Strengthening adolescents’ connection to their traditional food system improves diet quality in remote Alaska Native communities: results from the Neqa Elicarvigmun Pilot Study

Alaska Native students who participated in a school-based, multi-level intervention that emphasized the benefits of eating a traditional diet to personal, community, and environmental well-being had a higher diet quality and ate more traditional foods than students who did not participate.

Abstract

In remote Alaska Native communities, traditional foods are inextricably linked to health and food security. Degradation of the traditional food system over the past several decades has resulted in a shift in dietary patterns that have contributed to increased rates of chronic diseases and food insecurity among Alaska Native People. Interventions are needed to address this. Our objectives were to evaluate the preliminary efficacy of a school-based intervention—Neqa Elicarvigmun or the Fish-to-School Program—on diet quality, fish intake, and attitudes and beliefs around traditional foods (specifically fish) using a pre–post comparison group design with data collection occurring at three time points. Study participants were 76 middle and high school students in two remote Alaska Native communities (population <900) in southwestern Alaska. We used a participatory approach to design the school-based, multilevel intervention that included activities in the cafeteria, classroom, and community. Multilevel analyses showed that students in the experimental community showed significant improvements in diet quality compared to the comparison community (Beta = 4.57; p < .05). Fish intake, measured using the stable nitrogen isotope ratio of hair, a validated biomarker, also increased significantly in the experimental community (Beta = 0.16; p < .05). Leveraging the cultural and physical resources of the traditional food system for the Neqa Elicarvigmun program represents a strength-based approach that improves diet quality, increases adolescents’ connection to their traditional culture, and by promoting the local food system supports food security. Embedding the program into the local culture may result in faster adoption and greater sustainability of the program.

Implications.

Practice: School-based interventions can be used to reconnect Alaska Native middle and high school students to their traditional food system with benefits to their diet quality.

Policy: Policymakers who want to improve diet quality and reduce the risk of chronic diseases among Alaska Native middle and high school students should explore sustainable ways to strengthen links to the traditional food systems in schools.

Research: Future research is needed to examine the impacts of reconnecting Alaska Native middle and high school students with their traditional food system on overall well-being.

INTRODUCTION

The health of Alaska Native people is inextricably tied to their traditional food system [1]. In remote communities, traditional foods bolster diet quality, promote spiritual and physical health, and are critical to maintaining food security [2–4]. Indeed, in Alaska Native communities, conceptualization of food security goes beyond access to healthy and affordable foods. Traditional food security extends the concept of food security to encompass the rich sociocultural history of Alaska Native People and the state’s unique geography and food resources [5–7].

Historically, Alaska Native People relied on nutrient-dense traditional foods. Degradation of the traditional food system over the past several decades due to changes in climate and socioeconomic pressures, however, has resulted in a shift in dietary patterns and contributed to increased rates of obesity, diabetes, and other chronic diseases [8]. Today, shelf-stable, highly processed, and high-sugar foods (i.e., “market foods”) have replaced—to varying degrees—traditional foods. While traditional foods, the majority of which are fish [2], account for approximately 40% of energy intake among older adults, they account for less than 10% of energy intake among adolescents. Individuals consuming higher levels of traditional foods have significantly higher intakes of vitamin A, iron, protein omega-3 fatty acids, and vitamin D, the latter of which is particularly important given the lack of sunlight in Alaska for much of the year [9,10]. In addition, individuals consuming higher levels of traditional foods have a significantly more favorable cardiometabolic profile, which is attributed to the high intake of fish and marine mammals [3,11–13]. There is widespread concern that Alaska Native youth are the most vulnerable to poor health outcomes [14] because of particularly low intake of traditional foods and a lesser degree of enculturation, defined as the extent to which one is actively engaged in living out one’s traditional cultural norms and values [2,9,15].

To date, studies documenting disparities in chronic disease morbidity and mortality among American Indian and Alaska Native (AIAN) far outnumber health promotion interventions addressing those disparities. Indeed, despite living in one of the highest income countries in the world, AIAN people have among the worst health outcomes and lowest life expectancy compared to any other ethnic group [16–18]. There have been a handful of rigorously designed interventions among American Indian people that have had a positive impact on obesity rates in 2–5 year olds [19] and elementary students [20,21] and diabetes in high school students [22]. In addition, a number of smaller, tribally driven initiatives share valuable lessons about improving dietary outcomes and attitudes toward local and traditional foods [23]. Although these studies collectively highlight the importance of a community-based approach and culturally appropriate content to enhancing the success of the intervention, they generally do not explicitly reinforce cultural connectivity, an important protective factor associated with adolescent health [24,25] and overall well-being [26].

