-Reported Morbidities in 6 American Indian Communities

Background

American Indian (AI) have the highest rates of diet-related chronic diseases in the country. Yet, the relation between dietary patterns and chronic diseases in this population has not been well explored.

Objective

We aimed to characterize common dietary patterns among adults from 6 AI communities (N = 580) and assess their relation with BMI, percentage body fat, waist-to-hip ratio, hypertension, and self-reported type 2 diabetes and cardiovascular disease.

Methods

We conducted a baseline assessment of an obesity prevention study (N = 580). Dietary intake data were collected using a modified Block FFQ. Exploratory factor analysis was used to characterize dietary patterns. We used multivariate linear and logistic regression analyses to assess associations between dietary patterns and health outcomes, controlling for age, sex, employment status, smoking status, geographic region, and energy intake.

Results

Five dietary patterns, explaining 81.8% of variance in reported food consumption, were identified: “meat and fried foods,” “processed foods,” “fruits and vegetables,” “sugary snacks,” and “meat alternatives and high-protein foods.” “Those with higher consumption of “meat and fried foods” were associated with higher mean waist-to-hip ratio (0.03; 95% CI: 0.01, 0.04), higher mean BMI (2.45 kg/m2; 95% CI: 0.83, 4.07), and increased odds of being overweight or obese (OR: 2.63; 95% CI: 1.10, 6.31) compared to those with lower consumption of “meat and fried foods.” Higher consumption of “processed foods” was associated with increased odds of self-reported type 2 diabetes (OR: 3.41; 95% CI: 1.31, 8.90). No protective effect of consumption of “fruits and vegetables” was observed, although average consumption was below national recommendation levels.

Conclusions

AI dietary patterns corroborate nutritional concerns previously reported among AI populations. Future interventions should discourage overconsumption of meat, fried foods, and processed foods, and promote consumption of fruits and vegetables to reduce chronic disease burden in this population.

The Healthy Children, Strong Families 2 (HCSF2) Randomized Controlled Trial Improved Healthy Behaviors in American Indian Families with Young Children

BACKGROUND

American Indian (AI) families experience a disproportionate risk of obesity due to a number of complex reasons, including poverty, historic trauma, rural isolation or urban loss of community connections, lack of access to healthy foods and physical activity opportunities, and high stress. Home-based obesity prevention interventions are lacking for these families.

OBJECTIVE

Healthy Children, Strong Families 2 (HCSF2) was a randomized controlled trial of a healthy lifestyle promotion/obesity prevention intervention for AI families.

METHODS

Four hundred and fifty dyads consisting of an adult primary caregiver and a child ages 2 to 5 y from 5 AI communities were randomly assigned to a monthly mailed healthy lifestyle intervention toolkit (Wellness Journey) with social support or to a child safety control toolkit (Safety Journey) for 1 y. The Wellness Journey toolkit targeted increased fruit/vegetable (F/V) intake and physical activity, improved sleep, decreased added sugar intake and screen time, and improved stress management (adults only). Anthropometrics were collected, and health behaviors were assessed via survey at baseline and at the end of Year 1. Adults completed surveys for themselves and the participating child. Repeated measures analysis of variance was used to assess change over the intervention period.

RESULTS

Significant improvements to adult and child healthy diet patterns, adult F/V intake, adult moderate-to-vigorous physical activity, home nutrition environment, and adult self-efficacy for health behavior change were observed in Wellness Journey compared with Safety Journey families. No changes were observed in adult body mass index (BMI), child BMI z-score, adult stress measures, adult/child sleep and screen time, or child physical activity. Qualitative feedback suggests the intervention was extremely well-received by both the families and our community partners across the 5 participating sites.

CONCLUSIONS

This multi-site community-engaged intervention addressed key gaps regarding family home-based approaches for early obesity prevention in AI communities and showed several significant improvements in health behaviors. Multiple communities are working to sustain intervention efforts. This trial was registered at clinicaltrials.gov as NCT01776255.

Trends in height, weight, BMI, skinfolds, and measures of overweight and obesity from 1979 through 1999 among American Indian Youth: The Akwesasne Mohawk

BACKGROUND/OBJECTIVES

Information on recent changes in overweight, obesity, and adiposity among American Indians is scarce. To assess changes in size and adiposity among American Indian youth, data from two samples of Akwesasne Mohawk youth, were compared.

SUBJECTS/METHODS

Both project 1, conducted in 1979 (n = 75) and Project 2, conducted between 1996 and 1999 (n = 206), sampled youth 10-14 years of age from the Akwesasne Mohawk Reservation (aka St. Regis) that borders New York state, and Ontario and Quebec provinces. Heights, weights, and skinfold thicknesses were converted to z-scores using CDC reference values. BMI status was calculated in terms of WHO age-specific cutoffs and CDC cutoffs.

RESULTS

z-Scores for heights differed little between projects. The between-project difference in weight z-score is twice the between-project z-score difference for height. Differences among males are larger and more often significant. Triceps and subscapular skinfold thickness are significantly greater in Project 2. The rate of overweight and obesity combined, increased 3.3-fold. In multiple regression analyses with sex, height, and age in the model, project is a significant predictor of weight and skinfolds.

