(Over Age 30 Audience)
Trainer’s
Guide
If you are interested in implementing the Heart of Many Nations: Heart Attack Prevention & Response in
Native Communities curriculum, in your community, please contact the Minnesota Department of Health at
651-201-5411.
© 2010, Minnesota Department of Health
This information can be made available in alternative formats, such as Braille, large print, or audio tape,
upon request.
Printed on recycled paper.
Contact information:
Mail:
Heart Disease and Stroke Prevention Unit
Attn: Heart of Many Nations
Center for Health Promotion
Health Promotion and Chronic Disease Division
P.O. Box 64882
St. Paul, MN 55164-0882
Phone: 651 201-5411
Fax:
651 201-5800
TTY:
651 201-5797
Website: www.health.state.mn.us/cvh
Acknowledgments
Funders
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ProjeFt Partners and Community Advisory Committee
The Greater Minneapolis Council of Churches, Division of Indian Work staff provided significant
leadership and cultural expertise to develop this curriculum.
A Community Advisory Committee, consisting of the following community members and health care
professionals, provided invaluable knowledge and support to develop this curriculum. Those
members include:
Alameda Rocha, Community Leader
Adrienne Voorhees, Native American Community Clinic
Betty Moore, YWCA Minneapolis
Kateri Tuttle, Ain Dah Yung Center
Tammy Didion Heinicke, Indian Health Board
George Spears, Greater Minneapolis Council of Churches, Division of Indian Work
Suzanne Tibbetts Young, Greater Minneapolis Council of Churches, Division of Indian Work
Bob Klanderud, Greater Minneapolis Council of Churches, Division of Indian Work
The Heart Disease and Stroke Prevention Steering Committee also provided support and technical
expertise to create this project.
Curriculum Writer
Karen DeYoung, DeYoung Consulting Services, LLC
Contributing Author
Rosemary White Shield, Ph.D.
Illustrator
Robert Desjarlait
Disclaimer The Minnesota Department of Health is not able to provide individual health
advice. Please contact your medical care provider if you have specific questions about
your health
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Heart of Many Nations: Heart Attack Prevention and Response in Native Communities
3
Table of Contents
Curriculum Overview...........................................................................................5
Curriculum Aim and Goals..........................................................................................................................5
Workshop Objectives..................................................................................................................................5
Trainer Preparation ..............................................................................................6
Estimated Times ...................................................................................................9
Critical Content.............................................................................................................................................9
Optional Content....................................................................................................................................... 10
Trainer and Workshop Introduction ....................................................................11
Historical Trauma ...................................................................................................................................... 12
What is a Heart Attack?......................................................................................15
Signs and Symptoms..........................................................................................16
Calling 911.........................................................................................................18
Risk Factors ........................................................................................................21
Nutrition .............................................................................................................28
Workshop Review and Closure ..........................................................................30
Additional Learning Activities............................................................................31
Evaluation Instruments.......................................................................................32
References..........................................................................................................34
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Heart of Many Nations: Heart Attack Prevention and Response in Native Communities
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Trainer Preparation
Curriculum Overview
The Heart of Many Nations: Heart Attack Prevention and Response in Native Communities’ curriculum
has been created with the input of advisors from within the American Heart Association, the
Minnesota Department of Health, the Greater Minneapolis Council of Churches, Division of Indian
Work and other interested stakeholders (listed in acknowledgments). It is intended to present
medical content in a culturally relevant way, specific to Native communities.
Curriculum Aim and Goals
The project’s curriculum aim is:
To promote and sustain the health and well being of Minnesota’s Native Communities.
The curriculum’s goals are to:

Increase Native communities’ awareness of the signs and symptoms of a heart attack;

Increase awareness of the importance of calling 911;

Increase Native communities’ awareness of heart healthy lifestyle practices; and,

Minimize disabilities and prevent deaths caused by heart attacks.
Workshop Objectives
As a part of this session participants will:

List the risk factors associated with the likelihood of having a heart attack.

List the signs and symptoms (in both men and women) associated with having a heart
attack.

List three examples of lifelong, heart healthy lifestyle practices.

Understand the importance of calling 911 if they believe someone is having a heart attack
or they believe they are having a heart attack.
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Heart of Many Nations: Heart Attack Prevention and Response in Native Communities
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Trainer Preparation
Trainer Preparation
This section contains training preparatory information for the trainer.
Workshop Topics

Introduction and Historical Trauma

Definition of a heart attack

Signs and Symptoms of a heart attack

Calling 911

Risk factors we cannot change

Risk factors we can change


Cholesterol/Blood pressure

Sacred Tobacco Use

Diabetes

Nutrition
Close
Audience
The primary target audience for this curriculum is American Indians, and
their families, residing in both the Twin Cities metro area and Greater
Minnesota. Information dissemination is important for Native people who
may be at risk for heart disease, and therefore family members must be
included to augment culturally appropriate supports; American Indian
communities are traditionally family centered. Education of the family on
heart attack signs and symptoms, the most effective response in a health
emergency situation, and involvement in heart healthy lifestyle choices
and activities promotes success in individual and family health among
American Indians.
Classroom
Training Length
The session is intended to be 50 minutes long; the critical content has
been designed to fit into that time frame. However, optional content has
also been included to enable the trainer to extend the length of the
session to 85 minutes, if needed or desired.
Equipment Needed
This class requires the following equipment:
MDH

Whiteboard

Flip chart easel

Computer with MS PowerPoint

Projection screen and laptop projector

Tables and chairs for small group work
Heart of Many Nations: Heart Attack Prevention and Response in Native Communities
6
Trainer Preparation
Supplies Needed
Training Materials
Needed
Training
Preparation Tasks
Workshop Setting
Preparation Tasks
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Required supplies:

Flip chart and paper

Flip chart markers (at least 3 bold colors)

Whiteboard markers (at least 3 bold colors)

Notepad for trainer

Pencils/Pens

Sign in sheet
Required training materials:

Trainer Guide

Participant Materials

PowerPoint slide presentation
Complete these tasks in advance of training:

Confirm the time and location for the workshop. Ensure that you
will have all the equipment needed for the session noted above.

