Evaluation of Support, a self-guided online type 1 diabetes self-management education and support web application-a mixed methods study.

Background: Type 1 diabetes requires making numerous daily decisions to maintain normoglycemia. Support is an evidence-based self-guided web application for type 1 diabetes diabetes self-management. Objective: Evaluate users' satisfaction with Support and investigate changes in self-reported frequency of-, fear of- hypoglycemia, and diabetes-related self-efficacy. Methods: Adults from a Quebec type 1 diabetes registry used Support. Data was collected through online surveys or extracted from the registry at 0, 6, and 12 months (number of episodes and fear of hypoglycemia). At 6 months, participants reported satisfaction with Support and diabetes-related self-efficacy. A sub-group of 16 users was interviewed about their experience. Transcripts were analyzed using inductive and deductive approaches. Results: In total, 207 accounts were created (35% men, 96% White, mean age and diabetes duration: 49.3 ± 13.8 and 25.2 ± 14.7 years). At 6 months, the median [Q1; Q3] satisfaction was 40/49 [35; 45] with a mean decrease in hypoglycemia frequency of 0.43 episodes over 3 days (95% CI: -0.86; 0.00, p = 0.051) and of -1.98 score for fear (95% CI: -3.76; -0.20, p = 0.030). Half of the participants reported increased diabetes-related self-efficacy. Conclusions: Participants reported a high level of satisfaction with Support. Its use has the potential to facilitate hypoglycemia management and increase diabetes-related self-efficacy. Trial registration: This study is registered on ClinicalTrials.gov NCT04233138.

Traditional and Indigenous Fruits and Vegetables for Food System Transformation.

Fruit and vegetable consumption is recommended in numerous food-based dietary guidelines and forms a key recommendation in many international statements related to healthy diets. There are thousands of fruit and vegetable species from which to choose, but despite this abundance from nature, populations in most countries neither produce nor consume the recommended daily amounts of fruits and vegetables. There is enormous potential to better incorporate the wealth of diverse fruit and vegetable species and varieties into food systems. Known and preserved by indigenous communities, these hidden food treasures can foster collaborative research and learning. This perspective from the Task Force on Traditional and Indigenous Food Systems and Nutrition of the International Union of Nutritional Sciences (IUNS) highlights 5 key actions that can be taken by individuals, communities, and nations to reshape dialogue about traditional and indigenous fruits and vegetables to benefit people and planetary ecosystems.

Examining the Influence of Cultural Immersion on Willingness to Try Fruits and Vegetables among Children in Guam: The Traditions Pilot Study.

This pilot study examined the influence of cultural immersion on willingness to try fruits and vegetables (FV) among children 3-12 years old in three summer camps in Guam with different cultural exposure levels: cultural immersion camp (CIC), high exposure; university day camp (UDC), moderate exposure; and recreational sports camp (RSC), zero exposure. Children, ages 3-12 years old for CIC and UDC and 5-12 years old for RSC, participated: CIC (n = 47), UDC (n = 23), and RSC (n = 33). Children's willingness to try FV was assessed with the Adapted WillTry tool before and after each program. Whole FV intakes were assessed concurrently using the mobile food record in CIC and UDC. Using multivariate regression, WillTry post-assessment outcomes were modeled adjusting for pre-assessment, child characteristics, exposure, and parent cultural affiliation. Unique to the Adapted WillTry tool are three FV scales, local novel, local common, and imported, which are classified by source (local or imported) and/or familiarity (novel or common). WillTry adjusted mean FV post-scores by highest exposure camp to lowest were 2.2, 2.3, and 2.2 for local novel and 2.6, 2.6, and 2.6 for local common. No differences among camps were significant; however, there was an increase in the willingness to try scores for all FV score types and camps. The Traditions pilot study demonstrated: (1) feasibility of a multi-arm parallel design using existing community programs in limited-resource environments and (2) further examination of nutrition education components and contexts are needed to understand diet behaviors of indigenous populations.

Understanding how Indigenous culturally-based interventions can improve participants' health in Canada.

