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What is already known on this topic?Historical, economic, social, and environmental determinants of health are critical to understanding type 2 diabetes in American Indian and Alaska Native communities.What is added by this report?Integrating history and culture, 17 tribes and tribal organizations worked during 2008–2014 to increase and sustain community access to traditional foods to promote health and help prevent type 2 diabetes. In partnership with a federal program and each other, tribal partners evaluated community-based interventions locally and across their culturally and geographically diverse communities to demonstrate effectiveness.What are the implications for public health practice?Traditional healthy foods and food sovereignty are valuable areas for American Indian and Alaska Native communities to address chronic disease, specifically type 2 diabetes. AbstractPurpose and ObjectivesThe purpose of the Traditional Foods Project (TFP) was to implement and evaluate a community-defined set of strategies to address type 2 diabetes by focusing on traditional foods, physical activity, and social support. The TFP sought to answer 2 questions: first, how do we increase and sustain community access to traditional foods and related activities to promote health and help prevent type 2 diabetes?

Second, how do we evaluate interventions across culturally and geographically diverse communities to demonstrate success?Intervention ApproachPublic health interventions are most effective when communities integrate their own cultures and history into local programs. The food sovereignty movement among American Indians/Alaska Natives and indigenous populations globally offers ways to address public health issues such as chronic diseases like type 2 diabetes. Historical, economic, social, and environmental determinants of health are critical to understanding the disease.Evaluation MethodsDuring 2008–2014, seventeen tribal TFP partners implemented locally designed interventions and collected quantitative and qualitative data in 3 domains: traditional foods, physical activity, and social support. Partners entered data into a jointly developed evaluation tool and presented additional program data at TFP meetings. Partner observations about the effect of the TFP were gathered in planned discussions.ResultsQuantitative results indicate collaborative community engagement and sustained interventions such as gardening, availability of healthy foods across venues, new health practices, health education, and storytelling. Figure 1.Percentage of partners reporting healthy food selections at worksites and other venues over time, Traditional Foods Project, October 2009–September 2014. Percentages are based on the following denominators: 11 partners participated during T1–T2; 17 partners during T3–T8; and 16 partners during T9–T10.

Abbreviations: S, summer; W, winter. A is also available.Storytelling was an important teaching activity for most TFP partners in every period; for example, 14 of 16 (87.5%) in T10 reported 1 or more storytelling activities. Most incorporated 1 or more types of storytelling (eg, narrative, digital, music) into program activities. The highest proportions of storytelling activities were in the traditional foods domain, ranging from 52.9% (9 of 17) in T7 to 82.4% (14 of 17) in T3. Narrative storytelling activities were the most prevalent (mean, 58.3%, or 91 of 156 samples, over all periods), followed by digital (mean, 37.2%, or 58 of 156).Most TFP partners reported health education activities for each period (range, 76.5% 13 of 17 in T7 to 100% 11 of 11 in T2). Individual TFP partners reported implementing up to 180 health education activities in a 6-month period (T10) and involving a maximum of 10,900 participants (T5).TFP partners reported implementing new health practices (including behaviors, resolutions, policies, and other practices not done before) during each 6-month period at an overall rate of 43.6% (68 of 156 total data points), with a maximum of 58.8% (10 of 17 partners) in T5. The total number of new health practices over all groups for any 1 period ranged from 12 (T1) to 78 (T5).

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As an example, 1 partner reported that their after-school/summer camp implemented a policy that included not having sugar-sweetened beverages and candy available for purchase. In another, Head Start organizations added physical activities, gardening, and a health education curriculum to their programs.Most partners reported including organized physical activities in their programs (overall average for all periods, 60.9%, or 95 of 156). As many as 7,500 participants were involved in organized physical activities for an individual TFP partner during 1 period (T3). Examples of organized activities included traditional games such as stickball, fun runs, restoration work, canoeing, and dancing.Partners measured participant changes such as weight loss, improved levels of physical activity, and healthy food choices in 69 of 156 data points recorded during 10 periods.

In most periods, almost half (median, 47.1; 8 of 17) of partners were measuring participant change in 1 or more domains. Numbers of participants who made changes increased from T1 to T10 for each of the 3 domains, with a maximum at T6 in physical activity (n = 1,388 participants) and social support (n = 1,950 participants) and a maximum at T8 in traditional foods (n = 2,152 participants).Almost all TFP partners reported collaboration with other agencies in all 10 periods.

