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Published under the joint sponsorship of the United Nations Environment Programme, the International Labour Organization, and the World Health Organization, and produced within the framework of the Inter-Organization Programme for the Sound Management of Chemicals. The Inter-Organization Programme for the Sound Management of Chemicals (IOMC) was established in 1995 by UNEP, ILO, the Food and Agriculture Organization of the United Nations, WHO, the United Nations Industrial Development Organization, the United Nations Institute for Training and Research, and the Organisation for Economic Co-operation and Development (Participating Organizations), following recommendations made by the 1992 UN Conference on Environment and Development to strengthen cooperation and increase coordination in the field of chemical safety.
The World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full. The original impetus for the Programme came from World Health Assembly resolutions and the recommendations of the 1972 UN Conference on the Human Environment. The recommendations of the 1992 UN Conference on Environment and Development and the subsequent establishment of the Intergovernmental Forum on Chemical Safety with the priorities for action in the six programme areas of Chapter 19, Agenda 21, all lend further weight to the need for EHC assessments of the risks of chemicals.
Since the inception of the EHC Programme, the IPCS has organized meetings of scientists to establish lists of priority chemicals for subsequent evaluation. If an EHC monograph is proposed for a chemical not on the priority list, the IPCS Secretariat consults with the Cooperating Organizations and all the Participating Institutions before embarking on the preparation of the monograph. The order of procedures that result in the publication of an EHC monograph is shown in the flow chart on p.
The Task Group members serve as individual scientists, not as representatives of any organization, government or industry.
All individuals who as authors, consultants or advisers participate in the preparation of the EHC monograph must, in addition to serving in their personal capacity as scientists, inform the RO if at any time a conflict of interest, whether actual or potential, could be perceived in their work. When the Task Group has completed its review and the RO is satisfied as to the scientific correctness and completeness of the document, it then goes for language editing, reference checking and preparation of camera-ready copy.
All Participating Institutions are informed, through the EHC progress report, of the authors and institutions proposed for the drafting of the documents. A WHO Task Group on "Principles and methods for the assessment of risks from exposure to essential trace elements" met in Marbella, Chile, from 26 February to 2 March 2001. The purpose of this monograph is to develop the scientific principles that support the concept of an "acceptable range of oral intake" (AROI), which uses a "homeostatic model" for determining the range of dietary intakes for essential trace elements (ETEs) that meet the nutritional requirements of a healthy population and avoid excess intakes.
The principles and methods developed in this monograph are intended for ETEs and are not necessarily applicable to toxic non-essential elements or other chemicals.
A second group of elements (silicon, manganese, nickel, boron and vanadium), which might have some beneficial effects and which are classified by WHO as probably essential for humans (WHO, 1996), are not considered in this monograph. The need to develop methodology for assessing the toxicity of ETEs arose from an awareness that, for some ETEs, the margin between individual and population requirements and the estimate of the tolerable intake (TI) may be very small, and in some instances these values may overlap among individuals and populations.
The criteria for identifying nutritionally ETEs have evolved over the past fifty years and may be expected to expand as the result of future research. ETEs have homeostatic mechanisms involving regulation of absorption and excretion and tissue retention, which enable adaptation to varying nutrient intakes to ensure a safe and optimum systemic supply for the performance of essential functions (section 4.1). Risk assessments become more certain when the homeostatic mechanisms for each ETE are considered. The term ‘population’ refers to a group that is homogenous in terms of age, sex and other characteristics believed to affect requirement (WHO, 1996).
Requirement for the individual, as stated in WHO (1996), is the lowest continuing level of nutrient intake that, at a specified efficiency of utilization, will maintain the defined level of nutriture in the individual. Many different terms, definitions and values are used by various countries and organizations (European Union, North America and World Health Organization) in developing recommendations for dietary intakes of ETEs. Most earlier reports on recommended intakes of essential elements have provided estimates of the requirements of individuals, and the "recommended" dietary intake that would be expected to meet the needs of the majority (97.5%) of a defined population has been defined as the average dietary requirement plus 2 standard deviations (SD). Many terms and definitions have been proposed for the health-based guidance values developed from the dose–response relationships in toxicological studies. The US Environmental Protection Agency has replaced the ADI and TDI with the single term, reference dose (RfD), which is defined as an estimate (with uncertainty spanning perhaps an order of magnitude) of a daily exposure for the human population (including sensitive subgroups) that is likely to be without an appreciable risk of deleterious effects during a lifetime.
