This work is supported by grant U54 MD011240 – funded by the National Institute on Minority Health and Health Disparities

Chickasaw Healthy Eating Environments Research Study

(CHEERS)Charlotte Love, MPHTori Taniguchi, MPH

Center for Indigenous Health Research & PolicyOklahoma State University Center for Health Sciences

This work is supported by grant U54 MD011240 – funded by the National Institute on Minority Health and Health Disparities

Acknowledgements

Valarie JerniganDirector, Center for Indigenous

Health Research and Policy

Bobby SaunkeahChair, Institutional Review

Board of Chickasaw Nation

Kamry WalkerStaff, Nutrition Services of

Chickasaw Nation

Joy StandridgeDeputy Director, Nutrition Services of Chickasaw

Nation

Tyra ShacklefordManager, Nutrition Services

of Chickasaw Nation

Lisa SmithStaff, Nutrition Services of

Chickasaw Nation

Special thanks to all of our partners who make this work possible (those pictured and not pictured)!

This work is supported by grant U54 MD011240 – funded by the National Institute on Minority Health and Health Disparities

• Established in January 2019 by Dr. Valarie Blue Bird Jernigan

• Moved from University of Oklahoma to Oklahoma State University

• Center focuses on three primary areas:1. Reconnection2. Education3. Training

• Work with American Indian (AI) communities to improve the food environment and decrease diet-related chronic health outcomes

Center for Indigenous Health Research & Policy (CIHRP)

This work is supported by grant U54 MD011240 – funded by the National Institute on Minority Health and Health Disparities

• Several, large R01 research studies funded by the National Institutes of Health

• THRIVE (Tribal Health and Resilience in Vulnerable Environments) – NIH # R01HL117729

• FRESH (Food Equity and Sustainability for Health) – NIH # R01MD011266

• NOSH (Native Opportunities to Stop Hypertension) – NIH # R01HL126578

• CHEERS (Chickasaw Healthy Eating Environments Research Study) – NIH # U54MD011240

• Address diet-related chronic disease in various tribal nations across Oklahoma

Current Studies of CIHRP

This work is supported by grant U54 MD011240 – funded by the National Institute on Minority Health and Health Disparities

• AIs experience higher morbidity and mortality from chronic disease and associated risk factors1 compared to the all-races population.

• Obesity: 43% percent of AI adults are obese2

• Diabetes: AIs are twice as likely to develop diabetes compared to non-Hispanic whites2

• Hypertension: 34.5% among AIs compared to 25.7% among non-Hispanic Whites3

• There are significant disparities among chronic disease risk factors, such as tobacco use, physical activity, and fruit and vegetable intake in AIs.

Chronic Disease among American Indians

This work is supported by grant U54 MD011240 – funded by the National Institute on Minority Health and Health Disparities

• Lifestyle and diet have contributed to increases in cardiovascular disease (CVD) among AIs8,9

• CVD is more likely to be fatal in AIs relative to other races, with mortality rates 20% higher than in the general population8

• 36% of AIs with CVD die before age 65, versus 15% of non‐Hispanic Whites8

Cardiovascular Disease among American Indians

This work is supported by grant U54 MD011240 – funded by the National Institute on Minority Health and Health Disparities

• Food insecurity (FI), the limited availability of nutritional and safe foods, is an independent risk factor for chronic disease4

• Approximately 30% of AI households experience FI compared to 14% of non-AI households5

• FI is associated with poor food environments6, which are common in AI communities7

• Limited access to affordable healthy foods• High density of fast food chains and convenience stores• Few supermarkets or grocery stores

Food Insecurity among American Indians

This work is supported by grant U54 MD011240 – funded by the National Institute on Minority Health and Health Disparities

• Oklahoma is ranked 46th in the nation in regards to health outcomes

• AIs in Oklahoma have high rates of CVD-related chronic disease10

• Hypertension: 40% • Obese: 39% • Overweight: 39%• Diabetes: 17%

• Oklahoma AIs have low consumption of vegetables and fruits10

• 20% eat vegetables less than one time per day• 46% eat fruit less than one time per day

CVD-related Risk Factors among AIs in Oklahoma

This work is supported by grant U54 MD011240 – funded by the National Institute on Minority Health and Health Disparities

Partnership: Chickasaw Nation of Oklahoma

This work is supported by grant U54 MD011240 – funded by the National Institute on Minority Health and Health Disparities

