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The Food Resource Equity and Sustainability for Health (“FRESH”) study is an Indigenous-led intervention to increase vegetable and fruit intake among Native American children. As part of this study, we developed a hybrid (online and in-person) food sovereignty and nutrition education curriculum for the parents of these children. This 16-week curriculum was developed to promote household- and community-level healthy eating and food sovereignty practices to parents of preschool-aged children residing in Osage Nation, Oklahoma. A total of 81 parent/caregivers participated in the curriculum component of the FRESH study, with a median age of 34 years (range: 23–54 years). Most study participants were female (88.9%) and less than half (45.7%) had an annual household income of more than US$50,000. Most were married or had a significant other (76.5%) and worked full-time (65.4%). The median total number of children in the home

Very low food security among children (VLFS-C), often referred to as child hunger, can profoundly hinder child development, family well-being, and community health. Food pantries are important community resources that routinely serve at-risk families. This study investigated the influence of various candidate risk factors for VLFS-C within a food pantry population to inform the development of the "Pantry Assessment Tool against Child Hunger (PATCH)." We collected standardized surveys among a representative sample of households with children accessing food pantry services in Oklahoma (n = 188). Weighted analyses revealed a large majority of households experienced child-level food insecurity (70.6%), with nearly half reporting low food security and nearly one-quarter reporting VLFS-C. We then used logistic regression to identify factors associated with VLFS-C, followed by chi-square automatic interaction detection (CHAID) to assess if, and in what progression, significant risk factors predicted VLFS-C. In unadjusted models, annual household income

ObjectiveTo increase vegetable and fruit intake, reduce body mass index (BMI), and improve parental blood pressure among American Indian families.DesignRandomized, wait-list controlled trial testing a multi-level (environmental, community, family, and individual) multi-component intervention with data collection at baseline and 6 months post-intervention.SettingTribally owned and operated Early Childhood Education (ECE) programs in the Osage Nation in Oklahoma.ParticipantsAmerican Indian families (at least one adult and one child in a ECE program). A sample size of 168 per group will provide power to detect differences in fruit and vegetable intake.InterventionThe 6-month intervention consisted of a (1) ECE-based nutrition and gardening curriculum; (2) nutrition education and food sovereignty curriculum for adults; and (3) ECE program menu modifications.Main Outcome MeasuresThe primary outcome is increase in fruit and vegetable intake, assessed with a 24-h recall for adults and plate weight assessments for children. Secondary outcomes included objective measures of BMI among adults and children and blood pressure among adults.

Food preferences begin in early childhood, and a child’s willingness to try (WTT) new vegetables is an important determinant of vegetable intake. Young children living in rural communities are at increased risk for food insecurity, which may limit exposure to and consumption opportunities for vegetables. This manuscript describes the validation of the Farfan-Ramirez WTT (FR-WTT) measure using baseline data from the FRESH study, a gardening intervention for Native American families with preschool-aged children in Osage Nation, Oklahoma. Individually weighed vegetable containers were prepared with six types of vegetables and ranch dip. Researchers presented children (n = 164; M = 4.3 years, SD = 0.8) with these vegetables preceding a snack- or lunch time and recorded the child’s FR-WTT for each vegetable using a 5-point scale, ranging from “did not remove food (0)” to “put food in mouth and swallowed (4)”. After the presentation period, contents were re-weighed to calculate vegetable consumption. Household parents/guardians completed the Child Food Neophobia Scale (CFNS) for their child. FR-WTT scores were positively correlated with consumption weights of all vegetables (r = 0.7613, p < 0.0001) and each vegetable individually (r = 0.2016–0.7664). The total FR-WTT score was inversely correlated with the CFNS score (r = 0.3268, p < 0.0001). Sensitivity analyses demonstrated similar relationships by BMI, food security, and age. In conclusion, the FR-WTT is a valid method for assessing young children’s vegetable eating behavior and intake.