The proportion of partners reporting at least 1 type of collaboration ranged from 87.5% (14 of 16 in T10) to 100% (11 of 11 in T1; 17 of 17 in T5 and T8; and 16 of 16 in T9). Collaboration was reported most often in the traditional foods domain (89.7% of partners; 140 of 156 overall for the 10 periods), and by most grantees in the physical activity (59.6%; 93 of 156) and social support (56.4%; 88 of 156) domains.

Resources shared included staff (71.8%; 112 of 156), space (60.3%; 94 of 156), educational materials (59.6%; 93 of 156), traditional foods (55.1%; 86 of 156), marketing materials (44.9%; 70 of 156), and financial support, such as vouchers (40.4%; 63 of 156).Media outreach events and materials were described in 103 of 156 (66.0%) reports. In T10, 16 partners conducted 308 media outreach events, developed and distributed 9,264 materials, and affected 31,400 people with media materials. In T1, when programs were just getting started, media was even more commonly reported.

The 11 partners reported 1,614 media outreach events at which 77,523 media materials were distributed and 278,235 people affected.In T10, 56.2% (9 of 16) of TFP programs reported implementing environmental changes in 1 or more domain areas that were designed to be sustainable. Sustainability was also evidenced in activities reported in every period, eg, planting and gardening, particularly community gardening (ranging from 37.5% 6 of 16 to 64.7% 11 of 17 partners). Other examples of sustainable environmental changes included using heirloom seeds, composting, developing health education activities and materials, implementing media outreach activities, implementing health policies and health practices, and collaboration with other agencies. Qualitative findingsQualitative data portrayed the role of traditional foods in ways quantitative data could not. The data describe partner perspectives about traditional foods, how well the TFP worked, and why.

Results indicate that grantee partners embraced the TFP’s community-based, tribally driven approach. Themes and quotes underscore quantitative findings, such as participation, collaboration, and number of gardens.The following examples of tribal partner experiences further illustrate the 7 main themes. The examples usually include more than 1 theme, demonstrating not only their interconnectedness but also how difficult it was for us to separate them.Traditional knowledge and grassroots. Local elders remarked that corn did not grow very high in their community’s desert soil. The TFP coordinator took a course to become a Master Composter, balancing traditional ecological knowledge and western science. He created a compost pile to be used in the community garden to increase produce production. In addition to other compost materials, tribal leaders provided an endless supply of discarded paper and coffee grounds.

Community members, particularly the elders, were impressed with how tall the corn grew and marveled at the large yields of harvested produce from the garden. Figure 2.The compost pile was created to increase produce yield in the community garden, Traditional Foods Project, October 2009–September 2014. Compost materials included paper and coffee grounds provided by tribal leaders, Ramah Navajo, 2011. Photo courtesy of Randy Chatto. A is also available.Connections to health. TFP partners inspired the title of this article. “Traditional foods have become a way to talk about health” was a thread in every discussion.

Partners could not underscore enough that chronic disease is deeply connected to social determinants of health, such as historical trauma, adverse childhood experiences, and loss of traditional foodways. The way to reclaim health, they said, is to reconnect with the land, water, traditional foodways, and all that they mean.The power of stories and storytelling. Narrative stories — oral tradition — were most prevalent compared with other types of stories reported. However, TFP partners enthusiastically produced digital stories after learning from another partner how to create them. In turn, they shared the skill with their own people.

One story was by a young rapper who had struggled with identity and substance abuse. He “found himself through connection with the earth” in the community garden. He created his digital story to welcome all partners, skillfully rapping their names, at a TFP meeting.Community engagement. Meetings hosted by TFP partners provided settings for sharing traditional foods, cultural ways, and physical activity. One of the most anticipated activities was the traditional game of stickball. The community was invited to participate or observe (and cheer).

Stickball literally created a level playing field, where TFP partners, Native Diabetes Wellness Program team members, and community members, women against men, enjoyed a physically strenuous, humor-filled game.Knowledge sharing and gratitude. Dynamic exchange of knowledge demonstrated partners’ engagement with each other. They shared skills (how to create digital stories), traditional foods (meeting hosts always prepared a feast), and gifts (heirloom seeds, wild rice). Partners were grateful for being able to openly express the meaning of traditional foods and spend time together.Flexibility to do what works. At the request of grantee partners, we held a discussion on health policy in the second year of the TFP. Partners stated that measuring health policy only was unacceptable: “written policies tell people what to do.” Health practices, however, “are chosen by the people because they are good ideas and reflect traditional knowledge.” Subsequently, we measured both health policies and health practices.Program sustainability. TFP partners regularly addressed sustainability, particularly toward the end of the TFP.

