HMLTN. HMLTN RM RM 214 valDietary survey of Hopi Native American elementary students AMY C. BROWN, PhD, RD; BARRETT BRENTON, PhD Objective The purpose of this study was to evaluate the diets of $6 Hopi fith-and sixth-grade students on the Hopi reserva- tion in Arizona Design Dietary food intakes were collected using a 3-day dietary record and were analyzed with a computer software program to obtain infomation on the intake of eneray, protein, carbohydrate, total fat, saturated ft, cholesterol, ber, 10 vitamins, and six minerals. Setting The survey was conducted during the health class or homeroom period in the elementary schools located onthe Hop reservation in Arizona Subjects The survey population consisted of 96 ith-and sixth-grade Hop elementary seudents attending the ive Schools on the Hopi reservation. Main Outcome Before cata collection we hypothesized the average diet of Hopi elementary students didnot meet dietary recommendations (eg, Dietary Goals, Recommended Dietary Allowances (RDAs), and/or National Cancer Institute recom- ‘mendations. Statistics The nutrient analyses and demographic data were analyzed for frequencies and percentages of responses Descriptive and inferential statistics were ealeulated where appropriate. Fesults Results ofthe analysis vealed a mean daily dietary intake of 2,123 keal consisting of 35% fat (84 g), 48% carbohy- drate (261 g; 88% from sugar), and 17% protein (89g), with 27g saturated fat, 442 mg cholesterol, 11g ber, and 2477 mg sodium, Atleast 97% oF 100% of the RDA was met forall analyzed vitamins and minerals except for vitamin D (146 IU; 37% RDA), calcium (874 mg; 82% RDA), and zine (12 mg; 94% RDA), Conclusions Given the health problems relatively new to ‘Native Americans, such as diabetes, obesity, liver cirrhosis, hypertension, fetal alcohol syndrome, and increasing rates of heart disease andl cancer, dietary mosifiation may benefit them in their adult ite. Modifieatons to meet current recom: mended dietary doals would include redcing fat to below 309% of energy; cholestera oles than 250 me; sodium to lower levels but not below 500 malday; andl decreasing refined sugars. Carbohydrates would be increased to at least 58% energy; ber to 20 0 30g and vt D, calcium, and, possibly, zinc to RDA levels. J Am Diet Assoc. 1994,94: brrsee ‘Anasazi He-Su’sinom) tradition who settled in northeast Arizonaas early as 100 AD (1). Themajority of Hopis, more than 7,000, reside on the Hopi reservation located in the northeast corner of Arizona (Figure 1, Several health conditions afflicting Native Americans, such as diabetes, obesity, andlivercirthoss, are related tonutrition 23). Rates of heart disease and cancer are inereasing amon Native ‘Americans, but remain lower than rates in the general US popu- lation (4), Poor nutrition also contributesto the high ineidence of hypertension, fetal aleohol syndrome, and dental cares (2). Native Americans are alarmed by the drastic inerease in chronic «diseases, because these conditionsare relatively new tothemand few traditional medicines or approaches exist to prevent or treat them. Knowledge ofthe dietary patterns of Native Americansand, related populations is limited (5-12), especially among the Hopi People (1). Infact, Native Americansare notincludedin any ofthe national nutrition monitoring systems. Nutrition surveillance of ‘Native Americans residing on reservations is almost nonexistent. because they are not included in rst and second National Health and Nutrition Examination surveys (NHANES Tand I} and will not be included in NHANES I Native Americans appear to be more vulnerable to health conditions related to overnutrtion than the general US popula- tion, especialy diabetes, obesity, heart disease, hypertension, liver cirthosis, and dental caries. A search ofthe literature docu ‘menting a higher rate of these conditions in Native American populations did not contain many references specific tothe Hopi people because relatively few studies have been conducted; however, the health implications are enormous. HEALTH CONDITIONS AFFECTING NATIVE AMERICANS Diabetes Before the 1940s, diabetes was either rare in all tribes or was simply not reported, but now it is the second most common diagnosis for Native Americans admitted to the hospital (13,14), Pima Indians are reported tohave thehighest known diabetes rate for any population in the world (15-17). One of every two Pimas over the age of 35 years has diabetes, compared with one