CONCLUSIONS

Weight and adiposity have increased substantially from 1979 to 1996-99. Overweight and obesity became significantly more common. Given the increase in adiposity, these youth may be facing significant health risks as adults in terms of cardiovascular disease, cancer, and type II diabetes unless weight and adiposity is reduced.

Role of autophagy in a model of obesity: A long‑term high fat diet induces cardiac dysfunction

Obesity may induce end-organ damage through metabolic syndrome, and autophagy serves a vital role in the pathogenesis of metabolic syndrome. The purpose of the present study was to define the roles of autophagy and mitophagy in high fat diet (HFD)-induced cardiomyopathy. Male, 8 week-old C57BL/6 mice were fed either a HFD (60% kcal) or a diet of normal chow (NC; 10% kcal) for 42 weeks. Glucose tolerance tests were performed during the feeding regimes. Blood samples were collected for assaying serum triglyceride with the glycerol-3-phosphate oxidase phenol and aminophenazone (PAP) method and total cholesterol was tested with the cholesterol oxidase-PAP method. Myocardial function was assessed using echocardiography and hemodynamic analyses. Western blot analysis was employed to evaluate endoplasmic reticulum stress (ERS), autophagy and mitochondrial function. Electron microscopy was used to assess the number of lipid droplets and the degree of autophagy within the myocardium. The body weight and adipose tissue weight of mice fed the HFD were increased compared with the NC mice. The serum levels of blood glucose, total cholesterol and triglyceride were significantly increased following 42 weeks of HFD feeding. The results of the glucose tolerance tests additionally demonstrated metabolic dysregulation in HFD mice. In addition, HFD mice exhibited hemodynamic and echocardiographic evidence of impaired diastolic and systolic function, including alterations in the cardiac output, end-diastolic pressure, end-diastolic volume and left ventricular relaxation time constant (tau) following HFD intake. Furthermore, a HFD resulted in increased ERS, and a downregulation of the autophagy and mitophagy level. The present study investigated cardiac function in obese HFD-fed mice. These results aid the pursuit of novel therapeutic targets to combat obesity-associated cardiomyopathy.

The scope of sleep problems in Canadian children and adolescents with obesity

OBJECTIVE

To determine the scope of sleep concerns, clinical features, and polysomnography (PSG) results and to identify factors that predict obstructive sleep apnea (OSA) in a cohort of children with obesity.

METHODS

The study was a multicenter retrospective chart review. Data were collected from three pediatric sleep laboratories over a two year period for all children of age 8-16 years with a body mass index [BMI] ≥95th centile who were undergoing PSG. Data sources included clinical charts and PSG results. Clinical and PSG factors were examined as predictors of OSA.

RESULTS

A total of 210 children met inclusion criteria, and 205 had sufficient data for analysis. The mean age was 12.5 ± 2.7 years; and 65% were male. Multiple sleep concerns and comorbidities were reported in most children (90% and 91%, respectively). OSA was identified by PSG in 44% of children; and 28% of children demonstrated moderate/severe OSA. Mouth breathing/nasal congestion (odds ratio [OR] = 0.33, 95% confidence interval [CI] = 0.18-0.61), syndrome/multiple anomalies (OR = 2.4, 95% CI = 1.22-4.93), and family history of OSA (OR = 2.7, 95% CI = 1.2-5.8) or sleep problems (OR = 12.4, 95% CI = 1.5, 99.6) were the only factors predictive of OSA. Oxygen desaturation index <6 events/h measured by PSG showed an OR of 4.96 (95% CI = 2.27-10.86) for the absence of OSA.

CONCLUSIONS

Children with obesity who undergo PSG are medically complex with multiple sleep concerns including a high burden of daytime symptoms; slightly less than half of children demonstrate polysomnographic features of OSA. Earlier identification of OSA, recognition of non-OSA sleep concerns, and treatment strategies to improve sleep may contribute to overall health outcomes for children with obesity.

Obesity and Overweight in American Indian and Alaska Native Children, 2006-2015

OBJECTIVES

To estimate obesity and overweight prevalence in American Indian and Alaska Native (AI/AN) children across genders, ages, and geographic regions in the Indian Health Service active clinical population.

METHODS

We obtained data from the Indian Health Service National Data Warehouse. At least 184 000 AI/AN children aged 2 to 19 years had body mass index data for each year studied, 2006 to 2015. We calculated body mass index percentiles with the 2000 Centers for Disease Control and Prevention growth charts.

RESULTS

In 2015, the prevalence of overweight and obesity in AI/AN children aged 2 to 19 years was 18.5% and 29.7%, respectively. Boys had higher obesity prevalence than girls (31.5% vs 27.9%). Children aged 12 to 19 years had a higher prevalence of overweight and obesity than younger children. The AI/AN children in our study had a higher prevalence of obesity than US children overall in the National Health and Nutrition Examination Survey. Results for 2006 through 2014 were similar.

