Understanding the Role of the Food Environment on Diet and Health in Rural American Indian Communities: the Strong Heart Food Environment Study

The research activities proposed in this application address a pressing need in American Indian (AI) communities to better understand multi-level (i.e., community- , household- , and individual- level) factors in the physical and socio-cultural environment that impact diet and cardiovascular diseases. The premise of the

proposed project was informed by: (1) our previous work in the Strong Heart Study (SHS) and the Strong Heart Family Study (SHFS)—the largest multi-tribal cohort studies of risk factors for cardiovascular disease in AIs in the USA—that highlighted the exceedingly high burden of obesity and poor diet quality among AIs; and (2)

findings from our Healthy Food, Healthy Families Feasibility Study—a small pilot study in a SHS/SHFS community that assessed the major barriers and facilitators to eating healthy. Although the SHS/SHFS has followed more than 4,000 AIs from 12 rural communities for the past 34-years, all data collected as part of the

study has focused on individual-level biological and behavioral factors associated with cardiovascular diseases; no data has been collected on multi-level components of the physical or sociocultural food environments in this cohort. As such, we have incomplete knowledge about the influence of these domains on

diet and cardiovascular health in these rural AI communities. To address these gaps, we will leverage existing data from the SHS/SHFS, and add comprehensive assessments of multi-level factors related to the physical and socio-cultural environment (factors selected based on previous pilot work) that may impact diet and

cardiovascular health to the upcoming SHS/SHFS exam in 12 rural AI communities. For this project, we will assess associations of community-level (e.g., food outlet availability, food cost, norms around healthy eating), household-level (e.g., food insecurity, food outlet accessibility; food preferences), and individual-level (e.g., perceived nutrition environment) aspects of the physical and socio-

cultural environment with diet (reported intake of fruits and vegetables; sugar-sweetened beverages) and cardiovascular risk factors (BMI; fasting glucose) among SHS/SHFS participants from 12 tribes. We will also assess the influence of participation in nutrition assistance programs (i.e., supplemental nutrition assistance

program (SNAP) or the Food Distribution Program on Indian Reservations) on diet and cardiovascular risk factors (i.e., reported intake of fruits and vegetables; sugar-sweetened beverages; BMI; fasting glucose). Exploratory outcomes include: HDL cholesterol, triglycerides, systolic blood pressure, incident diabetes and

incident cardiovascular diseases. Greater efforts are needed to understand the most salient factors that impact diet and cardiovascular health in rural Tribal communities. This ancillary study will leverage existing resources from the SHS/SHFS, while adding a comprehensive dietary assessment, measures of food security, and assessments of nutrition

economic and neighborhood environments to the study.