in every 26 persons in the general US population. Seven often adults from the Tohono O'Oddham tribe in Arizona have the disease, About one in three Cherokees, Zunis, and Senecas and one in four T he Hopi are a Native American group of the Kayenta A. G, Brown (corresponding author) is an assistant professor in the Department of Health, Physical Education, and Nutrition at Northern Arizona University, Flagstaff, AZ 86011. B. Brenton is a member of the Department of, Anthropology at the University of Massachusetts, Amherst, MA 01003, For this article, copyright has been retained by the Hopi ‘Tribe. Permission to reprint should be directed to the author. JOURNAL OP THE AMBRICAN DIR'TRTIC ASSOCIATION / 517NATIVE AMERICAN RESERVATIONS ned sro nae Imes eet eeeGe0) Apaches, Pawnees, and Palutes develop diabetes by the age of 35, ‘years (18). Complications from diabetes include blindness, ampu- tation, and kidney failure. Between 1978and 1987,more than half (66%), of 377 lower-extremity amputations performed at Navajo area Indian Health Service (THS) facilities were associated with diabetes (18). The cost of treating diabetes-related kidney dis- ‘ease in one IHS region alone was $2.6 millon in 1984 (19). ‘Studies among Native Americanshave shown that theirrates of ‘gestational diabetes are among the highest in the world. The rate ofgestational diabetesis 2% 106% for thegeneral population (20), but approximately 10% among the Pimas (21). The rate of gestational diabetes is approximately 6.1% among Yupik Eskimos (23), 4.6% among Navalos (24), and 3.2% among northern Chey- enne (25). The IHS has emphasized the aggressive identification ‘and treatment ofall women with gestatioral diabetes, especially improved dietary management. Risk factors to the fetus include birth defects, premature birth, lungdisease,and fetal macrosomia Ge, excessively large baby) (22). The infant mortality rate asso- ciated with gestational diabetes is 0.9% for the general US popu- lation compared with 8.8% among Pimas (19). Obesity ‘National Center for Health Statistics data indicate that in 1981 nearly 60% of Arizona Pimas aged 20 to 34 years had a body mass indexexceeding the 90th percentile, compared with only 10% for the general US population (19). The rates of overweight Navajo men and women are 42.1% and 54.7% respectively, compared 518 / MAY 1994 VOLUME 94 NUMBER 5 04000 a0 FIG 1. The Hopi Native “Americans occupy the ‘sixth most-populated ‘reservation in the United States. Itis located in the northeast ‘comer of Arizona. (See No. 6.) 2000 16000 a rae zd with 22.8% and 29,5% nationwide (18). Obesity is anotable risk factor for non-insulin-dependent diabetes melitus. Heart Disease ‘Therate ofheart attacks in Navajomen hasdoubled in the past 10 years, whereas the heart disease rate nationwide has actually declined. This increase in heart disease may be related to the alarming increase in diabetes, which was rarely seen in Navajos before 1047, becauseapproximately 50% of myocardial infarctions among Navajos are suffered by persons with diabetes (18), Hypertension ‘Today, about half of all Navajos with diabetes have hypertension, compared with approximately 20% in the 1960s (18). Liver Cirrhosis Southwest Native Americans have higher rates of liver cirrhosis, than whites (1). Dental Caries "Native American children suffer rates of dental decay that are five times that of the average child in the United States (2) Focusing on Diet ‘The higher risk in Native Americans for these major conditions could possibly be related to diet, genetic background, physical ‘activity, or other factors. The purpose of this study was to focus‘on the dietary aspect alone by analyzing the food and beverage intake of Hopi fifth and sixth graders to determine the intake of ‘energy, protein, carbohydrate, total fat, saturated ft, cholesterol, ‘ber, 10 vitamins, and six minerals. The results will be used to suggest dietary recommendations to improve the current diet of Hopi students. METHODS ‘Sample A survey was conducted of 166 of approximately 200 fifth- and sixth-arade Hopi elementary students attending the five schools ‘on the Hopi reservation during October 1990 and February 1991, ‘The majority of the schools were under Bureau of Indian Affairs or Bureau of Indian Affairs contract jurisdiction. The five schools were the Hopi Day School in Kykotsmovi, Jeddito Public School, Hotevilla Bacavi School, Polaoea Day School, and Second Mesa Day School. Moenkopi Day