CONCLUSIONS

The prevalence of overweight and obesity among AI/AN children in this population may have stabilized, while remaining higher than prevalence for US children overall.

Changes in Body Mass Index During a 3-Year Elementary School-Based Obesity Prevention Program for American Indian and White Rural Students

BACKGROUND

Childhood obesity is a significant but largely modifiable health risk, disproportionately affecting socioeconomically disadvantaged, racial/ethnic minority, and rural children. Elementary school-aged children typically experience the greatest increases in excess weight gain and therefore are important targets for reducing adolescent and adult obesity while improving children's health. Our study evaluated outcomes of a 3-year elementary school-based program for reducing obesity in American Indian and White students attending eight rural schools in the U.S. upper Midwest.

METHOD

Researchers measured body mass indexes (BMI) and other health indicators and behaviors of 308 beginning third-grade students and then again at the end of students' third, fourth, and fifth grades. The primary focus of this study is a mixed multilevel longitudinal model testing changes in age- and gender-adjusted BMI z scores ( zBMI).

RESULTS

There was a significant decrease in zBMI across the 3-year study period. Ethnicity analyses showed that White students had overall decreases in zBMI whereas American Indian students' zBMIs remained stable across the program. Comparisons with children from an age- and cohort-matched national sample provided support for the effectiveness of the school program in reducing BMI and obesity during the study period.

CONCLUSION

An elementary school-based health program that addresses a range of students' obesity-related health behaviors, the school health environment, and that involves educators and parents is an effective intervention for reducing or stabilizing BMI in rural White and American Indian students. School health programs for students living in rural communities may be especially effective due to greater school and community cohesiveness, and valuing of the school's primary role in improving community health.

Prevalence and characteristics of overweight and obesity in indigenous Australian children: A systematic review

Evidence-based profiling of obesity and overweight in Indigenous Australian children has been poor. This study systematically reviewed evidence of the prevalence and patterns of obesity/overweight, with respect to gender, age, remoteness, and birth weight, in Indigenous Australian children, 0-18 years (PROSPERO CRD42014007626). Study quality and risk of bias were assessed. Twenty-five publications (21 studies) met inclusion criteria, with large variations in prevalence for obesity or overweight (11 to 54%) reported. A high degree of heterogeneity in study design was observed, few studies (6/21) were representative of the target population, and few appropriately recruited Indigenous children (8/21). Variability in study design, conduct, and small sample sizes mean that it is not possible to derive a single estimate for prevalence although two high-quality studies indicate at least one in four Indigenous Australian children are overweight or obese. Four of six studies reporting on gender, found overweight/obesity higher in girls and eight studies reporting on overweight/obesity by age suggest prevalence increases with age with one high quality large national study reporting total overweight/obesity as 22.4% of children aged 2-4 years, 27.5% of those aged 5-9, 38.5% aged 10-14, and 36.3% aged 15-17. Three of four studies, reporting obesity/overweight by region, found lower rates for children living in more remote areas than urban areas.

Racial discrimination associated with higher diastolic blood pressure in a sample of American Indian adults

OBJECTIVES

Hypertension prevalence is high among American Indians (AIs). AIs experience a substantial burden of interpersonal racial discrimination, which in other populations has been associated with higher blood pressure. The purpose of this study is to understand whether racial discrimination experiences are associated with higher blood pressure in AIs.

MATERIALS AND METHODS

We used the Everyday Discrimination Scale to evaluate the relationship between discrimination and measured blood pressure among 77 AIs from two reservation communities in the Northern Plains. We used multivariate linear regression to evaluate the association of racial discrimination with systolic and diastolic blood pressure, respectively. Racial discrimination, systolic blood pressure, and diastolic blood pressure were analyzed as continuous variables. All analyses adjusted for sex, waist circumference, age, posttraumatic stress disorder status, and education.

RESULTS

We found that 61% of participants experienced discrimination that they attributed to their race or ancestry. Racial discrimination was associated with significantly higher diastolic blood pressure (β = 0.22, SE = 0.09, p = .02), and with a similar non-significant trend toward higher systolic blood pressure (β = 0.25, SE = 0.15, p = .09).

CONCLUSION

The results of this analysis suggest that racial discrimination may contribute to higher diastolic blood pressure within Native communities. These findings highlight one pathway through which the social environment can shape patterns of biology and health in AI and other socially and politically marginalized groups.

Call to action: A new path for improving diabetes care for Indigenous peoples, a global review

Diabetes has reached epidemic proportions in Indigenous populations around the globe, and there is an urgent need to improve the health and health equity of Indigenous peoples with diabetes through timely and appropriate diabetes prevention and management strategies. This review describes the evolution of the diabetes epidemic in Indigenous populations and associated risk factors, highlighting gestational diabetes and intergenerational risk, lifestyle risk factors and social determinants as having particular importance and impact on Indigenous peoples. This review further describes the impact of chronic disease and diabetes on Indigenous peoples and communities, specifically diabetes-related comorbidities and complications. This review provides continued evidence that dramatic changes are necessary to reduce diabetes-related inequities in Indigenous populations, with a call to action to support programmatic primary healthcare transformation capable of empowering Indigenous peoples and communities and improving chronic disease prevention and management. Promising strategies for transforming health services and care for Indigenous peoples include quality improvement initiatives, facilitating diabetes and chronic disease registry and surveillance systems to identify care gaps, and prioritizing evaluation to build the evidence-base necessary to guide future health policy and planning locally and on a global scale.