For ETEs, the use of diet as the only source of exposure considered for a RDA is not too critical, since food makes by far the major contribution to exposure from an ETE.
The traditional approach to determining an uncertainty factor is to identify the individual factors influencing the uncertainty.
A factor of 100 is generally considered appropriate as a default factor for chronic animal exposures studies (IPCS, 1987). A refinement of using uncertainty factors is that of subdividing the two default factors of 10 to allow for any known toxicodynamic and toxicokinetic variability (IPCS, 1994). The acceptable range of oral intake (AROI) for an ETE is represented by a trough in the U-shaped dose–response curve spanning requirements for essentiality to toxic levels, as shown in Fig.
The figure of 2.5% is based on 2 standard deviations from the means of the distributions for requirements and risks of toxicity. Although the term AROI is used in this document to facilitate a comparison with the RDA, which only considers dietary intake, the concept of a range of intakes within which homeostasis is maintained can be applied to situations where other routes of exposure are significant. The concept of an AROI is fully consistent with the US Food and Nutrition Board (FNB) model for the determination of dietary reference intakes (DRIs) (IOM, 2001).
For each category the body has evolved specific mechanisms for the acquisition and retention, storage and excretion of the various elements. Homeostasis of the cationic ETEs results from the modifications of several of the stages in the elements’ chain, but the critical primary control point in limiting excessive accumulation differs between elements. Fetal requirements for ETEs result in increased maternal requirements, as discussed in section 4.5. Pregnancy and lactation increase demand for some ETEs, particularly copper, zinc, iron and iodine (Picciano, 1996). The chemical species of an ETE that is ingested may influence its solubility and bioavailability for gastrointestinal absorption, and, in many instances, alter the risks of deficiency and excess.
Copper has the potential for a variety of interactions with other nutrients, particularly other ETEs, which may be regulated, in part or fully, by the processes of gastrointestinal absorption. There are a number of disorders in homeostatic mechanisms that can result in deficiency or excess from exposure to ETE at levels that are within the AROI for the general population (IPCS, 1998).
Menkes disease is an X-linked recessive disorder of copper metabolism that resembles a copper deficiency state regardless of the level of copper intake above the AROI for the general population. Indian childhood cirrhosis (ICC) is an insidious disease of the liver progressing to cirrhosis. There are several acquired pathological states that might result in elevated requirements for ETEs. It should be noted, however, that there is no assumption that the shapes of the curves for deficiency and toxicity are necessarily symmetrical or similar in slope.
A number of subclinical biomarkers, such as changes in levels of enzyme activity, have been shown to occur in people with low intakes of some ETEs. Criteria for determining when such changes are physiological adaptations or adverse health effects have not been established. Subclinical effects encompass laboratory measures of different types (biochemical, physiological, immunological, metabolic balances). The overall objectives of the IPCS are to establish the scientific basis for assessment of the risk to human health and the environment from exposure to chemicals, through international peer-review processes, as a prerequisite for the promotion of chemical safety, and to provide technical assistance in strengthening national capacities for the sound management of chemicals. Applications and enquiries should be addressed to the Office of Publications, World Health Organization, Geneva, Switzerland, which will be glad to provide the latest information on any changes made to the text, plans for new editions, and reprints and translations already available.
They represent a thorough evaluation of risks and are not, in any sense, recommendations for regulation or standard setting. Once the RO finds the document acceptable as a first draft, it is distributed, in its unedited form, to well over 150 EHC contact points throughout the world who are asked to comment on its completeness and accuracy and, where necessary, provide additional material.
After approval by the Director, IPCS, the monograph is submitted to the WHO Office of Publications for printing. The monograph is designed to give methods that provide a framework for analysing the boundaries between deficient and excess oral intakes of ETEs.
