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7/30/2019 Am J Clin Nutr 2011 Gittelsohn 1179S 83S
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Preventing diabetes and obesity in American Indian communities: the
potential of environmental interventions14
Joel Gittelsohn and Megan Rowan
ABSTRACT
Obesity, diabetes, and other diet-related chronic diseases persist in
American Indians at rates that are significantly higher than those
in other ethnic minority populations. Environmental interventions
to improve diet and increase physical activity have the potential
to improve these health outcomes, but relatively little work has taken
place in American Indian communities. We reviewed the experiences
and findings of the following 3 case studies of intervention trials in
American Indian communities: the Pathways trial, which wasa school-based trial that focused on children; the Apache Healthy
Stores program, which was a food-store program that focused on
food preparers and shoppers; and the Zhiwaapenewin Akinomaage-
win trial, which was a multiinstitutional trial for First Nations adults
that worked with food stores, elementary schools, and health and so-
cial services agencies. All 3 trials showed mixed success. Important
lessons were learned, including the need to focus on supply and de-
mand, institutional and multilevel approaches, and the identification
of institutional bases to sustain programs. Am J Clin Nutr
2011;93(suppl):1179S83S.
INTRODUCTION
American Indian and First and diabetes Nations peoples suffer
from remarkably high rates of obesity and diabetes, and those
rates have been steadily increasing (1, 2). From 1994 to 2004, rates
doubled among American Indians aged
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necessary to investigate these key environmental antecedents to
American Indian nutrition, obesity, and chronic disease. More-
over, interventions are necessary to improve food availability in
these settings.
There are several strategies that can be used to improve access
(pricing and availability) to healthy foods in low-income minority
settings. Within food stores, interventions can decrease the
availability of unhealthy foods (eg, high fat and sugar), increase
the availability of healthy foods (eg, low fat and sugar and highfiber), alter physical features (eg, store layout, refrigeration units,
storage, and shelving), change the setting for the provision of
information (eg, point-of-purchase promotions), and manipulate
prices (1619). Alone or in combination, food storebased
strategies have the potential to affect access (ie, supply) and
point-of-purchase decision making regarding food choices (ie,
demand) and, thus, increase the likelihood of sustainability (16
19). However, the majority of store-intervention programs have
been conducted within supermarkets in large US cities (20, 21).
Few programs have worked with small convenience stores, which
constitute the most common day-to-day food-purchase outlets for
many rural American Indian populations. Environmental inter-
ventions can also change access to foods within neighborhoodsby building new supermarkets, developing farmers markets, and
improving transportation (21, 22). At the policy level, store
standards (eg, limiting the provision of unhealthy foods and the
promotion of those foods), pricing, menu labeling, and zoning
policies have been tested in several high- and middle-income
urban settings but have yet to be trialed in American Indian
communities (2325). Other approaches, such as improving food
networks (eg, distributors, producers, and retailers) and local
production and increasing the content of foods could spur wide-
ranging change that could reach American Indians. In short, little
work has been done to change the food environment in American
Indian communities.
With the use of 3 case studies of intervention trials in AmericanIndian communities, this article addressed the following key
questions:
1) Who are the key stakeholders in environmental interven-
tions in American Indian settings? How can they best be
involved?
2) What approaches, or combination of approaches, to envi-
ronmental change are likely to be most effective in Amer-
ican Indian communities?
3) What are some common lessons learned that can be ap-
plied to environmental intervention programs in other
American Indian communities?
METHODS
We addressed these questions by using a case-study approach
(25). We selected 3 programs that were implemented in varied
geographical settings and that sought to change the food and/or
physical activity environment as a means of addressing the
chronic-disease epidemic. The 3 case studies selected met the fol-
lowing criteria: 1) personal experience and familiarity of the
lead author with the program, 2) peer-reviewed publications that
detailed the formative research, process evaluation, and effect of
intervention trials, and 3) significant components of the in-
tervention sought environmental changes. Our analyses sought
to provide a contextually rich description of each case to permit
cross-case comparisons via pattern matching.