Tribally Affiliated Child-Care Center Environment and Obesogenic Behaviors in Young Children

BACKGROUND

Child-care centers are an integral part of life for many families with young children. American Indian children are at elevated health risk because of higher levels of obesity and associated health behaviors.

OBJECTIVE

Our aim was to assess the child-care environment and children's physical activity (PA) and dietary intake in young children attending tribally affiliated child care.

DESIGN

We conducted a cross-sectional study.

PARTICIPANTS/SETTING

Participants were from 11 tribally affiliated child-care centers across Oklahoma and included 82 children aged 3 to 5 years old.

MAIN OUTCOME MEASURES

Classroom observations were conducted using the Environmental and Policy Assessment Observation to measure PA and nutrition environments. Children wore an ActiGraph GT3X accelerometer and lunchtime plate waste was observed.

STATISTICAL ANALYSES

Descriptive statistics, including mean±standard deviation and frequencies, were calculated for the children's behaviors and environment.

RESULTS

The total environment score was 23.9±5.2 (maximum=43). The nutrition score was 12.5±3.1 (maximum=21). The PA score was 11.7±2.2 (maximum=22). The participants were 3.8±0.1 years old, 55% were male, 67% were American Indian, and 38% were overweight or obese. Accelerometers were worn for 5.9±1.7 hours, excluding naptime. Children accumulated 4.3±2.2 min/h of moderate to vigorous PA, 4,294±1,883 steps/day, and 12.1±3.7 steps/min. At lunch, children were served 510±241 kcal, and consumed 387±239 kcal. Lunches consisted of 47% carbohydrate, 20% protein, and 33% fat. Total number of F/V served was 2.9±1.9 and consumed was 2.3±1.8, while whole grains served and consumed were 0.3±0.4 and 0.2±0.4, respectively, and lean proteins served and consumed were 0.3±0.4 and 0.2±0.4, respectively.

CONCLUSIONS

This study describes obesogenic aspects of the child-care environment and identifies areas for improvement. Children did not accumulate adequate PA or consume calories or fat excessively. Children consumed multiple F/V; however, more whole grains and lean proteins could be provided. Future research might investigate how the healthfulness of the child-care environment can be improved by counseling providers on nutrition and PA strategies to prevent obesity.

Promoting Physical Activity Among Native American Youth: a Systematic Review of the Methodology and Current Evidence of Physical Activity Interventions and Community-wide Initiatives

Promoting physical activity using environmental, policy, and systems approaches could potentially address persistent health disparities faced by American Indian and Alaska Native children and adolescents. To address research gaps and help inform tribally led community changes that promote physical activity, this review examined the methodology and current evidence of physical activity interventions and community-wide initiatives among Native youth. A keyword-guided search was conducted in multiple databases to identify peer-reviewed research articles that reported on physical activity among Native youth. Ultimately, 20 unique interventions (described in 76 articles) and 13 unique community-wide initiatives (described in 16 articles) met the study criteria. Four interventions noted positive changes in knowledge and attitude relating to physical activity but none of the interventions examined reported statistically significant improvements on weight-related outcomes. Only six interventions reported implementing environmental, policy, and system approaches relating to promoting physical activity and generally only shared anecdotal information about the approaches tried. Using community-based participatory research or tribally driven research models strengthened the tribal-research partnerships and improved the cultural and contextual sensitivity of the intervention or community-wide initiative. Few interventions or community-wide initiatives examined multi-level, multi-sector interventions to promote physical activity among Native youth, families, and communities. More research is needed to measure and monitor physical activity within this understudied, high risk group. Future research could also focus on the unique authority and opportunity of tribal leaders and other key stakeholders to use environmental, policy, and systems approaches to raise a healthier generation of Native youth.

Indigenous and tribal peoples' health (The Lancet-Lowitja Institute Global Collaboration): a population study

BACKGROUND

International studies of the health of Indigenous and tribal peoples provide important public health insights. Reliable data are required for the development of policy and health services. Previous studies document poorer outcomes for Indigenous peoples compared with benchmark populations, but have been restricted in their coverage of countries or the range of health indicators. Our objective is to describe the health and social status of Indigenous and tribal peoples relative to benchmark populations from a sample of countries.

METHODS

Collaborators with expertise in Indigenous health data systems were identified for each country. Data were obtained for population, life expectancy at birth, infant mortality, low and high birthweight, maternal mortality, nutritional status, educational attainment, and economic status. Data sources consisted of governmental data, data from non-governmental organisations such as UNICEF, and other research. Absolute and relative differences were calculated.