Tribal Jurisdictions in Oklahoma

This work is supported by grant U54 MD011240 – funded by the National Institute on Minority Health and Health Disparities

This work is supported by grant U54 MD011240 – funded by the National Institute on Minority Health and Health Disparities

• A key benefit of CBPR is improved uptake of results by communities that have been engaged and empowered by the research process

• Understanding past grievances and distrust of investigators requires responsible interactions with these communities and explicit recognition that research must be designed to improve participants’ quality of life

• CBPR is appropriate in AI/AN communities, given their history of exploitation in research

Community-based Participatory Research

This work is supported by grant U54 MD011240 – funded by the National Institute on Minority Health and Health Disparities

• Started about 8 years ago with the Tribal Health Resilience in Vulnerable Environements (THRIVE) study (R01#)

• Partnership consisting of researchers and key stakeholders

Community-based Partnership: Chickasaw Nation

This work is supported by grant U54 MD011240 – funded by the National Institute on Minority Health and Health Disparities

CHEERS Study Purpose & Overview

• Study purpose: To improve blood pressure control in AIs with uncontrolled hypertension and improve body mass index (BMI)

• Study outcomes: Blood pressure and BMI (primary), diet, walking, and perceived food access (secondary)

• Study design: Cluster, multi-level randomized controlled trial• Four Chickasaw Nation communities (two intervention & two control)• Six-month intervention administered in longitudinal cohorts

• Intervention began in July 2019

This work is supported by grant U54 MD011240 – funded by the National Institute on Minority Health and Health Disparities

Multi-level Theoretical Model

This work is supported by grant U54 MD011240 – funded by the National Institute on Minority Health and Health Disparities

Study Aims

• Aim 1: To evaluate the study’s ability to improve healthy food access (environmental level)

• Aim 2: To measure change in blood pressure, BMI, & secondary outcomes among hypertensive community members at baseline and follow-up (individual level)

• Aim 3: To evaluate the documentary’s effect on tribal leaders’ readiness to implement the study across the Chickasaw Nation and other tribal communities (policy level)

This work is supported by grant U54 MD011240 – funded by the National Institute on Minority Health and Health Disparities

• Food environment assessments were done in each community (e.g., number and types of food stores in each, sociodemographic characteristics)

• Systematic assessments of feeding programs within Chickasaw Nation, identifying program gaps and priorities for the tribe

• Finalize high and low access communities for randomization• Ardmore and Ada (higher access)• Tishomingo and Sulphur (lower access)

Aim 1: Food Environment Component

This work is supported by grant U54 MD011240 – funded by the National Institute on Minority Health and Health Disparities

• Increase access to healthier food choices in poor food environments and to increase positive health outcomes

• Nutritional analysis and cost analysis were performed to find the most economical foods that meet the DASH (Dietary Approaches to Stop Hypertension) diet guidelines

• Food boxes consisting of heart-healthy foods, FRESH checks, recipes, and education materials

Aim 1: Food Environment Component

This work is supported by grant U54 MD011240 – funded by the National Institute on Minority Health and Health Disparities

• Intervention group participants receive monthly food box deliveries to their home

• Heart-healthy foods• 1 serving of fruit (fresh, dried, or canned) per day• 1 serving of vegetable (fresh or low sodium canned) per day• 1 serving of unsalted nuts or seeds per day• 1 serving of beans or lentils per day• 2 servings of fatty fish (canned) per week

• FRESH checks• $5 coupons to purchase fruits and vegetables at Farmer's markets

• Recipes• Education materials

Heart-healthy Food Boxes

This work is supported by grant U54 MD011240 – funded by the National Institute on Minority Health and Health Disparities

Educational Materials

This work is supported by grant U54 MD011240 – funded by the National Institute on Minority Health and Health Disparities

• Tribal gym membership• Fitbit

• Track walking/physical activity• AYA phone application

• Interactive mobile walking app• Features innovative step-tracking technologies• Grounded in Chickasaw story-telling, history, and culture• Designed to encourage and inspire users to walk more while

unlocking meaningful content

Aim 2: Individual-level Components

This work is supported by grant U54 MD011240 – funded by the National Institute on Minority Health and Health Disparities

Fitbit & AYA App

This work is supported by grant U54 MD011240 – funded by the National Institute on Minority Health and Health Disparities

Fitbit & AYA App

This work is supported by grant U54 MD011240 – funded by the National Institute on Minority Health and Health Disparities

