Topic: Diabetes in the Native American population

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Scholarly Paper Topic: Diabetes in the Native American population

Introduction:

Introduction of topic
Provides rationales from the literature, including relevant statistical data, for selecting this topic.
(10 Points)

Review of Literature:

Cites 10 sources (minimum) of literature related to selected issue in minority health.
***Strictly use provided 10 research articles for references/sources***
Include:
-Incidence/Morbidity/Mortality
-Risk Factors
-Social Aspects
-Cultural Aspects
-Economic Aspects
-Prevention
-Community Models of Intervention
(50 points)

Presents current literature from U.S. professional journals & books (primary sources within the last 5 years).
(5 Points)

Summary:

Summarizes major points of literature review.
(5 Points)

Conclusion:

Includes personal belief of issue
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Recommendation:

Makes a recommendation for potential, creative intervention(s)
(15 Points)

Composition, spelling, grammar, APA format
(10 Points)

TOTAL
(100 Points)

State of the Science: A Cultural View of Native Americans and
Diabetes Prevention
Karethy (Kay) Edwards, DrPH, FNP, BC and
Professor and Co-Director of the Center for Cultural Competency & Healthcare Excellence at the
University of Oklahoma Health Sciences Center
Beverly Patchell, MS, CNS
Assistant Professor & Co-Director of the Center for Cultural Competency & Healthcare
Excellence at the University of Oklahoma Health Sciences Center
Abstract
The purpose of this article is to present a review of the literature on diabetes type 2 prevention
interventions for Native American populations. The interrelation of the cultural role of food in
Native American diets, educational policies related to food, outcomes of federal policies, and the
historical background of diabetes are addressed. In addition, published studies of diabetes
prevention interventions with Native American populations are examined. Lastly, exemplars of
programs that represent best practices in the prevention of diabetes are described.
Keywords
Native America; Type 2 Diabetes; Prevention Programs; Cultural
Introduction
Much has been written about American Indians and Type 2 diabetes. Search engines bring
up hundreds of articles and internet sites on this topic. How do these published reports really
impact diabetes prevention for Native Americans? Has what is known gone from awareness
to intervention to success in preventing diabetes? The purpose of this article is to present a
review of the pertinent published literature about the prevention of Type 2 diabetes
(hereafter called diabetes) among Native Americans and to highlight exemplar programs and
empirically tested interventions in the literature that could make a difference. The impetus
for this process is the authors’ work as Co-Directors for the nursing research training core of
the American Indian Diabetes Prevention Center. The mission of the American Indian
Diabetes Prevention Center is to prevent or delay the onset of diabetes in American Indians
and Alaska Natives. The goal of this project is to teach tribal nurses, who work with Native
Americans, about research methods, the process of implementing evidence-based practice,
and the ethical conduct of research in the practice setting. In learning about any issue, it is
important to review its historical background.
History of American Indian Health in America
Native Americans have a rich history of healthy food systems and prosperous agricultural
economies. By 800 A.D., North American Indian farmers from Florida to Ontario, Canada
were cultivating several crops and developing varieties that were appropriate for the
growing season where they lived (Keoke & Porterfield, 2002). Explorers landing in the so
called new world marveled at the abundance of agricultural crops and the advanced
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agricultural technology. As a result, many explorers and settlers were aided by Indian
farmers’ bounty (Keoke & Porterfield, 2002).
This changed as colonization was established and the Indigenous people were pushed out of
their traditional homelands, subject to war and disease and finally, containment on
reservations or city slums. Surveys of Native American diets from the 1920s into the 1950s
found staples of canned meat and fish, bread, beans, sugar, and coffee or tea (Prucha, 1986).
On many reservations, malnutrition and nutritional deficiencies were endemic. Despite
recommendations to improve Native American diets, food aid provided to the tribes was
usually insufficient and of low quality. Also, the food aid did not include traditional foods,
leading to further deterioration in health. The history of food insecurity for Native
Americans that began with the establishment of reservations continues today. Until the
1950s, malnutrition and hunger were the primary food issues facing tribes (Prucha, 1986).
