Traditional Food Practices, Attitudes, and Beliefs in Urban Alaska Native Women Receiving WIC Assistance

Abstract

Objective:

To identify practices, attitudes, and beliefs associated with intake of traditional foods among Alaska Native women

Design:

Cross-sectional study that measured traditional food intake; participation in food sharing networks; presence of a hunter or fisherman in the home; the preference, healthfulness, and economic value of traditional foods; and financial barriers to obtaining these foods.

Participants:

A purposive sample of 71 low-income Alaska Native women receiving WIC (Special Supplemental Nutrition Program for Women, Infants, and Children) assistance in Anchorage, Alaska

Analysis:

Bivariate and multivariate regression analyses

Results:

Traditional foods contributed 4% of total daily calories. Given a choice, 63% of participants indicated that they would prefer that half or more of the foods that they eat were traditional (i.e. not store bought). The majority of participants (64%) believe that traditional foods are healthier than store bought foods. Of all participants, 72% rely on food sharing networks for their traditional foods; only 21% acquire traditional foods themselves. Participants who ate more traditional foods preferred traditional foods(B=.011 P = .02).

Implications for Research and Practice:

Traditional food intake is low, which may negatively impact food security, diet quality, and overall health. Findings suggests that Alaska Native women living in an urban setting would prefer to consume more but are unable to do so. Future research should examine the effect of enhancing social networks and providing food policy support on traditional food intake.

Introduction

Traditional foods, which include land and marine mammals, fish and other seafood, and plants and berries, are essential to the health, well-being, and food security of Alaska Native peoples.^1–3 People who consume more traditional foods have higher intakes of a number of important nutrients^1–5 and have higher overall diet quality.^2,6 Practices associated with hunting, fishing, and gathering of traditional foods also provide benefits beyond nutrition for Alaska Native peoples⁷, including promoting psychological and psychosocial health. These practices contribute to people’s sense of personal and cultural identity, to their practice and maintenance of traditions, and provide a basis for shared social activity and cohesion.^8–15 Some elders state that traditional foods are the manifestation between the spiritual and cultural ties of individuals, the community, and the land.¹⁶ Many Alaska Native peoples derive self-worth both individually and collectively from traditions associated with these foods and practices.^13,17–18

Traditional foods also support livelihood and social prosperity.^10,12,19 Alaska Native peoples have relied on a diverse portfolio of traditional food options that confer resilience during times of stress:^20–22 that is, if one or more important fish or game species became scarce in the short-term, they had numerous alternatives on which to rely. Additionally, traditional foods were often important for sharing, trade, and ritual,²³ and the hunting and fishing practices themselves were an essential platform for education and cultural pedagogy.²⁴ For these and other reasons, traditional foods today represent an important stage from which Alaska Native peoples are revitalizing culture and mounting resistance and adaptation to such global challenges as rapid societal and climate change.^10,25

Despite the many reasons that traditional foods are of great importance to Alaska Native peoples, consumption today is notably lower than even 30 years ago.^19,26–27 Intake of traditional foods has been estimated in a number of studies, the majority of which have been conducted in rural Alaska Native communities.²⁸ As of the early 2000s, research showed that on average, rural Alaska Native people consumed between 15 and 22% of their diet from traditional food.^1–2,29 This estimate varies by age, whereby older people typically consume more traditional foods than younger people,^2,29 and geographic location, whereby the intake in coastal villages is typically higher than in interior villages.³⁰ There is little information about traditional food intake in urban communities, where today more than half of the state’s Alaska Native people live,³¹ although some urban Alaska Native peoples still actively seek out and consume these foods.^32–34 Data from the Alaska Department of Fish and Game estimates that 23 pounds of traditional foods are harvested per person annually in urban areas, nearly 93% less than those living in rural areas,³⁵ suggesting that traditional food intake among Alaska Native people in urban areas is likely low.

Low-income Alaska Native women are particularly vulnerable to food insecurity and poor diet quality.^36–40 Vulnerability may be even higher among low-income Alaska Native women living in urban areas, where availability and access to traditional foods may be limited.^32,34,41 Some research has shown that access to traditional foods bolsters food security for low-income people in urban areas.⁴² The objective of the study was to examine factors associated with intake of traditional foods among low-income urban Alaska Native women receiving WIC assistance.

Methods

Study Design.

Participants were recruited from two WIC offices in an urban center in Alaska between September 2014 and June 2015. Inclusion criteria included participation in the WIC food assistance program, self-identification as Alaska Native, being 18 years or older, and not pregnant or breastfeeding. Interviews were conducted on site by the first author and a research assistant and took approximately one hour to complete. Participants completed two 24-hour dietary recalls, a traditional food frequency questionnaire (FFQ), and a survey that assessed practices, attitudes, and beliefs around traditional foods.