There is increasing recognition that culturally-based diabetes prevention programs can facilitate the adoption and maintenance of healthy behaviours in the communities in which they are implemented. The Kahnawake School Diabetes Prevention Project (KSDPP) is a health promotion, community-based participatory research project aiming to reduce the incidence of Type 2 diabetes in the community of Kahnawake (Mohawk territory, Canada), with a large range of interventions integrating a Haudenosaunee perspective of health. Building on a qualitative, naturalistic and interpretative inquiry, this study aimed to assess the outcomes of a suite of culturally-based interventions on participants' life and experience of health. Data were collected through semi-structured qualitative interviews of 1 key informant and 17 adult, female Kahnawake community members who participated in KSDPP's suite of interventions from 2007 to 2010. Grounded theory was chosen as an analytical strategy. A theoretical framework that covered the experiences of all study participants was developed from the grounded theory analysis. KSDPP's suite of interventions provided opportunities for participants to experience five different change processes: (i) Learning traditional cooking and healthy eating; (ii) Learning physical activity; (iii) Learning mind focusing and breathing techniques; (iv) Learning cultural traditions and spirituality; (v) Socializing and interacting with other participants during activities. These processes improved participants' health in four aspects: mental, physical, spiritual and social. Results of this study show how culturally-based health promotion can bring about healthy changes addressing the mental, physical, spiritual and social dimensions of a holistic concept of health, relevant to the Indigenous perspective of well-being.

Dietetics Practice in the Unique, Culturally Diverse Pacific Island Region.

The Pacific Island region is geographically the most isolated region in the world representing a diverse population of indigenous peoples, migrated groups and new-comers. Rates of chronic disease are predominately high in populations identified as Pacific Islander. The practice of dietetics, defined as nutrition education for the prevention of disease and medical nutrition therapy for the treatment of chronic diseases, proves challenging with the unique cultural diversity in the region. There is a need to describe dietetics practice, populations served, and needs for resources identified by nutrition-related topic and cultural relevance for Registered Dietitian Nutritionists in the Pacific Island region. An online survey was distributed to all members of the Hawai'i Affiliate of the Academy of Nutrition and Dietetics in 2013-2014. The online survey yielded 104 usable responses. Most participants were female and lived and worked in the Hawaiian Island region. One-third of practicing Registered Dietitian Nutritionists saw >100 patients or clients per month. Most prevalent populations served were identified as Asian and Pacific Islanders. Culturally relevant resources of the highest need were relevant to Asian and Pacific Islander cultures, specifically addressing weight control and diabetes. Dietetics practice in the Pacific Island region is unique given the prevalence of Asians and Pacific Islanders served by Registered Dietitian Nutritionists. Findings will inform the development of new, culturally appropriate online nutrition resources, to enhance dietetics practice in the region. Making these resources available online will be useful for Registered Dietitian Nutritionists and other health care practitioners working in the Pacific Island region.

Enhancing Indigenous Health Promotion Research Through Two-Eyed Seeing: A Hermeneutic Relational Process.

The intention of this article is to demonstrate how Indigenous and allied health promotion researchers learned to work together through a process of Two-Eyed Seeing. This process was first introduced as a philosophical hermeneutic research project on diabetes prevention within an Indigenous community in Quebec Canada. We, as a research team, became aware that hermeneutics and the principles of Haudenosaunee decision making were characteristic of Two-Eyed Seeing. This article describes our experiences while working with each other. Our learning from these interactions emphasized the relational aspects needed to ensure that we became a highly functional research team while working together and becoming Two-Eyed Seeing partners.

Indigenous Peoples' food systems, nutrition, and gender: Conceptual and methodological considerations.