The AROI is designed to limit deficient and excess intakes in healthy populations and is set for different age-sex groups and physiological states such as pregnancy and lactation. These mechanisms provide for an optimal systemic supply for the performance of essential functions and must be considered in establishing an AROI. A weight-of-evidence approach is then used for hazard identification, selecting relevant end-points of deficient and excess exposures. Although it includes examples, this monograph is not a compendium of assessments on ETEs, nor is it a textbook detailing the scientific basis of risk assessment or the derivation of dietary reference intakes. Trace elements currently regarded by the World Health Organization as essential for human health are iron (WHO, 1988), zinc, copper, chromium, iodine, cobalt, molybdenum and selenium (WHO, 1996). If any one of these, or other elements, becomes accepted as essential for humans and quantitative requirements are established, then the approaches devised in this monograph should be applicable for setting an AROI for these elements. Oral intake also includes intake from water and beverages, dietary supplements and a fraction of inhalation exposures that become orally available after having been transported via the mucillary transport system and swallowed.
A workshop sponsored by the US Environmental Protection Agency, the Agency for Toxic Substances and Disease Registry, and the International Life Sciences Institute’s Risk Science Institute (held in March 1992) reviewed the problems inherent in the assessment of risk from human exposure to low and high intakes of ETEs, and identified a number of topics that had been inadequately considered (Mertz et al., 1994).
The traditional criteria for essentiality for human health are that absence or deficiency of the element from the diet produces either functional or structural abnormalities and that the abnormalities are related to, or a consequence of, specific biochemical changes that can be reversed by the presence of the essential metal (WHO, 1996). To establish such criteria for particular elements requires an insight of their biological roles, sensitive methods to detect subtle effects, and accurate instrumentation to measure trace amounts of the ETEs (Mertz, 1993). Although the terminology and definitions are contained in many other reports, they are presented again as a basis for their use in this monograph. The "factorial model" is based on the minimum requirement of the nutrient for replacement of losses from excretion and utilization at low intakes without reducing body stores and is usually sufficient for prevention of clinical deficiency in adults. For nutritionally ETEs, the defined level of nutriture may concern a basal requirement or a normative requirement or both.
For example, new terms have been developed such as the dietary reference intake (DRI) (IOM, 2001) and by European Union (SCF, 2000).
Thus, for an individual consuming this amount of element there would be a very low probability of the requirement not being met.
These differences must be considered in determining for ETEs scientifically based assessments that are broadly protective for both low and high exposures.
These factors should represent the adequacy of the pivotal study, interspecies extrapolation, differences in susceptibility of individuals in the human population, nature of toxicity, and adequacy of the overall database, taking into account high-dose to low-dose extrapolations and extrapolations from short-term to chronic effects (Younes et al., 1998). The value of 100 has been regarded to comprise two factors of 10, to allow for inter-species extrapolation and inter-individual (within species) variations. On the other hand, differences in individual susceptibility may warrant a much larger UF than 10.
For these two substances the upper confidence limit around the dose–response curve for the critical effect was used to assure safety. A UF > 1 is often applied to account for person-to-person variability, although, if the most sensitive group of the population is studied, a UF of 1 may be used. Establishing an AROI for an ETE requires balancing the nutritional requirement for a particular element and the potential for a toxic effect from over-exposure. The value of 2.5% might change according to the nature and severity of the effects of concern, the shape of the distribution and the breadth of the AROI. The definition of nutritional requirement has been fixed for a population but there is considerable variability of requirement among individuals.
4 describes the dose–response curves for the development of deficiency effects when the basal requirements are not met.
In addition, the rigid application of large uncertainty factors to the NOAEL without concern for bioavailability, nutrient interactions and homeostatic mechanisms can lead to point B being given a lower value than point A in Fig. The European Union’s Scientific Committee on Food has also reported on the development of tolerable upper intake levels for vitamins and minerals (SCF, 2000).
These factors include homeostasis, bioavailability, dietary and nutrient interactions, and age-related factors. Scenarios for the events of carrier mechanisms and biokinetics in homeostasis can be induced from our current insight of carrier mechanisms and biokinetics, but definitive evidence for much of this is not yet available for humans.