Purpose The purpose of this study is to explore the associations between food insecurity (FI) and coping strategies of relevance to diabetes self-management among households of people with diabetes (HHDM) who access US food pantry programs. Methods The authors conducted a secondary data analysis of HHDM accessing US food pantry programs from the Hunger in America 2014 study ( n = 16 826). Weighted analyses included descriptive statistics for household sociodemographics, food pantry service utilization, FI, and coping behaviors. The authors used chi-square and logistic regression to estimate the relationship between FI and coping behaviors. Results Nearly one-half of HHDM reported visiting food pantries at least 6 times in the past year. Most HHDM were FI, with the majority experiencing the most severe form of FI. Over one-fifth of households reported lacking health insurance. The majority of HHDM reported purchasing inexpensive unhealthy foods to ensure household food adequacy, and many reported watering down food and beverages. The odds of reporting these behaviors significantly increased as FI worsened. Conclusion Food pantries represent an opportunity for the delivery of community-based diabetes self-management education and support programs. These programs should be adapted to address population barriers to self-management and to support access to healthful foods and medical care.

This cohort study evaluates the first 22 months of implementation of the Cherokee Nation Heath Services community-based program designed to eliminate hepatitis C virus (HCV) infection., Key Points Question Can a community-based tribal hepatitis C virus (HCV) elimination program be implemented successfully in a rural setting? Findings In this cohort study, first-time HCV screening coverage increased from 20.9% to 38.2% from 3 years before to 22 months into implementation of the Cherokee Nation Health Services HCV elimination program. Identification, treatment, and cure of newly identified current HCV infections increased. Meaning In this study, implementation of a community-based HCV elimination program was associated with an improved cascade of care; this information may serve other organizations planning to implement similar programs in large rural areas., Importance In 2019, hepatitis C virus (HCV) infection contributed to more deaths in the US than 60 other notifiable infectious diseases combined. The incidence of and mortality associated with HCV infection are highest among American Indian and Alaska Native individuals. Objective To evaluate the association of the Cherokee Nation (CN) HCV elimination program with each element of the cascade of care: HCV screening, linkage to care, treatment, and cure. Design, Setting, and Participants This cohort study used data from the CN Health Services (CNHS), which serves approximately 132 000 American Indian and Alaska Native individuals residing in the 14-county CN reservation in rural northeastern Oklahoma. Data from the first 22 months of implementation (November 1, 2015, to August 31, 2017) of an HCV elimination program were compared with those from the pre–elimination program period (October 1, 2012, to October 31, 2015). The analysis included American Indian and Alaska Native individuals aged 20 to 69 years who accessed care through the CNHS between October 1, 2012, and August 31, 2017. Cure data were recorded through April 15, 2018. Exposure The CN HCV elimination program. Main Outcomes and Measures The main outcomes were the proportions of the population screened for HCV, diagnosed with current HCV infection, linked to care, treated, and cured during the initial 22 months of the elimination program period and the pre–elimination program period. Data from electronic health records and an HCV treatment database were analyzed. The cumulative incidence of HCV infection in this population was estimated using bayesian analyses. Results Among the 74 039 eligible individuals accessing care during the elimination program period, the mean (SD) age was 36.0 (13.5) years and 55.9% were women. From the pre–elimination program period to the elimination program period, first-time HCV screening coverage increased from 20.9% to 38.2%, and identification of current HCV infection and treatment in newly screened individuals increased from a mean (SD) of 170 (40) per year to 244 (4) per year and a mean of 95 (133) per year to 215 (9) per year, respectively. During the implementation period, of the 793 individuals with current HCV infection accessing the CNHS, 664 were evaluated (83.7%), 394 (59.3%) initiated treatment, and 335 (85.0%) had documented cure. In less than 2 years, the 85% 3-year goal was reached for cure (85.0%), and the goal for linkage to care was nearly reached (83.7%), whereas screening (44.1%) and treatment initiation (59.3%) required more time and resources. Conclusions and Relevance This cohort study found that after 22 months of implementation, the CNHS community-based HCV elimination program was associated with an improved cascade of care. The facilitators and lessons learned in this program may be useful to other organizations planning similar programs.