Fitbit & AYA App

This work is supported by grant U54 MD011240 – funded by the National Institute on Minority Health and Health Disparities

Fitbit & AYA App

This work is supported by grant U54 MD011240 – funded by the National Institute on Minority Health and Health Disparities

Aim 3: Documentary and Dissemination

• Create a documentary film about the study's implications for public health and the local economy

This work is supported by grant U54 MD011240 – funded by the National Institute on Minority Health and Health Disparities

• Recruitment locations• Eligibility

• At least 18 years or older

• Identify as American Indian• Live in one of the four counties and plan to remain there for at least

12 months

• Rolling cohorts• 3 total cohorts with staggered intervention

• Data administration

Recruitment and Data Collection

This work is supported by grant U54 MD011240 – funded by the National Institute on Minority Health and Health Disparities

• Blood pressure• BMI• 24-hour dietary recall• Online surveys

Individual-level Measures

This work is supported by grant U54 MD011240 – funded by the National Institute on Minority Health and Health Disparities

• Total consented and enrolled: 268• Retention rate: 79.8% • Cohort 1: 136• Cohort 2: 78• Recruitment for Cohort 3 is ongoing

• Currently on hold due to COVID-19

Recruitment Status

This work is supported by grant U54 MD011240 – funded by the National Institute on Minority Health and Health Disparities

• Cohort 1 intervention complete as of beginning of November 2019• Cohort 2 intervention launched in April 2020

• Participants are about to receive their 3rd food box• Food box vendors transitioned from Feed the Children to Regional

Food Bank of Oklahoma

Intervention Status

This work is supported by grant U54 MD011240 – funded by the National Institute on Minority Health and Health Disparities

• This study will be the first to develop culturally relevant methods of assessing social and environmental influences on obesity among AIs

• Appropriate environmental interventions will be determined and feasibility for implementation will be assed in unique tribal settings

• The knowledge gained from this study will be disseminated to AI communities to aid in identifying which environmental and social strategies work and what kind of cumulative intervention effect is needed to result in widespread support for healthful behaviors in tribal communities

Proposed Outcomes

This work is supported by grant U54 MD011240 – funded by the National Institute on Minority Health and Health Disparities

1. Jernigan, Valarie, et al. "Changing patterns in health behaviors and risk factors related to cardiovascular disease among American Indians and Alaska Natives." American Journal of Public Health 100.4 (2010): 677-683.

2. Centers for Disease Control and Prevention, National Diabetes Statistics Report, 2014. 3. Barnes PM, Adams PF, Powell-Griner E (2010) Health characteristics of the American Indian or

Alaska Native adult population: United States, 2004–2008. Natl Health Stat Report 1–22. 4. Seligman HK, Laraia BA, Kushel MB. Food insecurity is associated with chronic disease among

low-income NHANES participants. J Nutr. 2010;140(2):304–10.5. Jernigan V. et al. (2016) Food insecurity among American Indians and Alaska Natives: a

national profile using the Current Population Survey–Food Security Supplement. J Hunger Environ Nutr. 107:1–10.

6. Story, M., et al. (2008). Creating healthy food and eating environments: policy and environmental approaches. Annu. Rev. Public Health, 29, 253-272.

7. Jernigan, Valarie, et al. (2011). "Addressing food insecurity in a Native American reservation using community-based participatory research." Health education research 27.4 (2011): 645-655.

8. Veazie M, Ayala C, Schieb L, Dai S, Henderson JA, Cho P. Trends and disparities in heart disease mortality among American Indians/Alaska Natives, 1990–2009. Am J Public Health. 2014; 104(suppl 3):S359–S367.

References

This work is supported by grant U54 MD011240 – funded by the National Institute on Minority Health and Health Disparities

9. Howard BV, Lee ET, Cowan LD, Devereux RB, Galloway JM, Go OT, Howard WJ, Rhoades ER, Robbins DC, Sievers ML, Welty TK. Rising tide of cardiovascular disease in American Indians. The Strong Heart Study. Circulation. 1999; 99:2389–2395.

10. Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Population Health. BRFSS Prevalence & Trends Data [online]. 2018. [accessed May 26, 2020]. URL: https://www.cdc.gov/brfss/brfssprevalence/.

References

This work is supported by grant U54 MD011240 – funded by the National Institute on Minority Health and Health Disparities

Questions?