American Indians working to stem tide of diabetes cases: Programs, communities taking action

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American Indians working to stem tide of diabetes cases: Programs, communities taking action
April 2004
Kim Krisberg

Fourth in an in-depth series on health disparities in conjunction with APHA's National Public Health Week 2004. The event, which will be held April 5-11, 2004, focuses on "Eliminating Health Disparities: Communities Moving From Statistics to Solutions."

While rates of diabetes are climbing across the United States, oftentimes linked to the nation's burgeoning waistlines, American Indians are witnessing near epidemic proportions of the disease in their communities - and with rapidly increasing diabetes diagnoses, Alaska Native communities aren't far behind.

More than 15 percent of American Indians and Alaska Natives who receive care through the Indian Health Service, the federal agency that upholds the country's obligation to provide health services to such communities, have been diagnosed with diabetes, according to the American Diabetes Association. American Indians are more than twice as likely as whites to be diagnosed with the disease, and diabetes prevalence is more than 25 percent among American Indians in the southeastern United States. In fact, one Arizona tribe has the highest diabetes rate in the world, with about half of its adult population living with diabetes, the association reported.

Disparities in health complications due to diabetes are accompanying the epidemic. Kidney failure is six times higher among American Indians with diabetes than for others with the disease, and diabetes-related amputation rates for American Indians are three-to-four times higher than the overall population. According to the National Institute of Diabetes and Digestive and Kidney Diseases, two overriding risk factors are contributing to American Indians' and Alaska Natives' higher type II diabetes risk: genetics and lifestyle. Increasing obesity, which is linked to the onset of type II diabetes, has been measured in many such communities, as well as major changes in diet and physical activity. In studies of certain tribes, researchers have also identified genes that may play a pivotal role in diabetes susceptibility, according to NIDDKD. Social factors such as low insurance coverage rates, poor health status as well as poor socioeconomic conditions also contribute to the communities' diabetes rate.

Because type II diabetes is preventable and manageable, however, health programs around the nation are taking action on those fronts. Many of the programs concentrate on education, such as "Awakening the Spirit: Pathways to Prevention and Control," a community-based outreach program of the American Diabetes Association. The program consists of a national team that advocates on behalf of diabetes prevention funding for American Indians, while local association offices sponsor outreach as well, according to Brenda Broussard, the program's coordinator.

"(Diabetes') magnitude (among American Indians) is huge and what's frightening is that it's growing," she told The Nation's Health. "At the root is poverty and stress - we know that there's a stress response to not being sure where your next meal will be and where you next job will be."

Begun about four years ago, Awakening the Spirit collaborates and supports other organizations working on diabetes prevention and partners with tribal leaders and groups already working in the communities.

An example of a successful program that Awakening the Spirit helped to support is "Strong in Body and Spirit," a curriculum developed for tribal communities through the Office of Native American Diabetes Programs at the University of New Mexico Health Sciences Center in Albuquerque. The curriculum, which sprang from research studies in the early '90s, was originally designed for the Rio Grande Pueblo people and is aimed at lay health workers and those living with diabetes, according to Janice Thompson, PhD, FACSM, director of the university office.

The curriculum is based on an American Indian story, "Through the Eyes of the Eagle," about an eagle who watches a strange sickness he calls "too much sugar in the blood" grow among his community. The eagle remembers "when running was a way of life for everyone and so was living off Mother Earth," but now "children seldom play but watch what they call television." The story then segways into the main education areas: exercising more, eating less fat and sugar, staying the course and finding support. To date, the curriculum has been used to train more than 120 tribal communities, Thompson said. Research has shown that in diabetic people who took the curriculum, it helped prevent the condition from worsening, she noted.

Awakening the Spirit has sponsored week-long training workshops of Strong in Body and Spirit in four states, inviting lay health promoters and tribal leaders from more than 20 states to attend, Broussard said. Today, the curriculum is being revived and updated to meet current tribal needs and will hopefully be available by the end of 2004, Thompson said.

"The wisdom of how you solve this problem lies within each tribe," Broussard said. "Instead of rushing, we have to listen mindfully and ask for help before we offer help."

The Zuni Wellness Center in Zuni, N.M., has earned national recognition for its community-based approach to diabetes. Opened in the early '80s, the center now welcomes hundreds of people each day who come to exercise and learn how to prevent or control diabetes, according to Lydia Simplicio, the center's health promotion specialist. The center, which is funded through IHS and thus free to join, also works directly with IHS-referred people recently diagnosed with diabetes, Simplicio said, adding that about 15 new people are referred every week.

"For almost all the families here, at least one person in the family is diagnosed with diabetes," Simplicio told The Nation's Health. "So, it's important we educate our younger generation to get out and exercise."

evention is also key at the wellness center, such as a 22-week weight loss program called the Holiday Eating Learning Program, otherwise known as HELP, that began in October. The program works on a buddy system in which two people support each other in exercising and eating right, keep an exercise log and weigh in every week, according to Simplicio. Participants then earn points for attending workshops or losing weight and can win a number of different prizes. The wellness center also sponsors an annual Zuni Fitness Series with the theme "Outrun Diabetes." The May event offers fitness challenges such as aerobics, runs, marathons, relays and biking.

Wellness centers are a critical part of any American Indian community, according to Margaret Garcia, division director for health services for the Zuni tribe. Zuni ancestors used to walk and run everywhere, but now everyone has a car; the Zuni people used to be ranchers and farmers, but as that died out people began concentrating on arts and crafts work, which is a sedentary lifestyle, she said. The diet of tribe members has also changed, transitioning from eating vegetables and lean game meat to processed food, candy and soda. Now, the dialysis center at the hospital has to expand because so many people have complications due to diabetes, she noted.

