Objective To understand how Osage Nation community members define healthy eating and develop a corresponding nutrition curriculum through community engagement. Design This project comprised a concurrent embedded mixed methods group concept mapping (GCM) study followed by focus group discussions (FGD) to provide feedback on a nutrition curriculum. Setting Osage Nation, Oklahoma. Participants In the GCM study, 54 participants were recruited from a study of an Indigenous-supported agriculture program. GCM study participants and the Go Healthy Advisory Group participated in 2 FGDs. Phenomenon of Interest For the first study, concepts related to healthy eating were explored. In the second study, participants provided feedback on curriculum clarity, perceived efficacy, and relevance. Analysis In the first study, a multidimensional scaling algorithm was used to plot statements, and concept clusters were interpreted in a facilitated meeting with participants. A basic content analysis approach was used in the second study. Results Five concept clusters related to healthy eating were identified. These clusters were used to generate an 8-module curriculum deemed clear, potentially efficacious, and relevant among FGD participants. Conclusions and Implications Community members contributed to a framework of healthy eating for the Osage community, which was used to develop a nutrition curriculum that will be integrated into an Indigenous-supported agriculture program. Future research should explore long-term sustainability and the broader cultural impacts of nutrition programs on Indigenous health and food sovereignty.

Mainstream approaches to nutrition typically focus on diet consumption, overlooking multi-dimensional aspects of nutrition that are important to American Indian/Alaska Native (AI/AN) communities. To address health challenges faced by AI/AN communities, strengths-based measures of nutrition grounded in community worldviews are needed. In collaboration with AI/AN communities in Baltimore and Minneapolis, we developed the Indigenous Nourishment Scales through three phases. Phase 1 involved focus group discussions with nine community-research council (CRC) members (n = 2) and four in-depth interviews (n = 4) to gather perspectives on existing models of nutrition. Phase 2 refined scales through two additional focus group discussions (n = 2) with a total of nine participants and two in-depth interviews (n = 2). Finally, in Phase 3, we held ten (n = 10) cognitive interviews with AI/AN community members to refine the scales. Participants appreciated the measures’ ability to provoke reflection on their relationship with nutrition and suggested adjustments to better capture cultural nuances, such as incorporating concepts like “being a good relative” to land. The Indigenous Nourishment Scales represent a departure from conventional approaches by encompassing multiple dimensions of nourishment, offering a framework that addresses epistemic injustices in nutrition measurement and grounds health measurement efforts directly in community perspectives and worldviews.

Background Dietary interventions are used for the treatment of hypertension. We evaluated the cost-efficacy of delivering boxes of healthy, culturally tailored foods and checks that can only be spent on produce in a Native American population. Methods We conducted a group randomized controlled trial from 2018-2020 with N = 2 treatment counties and N = 2 control counties and a total of N = 160 Native American adults with baseline stage 1 or stage 2 hypertension. Participants in the intervention group received monthly boxes of food that adheres to the Dietary Approaches to Stop Hypertension diet as well as checks that could only be spent on produce for 6 months. We measured blood pressure and quality of life at baseline and at a 6-month follow-up in both intervention and control groups. We used ordered logistic regression to estimate the effect of treatment on probability of blood pressure improvements. We then conducted a cost-efficacy analysis. Results We found that treatment was effective in women with stage 1 hypertension at baseline. Based on this finding, we also estimate that this intervention satisfies normative cost-effectiveness thresholds, even when lifetime treatment is needed to preserve the impact, so long as treatment is only continued in those who respond to treatment. Conclusions Direct delivery of healthy foods and checks that can only be spent on produce are a potentially cost-effective intervention for the management of hypertension among Native American women with stage 1 hypertension. Further research is needed to understand why we found an impact only for this group.

The Food Resource Equity for Sustainable Health (FRESH) study started as a tribe community-based nutrition education program in 2018, implemented with children and parents in Osage Nation. The purpose of the FRESH study is to examine the effects of a farm-to-school family intervention on diet. The FRESH study did not directly intervene on adult caregiver participants’ diet, and, as far as we know, it is the first of its kind to implement a farm-to-school intervention in rural/tribally owned Early Childhood Education. Two communities received intervention and two served as wait-list controls. Outcomes included diet and other secondary health outcomes including vitamin and mineral intake. There were 193 children (n = 106 intervention; n = 87 control) and 170 adults (n = 93 intervention; n = 77 control) enrolled. Among adult caregiver participants, carbohydrate, cholesterol, and caffeine intake significantly decreased after the intervention (p < 0.05). There is a hidden hunger issue among caregivers in Native American populations. The family-based nutritional intervention, which includes educational components for caregivers, might have some effect on improving micronutrient status. Future studies focusing on key micronutrients through efficient methods are warranted.