For all the elements the initial adaptation is a down-regulation of the enterocytic uptake mechanisms. In in vitro systems it can effectively compete with many other cationic ETEs and it is conceivable, therefore, that the physiological role for this metal as the highly regulated form in cobalamin has evolved to avoid these problems. The bioavailability of trace elements may vary considerably, depending on a number of factors such as food source or dietary matrix, oral intake, chemical form or species of the ETE, nutritional state (deficiency versus excess), age, gender, physiological state, pathological conditions, and interactions with other substances. For example, women have only about two-thirds the fat-free body mass (FFM) of men, while having a larger percentage of body fat. In some women, this extra need may be accommodated by sufficient iron stores, lack of menstrual losses and homeostatic adaptation, provided the dietary intake is adequate. It results from a defect in the gene coding for a P-type transporting ATPase, resulting in a marked reduction in the first phase of copper transport (IPCS, 1998). These are very important issues and need to be given special considerations that go beyond the framework of a risk assessment of an ETE for the general population.
This range off effects extends from lethality to subclinical and biochemical changes, which include evidence of homeostasis. In some cases the change in enzyme level is of functional significance and may even be the precursor of clinical disease. A designated staff member of IPCS, responsible for the scientific quality of the document, serves as Responsible Officer (RO). The contact points, usually designated by governments, may be Participating Institutions, IPCS Focal Points, or individual scientists known for their particular expertise. A summary and recommendations for further research and improved safety aspects are also required.
Although observers may provide a valuable contribution to the process, they can only speak at the invitation of the Chairperson. At this time a copy of the final draft is sent to the Chairperson and Rapporteur of the Task Group to check for any errors.
The Chairpersons of Task Groups are briefed before each meeting on their role and responsibility in ensuring that these rules are followed. Jenkins (IPCS Central Unit) were responsible for the technical content and technical editing, respectively, of this monograph.
The impact of other factors, such as chemical form, dietary characteristics and interactions amongst ETEs, are also critical in determining the AROI for ETEs. Similarly, a Nordic Working Group on Food and Nutrition and the Nordic Working Group on Food Toxicology have prepared a report "Risk evaluation of essential trace elements – essential versus toxic levels of intake" (Oskarsson, 1995), and a conference on "Risk assessment for essential trace elements – contrasting essentiality and toxicity" was held in Stockholm in May 1992 (Nordberg & Skerfving, 1993).
Factorial methods are used only as a first approximation to the assessment of individual requirements or when functional, clinical or biochemical criteria of adequacy have not been established (WHO, 1996). WHO (1996) is concerned with population (group) mean intakes rather than intakes of individuals. Nevertheless, research efforts are underway to identify means for using data-derived UFs (Dourson et al., 1996).
Therefore, selection of appropriate UFs for ETEs must consider potential effects in both directions, nutritional deficiency and toxicity.
Therefore, at intakes greater than B, the risk of toxicity will increase or the severity of effect noted might increase with dose, but not all individuals will have the same sensitivity at intakes above point B. In order to derive these points the full data set on which the dose–response curve for toxicity is based needs to be considered. However, where data are not available for the most sensitive population group or where there is a need to protect a larger proportion of the population than the benchmark chosen, a UF > 1 is applied. For iron the principal homeostatic control occurs by the induction in the enterocyte of apoferritin, which sequesters the metal and prevents its transfer into the body (i.e.
These processes are best understood for iodine, but the regulation of the enzymes and mechanisms involved are not well characterized.
It is likely that most of these factors have a role in bioavailability for each of the nutritionally essential trace elements.
For example, zinc is essential for development of the neural tube during embryonic life and differentiation of the brain during the fetal phase of development (Prasad, 1998). Absorption of chromium and selenium does not appear to be significantly different for elderly subjects (Anderson & Kozlowsky, 1985). For example, in aqueous solutions iron exists in two oxidation states: Fe(II), the ferrous form, and Fe(III), the ferric form. High zinc intakes (50 mg or more per day) inhibit absorption of copper by competing directly for serosal transport in the gut or by inducing metallothionein in the intestinal cells. The triiodothyronine must be formed from thyroxine in the cells of the brain by the enzyme type II iodothyronine deiodinase, a selenoprotein (Davey et al., 1995), because it does not have free access to the brain from serum. The disease is characterized by excessive iron absorption, elevated plasma iron concentration, transferrin saturation, and altered distribution of iron stores. While lethal effects and clinical disease must always be prevented, subclinical effects indicating impairment of organ function are often identified as critical effects. Other publications have been concerned with epidemiological guidelines, evaluation of short-term tests for carcinogens, biomarkers, effects on the elderly and so forth. The composition of the Task Group is dictated by the range of expertise required for the subject of the meeting and by the need for a balanced geographical distribution. Furthermore, recommended dietary allowances (RDAs) and TIs are determined by conceptually different approaches. There is need to harmonize universally the terms and definitions used to describe recommended dietary intakes, including the upper level of intake based on toxicological data. The ADI is applied to estimates for food additives, whereas TDI is used for those relating to contaminants. This approach was developed for providing TDIs for toxic metals with non-carcinogenic end-points, which are generally assumed to be threshold events. Human data are generally available for ETEs and often describes the variability between individuals.
