Barriers and Strategies for Healthy Food Choices among American Indian Tribal College Students: A Qualitative Analysis

Published:October 20, 2017DOI:



      American Indian and Alaskan Native individuals experience disproportionate levels of chronic health conditions such as type 2 diabetes and overweight and obesity that are influenced by dietary patterns and food choices. Understanding factors that influence healthy food choices among tribal college students can enrich education and programs that target dietary intake.


      To build an understanding of factors that influence healthy food choices among tribal college students at increased risk for college attrition.


      A nonexperimental cohort design was used for qualitative descriptive analysis.


      Participants (N=20) were purposively sampled, newly enrolled, academically underprepared tribal college students enrolled in a culturally relevant life skills course at an upper Midwest tribal college between September 2013 and May 2015. Participant demographic characteristics included various tribal affiliations, ages, and number of dependents.

      Main outcome measures

      Participant responses to qualitative research questions about dietary intake, food choices, self-efficacy for healthy food choices, psychosocial determinants, and barriers to healthy food choices during telephone interviews were used as measures.


      Qualitative analysis included prestudy identification of researcher bias/assumptions, audiorecording and transcription, initial analysis (coding), secondary analysis (sorting and identifying meaning), and verification (comparative pattern analysis).


      Qualitative analysis revealed a variety of themes and subthemes about healthy food choices. Main themes related to barriers included taste, food gathering and preparation, and difficulty clarifying healthy food choices. Main themes related to strategies included taste, cultural traditions and practices, and personal motivation factors.


      Qualitative analysis identified barrier and strategy themes that may assist nutrition and dietetics practitioners working with tribal/indigenous communities, tribal college educators and health specialists, and tribal community health workers who target health and dietary intake of American Indian and Alaskan Native students.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of the Academy of Nutrition and Dietetics
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


      1. National Conference of State Legislatures. Federal and state recognized tribes. Published 2013. Updated March 2016. Accessed August 2016.

      2. Norris T, Vines P, Hoeffel E. The American Indian and Alaska Native population: 2010 census briefs. Published January, 2012. Accessed January 2014.

      3. Centers for Disease Control and Prevention. Minority health surveillance – REACH U.S. 2009. Updated September 2014. Accessed August 2013.

      4. Centers for Disease Control and Prevention National Diabetes Statistics Report: Racial and ethnic differences in diagnosed diabetes. Published October 2014. Updated May 2015. Accessed August 2016.

      5. Centers for Disease Control and Prevention National Center for Chronic Disease Prevention and Health Promotion. Division of Population Health. Behavior Risk Factor Surveillance System [BRFSS] Prevalence and trends data. Updated June 23, 2015. Accessed July 21, 2015.

        • Zephier E.
        • Himes J.
        • Story M.
        • Zhou X.
        Increasing prevalence of overweight and obesity in Northern Plains American Indian children.
        Arch Ped Adolesc Med. 2006; 160: 34-39
      6. CDC. Overweight and obesity. Updated June 16, 2015. Accessed July 20, 2015.

        • Daniels S.
        • Arnett D.
        • Eckel R.
        • et al.
        Overweight in children and adolescents: Pathophysiology, consequences, prevention, and treatment.
        Circulation. 2005; 111: 1999-2012
      7. CDC. Age-adjusted rate per 100 of civilian, non-institutionalized population with diagnosed diabetes, by race, U.S., 1980-2011. Updated October 15, 2014. Accessed January 2015.