Ethical Approval of Human Subjects and Consent.

The research was approved by the University of Alaska Fairbanks and the Alaska Area Institutional Review Boards. Concept approval was obtained from Southcentral Foundation, and the study was reviewed and approved by the Alaska Native Tribal Health Consortium. Participants received prepaid gift cards to a grocery store as compensation for completing all surveys.

Demographics.

Sociodemographic characteristics including participants’ age, marital status, education, income, and years lived in a rural Alaska Native community were assessed (Table 1).

Table 1.

Socioeconomic and Lifestyle Characteristics of Participants (n=73)

Characteristic	Number	Percent
Age
18–29 years	33	45%
30–39 years	31	43%
40+ years	9	12%
Marital Status
Married	16	22%
Divorced/Separated	8	11%
Single	45	62%
Other	4	6%
Education
Less than 12 years	16	22%
High school graduate or GED	31	43%
Some college	9	13%
Technical training or Associates	16	22%
Bachelor’s degree	1	1%
Annual Income
Less than $10,000	34	47%
$10,000–24,999	16	22%
$25,000–44,999	9	12%
$45,000–64,999	3	4%
Don’t know or refused	11	15%
Years lived in rural AK community
Less than one year	10	14%
1–5 years	9	12%
6–10 years	7	10%
11–15 years	6	8%
16+ years	25	34%
Unknown	16	22%
Follow a traditional way of life
A lot	8	11%
Some	51	70%
Not at all	13	18%
Don’t know	1	1%
Follow a Western way of life
A lot	45	62%
Some	26	36%
Not at all	2	3%
	Range	Average
Dietary Intake	965–3405 kcals/day	1950 kcals
Traditional Food Intake	0% - 15%	4%

Dietary Assessment.

Diet was assessed using two interviewer administered 24-hour dietary recalls and a traditional food FFQ. Diet data were collected from each participant by certified interviewers using a computer assisted 24-hour dietary recall that uses a multiple-pass approach built into the software to minimize recall bias²⁴. The first 24-hour recall was collected in person. The second was collected over the phone within one week of the initial interview.

The FFQ was designed to estimate participants’ annual consumption of traditional foods. The FFQ was adapted from the Alaska Traditional Diet Survey, a validated FFQ that included Alaska Native foods that represent the most commonly consumed traditional foods in Alaska.⁴¹ Modifications to the FFQ included adding commonly consumed traditional foods that were missing such as agutuk and specific varieties of seal. Participants were asked to estimate the portion size and frequency consumed for each traditional food over the past 12 months. Because of the seasonal nature of the availability of traditional food, probes were used to determine differences in intake across months. To estimate average daily intake of traditional foods, data from the FFQ were entered into the NDS-R software and estimates were divided by 365 days. To estimate percent calories from traditional foods, average daily traditional food intake was divided by average calories consumed as estimated from the 24-hour recalls.

Traditional Food Survey.

Practices, attitudes, and beliefs about traditional foods were assessed using a newly developed traditional food survey. The survey was informed by a review of the literature examining factors that influence traditional food intake and discussions with stakeholders that represented nutrition educators and food security experts in Alaska. The survey assessed participation in food sharing networks, presence of a hunter or fisherman in the home, the preference, healthfulness, and economic value of traditional foods, and financial barriers to obtaining these foods. Previous studies have shown that these factors are related to access and intake of traditional foods.^{16,41,44–46} The survey was pilot tested with 10 individuals, including nutrition educators, WIC staff, food security experts, and the priority population. Feedback about wording, readability, and cultural appropriateness were incorporated into the final survey. The 8-item survey included closed ended questions with multiple response options (Table 2) and one open-ended question at the end of the survey.

Table 2.

Traditional Food Acquisition, Practices, Attitudes and Beliefs (n=73)

