Understanding the Training Needs 

of Older Americans Act (OAA) 

Title VI Program Nutrition 

And Aging Program Professionals 

SUMMER 2019 

Commissioned by NRCNA 

Written by: 

Jean L. Lloyd, MS, Consultant 

& Larry Curley, Consultant 

The National 

Resource Center on 

Nutrition & Aging 
Understanding the Training Needs 

of Older Americans Act (OAA) 

Title VI Program Nutrition 

And Aging Program Professionals 

The National Resource 

Center on Nutrition and 

Aging (NRCNA) is hosted by 

Meals on Wheels America as 

part of a cooperative agreement 

with the Administration for 

Community Living.

 www.nutritionandaging.org

 @NRCNAeng_Aging 
Table of Contents

Issue .................................................. 1 

Executive Summary .................................... 1 

Overview: U.S. Native American Population ............... 2 

Legislative History of the Older Americans Act Title VI...... 2 

Older Americans Act Title VI Funding and Services ......... 3 

Social Determinants of Health ........................... 4 

1) Food Security, Food Sovereignty and Food Deserts ..... 4 

2) Service Needs ...................................... 5 

3) Social Interactions/Social Connectedness ............. 5 

National Title VI Program Evaluation ..................... 7 

Comparison of National Title VI Surveys .................. 7 

National Title VI Program Survey “Serving Tribal Elders 

Across the United States” ............................... 7 

Nutrition Quality Standards ............................. 8 

Current Professional Training Availability................. 9 

Current Literature Review............................... 9 

Discussion............................................. 9 

Conclusions............................................ 10 

References ............................................ 11 

Appendix 1 ............................................ 12 

Appendix 2 ............................................ 17 
Executive Summary 

ISSUE 

Based on discussions with and requests from Title VI directors, the need was 

raised for the development and implementation of programs to meet the training 

needs of the Older Americans Act (OAA) Title VI nutrition and aging program 

professionals. Such training would improve the administration, implementation, 

quality, efficiency and effectiveness of the implementation of the OAA Title VI 

Nutrition Program. An environmental scan of available client needs assessments, 

program surveys, program evaluations, research and studies by federal, nongovernmental organizations and research institutions was conducted. This paper 

and the accompanying reference documents address this topic. 

The primary purpose of this paper was 

to examine the availability of data to 

help inform how to meet the training 

needs of OAA Title VI nutrition and 

aging program professionals. Data 

and conclusions reached in the studies 

cited suggest that social determinants 

of health (SDOH), such as access to 

healthy food, diet, nutrition and social 

interactions, play a significant role in 

determining the health status of the 

American Indian/Alaska Native/Native 

Hawaiian (AI/AN/NH) population. 

Diet and nutrition can improve the 

health and well-being of AI/NA/ 

NH elders. Yet it is important to 

understand the contextual setting 

of many in this population as well 

— high poverty rates, low income, 

low education attainment and high 

prevalence rate of chronic diseases. 

One study concluded that one in 

seven older American Indians will face 

hunger or food insecurity, thereby 

substantiating the crucial role that the 

Title VI Nutrition Program might have 

in mitigating the situation. 

OAA Title VI provides an opportunity 

to organizations and Tribal 

governments serving AI/AN/NH elders 

to improve health and nutrition 

services. However, as the studies 

by both the National Association of 

Area Agencies on Aging (n4a) and 

the University of North Dakota (UND) 

conclude: The available resources 

are inadequate and fall short of the 

stated purposes of Older Americans 

Act Title VI. 

Two key factors, available resources 

and the level of funding for these •

programs, affect the services that are 

needed by AI/AN/NH elders and Title 

VI program staff. There is also a strong 

correlation between funding levels 

and the impact of the programs in 

Tribal communities. 

In addition to bolstering funding, other 

clear needs exist. The studies cited 

in this paper identify and suggest the 

strong correlation between nutrition 

and health, the unmet needs in Tribal 

communities, and organizational 

issues facing Tribal aging programs, 

which include the high turnover of 

staff.

Key Take Home Messages 

• The OAA major focus is on the

delivery of congregate and

home-delivered meals to reduce

hunger and food insecurity, and to

promote socialization and health

among AI/AN/NH elders. But Title

VI directors shared experiences

regarding the limited longevity of

directors and the high turnover

of staff in Tribal aging programs

hinder accomplishment of these

goals. These observations identify

a need. New and incoming staff

increase the need for continual 

training and support and 

specifically for cooks for meal 

preparation. 

The strategies that could 

influence Title VI implementation 

include improving existing 

food programs; promoting 

food sovereignty and access to 

traditional foods and expanding 

locally cultivated foods. All of 

these strategies could be part of 

training for Title VI directors and 

staff.

This document identifies the need 

to develop and implement a 

standardized national Tribal 

nutrition training program. This 

would be extremely beneficial in 

the delivery of healthy, nutritious 

meals to improve the health status 

of the elders using these services. 

It is also critical to evaluate 

training effectiveness. At a 

minimum, a certificate program 

for nutrition program staff 

would provide the necessary 

credentials and training to inspire 

confidence by Tribal elders that 

the meals meet the nutrition 

and food safety requirements 

of the OAA, are appealing, and 

include foods to reinforce cultural 

traditions. 

• 

• 

1 
Introduction

Overview: U.S. Native American Population 

About 945,000 people age 60 and over identify themselves as Native American (NA) or Alaskan Native (AN) alone or in 

combination with another racial group. About 549,000 of those elders identify as NA or AN with no other racial group. 

There are 573 federally recognized American Indian (AI) tribes or AN villages, and more than 100 state-recognized 

tribes. About 26 percent of AI/AN live at the poverty level, compared to 11 percent of non-Hispanic Whites, in 2012.1 

This population faces challenges of poor housing and inadequate sewage treatment, cultural barriers, geographic 

isolation, low income and inadequate access to health care. Leading chronic conditions and causes of death include 

obesity, heart disease, cancer, accidents, diabetes and stroke. Many of these conditions are directly impacted by food, 

exercise and behavioral health habits.2 

Legislative

History of the

Older Americans 

Act Title VI 

The Older Americans Act (OAA) was 

signed into law by President Lyndon 

Johnson in 1965. It is administered by 

the Department of Health and Human 

Services (DHHS) Administration on 

Aging (AoA) within the Administration 

for Community Living (ACL). In the 

ensuing years, it was amended several 

times in response to the expressed 

needs of the aging community. 

The amendments in 1975 authorized 

grants to Indian Tribes under Title III 

(grants to states) to provide services 

(including congregate and homedelivered nutrition services). This was 

the first step toward recognizing the 

needs of the nation’s Native elder 

population. Under Title III, funds for 

aging programs were and currently 

are allocated to the State Units on 

Aging (SUAs) based on the total State 

older population. SUAs then allocated 

Title III funds to the Area Agencies 

on Aging (AAAs) to plan and develop 

services needed by older adults in 

the Planning and Service Areas. This 

included the Native elder population 

whose service providers were the 

Tribal governments. 

With the passage of P.L. 93-638, 

“The Indian Self-Determination and 

Education Assistance Act” in early 

1975, Tribes began to question why 

Under Title VI, services provided include congregate and homedelivered meals, information and referral, transportation, 

personal care, chores, health promotion and disease 

prevention, other supportive services and support for family 

and informal caregivers. 

they were not able to receive these 

funds directly from the federal 

government rather than having to 

request funding from either the AAAs 

or the SUAs. 

The 1978 amendments to the OAA 

authorized a separate title, Title VI for 

Grants for American Indians, Alaska 

Natives and Native Hawaiians (AI/ 

AN/NH) for nutrition and supportive 

services. In 2000, Title VI expanded 

to include caregiver support services. 

Eligible Tribal organizations receive 

Title VI grants in support of the 

delivery of home- and communitybased supportive services for their 

elders, including nutrition services 

and support for family and informal 

caregivers. 

Under Title VI, services provided 

include congregate and homedelivered meals, information and 

referral, transportation, personal care, 

chores, health promotion and disease 

prevention, other supportive services 

and support for family and informal 

caregivers.3 

2 
Older Americans 

Act Title VI 

Funding and

Services 

Initially, fewer than 30 Tribal programs 

were funded by Title VI in the early 

1980s. Congress appropriated $6 

million in the first year of funding. 

This level of funding remained static 

over the next few years as the number 

of Tribes applying for and receiving 

approval increased. As the number 

of grantees increased, the funding 

decreased to previously 

funded Tribes. 

needs of indigenous peoples. Among 

the myriad unmet needs are health 

care, education, public safety, 

housing and rural development. The 

Commission finds that significant 

disparities in federal funding exist 

between Native Americans and other 

groups in our nation, as well as the 

general population. Among immediate 

requirements for increased funding 

are: infrastructure development, 

without which tribal governments 

cannot properly deliver services; tribal 

courts, which preserve order in tribal 

communities, provide for restitution 

of wrongs, and lend strength and 

validity to other tribal institutions; and 

tribal priority allocations, which permit 

tribes to pursue their own priorities 

• 

• 

By 2018, there were 270 grantees 

under the Title VI program. A report 

by the U.S. Commission on Civil Rights, 

“A Quiet Crisis, Federal Funding and 

Unmet Needs in Indian Country,” 

concluded: “This study reveals that 

federal funding directed to Native 

Americans through programs at these 

agencies has not been sufficient to 

address the basic and very urgent 

and allow Tribal governments to 

respond to the needs of their citizens.”4 

This study clearly underscores that 

one of the contributing mitigating 

factors is funding of programs 

designed to meet the needs of 

American Indians, including the elderly 

Indian population. 

