Early childhood is a sensitive period for healthy weight development and is an important determinant of obesity risk across the life course.1Dixon B Peña MM Taveras EM. Lifecourse approach to racial/ethnic disparities in childhood obesity.Adv Nutr (Bethesda, MD). 2012; 3: 73-82Crossref PubMed Scopus (98) Google Scholar,2Lucas A. Programming by early nutrition in man.in: Bock G Whelan J The Childhood Environment and Adult Disease. John Wiley & Sons, 1991: 38-55Google Scholar Thus, early childhood is a critical window for obesity prevention,3Isong IA Richmond T Avendaño M Kawachi I. Racial/ethnic disparities: a longitudinal study of growth trajectories among US kindergarten children.J Racial Ethn Health Disparities. 2018; 5: 875-884Crossref PubMed Scopus (9) Google Scholar with particular opportunity for reducing Indigenous American Indian (AI) disparities.4Schell LM Gallo MV. Overweight and obesity among North American Indian infants, children, and youth.Am J Hum Biol Off J Hum Biol Counc. 2012; 24: 302-313Crossref PubMed Scopus (63) Google Scholar By the age of 2 years, the average AI child will weigh more than their White peer, and this excess weight usually persists into kindergarten.3Isong IA Richmond T Avendaño M Kawachi I. Racial/ethnic disparities: a longitudinal study of growth trajectories among US kindergarten children.J Racial Ethn Health Disparities. 2018; 5: 875-884Crossref PubMed Scopus (9) Google Scholar Disparities are particularly pervasive within rural AI communities.5James CV Moonesinghe R Wilson-Frederick SM Hall JE Penman-Aguilar A Bouye K. Racial/ethnic health disparities among rural adults — United States, 2012–2015.MMWR Surveill Summ. 2017; 66: 1-9Crossref PubMed Scopus (111) Google Scholar The causes of AI obesity disparities are multifactorial, which has important implications for early childhood obesity prevention programs in tribal communities. Political, structural, and economic pathways influence community food access, learned food preferences, and loss of traditional foodways.6Jernigan VB Salvatore AL Styne DM Winkleby M. Addressing food insecurity in a Native American reservation using community-based participatory research.Health Educ Res. 2012; 27: 645-655Crossref PubMed Scopus (74) Google Scholar Nationally, 1 out of 4 AI households experience food insecurity,7Jernigan VBB Huyser KR Valdes J Simonds VW. Food insecurity among American Indians and Alaska natives: a national profile using the current population survey–food security supplement.J Hunger Environ Nutr. 2017; 12: 1-10Crossref PubMed Scopus (60) Google Scholar with many tribal communities reporting even higher rates.8Jernigan VBB Wetherill MS Hearod J et al.Food insecurity and chronic diseases among American Indians in Rural Oklahoma: the THRIVE study.Am J Public Health. 2017; 107: 441-446Crossref PubMed Scopus (36) Google Scholar, 9Sowerwine J Mucioki M Sarna-Wojcicki D Hillman L. Reframing food security by and for Native American communities: a case study among tribes in the Klamath River basin of Oregon and California.Food Sec. 2019; 11: 579-607Crossref Scopus (15) Google Scholar, 10Bauer KW Widome R Himes JH et al.High food insecurity and its correlates among families living on a rural American Indian reservation.Am J Public Health. 2012; 102: 1346-1352Crossref PubMed Scopus (57) Google Scholar American Indian families with children are disproportionately affected by food insecurity10Bauer KW Widome R Himes JH et al.High food insecurity and its correlates among families living on a rural American Indian reservation.Am J Public Health. 2012; 102: 1346-1352Crossref PubMed Scopus (57) Google Scholar and commonly report poor access to fresh fruits and vegetables and a heavy reliance on energy-dense, commodity foods to feed their families.11Finegold K. Background Report on the Use and Impact of Food Assistance Programs on Indian Reservations (No. 4). US Department of Agriculture, Economic Research Service, 2005Google Scholar Although studies are limited, poor food access may contribute to obesity disparities among AI adults,8Jernigan VBB Wetherill MS Hearod J et al.Food insecurity and chronic diseases among American Indians in Rural Oklahoma: the THRIVE study.Am J Public Health. 