School, which is near Tuba City, was not included in the study because permission was not obtained. ‘The Hopi villages represented were Bacavi, Hano (Tewa), Hotevilla, Kykotsmovi, Mishongnovi, Old Oraibi, Polact Sichomovi, Sipaulovi, and Walp. The following Hopi clans were represented: Bear, Blue Bird, Coyote, Crow, Deer, Eagle, Fire, Greasewood, Kachina, Parrot, Rabbit, RoadRunner, Sand, Snake, Spider, Snow, Sun, and Water and Corn. Instrument ‘The 3-day dietary record was modified and pilot tested for comprehension at the fifth- and sixth-grade levels. A separate sheet picturing average serving sizes (eg, a cup, a 3+oz serving) ‘was attached to the 3-day dietary record, We made minor alter- ations to clarify choices before the instrument was given to the students. Procedure ‘The Northem Arizona University Institutional Review Board reviewed and approved the project for the protection of human subjects in research. After receiving approval by the Hopi Tribal Couneil to conduct the study on the Hopi reservation, we con- {acted the principals at each high school for permission toconduct the study. Individual fith- and sixth-grade teachers were asked if the survey could be administered during their homeroom or health class. The 3-day dietary records were presented and explained to the 166 students on a Monday. The students were instructed torecallthe type andamount of foods eatenion Sunday. ‘They werealso given two more forms to record the foods eaten on Mondayand Tuesday. The dietary record was returned on Friday. Seventy questionnaires were not returned or had tobe eliminated because of incomplete records, leaving 96 acceptable 3-day di- etary record (a 48% response rate), Data Analysis ‘The Ath and sixth graders’ diets were analyzed using Nutritionist Il (version 6.0, 1955 database, N-Squared Computing, Salem, Ore) to obtain information on the intake of energy, protein, carbohydrate, total fat, saturated fat, cholesterol, fiber, 10 vita- mins, and six minerals. The results of the nutrient analysis and demographic data were then analyzed using the Statistical Pack- ‘age forthe Social Sciences (version 3, Srd edition, 1986, SPS Chicago, I) for frequencies and percentages of responses. De- scriptive and inferential statistics were calculated where appro- priate. RESULTS Demographic data are reported in Table 1. All students were of Hopiheritageandranged roms to 13yearsofage (meanstandard Tablet Demographic characteristics of 96 Hopi elementary ith and sixth grade suerts completing the 3-day etary record (Characteristic No. * ioe 10 25 2 W 3 a @ wr 28 B 3 3 Sex Gis 0 st Boe a @ 1.1340.86 years). Ofthe respondents, 49 (51%) were airls and 47 (49%) were boys. The Hopi children represented 18, clans and were from 10 villages (Table 1). Clans are individual ‘groups of Hopi with respective roles in culture, tradition, and religion. This resulted ina participation rate of 83%, but because only 96 were acceptable, a 48% response rate was the result Figures 2 and 3 surumarize the data obtained from the dietary analysis, which revealed a mean daily dietary intake of 2,123 keal consisting of 35% fat (84 g), 48% carbohydrate (261 g; 38% from sugar), and 17% protein (89 g), with 27 g saturated fat, 4422 mg cholesterol, and 11 g fiber. Figure 4 shows that the smallest intakes were of vitamin D (146 IU; 37% Recommended Dietary Allowance [RDA]), calcium (874 mg; 82% RDA), and zine (12mg; 94% RDA [26)). The mean dally sodium intake was 2,47 mg. ‘The aforementioned nutrient intake was obtained despite the fact that 56% of the students skipped at least one or more meals of nine (ie, mealsevery day for 3days). We found that-30 (31.3%) ofthe students missed one meal, 12 (12.5%) missed twomeals, 11 (11.5%) skipped three meals, and 1 (1.0%) missed five meals. When analyzed by the number of meals the Hopi children skipped for breakfast, lunch, and dinner, the percentages were 6.9%, 2.4%, and 1.3%, respectively (I= 20, 7, and 4, respectively). DISCUSSION ‘The diets of the Hopi fifth and six graders were found to exceed recommended intakes for energy, fat, cholesterol, sodium, and refined sugtars, and were too low in coniplex carbohydrates, fer, vitamin D, calcium, and zine, This conclusion isbased on alimited sample size (n=96) because of the fact that there are only about 200 Hopi fith and sixth graders on the reservation. Extrapolation is tenuous at best, but it appears that the basic nutrient intake pattern ofthese Hopistudentsdoes