CASE STUDY 1: PATHWAYS TRIALCHANGING THE
SCHOOL FOOD AND PHYSICAL ACTIVITY
ENVIRONMENT
Stakeholder engagement
The Pathways trial was a multicenter intervention trial funded
by the National Heart, Lung, and Blood Institute that sought to
reduce obesity and common psychosocial and behavioral risk
factors in American Indian school children (2634). The trial
took place in 7 American Indian communities from 1993 to 2001
(2634). Key stakeholders included tribal health departments,
tribal administration and members, school administrators and
staff, and school board members who provided approval and
participated in program planning and implementation (2634).
Substantial formative research was conducted to aid in the design
of the intervention (26, 27).
Approach to environmental change
Pathways interventions were centered in elementary schools
and include 4 main components as follows: a specially designed
classroom curriculum for grades 35, changes to the school food
service, an enhanced physical education program, and a family
component (2830). The Pathways trial sought to change the
school food environment by providing training and guidelines for
school food-service workers on how to order, prepare, and serve
foods that were lower in fat compared with usual foods offered
(2830). In addition, teachers were given guidelines on nonfood
rewards as a means of reducing competitive foods within schools
(2830). Materials sent home with children and in-school events
encouraged parents to provide healthy foods at home (2830).
The Pathways trial also sought to change the school activity
environment through an enhanced physical education program on
the basis of the Sports, Play & Active Recreation for Kids
(SPARK) curriculum and including additional noncompetitive
American Indian games (30).
The Pathways process evaluation showed that the program was
implemented with different levels of success depending on the
intervention component (31). The school curriculum and food-
service components were implemented with a high reach and
dose, with improvement in implementation of the food-service
guidelines from year to year of the intervention (31). The physical
activity program was implemented with a high reach but only
a moderate dose because most schools were able to meet target
levels of 3 classes/student/wk but not the ideal dose of 5 classes/wk
(31). The family component was weakly implemented with drops
in rates of family pack return cards that came back and decreased
attendance at school events from year to year as the study
progressed (31).
Program effect
The Pathways trial saw positive changes in psychosocial
measures and improvements in diet associated with the in-
tervention (32, 33). However, no significant improvements were
seen in physical activity levels or in obesity, which was the
primary outcome (32, 33). Although the Pathways trial was
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successful in changing the school environment in American
Indian communities, factors outside schools counter-balanced
those within schools (33, 34). Therefore, changes in the home and
community were not present to adequately support changes in
schools.
CASE STUDY 2: APACHE HEALTHY STORES
PROGRAMCHANGING THE COMMUNITY FOODENVIRONMENT
Stakeholder engagement
The Apache Healthy Stores (AHS) program was a community-
based environmental intervention trial funded by the US De-
partment of Agriculture that sought to increase the availability of
healthy food options in local food stores and increase the pur-
chase and consumption of these foods (3537). The trial took
place in the White Mountain and San Carlos Apache reservations
from 2003 to 2005 (3537). Key stakeholders included tribal
administration and members, store owners and managers, and
tribal health departments, particularly the diabetes prevention
programs (35). Stakeholders contributed to program planning andassisted in the implementation of the program. The intervention
was developed through formative research and an engagement
process that centered on community workshops (35).
Approach to environmental change
The AHS program sought to change the food environment by
working with small and large food stores to increase the range of
healthy options and to promote these foods at the point of
purchase and through community media (36). Trained staff
worked with local stores owners and managers to increase the
stocking of healthy foods that were selected through the com-
munity workshop process (36). These foods were promoted in
stores through interactive sessions, posters, flyers, and small
promotional giveaways (eg, water bottles and food clips) (36).
Community media reinforced key messages through radio
announcements, newspaper articles, and cartoons (36).
At the store level, the program was implemented with a high
level of dose and reach and a moderate to high level of fidelity
(36). At the community level, the AHS program was imple-
mented with a moderate degree of fidelity and dose (36). At the
individual level, cooking demonstrations and taste tests reached
a large number of community members with a high dose (36).
Implementing the AHS program on multiple levels (store,
community, and individual) was challenging and differed be-
tween levels (36). Overall, improvements were seen from start to
finish as program staff monitored, documented, and responded to
barriers to implementation (36, 37).