We sought to evaluate the acceptability and feasibility of a culturally tailored food box intervention for improving blood pressure (BP), food security and Body Mass Index (BMI) among Chickasaw Nation adults with uncontrolled hypertension. As part of the Chickasaw Healthy Eating Environments Research Study (CHEERS), we administered a group randomized pilot study in four tribal communities (two intervention, two control). Participants in the intervention communities received six heart-healthy food boxes, culturally tailored to traditional Chickasaw diet and current food context. Outcomes were measured over 6 months. We enrolled 262 participants, and 204 with complete data on key variables were included in the analysis. The food boxes were very popular, and we achieved high retention for follow-up data collection. Intervention community participants had 2.6 mmHg lower mean systolic BP and improved diet quality and BMI compared with control participants, although, as expected for a pilot study, the differences were not statistically significant. The culturally tailored diet intervention and randomized trial study design were acceptable and feasible for Chickasaw Nation adults with uncontrolled hypertension. Our findings support the value of tribal-food bank partnerships as a potential approach for reducing food insecurity and hypertension-related disparities in Native American communities.

Abstract Background Dietary interventions are used for the treatment of hypertension. We evaluated the cost-efficacy of delivering boxes of healthy, culturally tailored foods and checks that can only be spent on produce in a Native American population. Methods We conducted a group randomized controlled trial from 2018 to 2020 with N = 2 treatment counties and N = 2 control counties and a total of N = 160 Native American adults with baseline stage 1 or stage 2 hypertension. Participants in the intervention group received monthly boxes of food that adheres to the Dietary Approaches to Stop Hypertension diet as well as checks that could only be spent on produce for 6 months. We measured blood pressure and quality of life at baseline and at a 6-month follow-up in both intervention and control groups. We used ordered logistic regression to estimate the effect of treatment on probability of blood pressure improvements. We then conducted a cost-efficacy analysis. Results We found that treatment was effective in reducing blood pressure in women with stage 1 hypertension at baseline. Based on this finding, we also estimate that this intervention satisfies normative cost-effectiveness thresholds, even when lifetime treatment is needed to preserve the impact, so long as treatment is only continued in those who respond to treatment. Conclusions Direct delivery of healthy foods and checks that can only be spent on produce are a potentially cost-effective intervention for the management of hypertension among Native American women with stage 1 hypertension. Further research is needed to understand why we found an impact only for this group.

BackgroundAdequately assessing nutrition is deeply important for understanding and addressing health inequities, especially for American Indian, Alaska Native, and Native Hawaiian (AI/AN/NH) peoples who have been subjected to the malnourishing effects of settler colonialism. Mainstream approaches to nutrition rely heavily on indicators of physical diet consumption, while ignoring the contributions of food to spiritual, social, and emotional health. Considering only physical aspects of dietary consumption paints a narrow picture of AI/AN/NH foodways and nutritional health further contributing to deficit-based narratives about AI/AN/NH peoples. To adequately understand and address the nutritional health of AI/AN/NHs, strengths-based approaches to nutrition that are rooted in Indigenous ways of knowing are urgently needed.ObjectiveTo define nutrition through AI/AN/NH worldviews.MethodsThree focus group discussions (n = 3) and in-depth interviews (n = 6) were conducted with 26 purposively identified AI/AN/NH food sovereignty experts and knowledge holders. Data collection and analysis were conducted iteratively. Through a process of open, focused, and axial coding, primary themes and supporting sub-themes were established and refined, and a conceptual framework (the Indigenous Nourishment Framework) was developed to reflect the relationships between primary themes, sub-themes, and the overall meaning of nourishment for AI/AN/NHs.ResultsThe Indigenous Nourishment Model contains four main domains of nourishment (Physical, Spiritual, Emotional, and Relational), and 8 sub-themes representing concepts, practices and beliefs which contribute to overall nourishment.ConclusionsDespite the importance of physical aspects of nutrition, our findings assert that spiritual, emotional, and relational wellbeing are inseparable and integral to the overall goal of nourishment for AI/AN/NHs. The resulting Indigenous Nourishment Framework developed with a diverse group of AI/AN/NH food knowledge holders reflects the strengths of AI/AN/NH foodways and builds upon existing approaches to nutrition by offering new directions for approaching and measuring nutrition.

