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Resistance to Change-Nutrition in Indian Country

January 2, 2015

Dr. Abram Hoffer, a psychiatrist and nutrition researcher, said something that resonated with me. It takes 40 to 60 years for new knowledge to become accepted enough to start entering mainstream dialogue. At the time the new knowledge is widely adopted, 10% of professionals in the field accept it, but about 50% of the general population does as well. While Dr. Hoffer was discussing nutrition knowledge, I believe this same principal applies to health in Indian Country.

As a baseball pitching coach, I understand the importance of good nutrition to a pitcher. Diet is critical to building strength and quickness. Exercise is well understood, and coaches can transform body fat into muscle in a very short period of time. 8 weeks of exercise and good nutrition can transform almost any body. Mental and emotional states are strongly considered when working with pitchers. Certain types of supplementation are normal.

When I began working in Tribal Health, I also saw the benefit of nutrition, but my vision was clouded by a lack of deep knowledge. Whenever I walked into a Village Alaska store, the shelves were full of soda pop, candy and chips of various kinds. Fruits, vegetables and proteins were sparsely represented. Most villages were low income, and relied on subsistence foods for a lot of their calories. But when you went to a community function, there were lots of sugars and empty calories represented. Cakes, pies, cookies, soda, coffee and tea with substantial quantities of sugar added, White bread sandwiches and other empty calories were common.

I also saw that our adults and children had many problems and issues to deal with. Evidence of Adverse Childhood Experiences was everywhere. The negative outcomes described by the ACE Study were visible everywhere. Anger. Violence. Depression. Alcohol abuse. Teen pregnancy. School dropouts. Diabetes 2. Heart disease. Everything discussed on this forum was visible in villages to outside observers trained in trauma. I eventually came to understand trauma extremely well. I wanted to do something about it, so in 2008, I began development of a Restoration to Health Strategy (RtH Strategy). The early strategy involved merging behavioral health and medical intake services to help patients identify behavioral health needs. This strategy was dependent on building a strong behavioral health program. Limited grant and compact funding made this difficult, especially in Alaska Villages. Virtually no tribal members were trained as licensed clinical workers, and housing is almost non-existent in most villages. In 9 years, I was able to find only one clinician to live and work in a village.

Nutrition was a later addition to the RtH Strategy. Guided by some earlier research about how supplementation for children with Omega 3 fatty acids had positive impacts on learning and behavior, I included nutrition as a screening device. Since then, I have intensely studied nutrition, and I am convinced that nutrition should be our first line of defense to many of the behavioral and health issues that American Indian/Alaska Native (AI/AN) people face. I will be blogging about nutrition issues at my Restoration to Health Blog (https://knightbird.wordpress.com).

One area of research is demonstrating a link between suicide and Omega 3 deficiencies. Dr. Joseph Hibbeln has published research showing both causation and correlation between Omega 3 deficiencies and suicide among U.S. Veterans (Link). Hibbeln et al identified a link among higher levels of hostility in adults and an imbalance of Omega 6 and Omega 3 essential fatty acids. (Link). The evidence is compelling and growing. Schoenthaler, et al. found that a lack of water soluble vitamins minerals in children led to increased violence. Supplementation reduced the violence by 47%.

While behavioral health services are still important in the RtH Strategy, I don’t believe we should overlook the important benefits that Omega 3 and vitamin/mineral supplementation can provide. It is my belief that supplementation may be able to improve many patients/clients to a level where further intervention may not be necessary. Supplementation should become a serious part of the ACE Study discussion.

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The Role of Nutrition for Reducing Violence in Indian Country

January 2, 2015

Indian Country experiences high rates of violence. Poverty levels are high. Sources of good foods are scarce. Walk into a store in Village Alaska and you are inundated with the soda, chips, candy, refined grain products (cereals) and sugar intense supplements. By the time they become adults (if they make it that far), children have accumulated substantial nutritional deficits. We see the results every day in the behaviors of our children and young adults, but do not recognize them as a consequence of poor nutrition. Violence, suicide, depression, anxiety, sleeplessness, schizophrenia, poor learning ability, and a host of other problems have been linked to poor nutrition. Yet the only nutrition related problems we recognize are health related, such as obesity, diabetes 2, heart disease and related problems. We need to expand our recognition of behavioral problems caused by poor nutrition because there are solutions readily available.

The first nutritional nightmare in Indian Country is sugar. Sugar is everywhere. It’s in soda, pastries, ice cream, breakfast cereals, candy and highly processed foods. Americans eat an average of about 160 pounds of sugar annually, or greater than 600 calories daily. Sugar displaces more important nutrients, and together with refined carbohydrates, leads to an increased insulin response. Most of our health care discussions I Indian Country are about the increase in Diabetes 2, yet it is well proven that excess sugar and insulin also impacts mood, especially emotional types of distress. [i] After two weeks of a low sugar, low carbohydrate diet, tested subjects had less emotional distress. An earlier study found a 44% reduction in antisocial behavior among 1,382 incarcerated juveniles after a dietary change that included less sugar. [ii] And a greater consumption of sugar in Westernized nations is correlated with a “worse outcome of schizophrenia and a greater prevalence of depression.” [iii]

Another source of mood disorders driven by sugar consumption comes from the release of excess glutamate in the brain. Excess insulin production caused by sugar and refined carbohydrates causes a spike in glutamate, which in turn produces side effects such as agitation, depression, anger, anxiety and panic attacks.[iv]

Another deficiency that contributes to both internal (cutting and suicide) and external (domestic and other violence) is Essential Fatty Acids (EFA’s), particularly Omega 3. Research by Hibblen, et al., revealed a substantial increase in suicide among military veterans who had deficiencies in Omega 3 (especially DHA)[v] and Vitamin D3.[vi]

Suicide victims are often diagnosed with depression and found with alcohol in their blood during autopsy. Low levels of DHA are implicated in depression as well as in violent behaviors.[vii] Suicide and depression are often linked through research.[viii]

An apparent reason for the effect of low Omega 3 levels on suicide and violence has been explained in terms of an imbalance of Omega 6 and Omega 3 levels in the body. Murder rate increases in Industrialized Countries correlate strongly with the increased use of 12 types of seed oils, all high in Omega 6 (linoleic acid).[ix] Reductions of up to 44% of antisocial and violent behaviors have been observed among incarcerated juveniles and adults supplemented with Omega 3.[x] [xi] [xii]

Special attention to nutrition in children and the behaviors they display in school, particularly aggression and bullying, may improve their chance for success. [xiii] Learning and cognition have improved Developmental Coordination Disorder with Omega 3 supplementation.[xiv]

Even the prevalence of alcohol abuse, which is frequently linked to violence and behavior/mood disorders, can be reduced through nutritional methods. Bill Wilson, a co-founder of Alcoholic Anonymous, spent the last 10 years of his life advocating the use of Vitamin B3 as a benefit to maintenance of sobriety and the reduction of depression.[xv]

Nutrition deficits experienced in Indian Country should become a major initiative. While it has been recognized that Developmental Trauma (Adverse Childhood Experiences) is a serious concern in Indian Country [xvi] [xvii], many of the trauma-induced behaviors may be significantly ameliorated by nutritional interventions. Research on the benefit of nutritional therapy for schizophrenics is well documented. Schizophrenics are at risk for suicide and it is likely that nutritional interventions, along with existing psychotropic medication use in reduced dosages, can help restore function to the brain.

I have recommended for the past 7 years that the Indian Health Service facilitate intake of new patients and clients with an assessment of health, behavior and nutrition. Treatment follows with nutritional intervention as a priority. The benefits can significant, particularly in the reduction of violent behaviors.

[i] Christensen, Larry; Krietsch, Kelly; White, Beth; Stagner, Brian Impact of a dietary change on emotional distress. Journal of Abnormal Psychology, Vol 94(4), Nov 1985, 565-579

[ii] S J Schoenthaler, “Los Angeles Probation Department Diet – Behavior Program – An Empirical Analysis of Six Institutional Settings.” International Journal of Biosocial Research  Volume:5  Issue:1  Dated:(1983)  Pages:88-98 (1983)

[iii] Malcolm Peet, “International variations in the outcome of schizophrenia and the prevalence of depression in relation to national dietary practices: an ecological analysis,” The British Journal of Psychiatry (2004) 184: 404-408. doi: 10.1192/bjp.184.5.404

[iv] Domschke K, Tidow N, Schrempf M, Schwarte K, Klauke B, Reif A, Kersting A, Arolt V, Zwanzger P, Deckert J. Epigenetic signature of panic disorder: a role of glutamate decarboxylase 1 (GAD1) DNA hypomethylation? J.Prog Neuropsychopharmacol Biol Psychiatry. 2013 Oct 1;46:189-96. doi: 10.1016/j.pnpbp.2013.07.014.

[v] Lewis MD, Hibbeln JR, Johnson JE, Lin YH, Hyun DY, Loewke JD., “Suicide deaths of active-duty US military and omega-3 fatty-acid status: a case-control comparison.” J Clin Psychiatry. 2011 Dec;72(12):1585-90. doi: 10.4088/JCP.11m06879. Epub 2011 Aug 23.

[vi] John C. Umhau , David T. George, Robert P. Heaney, Michael D. Lewis, Robert J. Ursano, Markus Heilig, Joseph R. Hibbeln, Melanie L. Schwandt. “Low Vitamin D Status and Suicide: A Case-Control Study of Active Duty Military Service Members.” PLoS One. 2013;8(1):e51543. doi: 10.1371/journal.pone.0051543. Epub 2013 Jan 4.

[vii] Horrocks LA, Yeo YK: Health benefits of docosahexaenoic acid (DHA). Pharmacol Res 1999; 40(3)211-25.

[viii] Hibbeln JR, et al.: Do plasma polyunsaturates predict hostility and violence? World Rev Nutr Diet 1996; 82:175-86.

[ix] “Increasing homicide rates and linoleic acid consumption among five Western countries, 1961-2000,” Joseph R. Hibbeln, Levi R. C. Nieminen, and William E. M. Lands, Lipids, Vol. 39, No. 12, 2004, 1207-13.

[x] “The effect of docosahexaenoic acid on aggression in young adults: a placebo-controlled double-blind study,” T. Hamazaki, S. Sawazaki, M. Itomura, E. Asoka, Y. Nagao, N. Nishimura, K. Yazawa, T. Kuwamori, and M. Kobayashi, Journal of Clinical Investiga ation, Vol. 97, 1996, pp. 1129-1133.

[xi][xi] C. Iribarren, J. H. Markovitz, D. R. Jacobs, Jr., P. J. Schreiner, M. Daviglus, and J. R. Hibbeln, “Dietary intake of omega-3, omega-6 fatty acids and fish: relationship with hostility in young adults—the CARDIA study,” European Journal of Clinical Nutrition, Vol. 58, No. 1, January 2004, 24-31.

[xii] Schoenthaler, ibid (2003)

[xiii] Liu J, Raine A. “The effect of childhood malnutrition on externalizing behavior.” Curr Opin Pediatr. 2006 Oct;18(5):565-70.

[xiv] Alexandra J. Richardson and Paul Montgomery, “The Oxford-Durham Study: a randomized controlled trial of dietary supplementation with fatty acids in children with developmental coordination disorder,” Pediatrics, Vol. 115, No. 5, May 2005, 1360-66.

[xv] http://vitaminb-3therapy.blogspot.com

[xvi] Felitti, V. J., & Anda, R. F. (1997.)The Adverse Childhood Experiences (ACE) Study. Centers for Disease Control and Prevention.

[xvii] Garner, A.S., Shonkoff, J.P., Siegel, B.S., Dobbins, M.I., Earls, M.F., McGuinn, L., … & Wood, D.L. (2012). Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science Into Lifelong Health.  Pediatrics, 129 (1), 224-231.

Change of Name

March 25, 2013

During March, I continued developing this passion of mine, Restoring our Health in Indian Country, though a couple of actions. While at Chugachmiut, I had been working on reforming the health care system I managed for the tribes to implement a new healing protocol. I no longer guide that effort, and continue to wish for their success at implementing the idea I started. Because of my separation from Chugachmiut, I no longer speak for them, and found it necessary to change the name of this blog to “Restoring our Health In Indian Country.”

But I believe the Restoring our Health healing protocol belongs in Indian Country, and I have been working with the National Congress of American Indians to start a Task Force on Children.  The foundations for my recommendation to NCAI President Jefferson Keel, Executive Director Jacqueline Johnson-Pata and Policy Center Director Malia Villegas were the Adverse Childhood Experience Study (Link Here), the National Institute of Health’s National Children’s Study (Link Here), the American Academy of Pediatric’s Policy Guidance on Childhood Trauma (Link Here) and the United State’s Attorney General’s  Defending Childhood Initiative (Link Here).

Our next step is to develop the Resolution establishing the Task Force and introducing it at the NCAI Mid Year Conference that will be held in Reno, Nevada on June 24-27, 2013. Seeking membership and becoming educated and informed about the major issues facing Indian Children will follow. Hopefully we will begin to discuss policy reforms necessary to protect children and give them the best opportunity to grow and develop into healthy and happy adults.

I am excited about this next phase of my advocacy career and look forward to learning a lot, and helping to reform our health care and behavioral health systems in Indian Country in a way that protects all of our Native Children, and heal those adults who are hurting themselves, and who raise them.

September 12, 2012

Addressing Trauma in School Districts

Lincoln Alternative High School, in Walla Walla, Washington, and Brockton Public Schools in Brockton, MA has innovated in bringing a new discipline process forward that deals with children on a different level. Their process now accounts for children living with trauma. The process does not do away with accountability or responsibility. Instead, it accounts for trauma as a mediator for the negative behavior (notice now I didn’t call it bad behavior?) Washington State has identified an average of 13 students in every classroom of 30 kids who are impacted by 3 or more Adverse Childhood Experiences. At Lincoln, suspensions have dropped by 85%. Teachers and administrators are being trained in a different method of responding to problems with students. Instead of asking why are you bad, they ask what is happening to you. You can read the story here. Here is Washington State’s graphic on the prevalence of ACE’s among their student population.

As a sharing individual with significant contacts, I offered this same information to the President of the Anchorage School District and the Superintendent. I get the same political response I always seem to get. The President acknowledged the receipt of the information, but was too busy to read it yet. The Superintendent assigned the information to their head nurse. I also shared it with the President of the School Board association. No response at all, but I don’t know her so I understand. She probably thinks I am a crackpot who doesn’t know what he’s talking about.

I did have success with the Juneau Douglas School District. I have a friend who works there and understands my Adverse Childhood Experience mission. They are looking at the information and wanting to learn more about this discipline process.

By the way, here is an outstanding addition to any teaching library, and it is free. It’s called Helping Traumatized Children Learn by Massachusetts Advocates for Children: Trauma and Learning Policy Initiative.

Toxic Stress

August 22, 2012

I will be blogging somewhat more frequently about Chugachmiut’s Restoration to Health (RtH) initiative now as we move to implement the board’s strategy. It is important that the knowledge behind the strategy is disseminated more widely. This first blog is about the impact of Toxic Stress on the human brain. I want to share the documents that helped us develop our RtH initiative.

The Adverse Childhood Experience (ACE) Study provides valuable knowledge about the link between what happens to a child who grows up with trauma as they are raised and both their adoption of coping behaviors to deal with the stress accompanying the trauma and their health outcomes later in life. A summary of the ACE Study is available at: http://www.cdc.gov/ncipc/pub-res/pdf/childhood_stress.pdf.

The American Academy of Pediatrics issued a policy statement about the impact of “Toxic Stress” on the developing brain, which can be found at: http://pediatrics.aappublications.org/content/129/1/e224.full.pdf. The Policy statement was accompanied by a technical report supporting the policy statement, and that can be found at: http://pediatrics.aappublications.org/content/early/2011/12/21/peds.2011-2662. The documents combined describe the science effectively.

Finally, here are three videos that describe the developing brain from the Center on the Developing Child at Harvard University. Dr. Jack Shonkoff, an author of both the AAP Policy statement and technical paper is director of the Center. http://developingchild.harvard.edu/index.php?cID=428

I will be building off of this knowledge in future blogs.

Childhood Trauma Cycles Rapidly Among Alaska Natives

October 2, 2011

Nicholas Kokotovich III was sentenced to 20 years in jail (5 years suspended) for a vicious assault on a 2 year old girl, according to an article in the Juneau Empire on September 15, 2011. The victim was the child of his girlfriend at the time. I am not an apologist for his actions or the sentence. The type of crime he committed is altogether too common among Alaska Native people. Close to 38% of Alaska’s considerable prison population is Alaska Native.

It is obvious from the article that the victim’s life will never be the same. She will endure a lifetime of medical and psychological trauma. It is likely that, without significant behavioral health intervention, she may grow into an adult with behavioral issues herself. The tragedy is that, once she becomes an adult, we will stop caring about her. Her behavioral abnormalities, even if linked to the vicious assault on her, will not be tolerated and her attempts to find solutions may lead her to the same behaviors as the man who assaulted her. Why do I say this?

The Adverse Childhood Experience study, conducted between 1992-1994, looked at adverse experiences during the childhood of approximately 17,400 adult patients of Kaiser Permanente in San Diego, CA. The results were astounding. Individuals who grew up with 4 or more ACE’s had strong graded relationship between the number of ACE’s in their childhood and the adoption of numerous negative behaviors. The young victim has obvious ACE’s in her life. She was subjected to physical and emotional abuse. The perpetrator was a drug abuser and possibly perpetrated domestic violence on the victim’s mother. She apparently has an absent biological parent. She has 5 ACE’s if my assessment is accurate, and may have more by the time she is an adult. She will be at risk for adopting negative behavioral choices to help her deal with her traumas.

A sad part of this story is that the perpetrator was once a child, and from what I read in the story, was also a victim of ACE’s. His father makes a regular appearance on the Alaska Court records, including Domestic Violence petitions and a DWI charge. His attorney tried to tell the court, Judge Phillip Pallenberg, about that abuse and the impact it had on his client. He is right. I talk to Alaska Natives frequently, and when they are willing to share the number of adverse childhood experiences they have suffered, it is high. I talk regularly to people who have all ten. The stories they tell me about the behaviors they have experienced are startling: alcohol and drug abuse; domestic violence (perpetrator and victim); sexual abuse; homelessness; attempts at suicide; promiscuity (50 or more lifetime partners); and crime (perpetration and victimization) leading to incarceration.

The perpetrator was once a child, and apparently a child victimized by ACE’s. His negative behavioral choices probably started early in his life, and nobody noticed enough to realize that he needed help. And the help wasn’t available. We live in a society that is critical of negative behaviors, and attributes the behaviors to personal choice. Pull yourself up by your bootstraps. Be a man (for men). You can change if you only want to. The problem is that the neurobiological changes in your brain from the infliction of ACE’s causes substantial resistance to change. The negative behaviors adopted help adults deal with the neurobiological consequence’s of ACE’s. As Dr. Vincent Felitti has said, “It’s hard to get enough of something that almost works.” For someone suffering from the negative consequences of unresolved childhood trauma, relief is necessary. Negative behaviors provide some of the relief the brain desires. But it doesn’t stop the need. It only resolves it for a short time.