After the 1950s, Native American dietary patterns were increasingly dictated by the arrival
of welfare checks and the distribution of government commodities (Bass, 1974 p.37). To
the contrary, despite the increase in federal food aid, Native American diets remained
inadequate to their needs.
By the 1960s most Native Americans had diets similar to those of the non-Indian population.
This trend continues. For example, documented reports indicate that as recently as the late
1990s, almost one-fourth of Native American households were food insecure, meaning that
they did not have access to enough food to meet their basic needs and one out of twelve
experienced food insecurity coupled with hunger (Henchy, Cheung, & Weill, 2002).
Access to food is complicated by the geographic isolation of many reservations and Native
communities. The failure of federal food programs to include or support the continued use of
traditional foods has contributed to the reliance of Native Americans on less healthy foods
and culturally inappropriate patterns of consumption (Bell-Sheeter, 2004).
Educational Policy
Food is more than sustenance to put into the body. For Indigenous people, it is intricately
tied to land, ceremony, family, and spirituality. At the same time the food system was being
dismantled by the reservation system and movement of the people off of their traditional
lands, the family system was being completely disrupted by the destruction of the traditional
clan and its teaching systems. Examples of the disruption of the family include the abrupt
changing of roles for tribal members and outlawing their practice of religion and language.
With the assault on religion and language, broken hearts resulted with the removal of their
children to boarding schools to be instructed in Christianity and civilized ways for
assimilation into the majority culture for the purpose of providing a working-class labor
force to benefit society.
Education was quickly identified as a critical tool in accomplishing this goal, but not
education as practiced today. This education was menial and focused on developing skilled
labor. To accomplish this goal, Native American children were removed from their families
as early as kindergarten levels and kept in these boarding schools until adulthood. This
assimilation policy advocated by Richard Pratt’s group, the Friends of the Indians, was
comprehensive and compulsory (Clarke Historical Library, 2009). Schools were created that
isolated the students from their tribal cultures and attempted to fully assimilate the students
into a European lifestyle. The vision of Indian education was built upon military subjugation
to achieve cultural assimilation. Its founder, Richard Pratt, started the first school at an
abandoned military post at Carlisle, Pennsylvania and its practices were based on an Indian
prison that he had overseen in Florida (Clarke Historical Library, 2009). The General
Allotment Act of 1887, more commonly referred to as the Dawes Act, incorporated the
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Carlisle model into government policy. Every head of Indian Education had a variation of
this theme. Estelle Reel, who was the head of Indian Education from 1901 to 1910, was
guided by the principle that actual instruction for Native American children was to be
secondary. On the other hand, industrial training was the primary goal of Indian education
(Clarke Historical Library, 2009). Most of the so called educational programs for Native
Americans were predicated on this premise. For example, in 1901 Reel instituted a
curriculum that focused on teaching agricultural skills, with little academic instruction. Reel
was fairly explicit in stating the assumption that Native Americans would never advance
beyond the lower economic strata of American society (Clarke Historical Library, 2009).
While there may be the impression that this attitude of low educational expectations for
Native American students is past history, its presence continues as evidenced by the very
low numbers of Native Americans who graduate from high school, even fewer who go to
college and achieve higher degrees. The massive effort to recruit Native Americans and
other minorities into higher education does little to address the underlying fact that they may
be entrenched in a system (or systems) that places them in a lower tier of expectation and
shunts them away from higher education and leadership positions at a very early age.
Societal expectations are also subliminally present in everyday activities, working to
maintain suppression and oppression and low expectations.
Outcomes of Federal Policy Toward Native Americans
For America’s Indigenous people of the last century, the land was gone, the food was gone,
and the Native American family structure was gone. Native Americans were deprived of
their religion and they were uneducated and the poorest of the poor. This culminated in the