Leveraging the resources offered by the traditional food system represents an important opportunity to improve diet quality and promote health and food security in AIAN communities. Furthermore, embedding an intervention in the local culture may lead to quicker adoption and greater sustainability of health promotion programs [27].

Farm-to-school efforts, which are implemented across North America, represent one approach to reconnect adolescents with their traditional food system and thereby promote cultural connectivity and food security. Farm-to-school programs are designed to connect school children with local agriculture by integrating locally grown foods into school cafeterias and through curricular activities to improve diet quality among children and support local food economies [28]. In recent years, AIAN communities have begun incorporating indigenous foods into their school meals programs and teaching their youth about their traditional food cultures [29]. The U.S. Department of Agriculture encourages Native communities to serve traditional foods and, in 2015, provided guidance on how traditional foods (e.g., sheep, wild rice) can be served as part of a reimbursable meal [30]. To date, no study published in the peer-reviewed literature has examined the impact of farm-to-school programs in Indigenous communities.

The purpose of this study was to evaluate the preliminary efficacy of a school-based, food systems intervention (modeled after Farm-to-School efforts) on middle and high school students’ diet quality, traditional food intake, and attitudes and beliefs in remote Yup’ik communities. With its emphasis on salmon caught and processed by Native and independently owned and operated local fish businesses, the Neqa Elicarvigmun or the Fish-to-School Program is designed to promote healthy eating habits while supporting more resilient food systems. The program builds on previous interventions in AIAN communities in two ways. First, it systematically integrates Yup’ik beliefs about how traditional foods contribute to well-being into the intervention, thereby supporting an Indigenous worldview. Second, in addition to assessing traditional outcome measures, such as diet quality, it also assesses intake of a culturally important food (i.e., fish), something that can be considered an aspect of cultural connectivity.

METHODS

Study design

Neqa Elicarvigmun is a school-based, multilevel intervention that includes activities in the cafeteria, classroom, and community that are designed to improve diet quality and increase intake of traditional foods. The preliminary efficacy of only the community and classroom components was evaluated using a pre–post comparison group design with data collection occurring at three time points: baseline, 4 months, and 9 months. The final data collection point followed the end of the 9 month intervention that was aligned with the academic year.

As with many community-based interventions, scientific rigor was balanced with community desires and practical considerations. Students in the intervention community received all components of the intervention throughout the academic year. Considering the research team’s obligation to ensure community benefits, students in the control community received the classroom lessons after the 4 month data collection point. In addition, because the school district uses a single menu created by the centralized office for all schools, cooks were unable to serve salmon in the school lunches differentially by condition and students in the control community also received the cafeteria intervention. We, therefore, examined the independent effects of the community and classroom components between baseline and the 4 month data collection point. Between the 4 month and final data collection point, we examined the independent effects of the community component and the long-term effect of the classroom component.

This study was approved by the Institutional Review Board at the University of Alaska Fairbanks and the Human Subjects Committee at the Yukon Kuskokwim Health Corporation. Parental consent and child assent were obtained from all participants included in the study.

Research setting

Neqa Elicarvigmun was tested in two rural, remote Alaska Native communities in southwestern Alaska (pop <900). This region, which is roughly the size of the state of Oregon, is the traditional homeland of about 24,000 Yup’ik people. Average per capita income in the region is approximately $11,000 and more than 35% of the population falls below the poverty line, making it one of the poorest regions in the USA. The prevalence of food insecurity in this region is 35% and can be explained in part by the geographic isolation and extreme climate. The two communities are located off the road system, which means that travel between communities occurs by bush plane year round, snow machine in the winter, and boat in the summer. Distinct from most of the USA, the food system in rural Alaska Native communities is based on a mixed subsistence-cash economy. Traditional foods, such as fish, birds, marine and land mammals, and tundra plants, are directly harvested from the natural environment, processed locally, and distributed through nonmarket channels [7]. These foods are commonly consumed and play an important role in the diets of Alaska Native People [2,9]. Market foods, such as the food served in the school cafeteria, are sourced from non-Alaskan producers and purchased through industrial-scale commercial food supply chains. Market foods must be flown into the communities on bush planes and are, therefore, typically shelf-stable, highly processed, and expensive. Food security is, therefore, dependent to a large extent on access and intake of traditional foods.