The magnitude of the confidence limits provides an indication of the power of the study and quality of the data. This would also be the case for an ETE that is known to result in less severe but adverse effects below the 95% CI of the BMD2.5. This is the case also for selenium, although characteristic excretion forms of reduced selenium are known.
The ferrous form is better absorbed than the ferric form, although reduction of ferric to ferrous iron readily occurs in the gastrointestinal tract at acidic pH (WHO, 1996). The following examples indicate that information regarding factors that influence absorption and bioavailability exists. Zinc is a good inducer of metallothionein but copper has a higher affinity for the protein. This subpopulation develops disease in the deficiency range of the AROI for the general population.
A number of biochemical changes such as enzyme activities are often used as biomarkers to assess various levels of intake of ETEs. The relationship to functional change may reflect whether the enzyme level is normally well above that which is rate-limiting in the pathway so that small quantitative changes are not reflected in a functional change. Toxicologists customarily think in terms of high intakes, the risk of toxicity, and application of uncertainty factors, at least for non-cancer endpoints, whereas nutritionists are primarily concerned with avoiding inadequate intakes and the risk of deficiency. In addition, the Food & Nutrition Board (FNB) of the United States National Academy of Sciences (IOM, 2001) has developed a risk assessment model for establishing "upper intake levels for nutrients" which recognizes the possible benefits of intakes above RDAs, the narrow margins between desirable and undesirable intakes for many ETEs, and the need to ensure that advice from toxicologists and nutritionists is compatible. Similarly, copper, iron and other ETEs are essential for intrauterine growth and development.
Iron salts in dairy products and vegetables account for approximately 40% of the diet in women in the USA, 31% coming from meat sources and 25% from food fortification (mainly cereal and wheat-based products) (Yip & Dallman, 1996). A more data-related approach for assessing toxicological risk for nutritionally essential trace elements may be possible, particularly if relevant information has been previously used to determine RDAs.
In his remarks, Dr Younes thanked the Ministry of Health of Chile for financial support and assistance in organizing the Task Group, as well as an earlier Working Group, and also the Office of Water, US Environmental Protection Agency, for financial support for the development of this monograph. Finally, a risk characterization enumerating the strengths and weaknesses of the databases is performed, integrating the AROI and exposure assessment.
The European Union Scientific Committee on Food has adopted a report that deals with the development of "tolerable upper intake levels" for vitamins and minerals (SCF, 2000). Because adult females have only two-thirds as much FFM as males, protein and energy requirements are correspondingly less.
Consequences of the high affinity of copper for zinc-induced metallothionein can be both negative (i.e.
Unfortunately, for several potentially useful markers there is a lack of such information and further definition of the clinical and functional significance of biomarkers is needed.
The Task Group reviewed and revised the draft monograph, and developed a series of scientific principles and a conceptual framework for the assessment of risks from exposure to essential trace elements. Basal metabolic rate is more closely related to FFM than it is to total body weight, so that total energy requirements are less for women than men (Forbes, 1996). The interactions described are dependent on dose, source and nature of diet, and previous nutritional status.
A detailed policy statement is available that describes the procedures used for unpublished proprietary data so that this information can be used in the evaluation without compromising its confidential nature (WHO (1999) Guidelines for the Preparation of Environmental Health Criteria.
In healthy individuals, when zinc burdens exceed the capacity of these primary mechanisms, an enterocytic "mucosal block" based on induced metallothionein develops. World view, life experiences, and the cultural context in which today’s American Indian elderly live is described as it relates to health care. Since all individuals in such a population group cannot be studied, the assessment will usually be based on measurements of intakes in a representative sample of the group. Although each such chain of control provides an overall selective pathway for its respective element, in vitro studies indicate that each step or carrier is not necessarily specific; interactions can occur with other metals at several sites. Differences in requirements for specific ETEs are noted in the examples cited in section 6. Develop awareness of the importance of the historical context in the lives of today’s American Indians and Alaska Natives.