        • Warne D.
        • Frizzell L.B.
        American Indian health policy: Historical trends and contemporary issues.
        Am J Public Health. 2014; 104: S263-S267
        • Deaton A.
        Policy implications of the gradient of health and wealth.
        Health Aff (Millwood). 2002; 21: 13-30
        • Going S.
        • Thompson J.
        • Cano S.
        • et al.
        The effects of the pathways obesity prevention program on physical activity in American Indian children.
        Prev Med. 2003; 37: s62-s69
        • Compher C.
        The nutrition transition in American Indians.
        J Transcult Nurs. 2006; 17: 217-223
        • Cunningham-Sabo L.
        • Bauer M.
        • Pareo S.
        • Phillips-Benally S.
        • Roanhorse J.
        • Garcia L.
        Qualitative investigation of factors contributing to effective nutrition education for Navajo families.
        Matern Child Health J. 2008; 12: s68-s75
        • Davis A.
        • Befort C.
        • Steiger K.
        • Simpson S.
        • Mijares M.
        The nutrition needs of low-income families regarding living healthier lifestyles: Findings from a qualitative study.
        J Child Health Care. 2012; 17: 53-61
        • Klempel N.
        • Kim S.
        • Wilson M.
        • Annunziato R.
        A measure of family eating habits: Initial psychometric properties using the profile pattern approach (PPA).
        Eat Behav. 2013; 14: 7-12
        • Fordyce-Voorham S.
        Identification of essential food skills for skill-based healthful eating programs in secondary schools.
        J Nutr Educ Behav. 2011; 43: 116-122
        • Larson N.
        • Perry C.
        • Story M.
        • Neumark-Sztainer D.
        Food preparation by young adults is associated with better diet quality.
        J Am Diet Assoc. 2006; 106: 2001-2007
        • Jackson A.P.
        • Smith S.A.
        • Hill C.L.
        Academic persistence among Native American College Students.
        J College Student Dev. 2003; (44(4)4:548-565)
        • Yosso T.
        Whose culture has capital? A critical race theory discussion of community cultural wealth.
        Race Ethn Educ. 2005; 8: 69-91
        • Keith J.F.
        • Stastny S.N.
        • Agnew W.
        • Brunt A.
        • Aune P.
        Life skills at a tribal college: A culturally relevant educational intervention.
        J Extension. 2017; 55
        • Cajete G.
        Look to the Mountain: An Ecology of Indigenous Education.
        Kivaki Press, Durango, CO1994
        • Calsoyas K.
        Considerations in the educational process relative to Native Americans.
        Cambridge J Educ. 2006; 35: 301-310
        • Varcoe C.
        • Botoroff J.
        • Carey J.
        • Sullivan D.
        • Williams W.
        Wisdom and influence of elders: Possibilities of health promotion and decreasing tobacco exposure in First Nations communities.
        Can J Public Health. 2010; 101: 154-158
        • Hays D.
        • Singh A.
        Qualitative Inquiry in Clinical and Educational Settings.
        The Guilford Press, New York, NY2012
        • Berg C.
        • Daley C.
        • Mzir N.
        • et al.
        Physical activity and fruit and vegetable intake among American Indians.
        J Comm Health. 2012; 37: 65-71
        • Eilat-Adar S.
        • Mete M.
        • Fretts A.
        • et al.
        Dietary patterns and their association with cardiovascular risk factors in a population undergoing lifestyle changes: The Strong Heart Study.
        Nutr Metab Cardiov Dis. 2013; 23: 528-535
        • Thompson F.
        • McNeel T.
        • Dowling E.
        • Midthune D.
        • Morrissette M.
        • Zeruto C.
        Interrelationships of added sugar intake, socioeconomic status, and race/ethnicity in adults in the United States: National Health Interview Survey, 2005.
        J Am Diet Assoc. 2009; 109: 1376-1383
        • Taylor C.
        • Keim K.
        • Gilmore A.
        • Parker S.
        • Delinder J.
        Most commonly consumed foods and food perceptions in Native American women.
        Am J Health Behav. 2006; 30: 613-625
        • Hodge F.
        • Nandy K.
        Predictors of wellness and American Indians.
        J Health Care Poor Underserved. 2011; 22: 791-803
        • DeLong A.
        • Larson N.
        • Story M.
        • Neumark-Sztainer D.
        • Weber-Main A.
        • Ireland M.
        Factors associated with overweight among urban American Indian adolescents: Findings from project EAT.
        Ethn Dis. 2008; 18: 317-323
        • Weaver H.
        • Jackson K.
        Healthy living in two worlds: Testing a wellness curriculum for urban Native youth.
        Child Adolesc Soc Work J. 2010; 27: 231-244
        • Saksvig B.
        • Gittelsohn J.
        • Harris S.
        • Hanley A.
        • Valente T.
        • Zinman B.
        A pilot school-based healthy eating and physical activity intervention improves diet, food knowledge, and self-efficacy for Native Canadian children.
        J Nutr. 2005; 135: 2392-2398
        • Gittelsohn J.
        • Anliker J.
        • Sharma S.
        • Vastine A.
        • Caballero B.
        • Ethelbah B.
        Psychosocial determinants of food purchasing and preparation in American Indian households.
        J Nutr Educ Behav. 2006; 38: 163-168
        • Ho L.
        • Gittelsohn J.
        • Sharma S.
        • et al.
        Food-related behavior, physical activity, and dietary intake in First Nations—A population at high risk for diabetes.
        Ethn Health. 2008; 13: 335-349
        • Harnack L.
        • Story M.
        • Holy Rock B.
        • Neumark-Sztainer D.
        • Jeffery R.
        • French S.
        Nutrition beliefs and weight loss practices of Lakota Indian adults.
        J Nutr Educ. 1999; 31: 10-15
      8. American Indian College Fund. Graduate survey. Published 2003. Accessed 2013.