The communities were selected because they are similar with respect to population size, geographic location, and engagement with commercial and subsistence fishing. The communities belonged to the same school district but travel between them is by plane only, thereby minimizing the risk of contamination.

Participants

All middle and high school students in the two communities were eligible and invited to participate. Virtually all students are Yup’ik and participate in the school lunch program. All communities in the school district are considered low income and qualify for the community eligibility provision that provides school meals to all students free of cost.

Intervention theoretical framework

To ensure that the intervention integrated behavior change theory with a Yup’ik worldview, a participatory approach to design the Neqa Elicarvigmun program was used. Details of the formative work are discussed elsewhere [31]. Briefly, over the course of a year, researchers collaborated with a 10-member community work group to design activities that combine a Yup’ik worldview with evidence-based strategies. This was accomplished in two phases. In Phase 1, nine major themes were identified that reflect how salmon contributes to well-being in Yup’ik communities. Salmon was selected as the focus of the intervention because it is both an important traditional food and is a commercial local product that can be served in school lunches. In Phase 2, the themes were integrated into activities in the cafeteria, classroom, and community. This participatory process ensured congruence between the program and Yup’ik values and traditional knowledge, thereby addressing a major challenge to program adoption and sustainability [32,33]. In addition, the program is responsive to a guiding principle of the school district’s strategic plan that includes providing students with Yup’ik cultural and subsistence skills so that they can be contributing members of the community.

Table 1 provides examples of intervention activities and illustrates how the social cognitive theory combined with indigenous traditional knowledge provided the overarching framework for the intervention. In the cafeteria, locally caught salmon was served in the school lunches weekly. In the classroom, researchers delivered five culturally responsive, experiential lessons that highlighted the benefits of eating a traditional diet to personal, community, and environmental well-being. A series of four intergenerational community events were held that celebrated traditional foods and were designed to link school-based activities with the home and community.

Table 1.

Examples of how intervention activities were grounded in Yup’ik perceptions of how salmon influences a “good life” and constructs from the social cognitive theory^a,b

Intervention activity	Intervention objective (social cognitive theory constructs)	Primary ways the activity supports Yup’ik people’s beliefs about how salmon supports a good life
Serve salmon in the school lunches, weekly	Increase opportunities to eat fish (behavioral capability)	Students learn that purchasing fish from a community-based, local processor creates a new market for the processor and supports local livelihoods. Students appreciate the contribution of community members to their lunch and feel socially connected. By adapting local salmon recipes for the cafeteria menu, students feel pride that the school values community salmon and salmon recipes.
Classroom lessons that demonstrate environmental, nutritional, and economic impacts by comparing of local and nonlocal food supply chains through classroom lessons and a board game	Increase students’ ability to choose foods that benefit their health, correspond with community values, and protect the earth (self-efficacy and outcome expectations)	Students feel pride as they learn about the benefits of their traditional foods. Students learn about how their food choices impact the environment thereby demonstrating their connection to the environment.
Communitywide, intergenerational Iron Chef Contest	Increase students’ confidence in their ability to prepare traditional foods for a community feast (self-efficacy, observational learning, and collective efficacy)	By working together in multigenerational teams, the contest supports family time. Students learn traditional skills by preparing salmon dishes. Students understand the process and hard work required to prepare a meal. Students feel pride in their accomplishments and new skills. By sharing their dishes with the community, students learn about reciprocity.

^aTable was adapted from Nu 2017 [31].

^bWords in bold represent the nine themes identified.

Measures

Diet was assessed in two ways: using a single 24 hr recall and a validated biomarker of fish and marine mammal intake, the nitrogen stable isotope ratio of hair [34,35].

Self-reported diet

Servings of fish and diet quality were assessed using a single 24 hour recall that was administered by a certified interviewer using the computer-assisted Nutrition Data System for Research (NDS-R) developed at the University of Minnesota (version 2012). Participants were asked to recall all food and beverages consumed over a 24 hr period using a multiple-pass approach that is built into the software to minimize recall bias. Food and nutrient calculations were performed using the NDS-R Food and Nutrient Database [36]. Many Alaska Native foods are found in the database. Foods missing from the database were either substituted for similar food items when appropriate or the food was added to the database by request.