At the time of first contact with Europeans, the continental United States was fully occupied by Indian Nations, and some 300 Indian languages existed, approximately 106 of which are still spoken.
The other states with a large number of American Indian elderly are Alaska, New York, Texas, Washington, and Michigan (John, 1999; US Dept. Influence of Historical Experiences on Today’s Cohort of Indian Elders The lives of today's Indian elders are likely to have been influenced by the history of oppression, repression, intergenerational anger, and intergenerational grief, experienced since North America was colonized by Europeans. The disenfranchisement, the tradition of extermination, the broken treaties, the forced marches of the 18th and 19th centuries were all part of the context of the world and family experiences in which many spent their childhood. In addition, there were specific events that made dramatic impacts on individual lives.
Indian Self-Determination and Self-Governance In the late 1970s and 1980s American Indian lawyers shifted their fight to the courtrooms, claiming treaty violations and the undervaluing of tribal lands. Religion The basic tenets of Christianity (love for God and fellow man, honor, generosity and sharing, compassion, forgiveness, and self-sacrifice for the good of the community) were already institutionalized in the belief systems of many indigenous cultures before the missionization of North America. However, Christian beliefs were likely to be added to Indian beliefs, rather than replacing them. For example, the Lakota belief system (as recorded by the spiritual leader and warrior Black Elk) differs from Christianity in that belief is in a parallel spirit world rather than one above this world, and that any member of the Indian community may be given a vision by God to benefit the whole community living on this earth. Prior to European contact, the Lakota did not have a concept of sin, redemption, salvation, or eternal damnation, but many believed that spiritual guidance was sent in the form of visions to sustain the whole community (Rice, 1991).
Therefore, the Christian denomination of the region may still be the religion of preference for Indian families, and denominational support is often solicited at the time of family crisis or serious illness (Hendrix, 1999).


The concept of healing power that is maintained by the collective consciousness and belief of people of an Indian community is referred to here. At the tribal level, each tribe determines the criteria for enrollment, and there is considerable concern about the dilution of Indian blood through intermarriage.
There are elders in their 40s and 50s, and many Indian grandparents in their late 30s. In addition, Indian elders are considered those 55 years of age and older by most Indian Health Service agencies.
The American Indian (AI) experience is different from other ethnic minority groups in that 1) AI nations were colonized by Europeans and did not immigrate from other places within the last 700 years, 2) health care, education, and social programs were bought and paid for with ceded land by treaty, and 3) each elder is defined by the experience of the tribe (or tribes) to which he belongs (whether officially enrolled or not) and that tribe's relationship with the federal government.
American Indian women over 65 had 2.4 times the rate of diabetes as older women in the general population.
In comparison with all Americans, American Indians had a lower prevalence of cancer, but higher prevalence of diabetes and gallbladder disease, as reported in the SAIAN (Survey of American Indians and Alaska Natives) conducted in 1987 of Indians eligible for IHS benefits (Johnson & Taylor, 1991). In 1985, 59% of American Indians over age 65 reported one or more activity limitations, the highest of any ethnic population (McCabe & Cuellar, 1994).
There is concern about the validity of using western measures of depression with American Indian populations due to vast differences in cultural beliefs about mental illness, cultural labeling of different emotions, variability of manifestations of depression (rarely DSM IV criteria), and conceptual language differences (Manson et al.). The Indian Depression Schedule (IDS) was developed by Manson and colleagues, which includes consideration of local cultural context (Baron, Manson, Ackerson, & Brenneman, 1990). Chapleski (1997) used the Center for Epidemiological Studies Depression Scale (CES-D) in a study of 309 Great Lakes American Indian elderly from urban, rural, and reservation settings, with good internal consistency of the tool (Curyto et al., 1997).
Most cases of elder abuse reported in Indian country are for neglect, although financial abuse is probably more widespread, but clouded by the cultural norm of sharing one’s material possessions, food and housing with other family members.