      9. National Center for Educational Statistics (NCES). Status and trends in the education of American Indians and Alaska Natives: 2008. Published September 2008. Accessed November 2013.

        • Juntunen C.
        • Barraclough D.
        • Broneck C.
        • Seibel G.
        • Winrow S.
        • Morin P.
        American Indian perspectives on the career journey.
        J Couns Psychol. 2001; 48: 274-285
        • White Shield R.
        Identifying and understanding indigenous cultural and spiritual strengths in the higher education experiences of indigenous women.
        Wicazo Sa Review. 2009; 24: 47-63
        • Bruner B.
        • Chad K.
        Dietary practices and influences on diet intake among women in a Woodland Cree community.
        J Human Nutr Diet. 2014; 27: 220-229
        • Kerpan S.
        • Humbert M.
        • Henry C.
        Determinants of diet for urban Aboriginal youth: Implications for health promotion.
        Health Promot Pract. 2015; 16: 392-400
      10. Freeman C, Fox M. Status and trends in education of American Indians and Alaska Natives (NCES 2005-108). Washington, DC: US Government Printing Office. Published 2005. Accessed 2013.

      11. Garden-Robinson, J. Seniors and food safety when grandparents take care of grandchildren. Published 2006. Updated October 2006. Accessed May 2015.

        • Farrow C.
        A comparison between the feeding practices of parents and grandparents.
        Eat Behav. 2014; 15: 339-342
        • Burgess-Champoux T.
        • Larson N.
        • Neumark-Sztainer D.
        • Hannah P.
        • Story M.
        Are family meal patterns associated with overall diet quality during the transition from early to middle adolescence.
        J Nutr Educ Behav. 2009; 41: 79-86
        • Franko D.
        • Thompson D.
        • Affenito S.
        • Barton B.
        • Striegel-Moore R.
        What mediates the relationship between family meals and adolescent health issues.
        Health Psychology. 2008; 27: S109-S117
        • Gillman M.W.
        • Rifas-Shiman S.L.
        • Frazier A.L.
        • et al.
        Family dinner and diet quality among older children and adolescents.
        Arch Fam Med. 2000; 9: 235-240
        • Neumark-Sztainer D.
        • Hannan P.
        • Story M.
        • Croll J.
        • Perry C.
        Family meal patterns: Associations with sociodemographic characteristics and improved dietary intake among adolescents.
        J Am Diet Assoc. 2003; 103: 317-322
        • Maxwell D.
        Native American college students: A population that can no longer be ignored.
        (Accessed August 23, 2017)
        • Brown B.
        • Harris K.
        • Harris J.
        • Parker M.
        • Ricci C.
        • Noonan C.
        Translating the Diabetes Prevention Program for Northern Plains Indian youth through community-based participatory research methods.
        Diabetes Educ. 2010; 36: 924-935
        • Eckhardt C.
        • Lutz T.
        • Karanja N.
        • Jobe J.
        • Maupome G.
        • Ritenbough C.
        Knowledge, attitudes, and beliefs that can influence infant feeding practices in American Indian mothers.
        J Acad Nutr Diet. 2014; 114: 1587-1593
        • Velardo S.
        The nuances of health literacy, nutrition literacy, and food literacy.
        J Nutr Educ Behav. 2015; 47: 385-389
        • Carone E.T.
        • Zoellner J.M.
        Nutrition and health literacy: A systematic review to inform nutrition research and practice.
        J Acad Nutr Diet. 2012; 112: 254-265
        • Condrasky M.
        • Quinn A.
        • Cason K.
        Cooking camp provides hands-on nutrition education opportunity.
        J Culinary Sci Tech. 2008; 5: 37-52
        • Karanja D.
        Experiential cooking classes for underserved audiences empowers families with skills to make healthy and affordable meals [abstract].
        J Nutr Educ Behav. 2014; 46: S113-S114
        • LaFromboise T.
        • Lewis H.
        The Zuni life skills development program: A school/community-based suicide prevention intervention.
        Suicide Life Threat Behav. 2008; 38: 343-353
        • Whitbeck L.B.
        • McMorris B.J.
        • Hoyt D.R.
        • Stubben J.K.
        • LaFromboise T.
        Perceived discrimination, traditional practices, and depressive symptoms among American Indians in the upper Midwest.
        J Health Soc Behav. 2002; 43: 400-418
      12. Feeding Ourselves: Food Access, Healthy Disparities, and the Pathways to Healthy Native American Communities. Echo Hawk Consulting, Longmont, CO2015
        • Huffman T.
        Resistance theory and transculturation hypothesis as explanations of college attrition and persistence among culturally traditional American Indian students.
        J Am Indian Educ. 2001; 40: 1-39
        • Atikesse L.
        • Boucher de Grosbois S.
        • St-Jean M.
        • Penashue B.
        • Benuen M.
        Innu food consumption patterns: Traditional food and body mass index.
        Can J Diet Pract Res. 2010; 71: e41-e49
      13. Keith J. Creating a multicultural classroom. 2016. Accessed August 23, 2017.