Diet quality was assessed by calculating the Healthy Eating Index-2010 score from the NDS-R output files, using the methods described by the University of Minnesota. The 12 components of the score include total vegetables, total fruit, whole fruit, greens and beans, whole grains, dairy, total protein foods, seafood and plant proteins, fatty acids, refined grains, sodium, and empty calories. Each component is differentially weighted and the highest possible score is 100, with lower scores indicating poorer diet quality [37,38].

Biomarker measurement

Fish and marine mammal intake was assessed using the nitrogen stable isotope ratio (¹⁵N/¹⁴N, expressed as the δ¹⁵N value as described below). This measure has been validated against other marine food biomarkers (Eicosapentaenoic Acid and Docosahexaenoic Acid) [24,28], as well as self-reported marine food intake [39], and is strongly correlated between hair, red blood cells, and plasma [30]. A sample of ~50 hairs was cut from below the external occipital protuberance, taped with the distal (cut) end marked, and stored in plastic bags for analysis. A 2 mm section of the distal end of each hair sample was cleaned, processed, and analyzed at the Alaska Stable Isotope Facility by continuous-flow isotope ratio mass spectrometry as described elsewhere [34]. Nitrogen stable isotope ratios are expressed as δ values in permil (‰) abundance of heavy isotope relative to a universal standard, atmospheric nitrogen (AN):

δ ¹⁵N = (¹⁵N/¹⁴N_sample – ¹⁵N/¹⁴N_AN)/(¹⁵N/¹⁴N_AN) × 1000‰.

To assess analytical precision, a laboratory standard was analyzed for every 10 samples; the standard deviation of these analyses were within 0.2‰.

Attitudes and beliefs

Enculturation was assessed with two questions that were based on focus groups and interviews to understand Yup’ik peoples’ conceptualizations of health and wellness [40,41] and were: “How often do you follow a Yup’ik way of life?” and “How often do you follow an American/white way of life?” Responses included “a lot,” “some,” and “not at all.”

In addition, attitudes and beliefs around traditional foods, focusing on salmon, were assessed with a 15-item survey that was used to assess the following four domains: perceptions of the benefits of salmon; perceptions of the impact of eating Yup’ik foods; attitudes toward the impact of food choice on the environment; and attitudes toward the importance of having skills to harvest, process, and prepare salmon. The survey was pretested and Cronbach’s alpha was used to assess internal consistency. Cronbach’s alpha was greater than 0.75 for all domains, which is indicative of acceptable internal consistency.

Data analysis

Descriptive statistics were examined for the total sample and by intervention condition. The study sample was limited to students who participated in all three rounds of data collection (N = 76). Attrition analyses indicated that students who did and did not participate in all three rounds were similar with respect to all study variables except age. Students who did not participate were significantly older (15.4 vs. 14.1 years, p = .01). The attrition rate was 26.9% for the intervention condition and 25.5% for the control condition (Χ² = .03, NS). Multilevel analyses were conducted in HLM version 7.0 software (Skokie, Illinois) to test study hypotheses, while adjusting for variance attributable to repeated observations nested within individuals. There were 228 Level 1 observations (i.e., three repeated observations per individual) with 76 individuals at Level 2. Initial models included time as a Level 1 predictor and intervention condition as a Level 2 predictor, with a cross-level intervention condition × time interaction term. Age, sex, and traditional and white way of life were included as Level 2 covariates. A significant intervention condition × time interaction indicated a between-condition difference in the outcome of interest (e.g., diet quality) over time. If the interaction term was not significant, it was dropped from the model, and the model was run again to examine the main effect of time on each outcome variable.

RESULTS

Participants were, on average, 14.1 years old (Table 2). Virtually all participants (99%) identified as Yup’ik and 31.5% reported following a Yup’ik way of life a lot. Participants in the two study conditions were similar with respect to most study variables at baseline. Participants in the intervention condition at baseline, however, consumed more servings of fish in the past 24 hr based on 24 hr recall data (1.3 vs. 0.3, p < .05), while participants in the comparison condition had higher hair δ¹⁵N values, indicating greater consumption of fish and marine mammals over the past several weeks (8.6‰ vs. 8.2‰, p < .05).

Table 2.

