Research Team l Challenge l Goal l Population l Background l Study Design l Intervention Procedures Joel Gittelsohn, PhD, Principal Investigator
Benjamin Caballero, MD, PhD, Co-Investigator
Jean Anliker, PhD, Co-Investigator
Becky Ethelbah, Project Coordinator
Obesity affects American Indian (AI) children and adults more than any other group in the United States. Data from specific tribes, as well as surveys in adult American Indian groups reported by the U.S. Indian Health Service show obesity rates of 34 percent for men and 40 percent for women, markedly higher than the all-race national averages of 24 percent for men and 25 percent for women. Another study reported 54-67 percent of men and 66-80 percent of women from 13 American Indian tribes as overweight. Obesity is common among preschool AI children and appears to develop in an early age.
These high rates of obesity have had severe consequences for the health of American Indians, who show chronic disease rates many times higher than national averages.
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This study aims to reduce body fat and chronic disease risk in Apache tribes via a store-based environmental intervention that will increase the availability of healthy foods and promote healthy choices and cooking methods.
The availability of very high-fat foods, advertisements for and low prices of energy dense foods, marketing of larger portion sizes, increased frequency of restaurant dining, and the use of more fast foods and convenience foods are all environmental factors believed to play a role in the development of obesity. Health education programs that have focused solely on individual behavior changes but have ignored important environmental and economic factors affecting dietary choice have been largely ineffective at preventing or reducing obesity.
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The White Mountain Apache Indian Reservation is located in the White Mountains of east-central Arizona. The tribe has about 16,000 members. Over 50 percent of households are estimated to have incomes below the U.S. poverty level. Over 1,200 tribal members receive WIC benefits, including 944 children and 264 women.
The primary sources of income for the reservation are lumber, tourism, and livestock. Other major employers include the Indian Health Service (IHS) and the tribal government.
The San Carlos Apache Indian Reservation is located in east-central Arizona and has approximately 14,000 members. The unemployment rate is 65 percent. The main employers on the reservation are the San Carlos tribe, IHS, and the tribal casino. Over 1,500 tribal members receive WIC benefits, including 1254 children and 328 women.
Both these reservations have limited access to healthy foods, with each having only one central grocery store and five or more smaller stores, all with a limited selection of healthy foods (e.g., skim milk is usually unavailable, and low-fat foods are scarce). To buy a wider selection of food off reservation necessitates a 30 to 60 minute drive.
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The project investigators have extensive experience working with the White Mountain and San Carlos Apache tribes. From 1993-2001, they worked with the two tribes on Pathways , a school-based intervention trial to prevent obesity.
From August 2000 to July 2001, the researchers also completed extensive formative research on the reservations in support of this store-based intervention. This research used in-depth interviews to understand organizational culture, decision-making, and interest in participating in a nutrition intervention of food stores in the two reservations. Investigators also looked at factors influencing food selection and purchasing at reservation stores, as well as preliminary testing of intervention materials.
This intervention will also build upon a pilot store-intervention trial conducted in the Republic of the Marshall Islands in 2000 and help to inform the development of a larger intervention program planned for Baltimore, MD. Formative research for Baltimore Healthy Stores was completed in Spring 2003 and a feasibility study for the Baltimore Healthy Stores intervention will begin in late 2003. More information on these and other future store interventions can be found on the Healthy Stores website.
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At the individual and behavioral levels, this one-year intervention will provide shoppers with the opportunity to acquire specific skills and knowledge that will support healthful changes in the ways they select, prepare, and serve foods. At the environmental level, intervention stores will be asked to stock and vigorously promote selected foods and preparation methods. A media campaign on the two reservations will actively support and reinforce key promotions and intervention messages. Intervention approaches will be closely linked to key educational constructs that are part of Social Cognitive Theory, including observational learning, role-modeling, and reinforcement. A key feature of this intervention is encouraging specific behavioral changes and learning to overcome barriers that previously impeded a healthy diet.
The study design is in two parts:
- We will conduct a randomized study with 20 local food sellers. Ten stores on the two reservations will be randomly allocated to implement the intervention, and ten will serve as comparison stores. Stores will be stratified on the two reservations based on overall size (there is one large grocery store on each reservation). Approximately one half of each tribe’s stores will be assigned to the intervention. This part of the study will assess how the intervention affects food ordering, food sales, and the promotion of healthier foods in the stores.
- We will conduct a pretest/posttest, prospective, longitudinal, cohort study of 300 consumer respondents, each representing a different household, at four different points (before the intervention, mid-intervention, immediately post-intervention, and 6 months post-intervention). We will examine differing levels of exposure to the intervention and assess changes in food purchasing, preparation, consumption, self-efficacy, etc.
The results of this intervention trial may be directly translatable to other reservation-based American Indian tribes in the United States and will have relevance to other rural U.S. populations and inner city urban populations that have reduced access to healthy foods in local stores. Return to top >>
Intervention stores will be encouraged to stock and promote healthy alternatives to commonly consumed foods that are high in fat and/or sugar and low in fiber. During the formative research, we gathered frequency data on the purchasing patterns of key foods that were higher in fat and sugar and low in fiber, as well as of healthier alternatives.
Stores will be encouraged to offer healthier alternatives, but will not be discouraged from offering their less healthy counterparts (which in most cases represent major sources of sales). During regular checks of shelf labels as part of the process evaluation, a data collector will note which foods are currently being offered and which are not, information he or she will report to the interventionist for follow-up. An emphasis will be placed on promoting WIC products.
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Each phase of the Apache Healthy Stores program will have one or two specific messages (such as "Low fat (1%) and skim milk contain all the nutrients without too much fat," "Breakfast cereal provides an easy and healthy morning meal," or "Have fruit in the morning"). Such messages will appear as part of the mass media and in-store strategies. In addition, several general themes will be used throughout the intervention (e.g., "Eat right, stay strong, live long!"). These themes were selected on the basis of the formative research, where participants emphasized economy and convenience as primary motivations for food purchasing.
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The in-store and mass media approaches described above will also be used to encourage healthy preparation methods. In the formative research, respondents were asked to describe their main method of preparation of seven common foods. The main methods of cooking reported were deep-frying and pan-frying, followed by baking. Use of cooking spray, broiling, and boiling were infrequently mentioned. Intervention strategies promoting healthy cooking will seek to reduce the fat content of food (e.g., by draining and rinsing ground meat, and broiling) or to discourage the addition of fat (e.g., by baking and the use of cooking spray).
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