Review the Trainer Guide several times and insert any comments
or key points you wish to make. The more familiar you are with
the content the more relaxed and effective you will be. You may
even want to practice your presentation with a trusted friend or
family member.

Think about any personal stories you would like to share about
your own experiences, which can help to make the presentation
more meaningful.

Familiarize yourself with the participant materials. Ensure that
you will be able to refer participants to the correct page in their
materials at the appropriate time.

Gather all the materials and supplies needed for the session.
Make sure that you have enough copies of the materials for all
participants.

Make sure the PowerPoint presentation works properly.
Complete these tasks to prepare the workshop setting:

Choose a setting with appropriate lighting and a comfortable
temperature.

Arrange tables and chairs, if necessary. It works well to have the
chairs in a circle, if that’s possible.

Ensure that your computer and PowerPoint are running properly.

Test and focus the projection equipment.
Heart of Many Nations: Heart Attack Prevention and Response in Native Communities
7
Trainer Preparation
During-Class
Tasks
After-Class Tasks
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Note the following during class:

Make sure everyone feels welcome and encourage participation
to each participant’s level of comfort.

You may want to open and close the workshop with a cultural,
traditional spiritual activity, such as smudging.

Encourage participants to share their own stories, as time allows.

Distribute evaluation forms to each participant, for the preevaluation.
Complete the following tasks after class:

Distribute post-evaluation forms, collect completed forms and
return to host organization or agency.

Rearrange room back to original setting, as requested.

Recycle flip charts unless follow up tasks are required.

Follow up on participants' unanswered questions.
Heart of Many Nations: Heart Attack Prevention and Response in Native Communities
8
Trainer Preparation
Symbol Key
This chart explains the symbols used throughout the Trainer's Guide.
Symbol
Meaning
Introduction

Objectives
Transition to Next Topic
Check for Understanding
Estimated Times
Critical Content
Topic
Trainer and Workshop Introduction
What is a Heart Attack?
Length
15 minutes
5 minutes
Signs and Symptoms
10 minutes
Calling 911
10 minutes
Workshop Review and Closure
10 minutes
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Heart of Many Nations: Heart Attack Prevention and Response in Native Communities
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Trainer Preparation
Additional Optional Content
Topic
Risk Factors
Blood Pressure
Blood Cholesterol
Non-Traditional Use of Tobacco
Diabetes
Diet High in Fat
Physical Inactivity
Stress
Nutrition
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Length
35 minutes
Heart of Many Nations: Heart Attack Prevention and Response in Native Communities
10
Critical Content
Topic 1: Trainer and Workshop Introduction – 15 minutes
Introduce yourself: your name and any personal history you would like to share.
Trainer and
Course
Introduction
Over the course of five years, leaders from local tribes, health care
organizations, social service agencies and community members gathered to talk
about ways to improve Natives’ heart health. As of result of that conversation,
and several other ones, this curriculum was developed.
Slide 2
Take about a minute to introduce the curriculum as an opportunity to talk about
ways to better care for the heart, acknowledging that it plays a key role in our
physical, mental and emotional well being. Caring for our hearts ensures that we
are better able to care for our families and contribute to the community.

Learning
Objectives
and
Overview
Slide 3
Ask participants to turn to page 5 in their guides.
As a part of this session you will be able to:

List the risk factors you can and cannot change that are associated with
the likelihood of having a heart attack

List the signs and symptoms (in both men and women) associated with
having a heart attack