not differ drastically from that of the average white American elementary student. Energy intakes were not extremely high, but lke the RDA for ‘younger age groups, the RDA for energy in adults is above the ‘actual mean caloric intake of women (1,600 keal) an men (2,400 to 2,600 keal) ina country where the percentage of overweight people are 22.8% and 29.5%, respectively. Energy intake would probably be considerably higher were it not for the fact that 55% of the students skipped at least one or more meals within the 3- day period. IFthese students had followed the standard 3-meal-a- day meal patter, they would probably have had a positive energy balance and would be prone to higher rates of obesity. The remaining meals were large enough to contribute a notable amount of dally nutrients despite the meal skipping oF possible underreporting. Researchers investigating the possible genetic predisposition of Native Americans to certain diseases have found that some JOURNAL OF THE AMERICAN DIETETIC ASSOCIATION /519Calories Carbohydrate A 261 on Fat ff ton Saturated Fat | 27 om 1000 1500 2000 2128 calories FIG 2. Mean nutrient intake of 96 Hopi futh ‘and sicth-grade students who com- pleted a 3day Wietary record, 2500 3000 Fat 30% Recommended FIG 3. Mean percent- age of energy from ‘carbohydrate, protein, ‘and fat of 96 fifth- and siath-grade Hopi students who com- pleted a S-day dietary record, Actual [Native American populations may struggle with obesity because ‘of what is called a “thrifty gene” (27,28). This gene, according to thetheory, encourages maximunt fat storagebecause of centuries ‘of conditioning caused by alternating periods of feast and famine. Lack of physical activity also contributes to obesity. The physical activity level has changed for Native Americans since the turn of, the century, For example, the Tohono O'Oddham no longer till four to five fields to harvest one to two crops, and yearly migra: tions between desert and mountain have been discontinued, ‘Today, a sedentary reservation lifestyle for many Native Ameri ‘ans is compounded by high unemployment rates, with up to 60% ‘of the population on welfare (22). Acomplexset of social, economic, cultural, and environmental circumstances have also led to the replacement of indigenous foods with a diet composed primarily of modern refined foods (2031). The traditional diet of the Hopi people, initially an agrarian society, was primarily a vegetarian diet—consisting mostly of corn, beans, and squash—because animal life was not ‘abundant in the desert (32). Wild game was consumed sporadi- cally in the form of an occasional rabbit, prairie dog, ora sheep or 620 / MAY 1994 VOLUME 94 NUMBER 5 ‘goat bought from the neighboring Navajos (83). Over time, the traditional Native American foods that were obtained from the land have been replaced by foods from government commodity programs and grocery stores (34). The high intake of fat (35% of ‘energy, 27 g saturated fat), cholesterol (442 mg), sodium (2,477 img), and refined sugar (38% of 261 g carbohydrate) inthe diet of the typical Hopi elementary student is negatively counterbal: anced by an inadequate consumption of carbohydrate (48% energy), especially complex carbohydrate, and fiber (11 g). This pattern may be attributable to the decreased use of indigenous foodsand inereased use of convenience foods. Although the Hopi tribe no longer accepts commodity foods such as butter, whole milk, and cheese, one study found that, 43% of energy in the diets of 107 Navajo women was derived from US Department of Agricul- ture commodity foods (3). Compared to a 1955 study in which only 15% of Navajo women were obese, 63% of the women in the later study were obese, which isa risk factor for diabetes, hyper: tension, heart disease, and cancer. A 1989 General Accounting Office reportstated that the prevalence of obesity diabetes, heart disease, and hypertension is “likely to continue” unless federalVitamin B 2 Niacin] Folate| Vitamin A] Vitamin D| 100% 200% Percent RDA food packages distributed to Native Americans are improved @5), ‘The use of traditional foods by Native Americans has been declining over the years (36). In the late 1800s, the Hopi corn: monly prepared more than 60 different maize dishes (32,37) Today, the Hopi dietis primarily beef, mutton, eggs, store-bought bread, potatoes, some canned vegetables, fruits and fruit juices, Jardand other fats, coffee, tea, milk, sweetened drink mixes, soda, commercial