Baseline characteristics of 76 Yup’ik middle and high school students

Variable	Total sample (N = 76)	Intervention community (n = 38)	Comparison community (n = 38)
Age (years)	14.1 (1.8)	13.9 (1.8)	14.3 (1.8)
Female (%)	55	47	63
Any fish (%)	21.0	26.3	15.8
Total fish servings	0.8 (2.0)	1.3 (2.6)	0.3 (0.9)*
Hair δ15N value (‰)	8.4 (0.6)	8.2 (0.6)	8.6 (0.6)*
Diet quality (HEI)a	50.0 (13.6)	48.5 (14.8)	51.6 (12.3)
Benefits of salmonb	3.0 (0.5)	2.9 (0.6)	3.1 (0.4)
Importance of salmon skillsc	3.2 (0.6)	3.1 (0.6)	3.3 (0.6)
Benefits of Yup’ik foodsb	3.0 (0.6)	2.9 (0.7)	3.1 (0.5)
Impact of food choice on environmentc	2.2 (0.7)	2.3 (0.8)	2.1 (0.6)
Traditional way of life
A lot (%)	31.5	33.3	29.7
Somewhat (%)	65.8	66.7	64.7
Not at all (%)	2.7	0.0	5.4
White way of life
A lot (%)	24.3	10.8	39.4*
Somewhat (%)	60.0	67.6	51.5*
Not at all (%)	15.7	21.6	9.1*

Values are mean (standard deviation) or percent.

HEI Healthy Eating Index.

^aDiet quality (HEI-2010) is measured on a scale of 0–100 (a higher value is indicative of higher diet quality).

^bResponse options ranged from 1 (strongly disagree) to 5 (strongly agree); higher scores indicate more favorable attitude.

^cResponse options ranged from 1 (not at all important) to 4 (very important); higher scores indicate more favorable attitude.

*p < .05.

Multilevel logistic regression analyses were conducted for any servings of fish because of the variables binary (0/1) distribution, and multilevel Poisson regression analyses were conducted for total fish servings due to its skewed, zero-inflated distribution. As shown in Table 3, the intervention condition × time term was not significant for either of these outcomes and was, therefore, dropped from the regression models. Subsequent analyses indicated that any and total servings of fish increased significantly in both conditions. Notably, the percentage of youth in the intervention condition who reported any fish servings increased from 25% to 48% over the study period, while increasing from 16% to 32% among youth in the comparison condition. A higher likelihood of fish servings was observed in regression analyses for the intervention condition relative to the comparison condition. None of the other individual level variables were associated with any or total fish servings.

Table 3.

Results of multilevel nonlinear regression analyses for fish servings, odds or event rate ratio among 76 Yup’ik middle and high school students (95% confidence interval [CI])

Variable	Any fish servingsa	Total fish servingsb
Individual level (N = 76)
Age	1.04 (0.89, 1.21)	1.04 (0.89, 1.23)
Female	0.85 (0.49, 1.50)	0.85 (0.46, 1.57)
Traditional way of life	0.97 (0.94, 1.00)	0.98 (0.94, 1.01)
White way of life	1.01 (1.00, 1.02)	1.01 (1.00, 1.03)
Intervention condition	1.85 (1.00, 3.45)*	2.22 (1.12, 4.35)*
Observation level (N = 228)
Time	1.64 (1.12, 2.41)*	1.45 (1.04, 2.03)*
Cross level
Intv. condition × time	NS	NS

^aOdds ratio (95% CI) from logistic regression.

^bEvent rate ratio (95% CI) from Poisson regression.

*p < .05.

Results of multilevel linear regression analyses are provided in Table 4. Significant intervention condition × time interactions were observed for hair δ¹⁵N values and diet quality, though the interaction term for hair δ¹⁵N values was only marginally significant (p = .05). The positive beta coefficients for the interaction terms indicate a relatively higher hair δ¹⁵N values and better diet quality among participants in the comparison condition relative to the intervention condition. The nature of the interaction for diet quality indicated that the Neqa Elicarvigmun program improved overall diet quality among participants in the intervention community after time 2, while diet quality declined among participants in the comparison community over the study period.

Table 4.