Program effect
The AHS program was successful in showing improvements in
food-related knowledge, healthy food intentions, and the fre-
quency of healthy food purchasing among the main food preparer
or shopper of studied households (37). Modest improvements in
gram intakes of promoted healthy foods and decreases in less
healthful high-fat, high-sugar foods, were shown in association
with the highest levels of exposure to the intervention (37). The
combination of mass-media activities, in-store signage at the
point of purchase, interactive sessions, and the increased avail-
ability of healthy food options in local stores were responsible for
the success of the intervention (37). The study results confirmed
that trials that seek to change the food environment have the
potential to favorably affect various psychosocial factors, food
consumption, and food-related behaviors that would reduce risk
of obesity and other diet-related chronic diseases. On the other
hand, potential improvements in health outcomes were not
assessed. Therefore, it is possible that improvements in diet weremarginal and not associated with measurable health benefits.
Interventions that engage multiple community settings are likely
to show a broader range of benefits. Finally, the AHS program
was sustained and still continues to operate in one of the 2
American Indian communities by the local diabetes prevention
program.
CASE STUDY 3: ZHIWAAPENEWIN AKINOMAAGEWIN
TRIALCHANGING THE FOOD AND PHYSICAL
ACTIVITY ENVIRONMENT
Stakeholder engagementThe Zhiwaapenewin Akinomaagewin (ZA) trial was a community-
based environmental intervention trial funded by the American
Diabetes Association that combined a food-store intervention
similar to that of the AHS program with a school program similar
to that in the Pathways trial and worked in partnership with staff
of the local health and social services (3842). The trial took
place in 7 First Nations reserves from 2004 to 2006 (3842). Key
stakeholders included band administration, store owners and
managers, school administrators and teachers, and staff of health
and social services (38). The ZA intervention was developed
through formative research and community workshops (38) in
which stakeholders contributed ideas and strategies.
Approach to environmental change
Similar to the AHS intervention, the ZA intervention sought to
change the food environment by working with local food stores to
increase the range of healthy options and to promote these foods
at the point of purchase and through community media (38, 39).
Promotions emphasized interactive sessions in stores, community
centers, and at school events and emphasized taste testing and
healthy cooking demonstrations (38, 39). A key difference be-
tween the ZA and AHS interventions was that, in addition to these
changes in local food stores, a locally developed health curricula
was introduced to students in grades 35 (38, 39). The school
curriculum, which was adapted from a previously successfulprogram (17), reinforced key messages introduced in stores.
Family packs were sent home with students (38, 39). Physical
activity and dietary changes were promoted through the school
program and community activities, including walking groups (38,
39).
School-curricula implementation had moderate fidelity with
63% of lessons delivered as planned. Store activities had mod-
erate fidelity; the availability of all promoted foods was 70%, and
appropriate shelf labels were posted 60% of the time (39).
Cooking demonstrations were performed with a 71% fidelity and
high dose (39). A total of 156 posters were placed in community
locations; radio, cable television, and newsletters were used (39).
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Interviews revealed that the program was culturally acceptable
and relevant, and suggestions for improvement were made (39).
Program effect
Baseline and follow-up data were collected before and after the
9-mo intervention program in schools, stores, and communities
that aimed to improve diet and increase physical activity in adults
(41). Regression analyses indicated a significant change in theknowledge of respondents in intervention communities (P ,
0.019) (41, 42). There was also significant increase in the fre-
quency of healthy food acquisition in respondents in the in-
tervention communities (P , 0.003) (41, 42). However, there
were no significant changes in the physical activity or body mass
index in either the intervention or comparison groups (41, 42).
The ZA program was expanded to additional First Nations re-
serves after completion of the trial.
