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Background American Indians (AIs) have significantly higher rates of diet-related chronic diseases than other racial/ethnic groups, and many live in environments with limited access to healthy food. Objective As part of the Tribal Resilience in Vulnerable Environments (THRIVE) study, we examined the relations between the perceived food environment, utilization of food retailers, fruit and vegetable intake, and chronic diseases, including obesity, hypertension, and type 2 diabetes among AI adults. Methods Through a community-based participatory research partnership, we surveyed a cross-sectional sample of 513 AIs living within the Chickasaw Nation and the Choctaw Nation of Oklahoma. Results Only 57% of participants reported that it was easy to purchase fruits and vegetables in their town, and fewer (35%) reported that available fruits and vegetables were of high quality. Additionally, over half (56%) reported traveling ≥20 miles round trip to shop for food. Few participants met the recommended daily intake for fruit (44%) or vegetables (25%). Obesity (55%), hypertension (49%), and diabetes (25%) were commonly reported. Obesity was significantly higher among participants who reported that the price of fruits and vegetables were cost-prohibitive (prevalence proportion ratio (PPR): 1.24; 95% CI: 1.02, 1.50) and those who shopped frequently for food at nontraditional food retailers, such as Dollar Stores (PPR: 1.35; 95% CI: 1.08, 1.69) and small markets (PPR: 1.38; 95% CI: 1.02, 1.86). Diabetes was significantly higher among participants who frequently shopped at convenience stores/gas stations (PPR: 2.26; 95% CI: 1.22, 4.19). Conclusions Our study found that the use of nontraditional food retailers, including convenience stores, gas stations, and Dollar Stores, as a regular source of food was associated with obesity and diabetes. These results underscore the importance of interventions to improve rural Tribal food environments. Healthy retail interventions in nontraditional retail settings, such as those implemented through the THRIVE study, may contribute to reducing AI health disparities.

Background The Tribal Health Resilience in Vulnerable Environments (THRIVE) study aimed to increase healthy food access in 2 rural American Indian communities. The intervention sought to increase fruit and vegetable availability, variety, and convenience through placement, promotion, and pricing of healthy foods and beverages in tribal convenience stores. Objective The aim of this study was to describe the development and implementation of the study process evaluation tool to assess intervention fidelity as part of this cluster-controlled trial. Methods Eight stores (2 intervention and 2 control stores per Nation) participated in the study, implemented from May 2016 to May 2017. A web-based survey tailored to store layouts and intervention components assessed how often intervention items were available, approximate quantity available, and whether placement of healthier food items and promotional materials were implemented as designed. After pilot testing the survey, tribal staff members implemented it to collect process evaluation data in the 8 stores during a period of 9–12 mo, assessing study implementation and potential changes in control stores. Results Promotional materials were available ≥75% of the time for most intervention locations. Fruit availability was similar in Nation A and Nation B intervention stores (79–100% compared with 70–100%), whereas fresh vegetable availability was higher in Nation B compared with Nation A (95–96% compared with 55–75%). Both control stores in Nation A and 1 control store in Nation B had moderate fruit and vegetable availability, ranging from 45% to 52%. No control stores in either Nation used intervention promotional materials. Conclusions Process evaluation data indicate that the study was implemented with moderate to high fidelity. The development and implementation of the tool can inform future healthy retail interventions that aim to improve rural and tribal food environments.

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.

OBJECTIVES: New Child and Adult Care Food Program (CACFP) meal patterns and best-practices were implemented nationally in 2017 to address the need to prevent chronic diseases. Young Native American children have disproportionately higher risk of chronic disease. Some Native American tribes operate early care and education (ECE) programs and have the opportunity to participate in the CACFP. The purpose of this paper is to describe a CACFP best-practice menu and training developed and implemented as part of the Food Resource Equity and Sustainability for Health (FRESH) study. METHODS: FRESH is a community-based participatory research (CBPR) intervention implemented within ECE programs in the Osage Nation of Oklahoma. Site managers and cooks from each of the nine ECE programs attended meetings and provided feedback to investigators which shaped the best-practice menu and training. Each site participated in a three-hour training in January 2018 to discuss the best-practice menu and ways to overcome implementation barriers. Goals of the menu aimed to increase intake of fruit and vegetables and whole grains and reduce pre-fried and processed foods without increasing cook burden. Training included application activities individually and in small and large groups. RESULTS: Though the project is still underway, lessons learned have emerged including the need for technical assistance, improved communication between ECE program staff and food supply vendors, and infrastructure barriers (e.g., limited space, lack of supplies) that challenge work-flow. CONCLUSIONS: Efforts to improve menus in rural and low-income ECE programs must consider these issues in developing feasible intervention strategies. Collaboration with the site manager and cook is essential to fully understand perceived and actual barriers to provide training that can provide necessary background rationale for nutrition recommendations as well as beneficial and productive activities and hands-on training to effect change outside the training. FUNDING SOURCES: This study was funded by the National Institute on Minority Health and Health Disparities (R01MD011266). The funding agency did not participate in the study design, data collection, analysis, decision to publish, or preparation of the manuscript.