Results of multilevel linear regression analyses, beta (standard error)

Variable	Hair δ15N value	Diet quality	Benefits of salmon	Importance of salmon skills	Benefits of Yup’ik foods	Impact of food choice on environment
Individual level (N = 76)
Age	0.03 (0.03)	−0.25 (0.51)	0.04 (0.04)	0.03 (0.05)	0.03 (0.04)	0.07 (0.03)*
Female	0.09 (0.11)	−0.88 (1.84)	0.17 (0.12)	0.08 (0.14)	0.15 (0.14)	−0.01 (0.13)
Traditional way of life	−0.0006 (0.003)	0.001 (0.14)	−0.002 (0.002)	0.01 (0.004)*	0.005 (0.005)	0.0006 (0.008)
White way of life	0.002 (0.003)	0.05 (0.08)	0.003 (0.002)	−0.004 (0.005)	0.002 (0.004)	−0.003 (0.005)
Experimental condition	0.32 (0.21)	8.15 (4.48)	−0.02 (0.13)	0.10 (0.15)	0.03 (0.14)	−0.15 (0.12)
Observation level (N = 228)
Time	0.25 (0.11)*	5.02 (3.49)	0.42 (0.03)**	0.47 (0.04)**	0.43 (0.04)**	0.53 (0.05)**
Cross level
Exp. condition × time	0.16 (0.08)*	4.57 (1.99)*	NS	NS	NS	NS

*p < .05; **p < .01.

The intervention condition × time terms were not significant in regression models for attitudinal outcome variables in Table 4. In subsequent regression analyses, time was positively associated with all of the attitudinal outcome variables, indicating an increase in beliefs regarding the benefits of salmon and Yup’ik food, the importance of having skills to harvest and store salmon, and the importance of food choice on the environment. Results also indicated a positive association between having a traditional way of life and beliefs regarding the importance of having skills to harvest and store salmon.

DISCUSSION

The results of the Neqa Elicarvigmun Pilot Study demonstrate the preliminary efficacy of using a culturally based, food systems intervention to improve diet quality and increase intake of traditional foods among middle and high school students in remote Alaska Native communities. Overall, the rate of improvement in diet quality was 4.57 times greater in the intervention group relative to the comparison group, although the overall improvement was modest. The rate of increase in fish intake, measured using the biomarker, was 0.16 times greater in the intervention relative to the comparison group. The positive impact on dietary behavior is consistent with Farm-to-School efforts that show an increase in fruit and vegetable intake among students [42,43]. While a number of studies have focused on improving diet quality in AIAN populations in the USA, to our knowledge, this is the first study to assess intake of traditional foods, an estimate of cultural connectedness, as a primary outcome measure.

Despite an initial decline in fish intake and diet quality, both increased modestly after time point 2 in the intervention group while continuing to decline in the comparison group. Diet quality is a function of the availability of high quality foods, arguably the most important of which is fish in remote Alaska Native communities [2]. The observed decline may represent a combination of a seasonal decline in fish availability (salmon fishing peaks in late July) and a shift in students consuming the majority of calories at home over the summer break to consuming them at school where fish is less available. The initial decline in fish intake suggests that serving fish in the school lunch once per week may not be sufficient to counteract the seasonal decline. The subsequent increase in the intervention group, however, suggests that the program may be having an impact on what students choose to eat at home. In addition, although improvements were modest, the intervention appears to counteract an otherwise substantial decline in fish intake and diet quality among students in the comparison group.

It is not surprising that data from the 24 hr recalls does not show the same significant increase in fish intake as the fish biomarker. The apparent discrepancy may be explained by the fact that the fish biomarker provides a superior estimate of habitual intake of fish than the 24 hr recall. While a single 24 hr recall is well suited for estimating the average diet of a population, and the only way to estimate overall diet quality, it is more subject to error introduced by day-to-day dietary variability [44]. The hair nitrogen isotope ratio integrates fish and marine mammal intake over several weeks; thus, it provides a stable, unbiased estimate of an individual’s usual intake [39]. This study is the first to use the hair nitrogen isotope ratio to evaluate an intervention targeting fish and marine mammal intake, and the results suggest that it is an effective, noninvasive tool that is sensitive to dietary change over the intervention timeframe. In addition, it represents an important growth in intervention studies using biomarkers to assess dietary outcomes [45].

That attitudes and beliefs around traditional foods, including fish, improved in both communities is consistent with evidence showing that it takes more effort to shift behavior than it does attitudes and beliefs [46]. Simply participating in the study may have served to improve attitudes, which is consistent with the Hawthorne effect. It is also possible that exposure to the fish in the school lunch (which increases social norms and acceptance of this food) might have contributed to the increase in attitudes for both communities. Nevertheless, our finding that behavior (i.e., diet quality and fish intake) improved significantly more in the intervention group is consistent with Liquori et al. who demonstrated the added impact of nutrition education over the change to the school lunch environment [47].

The following limitations should be considered in the interpretation of the study findings. First, a single 24 hr recall is subject to error because of day-to-day variability in diet [44]. Use of the fish biomarker may provide a more stable estimate of fish. Second, given the differences in fish intake at baseline between the intervention and control communities, it is possible some of the changes observed in fish intake over time were not attributable to the intervention. Finally, a number of constraints prevented examining the independent effects of providing salmon in the school lunches. In addition, by providing the comparison community with lessons, the time frame by which the impact of the lessons could be examined was shortened by 4 months. Nevertheless, study results were promising and provide preliminary evidence of the program’s effectiveness.

Despite some general similarities, communities within the Yukon Kuskokwim River Delta region are unique with respect to a number of factors and it is unknown whether study findings are generalizable to other communities. In addition, approximately 50% of Alaska Native people live in urban settings where the disconnect between adolescents and the traditional food system is expected to be even greater. Nonetheless, even in urban areas there is still a value placed on traditional foods and they are viewed as an essential connection to and representation of the traditional culture and central to the health and food security of Alaska Native people.

Results suggest that leveraging the cultural and physical resources of the traditional food system for the Neqa Elicarvigmun program represents a strength-based approach that builds on community assets and may improve diet quality and increase adolescents’ connection to their traditional culture. In addition, the program attempts to support the United Nations Declaration on the Rights of Indigenous Peoples that protects Indigenous peoples’ right to self-determination [48], particularly with respect to food security and sovereignty. The Neqa Elicarvigmun program has the potential to address interconnected public health concerns in populations undergoing a nutrition transition. Future research should explore how the program supports additional components of overall well-being, which reflect an Indigenous worldview.

Translational implications

Further research is warranted to explore the transferability of the program to other American Indian and Alaska Native communities, both rural and urban. While the specific focus on fish may be unique to the Yup’ik food system, the process of developing an intervention that serves to increase Indigenous youths’ connection to their culture through the traditional food system is transferrable. Successful adaptation and implementation in other Indigenous communities will necessarily require a participatory approach to align the intervention with local values and to adequately address contextual factors that may either support or impede program adoption [49]. Evaluation efforts should incorporate the RE-AIM framework and use a mixed-methods approach to systematically measure the public impact of programming. In particular, the extent to which local resources and infrastructure are committed for implementation of Neqa Elicarvigmun and the willingness and ability of stakeholders (e.g., school districts, teachers, community members) to adopt the program should be examined [50].

Policy

Policymakers, including school officials, who want to improve food security and diet quality in Alaska Native communities must understand the important role that traditional foods play in promoting well-being. Policies that require schools to adopt programs and curricula that meet standards for culturally responsive schools can help promote the cultural and physical well-being of students.

Practice

Codeveloping an intervention with community members using a strength-based approach may result in faster adoption of the program and greater sustainability. In addition, schools can serve as a key venue for health promotion programs to reach underserved students in remote communities.

Research

Programs that reconnect Indigenous youth with their traditional food system may be used to promote food security and improve diet quality.

Compliance with Ethical Standards

Funding: This research would not have been possible without support from the Agriculture and Food Research Initiative Competitive Grant no. 2011-69004-30218 from the USDA National Institute of Food and Agriculture (PI: Bersamin) and The National Institute of General Medical Sciences Grant No. P30GM10332505 (PI: Boyer).

Conflicts of Interest: All authors declare that they have no conflicts of interest.

Authors’ Contributions: A.B. took the lead on writing the article. A.B., B.I., and J.N. conceptualized the overall study design, measurement plan and data collection procedures. M.J.P. led the statistical analysis and wrote the results section. D.M.O. took the lead on the collection and analysis of the isotope data. All authors edited and contributed to the writing of the article. All authors approved the final version of the article.

Ethical Approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This study was approved by the Institutional Review Board at the University of Alaska Fairbanks and the Human Subjects Committee at the Yukon Kuskokwim Health Corporation. This article does not contain any studies with animals performed by any of the authors.

Informed Consent: Informed parental consent and child assent was obtained from all individual participants included in the study.