Indigenous Peoples, especially women and children, are affected disproportionately by malnutrition and diet-related health problems. Addressing this requires an investigation of the structural conditions that underlie unequal access to resources and loss of traditional lifestyles and necessitates inclusive approaches that shed light onto these issues and provide strategies to leverage change. Indigenous Peoples' food systems are inextricably connected to land, which in turn is interwoven with issues of self-determination, livelihoods, health, cultural and spiritual heritage, and gender. Ongoing loss of land and the dominant agri-food model further threaten Indigenous Peoples' food systems. Continuing gender-based discrimination undermines the self-determination and rights of women and negatively impacts their health, nutritional status, and overall well-being, as well as the well-being of households and communities. We suggest that feminist political ecology and modern matriarchal studies provide holistic interlinking frameworks for investigating underlying issues of power and inequality. We further argue that a focus on the principles of respect, responsibility, and relationships, and an openness to different worldviews, can facilitate a bridging of Indigenous and Western approaches in research and community action conducted in partnership with Indigenous Peoples. This can contribute to creating new ways of knowing regarding Indigenous Peoples' food systems, equally valuing both knowledge systems. Indigenous Peoples' rights, right to food, and food sovereignty are frames that, despite some tensions, have the common goal of self-determination. Through their ability to inform, empower, and mobilize, they provide tools for social movements and communities to challenge existing structural inequalities and leverage social change.

Reclaiming food security in the Mohawk community of Kahnawà:ke through Haudenosaunee responsibilities.

Indigenous Peoples are reclaiming their food security, nutrition, and well-being by revitalizing food systems, livelihoods, knowledge-systems, and governance. Our food security research is guided by sustainable self-determination that focuses on restoring Indigenous cultural responsibilities and relationships to land, each other, and the natural world (Corntassel, 2008). Our Kanien'kehá:ka (Mohawk) research team from Kahnawà:ke, in Quebec, Canada, examines food insecurity experiences in our community to explore ways of upholding our Haudenosaunee responsibilities and enhancing local food security. We collaboratively designed the study and interviewed Kahnawakehró:non (people from the Kahnawake community) with traditional knowledge, extensive community experience, and interests in food and culture. Interviews were audio-recorded, transcribed, and analysed by the team. Analysis characterized food insecurity experiences and conditions that challenge and enable food security with attention to traditional food systems, relationships to land, and gender-related responsibilities. Findings show that communal responsibilities generate resilient strategies that provide for all in times of crisis, and long-term food insecurity is managed through social programs, organized charities, and family support. Enhancing food security involves healing and protecting a limited land-base for food production, integrating food production with community priorities for education, training, health, economic development, and scientific innovation. Nurturing spiritual connections with tionhnhéhkwen (life sustaining foods), the natural world, and each other calls for accelerated teaching and practicing our original instructions. Challenges in developing food security leadership, balancing capitalism and subsistence economies, and strengthening social relationships are rooted in the historical colonial and current settler-colonial context that disrupts all aspects of Kanien'kehá:ka society.

Food-related Beliefs of Adolescent Girls Ages 9-13 and Their Mothers on O'ahu, Hawai'i.

A number of factors contribute to the development of obesity in adolescents, including various dietary and lifestyle behaviors, and a host of social and environmental factors, such as socioeconomic status, parental education, and culture. Research examining beliefs about behaviors related to weight status in adolescents, such as food intake, can create a better understanding of risk factors for obesity. This study explored beliefs about behaviors related to weight status in 20 early adolescent girls aged 9 to 13 years and their mothers in O'ahu, Hawai'i. Semi-structured individual interviews were conducted to elucidate beliefs through discussion of food purchasing, feeding practices, portion control strategies, eating outside the home, and body size perception. Interviews were transcribed verbatim and examined using directed content analysis. Both mothers and daughters believed that diets should consist of fresh foods and be based on principles of variety, balance, and moderation, and had negative perceptions of school lunch. In describing ideal body size, mothers expressed greater concern for overweight, as well as ethno-cultural beauty standards, than daughters. Mothers believed daughters should have a positive relationship with food but also applied various portion control strategies with them. Findings reveal how mothers' and daughters' beliefs may influence daily food-related practices in adolescent girls. Future studies may seek to investigate the role these factors may play in determining weight status in adolescents in Hawai'i, with findings to be used to inform health promotion programs.

Influences on eating: a qualitative study of adolescents in a periurban area in Lima, Peru.