Total 2019 Title VI funding is 

$34,308,000. “In Fiscal Year (FY) 2018, 

grants were awarded to 270 Tribal 

organizations (representing 400 

Tribes and villages), including one 

organization serving Native Hawaiian 

elders. Services provided by this 

program in FY 2017 include: 

• Transportation Services, which

• 

provided over 700,000 rides to

meal sites, medical appointments,

pharmacies, grocery stores and

other critical daily activities.

Home-Delivered Nutrition

Services, which provided almost

2.5 million meals to more than

24,000 homebound NA elders.

The program also provides social

contacts that help to reduce the

risk of depression and isolation

experienced by many homebound

NA elders.

Congregate Nutrition Services,

which provided almost 2.4 million

meals to more than 61,000 NA

elders in community-based

settings, as well as an opportunity

for elders to socialize and

participate in a variety of activities,

including cultural and wellness

programs.

Information, Referral and

Outreach Services, which provided

more than 810,000 hours of

outreach and information on

services and programs to NA

elders and their families, thereby

empowering them to make

informed choices about their

service and care needs.” 5 

Title VI Services FY 2017 

2.4 MILLION 

CONGREGATE MEALS 

810,000 HOURS 

OF INFORMATION, 

OVER 700,000 RIDES. OUTREACH & REFERRAL

2.5 MILLION HOME 

DELIVERED MEALS 

3 
 

 

Introduction Social 

Determinants of 

Health 

The World Health Organization defines 

social determinants of health (SDOH) 

as the conditions in which people 

are born, grow, live, work and age.6 

These SDOH are the economic and 

social conditions under which people 

live that help influence their health.7 

SDOH are risk factors in society such 

as income or employment; availability 

and access to affordable nutritious 

food; social isolation or social support; 

affordable, safe housing; utilities 

such as cooling in the summer and 

heating in the winter; transportation 

and access to community services; 

neighborhoods; and healthcare 

systems. 

AI/AN/NH are diverse in culture, 

history, health disparities and 

nutritional health. Many live in 

poverty, in poor housing conditions, 

and in rural and frontier areas. Many 

have decreased access to health care 

and decreased access to healthy 

foods. One result is increased risks of 

chronic disease — especially obesity, 

diabetes, heart disease and cancer — 

which are impacted by access or lack 

of access to adequate, quality, safe 

and nutritious food. 

A recent report from the Anthem 

Public Policy Institute indicated that 

socioeconomic factors and support 

networks may be responsible for as 

much as 40 percent of overall health 

risk. If individual factors such as 

diet, exercise and health habits are 

considered, these may account for 80 

percent of overall health risk. 

The research showed a difference 

between the perceptions of individuals 

and academic research on risk factors 

and their importance. Individuals 

attributed more importance to food 

and social support than academic 

research did.8 Title VI programs 

place significant importance on 

serving healthy meals, providing 

social activities and decreasing social 

isolation, and supporting families and 

caregivers — all of which are SDOH 

2) Food Security, Food

Sovereignty and Food

Deserts 

Food security is defined as consistent, 

dependable access to enough 

nutritious food for active, healthy 

living.9 One of the few studies of 

hunger and food insecurity among 

AI/AN elders was completed by First 

Nations.10 It found that that one in 

seven older AIs will face hunger or 

food insecurity. Through healthy 

meal provision, coordination with 

the United States Department of 

Agriculture (USDA) food assistance 

programs, and connections to social 

activities and interactions, the Title VI 

Program partially addresses hunger 

and food insecurity among AI/AN. 

Recent research has questioned the 

connection with USDA food assistance 

programs. Warne and Wescott (2019) 

discuss the role of SDOH influencing 

nutrition in Native communities. They 

posit that rather than addressing 

hunger and food insecurity, USDA 

food assistance programs such 

as Food Distribution on Indian 

Reservations may not be culturally 

sensitive and may have contributed to 

some of the health disparities found in 

Indian country through the provision 

of unhealthy food. Although conceding 

that some USDA food assistance 

programs have improved by offering 

healthier foods, this research indicates 

that more and diverse actions need to 

be taken to improve nutritional health. 

The research did not specifically 

address the Title VI Nutrition Program 

because it is not funded by the USDA. 

In addition, the researchers indicate 

that there may be resistance by 

both individuals and Tribes to the 

incorporation of more healthy 

foods into meals and to changing 

dietary habits due to the current 

acceptance of less healthy foods. 

These strategies recommended by 

the researchers could influence 

Title VI implementation: improving 

existing food programs, promoting 

food sovereignty and access to 

traditional foods and expanding 

locally cultivated foods.11 All of these 

strategies could be included in training 

for Title VI directors and staff.

Food sovereignty is the recognition 

of the right and ability of each 

Tribal nation to feed its people and 

the acknowledgement that Native 

traditional foods are important to 

the health and well-being of Native 

people. It includes concepts such as 

local control of agriculture, access 

to culturally appropriate healthy 

sustainable food and use of traditional 

knowledge in dietary habits and 

agricultural practices. 

As part of the food sovereignty 

movement, strategies address the 

issue of food deserts. Food deserts 

are locations without ready access 

to fresh, healthy and affordable 

foods.12 If there is less reliance on 

foods brought into communities from 

other places and more reliance on 

locally grown and/or processed foods, 

there may be more food security and 

healthier diets. This could possibly 

decrease the intake of too much 

sodium, added sugar and saturated 

fat, which are known to have adverse 

health effects. Traditional diets are 

limited in sodium, added sugar and 

saturated fat and are healthier due 

to the use of lean protein, fruits and 

vegetables, and whole grains as well 

as traditional food processing and 

preparation methods. 

Other factors that impact the health 

and well-being of AI elders include 

substandard housing; limited 

available housing stock on most 

Indian reservations; roads and 

transportation, especially when 

the nearest healthcare facility is 40 

miles away over impassable roads 

during inclement weather; and 

communication systems that are 

either unreliable or non-existent. 

These are all examples of key SDOH. 

In a study by the Navajo Nation 

Division of Health, Dr. Gayathri Kumar 

identified food deserts as a significant 

4 
 

issue and said that where there are 

stores, the availability of healthy foods 

is limited and more expensive.13 

A unique approach to addressing the 

nutrition needs of Tribal communities 

is one taken by the Navajo Nation, 

which published a toolkit to develop 

and implement comprehensive Tribal 

food policies and laws.14 The toolkit 

is designed to increase Tribal food 

sovereignty and security. 

It is unclear, however, if the toolkit 

or the use of the toolkit has had an 

impact in improving the health and 

well-being of the Navajo people, i.e. 

decreasing prevalence of diabetes, 

obesity or chronic diseases. Evaluation 

of its impact on the health data is too 

early to determine its effectiveness. 

Still, it is an example of laws, policies 

and programs that tribes could 

develop that emphasize traditional 

foods and limit sodium and sugar 

intake by regulating sales of junk food 

in Tribal communities. 

Poverty influences access to healthy 

food. Food insecurity is higher in lowincome populations and food deserts 

are more prevalent in lower income 

areas. Surveys of 18,134 Native elders 

found that 47.3 percent of Native 

elders had incomes below $14,999 

compared to 15 percent of the U.S. 

adults aged 65 and older — or a 

poverty rate three times higher.15 This 

UND survey assesses the health and 

social needs of Native elders in Tribal 

communities every three years. The 

2017 poverty threshold was $11,756 

for a single older adult living alone. 

AI/AN/NH program elders are 

poorer and influenced by their food 

environment. Concepts of food 

security, food sovereignty, use of 

traditional foods, and food deserts 

may influence what food is or is not 

be available to local tribes to be eaten 

at home and served in the Title VI 

Nutrition Program. The prevalence of 

food insecurity, food deserts, and lack 

of access to healthy foods emphasizes 

the importance of serving healthy 

meals as well as meals that reinforce 

culture. Other SDOH such as poor 

housing, transportation limitations 

and healthcare access also impact AI/ 

AN/NH health and well-being. 

2) Service Needs

The population of elderly American 

Indians is growing with each decade. 

They are living longer, and recent 

studies indicate they have a high 

rate of diabetes, obesity and chronic 

diseases. These factors contribute 

to high health care costs in Tribal 

communities and the expenditures 

of the Indian Health Service’s (IHS) 

Preferred Referral Care (PRC), formerly 

Contract Health Care funds. PRCs 

are designated funds appropriated 

by Congress to the IHS to pay for 

specialty care that is not provided by 

the IHS, such as heart surgery and 

liver transplants. Unfortunately, these 

funds are limited and it is not unusual 

that funds appropriated in October, 

the new fiscal year, are depleted by 

March of the following year. The result 

is that if one needs a heart transplant 

in July, he would have to wait until 

October when the new appropriations 

are allocated. 

The incidence and prevalence of 

chronic diseases among the AI elderly 

population are also captured in the 

UND “Identifying Our Needs: A Survey 

of Elders” Title VI Cycle VI Needs 

Assessment surveys. The data show 

that “American Indian elders have a 

higher prevalence of chronic disease 

than other races in the U.S. population 

yet are largely overlooked in research 

and in proposed federal, social, and 

tribal interventions. We identified the 

influence of social variables on the 

health status of AI/AN/NH elders and 

found that 90% of elders surveyed 

from 2011 through 2014 had at least 

one chronic disease.”16 Comparatively, 

the National Council on Aging, using 

2015 Medicaid and Medicare data, 

reported that 80 percent of older 

adults of all race/ethnic groups had at 

least one chronic condition.16 

According to the UND data, high blood 

pressure, diabetes and arthritis were 

the three leading chronic conditions 

for AI/AN/NH elders. The frequency 

of hypertension among AI/AN/NH 

elders (59 percent) nearly mirrored 

the national average (58 percent). 