2017; 107: 441-446Crossref PubMed Scopus (36) Google Scholar and may also negatively influence fruit and vegetable food preferences among AI families with young children.10Bauer KW Widome R Himes JH et al.High food insecurity and its correlates among families living on a rural American Indian reservation.Am J Public Health. 2012; 102: 1346-1352Crossref PubMed Scopus (57) Google Scholar The Indigenous food sovereignty movement is a grassroots community organizing movement that emphasizes the mobilization of tribal resources to reclaim food systems.12Jernigan VBB. Health and social issues of Native American women.in: Joe JR Gachupin FC Addressing Food Security and Food Sovereignty in Native American Communities. Praeger, 2012: 113-132Google Scholar It promotes active participation in food harvesting at the individual, family, community, and regional levels as a strategy to protect cultural heritage, promote health, and ensure food security.13Indigenous Food Systems Network. Indigenous food sovereignty.https://www.indigenousfoodsystems.org/food-sovereignty. Accessed July 7, 2020.Google Scholar Early childcare and education centers (ECEs) are long-recognized as an important environmental influence on learned eating behaviors. Several ECE obesity programs have been successfully implemented in urban schools,14Yin Z Parra-Medina D Cordova A et al.Míranos! Look at us, we are healthy! An environmental approach to early childhood obesity prevention.Child Obes. 2012; 8: 429-439Crossref PubMed Scopus (63) Google Scholar,15Natale RA Messiah SE Asfour LS Uhlhorn SB Englebert NE Arheart KL Obesity prevention program in childcare centers: two-year follow-up.Am J Health Promot. 2017; 31: 502-510Crossref PubMed Scopus (28) Google Scholar many serving Hispanic and Black youth. However, little information is available for rural AI communities, in which tribes often operate their own ECEs. Implemented in tribal ECEs, the Food Resource Equity and Sustainability for Health (FRESH) study aimed to improve vegetable intake, food security, and body composition of preschool-aged children and their families. Consisting of child, parent, and ECE environmental interventions, this longitudinal randomized control study was designed to advance Indigenous food sovereignty within the Osage Nation, a rural reservation community in Oklahoma. This study describes the processes used to develop, implement, and evaluate the preschool curriculum component designed to increase children's exposure to vegetables as a pathway toward learned food preferences for these foods. The FRESH study used a community-based participatory research process that involved Osage Nation tribal leaders from the early childhood education and agricultural sectors in every aspect of the research, from the development of the research questions and study implementation to the data collection, analysis, and dissemination of the findings. As 1 element of a multicomponent intervention for ECE families, the FRESH preschool curriculum was accompanied by a school menu best practices redesign16Sisson SB Sleet K Rickman R Love C Williams M Jernigan VBB. The development of child and adult care food program best-practice menu and training for Native American head start programs: the FRESH study.Prev Med Rep. 2019; 14100880Google Scholar and a supplemental teacher training on responsive feeding practices17Sleet K Sisson SB Dev DA et al.The impact of responsive feeding practice training on teacher feeding behaviors in tribal early care and education: the food resource equity and sustainability for health (FRESH) study.Curr Dev Nutr. 2019; 4: 23-32Crossref PubMed Google Scholar described elsewhere. Intervention ECE school menus incorporated local, fresh, and culturally tailored foods from the tribe's newly launched farm. A complimentary, parent-focused, 16-week hybrid curriculum was delivered via a combination of weekly online learning modules and monthly in-person family nights. These family nights featured Indigenous foods and food sovereignty activities to promote community awareness and collective efficacy for a more equitable and sustainable tribal food system. All participating families included 1 or more members who self-identified as AI. The FRESH study was approved by the Oklahoma State University Center for Health Sciences Institutional Review Board. We adapted the FRESH preschool curriculum through a series of meetings with Osage leadership and teachers over 6 months. Members of the academic team completed tours of the schools, discussed