Administrative health databases have been used to monitor trends in infective endocarditis hospitalization related to nonprescription injection drug use (IDU) using International Classification of Diseases (ICD) code algorithms. Because no ICD code for IDU exists, drug dependence and hepatitis C virus (HCV) have been used as surrogate measures for IDU, making misclassification error (ME) a threat to the accuracy of existing estimates. In a serial cross-sectional analysis, we compared the unadjusted and ME-adjusted prevalences of IDU among 70,899 unweighted endocarditis hospitalizations in the 2007–2016 National Inpatient Sample. The unadjusted prevalence of IDU was estimated with a drug algorithm, an HCV algorithm, and a combination algorithm (drug and HCV). Bayesian latent class models were used to estimate the median IDU prevalence and 95% Bayesian credible intervals and ICD algorithm sensitivity and specificity. Sex- and age group-stratified IDU prevalences were also estimated. Compared with the misclassification-adjusted prevalence, unadjusted estimates were lower using the drug algorithm and higher using the combination algorithm. The median ME-adjusted IDU prevalence increased from 9.7% (95% Bayesian credible interval (BCI): 6.3, 14.8) in 2008 to 32.5% (95% BCI: 26.5, 38.2) in 2016. Among persons aged 18–34 years, IDU prevalence was higher in females than in males. ME adjustment in ICD-based studies of injection-related endocarditis is recommended.

In rural American Indian (AI) communities, access to affordable, healthy foods is often limited. Understanding AI food choice considerations when selecting foods, such as sensory appeal, cost, or health, is an important yet understudied topic for eliminating persistent AI health disparities. In partnership with the Chickasaw Nation and Choctaw Nation of Oklahoma, we administered a modified version of the Food Choice Values (FCV) Questionnaire to a cross-sectional sample of 83 AI patrons shopping at tribally-owned convenience stores ≥3 times per week. The FCV Questionnaire uses 25 items to assess eight FCV subscales related to buying and eating food, including sensory appeal; safety; accessibility; convenience; health/ weight control; organic; tradition; and comfort. We compared mean scores for each FCV subscale by demographic groups using t-tests and ANOVA. We used confirmatory factor analysis (CFA) to examine how well the data from this population fit FCV subscale constructs. We then used cluster analysis, MANOVA, and discriminant analysis to characterize distinct segments of the population based on patterns of FCV endorsement. Appeal, safety, and access FCVs were most strongly endorsed across the sample. Prioritization of FCVs varied by age, gender, income, and education. Our cluster analysis identified four groups, or segments, each with distinct patterns of FCV endorsement: limited endorsement of any FCVs (23.3%); safety and sensory appeal (32.9%); health/weight control (17.8%); and broad endorsement of FCVs (26.0%). These groups varied by age and employment status. Findings from this analysis informed the design and implementation of a healthy retail intervention comprised of new healthful foods and beverages, product placement and marketing strategies within four tribally-owned and operated convenience stores. Public health interventions aimed at reducing nutrition-related disparities in rural AI populations may benefit from assessing food choice considerations.

Objectives. To assess a healthy retail intervention in Tribal convenience stores in Oklahoma. Methods. We adapted healthy retail strategies to the context of 8 Tribally owned stores. We assessed individual- and store-level outcomes in a cluster-controlled intervention trial (April 2016–June 2017). We measured fruit and vegetable intake, store environment perceptions, and purchases before and after the intervention among a cohort of 1637 Native American shoppers. We used mixed-effects linear regression to estimate pre- to postintervention changes in and between groups. Results. We followed 74% of participants (n = 1204) 9 to 12 months. Intervention and control participants perceived healthier stores after intervention. Higher shopping frequency was related to purchases of fruits, vegetables, and healthy items. Conclusions. Intervention exposure was associated with healthy purchasing but not fruit and vegetable intake. Research is needed to further assess impacts of environmental interventions on intake. Public Health Implications. As the first healthy retail intervention in Tribally owned stores, our results contribute evidence for environmental and policy interventions to address obesity in Tribal Nations. Multicomponent interventions, led by Tribal leaders from diverse sectors, are needed to create healthy environments and sustainable improvements in Native American health.