However, other chronic conditions 

among AI/AN elders occurred 

at double the national average. 

Specifically, 54 percent of the AI/

AN/NH elders reported diabetes, 

compared with only 27 percent of the 

U.S. population aged 65 years or older. 

Thirtyone percent of all U.S. adults 

aged 65 or older were diagnosed 

with arthritis in 2015, compared 

with 47 percent of AI/AN/NH elders. 

About 78 percent of AI/AN/NH elders 

were considered overweight/obese 

compared to 62 percent of all U.S. 

adults aged 65 or older.16 

The Kumar study suggests there 

is substantial evidence that 

improvement of the population’s 

diet and nutrition might reduce the 

incidence and prevalence of these 

chronic diseases. As in studies by 

Adamsen and others (2018), it is 

possible that with the improvement of 

diet and nutrition, the life expectancy 

of AI elders could be increased. 

2) Social Interactions/Social

Connectedness

Social interaction and social 

connectedness are basic SDOHs, 

essential to health and quality of 

life. Loneliness, including feeling 

socially isolated or feeling a lack 

of companionship, has major 

implications for the physical, 

emotional and cognitive health of 

older adults. An evaluation of the Title 

III Nutrition Program found that better 

social integration and socialization can 

delay memory loss, reduce obesity 

and hypertension, and lower mortality. 

Greater social integration has been 

associated with Medicare savings.17 

5 
Similar benefits may occur with the 

Title VI Nutrition Program as well. 

Like Title III and in keeping with 

the purposes of the OAA Nutrition 

Program, a primary component 

of the Title VI Nutrition Program is 

socialization and social activities. 

Social activities reduce social isolation 

and reinforce culture and tradition. 

Social isolation and living in rural areas 

present barriers to this basic SDOH in 

Indian country. Research has found 

that cultural practices, traditions, 

ceremonies, spiritual practices, 

traditional dance and beadwork are 

important to resilience and related to 

improved physical health and lower 

rates of depression. An examination 

of the UND survey results suggest 

that a “degree of participation in 

traditional cultural practices is directly 

related to happiness and a sense of 

peacefulness and calm among AI/AN/ 

NH elders.”18 

6 
Introduction Understanding the National Title VI

Program: Client and Staff Needs. 

The Administration for Community Living (ACL) evaluates federally funded programs on a regular basis including program 

implementation, service, accomplishments and outcomes, and participant feedback. These evaluations are conducted 

through independent contractors like ICF International (the National Title VI Program Evaluation), the University of North 

Dakota (Identifying Our Needs: A Survey of Elders) and the National Association of Area Agencies on Aging (Serving Tribal 

Elders Across the United States). The next section reviews current progress of these Title VI Program national evaluations. 

National Title 

VI Program

Evaluation 

According to the Year 2 Interim 

Report, most elders and program 

staff indicated that Nutrition Services 

served a critical need. Data from 

elders and staff indicated that the 

program meal was the only hot and 

nutritious meal that they had in the 

day, in part because it was difficult 

for many of the elders to cook due 

to illness or disability. Both elders 

and staff emphasized the crucial role 

of the meals, the social and cultural 

connections that occurred during 

mealtime, and importance of the meal 

and activities to stress reduction for 

elders and family caregivers. 

One elder reported, “We come here 

and share. Everybody is eating it. It 

makes you feel good...It’s the way 

the cook prepared it. The native 

culture, you have it here and we 

all share that because we can’t go 

home to do that, have native food.” 

Elders in some programs offered 

suggestions to improve meals, 

including rotating menus more often, 

serving more traditional foods, and 

providing separate meals to meet 

special dietary needs such as for 

allergies and diabetes. Because many 

programs serve fewer than five days 

per week, elders suggested serving 

more meals per week would be 

helpful. Staff recognized the validity of 

these suggestions and responded that 

they could improve quality, variety and 

number of meals per week if more 

funding was available.19 

The Interim results of the Title VI 

evaluation reinforce the nutritional 

value of the meals, the social 

connectedness among participants 

that occurs at the site, the role of the 

nutrition program in supporting family 

and caregivers, and the importance of 

native culture and traditional foods. 

All of these factors provide a basis 

for recommendations for improving 

nutrition services. 

Comparison of

National Surveys 

National Survey of OAA Title III

Nutrition Program Participants

vs Identifying Our Needs: A

Survey of VI Cycle VI Needs

Assessment 

The National Survey of OAA Title III 

participants in 2014 found that “63 

percent of Home-Delivered Nutrition 

Program participants relayed that 

the program meal provides onehalf or more of their food for the 

day. More than half (52 percent) of 

Home-Delivered Nutrition Program 

participants live alone. About twothirds (69 percent) of Home-Delivered 

Nutrition Program participants are 

over the age of 75.”20 Since this survey 

was implemented, succeeding studies 

have shown similar results. 

A similar survey of OAA Title VI 

participants by UND reported that 

out of a sample of 18,134 Native 

elders, 15 percent were using HomeDelivered meals; however, more 

than twice this number (34 percent) 

would use these services if they were 

available. From a needs perspective, 

this finding suggests that the Title VI 

Home-Delivered meals are meeting 

approximately half of the perceived 

needs as expressed by the elders. 

Compare this data with the Title VI 

Congregate meals program, wherein 

17 percent of the respondents 

indicated they participate in the 

programs and another 18 percent 

would participate in the meals 

programs if they were available. This 

suggests that only 50 percent of the 

elders’ perceived needs are being met 

by the program.16 

National Title VI 

Program Survey 

Serving Tribal Elders Across the

United States 

The National Association of Area 

Agencies on Aging (n4a) and the 

Scripps Gerontology Center at Miami 

7 
University surveyed Title VI directors 

on the needs of Title VI programs 

across the country. Their 2017 report, 

“Serving Tribal Elders Across the 

United States,” provides valuable data 

and a snapshot of the successes and 

unmet needs of the Title VI programs. 

This report cited the First Nations 

study, which concluded that one in 

seven older American Indians will face 

hunger or food insecurity, thereby 

substantiating the crucial role that the 

Title VI Nutrition Program might have 

in mitigating the situation.21 

The survey examined other aspects 

of the Tribal service delivery system 

including questions related to 

organizational structure and staffing 

of the program; programs and 

services; elder abuse programs; use 

of technology and infrastructure; 

partnerships for service delivery; 

health care and long-term care 

services; and training and technical 

assistance needs of the programs and 

staff.

The report considered the 

environmental context of Tribal 

elders nutrition programs to be 

critical in assessing the status of the 

program. Respondents indicated that 

Title VI funds were used to provide 

Congregate meals (96 percent) and 

Home-Delivered meals (95 percent), 

and 72 percent used Title VI funds 

for senior center activities. Tribes 

accessed other sources such as 

Tribal, OAA Title III, state and smaller 

miscellaneous other funding to meet 

this need. Despite leveraging funds 

from other sources, funding remains 

a constant constraint. The report 

indicates the need for more funding 

for case management, caregiver 

services and increased access to 

assisted-living housing. 

The “Serving Tribal Elders” report 

provides key information on 

organization and staffing patterns of 

Title VI programs. The turnover rate 

among Title VI programs is high and 

there is a constant need for training 

and re-training to ensure continuity 

and maintain a quality program. 

Limited Title VI staff training and 

inadequate staffing levels are 

basic program implementation 

difficulties.

The report identifies staff training and 

inadequate staffing levels as basic 

program implementation difficulties. 

The mean number of full-time staff is 

two; part-time staff is also two; and 

volunteers is one. This adds up to a 

mean of four full-time equivalents 

(FTEs). Given these constraints, 

staff assume multiple roles within 

programs, from meal preparation 

and intake functions to providing 

information and referral, coordinating 

caregiver and transportation 

programs and writing grants. The 

result is that services are limited to 

health and well-being of older adults. 

The services are intended to: 

• Reduce hunger and food

insecurity,

• Promote socialization, and

• Delay the onset of adverse health

conditions.23 

The OAA requires both Title III and 

Title VI to adhere to basic nutrition 

quality standards. Under Title III, the 

OAA requires that all meals served 

using OAA funds adhere to the current 

Dietary Guidelines for Americans, 

those most crucial to funding sources, 

i.e. congregate meals, home-delivered

meals, transportation and caregiver

services.

The report discussed current training 

and future needs. Currently staff and 

volunteers received training in food 

safety (99 percent), menu planning (86 

percent) and diabetes awareness (78 

percent). The report indicates unmet 

needs in the areas of staff computer 

literacy (69 percent), and the need for 

both computer software (59 percent) 

and computers (56 percent). Resource 

development was identified as a key 

training need. 

Nutrition Quality

Standards 

The Title III and VI Nutrition Programs 

are designed to promote the general 

provide a minimum of one-third of 

the Dietary Reference Intakes, meet 

state or Tribal and local food safety 

and sanitation requirements, and be 

appealing to older adults.24 

Title VI requires that meals served are 

to be comparable to those funded 

under Title III, be substantially in 

compliance with Title III, be provided in 

a manner that preserves and restores 

their respective dignity, self-respect, 

and cultural identities, and takes into 

account subsistence needs, local 

customs, and other characteristics that 

are appropriate to the unique cultural, 

regional, and geographic needs of the 

Indian populations to be served.25 

As a result of these legislative 

requirements, Title VI program 

directors and staff need a basic 

understanding of nutrition, health 

conditions related to nutrition, menu 

planning, food service and food 

8 
production, food safety and sanitation, 

and site operations as well as cultural 

traditions and foods representative of 

the AI/AN/NH population being served. 

