It’s nearly noon in Lualualei Valley, and the sun beats down on Khrystyna Kanahele’s back as she sprinkles lettuce seeds down a long row of tilled soil. It’s part of her routine as an intern at MA’O Organic Farm’s farm-to-college program.

When her friend and colleague Kiana Tector, a MA’O youth leader, approached her in December and asked her to participate in a Waianae health study, she was hesitant. University of Hawaii researchers wanted to analyze the bacteria in her gut, among other things, and that was extremely personal.

“It was weird giving stuff at first, like the stool sample,” said Kanahele, a student at Leeward Community College.

But it helped that she wasn’t alone — she and 80 of her colleagues decided to share their health data and participate in the UH study, which looks at the potential health benefits of changes in lifestyle and working in a healthy environment like the farm.

The first results of the study after just a year are promising. Most interns saw improvements in health indicators including lowered risk for diabetes. And some of those benefits spilled over to friends and family members who made similar behavior changes.

For Kanahele, taking part in the study was eye opening.

A small prick of a thumb for a drop of blood had heavy results — at just 18 years old, Kanahele’s hemoglobin levels indicated she was pre-diabetic. She was shocked. But then she remembered her grandfather’s experience with diabetes and how difficult it was when he had to have surgery to remove some of his toes.

“I really didn’t want that,” she said.

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Kanahele began to make more of an effort to arrive on time at the farm, starting her days at dawn rather than sleeping in until noon. She also took more salad greens home to eat. When she measured her average blood sugar level once more in April, she found that it had dropped back in the healthy range.

The positive health shifts among the interns occurred significantly swifter than “a typical medical intervention would be achieving,” said Ruben Juarez, the study’s co-investigator and a mathematical economist at the University of Hawaii Economic Research Organization.

Preliminary findings of the UH Mauli Ola study indicate that 60% of interns who were found to be pre-diabetic or diabetic saw an improvement in their blood sugar control.

Juarez’s partner in the project is Alika Maunakea, a biomedical researcher at the University of Hawaii John A. Burns School of Medicine who was raised in Waianae and has family ties to MA’O Organic Farms. In 2017, they began to analyze the influence of the MA’O program on the health of the participants.

Equally encouraging was the finding that some family and friends of interns began to exhibit the same healthy behaviors as the interns, who range from 16 to 23 years old. This trend, Maunakea and Juarez believe, is showing that a non-health program like MA’O might have a significant influence on the health of participants and, perhaps more surprisingly, a ripple effect on the Waianae community.

Sponsored by the HMSA Foundation and Kamehameha Schools, the study’s first round included approximately 400 individuals from around Oahu, about two-thirds of whom have Native Hawaiian or Pacific Islander ancestry.

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The study has not yet been published or peer-reviewed. But the researchers believe it could illustrate a link between gut microbiome composition, risk for diabetes, and the influence of social networks on healthy behavior among Native Hawaiian and Pacific Islanders.

The researchers are actively sharing data and findings with participants so they can use the preliminary results in their daily lives.

“It can help us see how organizations can help address the health needs of a community, even if those organizations aren’t part of the traditional health care system,” said Maunakea.

MA’O’s Mission

In the shade of the MA’O production center, music and mist fill the air as interns spray-wash fresh kalo, radishes, ulu and colorful salad greens. In an organized shuffle, the team prepares 3,000 pounds of produce each week to distribute to grocery stores, restaurants and farmer’s markets.

These high school and college students also tend to more than 40 varieties of organic fruits and vegetables.

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MA’O is an acronym for Mala Ai Opio, which translates to youth food garden. It’s a healthy oasis, tucked along Oahu’s west side, where there are often more unhealthy food choices available than healthy ones.

MA’O Organic Farms was founded in 2001 to combat that trend. The farm is an initiative of the Waianae Community Redevelopment Corp., a nonprofit with the mission of addressing socioeconomic inequities through agricultural and educational programming rooted in Hawaiian culture.

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Executive Director Kukui Maunakea-Forth is also the aunt of Alika Maunakea, the researcher. The study was an opportunity to measure the farm’s impact, she said.

“We wanted evidence that there were quantifiable health impacts to what we were doing, though that’s not necessarily what we’re doing — we’re a production farm,” Maunakea-Forth said.

She had an inkling healthy habits were being adopted by the interns’ family members, too, since they are encouraged to take fresh produce home.

Closing The Gap On Health Disparities

For Alika Maunakea, documenting MA’O’s influence was a way to bring his expertise in epigenetics home to Waianae.

He had already been involved with the MA’O board and leadership, and felt the farm was a good place to start, since Waianae is home to the highest concentration of Native Hawaiians and Pacific Islanders in the state. Residents also have higher rates of preventable diseases, including diabetes, heart disease and some cancers compared to many other parts of Hawaii.