“Sickle cell anemia: tracking down a mutation” is a full-day, inquiry-based, biology experience for high school students enrolled in genetics or advanced biology courses. In the experience, students use restriction endonuclease digestion, cellulose acetate gel electrophoresis, and microscopy to discover which of three putative patients have the sickle cell genotype/phenotype using DNA and blood samples from wild-type and transgenic mice that carry a sickle cell mutation. The inquiry-based, problem-solving approach facilitates the students' understanding of the basic concepts of genetics and cellular and molecular biology and provides experience with contemporary tools of biotechnology. It also leads to students' appreciation of the causes and consequences of this genetic disease, which is relatively common in individuals of African descent, and increases their understanding of the first principles of genetics. This protocol provides optimal learning when led by well-trained facilitators (including the classroom teacher) and carried out in small groups (6:1 student-to-teacher ratio). This high-quality experience can be offered to a large number of students at a relatively low cost, and it is especially effective in collaboration with a local science museum and/or university. Over the past 15 yr, >12,000 students have completed this inquiry-based learning experience and demonstrated a consistent, substantial increase in their understanding of the disease and genetics in general.

Background International Classification of Diseases (ICD) code algorithms are routinely used to estimate the frequency of illicit injection drug use (IDU)-associated hospitalizations in administrative health datasets despite a lack of evidence regarding their validity. We aimed to measure the sensitivity and specificity of ICD code algorithms used to estimate the prevalence of current/recent IDU among infective endocarditis (IE) hospitalizations without a reference standard. Methods We reviewed medical records of 321 patients aged 18–64 years old from an urban academic hospital with an IE diagnosis between 2007 and 2017. Diagnostic tests for IDU included self-reported IDU in medical records; a drug use, abuse and dependence (UAD) ICD algorithm; a Hepatitis C Virus (HCV) ICD algorithm; and a combination drug UAD/HCV ICD algorithm. Sensitivity, specificity and the misclassification error (ME)-adjusted IDU prevalence were estimated using Bayesian latent class models. Results The combination algorithm had the highest sensitivity and lowest specificity. Sensitivity increased for the drug UAD algorithm in the ICD-10 period compared to the ICD-9 period. The ME-adjusted current/recent IDU prevalence estimated using the drug UAD and HCV algorithms was 23 % (95 % Bayesian credible interval: 16 %, 31 %). The unadjusted prevalence estimate from the drug UAD algorithm underestimated the ME-adjusted prevalence, while the combination algorithm overestimated it. Conclusion The validity of ICD code algorithms for IDU among IE hospitalizations is imperfect and differs between ICD-9 and ICD-10. Commonly used ICD-based algorithms could lead to substantially biased prevalence estimates in IDU-associated hospitalizations when using administrative health data.

In rural American Indian (AI) communities, where supermarkets are rare, tribally owned and operated convenience stores are an important food source. Food environment measures for these settings are needed to understand and address the significant diet-related disparities among AIs. Through a tribal-university partnership that included tribal health and commerce representatives from two Native Nations in rural southeastern Oklahoma, we developed the Nutrition Environment Measures Survey for Tribal Convenience Stores (NEMS-TCS) to inform the development and evaluation of a healthy food retail intervention. The NEMS-TCS assessed four scored domains of the rural convenience store food environment—food availability, pricing, quality, and placement—and included 11 food categories that emphasized ready-to-eat food items. Trained raters administered the NEMS-TCS using a sample of 18 rural convenience stores (primarily ranging between 2,400 and 3,600 square feet). We assessed interrater reliability with kappa statistics for dichotomized variables and intraclass correlation coefficients (ICC) for continuous variables. NEMS-TCS demonstrated high inter-rater reliability for all food categories (>85% agreement), subscores (ICC = 0.73-1.00), and the total score (ICC = 0.99). The NEMS-TCS responds to recent calls for reliable measures for rural food environments and may be valuable for studying food environments of large convenience stores in other Native Nations as well as other rural settings.

Although the majority of smokers attempting to quit do so without assistance, research in the area of unassisted quit behaviors is limited. The aim of this study was to investigate whether population-level policies and programs, such as smoke-free air policies and tobacco control programs, contribute to unassisted quit attempts and cessation.The current study used the 2003 Tobacco Use Supplement to the Current Population Survey (TUS-CPS) special Cessation Supplement (CS) to estimate unassisted quit attempt and success rates by state. Linear regression was used to examine whether state-level unassisted quit attempt and success rates were related to state-level policies and social norms. State-level factors investigated were tobacco control program funding, tobacco taxes, smoke-free air policies, state anti-smoking sentiment and recent change in smoking prevalence.Consistent with previous studies, this study found the majority of smokers who attempted to quit did so without assistance. This study also found unassisted quit attempt rates were higher than assisted attempt rates in every state and DC. Additionally, unassisted quit success rates were higher than assisted quit success rates in most states; however, some states had higher assisted quit success rates. State-level factors associated with unassisted quit attempt rates included anti-smoking sentiment and tobacco taxes; however, no significant relationships were uncovered between unassisted quit success rates and state-level factors.These results suggest that state-level factors may be more important in motivating smokers to attempt quitting, and other individual factors or unmeasured state factors may be related to quit success.

Objective To describe the design, implementation, and consumer response to a coupon-style intervention aimed to increase Supplemental Nutrition Assistance Program (SNAP) use at a farmers' market (FM) among Temporary Assistance for Needy Families (TANF) participants. Design A quasi-experimental trial to evaluate redemption response to 2 coupon interventions; baseline surveys characterized coupon redeemers and non-redeemers. Setting Urban. Participants The TANF recipients were assigned to either a plain (n = 124) or targeted marketing coupon intervention (n = 130). Intervention(s) Both groups received 10 $2 coupons to double fruit and vegetable SNAP purchases at the FM. The targeted marketing group also received an oral presentation designed to reduce perceived barriers to FM use. Main Outcome Measure Coupon redemption. Analysis The researchers used t tests and chi-square/Fisher exact tests to examine associations between redeemers and non-redeemers; logistic regression was used to adjust for the intervention. Results No male and few female participants redeemed coupons (6.3%). Among women, those with knowledge of vegetable preparation were 3 times more likely to redeem coupons than were those with little or no knowledge (odds ratio = 3.77; 95% confidence interval, 1.03–13.77). Conclusions and Implications Stand-alone coupon incentive programs may not be a high-reach strategy for encouraging FM use among the population using TANF. Complementary strategies to build vegetable preparation knowledge and skills are needed.

The relationship between alcohol use prior to suicide was explored among American Indian decedents in New Mexico for the years 1980 through 1998. The suicide data were collected from New Mexico Vital Statistics and toxicology reports from the New Mexico Office of the Medical Investigator and matched on a case-by-case basis. Detailed analyses were undertaken for all cases of resident New Mexico Indians from the Navajo, Pueblo, and Apache cultures. Alcohol was detected in 69% of all suicides of American Indians with some variance by major tribal cultural groups (range = 62.1% to 84.4%). This is higher than in suicides among the overall New Mexico population (44.3%). The mean blood alcohol concentration (BAC) of the drinking Indian decedents at suicide was 0.198 (+/- SD of .088). Mean BACs were high for both males (0.199) and females (0.180) who had been drinking. Over 90% of the Indian decedents who had been drinking had BACs greater than the legal intoxication level of 0.08. The Navajo had the lowest percentage of cases that were alcohol involved, and their mean BAC was lower than the other two cultural groups. Alcohol use for completed suicides also varied somewhat by age, sex, method of suicide, and place of occurrence, but very little by whether the decedent was an on or off reservation resident. Analyses indicated that alcohol use prior to suicide was significantly more associated with male suicides than for females, and it was negatively correlated for those who died by overdose and also those using other drugs at suicide. Otherwise, alcohol use did not significantly differentiate American Indian suicides by age, use of firearms, hanging, use of other methods, or residence, for the presence of alcohol was a factor very commonly associated with all of these variables. Heavy alcohol consumption is, therefore, an important factor in over two thirds of all completed suicides among the Indians of New Mexico.