Characteristics	Number	Percent
Family or friends in rural Alaska (yes)	68	93%
Receive traditional foods from family or friends in rural Alaska (yes)	48	66%
Do you or someone in your home gather, hunt, or fish for food? (yes)	48	66%
From whom or where do you get the most traditional foods?
Shared	53	73%
Self	11	15%
Grocery store	6	8%
Barter or trade	2	3%
Hunter or fisherman	1	1%
Traditional food preference (if I had a choice I would eat)
Only traditional foods and little to no store bought foods	4	6%
Mostly traditional foods and some store bought foods	14	19%
About the same amount of traditional and store bought foods	28	38%
Mostly store bought foods and some traditional foods	24	33%
Only store bought foods and little to no traditional foods	3	4%
Which of the following do you most generally agree with?
It costs more for me to get traditional foods than store bought foods	15	21%
It costs the same for me to get traditional and store bought foods	7	10%
It costs more for me to get store bought foods than traditional foods	34	47%
Unknown if store bought or traditional foods cost more	17	23%
Which of the following do you generally believe?
Traditional foods are healthier than store bought foods	47	64%
Traditional foods and store bought foods are equally healthy	19	26%
Store bought foods are healthier than traditional foods	2	3%
Unknown if store bought or traditional foods are healthier	5	7%
How much do you agree with the statement ‘The lack of money for subsistence hunting or fishing keeps me from getting all the traditional foods I want’
Strongly agree	27	37%
Somewhat agree	17	23%
Somewhat disagree	8	11%
Strongly disagree	5	7%
Don’t know	16	22%

Statistical Analysis.

Data analysis was performed using a statistical software program (version 22, SPSS, IBM Corporation, Armonk, NY, 2013).⁴⁷ Frequencies were calculated to summarize participant demographic characteristics. Bivariate correlations were run between traditional food intake and the predictive variables to gain an increased understanding into the relationships among these variables. We conducted a single multivariate linear regression to examine the unique effects of each predictor variable that emerged as significant in the bivariate analysis on traditional food intake.

Results

The majority of participants were 18 – 39 years old (88%), were single (62%), had no college experience (64%), and had an annual income of less than $25,000 (69%). At least 42% had lived in a rural Alaska Native community for 11 years or longer. A majority of participants stated they followed a traditional way of life (characterized by activities such as food sharing, taking part in subsistence activities, and eating traditional foods)⁴⁸ either somewhat (70%) or a lot (11%). Many also stated they followed a Western way of life either somewhat (36%) or a lot (62%). On average, participants consumed 1950 calories (SD +/− 818 calories) each day and approximately 4% (SD +/− 3%) of those calories came from traditional foods (Table 1).

A majority of participants had family or friends in rural Alaska (93%) and approximately two-thirds (66%) received traditional foods from them (Table 2). Most participants indicated that they, or someone in their home, either gathered, hunted, or fished for food (66%). When asked where or from whom participants received the most traditional foods, results indicated that sharing was most common (73%) followed by harvesting foods themselves (15%). Given a choice, 63% of participants indicated that they would prefer that half or more of the foods that they eat were traditional (i.e. not store bought). Only 4% reported preference for only store bought foods with little to no traditional foods. The majority of participants (64%) believe that traditional foods are healthier than store bought foods. Nearly half of the participants (47%) indicated that it costs more for them to get store bought foods than traditional foods. Sixty percent of participants either somewhat or strongly agreed that ‘the lack of money for subsistence hunting or fishing keeps me from getting all the traditional foods I want’, while only 18% either somewhat or strongly disagreed.

An open-ended question asked participants if there were other difficulties getting or eating all the traditional foods they wanted. Among 45 responses, the most common was the extra expenses associated with obtaining traditional foods (n=10). Other responses included living in an urban area (n=8), a lack of transportation to go hunting, fishing, or gathering (n=5), the need to work or lack of time due to working (n=5), restrictions due to licenses or laws (n=4), family commitments (n=4), not knowing how to hunt or fish (n=3), a general lack of availability of traditional foods (n=2), competing with non-natives (n=2), and environmental changes (n=1).

A single multivariate linear regression was run to examine the independent contribution of predictor variables that emerged as significant in the bivariate correlations. These predictor variables included travel to a rural Alaska Native community over the past year (r=−0.40; p=0.001), preference of traditional foods (r=−0.30; p=0.02), and if traditional foods were received from family and/or friends in rural Alaska in the past year (−0.28; p=0.03). The model controlled for age, marital status, education level, and income. Results indicated that participants who ate more traditional foods were more likely to have a preference for traditional foods over store-bought foods (B = -.011, p = .02) (Table 3). The model explained 28% of the variability in traditional food intake (R² =0.28).

Table 3.

Multiple Linear Regression Predicting Traditional Food Intake

Model	β	B	SE	p-value
Age	−.068	.000	.001	.606
Marital status	−.062	−.001	.002	.636
Education level	−.142	−.003	.003	.297
Income	.272	.005	.003	.048*
Traveled to rural Alaska Native community in past year	−.281	.021	.011	.060
Preference for traditional foods	−.327	.011	.004	.017*
Receive traditional foods from family/friends in rural Alaska in past year	−.102	.006	.009	.489

β= standardized coefficient; B = unstandardized coefficient; SE = standard error

^*Significance determined at p-value </= .05

Discussion

Findings provide an estimate of traditional food intake from a sample of low income Alaska Native women living in the largest urban area in Alaska and receiving WIC assistance. Our results show that traditional food intake may be even lower than previously documented in urban areas.³⁴ This is of concern because low traditional food intake can negatively impact food security, diet quality, and overall health, and findings suggests that some urban dwelling Alaska Native women would prefer to consume more but are unable to do so.^2,12 Findings showed that women rely on food sharing networks for traditional foods and acquire little themselves. Women who preferred traditional food and who had a network in rural Alaska were more likely to consume these foods.