DISCUSSION AND CONCLUSIONS
As we examined our3 environmental intervention case studies,
several key common patterns emerged. First, American Indianchronic diseaseprevention strategies appeared to be successful
when they functioned at multiple levels, including environmental
and individual levels. An additional pattern was that such pro-
grams sought to change the food and physical activity envi-
ronments by partnering with key local stakeholders such as food
retailers, schools, and other community organizations. With the
use of these strategies, institutional-level intervention compo-
nents promoted healthy dietary and behaviors in a way that
influenced household (eg, food purchasing) and individual food-
related psychosocial factors and behaviors, which ultimately
affected obesity and other diet-related chronic disease. Also, the
interventions directly influenced individual-level behaviors such
as food choices.Second, complementary supply-and-demand approaches were
important components of environmental interventions. Multilevel
approaches were successful in changing diabetes- and obesity-
related psychosocial factors and dietary risk behaviors in each of
the rural Native North American settings addressed in our case
studies. As illustrated by the Pathways trial, the success of en-
vironmental changes in schools hinged on changes, support, and
reinforcement at household and community levels. A change in
any single institution should be complemented by reinforcing
strategies in other institutions or at other levels. The AHS pro-
gram successfully integrated each level of the food environment
in its strategy, and by doing so, the program addressed the
supply and demand needed to produce a significant effect. Theintroduction of key foods addressed the supply, whereas
workshops, interactive sessions, community media, and point-
of-purchase marketing spurred the demand needed to sustain
food supplies without subsidies or external reinforcements.
However, despite this evidence, the majority of food-intervention
programs operated at the store-level only. Other programs sought
to increase demand through nutrition education but did little to
affect availability or supply.
Third, it was important to work in multiple institutions to
achieve high exposure. Other programs have addressed demand
through the media, point-of-purchase displays, and structural
adjustments within stores but failed to extend their communi-
cations efforts to the greater community. The AHS and ZA
programs achieved a high exposure by working with community
leaders, such as local health services and community organ-
izations. These leaders contributed to the design of a setting-
appropriate strategy and helped to extend the program reach
through intertribal dissemination. By working in multiple insti-
tutions, such as schools, food stores, and community events, the
AHS and ZA programs also increased the likelihood of in-
terpersonal contact and reinforced messaging.Finally, it was important to find an appropriate institutional
base to sustain activities. Although addressing demand and
working in multiple institutions provided the necessary mecha-
nisms to produce a program effect, the long-term sustainability
was dependent on the involvement of community partners. This
was especially important in the American Indian communities in
which tribal and local health-service agencies played a significant
role in the health and wellness of community members. As shown
by the AHS and ZA programs, staff of health and social services
could be useful collaborators because they had a vested interest in
changing health behaviors. By engaging staff at the start of the
program, ownership and capacity can be increased, which can be
sustained post-intervention.This review had several limitations:
1) We considered interventions that took place in different
settings and used varying approaches with a varying em-
phasis on changing the food environment, which made
direct comparisons complex. We considered our findings
suggestive and provocative but not conclusive.
2) Our analyses were limited to retail food-store interven-
tions. Environmental interventions could also include the
provision of new supermarkets and farmers markets and
improved transportation.
3) The cases selected did not address other variables within
the food environment that affected the availability andconsumption of retail store food in American Indian set-
tings. Local hunting, farming, and food production and the
external food-distribution chain needed to be analyzed to
determine the sourcing variables that affected food access
(availability and pricing).
4) As noted in our analysis of the Pathways trial, more re-
search was needed to address the factors within the com-
munity that affected food choices. Those community
factors and the associated organizations need to be in-
cluded in future interventions and analyzed for effect.
The environmental intervention showed great promise as
a means to address the high rates of obesity and chronic disease
in American Indian communities. Environmental interventionsprovided opportunities for improved diet and increased physical
activity. Much future work remains. Often, behavior-change
theories do not adequately address the inclusion of environmental
factors as modifiable elements of intervention strategies. We need
refined approaches for modifying the food environment on the
basis of solid evidence. There has been a lack of food-store
interventions in urban American Indian settings where there is
a greater dependence on small stores that lack access to local food
producers. Future work should consider the role of prepared
foods and the prepared-food environment (eg, menus, food-
preparation methods, and pricing) in the American Indian diet
and develop and test pilot interventions that address these
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concerns. Future interventions should also place greater emphasis
on the involvement of community members and organizational
leaders in the development and implementation of interventions.
A community-based approach is key to sustainability and ac-
ceptability. Long-term sustainability is also dependent on sup-
portive policies. However, policy-makers are typically interested
in health outcomes as a measure of the program success. Future
work needs to show the benefits of these programs by including
long-term-effect health assessments.
The authors responsibilities were as followsJG: was the primary inves-
tigator or coinvestigator on all studies reviewed and assisted with the prep-
aration andreview of themanuscript; andMR: performedthe literature review
and drafted the manuscript. Neither of the authors had a conflict of interest.
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