List three examples of lifelong, heart healthy lifestyle practices

Understand the importance of calling 911 if you believe someone is
having a heart attack or you believe you are having a heart attack
Encourage participants to share their personal stories throughout the session,
which will make it more meaningful. While sharing is encouraged, remain mindful
of the time allotted to share the curriculum content.
Introduction
Ask participants to turn to page 6 in their guides.
In many of our Native traditions, we must seek healing whenever imbalance
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Heart of Many Nations: Heart Attack Prevention and Response in Native Communities
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occurs in ourselves or our communities. Many Native people view healing in a
holistic way. Healing is a relationship between the spiritual, mental, physical,
and emotional aspects of a person. When one of these aspects is out of
balance, then the person becomes prone to illness.
Slide 4
Historical
Trauma
Many Native researchers believe that Native people have greater needs for
healing and balance because of the recent colonization by other nations. We
define colonization as the taking over of resources and/or the harming of those
resources. Over thousands of years, Indian Nations developed many resources
that contributed to their progress as tribes. These resources included spiritual
practices, oral traditions, traditional foodways, and many others. The use of
these resources was refined over many generations and thousands of years.
The resources gave us social, physical, mental, emotional, cultural and spiritual
health.
However, colonization by European nations and others during the last few
hundred years has harmed these tribal resources, and actually caused historical
trauma to Indian people. The trauma occurred in a number of ways, including
taking homelands by force, bringing diseases that were foreign to Native
people, and forcibly removing Indian children from their homes and placing
them in Boarding Schools. Every tribe’s experience with colonization was
different. For example, some tribes were able to hold on to their spiritual
practices more than others.
Slide 5
Some of the things we've seen come into our Nations since the historical trauma
include unhealthy family dynamics, poverty, loss of traditional values and
spirituality, and loss of Indian identity.
Slide 6
This imbalance in our communities has also resulted in the near destruction of
traditional food systems due to the loss of traditional lands; this includes a loss
of animal herds, fish, plants, and water sources. Traditionally, as Native
people, we led an active Hunter-Gatherer lifestyle, but as our land shrank and
we became more sedentary, packaged foods, highly processed meats, and
soda have replaced gathered plants, lean buffalo meat, and fresh water. With
the changes in how we ate came diabetes, obesity, and heart disease.
Restoring a balance in how we nourish our bodies can create healing and help
prevent heart disease and heart attacks.
The effects of historical trauma on Native well being are so pervasive and
longstanding that many Native people view the high rates of heart disease in
urban and reservation communities as an unavoidable part of being Native.
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Heart of Many Nations: Heart Attack Prevention and Response in Native Communities
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Even though we are People of the heart, our community has been affected by
heart disease:
1. Heart disease is the leading cause of death for American Indians in the
United States, and in Minnesota.
MDH Center for Health Statistics
2. In Minnesota, death rates due to heart disease are higher in American
Indians than in any other racial or ethnic group.
MDH Center for Health Statistics
3. A study of American Indian women in Minnesota shows only two-thirds would
seek immediate medical care when experiencing crushing chest pain, one of the
most important signs of heart attack.
Struthers, R., Savik, K., & Hodge, F.S. (2004) J Cardiovasc Nurs
4. The Indian Health Service (IHS) reports that the Bemidji district (which
includes Minnesota) has the second-highest death rate due to coronary heart
disease of all 13 IHS regions across the United States.
U.S. Department Health and Human Services, IHS
5. A national study of heart attacks shows that American Indians, especially
living in rural areas, have the longest time to treatment after symptoms begin
of any racial or ethnic group.
Canto JG, et al. (1998). Am J Cardiol.
Healing from
Historical
Trauma
But, there's good news. Many Indian Nations and communities are seeking
healing from historical trauma. One way Indian peoples are healing is by
connecting with those spiritual and cultural resources and strengths that have
traditionally restored balance to our lives.
Slide 7
One resource is the Medicine Wheel. The Medicine Wheel is a sacred symbol
used by Plains tribes and others. It is a symbol representing all knowledge of
the universe. Its universal knowledge is looked to by many who seek wisdom,
healing and direction.
Conti, K. (2001). Medicine Wheel nutrition model. “Unpublished manuscript"
Each tribe has a slightly different way of understanding or representing the
Medicine Wheel. For example, the sacred colors associated with the four
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Heart of Many Nations: Heart Attack Prevention and Response in Native Communities
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Critical Content
sacred directions of creation may vary between tribes. Also, the concept may
be referred to as the Sacred Hoop or the Circle of Life. These differences
represent the beauty of diversity found in the spiritual and cultural thought and
experience of Indian peoples.
The Medicine Wheels we'll talk about here today reflect the perspectives of
many Native people. The circle represents life as a continuous cycle. The four
lines crossing and intersecting within the circle represent the sacred Four
Directions (East, West, North and South). The four areas held within the lines
can represent different dimensions of creation and human experience, such as
the stages of human life or aspects of personhood. In other understandings of
the Medicine Wheel, the four areas can represent the four seasons, elements of
the universe or four sacred values: respect, generosity, fortitude and wisdom.
(Optional: Depending on the tribal tradition, there can be other directions
within the Medicine Wheel also).
Please take about a minute to share your own tribal perspectives on the Medicine
Wheel.
Slide 8
The Medicine Wheel focusing on the four aspects of self or personhood shows
us how we have mental, physical, emotional and spiritual aspects. All of these
things are interconnected within the Circle of Life. For example, making the
decision to choose healthy foods, increase physical activity, use tobacco in
traditional spiritual ways, and do other things to take care of your heart can
come from thoughts or from spiritual inspiration or from the cante or inde itself,
where feelings and emotions arise. The information we are about to cover is
structured so that it can touch all aspects, including the physical being, of a
person as they learn about how to care for their heart.
Family
Centered
The Medicine Wheel showing the life stages of a person (child, youth, adult,
Elder) reflects that all members of a family are important in caring for each
other. In many Indian societies, the family is the center of the Nation. Elders are
the experts in Native Nations, but children are seen as wakanjapi (pronounced
wakanjapee), the sacred ones, and can teach others as well. All family
members, within many Native traditions, bring unique gifts to the family by who
they are and how they live in each stage of life. They are interconnected and
affect each other.
Slide 9
Caring for your own heart affects the health and well being of your family
members. For example, a person in the youth stage of life learning how to care
for their heart can be a role model and support for an Elder in encouraging
her or him to care for their heart also. A person in the adult stage of life not
allowing second hand smoke in the house with children is helping promote heart
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Heart of Many Nations: Heart Attack Prevention and Response in Native Communities
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Critical Content
health for everyone in the family.
Let’s take a couple of minutes to reflect on the role of the Medicine Wheel in
our own lives.
Instructions:
Ask participants to turn to the person sitting next to them on the left and
visit with them about the following question. (If group is an odd number
of participants, the facilitator can pair up with the extra person).
What is your tribal perspective on the Medicine Wheel and how to stay
in balance?
Transition to
next section
Because caring for one’s heart is so important, regardless of our place in the
family system, let’s talk about some ways to make sure that we remain heart
healthy. The heart serves many roles, including helping to sustain us physically.
We’ll begin by taking a look at what the heart is and its role in our physical
well being.
Topic 2: What is a Heart Attack – 5 minutes
What is a
Heart Attack?
Slide 10
Ask participants to turn to page 10 in their guides.
The heart is a fist-sized muscle located in the middle of the chest. Its job is to
pump blood to the lungs where it picks up oxygen and then sends the
oxygenated blood to all parts of the body. The heart is remarkably well
designed and efficient but certain circumstances can cause its normal function
to be disrupted.
Display Model
Slide 11
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Heart attacks often happen because of a type of heart disease called
coronary artery disease, or CAD. With heart disease, a fatty material called
plaque (pronounced "plack") builds up over many years on the walls of the
arteries that supply blood and oxygen to the heart. It hardens the artery
walls and can block the flow of blood. The narrowed arteries cannot deliver
enough blood to maintain normal function of the parts of the body they
supply.
Heart of Many Nations: Heart Attack Prevention and Response in Native Communities
15
Critical Content
Slide 12
Heart Attacks
and Heart
Disease in the
Native
Community
When blood flow to a part of the heart is completely blocked, a heart attack
occurs. The part of the heart muscle that is not receiving blood dies and is
replaced by scar tissue. The longer the blood flow to the heart is stopped,
the greater the damage. Without quick treatment, it may cause damage that
we can’t see, or it could cause permanent or severe problems, even death.
As the statistics I quoted earlier indicate, heart attacks pose a serious threat to
the Native community. Focus groups conducted for this project
indicated that Native people know they are at a higher risk for diabetes,
but many do not know they are also at high risk for heart disease.
As we said before, heart attacks often happen because of a type of heart
disease called Coronary Artery Disease (CAD).
It is not just our Elders who need to recognize the signs and symptoms of a
heart attack, it is all generations of our people. Heart attacks can happen in
younger adults as well.
Transition to
next section
Whether we are concerned about our own health or the health of a relative,
it’s important to know the signs and symptoms of a heart attack. How can we
tell and what do we do if we suspect a heart attack? Here are some specifics.
Topic 3: Signs and Symptoms – 10 minutes
Signs and
Symptoms for
Men and
Women
Slide 13
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Ask participants to turn to page 11 in their guides.
Heart attacks can be fatal, but often people affected don't know what's
wrong and wait too long before they get help. Knowing the signs and
symptoms of a heart attack gives you the power to save your life or the life
of a family member.
Maybe you’ve seen a movie or a TV show in which the character experiences
extreme pain, clutches his chest and falls to the ground. Very few people
experience the "Hollywood" heart attack. While some heart attacks are
sudden and intense, most start slowly with mild discomfort or pain. Symptoms
can be different for men and for women.
Heart of Many Nations: Heart Attack Prevention and Response in Native Communities
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Slide 14
Often men and women share some of the same heart attack symptoms. This
can include:

Pain or discomfort in the jaw, neck or back.

Feeling weak, lightheaded or faint.

Chest discomfort or pain. Usually heart attacks involve discomfort in
the center of the chest that feels like pressure, squeezing, fullness, or
pain. The discomfort may last more than a few minutes, or may go
away and come back again.

Pain or discomfort in the shoulders or in one or both arms.

Shortness of breath. You pant for breath or feel like you have to take
deep breaths to get enough air. This can occur with or without chest
pain, or can come before chest pain.

Breaking out in a cold sweat. You suddenly start sweating or have
cold, clammy skin.
In some cases, Native men may be inclined to ignore any symptoms they are
feeling and won’t want to talk about them. If a male relative is experiencing
these symptoms, please encourage him to seek emergency services. It’s
important if you are experiencing these symptoms you call 911 or tell
someone else who cares about you to call 911 for you. Even if you or your
family member is not sure it’s a heart attack, it’s better to call just in case.
Slide 15
Women's heart attack symptoms are often less predictable than men's.
Women may experience all, none, or some of the symptoms we just covered.
They are more likely than men to experience shortness of breath or back/jaw
pain. Women are more likely than men to not have any chest pain during a
heart attack. Some additional symptoms that a woman may experience
during a heart attack include:

Nausea (feeling sick to your stomach) or vomiting. It may feel like the
stomach flu.

Fatigue or tiredness. You feel unusually worn out or exhausted.

Severe indigestion. This can feel like severe heartburn or stomach
pain.

Depression can sometimes be a symptom.
Men can experience these symptoms as well, but it's not as common.
Often, women are so busy caring for others that they don’t care for
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Heart of Many Nations: Heart Attack Prevention and Response in Native Communities
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Critical Content
themselves. But it’s important to be aware of your health, so that you can be
here for your family.
Both men and women may also begin to notice symptoms before having a
heart attack. These symptoms can occur when a person is resting or active.
Let’s take a couple of minutes to reflect on what we just learned.
Instructions:
Ask participants to turn to the person sitting next to them on the left and
visit with them about the following questions. (If group is an odd number
of participants, the facilitator can pair up with the extra person).
What have you learned about the signs and symptoms of a heart
attack that will help you stay in balance, especially related to your
heart?
Transition to
next section
What if you or a family member is experiencing these symptoms? What do
you do? There are some steps you can take that may help to save your own
life or the life of a family member.
Topic 4: Calling 911 – 10 minutes
Importance of
Calling 911
Ask participants to turn to page 13 in their guides.
As scary as heart attacks are, they are treatable. A heart attack is most
treatable when treatment is started within an hour of the beginning of
symptoms. This means that if you or someone you’re with is experiencing any
of the signs we discussed, it is important to call 911.
Slide 16
If you're in doubt about whether you or someone else is having a heart attack,
it's much better to call for help just in case. You could end up saving your or
their life.
Slide 17
Don't wait any more than five (5) minutes before calling for help if you
suspect you or someone else is having a heart attack. Even if symptoms stop
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Heart of Many Nations: Heart Attack Prevention and Response in Native Communities
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Critical Content
within five minutes, you still should call 9-1-1. When you act fast at the first
signs of a heart attack, you can save your life and limit damage to your
heart. Calling 911 for an ambulance is almost always the fastest and most
effective way to receive treatment. You'll be treated faster when you arrive
to the hospital by ambulance. When you arrive at the hospital, emergency
medical staff can begin providing treatment immediately, up to an hour
sooner than if you arrive by car. Also, the staff in the ambulance is trained to
handle heart attacks.
We probably all know about 911, and have maybe even called it before,
but what is it? 911 is a national emergency number that we can use to call
for help from local police, fire, and ambulance services; we can even use it to
get information about poison control. It provides an easy number for people
to call when there is an emergency or to call for assistance. Almost all areas
of the United States, and most of Canada, use 911 as their connection to
emergency services.
Even though some Native people have voiced that there is fear of
discrimination, or cost for care, or not wanting to go to the hospital because
cultural ways are not often understood, we should remember that we are all
very important to our relatives and moving through these hard things to take
care of ourselves in the best way will mean so much to our families, children
and grandchildren. If we take those actions to help our heart, this will greatly
help our family members.
911 is free, and you can call from any phone, no matter what kind it is: push
button, rotary, cellular/wireless, cordless, or pay phone. When you call 911
from a payphone, you do not need to put in any money. You can also call
911 whether or not your phone is in service. Disconnected and old phones can
connect to 911 services.
All 911 dispatchers and answering points are set up to respond to callers of
all types, including kids and those who are hearing/speech impaired. Kids
should be taught to call 911 if there is an emergency, and should know their
names and addresses to give to responders. You can post your address by
your phone to make it easier. Kids should only be taught the phone numbers
as 9-1-1 and not 9-11, so that when scared they don't look for the "eleven"
button.
Slide 18
MDH
Once you’ve dialed the numbers 9-1-1 into your phone, your call will
automatically be directed to a local Public Safety Answering Point, or PSAP.
The workers at these answering points are all trained professional staff whose
job it is to identify and respond to emergencies. Stay calm and state your
Heart of Many Nations: Heart Attack Prevention and Response in Native Communities
19
Critical Content
emergency. When you are talking to them, you are their eyes and ears into
the emergency. They will ask you questions to determine what exactly is going
on and what help is needed. Some questions they may ask include:
Slide 19

"Nine-one-one operator. What is your emergency?"

