**Background:** Indigenous communities worldwide are experiencing diet changes as they become more integrated into globalized economic systems, often shifting from traditional diets toward westernized food patterns. These changes can have profound implications for food security, health, cultural practices, and environmental sustainability. The Guna people of Gunayala, Panama, have strong autonomous institutions but have experienced increased connectivity since the 1990s through road access and tourism development. This study aims to comprehensively understand the characteristics, drivers, and sustainability impacts of diet change in three Guna communities representing different levels of development and western influence.
**Methods:** The study employed a Sustainability Science lens combining expert interviews and household surveys. Thirty expert interviews were conducted between February-March 2018 with representatives from government, NGOs, religious and cultural institutions, and Indigenous authorities. Household surveys (n=232) were conducted between March-April 2019 across three islands: Gardi Sugdub (medium development, n=90), Soledad Miria (low development, n=98), and Nargana (high development, n=82). Respondents were stratified into four groups: young men (<30 years), adult men (>30 years), young women, and adult women. A modified Food Consumption Score (FCS) was used to assess dietary diversity before and after diet change, with 11 food items identified through expert consultation to distinguish traditional from western food items. Statistical analyses included one-way ANOVA with Bonferroni correction, Welch's ANOVA with Games-Howell post hoc, Kruskal-Wallis tests, and paired t-tests. A causal loop diagram was constructed to systematize linkages between drivers and impacts.
**Key Results:** Across all sites, the average FCS increased by 18%, from 63.4 points (SD=16.7) before diet change to 74.7 points (SD=16.9) after change. Soledad Miria (least developed) showed the highest improvement with a 30% increase (from 55.9 to 72.7 points), while Gardi Sugdub showed the lowest at 6% (from 70.4 to 74.7 points). All groups in Soledad Miria showed statistically significant FCS increases (p<0.001 for all four groups). In Gardi Sugdub, only men showed significant increases (young men: 69.7 to 75.9, p=0.016; adult men: 71.0 to 77.9, p=0.002). In Nargana, only adult women showed a significant increase (65.2 to 85.5, p<0.001). Consumption of traditional meals, local bushmeat, and traditional drinks declined, while imported meat, carbonated soft drinks, pulses, vegetables, fruits, dairy, and other fats increased. The main drivers reported were reduced availability of traditional ingredients, high prices of traditional foods, convenience of western foods, and loss of traditional food preparation knowledge. The onset of diet change varied: Nargana groups had the earliest onset (adult women: 16.8 years ago; adult men: 15.1 years), while Soledad Miria groups had the latest (young women: 3.8 years; young men: 4.7 years). Expert interviews identified five reinforcing feedback loops linking diet change to loss of Indigenous and local knowledge (ILK), livelihood shifts toward tourism, overexploitation of marine species (e.g., lobster), waste generation from food packaging, and increased vulnerability to food supply disruptions.
**Clinical Implications:** While this study is not a clinical trial, it identifies significant health concerns associated with diet change in Gunayala. Experts reported increased consumption of high-sugar and high-fat foods (soft drinks, processed items, fried foods) alongside reduced consumption of traditional foods. Health officials noted emerging cases of hypertension and diabetes that were previously uncommon. The switch from traditional boiled beverages to instant flavored drinks has reduced the practice of boiling water, potentially increasing communicable diseases such as diarrhea. The study underscores the need for comprehensive health assessments in the region and highlights that dietary diversity improvements do not necessarily equate to healthier eating patterns. The findings support calls for systemic, culturally appropriate interventions that preserve traditional food systems and Indigenous knowledge while addressing emerging health challenges.