BACKGROUND: Peruvian adolescents are at high nutritional risk, facing issues such as overweight and obesity, anemia, and pregnancy during a period of development. Research seeking to understand contextual factors that influence eating habits to inform the development of public health interventions is lacking in this population. This study aimed to understand socio-cultural influences on eating among adolescents in periurban Lima, Peru using qualitative methods. METHODS: Semi-structured interviews and pile sort activities were conducted with 14 adolescents 15-17 years. The interview was designed to elicit information on influences on eating habits at four levels: individual (intrapersonal), social environmental (interpersonal), physical environmental (community settings), and macrosystem (societal). The pile sort activity required adolescents to place cards with food images into groups and then to describe the characteristics of the foods placed in each group. Content analysis was used to identify predominant themes of influencing factors in interviews. Multidimensional scaling and hierarchical clustering analysis was completed with pile sort data. RESULTS: Individual influences on behavior included lack of financial resources to purchase food and concerns about body image. Nutrition-related knowledge also played a role; participants noted the importance of foods such as beans for anemia prevention. At the social environmental level, parents promoted healthy eating by providing advice on food selection and home-cooked meals. The physical environment also influenced intake, with foods available in schools being predominantly low-nutrient energy-dense. Macrosystem influences were evident, as adolescents used the Internet for nutrition information, which they viewed as credible. CONCLUSIONS: To address nutrition-related issues such as obesity and iron-deficiency anemia in Peruvian adolescents, further research is warranted to elucidate the roles of certain factors shaping behavior, particularly that of family, cited numerous times as having a positive influence. Addressing nutrition-related issues such as obesity and iron-deficiency anemia in this population requires consideration of the effect of social and environmental factors in the context of adolescent lifestyles on behavior. Nutrition education messages for adolescents should consider the cultural perceptions and importance of particular foods, taking into account the diverse factors that influence eating behaviors.

Children's Healthy Living Program (CHL) Indigenous Workforce Training to Prevent Childhood Obesity in the Underserved U.S. Affiliated Pacific Region.

The U.S. Affiliated Pacific Region (USAPR) is an underserved region with high rates of obesity-related, non-communicable diseases and a low proportion of trained obesity prevention professionals, especially indigenous professionals. The Children's Healthy Living Training Program was developed to enhance the USAPR's capacity to address childhood obesity prevention.

A socioecological framework to understand weight-related issues in Aboriginal children in Canada.

Obesity prevention efforts in Aboriginal (First Nations, Métis, or Inuit) communities in Canada should focus predominantly on children given their demographic significance and the accelerated time course of occurrence of type 2 diabetes mellitus in the Aboriginal population. A socioecological model to address childhood obesity in Aboriginal populations would focus on the numerous environments at different times in childhood that influence weight status, including prenatal, sociocultural, family, and community environments. Importantly, for Aboriginal children, obesity interventions need to also be situated within the context of a history of colonization and inequities in the social determinants of health. This review therefore advocates for the inclusion of a historical perspective and a life-course approach to obesity prevention in Aboriginal children in addition to developing interventions around the socioecological framework. We emphasize that childhood obesity prevention efforts should focus on promoting maternal health behaviours before and during pregnancy, and on breastfeeding and good infant and child nutrition in the postpartum and early childhood development periods. Ameliorating food insecurity by focusing on improving the sociodemographic risk factors for it, such as increasing income and educational attainment, are essential. More research is required to understand and measure obesogenic Aboriginal environments, to examine how altering specific environments modifies the foods that children eat and the activities that they do, and to examine how restoring and rebuilding cultural continuity in Aboriginal communities modifies the many determinants of obesity. This research needs to be done with the full participation of Aboriginal communities as partners in the research.

Community capacity as an "inside job": evolution of perceived ownership within a university-aboriginal community partnership.