Not only does this model provide a framework for history taking in the clinical setting, but also provides clues to intergenerational differences and perceptions, and clues to mental health issues. He has been a sober and productive member of a large urban Indian community for the last 20 years, and he presents with chronic uncontrolled diabetes. Historical events, such as attendance in Indian boarding schools experienced by a high percentage of the current cohort of older American Indians, play a very important role in their daily lives. Indicators of Conflicting Expectations Cultural values affect behavior, attitudes, and beliefs about health care and treatment, as well as expectations of health care providers. Cultural bias colors the way that individuals perceive the world around themselves and their response to situations and persons. His childhood was spent in Canada as a traditional Native American, taught the ways of the forest and his people, when his band of Sioux fled to avoid internment and starvation after the Sioux uprising of 1862. Eastman spent many years in the Indian Health Service as a physician at the Pine Ridge reservation, and tended the survivors of the Wounded Knee Massacre (1890). He seeks in this writing to explain the nature of Indian religious and spiritual belief and the tenets of Christianity -- how the two can be combined (pluralism), and how this may be a foundation for common ground between the Indian and non-Indian.
Questions should be carefully framed to convey the message of caring, and not indicate idle curiosity about the culture or cultural practices.
American Indian languages have some of the longest pause times, compared to other languages, and especially English. Literacy level should be assessed, especially if written forms or educational materials are used.
Language Line Services may not be proficient in American Indian languages, of which some 150 are still spoken.
Touching of the body (by a stranger or family member) in some Indian cultures is inappropriate. The Mini-Mental Status Exam (MMSE) (modified for cultural relevancy and language consistency), the Indian Depression Schedule (IDS), and the Center for Epidemiological Studies Depression Scale (CES-D) have been used with internal consistency for this population. DSM IV Diagnostic Criteria for mental disorders may not be applicable as there are vast differences in cultural (tribal) beliefs about mental illness, cultural labeling of different emotions, and conceptual language differences (Manson et al., 1985). Hendrix, MSN, GNP, PhD Although dementia is relatively rare in American Indian elderly, it is anticipated that as Indians’ life expectancy increases, so will the incidence of dementia. Treatment may require the services of traditional Indian medicine and not necessarily Western medicine (Navajo). 3. In some Indian communities this is a mark of elevated spiritual status for the family (Oklahoma Choctaw). 4. Dementia is caused by the stress on Indians of trying to live in two worlds at one time.
Especially, the stress of a rigid Christian belief system of traditionally reservation-raised elderly, and the stress, over time, of urban Indian living and family life. The lack of a collective consciousness in Indian spiritual belief dilutes the power of the Indian spiritual community and allows stress to develop illness, of which dementia is one form. Most American Indians have had some exposure to allopathic medicine through Indian Health Service units, or care in urban clinics or military settings. It is important to again emphasize the importance of obtaining a detailed history in a respectful manner in order to understand as much of the tribal and cohort influence on the individual elder as possible, given the heterogeneity of responses among AI elders. In addition, elders have asked for one-on-one education with a trained provider, rather than written printed materials, or educational lectures.
Commodities programs have provided such foods as cheese, peanut butter, lard, sugar, condensed milk, and white flour to contribute to an unbalanced diet. Many Indian communities are looking to re-create the more healthy diet of their ancestors, with squashes, melons, corn, beans, fruits, other vegetables, and some meat.
Nutrition guidance is helpful for special diets, especially for diabetes and gallbladder disease, but care must be taken to use culturally acceptable foods, portions, and timing of meals, as well as food preferences and foods used in ritual and ceremony. Several programs have been implemented in Indian Country and in urban centers with varying results. Many Indian languages do not have equivalent words or concepts for many English words, especially medical language. Medical procedures may be appropriate only on certain dates for an individual in consultation with traditional Indian healers. It is not unusual for AI patients to request any removed body tissues be returned to them after surgery. Although Older American Indians may be less likely to have written Advance Directives, due to historical misuse of signed documents, distrust of the dominant system, and belief that families will take care of decision making, many Indians know what their preferences are. A request for assistance may not be repeated, or may be told to a family member who will relay the request (Kramer, 1996). 6. American Indians appear to have a lower frequency of dementia than other populations and are less likely to be institutionalized than older Whites or Blacks despite higher rates of chronic illness (Chapleski, Lichtenberg, Dwyer, Youngblade, & Tsai, 1997). Also, AI caregivers did not expect to control or to be able to gain control of the situation of caregiving for a cognitively impaired elder, whereas the White caregiver did expect control, leading to anger and frustration (Strong, 1984). However, cultural respect for elders with or without dementia does not allow for the direct expression of anger toward the elder or for infantilization witnessed in Anglo settings (John et al., 1996). The cultural incongruence of caring for an elder with cognitive impairment and the cultural values of non-interference, individual freedom, non-directive communication and respect for elders may increase stress felt by the caregiver significantly. Culturally appropriate support systems would be important resources for providers to offer as resources to AI caregivers. 7.