Life expectancy among American Indians and Alaska Natives (AI/ANs) has declined from 72 years in 2019 to 68 years in 2021. This current life expectancy for AI/ANs is equivalent to the overall life expectancy in the United States population in the 1940s. The significant and persistent nature of AI/AN health inequities, and the lack of clarity around what is driving them, requires urgent action. The purpose of this article is threefold. First, we provide a comprehensive conceptual framework of health that presents Indigenous perspectives of health and recognizes settler colonialism as a key structural determinant of the health of AI/ANs. Second, we underscore the importance of Tribal self-determination and sovereignty in public health research and practice and identify successful initiatives centering these efforts. Finally, we conclude with recommendations for future research, practice, and policy.

Background: Prevalence of obesity in Native American (NA) children is disproportionately high, indicating a higher risk of health dis-parities. Many children attend early care and education (ECE) programs, presenting an opportune environment to improve meal and menu quality as the intake of healthy foods is associated with lowered risk of childhood obesity. Objectives: We aimed to examine the effectiveness of food service staff training on meals and menu quality across NA ECEs. Methods: Food service staff from 9 participating ECE programs attended a 3-h training focused on Child and Adult Care Food Program (CACFP) best practices, and received a tailored, best-practice menu, and healthy recipes. Meals and menus prepared across 1 wk were examined per CACFP serving size assumptions at baseline, 4 mos, 6 mos, and 12 mos for all 9 programs. Healthy Eating Index (HEI), CACFP requirements and best practices achievement, and food substitutions quality (classified into superior, equivalent, and inferior based on the nutritional quality) were calculated. A repeated measures ANOVA model was used to determine the differences across time points. Results: The total meal HEI score increased significantly from baseline to 4 mos (71.1 +/- 2.1; 78.6 +/- 5.0; P = 0.004), but did not differ from baseline to 12 mos. Menu CACFP requirements and best practices achievement did not differ across time points, although achievement with CACFP requirements was already high at baseline. Superior nutrition quality substitutions declined from baseline to 6 mos (32.4 +/- 8.9; 19.5 +/- 10.9; P = 0.007); however, it did not differ from baseline to 12 mos. Equivalent and inferior quality substitutions did not differ across time points. Conclusions: Implementing a best-practice menu with healthy recipes showed immediate improvements in meal quality. Although the change did not sustain, this study showed evidence of an opportunity to educate and train food service staff. Robust efforts are needed for improving both meals and menus.

Access to healthy and appealing food is essential for individuals to be able to live a healthy and quality life. For decades, food security has been a priority issue for public health professionals. Food sovereignty expands upon the concept of food insecurity (i.e., having access to nutritious and culturally relevant food) by incorporating people’s rights to define their own food system. The expanded focus of food sovereignty on food systems prioritizes public health professionals’ role in supporting environmental- and systems-level initiatives and evaluating their implications for health, economics, and the natural environment. Food sovereignty is of particular importance for Indigenous peoples (i.e., American Indian, Alaska Native, Native Hawaiian, and Pacific Islander communities). Colonization had demonstrable consequences, with many Indigenous communities being forcibly relocated from traditional lands, alongside the destruction of traditional food sources. Indigenous food sovereignty aligns with the sovereign nation status that American Indian tribes and Alaska Native communities have with the United States. Furthermore, the worldviews that incorporate Indigenous communities’ relational responsibilities to care for their food systems, according to their traditional practices and beliefs (Coté, 2016; Morrison, 2011), uniquely positions Indigenous peoples to lead food sovereignty initiatives. In this article, we explore what is currently known regarding food sovereignty and health. We then discuss opportunities to expand the evidence on Indigenous food sovereignty’s relationships with (1) health and well being, (2) economics, (3) the natural environment, and (4) programming facilitators and barriers.