These requirements are in addition to 

the federal and Tribal administrative 

requirements such as reporting, fiscal 

management, human resources and 

computer skills needed to operate a 

program. 

Current 

Professional 

Training

Availability 

The AoA provides training and 

technical assistance to Tribal 

organizations to support the 

development of comprehensive and 

coordinated systems of services to 

meet the needs of NA elders. Training 

and technical assistance is provided 

through national conferences, 

regional cluster trainings targeted 

to the needs of a specific region, site 

visits, monthly webinars, website, 

e-newsletters, telephone and written

consultations, and through the Native

American Resource Centers.25 Despite

these efforts, Title VI directors have

requested more specific training

targeted to meeting the needs of the

Title VI Nutrition Program.

Current 

Literature Review 

There is limited current published 

literature about the AI/AN/NH elders, 

nutrition of Native elders, the OAA 

Title VI Nutrition Program, or its 

operations. The National Resource 

Centers at the University of North 

Dakota (https://ruralhealth.und.edu/ 

projects/nrcnaa), at the University 

of Alaska (https://www.uaa.alaska. 

edu/academics/college-of-health/ 

nrc-alaska-native-elders/) and 

the University of Hawaii (http:// 

manoa.hawaii.edu/hakupuna/) list 

publications specific to the AI/AN/NH 

elders, but capture limited information 

on the OAA Title VI Nutrition Program 

(see Appendix 1). Also listed is a 

website from First Nations, which 

includes a bibliography on various 

topics including Native nutrition and 

health. This bibliography includes few 

references to Native elders. 

As a result, current published 

literature provides little guidance 

for specific training needs, and the 

sources cited in this document may 

provide the best foundation. 

Publicly available websites provide 

the information necessary for staff 

training for the Title VI Nutrition 

Program on nutrition, health, food 

service, sanitation and program 

implementation. (See 

Appendix 2.) 

Discussion 

Each of the cited studies, surveys 

and reports provides the contextual 

basis for an examination of the role 

nutrition plays in the health and wellbeing of elderly American Indians. 

The contextual setting includes the 

high poverty rates, low income, 

low education attainment and high 

prevalence of chronic diseases. 

Each of these variables are SDOH. 

As this population ages, the lower 

life expectancy and the high loss of 

lives during the greatest period of 

productivity will have a significant 

social and health impact. There also 

will be a significant impact from 

the high costs (social and financial) 

associated with statistical data on 

housing, income, etc. among the AI 

population. 

The sources conclude the crucial 

role that diet and nutrition play in 

improving the health and well-being 

of AI/AN/NH elders. For AI/AN/NH 

elders, Title VI of the OAA provides 

an opportunity to improve these 

conditions. However, as the studies 

by both n4a and UND conclude, the 

available resources are inadequate 

and fall short of the stated 

purposes of Title VI of the OAA. 

These sources concur with the 

statement that “It is the purpose of 

this title to promote the delivery of 

supportive services, including nutrition 

services to American Indians, Alaskan 

Natives, and Native Hawaiians that 

are comparable to services provided 

under Title III” and “that such services 

and benefits should be provided in a 

manner that preserves and restores 

their respective dignity, self-respect 

and cultural identities.”25 

The provisions of the OAA as it relates 

to both Title VI and Title III depend 

heavily on congressional funding that 

supports the organizational structure 

and staffing of Tribal programs. Two 

key factors—available resources 

and the level of funding for these 

programs— impact the provision of 

services needed by both AI/AN/NH 

elders and Title VI program staff.

9 
Conclusions 

Data and conclusions reached in the studies cited suggest that SDOH such as access to healthy food, diet, nutrition and 

social interactions play a significant role in determining the health status of the AI/AN/NH population. There is also a 

strong correlation between funding levels and the impact of the programs in Tribal communities. 

The primary purpose of this paper was to examine available data to help inform how to meet the training needs of OAA 

Title VI nutrition and aging program professionals. The summarization cannot ignore the important variable of resources. 

Concurrently, the studies cited in this paper identify and suggest the strong correlation between nutrition and health, 

the unmet needs in Tribal communities, and organizational issues facing Tribal aging programs, which include the high 

turnover of staff. 

Recommendations 

ONE 

New and incoming 

staff increase the need 

for continual training 

and support and 

specifically for cooks for 

meal preparation. The 

experiences shared by 

Title VI directors regarding

the limited longevity of 

directors and the high 

turnover of staff in Tribal 

aging programs highlight 

this need. 

TWO 

Thee strategies that 

could influence Title VI 

implementation include 

improving existing food 

programs, promoting food 

sovereignty and access 

to traditional foods and 

 expanding locally cultivated 

foods. All of these strategies 

could be part of training for 

Title VI directors and staff.

THREE 

Staff in Tribal aging 

programs would 

significantly benefit 

from the development 

and implementation 

of a standardized 

national Tribal nutrition 

training program. This 

training program would 

be extremely beneficial 

in the delivery of healthy 

nutritious meals to impact 

the health status of the 

elders utilizing these 

services. 

FOUR 

Implementing policies 

and procedures to ensure 

continued measurement 

and evaluation of training 

effectiveness is critical. 

At a minimum, a certificate 

program for nutrition 

program staff would 

provide the necessary 

credentials and training 

to inspire confidence by 

Tribal elders that the meals 

meet the nutrition and food 

safety requirements of the 

OAA, are appealing, and 

include foods to reinforce 

cultural traditions. 

The National Resource Center on Nutrition and Aging is 

grateful for the support of the Administration for Community 

Living’s Office of Native Americans, Alaskan Native and Native 

Hawaiian Programs in the preparation of this report. 

10 
References 

1. Department of Health and Human

Services Fiscal Year 2020 Administration for

Community Living Congressional Budget

Justification. Available at: https://acl.gov/

about-acl/budget . Retrieved June 18, 2019.

2. Department of Health and Human

Services Office of Minority Health. Profile of

American Indian Alaska Natives. Available at:

https://minorityhealth.hhs.gov/omh/browse.

aspx?lvl=3&lvlid=62. Retrieved June 18, 2019.

3. Administration for Community Living.

Services for Native Americans (OAA Title

VI). Available at: https://acl.gov/programs/

services-native-americans-oaa-title-vi.

Retrieved: June 18, 2019.

4. U.S. Commission on Civil Rights. A Quiet

Crisis: Federal Funding and Unmet Needs

in Indian Country (July 2003). Available

at: https://www.usccr.gov/pubs/na0703/

na0204.pdf. Retrieved June 18, 2019.

5. Department of Health and Human

Services. Fiscal Year 2020 Administration

for Community Living Congressional Budget

Justification. Available at: https://acl.gov/

about-acl/budget. Retrieved June 18, 2019.

6. World Health Organization. Social

Determinants of Health. Available at:

http://who.int/gender-equity-rights/

understanding/sdh-definition/en/ Retrieved

June 18, 2019. 

7. Magnan S, 2017. Social Determinants

of Health 101 For Health Care. National

Academy of Sciences. Available at: https://

nam.edu/social-determinants-of-health-101-

for-health-care-five-plus-five/. Retrieved

June 18, 2019. 

8. Bridging Gaps to Build Healthy

Communities. Anthem Public Policy Institute.

May, 2019. Available at: https://www.

anthempublicpolicyinstitute.com/userFiles/

uploads/28/28_Report_Bridging-Gaps-toBuild-Healthy-Communities.pdf. Retrieved

June 18, 2019. 

9. United States Department of Agriculture.

Economic Research Services. Food Security

in the U.S. Available at: https://www.ers.

usda.gov/topics/food-nutrition-assistance/

food-security-in-the-us. Retrieved June 18,

2019. 

10. First Nations, Nourishing Native Foods

and Health. Available at: https://www.

firstnations.org/our-programs/nourishingnative-foods-health/. Retrieved June 19,

2019. 

11. Warne, D. and Wescott, S. Social

Determinants of American Indian

Nutritional Health. June. 2019. Available

at: https://academic.oup.com/cdn/

advance-article/doi/10.1093/cdn/

nzz054/5497919?searchresult=1. Retrieved

June 18. 2019. 

12. United States Department of Agriculture.

Economic Research Service. Documentation.

Available at: https://www.ers.usda.gov/

data-products/food-access-research-atlas/

documentation. Retrieved June 18, 2019.

13. Kumar G, Jim-Martin S, Piltch E, Onufrak

S, McNeil C, Adams L, Williams N, Blanck

HM, & Curley L, 2016. Healthful Nutrition of

Foods in Navajo Nation Stores: Availability

and Pricing. American Journal of Health

Promotion, 30(7):501-510; doi: 10.4278/

ajph.140821-QUAN-44.

14. Harvard Law School, Food Law and

Policy Clinic, Community Outreach and

Patient Empowerment, & the Navajo

Nation, 2015. Good Laws, Good Food:

Putting Food Policy to Work in the Navajo

Nation. Available at: http://www.chlpi.org/

wp-content/uploads/2013/12/Navajo-FoodPolicy-Toolkit-May-2015.pdf. Retrieved June

18, 2019. 

15. University of North Dakota National

Resource Center on Native American Aging,

2014. Identifying Our Needs: A Survey of

Elders Cycle VI, University of North Dakota.

Available at: https://www.nrcnaa.org/needsassessment. Retrieved June 18, 2019.

16. Adamsen C, Schroeder S, LeMire S,

Carter P (2018). Education, Income, and

Employment and Prevalence of Chronic

Disease Among American Indian/Alaska

Native Elders. Preventing Chronic Disease,

22;15:E37. Doi: 10.5888/pcd15.170387.

Available at: https://www.cdc.gov/pcd/

issues/2018/17_0387.htm. Retrieved June

18, 2019. 