FINDINGS

Our data (23 countries, 28 populations) provide evidence of poorer health and social outcomes for Indigenous peoples than for non-Indigenous populations. However, this is not uniformly the case, and the size of the rate difference varies. We document poorer outcomes for Indigenous populations for: life expectancy at birth for 16 of 18 populations with a difference greater than 1 year in 15 populations; infant mortality rate for 18 of 19 populations with a rate difference greater than one per 1000 livebirths in 16 populations; maternal mortality in ten populations; low birthweight with the rate difference greater than 2% in three populations; high birthweight with the rate difference greater than 2% in one population; child malnutrition for ten of 16 populations with a difference greater than 10% in five populations; child obesity for eight of 12 populations with a difference greater than 5% in four populations; adult obesity for seven of 13 populations with a difference greater than 10% in four populations; educational attainment for 26 of 27 populations with a difference greater than 1% in 24 populations; and economic status for 15 of 18 populations with a difference greater than 1% in 14 populations.

INTERPRETATION

We systematically collated data across a broader sample of countries and indicators than done in previous studies. Taking into account the UN Sustainable Development Goals, we recommend that national governments develop targeted policy responses to Indigenous health, improving access to health services, and Indigenous data within national surveillance systems.

FUNDING

The Lowitja Institute.

Obesogenic environments in tribally-affiliated childcare centers and corresponding obesity rates in preschool children

BACKGROUND

Determine the relationship between obesogenic characteristics of childcare and child adiposity in tribally-affiliated centers in Oklahoma.

METHODS

The two-day Environment and Policy Assessment and Observation (EPAO) included a total environment (TE), nutrition (N), and physical activity (PA) score and took place in 11 centers across Oklahoma. Eighty-two preschool children (3-5 years) participated. Child height and weight were measured and overweight status (≥ 85th percentile for age and sex) was determined. Regression models, fit using Generalized Estimating Equations methodology to account for clustering by center were used and adjusted for center characteristics.

RESULTS

Participants were 3.8 (0.8) years old, 55% male, 67% American Indian (AI) and 38% overweight. A healthier TE and PA was associated with a reduced odds of overweight, which remained significant after adjusting for some center characteristics, but not all. A healthier TE, N, and PA was associated with lower BMI percentile, which remained significant after some center-level adjustments, but not all. Lower sedentary opportunity and sedentary time were no longer associated with reduced odds of overweight following adjustment. Lower opportunity for high sugar and high fat foods and minutes of active play were associated with reduced odds of overweight in some adjusted models.

CONCLUSIONS

Collectively unadjusted and adjusted models demonstrate that some aspects of a healthier childcare center environment are associated with reduced odds of overweight and lower BMI percentile in preschool children attending tribally-affiliated childcare in Oklahoma. Future research should examine the association of childcare and health behaviors and further explore the role of potential confounders.

Using Electronic Health Records to Examine Disease Risk in Small Populations: Obesity Among American Indian Children, Wisconsin, 2007-2012

Introduction

Tribe-based or reservation-based data consistently show disproportionately high obesity rates among American Indian children, but little is known about the approximately 75% of American Indian children living off-reservation. We examined obesity among American Indian children seeking care off-reservation by using a database of de-identified electronic health records linked to community-level census variables.

Methods

Data from electronic health records from American Indian children and a reference sample of non-Hispanic white children collected from 2007 through 2012 were abstracted to determine obesity prevalence. Related community-level and individual-level risk factors (eg, economic hardship, demographics) were examined using logistic regression.

Results

The obesity rate for American Indian children (n = 1,482) was double the rate among non-Hispanic white children (n = 81,042) (20.0% vs 10.6%, P < .001). American Indian children were less likely to have had a well-child visit (55.9% vs 67.1%, P < .001) during which body mass index (BMI) was measured, which may partially explain why BMI was more likely to be missing from American Indian records (18.3% vs 14.6%, P < .001). Logistic regression demonstrated significantly increased obesity risk among American Indian children (odds ratio, 1.8; 95% confidence interval, 1.6–2.1) independent of age, sex, economic hardship, insurance status, and geographic designation.

Conclusion

An electronic health record data set demonstrated high obesity rates for nonreservation-based American Indian children, rates that had not been previously assessed. This low-cost method may be used for assessing health risk for other understudied populations and to plan and evaluate targeted interventions.