There is a general preference for naturalness, and home care is preferred unless there is a cultural taboo regarding death (Navajo). Ignace (1998) surveyed 150 patients at an urban Indian Health Service clinic in Milwaukee, Wisconsin, on concurrent use of Native American healers and physicians. This study underscores the need for culturally sensitive dialog with patients about concurrent treatment and collaborative relationships with American Indian healers.
If an AI elder is hospitalized and requests it, arrangements may be made for ritual or ceremony at the bedside, which may include smudging with sage or sweet grass smoke. Other arrangements could be for Indian medicine pouches, bundles, or other specific items of sacredness and healing, that should not be disturbed or touched by health care personnel or hospital staff. VI.
To help serve the urban Indian population there are a small number of urban Indian health programs which comprise only 1.2% of the IHS annual budget. A large focus group of American Indian Elders (IHS Annual Research Conference, Albuquerque, NM, 2001), indicated that elders considered Long- Term Care and Diabetes their #1 and #2 priorities. There are very few LTC resources in Indian Country, and no Adult Day Health or respite services, although some tribes have established social models of Adult Day Care. Since IHS does not include LTC services, tribes are responsible for providing any LTC that exists.
There are only 12 tribally run Nursing Homes, and elderly AI have to be placed sometimes several hundred miles away from family, ancestral lands, and other Indians. However, today’s Indian families are subject to the same stresses for economic survival as other ethnic groups.
Despite a high need for social support, AI elders consistently underutilize services which may be available (John, 1999). 2. A major barrier to service provision for many elders living on or near reservations is the long distance to clinics and hospitals, many times coupled with lack of transportation. Bruce Finke, MD, (IHS Elder Care Initiative, personal communication) points out that IHS data indicate increased use of services as a percentage of population, but decreased hospital use when compared to all races (based on discharge days), and increased length-of-stay.
There is considerable concern in the Indian community that the health care system, built over the last 20 years to address the needs of American Indians in a culturally competent delivery system, will disappear with the advent of managed care contracting for Medicare and Medicaid funding. It is estimated that 30% of all Indians are utilizing Medicare or Medicaid coverage, but that less than 0.5% of any state Medicaid funding is spent on services to Indians. Assign students to read and prepare for discussion one or more of the cases included in the module and Appendix B. 3. Ask students to research the availability of outpatient care, hospital care, long- term care and senior centers for Indian elders in their area. 4. If there is an Indian or Alaska Native community available, ask the students to use the cohort analysis model as a basis to develop one that is specific to the historical experiences of the elders in that community. 7. Ask students to identify the tribal affiliation(s) of older patients that health care providers are most likely to see in your area and research the explanatory models of dementia (or another illness), preferences for end-of-life care, and healing ceremonies traditionally found in those communities. 8.
As a child attending public school in the area in which she lived, she was beaten and severely punished (as were her older brothers and sisters) for speaking her Indian language.
Health care, education, and social programs were paid for with ceded land, by some 800 treaties with the US Government.
Indians throughout the 20th century were told that their culture, religion, and way of life was without value C. Should be used only as a starting point for the gathering of information concerning a particular individual. Begay (not her real name) has come to a clinic for evaluation of a large mass in her right breast.
Home and community-based long-term care in American Indian and Alaska Native communities Washington, DC: Author Alvord, L. Depressive symptomatology in older American Indians with chronic disease: Some psychometric considerations.
Morbidity and comorbidity among Great Lakes American Indians: Predictors of functional ability. Alcohol drinking patterns of adult American Indians and Alaska Natives: Finding from the Behavioral Risk Factor Surveillance System, 1993-1997. Abstract #020, 13th annual conference, Indian Health Service Research Program, Albuquerque, NM. Eastman, C.
Cultural support in health care: The older urban American Indian of the San Francisco Bay Area.



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