17. Mabli, J. and Schenk, M. 2019. Older

Americans Act Title III-C Nutrition Services

Program: An Examination of Social Activities

at Congregate Meal Sites and Their Role

in Improving Socialization Outcomes of

Participants. Available at:

https://acl.gov/sites/default/files/

programs/2018-12/AoAevaluation_

socialization.pdf. Retrieved June 18, 2019.

18. Herting, A and Adamsen, C. 2018.

Participation in Cultural Traditions Promotes

Happiness and Peacefulness Among

American Indian, Alaska Native, and Native

Hawaiian Elders. Available at: https://

ruralhealth.und.edu/assets/2550-9439/

participation-in-cultural-traditionspromotes-happiness.pdf. Retrieved June 18,

2019. 

19. ICF International. Evaluation of the ACL

Title VI Programs Year 2 Interim Report.

2019. Available at: https://acl.gov/sites/

default/files/programs/2019-03/16004_ACL_

TitleVI_Year2_Report_012219_508v2.pdf.

Retrieved June 18, 2019.

20. Administration for Community Living/

Administration on Aging. A National Survey

of Older Americans Act Participants, 2014.

Available at: https://aoasurvey.org/source/

priorresults.asp. Retrieved June 18, 2019.

21. First Nations Development Institute.

Senior Hunger and Food Insecurity in Indian

Country: Community-Based Solutions to

Improve the Health and Well-Being of Tribal

Elders. Available at: https://www.firstnations.

org/publications/senior-hunger-and-foodinsecurity-in-indian-country-communitybased-solutions-to-improve-the-health-andwell-being-of-tribal-elders/. Retrieved June

18, 2019. 

22. National Association of Area Agencies on

Aging (N4a) and Scripps Gerontology Center,

Miami University. 2017. National Title VI

Program Survey Serving Tribal Elders Across

the United States 2017 Report. Available

at: https://www.n4a.org/Files/Title%20

VI%20Survey/Title%20VI%20Program%20

Survey_508.pdf. Retrieved June 18, 2019.

23. Older Americans Act of 1965, Section

330. Available at: https://legcounsel.house.

gov/Comps/Older%20Americans%20Act%20

Of%201965.pdf Retrieved June 18, 2019.

24. Older Americans Act of 1965, Section

339. Available at: https://legcounsel.house.

gov/Comps/Older%20Americans%20Act%20

Of%201965.pdf Retrieved June 18, 2019.

25. Older Americans Act of 1965, Sections

601, 602, 614. Available at: https://

legcounsel.house.gov/Comps/Older%20

Americans%20Act%20Of%201965.pdf

Retrieved June 18, 2019.

11 
Appendix 1 

Listing of Published Literature on American Indians

June 2019 

Key Resources 

Adamsen C, Schroeder S, LeMire S, Carter P 

(2018). Education, Income, and Employment 

and Prevalence of Chronic Disease Among 

American Indian/Alaska Native Elders. 

Preventing Chronic Disease, 22;15:E37. Doi: 

10.5888/pcd15.170387. Available at: https:// 

www.cdc.gov/pcd/issues/2018/17_0387.htm. 

Retrieved June 18, 2019. 

Adamsen C, Schroeder S, LeMire S, Carter 

P. Education, Income, and Employment

and Prevalence of Chronic Disease Among

American Indian/Alaska Native Elders.

University of North Dakota National

Resource Center on Native American Aging.

(2018)

Administration for Community Living/ 

Administration on Aging. A National Survey 

of Older Americans Act Participants, 2014. 

Available at: https://aoasurvey.org/source/ 

priorresults.asp. 

Administration for Community Living, 

January 2019. Evaluation of the ACL Title VI 

Programs, Year 2 Interim Report. Available 

at: https://acl.gov/sites/default/files/

programs/2019-03/16004_ACL_TitleVI_ 

Year2_Report_012219_508v2.pdf. Retrieved 

on July 22, 2019. 

Department of Health & Human Services, 

Centers for Medicare & Medicaid Services. 

Tribal Nursing Home Best Practices: 

Traditional Foods. December 2016. Available 

at: https://www.cms.gov/Outreach-andEducation/American-Indian-Alaska-Native/ 

AIAN/Downloads/NH-best-practicestraditional-foods.pdf. Retrieved July 22, 

2019. 

Echo Hawk Consulting, 2015. “Feeding 

Ourselves: Food access, Health Disparities, 

and the Pathways to Healthy Native 

American Communities.” Longmont, CO. 

Available at: https://seedsofnativehealth. 

org/echo-hawk-consulting-releases-feedingourselves-food-access-health-disparitiesand-the-pathways-to-healthy-nativeamerican-communities/. Retrieved on July 

22, 2019. 

Goins TR, Schure MB, Crowder J, Baldridge 

D, Benson W, Aldrich N. Lifelong Disparities 

among Older American Indians and Alaska 

Natives. AARP Public Policy Institute. 

November 2015. Available at: https://www. 

aarp.org/content/dam/aarp/ppi/2015/ 

Lifelong-Disparities-among-Older-AmericanIndians-and-Alaska-Natives.pdf. Retrieved 

July 22, 2019. 

Harvard Law School, Food Law and Policy 

Clinic, Community Outreach and Patient 

Empowerment, & the Navajo Nation, 2015. 

Good Laws, Good Food: Putting Food Policy 

to Work in the Navajo Nation. Available 

at: http://www.chlpi.org/wp-content/ 

uploads/2013/12/Navajo-Food-PolicyToolkit-May-2015.pdf. Retrieved June 18, 

2019. 

Journal of the Academy of Nutrition and 

Dietetics. “Position of the Academy of 

Nutrition and Dietetics: Food and Nutrition 

for Older Adults: Promoting Health and 

Wellness.” Volume 112, August 2012. 

Available at: https://www.andeal.org/ 

vault/2440/web/Older_Adults_JADA.pdf. 

Accessed July 22, 2019. 

Kumar G, and colleagues, 2016. Healthful 

Nutrition of Foods in Navajo Nation Stores: 

Availability and Pricing. American Journal 

of Health Promotion, 30(7):501-510; doi: 

10.4278/ajph.140821-QUAN-44. 

National Indian Council on Aging. The 

Indian Elder: The Forgotten American. 1976. 

Available at: https://pdfs.semanticscholar. 

org/ 

Noelker LS, Browdie R, 2013. “Sidney Katz, 

MD: a New Paradigm for Chronic Illness 

and Long-Term Care.” The Gerontologist, 

54(1),13-20. doi: 10.1093/geront/gnt086. 

Schroeder S, Adamsen C, & Ward C. 

Dental Care Utilization and Service 

Needs Among American Indian/Alaska 

Native/Native Hawaiian Elders: 2008-

2017. Journal of Aging and Health, doi: 

10.1177/0898264318800598. 

Bibliography from First

Nations on Indigenous Food

Sovereignty 

This bibliography compiled by First Nations 

includes references on a number of topics 

including a chapter with native health and 

nutrition references: 

First Nations Development Institute. 

2018. Indigenous Food Sovereignty Guide. 

Retrieved from 

https://www.firstnations.org/publications/

indigenous-food-sovereignty-sources-guide/. 

Published Literature on 

Native American Elders Older 

Americans Act Nutrition 

Program, Title VI 

The literature listed below is compiled from a 

library search conducted in Spring 2019 that 

included terms such as nutrition, health, Native 

Americans, elders, Title VI, etc. 

Barrington WE, White E.Mortality outcomes 

associated with intake of fast-food items and 

sugar-sweetened drinks among older adults 

in the Vitamins and Lifestyle (VITAL) study. 

Public Health Nutr. 2016 Dec;19(18):3319-

3326. Epub 2016 Jun 24. PMID: 27338763 

[PubMed - indexed for MEDLINE 

Bell RA, Vitolins MZ, Arcury TA, Quandt 

SA.Food consumption patterns of rural older 

African American, Native American, and 

white adults in North Carolina. J Nutr Elder. 

2003;23(2):1-16. PMID: 14714678 [PubMed -

indexed for MEDLINE] 

Bernard MA, Lampley-Dallas V, Smith L. 

Common health problems among minority 

elders. J Am Diet Assoc. 1997 Jul;97(7):771-6. 

Review. PMID: 9216555 [PubMed - indexed 

for MEDLINE] 

Berryhill K, Hale J, Chase B, Clark L, He 

J, Daley CM. J Food Security and Diet 

Among American Indians in the Midwest. 

Community Health. 2018 Oct;43(5):901-907. 

doi: 10.1007/s10900-018-0501-5. PMID: 

29623570 [PubMed - in process]. 

12 
Bindon J, Dressler WW, Gilliland MJ, Crews 

DE. A cross-cultural perspective on obesity 

and health in three groups of women: the 

Mississippi Choctaw, American Samoans, 

and African Americans. Coll Antropol. 2007 

Mar;31(1):47-54. PMID: 17598383 [PubMed -

indexed for MEDLINE] 

Brandenburger SJ, Wells K, Stluka S. Utilizing 

Talking Circles as a Means of Gathering 

American Indian Stories for Developing a 

Nutrition and Physical Activity Curriculum. 

Health Educ Behav. 2017 Jun;44(3):448-453. 

doi: 10.1177/1090198116674888. Epub 2016 

Nov 19.PMID: 27866160 [PubMed - indexed 

for MEDLINE 

Brown B, Harris KJ, Heil D, Tryon M, Cooksley 

A, Semmens E, Davis J, Gandhi K. Feasibility 

and outcomes of an out-of-school and 

home-based obesity prevention pilot study 

for rural children on an American Indian 

reservation. Pilot Feasibility Stud. 2018 Jul 

26;4:129. doi: 10.1186/s40814-018-0322-4. 

eCollection 2018. PMID: 30065847 [PubMed] 

Free PMC Article 

Brown B, Noonan C, Harris KJ, Parker 

M, Gaskill S, Ricci C, Cobbs G, Gress S. 