mid-nineteen hundreds. After centuries of federal and state policies of termination, removal,
and assimilation, Native Americans were substantially worse off than white American
society. Yet, the fact that tribal nations endured and survived, some have even thrived, is a
testament to their resilience and strength. The changing policies of the 1970€²s, 1980€²s, and
1990€²s reinvigorated tribal self-governance and its ability to direct its own destiny and that
of its people. Yet, much damage had been done. The United States Commission on Civil
Rights Report, Broken Promises: Evaluation the Native American Health Care System
(2004) found that Native Americans experience a significantly lower health status and
disproportionate rates of disease compared with all other Americans. Furthermore, The
United States Commission on Civil Rights Report attributes the current health and illness
states to these policies and states the following:
This is the result of the nation’s lengthy history of failing to keep its promises to
Native Americans, including the failure of Congress to provide the resources
necessary to create and maintain an effective health care system for Native
Americans€¦and cultural, social, and structural barriers continue to exist and limit
Native American access to health care (2004, p. iii).
This is no more starkly indicated than the reported per capital health care expenditures for
2003 by the U.S. Department of Health and Human Services (USDHHS). According to the
USDHHS, in 2003 the per capita spending for health was $5,065. Spending for each federal
prisoner and was $3,803, and the federal allotment to Indian Health Services for medical
care was $1,914 (United States Commission on Civil Rights Report, 2004, p. 98). Hence,
spending priorities on health may be directly linked to access to care and health outcomes.
These facts are directly linked to the limited resources allotted to Indian Health Services and
diabetes prevention strategies.
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Brief Historical Background of Diabetes and Native Americans
Diabetes in the Native American population was virtually unknown in 1940. Diabetes
started in the 1950€²s and its increasing frequency was noted in the mid-1960€²s literature
(Szathmary, 1994). Diabetes mellitus is characterized by the presence of higher than normal
levels of glucose in the blood. Until 1980, there was no universal agreement on the level of
glucose that constituted abnormality, so diagnostic standards varied nationally and
internationally, complicating the diagnosis process (Szathmary, 1994, p. 458). The Pima
tribe has been studied longitudinally since 1963, and their prevalence of diabetes was found
to have increased 42 percent in the period between 1967 and 1977 (Carter, Horowitz,
Wilson, Sava, Sinnock, & Gohdes, 1989). Acton, Burrows, Moore, Querec, Geiss, &
Engelgau (2002) found that between 1990 and 1998, diabetes prevalence among American
Indians and Alaska Natives younger than 35 years increased by 46 percent. The largest
increase was among young American Indians which represented almost two times that of the
total Alaska Native population (Acton, Burrows, Moore, Querec, Geiss, &Engelgau, 2002,
p. 1488). These epidemiological trends are based on the Indian Health Service database for
outpatient visits for the time periods cited. The Indian Health Service (IHS) provides care to
a service area population comprised of approximately 57 percent of the U.S. Indian
population, and its service population increases at a rate of approximately 2.0 percent per
year (Indian Health Service, 2009).
More recent reports indicate that 16.3 percent of American Indian and Alaska Native adults
are diagnosed with diabetes compared with 8.7 percent of non-Hispanic whites. It is
estimated that an additional 30 percent of American Indian and Alaska Native have pre-diabetes. There has been a 68 percent increase in diabetes from 1994 to 2004 with 95
percent of the diagnoses representing diabetes type 2. There has been a 58 percent increase
in diabetes prevalence among AI/AN ages 20-29 from 1990-1998 compared with 9.1 percent
of the general population (National Diabetes Education, 2008). In 2004, the death rate due to
diabetes for American Indian and Alaska Native was three times higher than the general
population. It is estimated that diabetes can shorten a person’s life span by fifteen years.
Moreover, the average annual medical care cost for the person with diabetes is $13,243,
compared to the average cost of $2,560 for a person without diabetes (National Diabetes
Education, 2008). In addition, total diabetes rates vary from 6.0 percent among Alaska
Natives to 29.3 percent among American Indians in southern Arizona (National Diabetes
Education Program, 2008). It is vital to the continued survival of tribal nations that this
condition be avoided. The effort put forth by many groups has resulted in some successes.
