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From 2008 to 2012, the American Indian Healthy Eating Project worked on developing planning and policy strategies to improve access to healthy, affordable foods within American Indian communities in North Carolina.

We have been blessed with the opportunity to build partnerships with the NC Commission of Indian Affairsseven tribes in North Carolina, and with all the tribal leaders, liaisons, and advisors who have given so much of their time and thoughts to facilitate united approaches to advance American Indian health within their tribes, across the state, and throughout Indian Country.  This project is just one fruitful example of the talent, assets, and potential living within American Indian communities in North Carolina.  Native people have the power and wisdom to live long, healthy lives!

Support for this project was provided by Healthy Eating Research, a national program of the Robert Wood Johnson Foundation (RWJF) (ID#66958) and a National Institutes of Health (NIH) University of North Carolina Interdisciplinary Obesity Training Grant (T 32 MH75854-03).  The content is solely the responsibility of the authors and does not necessarily represent the official views of the RWJF or NIH.
Requested Website Citation:

The American Indian Healthy Eating Project in partnership with seven American Indian tribes in North Carolina.  Tools for Healthy Tribes.  Chapel Hill, NC; 2011.

American Indian Health Disparities

American Indians have long experienced disproportionately high mortality rates from diet-related chronic diseases compared to other Americans.  As young as four-years-old, striking disparities are seen in American Indian childhood obesity rates.  To illustrate, a recent cross-sectional study using a nationally representative sample of US children born in 2001 (n=8550) with height and weight measured in 2005 reported that American Indian children had the highest prevalence of obesity among five major racial/ethnic groups (Anderson SE & Whitaker RC. Arch Pediatr Adolesc Med. 2009;163(4):344-348).  While the prevalence among four-year-old US children was 18.4%, the prevalence rates differed significantly by racial/ethnic group.  American Indian rates doubled the non-Hispanic white and Asian rates and were notably higher than rates endured by Hispanic and non-Hispanic black children.  This study produced the first national estimates of obesity prevalence among American Indian preschoolers.  Study investigators recommended future studies focus on how community context influences differences in eating and exercise behaviors across various racial/ethnic minority populations.

Little is Known about the American Indian Food Environment

Changing a community’s context or specifically its built environment is a promising strategy to reduce American Indian health disparities.  The built environment encompasses all the buildings, spaces, and products created or modified by people.  These buildings and spaces include homes, schools, workplaces, park/recreational areas, greenways, business areas, and transportation systems.  In addition, the built environment takes into consideration the land-use planning and policies impacting our communities in urban, rural, and suburban areas.  The food environment specifically includes the availability, accessibility, and affordability of both healthy foods and beverages, such as fruits and vegetables, as well as nutrient-poor, calorie-dense foods and beverages, such as sugar-sweetened beverages.  Few research efforts have rigorously examined the built environment  within American Indian communities, especially within American Indian communities living off reservations—estimated to be as high as 60% of the American Indian population.

Facilitating Tribally-Led Environmental and Policy Strategies to Healthy Eating

Public health professionals are increasingly exploring how local, state, and federal policymakers can prevent and control chronic diseases such as obesity, Type 2 diabetes, cardiovascular disease, and certain types of cancer.  For instance, the Centers for Disease Control and Prevention (CDC) recommended twenty-four strategies communities could implement to prevent obesity in the US.  Tribal communities were not explicitly mentioned in this report.  Moreover, in comparison to local, state, and federal policymakers, little attention is given to the role tribal leaders can have in improving access to healthy, affordable foods within their tribal communities.  This is the first study to our knowledge that works directly with tribes to explore the potential for tribally-led efforts to maximize environmental and policy strategies to improve access to healthy, affordable foods.


Our approach, or theoretical framework, to understanding the relationship between public health, planning, and policy is based on Social Cognitive Theory (Bandura A. Social Foundation of Thought and Action: A Social Cognitive Theory. Englewood Cliffs, NJ: Prentice Hall; 1986).  Social Cognitive Theory sets forth that health behaviors, such as diet, are influenced by individual factors in combination with the social and physical environment.  A more recent ecological-based model of community nutrition environments includes relevant constructs, such as government policies and the type and location of food outlets (Glanz, et al. Am J Health Promot. 2005;19(5):330-333).  We also were influenced by Community-Based Participatory Research, various theories and concepts trying to explain political decision making and public participation in policy, and consumer behavior models.

The American Indian Healthy Eating Project Aims

Our multidisciplinary project aimed to build the partnerships and evidence-base necessary to improve access to healthy, affordable foods within American Indian communities in North Carolina.  Specifically, this project
(Aim 1) Applied Community-Based Participatory Research (CBPR) to build partnerships with the NC Commission of Indian Affairs and seven tribes in North Carolina to gain an understanding of how environmental and policy factors influence access to healthy foods;
(Aim 2) Examined existing data sources to identify and map the type and location of food outlets, such as grocery stores and restaurants, within the seven communities;
(Aim 3) Assessed agreement among existing (secondary) food outlet data sources and validated existing data using primary field-based observations; and
(Aim 4) Conducted legal and policy analyses of regulations and rules relating to healthy food access in order to guide solution-oriented strategies and develop a toolkit for improving access to healthy foods within each of the tribal communities.