Developing and piloting the Journey to 

Native Youth Health program in Northern 

Plains Indian communities. Diabetes 

Educ. 2013 Jan-Feb;39(1):109-18. doi: 

10.1177/0145721712465343. Epub 2012 Nov 

13. PMID: 23150531 [PubMed - indexed for

MEDLINE]

Bruner BG, Chad KE.Dietary practices and 

influences on diet intake among women 

in a Woodland Cree community. J Hum 

Nutr Diet. 2014 Apr;27 Suppl 2:220-9. doi: 

10.1111/jhn.12121. Epub 2013 May 13. 

PMID: 23662654 [PubMed - indexed for 

MEDLINE] 

Buchwald D, Tomita S, Hartman S, Furman 

R, Dudden M, Manson SM. Physical abuse 

of urban Native Americans. J Gen Intern 

Med. 2000 Aug;15(8):562-4. PMID: 10940148 

[PubMed - indexed for MEDLINE] Free PMC 

Article 

Byker Shanks C, Smith T, Ahmed S, Hunts 

H. Assessing foods offered in the Food

Distribution Program on Indian Reservations

(FDPIR) using the Healthy Eating Index 2010.

Public Health Nutr. 2016 May;19(7):1315-26.

doi: 10.1017/S1368980015002359. Epub

2015 Aug 24. PMID: 26298513 [PubMed -

indexed for MEDLINE] Free PMC Article

Collings P, Marten MG, Pearce T, Young 

AG.Country food sharing networks, 

household structure, and implications for 

understanding food insecurity in Arctic 

Canada. Ecol Food Nutr. 2016;55(1):30-49. 

doi: 10.1080/03670244.2015.1072812. Epub 

2015 Nov 23. PMID: 26595315 [PubMed -

indexed for MEDLINE] 

Çayır E, Burke MP, Spencer M, Schure 

MB, Goins RT. Lifetime Trauma and 

Depressive Symptomatology Among Older 

American Indians: The Native Elder Care 

Study. Community Ment Health J. 2018 

Aug;54(6):740-747. doi: 10.1007/s10597-017-

0179-7. Epub 2017 Nov 20. PMID: 29159495 

[PubMed - in process]June, 2019 

Chang Y, Hickman H. Food Insecurity and 

Perceived Diet Quality Among Low-Income 

Older Americans with Functional Limitations. 

J Nutr Educ Behav. 2018 May;50(5):476-484. 

doi: 10.1016/j.jneb.2017.09.006. Epub 2017 

Nov 6. PMID: 29107473 

Daley CM, Hale JW, Berryhill K, Bointy S, Clark 

L, Chase B, LeMaster J, He J. Diabetes SelfManagement Behaviors among American 

Indians in the Midwestern United States. 

ARC J Diabetes Endocrinol. 2017;3(1):34-41. 

doi: 10.20431/2455-5983.0301005. PMID: 

30637353 28491205. Free PMC Article 

Denny CH, Holtzman D, Cobb N. Surveillance 

for health behaviors of American Indians 

and Alaska Natives. Findings from the 

Behavioral Risk Factor Surveillance System, 

1997-2000. MMWR Surveill Summ. 2003 Aug 

1;52(7):1-13. PMID: 14532869. Free Article 

de Rus Jacquet A, Timmers M, Ma SY, 

Thieme A, McCabe GP, Vest JHC, Lila MA, 

Rochet JC. Lumbee traditional medicine: 

Neuroprotective activities of medicinal 

plants used to treat Parkinson’s diseaserelated symptoms. J Ethnopharmacol. 

2017 Jul 12;206:408-425. doi: 10.1016/j. 

jep.2017.02.021. Epub 2017 Feb 15. PMID: 

28214539 [PubMed - indexed for MEDLINE] 

Free PMC Article 

Dillinger TL, Jett SC, Macri MJ, Grivetti 

LE. Feast or famine? Supplemental food 

programs and their impacts on two 

American Indian communities in California. 

Int J Food Sci Nutr. 1999 May;50(3):173-87. 

PMID: 10627833 

Elwan D, de Schweinitz P, Wojcicki JM. 

Beverage consumption in an Alaska Native 

village: a mixed-methods study of behaviour, 

attitudes and access. Int J Circumpolar 

Health. 2016 Feb 24;75:29905. doi: 10.3402/ 

ijch.v75.29905. eCollection 2016. PMID: 

26928369 [PubMed - indexed for MEDLINE] 

Free PMC Article 

Eckhardt CL, Lutz T, Karanja N, Jobe JB, 

Maupomé G, Ritenbaugh C. Knowledge, 

attitudes, and beliefs that can influence 

infant feeding practices in American 

Indian mothers. J Acad Nutr Diet. 2014 

Oct;114(10):1587-93. doi: 10.1016/j. 

jand.2014.04.021. Epub 2014 Jun 18. PMID: 

24951434 [PubMed - indexed for MEDLINE] 

Free PMC Article 

Fialkowski MK, McCrory MA, Roberts SM, 

Tracy JK, Grattan LM, Boushey CJ. Evaluation 

of dietary assessment tools used to assess 

the diet of adults participating in the 

Communities Advancing the Studies of 

Tribal Nations Across the Lifespan cohort. J 

Am Diet Assoc. 2010 Jan;110(1):65-73. doi: 

10.1016/j.jada.2009.10.012. PMID: 20102829 

[PubMed - indexed for MEDLINE] Free PMC 

Article 

Fialkowski MK, Okoror TA, Boushey CJ. The 

relevancy of community-based methods: 

using diet within Native American and 

Alaska Native adult populations as an 

example. Clin Transl Sci. 2012 Jun;5(3):295-

300. doi: 10.1111/j.1752-8062.2011.00364.x.

Epub 2012 Jan 10. Review. PMID: 22686210

Free PMC Article

Fleischhacker S. Emerging Opportunities 

for Registered Dietitian Nutritionists to 

Help Raise a Healthier Generation of 

Native American Youth. J Acad Nutr Diet. 

2016 Feb;116(2):219-25. doi: 10.1016/j. 

jand.2015.10.018. Epub 2015 Dec 8. No 

abstract available. PMID: 26680608 [PubMed 

- indexed for MEDLINE] Free PMC Article

Fretts AM, Huber C, Best LG, O’Leary 

M, LeBeau L, Howard BV, Siscovick DS, 

Beresford SA. Availability and Cost of 

Healthy Foods in a Large American Indian 

Community in the North-Central United 

States. Prev Chronic Dis. 2018 Jan 4;15:E03. 

doi: 10.5888/pcd15.170302. PMID: 29300694 

[PubMed - indexed for MEDLINE] Free PMC 

Article 

Galloway JM. Cardiovascular health among 

American Indians and Alaska Natives: 

successes, challenges, and potentials. Am 

J Prev Med. 2005 Dec;29(5 Suppl 1):11-7. 

PMID: 16389120 

Geana MV, Daley CM, Nazir N, Cully 

L, Etheridge J, Bledowski C, Choi WS, 

Greiner KA. Use of online health 

information resources by American 

Indians and Alaska Natives. J Health 

Commun. 2012 Aug;17(7):820-35. doi: 

10.1080/10810730.2011.650831. Epub 2012 

May 29. PMID: 22642739 Free PMC Article 

13 
Gibbs HD, Pacheco C, Yeh HW, Daley C, 

Greiner KA, Choi WS.Accuracy of Weight 

Perception Among American Indian Tribal 

College Students. Am J Prev Med. 2016 

Nov;51(5):e139-e144. doi: 10.1016/j. 

amepre.2016.06.002. Epub 2016 Jul 21. 

PMID: 27450725 [PubMed - indexed for 

MEDLINE] Free PMC Article 

Goins RT, Pilkerton CS. Comorbidity among 

older American Indians: the native elder 

care study..J Cross Cult Gerontol. 2010 

Dec;25(4):343-54. doi: 10.1007/s10823-010-

9119-5. [PMID: 20532973] Free PMC Article 

Goins RT, Innes K, Dong L. Lower body 

functioning prevalence and correlates in 

older American Indians in a southeastern 

tribe: the Native Elder Care Study. J Am 

Geriatr Soc. 2012 Mar;60(3):577-82. doi: 

10.1111/j.1532-5415.2011.03869.x. Epub 

2012 Feb 8. [PMID: 22316130] Free PMC 

Article 

Grzywacz JG, Arcury TA, Ip EH, Nguyen 

HT, Saldana S, Reynolds T, Bell RA, Kirk JK, 

Quandt SA. Cultural basis for diabetesrelated beliefs among low- and higheducation African American, American 

Indian, and white older adults. Ethn 

Dis. 2012 Autumn;22(4):466-72. [PMID: 

23140078] Free PMC Article 

Haring RC (Seneca Nation), Hudson M 

(Whakatohea Māori), Erwin D, Rodriguez 

EM, Henry WAE (Tuscarora Nation), Haring 

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Power EM. Conceptualizing food security or 

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Quandt SA, Bell RA, Snively BM, Vitolins 

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2013 Dec 3. PMID: 24295080 [PubMed -

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Ricci CL, Brown BD, Noonan C, Harris KJ, 

Dybdal L, Parker M, Gress S. Parental 

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E. Decreased ratio of fat to carbohydrate

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Kanott Lambert S, Powell J, James R, Percy C, 

Jenks BF, Testaverde L, Thomas JM, Barber R, 

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Bradley V. Dietary Beliefs and Management 