Maunakea credits his grandmother, Katherine Maunakea, a Hawaiian traditional health practitioner, for passing down the understanding that the environment is intertwined with health.

Her mantra, “Ne huli ka lima iluna, pololoi ka opu. Ne huli ka lima ilalo, piha ka opu,” is painted across their front glass doors. In English, “When your hands are turned up, you will be hungry. When your hands are turned to the soil, you will be full.”

“Aina (land) is part of your family, and taking care of the aina enables it to take care of you,” says Maunakea. “It’s a reciprocal relationship that we have with our environment that’s really key to our livelihood.”

Epigenetics, his speciality, examines the biological interaction between health and the environment. His research resonates with the Hawaiian perspective of his ancestors.

“It’s sort of an understanding and re-learning these ancient concepts, that environment connects to health through an interface on a cell and molecular level,” he said. “The things we do to the environment and how it affects our development can actually have a role on the health of our offspring and future generations.”

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Knowing that it would take time and funding to launch the study, Maunakea and Juarez began a conversation with interns a few years ago, pulling weeds alongside them to gain their trust.

Offering a cash incentive for participation, the survey incorporated questions about socioeconomic status, anxiety, stress and diet. Researchers tracked changes in blood sugar control, weight loss or gut microbiome composition and also quizzed interns on how much their family members and friends influence them when it came to nutrition, exercise, career and life advice.

Juarez has studied how social and economic networks can influence choices and behaviors, and knew that such networks have been shown to have an effect on obesity in white populations elsewhere in the United States.

But this study could be the first to examine the power of relationships on health among Native Hawaiians, who experience a higher prevalence of obesity-related diseases such as diabetes.

“In Hawaii, we see even stronger relationships and influence that your friends have on obesity-related behaviors,” he said. “If we are able to pinpoint the important components of changing behavior to be able to decrease obesity, that’s huge. I’m the analytics guy, and I was thoroughly shocked that there was incidental evidence.”

Among the 60% of interns who saw an improvement in blood sugar levels, early data shows signs of improved health and lowered risk for diabetes. Another 14.5% of the family and friend contacts they listed in their network saw improvement as well.

Approximately one-fifth of participants also reported improved self esteem. However, body mass indexes remained relatively steady, with only 5% of interns seeing a decline in their BMI to a healthier level.

Inspiring Change Among Friends And Families

Native Hawaiians have been studied many times before, but usually lose access to the data and findings of researchers.

“Unfortunately, we call them ‘helicopter researchers,’ those who just come over, extract data, write the paper and never show up again,” said Juarez. “We love going back (to the participants) and telling them what the results of the study are. We have recruitment and data sharing events … and you see the previous interns telling others what the study is about.”

Now, diabetes and gut microbiota are common conversation topics over meals at the farm, according to Maunakea-Forth, especially because MA’O interns were able to serve as co-researchers.

As a student of nutrition and dietetics at Leeward Community College, 21-year-old Nanakuli native Kiana Tector quickly became a key liaison between the UH team and the MA’O interns.

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“Making them understand the importance of their gut health was important,” she said. “They were like, ‘What can you get from my poop? Why do you need it? I read an article about how there’s actually stool sample transplants, so I asked them, ‘Do you want to need to do that? Or do you want to take care of it now?’”

Tector also convinced her family to participate. After they got their blood results in April, they made some changes.

“They immediately went home, cleaned the fridge and went shopping,” she recalled. “They bought things they knew from the farm that I had brought home before, like beets and carrots. They got kalo from one of my aunts and they stopped eating that much rice.”

Next Phase

Maunakea and Juarez will lead a third recruitment in the coming weeks, and plan to submit their preliminary findings to a journal for publication.

As data collection continues into the second year of the study, Juarez hopes the findings can be used by community organizations and health providers and insurers, especially when it comes to decisions about funding.

Diseases such as diabetes can be extremely expensive to treat. This study could quantify how much is saved in medical costs by improving participants’ health.

Based on figures from the American Diabetes Association, Juarez estimated the total lifetime savings for all participants who saw improved diabetes-related health outcomes could total approximately $120,000.

“That pilina (relationship) that we create with the land and with one another is automatically an asset,” Maunakea-Forth said. “It’s relatable to people in academic institutions and health insurers. Illnesses are skyrocketing and it’s costing everybody, including them.”

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This year, backed by community beneficiaries, the farm acquired 236 more acres in Lualualei Valley and is increasing its size 10-fold. Four times as many interns are expected to work at the farm over the next decade.

A group from Oklahoma took notice of MA’O’s success and recently visited to learn more about how to develop partnerships that address health disparities. The group also helped plant the first 21 acres of the newly acquired land.

Maunakea and Juarez want to expand the study to other regions of Oahu, and they are in discussions with funding groups to create a health hub, where members of the community can continue to track their health.

“The same framework and approaches could be used to address the needs of other populations throughout the country,” Maunakea said.