Previous research in American Indian and Alaska Native (AI/AN) communities has documented high prevalence of food insecurity. Yet many AI/AN scholars and communities have expressed concerns that the dominant societal conceptions of food security are not reflective of the teachings, priorities, and values of AI/AN communities. Food security initiatives often focus on access to food and, at times, nutrition but little consideration is given to cultural foods, the spirituality carried through foods, and whether the food was stewarded in a way that promotes well-being not just for humans but also for plants, animals, land, and water. Despite the concerns of AI/AN communities that their needs are not centered in dominant societal food conceptualizations and food security programming, the food sovereignty efforts of AI/AN communities have captured national attention as a solution to modern food system inequities. Indigenous Food Sovereignty (IFS) is a holistic approach to food that incorporates values of relationality, reciprocity, and relationships. Fundamental differences exist between food security and food sovereignty, yet dominant society often reduces IFS as a solution to food security, rather than an entirely different food system that is predicated on values that contrast with that of dominant society. Despite calls to decolonize the definition and measurement of food security, we explore whether fixing the concept of food security is a worthy endeavor or whether efforts would be better spent supporting the resurgence and revitalization of AI/AN food values, food knowledge, and community food sovereignty initiatives.

The Center for Indigenous Innovation and Health Equity (CIIHE) at Oklahoma State University Center for Health Sciences (OSU-CHS) is a community-academic partnership with Indigenous peoples from Alaska, Hawai'i, and Oklahoma. The CIIHE supports communities to strengthen traditional food practices and food sovereignty and evaluate the impact of those efforts on health. In February 2022, the CIIHE sponsored and hosted a virtual conference to better understand how food sovereignty initiatives can improve health. More than 600 participants gathered to hear the latest research and practice in the areas of public health and agriculture, nutrition, community-based and Indigenous knowledge, and health economics. Community-led food sovereignty initiatives being implemented as part of the CIIHE were featured along with other Indigenous initiatives in urban, rural, and reservation communities. A survey was administered to conference participants to assess food sovereignty topics and priorities for future research. In this Practice Note, we describe innovative community-led initiatives presented as part of the conference and recommendations for action emerging from qualitative and quantitative data collected from conference participants.

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 <18 years of age was three (range: 1–8). Participation among the 94 parents was 56% during the first week and was 12% in the final week. Having some college or technical training (vs. having a college degree) and having an annual household income of US$20,000–US$50,000 (vs. more than US$50,000) were associated with fewer sessions attended ( p = 0.004 and 0.02, respectively) Being married (vs. not) was associated with higher attendance ( p < .0001). Participation in a hybrid food sovereignty and nutrition education curriculum for parents was generally low, but income, education, and marital status were associated with curriculum participation. Our research adds to the literature by describing the development and implementation of this curriculum and recommendations for future research incorporating Indigenous approaches to health.

Background Inequities in access, availability, and affordability of nutritious foods produced by settler colonialism contribute to high rates of food insecurity among American Indian and Alaska Native (AI/AN) households. Efforts to understand the influences of food security programming among AI/AN individuals in the United States are constrained by the absence of validity evidence for food security assessments for this population. Objective This study assessed whether AI/AN adult responses on the Food Security Survey Module provide an accurate assessment of food security prevalence, especially when compared with other racial and ethnic groups. Design A correlational design with the cross-sectional 2019 National Health Interview Survey was used to address the research objective. Participants and setting The 2019 National Health Interview Survey contains a sample (N = 30,052) representative of the resident civilian noninstitutionalized population. Main outcome measures The primary outcome was food security, as characterized by the 10-item US Department of Agriculture Adult Food Security Survey Module. The module evaluates whether insufficient finances result in perceived food shortages and a reduction in the quantity and/or quality of food intake during the prior 30 days. Statistical analyses performed Data were analyzed by racial and ethnic subsamples to assess scale dimensionality (confirmatory factor analysis), Item Response Theory item analysis, differential item functioning, and external validity (chi(2) tests). Results Results supported the use of the 10-item module for racial and ethnic groups. However, differential item functioning effect sizes exceeded criteria for the Asian, AI/AN, and Hispanic respondents when compared with White respondents. Food security was not significantly related to all expected correlates in the AI/AN subsample. Conclusions Compelling evidence is presented for validity of the FSSM scores in determining food security status of AI/AN adults. Qualitative inquiry that explores how culture influences the way food security is conceptualized and experienced is warranted.