"Where are you?"

"What is your name?"

"What symptoms are you / are they experiencing?"

"When did the symptoms start?"

"Don't hang up. Help is on the way but I still have a few more
questions."
As they are asking you questions, they are also contacting the closest
emergency response teams to send your way. Be prepared to provide
information like your name, phone number, address, and anything else they
may need to know to make sure the emergency is responded to properly.
Don't hang up until they say it is okay to. The operator may also give you
first aid / CPR instructions for you to implement until help arrives. If you are
unable to communicate, call 911 and stay on the line. Don't hang up! The
operator will understand that there is an emergency, will figure out where you
are with the satellite technology and will send help your way.
Instructions:
If time allows, ask for a volunteer to come forward. Role play a 911
call in which the participant is concerned that he or she is having a
heart attack.
Transition to
next section
MDH
It may be tempting to think that if you are fated to have a heart attack there
is nothing you can do. But we can greatly reduce the risk of a heart attack by
being mindful of our behavior – how we eat and what we do to bring all
aspects of ourselves, as reflected in the Medicine Wheel. We want to bring
balance within ourselves for our well being and the well being of our families.
Heart of Many Nations: Heart Attack Prevention and Response in Native Communities
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Optional Content
Optional Content
If you will not be presenting the optional content please go directly to the Workshop Review and
Close.
Topic 5: Risk Factors – 20 minutes
Risk Factors
We Can and
Can’t Change
Slide 20
Slide 21
MDH
Ask participants to turn to page 15 in their guides.
Knowing and understanding lifestyle behaviors that make a heart attack more
likely, or risk factors, can empower you to be proactive in preventing heart
attacks in yourself and others.
There are two kinds of risk factors, ones we can't change and ones we can.
When we find out we have a risk factor that we can't change, it doesn't mean
that we're going to have a heart attack; it just means that we have a higher
chance of having one than someone who does NOT have the risk factor. It tells
us that we need to be more aware of our actions to try to prevent a heart
attack. When we find out we have a risk factor that we can change, we can
make changes to our lifestyle to become healthier and reduce our risk of
having a heart attack. Even the smallest changes can make a difference.
Risk factors that we can't change, include:

Increasing age. Most people who die from heart disease are 65 or
older. But taking care of yourself when you’re younger can help
decrease that risk.

Family history of heart disease. If there is a history of heart disease in
your family, you are more likely to develop it yourself.

Post-menopausal. Before menopause, women seem to be at least
partly protected against heart attacks. After menopause, a woman's
chance of having a heart attack increases.

Previous heart attack. After you have had a heart attack, you are at a
higher risk for having another one.
Heart of Many Nations: Heart Attack Prevention and Response in Native Communities
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Optional Content
Slide 22
MDH
Those are the things that we can’t change. Here are the risk factors that we
can change. They include:

High cholesterol. A high level of "bad" cholesterol increases your
chances of having a heart attack.

High blood pressure. This is a condition where the pressure of the
blood in the arteries is too high. We will discuss cholesterol and blood
pressure in more detail in a few minutes.

Smoking. The non-traditional use of tobacco and long-term exposure
to tobacco smoke damages the walls of arteries leading to your heart,
which allows cholesterol and other substances to build up and slow
blood flow. Smoking also increases the chance of developing a
deadly blood clot. A person's risk of heart attack decreases soon after
quitting. If you smoke, your doctor can help you develop a plan to
quit. We’ll talk about sacred tobacco use in a few minutes.

Diabetes. Diabetes can be prevented with healthy weight loss and
physical activity. When you have diabetes, sugars build up in your
blood because your body doesn't produce or respond to natural
insulin. Having diabetes can increase your risk of heart attack. Seventy
five percent of people with diabetes die from some form of heart or
blood vessel disease. If you already have diabetes, it's important to
make sure you are properly managing it. You can work with your
healthcare provider to learn how to control it.

Eating a diet high in meats, cheeses, and fried foods that is low in
fruits and vegetables. It is recommended to eat more fiber: found in
oats, fruits, vegetables, and legumes. Watch sodium intake, and
increase the healthy fats in your diet: nuts, avocados, olive oil, canola
oil, and peanut butter, plus fish and other foods containing omega-3
fatty acids. More detailed information about our ancestor’s diets is
provided later.

Physical inactivity. Regular physical activity, such as 30 minutes of
moderate activity most days of the week, lowers your risk of heart
disease and heart attack. Being active also can help control
cholesterol, blood pressure, diabetes, and weight. Plus, once you get
used to it, it just feels good! And exercise doesn’t have to cost
anything. Walking is great exercise. Many malls have walking routes
you can use during the winter. Other kinds of exercise include skating
inside or outside, gardening, lawn work and even housework.
Heart of Many Nations: Heart Attack Prevention and Response in Native Communities
22
Optional Content

Being overweight or obese. Excess body weight, even without any
other risk factors, is a stress for your body and increases your risk of
heart attack. Your heart has more work to do than it is set up for.
Being overweight or obese can also raise cholesterol and blood
pressure, and lead to diabetes. Eating a healthy, balanced diet and
exercising regularly can help you lose weight. Even losing as few as
ten pounds can lower your risk.