existing curricula with teachers, and reviewed preexisting school-based gardening curricula. As an outcome of these early meetings, the FRESH preschool curriculum was ultimately informed by 2 preexisting preschool-gardening curricula. First piloted in New Hampshire, the original Early Sprouts curriculum spans 24-weeks through 6-week cycles to illustrate the 4 growing seasons, with each weekly cycle featuring 1 of 6 target vegetables.18Kalich K Bauer D McPartlin D. Early Sprouts: Cultivating Healthy Food Choices in Young Children. Redleaf Press, 2009Google Scholar This curriculum was the primary source for the adapted FRESH preschool curriculum. Piloted in North Carolina, Watch Me Grow19Namenek Brouwer RJ Benjamin Neelon SE Watch Me Grow: a garden-based pilot intervention to increase vegetable and fruit intake in preschoolers.BMC Public Health. 2013; 13: 363Crossref PubMed Scopus (30) Google Scholar involved a crop-a-month structured curriculum spanning 4 months. We added elements from this second curriculum to supplement the teacher's manual, primarily classroom discussion questions and introductory reading activities. Before developing the FRESH preschool curriculum, 2 members of the research team reviewed the Early Sprouts implementation resource manual (E.E.B. and M.S.W.),18Kalich K Bauer D McPartlin D. Early Sprouts: Cultivating Healthy Food Choices in Young Children. Redleaf Press, 2009Google Scholar and 1 member who led the adaptation completed the corresponding 10-hour online training program (E.E.B.). The FRESH preschool curriculum preserved fidelity to Early Sprouts by retaining a combination of sensory exploration, gardening, classroom cooking, and take-home recipe kits to promote family involvement. All of these activities are theoretically designed to help young children overcome innate neophobia for vegetables. In our discussions with teachers, we prioritized maintaining fidelity to the intervention and focused on making adaptations when necessary in the delivery of the intervention rather than core elements of the content. For example, we discussed the availability and comfort level of teachers in conducting selected gardening activities that supported the curricula delivery and what supports needed to be in place for the teachers to successfully implement the curricula. Additional factors, including vegetable cost and regional availability in this reservation setting, were also an important consideration, and ultimately the FRESH preschool curriculum was adapted to span 15-weeks through 3 5-week cycles (Explore, Sprout, and Harvest). The primary adaptations included replacement of swiss chard with spinach and green beans with butter (lima) beans while retaining tomatoes, bell peppers, carrots, and butternut squash target vegetables from the original Early Sprouts curriculum. Butter beans and squash were combined into a single weekly module to introduce children to Three Sisters, a traditional Indigenous approach for growing these 2 crops with corn.20Pleasant Mt J. Food yields and nutrient analyses of the three Sisters: a Haudenosaunee cropping system.Ethnobiol Lett. 2016; 7: 87-98Crossref Scopus (18) Google Scholar Inspired by Watch Me Grow,19Namenek Brouwer RJ Benjamin Neelon SE Watch Me Grow: a garden-based pilot intervention to increase vegetable and fruit intake in preschoolers.BMC Public Health. 2013; 13: 363Crossref PubMed Scopus (30) Google Scholar we added an introductory activity (eg, book or song) for the first 5 weeks to introduce the children to the vegetable of the week in an engaging and interactive way, including discussion questions for teachers before, during, and after each reading. A unique storytelling activity included an introduction to Three Sisters.20Pleasant Mt J. Food yields and nutrient analyses of the three Sisters: a Haudenosaunee cropping system.Ethnobiol Lett. 2016; 7: 87-98Crossref Scopus (18) Google Scholar In addition, 5 of the 15 recipes for in-class preparation and take-home kits were modified to integrate spinach and butter beans and simplified cooking methods. Recipes were taste-tested among a sample of teachers before finalization. Esteemed tribal elders fluent in the Osage language contributed translations for the names of target vegetables (eg, is carrot) and other gardening terms (eg, is garden). See Supplementary Data for a summary of adaptations and