Increased arterial stiffness in South Dakota American Indian children

Arterial stiffness has been observed in white American obese children, yet there are no data in American Indian youth, who are affected disproportionately by the cardiovascular consequences of childhood obesity and its accompanying risk factors. The purpose of this study was to determine the association of childhood overweight-obesity and cardiometabolic risk factors with arterial stiffness in South Dakota white American and American Indian children. Thirty-six (28 white American and 8 American Indian) children (age, 13 ± 1 years; grades 6-8) from a rural South Dakota elementary and middle school were studied: 18 had a healthy weight (body mass index (BMI), 19.5 ± 1.9 kg/m(2)) and 18 were overweight-obese (BMI, 26.8 ± 3.5 kg/m(2)). Arterial stiffness was assessed using applanation tonometry via pulse wave analysis to determine carotid-radial pulse wave velocity (crPWV) and aortic augmentation index (AIx). There were no differences (P = 0.94) in crPWV between healthy weight (7.1 ± 1.4 m/s) and overweight-obese (7.3 ± 1.0 m/s) children, even after controlling for risk factors. However, crPWV was markedly elevated (P = 0.002) in overweight-obese American Indian children (7.7 ± 1.1 m/s) compared with white American children (6.8 ± 0.5 m/s), and these differences remained after controlling for blood pressure and more severe obesity in the American Indians. An obesity-matched subgroup analysis indicated that crPWV (7.7 ± 1.1 vs 6.8 ± 0.4 m/s) remained significantly greater in the American Indians (P = 0.03). There were no between-group differences in aortic AIx. These findings indicate an adverse influence of American Indian ethnicity on arterial stiffening in children with elevated adiposity. Arterial stiffness in American Indian children may accelerate early adulthood vascular disease.

Nutritional epigenetics with a focus on amino acids: implications for the development and treatment of metabolic syndrome

Recent findings from human and animal studies indicate that maternal undernutrition or overnutrition affects covalent modifications of the fetal genome and its associated histones that can be carried forward to subsequent generations. An adverse outcome of maternal malnutrition is the development of metabolic syndrome, which is defined as a cluster of disorders including obesity, hyperglycemia, hyperinsulinemia, hyperlipidemia, hypertension and insulin resistance. The transgenerational impacts of maternal nutrition are known as fetal programming, which is mediated by stable and heritable alterations of gene expression through covalent modifications of DNA and histones without changes in DNA sequences (namely, epigenetics). The underlying mechanisms include chromatin remodeling, DNA methylation (occurring at the 5'-position of cytosine residues within CpG dinucleotides), histone modifications (acetylation, methylation, phosphorylation, ubiquitination and sumoylation) and expression and activity of small noncoding RNAs. The enzymes catalyzing these reactions include S-adenosylmethionine-dependent DNA and protein methyltransferases, DNA demethylases, histone acetylase (lysine acetyltransferase), general control nonderepressible 5 (GCN5)-related N-acetyltransferase (a superfamily of acetyltransferase) and histone deacetylase. Amino acids (e.g., glycine, histidine, methionine and serine) and vitamins (B6, B12 and folate) play key roles in provision of methyl donors for DNA and protein methylation. Therefore, these nutrients and related metabolic pathways are of interest in dietary treatment of metabolic syndrome. Intervention strategies include targeting epigenetically disturbed metabolic pathways through dietary supplementation with nutrients (particularly functional amino acids and vitamins) to regulate one-carbon-unit metabolism, antioxidative reactions and gene expression, as well as protein methylation and acetylation. These mechanism-based approaches may effectively improve health and well-being of affected offspring.

Clinicians' Implicit and Explicit Attitudes about Weight and Race and Treatment Approaches to Overweight for American Indian Children

PURPOSE

Obesity is one of the most serious health problems among American Indian/Alaska Native (AI/AN) children. We investigated Indian Health Service (IHS) primary care providers' implicit and explicit attitudes about weight and race and their association with treatment approaches to overweight in children.

METHODS

We conducted an online survey of long-term primary care clinicians in two western regions of the IHS. We used the existing Weight Attitude Implicit Association Test (IAT) and developed a new Native American Attitude IAT to measure implicit attitudes. Explicit attitudes about weight and race were assessed through self-report. We assessed self-rated treatment approaches to childhood overweight. We used linear regression models to evaluate the association of attitudes about weight and race with treatment approaches.

RESULTS

Our sample included 75 clinicians (56% response rate) who, on average, saw 74 patients per week. Fifty-five percent of clinicians reported that 30-60% of their child and adolescent patients were overweight or obese, and 25% of clinicians reported that 60-100% of their patients were overweight or obese. We found strong implicit bias favoring thin people (Cohen's d=1.44) and weak implicit bias favoring whites (Cohen's d=0.35). We found no association between implicit or explicit bias scores and self-reported treatment of childhood overweight. Continuing education on obesity was associated with self-rated success and competence in weight management.

CONCLUSIONS

Weight and race bias exists among long-term IHS clinicians, but may not influence treatment approaches for overweight AI/AN children. Further research should assess the effect of clinicians' attitudes on real-world weight management.

Partnering with Indigenous student co-researchers: improving research processes and outcomes

Objective

To examine the contribution of student co-researchers to a community-based participatory Photovoice investigation of Indigenous children's food-related lived experience. We examine co-researchers’ contributions to the research process, their role in knowledge co-generation and dissemination, and factors that fostered research partnership with the teenage co-researchers.