Stress. Stress relates to heart disease. It usually happens when we
consider a situation to be difficult or feel unable to manage it. Too
much stress can worsen other risk factors because it can result in
overeating, drinking too much, non-traditional uses of tobacco, and not
taking care of your body.
We can change the way that we respond to stress. Listen to your
body. Reach out to those around you for support. Use our culture's
unique traditions and practices such as prayer, smudging,
sweatlodges, focusing on the gifts each new dawn brings in their
thoughts throughout the day, and stories of living through traditional
values. Eat a balanced diet and stay physically active. Learn to
refocus your thoughts from negative to positive. If you realize that you
can't manage your stress on your own, a mental health professional
can help you too.
Instructions:
Ask participants to turn to the person sitting next to them on the left and
visit with them about the following question. (If group is an odd number
of participants, the facilitator can pair up with the extra person).
What has been your experience or your family’s experience with
these risk factors? For example, if you suffer from diabetes, how has it
affected the way in which you live your life?
Slide 23
Let's dig a little bit deeper into some of the preventable risk factors.
What is cholesterol? We said that high cholesterol is a risk factor. Cholesterol
is a waxy fat-like substance that is produced by the liver and is necessary to
function normally. Cholesterol is present in all parts of our bodies, in the brain,
skin, nerves, muscles, and heart. Our bodies use cholesterol to produce
hormones and to digest fat. Our livers naturally make enough cholesterol for
the body's needs. However, diets high in saturated and trans fats can add to
the cholesterol already in our bodies.
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Heart of Many Nations: Heart Attack Prevention and Response in Native Communities
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Optional Content
When you have too much cholesterol in your body, because of your diet or
because of the rate at which your body is processing it, fatty plaques can
form in your arteries, including the arteries of your heart. These fatty plaques
build up, and lead to the narrowing and hardening of your arteries and the
increased risk of blockages.
A high level of cholesterol results in heart disease and significantly raises our
risk of heart attack. When adequate blood flow leading to part of your heart
is cut off, you have a heart attack.
Slide 24
Slide 25
Three types of cholesterol are:

LDL cholesterol (known as “bad” cholesterol) can build up on the inside
of artery walls. The deposits, called plaque, narrow the arteries. This
condition is called atherosclerosis. Higher LDL cholesterol means
higher risk of heart disease.

HDL cholesterol (known as "good" cholesterol) helps prevent arteries
from becoming clogged. Higher HDL cholesterol generally means
lower risk of heart disease.

Total cholesterol is the amount of HDL and LDL in the blood added
together.
Diets high in saturated fats, trans fat and cholesterol can lead to high overall
cholesterol levels and especially high “bad” cholesterol levels. Saturated fat is
a type of fat found mostly in foods that come from animals, and cholesterol
comes only from animal products. Saturated fat, though, is the most harmful
one to worry about, because it is the one that really raises your “bad”
cholesterol. It is found in pork, fatty beef, processed meats such as hotdogs,
poultry with skin, lard, and dairy products made from whole or 2% milk such
as butter, cream, and cheese. It is also found in many packaged baked
goods and fried foods. Palm oil and coconut oil contain saturated fats as well.
Trans fat is common in commercial baked goods like crackers, cookies and
cakes.
Reducing how much saturated fat you eat reduces your LDL cholesterol, which
reduces your risk of a heart attack. You can also raise you HDL, or good
cholesterol, levels to help fight the bad cholesterol by:
MDH

Eating a balanced diet.

Eating more fiber: found in oats, fruits, vegetables, and legumes.

Increasing the healthy fats in your diet: nuts, avocados, olive oil,
canola oil, and peanut butter, plus fish and other foods containing
Heart of Many Nations: Heart Attack Prevention and Response in Native Communities
24
Optional Content
omega-3 fatty acids.

Slide 26
Exercising regularly, quitting smoking, and losing weight if you are
overweight all also help in raising HDL levels.
What are appropriate cholesterol levels? It’s important to know your
cholesterol levels. Cholesterol is measured with a simple blood test, often
called a lipid profile. The lipid profile will give you four numbers. Healthy
cholesterol levels are when:

Your LDL (low-density lipoprotein or your “bad” cholesterol) is less
than 100.

Your HDL cholesterol (high-density lipoprotein, or your "good"
cholesterol) is greater than 40 for men or greater than 50 for women.
A level greater than 60 is considered protective against heart
disease; and,

Your total cholesterol is less than 200.
If your total cholesterol or LDL cholesterol is high, or HDL is low, your doctor
will probably want to monitor it more closely and will give you advice about
how to manage it. This is especially true if you have been diagnosed with
diabetes or coronary artery disease.
Slide 27
Many of the factors that contribute to high cholesterol are similar to the ones
that increase our risk of heart attacks. They include:

A diet high in meats, cheeses, and fried foods and that is low in fruits
and vegetables.

Older age

Being overweight or obese

Family history
Check for understanding.
Ask if participants have questions about cholesterol: what it is or how it can
affect their heart health.
Slide 28
MDH
What is High Blood Pressure? Blood pressure is the force of the blood
flowing through your body and pushing against the walls of your arteries as
your heart pumps out blood. High blood pressure means that this pressure
has risen and stayed there, which damages your body over time. High blood
pressure increases the work that your heart has to do, which causes the heart
Heart of Many Nations: Heart Attack Prevention and Response in Native Communities
25
Optional Content
to thicken and become stiffer. In addition to increasing your risk of heart
attack, this also increases your risk of stroke, kidney failure and congestive
heart failure. There are often no symptoms to let you know that you have a
high blood pressure, which is why it is important to monitor your risk factors
and have your blood pressure checked regularly.
Slide 29
What are appropriate blood pressure levels? Healthy blood pressure is
below 120/80 mmHg. "mmHg" is a term of measurement which refers to
millimeters of mercury—the units used to measure blood pressure. If your
blood pressure is above 120/80 mmHg, your risk for health problems rises,
and the risk grows steeply as your blood pressure increases. If your systolic
(top) number is over 140, or your diastolic (bottom) number is over 90, you
have high blood pressure. If you have high blood pressure, you can take steps
to control it by working on a healthy lifestyle, taking your medications as
prescribed, and regularly seeing your healthcare provider.
Slide 30
Some of the factors that contribute to having high blood pressure include:

Being overweight or obese. When you have excess weight, your heart
has to do excess work to pump the blood through your body.