"It seems like every family has parents or someone in their bloodline that has diabetes - in some families, everyone has diabetes," Garcia told The Nation's Health. "It's an epidemic in our community. That's why the heart of the wellness center is prevention and then intervention."

In Phoenix, Ariz., health professionals are beginning diabetes prevention at birth. Armed with research showing a substantial reduction in diabetes incidence among children who are breastfed, the Breastfeeding Support Program of the Diabetes Center of Excellence at Phoenix Indian Medical Center is reaching out to pregnant women with support and education.

The project began in 1999 and now more than 3,000 women are currently in the registry, according the program's coordinator, Sue Murphy. Program staffers visit with women when first diagnosed with pregnancy at the center, during pre-natal clinics, at birth and eight weeks after birth to check on a mother's breastfeeding status. The goal is to have women breastfeed for the first two months of their babies' lives.

"Our hope is that (the program) reduces the number of people that have diabetes by age 40," Murphy told The Nation's Health.

The breastfeeding program can potentially be the same kind of intervention as childhood immunizations, as they can both result in lifelong prevention, according to physician Charlton Wilson, who oversees the Diabetes Center of Excellence. In addition, there can be a number of collateral health benefits to increased breastfeeding, so "it serves to provide a good leveraging of public health intervention," Wilson said.

The breastfeeding program also offers round-the-clock support via a breastfeeding hotline, which receives about 150–200 calls per month, according to Murphy. To date, breastfeeding rates among the American Indian women involved in the program have risen substantially: between 55 percent and 65 percent of the women are now breastfeeding at eight weeks, up from between 25 percent and 35 percent in the past, Murphy said.

"Since so many families in our service unit have had their lives touched by diabetes, they're very eager to do what they can to slow it down," she said.

Alaska Natives face rapid diabetes increases

Although Alaska Natives have a low diabetes prevalence rate, they face the highest increasing rate among native people, with a 44 percent increase in diabetes diagnoses between 1997 and 2002, according to Julien Naylor, MD, MPH, director of the Alaska Medical Center Diabetes Program in Anchorage, which provides consultative services throughout the state. Because of the low prevalence rate, Naylor said there's an "open window of opportunity" for prevention.

"On one hand, you have to treat people with diabetes, but at the same time, the message has got to get out there that diabetes is preventative," she told The Nation's Health.
In Alaska Native villages, health stations are staffed by community health aides and practitioners, who are trained in basic medical care in conjunction with a referral hospital, Naylor said. In the early '90s, the Anchorage diabetes program developed a diabetes training course for health practitioners that had originally focused on treatment, but has evolved to be more prevention-centered, highlighting healthy eating and physical activity. The program is taught about four times per year, training about 400 health aides overall, Naylor said.

In the Yukon Kuskokwim Delta region of southwest Alaska, Naylor has been working with local school boards to help bring diabetes prevention into the classroom. The school programs are developed to promote physical activity and healthy eating, such as choosing a native diet. Depending on the region of Alaska, a native diet can include caribou, seal oil, fish, sea mammals, deer, eggs and seaweed, Naylor said. It can be difficult to rely on grocers for a healthy diet, Naylor said, because by the time fresh vegetables and fruits get to the villages, they're often very expensive and beginning to spoil. She added that because the water treatment system in some villages can make the water taste bad, a lot of people are turning to soda, and in turn, cavities are becoming a big issue.

"If you have that top-down programming, it's a guarantee for failure," Naylor said. "But if you partner with community people and programs, it's a far more successful message."
In the Norton Sound region of western Alaska, Angie Gorn is filling local children's summer months with diabetes prevention tools. Gorn directs the Norton Sound Health Corporation's Chronic Care Active Management and Prevention Program, otherwise known as CAMP, which was initiated to conduct diabetes prevention and management. Norton Sound Health Corporation is a rural IHS hospital, acting as a hub for 15 villages in the region and serving just under 10,000 people.Four years ago, Gorn started Summercise, a nutrition and physical fitness program targeting youth ages 5 to 15. The eight-week program is offered during the summer and kids can choose from range of classes, from cooking to fitness, Gorn said. An example of a class is "Clue for Healthy U," a scavenger hunt that sends kids looking for healthy foods.
"Generally, I'm amazed that the program has become so popular," Gorn told The Nation's Health. "I think having young, energetic role models (work at Summercise) has really made it successful."

More than 600 kids, the majority of whom are Alaska Natives, have participated in the program so far, Gorn said. When the program first began, the youngest age group was 8, but Gorn quickly realized children that age were already used to certain eating habits. Although working with 5-year-olds can be difficult, it's the age at which children should begin learning good nutrition, she said.

Gorn's organization also sponsored a local "musher" in Iditarod 2004, Alaska's sled race which began in early March, to be a diabetes prevention spokesperson, according to Gorn.
With a theme of "Traditional Living Prevents Diabetes: Long May You Run," spokesman Joe Garnie, who embarked on his 15th Iditarod race, went to schools and spoke to thousands of children about eating native foods, not smoking, exercising and choosing water over soda. During his schools visits, Garnie invited children to pledge to give up unhealthy foods during the many days he would be on the Iditarod trail.

"The most important thing is for communities to take ownership, for them to take the leadership and highlight their own role models within their own communities," Gorn said.

For more information on American Indians and Alaska Natives and the epidemic of diabetes, visit www.diabetes.org or www.ihs.gov

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