Studies of Diabetes Prevention Interventions with Native Americans
The literature search to locate studies of the efficacy of diabetes type 2 prevention
interventions among Native American populations involved several strategies. First, Native
American researchers and clinicians were contacted for sources of information about
published diabetes prevention intervention programs. Secondly, the Medline database and
the Western History Collection at the University of Oklahoma were included in the literature
review. This review does not include dissertations, books, or newsletters.
Although, diabetes type 2 is a major contributor of morbidity and mortality among Native
American populations, few diabetes prevention clinical trials were reported in the research
literature. For example, from 1990 to 2008, fifteen reports of diabetes intervention studies
were identified. Three studies demonstrated long-term effective outcomes. Ten studies were
primarily descriptions without evaluation outcomes.
Using a randomized controlled clinical trial, Thompson, Allen, Helitzer, Qualls, Whyte,
Wolfe and Herman (2008) examined the effectiveness of a culturally influenced, low
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intensity lifestyle intervention with 200 urban Native American females aged 18 through 40.
The intervention group received a five month program that consisted of monthly discussion
groups aimed at healthy eating, physical activity, setting goals and social support. The
researchers found that the intervention group significantly increased their mean intake of
vegetables and fruits over the intake of the control group. Both the intervention and control
groups demonstrated significant decreases in waist circumference, insulin sensitivity, total
blood cholesterol, saturated fat and sugar intake (Thompson, Allen, Helitzer, Qualls, Whyte,
Wolfe and Herman, 2008).
In 1999, the Eastern Band of Cherokee Indians developed and implemented a culturally
competent community-based intervention called Cherokee Choices (Bachar, Lefler, Reed,
McCoy, Bailey, and Bell, 2006). The Eastern Band of Cherokee Indians lives in the Great
Smokey Mountains of North Carolina. The goal of the Cherokee Choices intervention was
to prevent diabetes type 2, especially among children. The key components of the Cherokee
Choices community-based intervention included an elementary school mentoring
intervention, an adult worksite wellness intervention, and a church-based health promotion
program. Indicators of successful outcomes of the Cherokee Choices intervention were the
obtainment of dietary and physical activity benchmarks, and decreases in body mass
indexes. Psychosocial indicators for the children who participated in the mentoring
intervention reported increased interest in school and grades, fewer days of school missed
and fewer conflicts (Bachar, Lefler, Reed, McCoy, Bailey, and Bell, 2006).
In another community-based intervention, researchers tested the effectiveness of the Ho-Chunk Youth Fitness Program. Carrel, Meinen, Garry and Storandt report that this program
was designed to examine the efficacy of a 24-week intervention with supervised classes in
nutrition and exercise. The intervention population included both native and non-native
American youth ages 6 to 18. Mean fasting plasma insulin levels decreased significantly for
the intervention population. In fact, the researchers concluded that supervised nutrition and
exercise classes were effective in reducing the risk for insulin resistance and type 2 diabetes
(Carrel, Meinen, Garry and Storandt, 2005).
A culturally sensitive intervention was the focus of the Sandy Lake School-based diabetes
prevention program. Saksvig, Gittelsohn, Harris, Hanley, Valente, and Zinman used as
pretest-posttest, single sample design to study the effectiveness of a diabetes prevention
program aimed at changing dietary intake behaviors and dietary self-efficacy. The outcomes
included significant increases in dietary intention, preference, knowledge, and dietary self-efficacy (Saksvig, Gittelsohn, Harris, Hanley, Valente, and Zinman, 2005).
In one long-term study, the investigators did not achieve significant outcomes in diabetes
prevention. Paradis, Levesque, Macaulay, Cargo, McComber, Kirby, Receveur, Kishchuk
and Potvin (2005) reported on the impact of the Kahnawake School Diabetes Prevention
Project, an 8 year elementary school-based diabetes prevention intervention program in the
Mohawk community. Over time, the researchers concluded that the study population did not
show continued participation in physical activity and fitness (Paradis, Levesque, Macaulay,
Cargo, McComber, Kirby, Receveur, Kishchuk and Potvin, 2005).
Best Practices in Diabetes Prevention Programs
The literature review revealed five best practice programs focused on diabetes prevention.
All five programs were selected by the Indian Health Services. The first program, The