We can heal our current generation of children by stopping their exposure to ACE’s. To do this, we will need to heal our parent and grandparent generations. This is a dialogue we, as Alaska Native leaders, need to start immediately.

Mr. Kokotovich’s childhood trauma led him to behaviors that have caused trauma for the child of his former girlfriend. Lives have been damaged because trauma cycles rapidly through our generations.

Another Short Alaska Native Life

October 2, 2011

Lena “Terri” Joseph passed away while living on the streets in Anchorage. I didn’t know her, but she had friends who loved her and discussed her on Facebook. One of her friends shared a picture of a very beautiful young Terri. It was said of her, “She experienced a lot (sic) tragedy in her life,.…” She was Alaska Native and died too young.

Hannah6, a hater blogger on Anchorage Daily News, stated a viewpoint common among readers of a tragic story like this. Responding to a compassionate comment berating another writer, Hannah6 said “You condone people who are so irresponsible they won’t even take proper care of themselves,…”

My friend John Franklin, former Anchorage Commissioner of Public Safety who has since passed on, shared a more compassionate view with me. John would sit at Peratrovich Park in downtown Anchorage in the early 1980’s and greet street people by name. Because of his own challenges in life, John knew the challenges they faced and respected them as people enough to know them.

After a lifetime of working to find solutions to the problems of homelessness, alcohol abuse, domestic violence and other social and behavioral problems, I believe the solution has been identified. Dr. Vincent Felitti, a hero of mine just like John is, cared so much about his morbidly obese patients that he asked one question of a patient that changed his life—“What happened to you?” The answer surprised him and set him on a path that resulted in the Adverse Childhood Experience Study (ACES). The results of the study identified the considerable impact of ACE’s on the adoption of negative behaviors later in life. The neurodevelopment of adolescents is affected when they grow up with ACE’s. Having an alcoholic parent, depressed parent, absent biological parent, witnessing domestic violence in the home and 6 other adverse experiences has an impact on you as an adult. 15% of adults with 4 ACE’s become alcoholic, and 25% have severe problems with alcohol. With no ACE’s, the impact is about 5%.

Haters like Hannah6 attribute problems experienced by people like Terri to be personal moral failings. Science tells us that Terri experienced multiple ACE’s in her life, and never got the help she needed to escape the neurobiological pull of those same negative behaviors in her life. They are in many ways a biological imperative, or solution, for ACE victims wanting to find a normal life. The problem is the solutions don’t work. They become problems instead.

ACE’s can impact children in all homes. Mommy Dearest is a book about Joan Crawford, a white wealthy mother who perpetrated ACE’s on her daughters. While we may not feel sympathy towards Joan, the chances that she experienced multiple ACE’s in her life is reported to be high and undoubtedly affected her behaviors, and the behaviors of her children.

My Alaska Native people experience a lot of ACE’s in their lives. Historical trauma drove our ancestors to behaviors that now pass trauma intergenerationally from grandparent to parent to child. I have been advocating for an ACE’s study to be conducted among Alaska Natives and American Indians so we can understand the impact of ACE’s in our lives. I have been advocating for a reformation of our Health Care System to integrate behavioral health services into our primary care offerings. And I am asking that we have a dialogue on the impact of ACE’s in the lives of our people.

My hope is that the knowledge that our behaviors are not always the result of personal moral failing, but from neurological adaptations to childhood trauma, will start us on a path to healing. Terri’s life ended tragically, decades before it should have. A girl who should have developed into a woman full of life and love ended up on the streets because of issues in her childhood beyond her control.