Sodium intake (the amount of salt you take in). Too much sodium in
your diet can cause you to retain fluid, which in turn increases blood
pressure. This doesn’t necessarily refer to the salt that we put in our
foods, but the salt we take in when we eat fast food or processed
foods we buy from the grocery store.

A lack of physical activity. It doesn't take long to see a positive
change in your blood pressure after you become more active.

Heavy alcohol consumption. Drinking more than one drink a day for
women and two drinks a day for men can raise your blood pressure
by several points and damage your heart. It can also reduce the
effectiveness of high blood pressure medications.

Non-traditional tobacco use. The nicotine in tobacco raises your blood
pressure for up to an hour after each time you smoke, and the
chemicals in tobacco also damage your arteries and cause you to
retain fluid.

Diabetes and other conditions.
There are also factors that we can't control that contribute to having high
blood pressure. Like we talked about earlier, this doesn't mean that we will
get high blood pressure; it just means we have a higher chance of getting it
and need to be more careful. These factors include:
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Heart of Many Nations: Heart Attack Prevention and Response in Native Communities
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Optional Content

Older age

Family history
Slide 31
Check for understanding.
Ask if participants have questions about blood pressure: what it is or how it can
affect their heart health.
Sacred
Tobacco Use
Slide 32
Sacred Tobacco Use. We talked about tobacco use as a risk factor in
contributing to heart disease. In many Native traditions, tobacco is sacred,
and given by the Creator for use only for spiritual purposes. These purposes
include medicine, prayer, purification, and communicating thoughts and
feelings to other beings and/or the spirit world.
It is estimated that tobacco has been used in sacred ways by American
Indians for over 18,000 years. Traditional uses of tobacco vary from tribe to
tribe, as does the types that are grown, who tends them, and how they are
harvested. Oral traditions and stories about how tobacco came to the People
vary as well.
Many Native people view returning to the spiritual tradition of using tobacco
in a ceremonial way as vitally important to health of Native communities.
Returning to the sacred use of tobacco with the guidance of spiritual leaders
and Elders, rather than continuing the non-sacred use of it, as in smoking
cigarettes, will promote the health of a person in all aspects.
Transition to
next section
MDH
Along with the tradition of sacred tobacco use, there are also traditional
ways of eating that honor our history and culture. We’ll talk about that next.
Heart of Many Nations: Heart Attack Prevention and Response in Native Communities
27
Optional Content
Topic 6: Nutrition – 15 minutes
Nutrition
Ask participants to turn to page 22 in their guides.
Slide 33
As we discussed earlier, colonization of our people and our lands has
resulted in an imbalance in our communities and in ourselves.
But across the Indian Nations, there are many examples of people working
to protect or restore traditional food practices. They are planting gardens
of traditional foods, teaching traditional ways of preparing foods,
increasing standards for our quality of water, establishing game reserves,
and re-claiming traditional land to use for making food.
Slide 34
A challenge in healing our bodies and our hearts is leaning how to live in a
modern time while still attempting to eat in a way that honors our
traditional lifestyle. The Woodlands Foodway Traditional Model reflects
the key parts of our ancestors’ diets: Four legged and Finned; Gathered
Ones; Harvested Crops and Water.
Slide 35
Now, that traditional model has been updated for modern times: It is based
on the Medicine Wheel, and called the Four Winds Model. It reflects the
traditional make-up of our diet and our traditional practices while including
both conventional and modern foods. It was developed by Kibbe Conti,
Lakota, a Native nutritionist, and Elder Bob Chasing Hawk, Cheyenne River
Sioux.
The model begins with the West Wind. The western sky brings the life
giving rains. Traditionally we drank pure water and teas. Today the West
Wind is represented on the model by sugar-free and alcohol-free drinks.
The North Wind brings cold winds that are represented by the strength and
endurance of the Buffalo. Buffalo and large game were plentiful and
always lean. Today the North Wind incorporates the important protein
contributions of all lean animal food products. Lean animal products include
loin cuts of pork and beef, chicken without the skin, 90% lean ground beef,
turkey and eggs.
The East Wind represents the dawn of a new day. Traditionally, spring was
a time of new plant growth and the beginning of the gathering season. Our
ancestors used to gather roots, berries, seeds, and leafy greens. Today this
East Wind is represented by fruit and vegetable plant products.
The South Wind is represented by the warm summer wind and the energy
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Heart of Many Nations: Heart Attack Prevention and Response in Native Communities
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Optional Content
we receive from plants that require the long growing season. Corn, beans,
potato and squash, were grown by some tribes along the river and traded
with the migratory tribes for wild game. The Europeans introduced new
grains: wheat, rye, oats, barley and rice. All grains and starchy vegetables
are represented in the South Wind.
All four of these food groups are important to create a balanced meal and
a healthy diet. We need water, protein, fruits and vegetables, and starchy
plants. No one group should dominate. We can use the Four Winds Model
to create balance on our plate, and balance in our lives.
From Kibbe Conti's (2004) article "The four winds model for healthy
eating." Retrieved from Tribal Connections: http://www.tribal
connections.org/health_news/native_roots/april2004p1.html
Slide 36
Slide 37
MDH
As we learn to eat more healthfully, there are a few things we can keep in
mind:

We need much less energy than we once did when we labored at
hunting and gathering. Healthy, modestly active adults need 1800
to 2200 calories.

Meat portions are the size of the palm of your hand. Fruit or juice
portions are four to six ounces. Vegetables should be half a cup to
a full cup. Grains and starches should be about one-fourth to onethird of your meal.

Breakfast doesn't always have to include a North, or protein food.
Our goal can be to have protein at least twice a day.

