PANEL 4.4 TARGETING MINORITY GROUPS AT RISK IN THE UNITED STATES JENNIFER REQUEJO AND JOEL GITTELSOHN
I
n the United States, overweight and obesity disproportionately affect American Indians and Alaskan Natives1
(Wang and Beydoun
2007; O’Connell et al. 2010). About 5.2 mil- lion American Indian and Alaskan Natives live in the United States. For many living on reservations, access to supermarkets is limited and residents are largely dependent upon convenience or gas-station stores primarily stocked with unhealthy foods (chips, soda, candy) and few fruits and vegetables. Many American Indian communities harbor a deep mistrust and suspicion of all nonresidents—a consequence of their long history of marginal- ization and disenfranchisement. One approach proven successful in addressing this challenge is ensuring that community members actively participate in designing, implementing, and evaluating interventions (Gittelsohn and Rowan 2011; Gittelsohn et al. 2013). Three intervention trials that aimed to reduce obesity and diabetes in American Indian communities by modifying the food environ- ment have been rigorously tested and offer lessons for designing future nutrition-related
programs for American Indians and potentially other disadvantaged US groups. In 1993–2001 the Pathways School–based
trial in seven American Indian communities focused on improving the nutrition curriculum and physical education program for children in grades 3–5 and improving the school food service; it also included a family component (Davis 2003). Although the intervention did not lead to changes in the primary out- comes—physical activity and obesity—it was associated with positive changes in psychoso- cial measures and improvements in diet. The Apache Healthy Stores Program from 2003 to 2005 aimed to make healthy food options more available in local food stores on two reservations and to lead people to buy and consume more of these foods (Curran et al. 2005). The program resulted in measur- able improvements in food-related knowl- edge, healthy food intentions, and purchasing. Health outcomes were not assessed. From 2007 to 2009 the Navajo Healthy Stores Program was introduced into 10 pro- gram regions. At each store, customers could see demonstrations of healthier cooking
methods, taste-test healthy foods, and ask questions (Gittelsohn et al. 2013). Like the other two trials, the program improved peo- ple’s nutrition knowledge and raised their purchases of healthy foods. It also reduced the prevalence of overweight and obesity. Key lessons include the following: (1) institutional-level interventions affecting, for example, schools and stores work better when they are reinforced in the home and commu- nity; (2) reinforcing messages requires engag- ing with a range of institutions including local media, schools, existing community structures, and food stores; (3) program sustainability hinges upon active community engagement and an appropriate institutional base; and (4) longer-term follow-up is needed to detect changes in impact measures such as body mass index and chronic disease. Although changing nutrition-related behaviors and outcomes in low-income ethnic minority groups such as American Indians and Alaskan Natives in the United States is com- plex, progress is possible and indeed impera- tive if the United States is to achieve its health objectives for 2020.2
TABLE 4.4 TRENDS IN STUNTING EQUITY OVER TIME
Change over time in inequality of stunting across wealth quintiles Inequality is increasing Inequality is unchanged
Inequality is decreasing Countries Azerbaijan, Bangladesh, Burkina Faso, Chad, Ethiopia, India, Lao PDR, Nepal, Nicaragua, Niger, Peru
Albania, Armenia, Benin, Bolivia, Cambodia, Cameroon, Central African Republic, Côte d’Ivoire, Democratic Republic of the Congo, Ghana, Guinea, Guinea-Bissau, Guyana, Haiti, Jordan, Kenya, Lesotho, Madagascar, Malawi, Mozambique, Namibia, Rwanda, Senegal, Sierra Leone, Suriname, Togo, Uganda, United Republic of Tanzania, Uzbekistan, Zimbabwe
Colombia, Comoros, Dominican Republic, Egypt, Kazakhstan, Kyrgyzstan, Mongolia, Morocco, Nigeria, Turkey, Zambia Source: Adapted from Figure 2 in Bredenkamp et al. (2014).
DATA GAPS 1. More estimates are needed of overlaps of different forms of malnutrition at the individual, household, and subnational levels.
2. To help navigate complexity, tools for sequencing and prioritizing nutrition actions and programs in a given context need to be developed.
3. More disaggregated data—existing and new—are needed. But so too is the capacity to collect, use, and leverage the data for politi- cal action and to stimulate the demand for more data.
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GLOBAL NUTRITION REPORT 2014
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