Traditional foods made up on average just 3.7% of the overall energy intake of the participants’ diet, which is substantially less than estimates from rural Alaskan communities that range from 15–22%.^1,2,29 To our knowledge, only three research studies have estimated intake of traditional foods in urban areas, however, it is difficult to compare findings because of differing methodologies. Nobmann and Lanier (2001) found that only 27% of participants reported consuming traditional foods at least once during the dietary recall period (up to four days), whereas the Education and Research Towards Health study found 92% of the participants had consumed traditional foods at least once in the past year.⁴⁶ Smith et al. (2008) used two different dietary intake methodologies to determine overall intake, including both a 24-hour recall and an FFQ. The author concluded that traditional food intake was being consumed regularly in 84% of urban participants.

Among the various barriers that participants noted to accessing traditional foods, lack of time, transportation, and knowledge for harvesting are somewhat unique to the urban experience. In rural Alaska, food sharing among households is widespread, and an essential aspect of household security and resilience.^49–50 This kind of sharing does not eliminate the problem of food insecurity and marginalization for some,⁵¹ but overall it makes a noteworthy impact at the community level. Thus, while food sharing networks remain critical to urban mothers’ ability to acquire traditional foods, most participants do not appear to have access to the same level of social capital through social networks as their rural counterparts. This highlights the importance of developing intervention programs that seek to enhance social networks for those who are participating in nutrition assistance programs.

Low income Alaska Native women receiving WIC assistance recognize the healthfulness of traditional foods and those who have a preference for traditional foods are more likely to consume them. This creates an opportunity for state and local nutrition education programs to tailor their messages to highlight the benefits of traditional foods. By supporting women’s positive attitudes and beliefs around traditional foods, advocates and nutrition staff may help low-income women prioritize consuming these foods. Options of support include cooking demonstrations or taste tests, distributing cookbooks, and workshops to increase awareness and competence of processing or storing traditional foods. Actual intake, however, is contingent upon policies that reduce identified barriers and improve access. Policy changes at the state and federal level will need to address foods allowable for purchase in food and nutrition assistance programs.

A possible limitation is that the FFQ may have overestimated traditional food intake. However, any impact on the study results is likely to have been minor given that intake was very low. As with all infrequently consumed foods, intake of traditional foods is difficult to measure through standard dietary assessment methods and use of a biomarker, such as the nitrogen stable isotope ratio of hair,^52–53 in combination with dietary assessments based on self-report could have better estimated intake. In addition, although we did not validate the survey questions, we did review the survey in one focus group for wording, cultural appropriateness, and flow. Although it’s possible that some participants may have misreported answers on the survey, misreporting is unlikely to have differed among those who consume more or less traditional foods and it’s therefore be unlikely to have affected our key findings. Finally, the generalizability of the study findings may be limited by the small sample size. Although only 71 women participated, low-income, Alaska Native women living in urban areas represent a hard to reach and underserved population. A larger sample size may be able to more fully address other factors that impact traditional food intake.

Implications for Research and Practice

Participants in the study continue to live a traditional way of life despite living in an urban area. The overall intake of traditional foods was lower than previously documented, with nearly 25% preferring to consume mostly or only traditional foods. Factors associated with the intake of traditional foods included traveling to a rural community within the past year and having a preference for traditional foods. Largely participants believe that traditional foods are healthier than store bought foods and a majority continue to participate in sharing networks and harvesting activities. Participants identified the two greatest barriers to consuming traditional foods as a lack of time and money to participate in hunting or fishing activities and limited access to traditional foods. Addressing the barriers associated with decreased intake of traditional foods will be difficult to resolve without strong policies in place. Expanding the Supplemental Nutrition Assistance Program to allow additional Alaska communities to purchase items for subsistence hunting and fishing³¹ and changing WIC regulations to include traditional foods for purchase are two recommendations. Working with an organization such as the Alaska Federation of Natives, whose mission is to enhance and promote the cultural, economic and political voice of the entire Alaska Native community,⁵⁴ and prioritizing traditional food access in any Alaska Food Policy Council initiatives may be other important places to begin.