translated words. Before implementation, all teachers received a 3-hour training in July 2017 on the beta version of the adapted preschool curriculum, including a step-by-step manual, which also provided 1 final opportunity for teacher feedback. An essential part of the training prioritized importance of fostering a student's willingness to try over the actual eating of vegetables. This was achieved by training teachers to role model willingness to try and to encourage students less willing to try vegetables to explore with their other senses (sight, feel, smell, sound). Example teacher response scripts for reluctant students were included for teacher reference. Teachers were also trained to ask the question of whether or not each student liked the vegetable a lot, a little, or not yet18Kalich K Bauer D McPartlin D. Early Sprouts: Cultivating Healthy Food Choices in Young Children. Redleaf Press, 2009Google Scholar on the conclusion of each weekly sensory and cooking activity. The teacher's manual also included supplemental information with each lesson (eg, pictures identifying the parts of vegetable plants and basic nutrition information) to support teacher confidence in curriculum implementation regardless of their background. The final written curriculum was later distributed to all participating classrooms in January 2018 during a recap training delivered to 38 teachers and aids immediately before implementation. Curriculum implementation boxes were also provided to create a classroom environment that stimulated food learning. Example items included vegetable-themed toys, chef-dress-up costumes, and items required for teaching specific activities, such as vegetable-themed books, magnifying glasses, and child gardening supplies. Each week, classrooms were provided with food ingredients needed to complete sensory and in-classroom cooking activities and prepared take-home kits for children to prepare each week's recipe again at home with their families. During the study's intervention phase (January and May 2018), 13 classrooms implemented the curriculum across 5 ECE sites owned and operated by the Osage Nation (2-4 classrooms per site). Because the curriculum involved outdoor gardening activities, demonstration gardens were built for each participating ECE site. On concluding each weekly lesson, teachers completed an implementation survey to evaluate fidelity to the preschool curriculum and how it was received by teachers and students. Overall implementation each week was high across all 15 weeks. All classrooms reported completing each weekly reading activity during the first 5 weeks. Completion of sensory activities ranged from 100% to 84.6%, and completion of cooking activities ranged from 100% to 76.9% across classrooms (Table 1).TableProcess Evaluation Results for the FRESH Curriculum (n = 13 Classrooms)Introductory ReadingSensory ActivityaFor weeks 11–15, completion of sensory activities includes indoor, outdoor, or bothCooking ActivityOverall Class Response to Recipe TastebTeacher observed assessment of children's overall liking of the recipe. Originally measured as overall enjoyed, neutral, mixed, or disliked. Percent reported represents enjoyed and neutral combined,cPercentages are adjusted for classrooms that completed the cooking activity.Week% Activity Completion (No. Classrooms)Enjoyed or Neutral (No. Classrooms)110010010069.2 (9)210010010038.5 (5)310010010069.2 (9)410010084.6 (11)45.5 (5)510084.6 (11)92.3 (12)61.5 (8)6–10084.6 (11)81.2 (9)7–92.3 (12)92.3 (12)41.7 (5)8–10010061.5 (8)9–92.3 (12)76.9 (10)60.0 (6)10–10010076.9 (10)11–10010076.9 (10)12–10092.3 (12)54.5 (6)13–92.3 (12)92.3 (12)50.0 (6)14–91.7 (12)91.7 (11)72.7 (8)15–10010076.9 (10)FRESH indicates Food Resource Equity and Sustainability for Health.a For weeks 11–15, completion of sensory activities includes indoor, outdoor, or bothb Teacher observed assessment of children's overall liking of the recipe. Originally measured as overall enjoyed, neutral, mixed, or disliked. Percent reported represents enjoyed and neutral combinedc Percentages are adjusted for classrooms that completed the cooking activity. Open table in a new tab FRESH indicates Food Resource Equity and Sustainability for Health. Teachers were also asked to provide written, open-ended feedback each week about the real-world implementation of the project (Figure 1). Thematic