Wednesday, March 23, 2011

Oklahoma City Indian Clinic

We have written before about the health issues often associated with food insecurity in America, issues such as obesity, diabetes, and heart disease. In addition to ensuring that healthy food is available through food banks, food pantries, and SNAP benefits, what should be done to stem the tide of these insidious conditions?

One population that has a very high incidence of these health problems is American Indians. American Indians in the US suffer from food insecurity and poverty at twice the rates of the general population.  But American Indians suffer from disproportionately higher rates of obesity, diabetes, and other related health issues than would be predicted by socioeconomic status alone.


First, there is a genetic component – some tribes appear to be particularly susceptible to diabetes. For example, the Tohono O’odham tribe in Arizona is reported to have the highest rate of adult onset diabetes in the world, up to 70%.  Other tribes have lower diabetes rates, but still higher than other ethnic groups.
A second factor is diet. Today, American Indians are not generally eating the traditional diet to which they had adapted. The Tohono O’odham tribe had no reported cases of diabetes in 1960, when they ate mostly traditional foods rather than a diet high in fat and calories.

In the 19th century, many American Indian tribes were forcibly removed from their ancestral lands and lost access to their traditional foods and methods of acquiring it.  In the mid 1930’s, the US government created the commodity program to distribute excess food, and in 1949 the program was expanded to explicitly include American Indians. Today, the Food Distribution Program on Indian Reservations (FDPIR) provides commodity foods to low-income Native Americans and serves as an alternative to SNAP in areas of the country where access to grocery stores is limited.

Initially, commodity foods were high in fats and refined carbohydrates (e.g., white flour, lard, butter, cheese). Today, the commodities provided are healthier, but still higher in refined carbohydrates and fat than the ancestral American Indian diet. Partly in response to the available commodities, Indians developed new “traditional” foods, such as fry bread, that provided less than optimal nutrition. 

Steve Barse, shown beside painting
by Thomas Poolaw, Kiowa/Delaware

The state of Oklahoma has the second largest number of American Indians in the country (8.6% of the state's population), and is the home of 39 Indian tribes. We visited the Oklahoma City Indian Clinic to learn about their nationally recognized approach to prevention of these health problems. Our host was Steve Barse, Community Liaison; and we also spoke with Diane Brown, Health Promotion and Disease Prevention Director, David Toahty, Chief Development Officer, and Hazel Lonewolf, Epidemiologist/ Quality Improvement Coordinator. Here is some of what we learned.

The clinic is open to any American Indian with a Certificate of Degree of Indian Blood. It has served patients from 220 of the nation’s 569 different Indian tribes. About 70% of their 16,000 patients have no health insurance, so most of the funding for the clinic comes from the Indian Health Service and grants. About 10% of their patients have diabetes, and 60-70% are overweight or obese. 

Diane Brown serves veggies at Turtle Camp
In an effort to cut their rate of diabetes and obesity, the clinic offers a large number of wellness programs focused on disease prevention for both children and adults. One that especially caught our attention is Turtle Camp (Teaching Urbans Roads to Lifestyle and Exercise) – a diabetes prevention and wellness program for children ages 6-12.

We got a first-hand look at Turtle Camp, which was underway during the children’s spring break at a local camp facility just outside the city. There were about 52 children in attendance, all patients at the clinic. We helped one day to serve lunch, assess the children’s post-camp understanding, and observe their final fun activities.

One aspect of the nutrition education they’d received that really impressed us was the focus on “everyday” foods and “sometimes” foods. Healthy foods that should be eaten every day, such as fruits and vegetables, were contrasted with food that should only be eaten occasionally, such as cookies and French fries. During the post-camp evaluation, we felt that most kids grasped and could use this distinction. (See also the similar 3-part distinction of “Go, Slow, and Whoa” foods from the National Institutes of Health.)

Ropes Course at Turtle Camp (photo by Andii Tittle)
The staff uses Turtle Camp to “get in all the healthy living education they can.” For example, the camp curriculum also included education on resisting drugs, alcohol,and tobacco. The kids also have lots of time for physical activities. We watched them shoot arrows, trust each other on a low ropes course, and have the thrill of sliding along a low zip line. We also heard about canoeing and playing outdoor games. The kids were obviously having a wonderful time! To help reinforce Turtle Camp’s messages, the kids set at-home goals for themselves and parents receive recipes and cost information on the healthy food that the kids ate during the day.

Archery at Turtle Camp
Turtle Camp does seem to have a long-term positive effect. (See The IHS Primary Care Provider, Volume 30 Number 7, 2005, pages 180-181.)  We were told that Turtle Camp kids are monitored and a reunion is held about 6 months later to see how they’re doing on the goals they set regarding activity and nutrition. Only a very small number of the kids who have been to Turtle Camp have developed diabetes as teens. Turtle Camp was among the programs that won an Indian Health Service National Health Promotion/Disease Prevention award for exceptional performance in 2009. (See American Indian Horizons, Spring 2009, page 11.)

In addition to Turtle Camp, the clinic offers a huge number of other facilities and programs focused on wellness for people of all ages. For example:
  • A large fitness center with treadmills, stair-steppers, weight equipment, fitness classes, and personal trainers. About 60 people/day use this center.
  • Get-SET – a 12-week exercise, weight-loss, and diabetes prevention program for adults
  • Moccasin Movers – an exercise program for elders
  • Project POWER (Providing Opportunities for Wellness, Exercise and Recreation) – a fitness program for youth and families
  • A separate WIC clinic for pregnant and breastfeeding mothers and their children up to the age of 5
    Offering nutritious recipes
  • Lunch-time talks on preparing nutritious, inexpensive food, including recipes and the costs of preparation. Participation is usually 40-60 people/day.
The wellness center at the clinic also makes a special effort to improve the nutrition of all patients. To supplement the work of staff dieticians, the clinic hosts dietetics interns from the University of Oklahoma. We helped intern Jenny Graef distribute information at a National Nutrition Month display in the clinic lobby. We offered recipes for “Eating Well on a Budget” as well as handouts on local farmer’s markets, how to incorporate more exercise into your day, and tips on eating more fiber, fruits and vegetables. 

These and other programs run by the clinic are having the desired effects. The clinic exceeded the goals for diabetes control set by the Oklahoma City Area Indian Health Service (as well as all but one of the other medical goals), and individual patients are lowering their risk for diabetes by controlling their weight and eating healthier food. (See American Indian Horizons, Fall 2010, pages 6- 7.)

Multi-media Image by Shan Goshorn
One more thing about the clinic that impressed us:  it’s not just a full-service clinic. It’s an entire community, focused on the overall physical, behavioral, and spiritual well-being of its American Indian members. A powerful symbol of this holistic approach is that the clinic has five partner Native American artists whose work adorns the corridors of the clinic. (See American Indian Horizons, Fall 2010, pages 48-49.) Here’s an example we particularly liked, a work by Shan Goshorn, Eastern Band Cherokee.

As Steve Barse said in describing the broad approach of the Oklahoma City Indian Clinic, “5 fingers make a fist. The fist is more powerful than the fingers alone.”

1 comment:

  1. Steve Barse kindly included Facing Hunger in America in the Spring 2011 issue of their "Horizons" magazine. You can see it here: