Facilitators and Barriers to Healthy Eating Among American Indian and Alaska Native Adults with Type 2 Diabetes: Stakeholder Perspectives

Sarah A Stotz; Angela G Brega; Kelly Gonzales; Luciana E Hebert; Kelly R Moore; AI/AN WCIE Study Group

doi:10.1093/cdn/nzaa114

Facilitators and Barriers to Healthy Eating Among American Indian and Alaska Native Adults with Type 2 Diabetes: Stakeholder Perspectives

Curr Dev Nutr. 2021 May 14;5(15):22-31. doi: 10.1093/cdn/nzaa114. eCollection 2021 Jun.

Authors

Sarah A Stotz¹, Angela G Brega¹, Kelly Gonzales², Luciana E Hebert³, Kelly R Moore¹; AI/AN WCIE Study Group

Collaborators

AI/AN WCIE Study Group:
G Austin, D Bellinger, K Conti, N Couture, A Brega, H Garrow, K Gonzales, C Hinchcliff, E Juarez-Colunga, K Moore, M McNulty, N O'Banion, H Pontius, S Stotz

Affiliations

¹ The University of Colorado Anschutz Medical Campus, Colorado School of Public Health, Centers for American Indian and Alaska Native Health, Aurora, CO, USA.
² Oregon Health Sciences University-Portland State University School of Public Health , Portland State University, Portland, OR, USA.
³ Institute for Research and Education Advancing Community Health (IREACH), Elson S. Floyd College of Medicine, Washington State University, Seattle, WA, USA.

Abstract

Background: American Indian and Alaska Native (AI/AN) adults have a higher prevalence of type 2 diabetes (T2D) and related complications than non-AI/AN adults. As healthy eating is a cornerstone of diabetes self-management, nutrition education plays an important role in diabetes self-management education.

Objective: To understand stakeholder perspectives on facilitators and barriers to healthy eating for AI/AN adults with T2D in order to inform the cultural adaptation of an existing diabetes nutrition education curriculum.

Methods: Individual interviews were conducted with 9 national content experts in diabetes nutrition education (e.g. registered dietitians, diabetes educators, experts on AI/AN food insecurity) and 10 community-based key informants, including tribal health administrators, nutrition/diabetes educators, Native elders, and tribal leaders. Four focus groups were conducted with AI/AN adults with T2D (n = 29) and 4 focus groups were conducted with their family members (n = 22). Focus groups and community-based key informant interviews were conducted at 4 urban and reservation sites in the USA. Focus groups and interviews were recorded and transcribed verbatim. We employed the constant comparison method for data analysis and used Atlas.ti (Mac version 8.0) to digitalize the analytic process.

Results: Three key themes emerged. First, a diabetes nutrition education program for AI/ANs should accommodate diversity across AI/AN communities. Second, it is important to build on AI/AN strengths and facilitators to healthy eating (e.g. strong community and family support systems, traditional foods, and food acquisition and preparation practices). Third, it is important to address barriers to healthy eating (e.g. food insecurity, challenges to preparation of home-cooked meals, excessive access to processed and fast food, competing priorities and stressors, loss of access to traditional foods, and traditional food-acquisition practices and preparation) and provide resources and strategies for mitigating these barriers.

Conclusions: Findings were used to inform the cultural adaptation of a nutrition education program for AI/AN adults with T2D.

Keywords: American Indian and Alaska Native; cultural adaptation; diabetes nutrition education; qualitative methods; type 2 diabetes.