review of qualitative survey responses indicated that children particularly enjoyed activities involving cutting with the knives and cutting boards and mystery bags (paper bags that contained the weekly vegetable). Teachers organically wove FRESH curricula together with other lessons, including repurposing a fruit can as a pen holder to demonstrate repurposing and hanging aprons on the clothesline to dry as part of lessons about clothing. Noted challenges included the need for 2 teachers to help implement lessons and sometimes not having adequate time to prepare for the lesson or deliver the full lesson. Classroom cooking plans were sometimes altered, including asking the school cook to prepare the recipe for student tasting, or students prepared the recipe but did not get to taste the final product in the classroom. Areas for improvement included a need for more flexibility with the curriculum (eg, shorter lessons or being able to split activities into smaller components). Teachers suggested the use of time-lapse videos of plants growing. Evaluation of the FRESH curriculum indicates it can be implemented successfully in ECE classrooms, so long as adequate support is provided to teachers. Flexibility in delivering the curriculum proved essential, especially for the multiage ECE classroom setting. Tailoring the curriculum to local AI cultural traditions supported community interest and participation in the program, as demonstrated by families sharing photographs of themselves preparing their take-home meal kits. Future curriculum refinements could include modifications to lesson plans to allow for flexibility in weekly implementation and provision of preportioned classroom recipe kits for easier preparation in the classroom by teachers and students. The impact of the curriculum on food security, vegetable intake, and body composition will be described in a forthcoming manuscript. Since its original implementation, the FRESH Children's Gardens and classroom curriculum have become an integral component within ECE settings within the Osage Nation. To optimize the use of raised bed growing space, vegetables have since been modified through school cook and teacher input. The current planting design includes tomatoes, potatoes, bell peppers, and onions for spring planting and radishes, spinach, beets, and mixed lettuce for fall planting. Harvested produce is first used by ECE school kitchens, and excess produce is distributed through the Elder Nutrition Program to Osage elders as part of a broadening effort to foster tribal resilience and community health. The Osage Nation has incorporated lessons from this study into a new and expanded Community Supported Agriculture program that will be launched in the near future and provide farm produce weekly to more AI families across the Osage Nation. Collectively, this food knowledge, production, and access initiatives support the goal of creating a more food secure, food sovereign tribal nation. The study was approved by the Institutional Review Board of Oklahoma State University Center for Health Sciences and funded by the National Institutes on Minority Health and Health Disparities (5R01MD011266-03). The Osage Nation congress provided study oversight and tribal approval of the study. The contents of this publication are solely the authors’ responsibility and do not necessarily represent the official views of the National Heart, Lung, and Blood Institute or the National Institutes of Health. The funding agency did not participate in the study design, data collection, analysis, decision to publish, or manuscript preparation. The authors would like to acknowledge and thank the members of the FRESH Study Executive Committee and all who participated in the project, too numerous to mention, but including Assistant Chief Raymond RedCorn, David Webb, Michelle Harding, Melvina Prather, Denise Keene, Dana Daylight, Helen Brumley, Shane Rencountre, Margaret Sisk, Jason George, and Jann Hayman. The authors would also like to thank Ms Gail Boe for her leadership in initiating preliminary intervention work. The authors thank Robynn Rulo for her leadership in implementing this study within the schools. Finally, the authors thank all study participants for their time, knowledge shared, and continued commitment to their children's health and well-being. Download .docx (.21 MB) Help with docx files