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M, Standridge J, Fox J, Spiegel J, Blue 

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16 
Appendix 2 

Food and Nutrition Websites for Older Americans Act 

Title VI Program Accessed June 2019 

Administration on Aging and

Older Americans Act 

2016 Compilation of the Older American 

Act: https://legcounsel.house.gov/Comps/ 

Older%20Americans%20Act%20Of%201965. 

pdf 

Administration for Community Living 

Published Guidance: 

https://acl.gov/about-acl/administrationaging-program-instructions 

Fact sheet for Title VI: 

https://acl.gov/programs/services-nativeamericans-oaa-title-vi 

Fact sheet for Title III: 

https://acl.gov/programs/health-wellness/ 

nutrition-services 

Data at a Glance for Title VI, including 

Census Data 

https://agid.acl.gov/DataGlance/NA/ 

Did You Know....Questions and Answers 

about the Older Americans Act Nutrition 

Program: 

https://acl.gov/sites/default/files/

programs/2016-11/OAA-Nutrition-ProgramFAQ.pdf

Emergency Planning Resources https://acl. 

gov/programs/emergency-preparedness 

Fact Sheet for Title VI: 

https://acl.gov/programs/services-nativeamericans-oaa-title-vi 

Fact Sheet for Title III: 

https://acl.gov/programs/health-wellness/ 

nutrition-services 

Funding Allocations for States and Tribes: 

https://acl.gov/about-acl/older-americansact-oaa

Title VI Evaluation: 

https://acl.gov/sites/default/files/

programs/2018-03/ACL_TitleVI_Evaluation_ 

Report_FINAL_508.pdf 

Title VI Resource Centers: 

https://acl.gov/programs/services-nativeamericans-oaa-title-vi 

Older Indians: website includes checklist 

for Title VI grants, archived cluster training 

presentations, webinars, resources, 

frequently asked questions, reporting and 

record keeping, and implementation manual 

https://olderindians.acl.gov/ 

National Resource Center on Nutrition and 

Aging 

http://nutritionandaging.org/ 

AARP Foundation 

https://www.aarp.org/aarp-foundation/ 

Lifelong Disparities Among Older American 

Indians and Alaska Natives https://www. 

aarp.org/ppi/info-2015/lifelong-disparitiesamong-older-american-indians-and-alaskanatives.html 

Multicultural Fact Sheets 

https://www.aarp.org/research/topics/life/ 

info-2017/multicultural-population-statefact-sheets.html 

Crossing the Great Divides: A Guide to Elder 

Mobility Resources and Solutions in Indian 

Country 

https://www.aarp.org/livable-communities/ 

act/walkable-livable-communities/info-12-

2012/crossing-great-divides-guide-eldermobilityresources-indian-country.html 

Demographics 

Administration on Aging Statistical Profile

https://acl.gov/aging-and-disability-inamerica/data-and-research/minority-aging 

Office of Minority Health

https://minorityhealth.hhs.gov/omh/browse. 

aspx?lvl=3&lvlid=62 

National Resource Center on Native 

American Aging (NRCNAA) 

https://ruralhealth.und.edu/projects/nrcnaa 

National Resource Center for Native Elders 

https://www.uaa.alaska.edu/academics/ 

college-of-health/nrc-alaska-native-elders/ 

National Resource Center for Native 

Hawaiian Elders 

http://manoa.hawaii.edu/hakupuna/ 

Emergencies 

Food Preparedness https://www.ready.gov/ 

food 

Food Safety During Power Outages https:// 

www.in.gov/health/food-protection/

files/Power_Outages__2_. pdf 

Federal Emergency Management 

Administration (FEMA) https://www.fema. 

gov/

Disaster Planning https://www.ready.gov/ 

Capacity Building Toolkit for Including Aging 

and Disability Networks in Emergency 

Planning https://www.naccho.org/uploads/ 

downloadable-resources/Capacity-BuildingToolkit-for-Aging-and-DisabilityNetworks-2-5-19.pdf 

Food Safety 

Centers for Disease Control and Prevention: 

https://www.cdc.gov/foodsafety/ 

https://www.cdc.gov/features/food-safetysmarts/index.html 

https://www.cdc.gov/foodsafety/people-atrisk-food-poisoning.html 

https://www.foodsafety.gov/risk/ 

olderadults/index.html 

https://www.foodsafety.gov/risk/deliveries/ 

index.html - home-delivered meals 

Food and Drug Administration: 

Food Code 2017: https://www.fda.gov/food/ 

fda-food-code/food-code-2017 

Recalls, Outbreaks, and Alerts: https://www. 

fda.gov/food/recalls-outbreaks-emergencies 

Food Safety During Power Outages: https://

www.in.gov/health/food-protection/

files/Power_ Outages__2_.pdf 

General Food Safety: https://www. 

foodsafety.gov/ 

National Restaurant Association: ServSafe 

https://www.servsafe.com/ 

United States Department of Agriculture: 

General Information - https://www.usda. 

gov/topics/health-and-safety 

Food Safety Fact Sheets - https://www.fsis. 

usda.gov/wps/portal/fsis/topics/food-safetyeducation/get-answers/food-safety-factsheets 

17 
 

 

Is it done yet? - https://www.fsis.usda. 

gov/wps/portal/fsis/topics/food-safetyeducation/teach-others/fsis-educationalcampaigns/is-it-done-yet 

Thermometers and Food Safety - https:// 

www.fsis.usda.gov/wps/portal/fsis/topics/ 

food-safety-education/teach-others/ 

fsis-educational-campaigns/thermy/ 

thermometers-and-food-safety/ct_index 

Choose My Plate 

http://www.choosemyplate.gov/food-safety 

2016 Resource Guide for American Indians 

and Alaska Natives 

https://www.usda.gov/sites/default/files/

documents/2016-usda-tribal-guide.pdf 

Food Ordering and Purchasing 

United States Department of Agriculture 

https://www.fns.usda.gov/tn/food-buyingguide-school-meal-programs 

https://www.fns.usda.gov/tn/food-buyingguide-for-child-nutrition-programs 

Food Security 

Centers for Disease Control and Prevention 

Who is Food Insecure....https://www.cdc. 

gov/pcd/issues/2016/16_0103.htm 

Feeding America: https://www. 

feedingamerica.org/ 

Research on Senior Hunger https://www. 

feedingamerica.org/research/senior-hungerresearch 

United States Department of Agriculture, 

Economic Research Service 

https://www.ers.usda.gov/topics/foodnutrition-assistance/food-security-in-the-us 

https://www.ers.usda.gov/topics/foodnutrition-assistance/food-security-in-the-us/ 

readings/#elderly 

General Nutrition Information 

Dietary Guidelines for Americans: 

https://health.gov/dietaryguidelines/2015/ 

Choose My Plate: Practical Tips for 

Implementing the Dietary Guidelines for 

Americans 

https://www.choosemyplate.gov/dietaryguidelines 

http://www.choosemyplate.gov/10-tipsnutrition-education-series 

American Society on Nutrition: Current 

Developments in Nutrition 

Social Determinants of American Indian 

Nutritional Health 

https://academic.oup.com/cdn/ 

advance-article/doi/10.1093/cdn/ 

nzz054/5497919?searchresult=1 

Tools and Resources: 

https://health.gov/dietaryguidelines/2015/ 

resources.asp 

Information for Consumers about Diseases 

and Conditions 

Centers for Disease Control and Prevention: 

https://www.cdc.gov/diseasesconditions/ 

index.html 

Native Diabetes Wellness Program 

https://www.cdc.gov/diabetes/ndwp/index. 

html 

Healthy Tribes: https://www.cdc.gov/ 

healthytribes/index.htm?CDC_AA_ 

refVal=https%3A%2F%2Fwww.cdc. 

gov%2Fchronicdisease%2Ftribal%2Findex. 

htm 

https://www.cdc.gov/chronicdisease/tribal/ 

index.htm 

Indian Health Services: https://www.ihs.gov/ 

forpatients/ 

National Indian Health Board: https://www. 

nihb.org/sdpi/food_and_fitness.php#food

National Institute on Health: American 

Indian and Alaska Native Health: 

Information for People and Communities 

https://americanindianhealth.nlm.nih.gov/ 

subtopic/2/Health-Wellness/35/EatingHealthy-and-Nutrition 

National Institute on Aging: https://www.nia. 

nih.gov/health/topics 

Office of Health Promotion and Disease 

Prevention: https://healthfinder.gov/

Dietary Reference Intakes Information: 

https://www.nal.usda.gov/fnic/dietaryreference-intakes 

Academy of Nutrition and Dietetics https:// 

www.eatright.org/ 

• Position Papers: https://www.

eatrightpro.org/practice/position-andpractice-papers/position-papers

• Practice Papers: https://www.

eatrightpro.org/practice/position-andpractice-papers/practice-papers

• Position Paper of the American

Dietetic Association, American Society

on Nutrition and the Society for

Nutrition Education and Behavior: 

Food and Nutrition Programs for 

Community Residing Older Adults 

https://www.eatrightpro.org/-/media/ 

eatrightpro-files/practice/position-andpractice-papers/position-papers/pp_ 

foodnutritionprogramsolderadults.pdf 

• Information for older adults: https://

www.eatright.org/for-seniors

Nutrition Labeling 

Food and Drug Administration - Food Label: 

https://www.fda.gov/food/food-labelingnutrition 

Food and Drug Administration – Changes to 

the Food Label: 

https://www.fda.gov/food/food-labelingnutrition/changes-nutrition-facts-label 

Food and Drug Administration – New and 

Improved Nutrition Facts Label 

https://www.fda.gov/food/nutritioneducation-resources-and-materials/newand-improved-nutrition-facts-label 