Most partners (11 of 17) sustained some or all activities after the TFP ended in September 2014. Partners secured funding from tribal councils, university partnerships, state and county health departments, federal agencies, or nonprofit organizations (13).Implications for Public HealthThe TFP’s challenge was to answer 2 questions: How do communities increase and sustain access to traditional healthy foods, physical activity, and social support to promote health and help prevent type 2 diabetes? And, how do we, in partnership with one another, successfully evaluate community-based interventions?Increasing and sustaining access to traditional foods depends on strong local support, collaboration, and traditional knowledge (25–30,33). Grantee partners believed that traditional foods programs can be sustained if the following conditions are met:.First, human and financial resources are necessary.

A local natural leader, knowledgeable about traditional foods and supported financially, is vital.Second, tribal leadership support is needed. Where tribal leadership was not supportive, TFP programs were less productive.

Honda jazz automatic workshop manual. In contrast, strong backing by tribal leadership contributed to project endurance.Third, sustainability is likely when programs are relevant and meaningful. Local decisions about program content, including what constitutes traditional foods, are critical.Fourth, collaborating with programs that have related goals strengthens community infrastructure. Partners noted that, over time, other programs sustained activities originated by the TFP.Fifth, communities with few resources need time to grow infrastructure. Among TFP partners, small communities demonstrated change quickly but, without strengthened infrastructure, changes were temporary.Tribally based health promotion efforts to address access to traditional foods in Indian Country are described in the 2015 report, Feeding Ourselves (34).

Our conclusions are consistent with those described in the report in the section “Case studies: lessons learned and challenges faced by grassroots, nonprofit and tribal food access and health innovators.” As an example, the Communities Creating Healthy Environments program addressed childhood obesity by changing communities rather than focusing on individual behaviors, incorporating aspects such as food inequity, safe places for play, and the social environment. The program noted not only the need for local partners but also the need for ongoing support to “implement victories, consolidate gains, and plan next steps” (34).For our project to be successful, forging trust among TFP partners and the Native Diabetes Wellness Program was paramount (40). Further, equal funding, regardless of community size, gave every program equal voice. In the end, relationships were everything (13,14,26–30,33,34,40).TFP data did not include aggregated health measures for individual participants (eg, weight change over time) because of funding restrictions and the focus on environment and community. Future TFPs would benefit from tracking changes in individual health outcomes across communities. Collecting local health data may be challenging, however, because of the sensitivity of personal health information.

Tribal nations are particularly cautious about sharing personal health data because of their experiences with data misuse (40,43). This history underscores the critical importance of a tribally driven participatory approach (41), where tribes steer the agenda in partnership with the funding entity to develop the program, choose local and aggregate evaluation measures, and select outcomes.Population sizes and geography varied widely among participating communities.

TFP partners used intervention combinations designed for local conditions that could not be directly compared across sites. Environmental factors also made it difficult to compare certain interventions, such as gardening, because some communities had longer growing seasons than others.We did not conduct bivariate analyses of the relationships between interventions and outcomes (eg, gardening activities and health policy changes). The project was not designed to imply such causal relationships.It is methodologically challenging to distinguish effects of a particular program when multiple agencies work together.

However, working collaboratively makes any single program, and subsequent community infrastructure, stronger.The TFP addressed physical activity, social support, and healthy diet, factors associated with individual and community health. Partners developed local programs, framed in local cultural, historical, and environmental contexts, which included social determinants of health. Activities incorporated traditional ecological knowledge and western science, illustrating the integral relationship of traditional foods with community history, culture, and health.

The TFP demonstrated that tribally driven programs, guided by traditional knowledge, can facilitate access to traditional foods as part of community health interventions to address chronic disease.“Traditional ways of knowing” have, for generations, linked physical and spiritual health to traditional foods (9,25–30,34,44). The concept is far from new.

What is new is the burgeoning food sovereignty movement that reclaims traditional foods in relation to tribal sovereignty, food security and, in this instance, public health. Traditional foods have become, once again, a way to talk about health.AcknowledgmentsSeventeen tribal partners were the cornerstone of the Traditional Foods Project (2008–2014).

They are part of the indigenous food sovereignty movement sweeping the globe.