Our ancestors spent a long time getting and preparing food, but
these days we spend almost no time doing so. When grocery
shopping, slow down, look at all of the sections, and read the food
labels. Preparing fresh meals for ourselves and our families can be
a fun, tasty, and healthy way to nourish our bodies and souls.
Balanced eating can help us reach or maintain a healthy weight, prevent
diabetes, lower cholesterol and blood pressure, reduce stress, and reduce
our risk of heart attack. And, when we eat healthfully and encourage
others to do the same, we can pass this knowledge and the healing that
comes with it on to our family members and future generations.
Heart of Many Nations: Heart Attack Prevention and Response in Native Communities
29
Review and Closure
Topic 7: Workshop Review and Closure – 10 minutes
Discussion:
Putting it All
Together
Thank you so much for spending your valuable time with us! We’ve spent
some time learning, discussing, and participating in activities. Hopefully
you’ve learned some things that can help to keep yourself in balance and
your body healthy. You can, in turn, better care for your family and help
your community.
Instructions:
Ask participants to turn to the person sitting next to them on the
left and visit with them about the following questions. (If group is
an odd number of participants, the facilitator can pair up with the
extra person).
What have you learned today that is useful to help you and
your family take care of their hearts?
When the talking has come to closure, ask the participants if anyone would
like to share what they learned in their talking with others.
Closure
MDH
If applicable, promote upcoming “Ask the Expert” session. Note that they must
have attended one of these initial sessions to participate.
Heart of Many Nations: Heart Attack Prevention and Response in Native Communities
30
Additional Learning Activities
Additional Learning Activities
The following activities can be added to increase the level of interactivity of the workshop. Choose
those activities that best fit your teaching style and the time allotted.
1. Share your knowledge of the Drum from their own tribal traditions and
how this is connected in spiritual and other ways to the heart. Invite
participants to divide into small groups of four and share their own tribal
traditions in this area. Invite participants to listen to their own heart with a
stethoscope and share their reflections in the small and/or large group.
2. Ask participants to divide into small groups of four. Invite them to think of
a younger person in their community who they may feel comfortable
mentoring, and sharing their knowledge about making choices that will
support this younger person in caring for their health, including their
physical, mental, spiritual and emotional health. (Refer back to Aspects of
Self in the Medicine Wheel.)
3. Share about the Grandfathers from the Stone Nation and place four of
them in ways that show the sacred four directions. You can share about the
understandings you have from your own tribal traditions. Invite
participants to reflect on their own tribal traditional understandings about
these things. Invite participants one at a time to walk in the circle of the
four Grandfathers and “reflect on what the Grandfathers can teach us
about caring for ourselves and our heart”. Reminder: you may want to
extend this activity to include reflections on supporting “our family
members in making heart healthy choices.”
4. Invite participants to divide into groups of four and share about how they
have coped successfully with stress during their life stages. (Refer to the
Life Stages in the Medicine Wheel). The facilitator may want to identify
tribe specific traditional ways which may include, prayer, smudging,
sweatlodges, focusing on the gifts each new dawn brings in their thoughts
throughout the day, and stories of living through traditional values.
5. Invite participants to discuss, in small groups of four, the signs of a heart
attack and what family members can do to help the person in distress.
Invite several participants to role play in small groups (or the large group
depending on the number of participants) what they learned in the
sessions. Reminder: Invite participants before the role play to identify what
roles (from the Stages of Life in the Medicine Wheel) each group member
will assume to portray the family circle (and to identify those roles
verbally first if presenting their role play in front of the larger group).
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Heart of Many Nations: Heart Attack Prevention and Response in Native Communities
31
Evaluation Instruments
Evaluation Form
Thank you for taking the time to complete this evaluation of the Heart of Many
Nations: Heart Attack Prevention and Response in Native Communities’ curriculum.
In order for the curriculum to be of excellent service to you and your community,
it must be useful to you and responsive to your needs. Your experience you share with us through
the evaluation will help us to also understand how effective the curriculum will be for many other
Native families and communities. Your responses will be kept confidential.
Please circle the number and description for each item that best reflects your current thoughts and
feelings.
1. I know six major symptoms of heart attacks for men and women.
1=strongly disagree
2=disagree
3=agree
4=strongly agree
2. I know how heart attack symptoms may differ in women.
1=strongly disagree
2=disagree
3=agree
4=strongly agree
3. I know the fastest and most effective way I or a family member can respond to receive
treatment for a heart attack.
1=strongly disagree
2=disagree
3=agree
4=strongly agree
4. I know four risk factors for a heart attack that cannot be changed.
1=strongly disagree
2=disagree
3=agree
4=strongly agree
5. I know six risk factors for heart attacks that can be changed.
1=strongly disagree
2=disagree
3=agree
4=strongly agree
6. I know three ways to improve the healthy balance levels of cholesterol in the body.
1=strongly disagree
2=disagree
3=agree
4=strongly agree
7. I know specifically how high blood pressure can affect the heart.
1=strongly disagree
2=disagree
3=agree
4=strongly agree
8. I know two important ways to help my blood pressure stay at a healthy level.
1=strongly disagree
2=disagree
3=agree
4=strongly agree
9. I know three traditional ways from my culture to have a healthy diet.
1=strongly disagree
2=disagree
3=agree
4=strongly agree
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Heart of Many Nations: Heart Attack Prevention and Response in Native Communities
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Additional Learning Activities
Please list the specific strengths of the curriculum.
Please list any specific areas of the curriculum that you would suggest could be improved.
Additional comments:
MDH
Heart of Many Nations: Heart Attack Prevention and Response in Native Communities
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References
References
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American Heart Association, Inc. (2010). Cholesterol levels. Retrieved from
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American Heart Association, Inc. (2010). Heart attack symptoms and warning signs. Retrieved from
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American Heart Association, Inc. (2010). Menopause. Retrieved from http://www.american
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Brownsten, J.N., Veazie, M.A., Brody, E.A., et al. (2007). Improving time to treatment following
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Center for Disease Control and Prevention. (2008, January 7). American Indian and Alaska Native
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Heart of Many Nations: Heart Attack Prevention and Response in Native Communities
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References
Center for Disease Control and Prevention. (2009, October 26). Heart disease risk factors.
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ba60ea0613d93110VgnVCM10000013281eac____
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References
Longley, R. (2010). Women's heart attack symptoms different from men's: Symptoms may appear up
to a month before attack. Retrieved from http://usgovinfo.
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clinic.com/health/heart-attack/DS00094/DSECTION=risk-factors
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References
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Struthers, R., Savik, K., & Hodge, F.S. (2004, May-June). American Indian women and
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MDH
Heart of Many Nations: Heart Attack Prevention and Response in Native Communities
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