The Oklahoma Communities of Excellence in Tobacco Control (CX) program was established in 2004. Thirty-three CX grants have been funded to implement comprehensive tobacco control programs in 50 counties and one tribal nation.To describe local tobacco policy gains within CX counties and short-term and intermediate outcomes such as Oklahoma Tobacco Helpline registration and awareness, quit attempts, and home smoking bans among adults.A before-and-after study design examined outcomes within CX counties and among CX urban and rural counties. Comparisons were made with non-funded counties when possible. Local policy tracking databases were reviewed for the number of policies implemented from 2004 to 2013 in CX counties. Population-level tobacco indicators, using Helpline registration and 2004-2010 Behavioral Risk Factor Surveillance System data, quantified changes over time. Data were collected in 2003-2013 and analyzed in 2013.Eight hundred thirty-one legislated and voluntary policies were implemented in CX counties and high levels of Helpline registration were maintained. Statistically significant increases were observed in CX counties for the proportion of smokers making a quit attempt, Helpline awareness, and home smoking bans among smokers. These observed increases were greater in rural CX counties than urban. Non-CX counties only experienced a statistically significant increase in Helpline awareness.Using community-based best practices in tobacco control while focusing on social norm change, CX counties experienced positive changes in smoking-related attitudes and behaviors. This study expands the evidence base for statewide tobacco control programming and underscores the value of community-based tobacco control programs.

Background. The current study describes concurrent use of cigarettes and smokeless tobacco (CiST) among males and females and evaluates factors associated with CiST use.Methods. Cross-sectional data were drawn from the 2010 Behavioral Risk Factor Surveillance System (BRFSS). Weighted stratified analyses were performed to find associations between CiST use and sociodemographic factors by gender. CiST users were compared to three different tobacco use groups: nonusers, exclusive smokers, and exclusive ST users.Results. Younger age and heavy alcohol consumption were consistently associated with increased odds of CiST use among both males and females, and regardless of comparison group. Among males, education was inversely related to CiST use, and these findings were consistent in all three comparisons. Among women, those unable to work or out of work were more likely to be CiST users, which was consistent across comparisons. American Indian females had higher odds of CiST use than White females when nontobacco users or smokers were the comparison group.Conclusion. This study identified sociodemographic characteristics associated with CiST use, and differences in these associations among women and men. Additionally, this study highlights the need to carefully consider what comparison groups should be used to examine factors associated with CiST use.

Sufficient evidence of a correlation between infrequent coitus and Down syndrome (DS) has now accumulated to warrant reevaluation of the suggested biological mechanisms. The evidence provides no support for delayed fertilization as the mechanism responsible for this correlation, as was originally proposed by German [Nature 217:516-519, 1968]. A better explanation of this association is provided by the sperm aging hypothesis, which gains its support from both animal studies and chromosomal findings of a paternal contribution to DS. The animal studies supporting this hypothesis show an increased incidence of sperm-derived trisomies resulting from sperm stored for prolonged periods in the male tract. The chromosomal findings show a paternal origin in 20% of DS infants; the sperm aging hypothesis concerns the biological mechanism in this 20%. In addition to explaining the excess of DS for older mothers, the sperm aging hypothesis explains the excess for teenage unwed mothers and indicates that sperm aging from decreased ejaculatory frequency may be a cause of DS in all age groups. Testable directly in humans against German's delayed fertilization hypothesis, the sperm aging hypothesis has immediate clinical implications. It suggests 1) an approach to reduce the incidence of DS and miscarriages and 2) clinical research that will increase knowledge of the circumstances indicating a need for antenatal monitoring.

This paper describes a type of fitness indicating trait which is particularly likely to be exaggerated because of sexual selection on fitness-faking modifier genes, describes the selection process which tends to exaggerate such traits, and indicates by citing examples from different taxa the wide range of traits which can be explained as resulting from this type of selection.