Methods

High school students attending a First Nation community school in Canada were trained as research partners. They contributed to aspects of research design, conducted interviews with grades 3 and 4 Photovoice participants, and participated in data analysis and the development of a culturally relevant photobook. The study was initiated by the community's research committee. It is informed by critical consciousness theory and the positive youth development framework.

Results

Student co-researchers incorporated culturally appropriate strategies as they interviewed participants. Co-researchers adopted conversational approaches, built rapport by articulating personal and cultural connections, and engaged in mentoring and health promotion as they interviewed participants. They made critical contributions to dissemination by developing photobook content that promoted the importance of traditional foods and the vital role of family and community in healthy eating practices. Relationships and “dialogic” space were important to building partnership with and promoting capacity development among youth co-researchers.

Conclusions

Partnership between university researchers and Indigenous student co-researchers holds great promise for health promotion in communities. Co-researchers developed research and leadership skills, gained understanding of health challenges facing their community, and initiated health and cultural promotion through the project's Photobook. This investigation supports the powerful potential of student co-researchers to meaningfully contribute to research processes and to build knowledge that is relevant and credible both within and outside of their communities. Findings have implications for youth, communities and researchers.

Through the lens of our cameras: children's lived experience with food security in a Canadian Indigenous community

BACKGROUND

The related issues of food security and obesity among North American Indigenous children are serious public health concerns. This community-based participatory study sought to gain deeper understanding of young First Nation children's lived experience with food and to learn, from their perspective, about food security issues in their community.

METHODS

In this Photovoice investigation 26 young children attending a rural reserve school in Canada were asked to take photographs of the food they ate. Nine high school students from the same school were trained as co-researchers: they interviewed the younger students, helped identify emerging themes and contributed to knowledge translation. Data analysis incorporated conventional content analysis, grounded theory's constant-comparative method, and examination of photos and texts.

RESULTS

Five primary findings emerged from photographs and interviews: (1) children had a dualistic understanding of healthy vs. unhealthy foods; (2) packaged, quick-preparation foods played a dominant role in children's everyday food experiences; (3) families were critical to children's food-related experiences; (4) although traditional foods are viewed as central to Aboriginal health, few were depicted in the photographs; and (5) photos do not tell the whole story - despite the smaller numbers of fruits and vegetables in photos, children like to eat these foods when they are available at home.

CONCLUSIONS

The study improved understanding of children's everyday food-related experiences, provided insight into community food security, and demonstrated the contribution of children and youth as experts on their lives and matters affecting them. A photobook representing findings provided a rich, visual tool for communicating the food-related experiences of children and messages about healthy eating within the school and to community members and leaders. Intervention efforts can build on participants' understanding of healthy versus unhealthy foods and on the critical role of family for healthy eating.

Blood inorganic mercury is directly associated with glucose levels in the human population and may be linked to processed food intake

Background:

The goals of the study were (1) to determine the impact of inorganic mercury exposure on glucose homeostasis; and (2) to evaluate the effectiveness of two community-based interventions in promoting dietary changes among American Indian college students to reduce risk factors for Type-2 Diabetes including fasting glucose, insulin, and mercury levels, weight, and body mass index.

Methods:

To accomplish goal one, the National Health and Nutrition Examination Survey (NHANES) dataset was analyzed using a previously published method to determine if there is a relationship between inorganic blood mercury and fasting glucose. To accomplish goal two, ten college students were recruited and randomly assigned to a group receiving the online macroepigenetics nutrition course and the support group for eliminating corn sweeteners. Participants in both groups were assessed for diet patterns, weight, body mass index (BMI), fasting glucose, insulin, and mercury levels. The interventions were implemented over a 10-week period.

Results:

Analysis of the NHANES data (n=16,232) determined a direct relationship between inorganic mercury in blood and fasting glucose levels (p<0.001). The participants who took the online macroepigenetics nutrition intervention course significantly improved their diets (p<0.01), and fasting blood glucose levels (p<0.01) while having lower levels of inorganic mercury in their blood compared to the subjects in the group who eliminated corn sweeteners from their diet and participated in the support group. The trend in lower blood inorganic mercury was strong with p=0.052. The participants in the support group who eliminated corn sweeteners from their diet achieved significant weight loss (p<0.01) and reduced their body mass index (p<0.01).

Conclusion:

Total blood mercury levels may be influenced by dietary intake of highly processed foods and lower inorganic mercury levels are associated with lower fasting glucose levels. Alternative community-based interventions emphasizing the role food ingredients and toxic substances play in gene modulation and the development of diseases can result in significant dietary improvements and reductions in risk factors associated with type-2 diabetes. A healthier diet can be promoted among community members using a novel online nutrition course. Consumption of corn sweeteners may be a risk factor in the development of obesity.