pastries, and sweet and salty snacks. Very few fresh fruits and vegetables were consumed by the Hopi children in our study. Other researchers (38) have found an overall preponder ance of refined cereals, animal fats, and sucrose-rich foods, all of ‘which wre not used previously in the Native American diet. The lower calcium intake (872 mg) observed in the Hopi students is probably attributable to the historically higher incidence of lac tase deficiency among Native Americans, Zinc and vitamin D levels are usually low in dietary analyses because of the limited ‘number of foods containing these nutrients, however, vitamin D can be indirectly obtained from the sun. ‘The high intake of refined foods by students in this study is supported by the only other known dietary study of Hopi children conducted by Kuhnlein and Calloway (1), who analyzed 5-day dietary records of 343 Hopi children attending all elementary grades in Hopi reservation schools (60% were in the fourth through seventh grades). Kuhnlein and Calloway reported that 27% of the children consumed cola or sweetened drink mixes on. weekdays and 43% did so on Sunclay, We could not compare our data with that of Kuhnlein and Calloway because they had a wide range of age differences, which influences the amount of food ‘consumed and the number of RDA age groups. Kochler etal (39) found that the diets of9- to 16-year-old Navajo young people were: high in fats, sweets, and snack foods Foods that are traditional to preindustrial native groups are ‘generally regardedl as more healthful than refined food products (644041), Researchers have suggested tat the high incidence ‘of modern-day health disorders in Native Americans is retated in part to changing dietary pattems, however, this has not been specifically documented in Native American populations (41). a FIG 4, Mean percent Recommended Dietary Allowance (RDA) of vitamins and minerals 0f 96 Hopi fifth- and sixth-grade students who completed a 3-day dietary record. The RDA for 11-to 14-year old boys was selected as the standard. 8% 400% 500% © 600% Tablez Mean dally nutrient intake of 96 fith- and sixth-grade Hopi children who completed a 3-day dietary racord (1090-199) Natront Range Eneray rea aaa. Pring) 78-202 Carvonyarare(@) war Fatla) 23.229 strated ata) 27-9 i047 CChoestorl (ng) 4022007 s2.10010 Foerim) 1126 139 Viamin A 0U) 16226.117 90450, 120 Vann Cima) T2276 Baie iootavin ng) 18205 ora ach ima) 19-8 a Pynooxne (mg) 17207 0245, Viamin 8-12 a) T=15 Tas Panthers aid (ra) S021? 13407 acum may B74 =288 Be Copper (rg) 2209 see irontmay 216 316165 Prosphoxus (ma) 1.961 487 3733.188 Bias (ma) 2881 805 565.000 Sodium ma) Darr s608 4545,098 2ncimg) 1246 ‘35341 —___. JOURNAL OF THE AMBRICAN DIETETIC ASSOCIATION / 524Modifying the diets of fifth and sixth graders to meet recom- ‘mended dietary goals would include reducing fat to below 30% energy; cholesterol toless than 250.mg;soxium tolower levels, but not below 500 mg/day; and decreasing refined sugars. Intakes of carbohydrate would be increased to at least 58% of energy; fiber {020 to 00g and warn , caleun, ad, poy, zn to RDA levels. IMPLICATIONS Health problems such as diabetes, obesity, liver cirthosis, hyper- tension, fetal alcohol syndrome, and increasing rates of heart disease and cancer, which are relatively new to Native American populations, pose a serious threat to their traditional existence ‘and way of life. Although research has not shown that the dietary risk factors of white populations are similarfor Native Americans, itmay be wise to take progressive steps toward possible preven- tion, Because lifestyle changes often begin with young people, perhaps the elementary schools on the reservation could serve as ‘vehicle for nutrition education and health promotion. The US government should also address its possible proactive role in disease preventionand reassess the nutrient content ofthe schoo! foodservice meals and federal food packages that are distributed to Native Americans. A move back toward a more traditional diet that meets all of the dietary recommendations may better serve the Hopi people. i ‘This study was supported by a research grant from KIPS. Corporation, Las Vegas, New. We are also grateful to the Hopi Tribal Council and the Human Services Committee for their permission to allow us to conduct our study on the ‘Hopi reservation. References 1. Kuhnlein HV, Calloway DE. 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