Nutrition, Physical Activity and

Older Adults 

National Institute on Aging: Nutrition and 

Physical Activity-Go4 Life 

https://go4life.nia.nih.gov/ 

National Institute on Aging: Healthy Eating 

https://www.nia.nih.gov/health/healthyeating 

National Institute on Aging: Physical Activity 

Go4Life: 

https://www.nia.nih.gov/health/exercisephysical-activity 

Centers for Disease Control and Prevention: 

https://www.cdc.gov/prc/study-findings/

healthy-aging.html 

https://www.cdc.gov/pcd/ 

issues/2016/16_0098.htm - Older Indians’ 

Perspectives on Health, Arthritis and 

Physical Activity 

National Institutes of Health: American 

Indian and Alaska Native Health https:// 

americanindianhealth.nlm.nih.gov/ 

https://americanindianhealth.nlm.nih.gov/ 

subtopic/2/Health-Wellness/47/EldersHealth 

https://www.nhlbi.nih.gov/health/ 

healthdisp/an.htm Heart Health 

18 
Recipe Sites: 

AARP 

Slow Cooking: Maidu Indian Style 

https://blog.aarp.org/2012/08/09/maiduindian-banana-acorn-muffin-recipe /

Native Origins Cooking Series 

http://videos.aarp.org/search?q=Native%20 

Origins 

Basic Quantity Production: 

Food for Fifty - Download for free 

http://www.survivorlibrary.com/library/foodfor-fifty.pdf 11th edition 

http://www.pdfsdocuments.com/food-forfifty-13th-edition.pdf 

https://www.nwcbooks.com/get/ebook. 

php?id=ULRbvgAACAAJ 

United States Department of Agriculture: 

Quantity Standardized Recipes from 

USDA https://www.fns.usda.gov/usdastandardized-recipe 

Health and Human Services Recipe Sites – 

recipes are family sized: 

Healthy Recipes http://www.cdc.gov/ 

healthyweight/healthy_eating/recipes.html 

Keep the Beat: Heart Healthy Recipes 

https://www.nhlbi.nih.gov/health-topics/

all-publications-and-resources/

keep-beat-recipes-deliciouslyhealthy-family-meals

National Heart Lung Blood Institute Recipe 

Books: http://www.nhlbi.nih.gov/health/ 

educational/lose_wt/eat/recipes.htm https://

healthyeating.nhlbi.nih.gov/ 

National Institutes of Health 

American Indian Health-Recipes http:// 

americanindianhealth.nlm.nih.gov/eating. 

html 

Recipes from the Departments of Health 

and Human Services and Agriculture: 

https:// www.nutrition.gov/topics/

shopping-cooking-and-meal-planning

Health Organization Recipe Sites: American 

Cancer Association: 

https://www.cancer.org/healthy/eat-healthyget-active.html 

https://www.cancer.org/healthy/eat-healthyget-active/eat-healthy.html 

American Diabetes Association: Food, 

Fitness, Recipes, Healthy Cooking, http:// 

www.diabetes.org 

American Heart Association: Recipes, 

Healthy Cooking, Physical Activity 

http://www.heart.org/ 

Traditional Foods Recipe Sites: 

American Indian Health-Recipes: 

http://americanindianhealth.nlm.nih.gov/ 

eating.html 

Department of Wildlife Management – North 

Slope Borough 

http://www.north-slope.org/assets/images/ 

uploads/Traditional%20Foods%20Recipes. 

pdf 

Healthy Traditions: Recipes from Our 

Ancestors https://ruralhealth.und.edu/ 

projects/nrcnaa/pdf/cookbook.pdf 

iGrow South Dakota State University: 

http://igrow.org/community-development/ 

local-foods/native-american-gardens/ 

Intertribal Bison Cooperative: 

http://itbcbuffalo.com/view/recipes

List of recipes from Indian Country Today 

utilizing traditional native foods: 

http://indiancountrytodaymedianetwork. 

com/department/native-recipes 

List of Native Berry Recipes from the 

Survivor Library http://www.survivorlibrary. 

com/library/native-berry-recipes.pdf 

Traditional Native Recipes: 

www.aihd.ku.edu/recipes/index.html

(American Indian Health & Diet Project) 

Sources of American Indian Food Products 

American Indian Foods http://www. 

americanindianfoods.com/ 

Intertribal Bison Cooperative http:// 

itbcbuffalo.com/view/recipes

United States Department of Agriculture 

Recipe Sites – recipes are family sized: 

Recipe Finder http://healthymeals.nal.usda. 

gov/recipes 

What’s Cooking? USDA Mixing Bowl, recipes, 

cookbooks, menus http://www. 

choosemyplate.gov/recipes-cookbooksand-menus 

Recipes for tribes using USDA commodity 

foods http://www.fns.usda.gov/fdd/recipes/ 

hhp/fdpir-cookbk_river1.pdf

Recipes from the Departments of Health 

and Human Services and Agriculture http:// 

www.nutrition.gov/shopping-cooking-mealplanning/recipes 

Traditional Foods and 

Utilization 

Alaska Native Tribal Health Consortium 

https://anthc.org/ 

https://anthc.org/what-we-do/traditionalfoods-and-nutrition/ 

https://anthc.org/what-we-do/traditionalfoods-and-nutrition/alaskan-plants-as-foodmedicine/ 

https://anthc.org/what-we-do/traditionalfoods-and-nutrition/food-distributionprogram-on-indian-reservations/ 

https://anthc.org/what-we-do/traditionalfoods-and-nutrition/store-outside-yourdoor/ 

Healthy Native Foods for American Indian 

Communities 

http://www.americanindiancancer.org/wpcontent/uploads/2015/06/TOOLKIT_NEW_04-

2015.pdf 

Alaska Department of Health 

http://dhss.alaska.gov/sites/takeheart/ 

documents/traditionalfoods.pdf 

Alaska Cooperative Extension 

http://www.uaf.edu/ces/foods/ 

American Indian Cancer 

Foundation Resources https://www. 

americanindiancancer.org/resources-2 

Healthy Native Foods Toolkit https://www. 

americanindiancancer.org/wp-content/ 

uploads/2014/01/Toolkit_NEW_03_2014-2. 

pdf 

First Nations Resources from Canada 

Professional: Food Safety for First Nations 

People of Canada: A Manual for Healthy 

Practices 

https://www.canada.ca/en/health-canada/ 

services/first-nations-inuit-health/reportspublications/health-promotion/food-safetyfirst-nations-people-canada-manual.html

Professional: Traditional Foods: Are They 

Safe for First Nations Consumption? 

http://www.afn.ca/uploads/files/rptraditional_foods_safety_paper_final.pdf

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Consumer: Food Safety Tips 

https://www.canada.ca/en/health-canada/ 

services/food-safety-vulnerable-populations/ 

food-safety-first-nations.html

Native Food Resource Center www. 

nativefoodsystems.org/ This site addresses 

assistance in the form of financial and 

technical support, including training 

materials, to projects that address 

agriculture and food sectors in Native 

communities. 

Ordering Nutritious and Indigenous Foods: 

Guidelines and Checklist 

https://www.americanindiancancer.org/wpcontent/uploads/2017/12/IFGChecklist.pdf 

State of Alaska Division of Environmental 

Health – Food Safety and Sanitation Program 

http://dec.alaska.gov/eh/fss/food/ 

traditional_foods.html 

http://keepitsacred.itcmi.org/traditionalfoods-resource-guide/ 

http://anthc.org/news/second-edition-oftraditional-food-guide-supports-modernhealth/ 

Traditional Foods Project 2008-2014 

https://www.cdc.gov/diabetes/ndwp/ 

traditional-foods/index.html 

Training for USDA Funded Child

Nutrition Programs 

(Professional Standards for Nutrition, 

Operations, Administration, and 

Communications/Marketing) 

The site is geared to the various USDA 

funded Child Nutrition Programs, but 

includes information on culinary techniques, 

quantity recipes, food safety in on-line, 

webinar, and video formats. Some materials 

such as administration are geared toward 

administration of USDA funded programs, 

but provide a format that shows how to 

provide successful training. 

https://professionalstandards.fns.usda.gov/ 

Websites for American 

Indians, Alaska Natives, Native 

Hawaiians 

Feeding Ourselves: Food Access, health 

disparities, and the pathways to healthy 

Native American Communities Seeds of 

Native Health: http://seedsofnativehealth. 

org/resources/ 

http://www.heart.org/idc/groups/ 

heart-public/@wcm/@adv/documents/ 

downloadable/ucm_475566.pdf 

First Nations Development Institute: http:// 

www.firstnations.org/ • Nourishing Native Foods and Health http://www.firstnations.org/programs/

foods-health

• Knowledge Center http://www.

firstnations.org/knowledge-center/

foods-health

Senior Hunger and Food Insecurity in Indian 

Country: Community Based Solutions to 

Improve the Health and Well-Being of Tribal 

Elders http://www.firstnations.org/system/

files/Senior_Hunger_in_Indian_Country.pdf 

Indigenous Food Sovereignty Sources Guide 

https://www.firstnations.org/wp-content/

uploads/publication-attachments/Food_ 

Sovereignty_Bibliography_FINAL2.pdf 

North American Traditional Indigenous Food 

Systems http://www.natifs.org/ 

Social Determinants of American Indian 

Nutritional Health 

Warne, D. and Wescott, S. Social 

Determinants of American Indian Nutritional 

Health. June. 2019. https://academic.oup. 

com/cdn/advance-article/doi/10.1093/cdn/ 

nzz054/5497919?searchresult=1 

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