        • Castagna A.
        • Brayboy B.
        Culturally response schooling for indigenous youth: A review of the literature.
        Rev Edu Res. 2008; 78: 941-993
        • Hooker D.
        Small, peer-led collaborative learning groups in developmental math classes at a tribal community college.
        Multicult Perspect. 2011; 13: 220-226
        • Ingalls L.
        • Hammond H.
        • Dupoux E.
        • Baeza R.
        Teachers’ cultural knowledge and understanding of American Indian students and their families: Impact of culture on a child’s learning.
        Rural Special Educ Q. 2006; 25: 16-24
        • Schanche Hodge F.
        • Pasqua A.
        • Marquez C.
        • Geishirt-Cantrell B.
        Utilizing traditional storytelling to promote wellness in American Indian communities.
        J Transcult Nurs. 2002; 13: 6-11
        • Chen D.
        • Garmararian J.
        Impact of personal preference and motivation on fruit and vegetable consumption of WIC-participating mothers and children in Atlanta, GA.
        J Nutr Educ Behav. 2014; 46: 62-67
        • Eertmans A.
        • Victor A.
        • Vansant C.
        • van den Bergh O.
        Food-related personality traits, food choice motives, and food intake. Mediator and moderator relationships.
        Food Qual Prefer. 2005; 16: 714-726
        • Sproesser G.
        • Strohbach S.
        • Schupp H.
        • Renner B.
        Candy or apple? How self-control resources and motives impact dietary healthiness in women.
        Appetite. 2011; 56: 784-787
        • Steptoe A.
        • Wardle J.
        Motivational factors as mediators of socioeconomic variations in dietary intake patterns.
        Psychol Health. 1999; 14: 391-402
        • Contento I.
        Nutrition Education: Linking Research, Theory, and Practice.
        2nd ed. Jones & Bartlett, Sudbury, MA2011
        • Bandura A.
        Self-efficacy: The exercise of control.
        Freeman, New York, NY1997
        • Hill M.
        The diabetes epidemic in Indian country.
        Wind Change Am Indian Sci Engineer Q. 1997; Summer: 26-31
        • Eikenberry N.
        • Smith C.
        Healthful eating: Perceptions, motivations, barriers, and promoters in low-income Minnesota communities.
        J Am Diet Assoc. 2004; 104: 1158-1161
        • Steptoe A.
        • Pollard T.
        • Wardle J.
        Development of a measure of the motives underlying the selection of food. The food choice questionnaire.
        Appetite. 1995; 25: 267-284
        • Sun Y.
        Health concern, food choice motives, and attitudes toward healthy eating: The mediating role of food choice motives.
        Appetite. 2008; 51: 42-49


      J. F. Keith is an assistant professor, Department of Family and Consumer Sciences, University of Wyoming, Laramie.


      S. Stastny is an associate professor, Department of Health, Nutrition, and Exercise Sciences, North Dakota State University, Fargo.


      A. Brunt is a professor, Department of Health, Nutrition, and Exercise Sciences, North Dakota State University, Fargo.


      W. Agnew is a faculty and extension nutrition educator, Land Grant Department, United Tribes Technical College, Bismarck, ND.