Traditional foods and foodways are a critical part of health and well-being for Alaska Native/American Indian (ANAI) peoples. However, many of these foods are being replaced by ultra-processed foods high in fat, sugar, and sodium. The cultural knowledge needed to gather, hunt, and fish to acquire these foods is not being passed down to younger generations, due to lingering effects of colonialism, leading to poor health outcomes among ANAI peoples. Southcentral Foundation (SCF) and the Center for Indigenous and Health Equity (CIIHE) are using community-based participatory research to identify and prioritize food sovereignty interventions to strengthen the transmission of cultural knowledge across generations and improve ANAI health. Through the implementation of a comprehensive landscape analysis and the development of a community advisory board, SCF has planned an Alaska Native Traditional Foods Gathering to highlight regional efforts to document, revitalize, and share cultural food knowledge and practices to build healthy communities.

The Choctaw Nation of Oklahoma's Historic Preservation Department (HPD) and the Center for Indigenous Health Equity (CIIHE) are partnering to implement and evaluate food sovereignty interventions to better understand the potential impact of such programs on individual and community health. The HPD's Growing Hope Program is a food sovereignty initiative that aims to restore traditional Choctaw gardens, which were once a physical, social, and cultural center of Choctaw life. The program combines heirloom seeds and the stories of their origins, gardening education and technical assistance, cooking classes, and a Choctaw youth internship program to support intergenerational knowledge and the restoration of culture and food security. Since its inception the program has provided Choctaw families with ancestral Choctaw cultivar seeds and provided the technical assistance to support the growing of sustainable, healthy, traditional Choctaw foods.

The transmission of generational knowledge in Alaska Native communities has been disrupted by colonization and led to declining health among Alaska Natives, as evidenced by the loss of knowledge regarding traditional foods and foodways and increasing rates of cardiometabolic disorders impacting Alaska Natives. Elders play a central role in passing down this generational knowledge, but emerging Elders may have difficulty in stepping into their roles as Elders due to the rapid social and cultural changes impacting their communities. The Center for Alaska Native Health Research (CANHR) and the Denakkanaaga Elders Program are partnering with the Center for Indigenous Innovation and Health Equity to uplift and support traditional food knowledge and practices to promote health in Alaska Native communities. Guided by a decolonizing and Indigenizing framework, researchers at CANHR are working with Athabascan Elders in the Interior of Alaska to strengthen and protect the intergenerational transmission of cultural knowledge and practices for emerging Elders. This community-academic partnership will implement and evaluate an Elders Mentoring Elders Camp to focus on repairing and nurturing relationships through the practice and preservation of cultural knowledge and practices, including traditional foodways. This initiative contributes to the intergenerational transmission of knowledge, which is necessary to keep culture alive and thriving.

Introduction:American Indian and Alaska Native (AI/AN) adults experience disproportionate cardiovascular disease (CVD) morbidity and mortality compared to other races, which may be partly attributable to higher burden of hypertension (HTN). Dietary Approaches to Stop Hypertension (DASH) is a high-impact therapeutic dietary intervention for primary and secondary prevention of CVD that can contribute to significant decreases in systolic blood pressure (BP). However, DASH-based interventions have not been tested with AI/AN adults, and unique social determinants of health warrant independent trials. This study will assess the effectiveness of a DASH-based intervention, called Native Opportunities to Stop Hypertension (NOSH), on systolic BP among AI/AN adults in three urban clinics. Methods:NOSH is a randomized controlled trial to test the effectiveness of an adapted DASH intervention compared to a control condition. Participants will be aged ≥18 years old, self-identify as AI/AN, have physician-diagnosed HTN, and have elevated systolic BP (≥ 130 mmHg). The intervention includes eight weekly, tailored telenutrition counseling sessions with a registered dietitian on DASH eating goals. Intervention participants will be provided $30 weekly and will be encouraged to purchase DASH-aligned foods. Participants in the control group will receive printed educational materials with general information about a low-sodium diet and eight weekly $30 grocery orders. All participants will complete assessments at baseline, after the 8-week intervention, and again 12 weeks post-baseline. A sub-sample of intervention participants will complete an extended support pilot study with assessments at 6- and 9-months post-baseline. The primary outcome is systolic BP. Secondary outcomes include modifiable CVD risk factors, heart disease and stroke risk scores, and dietary intake. Discussion:NOSH is among the first randomized controlled trials to test the impact of a diet-based intervention on HTN among urban AI/AN adults. If effective, NOSH has the potential to inform clinical strategies to reduce BP among AI/AN adults. Clinical trials registration:https://clinicaltrials.gov/ct2/show/NCT02796313, Identifier NCT02796313.