Determinants of Diet for Urban Aboriginal Youth

Overweight and obesity are associated with several life-threating comorbidities, including type 2 diabetes and cardiovascular disease. Obesity is a growing health concern in North America, with some groups experiencing higher levels of obesity than others. One group of particular interest is urban Aboriginal youth because they are a quickly growing population who experience high rates of obesity. Obesity is a complex condition with many contributing factors, diet being one of the primary contributors. In this article, we discuss the findings from an ethnographic study that examined determinants of diet for urban Aboriginal youth. Results revealed two themes: (a) Traditions and Sharing, and (b) The Struggle. The findings with Traditions and Sharing showed that food-sharing networks are often used to acquire traditional food. Traditional foods were believed to be healthy and desired by the participants. The theme The Struggle provides insight into the daily challenges the participants faced with food insecurity. Health promotion professionals need to consider the multiplicity of determinants of diet for urban Aboriginal youth in order to plan and implement culturally appropriate health promotion programs.

Healthy Weights Interventions in Aboriginal Children and Youth: A Review of the Literature

There is evidence that Aboriginal children and youth in Canada and elsewhere are at higher risk of obesity and overweight than other children. However, there has been no review of healthy weights interventions specifically aimed at Aboriginal children. A structured search for peer-reviewed articles presenting and evaluating healthy weights interventions for Aboriginal children and youth was conducted. Seventeen articles, representing seven interventions, were reviewed to identify their main characteristics, evaluation design, and evaluation outcomes. Interventions included several large community-based programs as well as several more focused programs that all targeted First Nations or American Indians, rather than Métis or Inuit. Only 1 program served an urban Aboriginal population. None of the published evaluations reported significant reductions in obesity or overweight or sustained increases in physical activity, although some evaluations presented evidence of positive effects on children's diets or on nutrition knowledge or intentions. We conclude that broader structural factors affecting the health of Aboriginal children may limit the effectiveness of these interventions, and that more evidence is required regarding interventions for Aboriginal children in various geographic and cultural contexts in Canada including Inuit and Métis communities.

The impact of interventions to prevent obesity or improve obesity related behaviours in children (0-5 years) from socioeconomically disadvantaged and/or indigenous families: a systematic review

BACKGROUND

Children from disadvantaged families including those from low socioeconomic backgrounds and Indigenous families have higher rates of obesity, making early intervention a priority. The aim of this study was to systematically review the literature to examine the effectiveness of interventions to prevent obesity or improve obesity related behaviours in children 0-5 years from socioeconomically disadvantaged or Indigenous families.

METHODS

Searches of major electronic databases identified articles published from 1993-2013 targeting feeding practices, anthropometric, diet, activity or sedentary behaviour outcomes. This was supplemented with snowballing from existing reviews and primary studies. Data extraction was undertaken by one author and cross checked by another. Quality assessments included both internal and external validity.

RESULTS

Thirty-two studies were identified, with only two (both low quality) in Indigenous groups. Fourteen studies had a primary aim to prevent obesity. Mean differences between intervention and control groups ranged from -0.29 kg/m(2) to -0.54 kg/m(2) for body mass index (BMI) and -2.9 to -25.6% for the prevalence of overweight/obesity. Interventions initiated in infancy (under two years) had a positive impact on obesity related behaviours (e.g. diet quality) but few measured the longer-term impact on healthy weight gain. Findings amongst pre-schoolers (3-5 years) were mixed, with the more successful interventions requiring high levels of parental engagement, use of behaviour change techniques, a focus on skill building and links to community resources. Less than 10% of studies were high quality. Future studies should focus on improving study quality, including follow-up of longer-term anthropometric outcomes, assessments of cost effectiveness, acceptability in target populations and potential for implementation in routine service delivery.

CONCLUSION

There is an urgent need for further research on effective obesity prevention interventions for Indigenous children. The findings from the growing body of intervention research focusing on obesity prevention amongst young children from socioeconomically disadvantaged families suggest intervention effects are modest but promising. Further high quality studies with longer term follow up are required.

TRIAL REGISTRATION

PROSPERO Registration no: CRD42013006536.

Body fatness in relation to physical activity and selected socioeconomic parameters of adolescents aged 15-17 years in Merida, Yucatan

BACKGROUND

Increasing rates of overweight and obesity in adolescents are major concerns in many countries, including Mexico.

OBJECTIVES

To study anthropometric and body composition characteristics (BCC) and their relations with socioeconomic status (SES), biological history and physical activity (PA) of school-going adolescent boys and girls in the city of Merida, Yucatan, Mexico.

SUBJECTS AND METHODS

In this cross-sectional study, a sample of 321 adolescents (156 boys and 165 girls) aged 15-17 years from public and private schools in Merida, was taken from a study carried out in 2008-2009.

RESULTS

Body mass index had significant correlations to BCC (fat mass and fat-free mass). The rate of stunting was higher in girls (18.20%) than in boys (7.69%). Stunted adolescents had higher body fat (%) than normally growing peers. High rates of overweight (boys 26.28%, girls 24.24%) and obesity (boys 10.26%, girls 6.06%) were recorded. SES (parents' age, education and occupation; crowding index in the family; household food expenditure), participants' biological history and PA are related with height and BCC by age and sex.

CONCLUSION

Adolescents with excess weight (overweight + obesity) reported being less physically active. SES and PA were strongly related to growth and body fatness in the studied adolescents.