PURPOSE. To assess the evolution of perceived ownership of a university-Aboriginal community partnership across three project stages. DESIGN. Survey administration to project partners during project formalization (1996-T1), mobilization (1999-T2), and maintenance (2004-T3). SETTING. Aboriginal community of Kahnawake, outside Montreal, Quebec, Canada. PARTICIPANTS. Partners involved in influencing decision making in the Kahnawake Schools Diabetes Prevention Project (KSDPP). MEASURE AND ANALYSIS . A measure of perceived primary ownership subjected to linear trend analysis. RESULTS. KSDPP staff were perceived as primary owner at T1 and shared ownership with Community Advisory Board (CAB) members at T2 and T3. Trend tests indicated greater perceived ownership between T1 and T3 for CAB (χ(2)(1)  =  12.3, p < .0001) and declining KSDPP staff (χ(2)(1)  =  10.5, p < .001) ownership over time. Academic partners were never perceived as primary owners. CONCLUSION. This project was community driven from the beginning. It was not dependent on an external academic change agent to activate the community and develop the community's capacity to plan and implement a solution. It still took several years for the grassroots CAB to take responsibility from KSDPP staff, thus indicating the need for sustained funding to build grassroots community capacity.

Food and eating as social practice--understanding eating patterns as social phenomena and implications for public health.

Globally, public health agencies recognise obesity trends among populations as a priority. Explanations for population obesity patterns are linked to obesogenic environments and societal trends which encourage patterns of overeating and little physical activity. However, obesity prevention and nutrition intervention focus predominantly on changing individual level eating behaviours. Disappointingly, behaviour-based nutrition education approaches to changing population eating patterns have met with limited success. Sociological perspectives propose that underlying social relations can help explain collective food and eating patterns, and suggest an analysis of the sociocultural context for understanding population eating patterns. We propose a theoretical framework for the examination of eating patterns as social phenomena. Giddens' structuration theory, in particular his concept of social practices understood as an interplay of 'agency' and 'social structure' (rules and resources), is used to study food choice patterns. We discuss the application of these concepts for understanding routine food choice practices of families, elaborating how rules and resources configure the enabling or constraining conditions under which actors make food choices. The framework assists in characterising how social structural properties are integral to food choice practices, and could direct attention to these when considering nutrition interventions aimed at changing population eating patterns.

Can the democratic ideal of participatory research be achieved? An inside look at an academic-indigenous community partnership.

Democratic or equal participation in decision making is an ideal that community and academic stakeholders engaged in participatory research strive to achieve. This ideal, however, may compete with indigenous peoples' right to self-determination. Study objectives were to assess the perceived influence of multiple community (indigenous) and academic stakeholders engaged in the Kahnawake Schools Diabetes Prevention Project (KSDPP) across six domains of project decision making and to test the hypothesis that KSDPP would be directed by community stakeholders. Self-report surveys were completed by 51 stakeholders comprising the KSDPP Community Advisory Board (CAB), KSDPP staff, academic researchers and supervisory board members. KSDPP staff were perceived to share similar levels of influence with (i) CAB on maintaining partnership ethics and CAB activities and (ii) academic researchers on research and dissemination activities. KSDPP staff were perceived to carry significantly more influence than other stakeholders on decisions related to annual activities, program operations and intervention activities. CAB and staff were the perceived owners of KSDPP. The strong community leadership aligns KSDPP with a model of community-directed research and suggests that equitable participation-distinct from democratic or equal participation-is reflected by indigenous community partners exerting greater influence than academic partners in decision making.

Unpacking the black box: a deconstruction of the programming approach and physical activity interventions implemented in the Kahnawake Schools Diabetes Prevention Project.

An ecological lens was used to deconstruct the programming approach and unpack physical activity interventions implemented through the Kahnawake Schools Diabetes Prevention Project. Despite a surge of interest in ecologically based health promotion programming, optimal combinations of interventions and programming approaches to promote community physical activity involvement have not been systematically studied. The authors obtained physical activity intervention descriptions through archive retrieval and face-to-face interviews with intervention staff. Programming approach, intervention targets, strategies for change, and delivery settings were assessed by applying the intervention analysis procedure to intervention descriptions. A complex intervention package was found containing a host of multitarget, multisetting intervention strategies designed and implemented through dynamic exchanges between a diversity of community partners. This study provides a first step toward better understanding community intervention packages and programming strategies for promoting physical activity involvement within a community setting.