Trimdown Program, is sponsored by the Albuquerque Service Unit and is a six-week
intervention aimed at assisting participants to incorporate healthy eating habits and physical
activity with the support of others (Indian Health Service, 2006).
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A second program, the Lifestyle Balance Program sponsored by the Gallup Medical Center,
is a twenty-two week comprehensive program that adheres to the Diabetes Prevention
Program curriculum. Participants meet weekly and individually with a coach on a regular
basis. This program includes problem identification and solving, positive thinking and tools
for stress management (Indian Health Service, 2006).
In the third program, the Lionel R. John Health Center-The Seneca Health Trail Blazers-Trails of the Iroquois, the participants attend weekly sessions for support. The progress of
each participant is tracked. Using a clan animal, the participant’s progress is tracked by
moving the animal across a map of the state of New York and along a trail from the tribal
territory to other tribes across the state. Participants receive beads and leather to make a
bracelet or necklace for weight loss (Indian Health Service, 2006).
The fourth program, the Red Lake Band of Chippewa Indians-Weight Management
Program, is community-based and meets twice a week for six to eight weeks. The focus is
on lifestyle change and group support. Lastly, the fifth program, Fresno Native American
Health Centers-Greatest Loser Program, incorporates behavior modification, spiritual and
mental health approaches in this ten week wellness program for Native Americans who live
in an urban area.
Recommendations for Future Diabetes Prevention for Native Americans
Although, there are many epidemiological articles of diabetes among Native Americans,
there is a paucity of studies on effective interventions. Moreover, the diabetes prevention
programs reported in the literature are primarily descriptions. Therefore, more studies that
evaluate the effectiveness of culture-specific diabetes prevention interventions with Native
American populations are needed.
Acknowledgments
Disclaimer: The University of Oklahoma Health Science, Center American Indian Diabetes Center project
described was supported by Award Number P20MD000528 from the National Center on Minority Health and
Health Disparities The content is solely the responsibility of the authors and does, not necessarily represent the
official views of the National Center on Minority Health and Health Disparities or the National Institutes of Health.
References
Acton K, Burrows N, Moore K, Querec L, Geiss L, Engelgau M. Trends in diabetes prevalence among
American Indian and Alaska native children, adolescents, and young adults. American Journal of
Public Health 2002;92(9):1485€“1490. [PubMed: 12197981]
Bachar J, Lefler L, Reed L, McCoy T, Bailey R, Bell R. Cherokee Choices: a diabetes prevention
program for American Indians. Preventing Chronic Disease 2006;3(3):A103. [PubMed: 16776864]
Bass M, Wakefield L. Nutrient intake and food patterns of Indians on Standing Rock Reservation.
Journal of the American Dietetic Association 1974;64(1):36€“41. [PubMed: 4808793]
Bell-Sheeter, A. Food Sovereignty Assessment Tool. Fredericksburg, VA: First National Development
Institute; 2004.
Carrel A, Meinen A, Garry C, Storandt R. Effects of nutrition education and exercise in obese
children: the Ho-Chunk Youth Fitness Program. WMJ 2005;104(5):44€“47. [PubMed: 16138515]
Carter J, Horowitz R, Wilson R, Sava S, Sinnock P, Gohdes D. Tribal differences in diabetes:
prevalence among American Indians in New Mexico. Public Health Reports 1989;104(6):665€“669.
[PubMed: 2511603]
Clarke Historical Library, Central Michigan University; Federal Education Policy and Off-Reservation
Schools: 1870-1933. Retrieved February 5, 2009 from

http://clarke.cmich.edu/indian/treatyeducation.htm#nas

Edwards and Patchell Page 6
J Cult Divers. Author manuscript; available in PMC 2010 July 16.
NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript
Hency, G.; Cheung, M.; Weill, J. Washington, DC: Food Research and Action Center; 2002. WIC in
Native American Communities: Building A Healthier America. Retrieved January 21, 2009 from

wic0lsummary.pdf+WIC+in+native+american+communities&hl=en&ct=clnk&cd=l&gl=us
Indian Health Service. Facts at-a-Glance. 2009. Retrieved January 14, 2009 from

http://www.ihs.gov/MedicalPrograms/Diabetes/index.cfm?module=resourcesFactSheets

Indian Health Service. Indian Health Diabetes Best Practices: Adult Weight Management and
Diabetes. 2006. Retrieved January 22, 2009 from

http://www.ihs.gov/MedicalPrograms/Diabetes/index.cfm?module=toolsBestPractices

Keoke, ED.; Porterfield, KM. American Indian Contributions to the World: Fifteen Thousand Years of
Inventions. Checkmark Books; 2003.
National Diabetes Education Program. The Diabetes Epidemic among American Indians and Alaska
Natives: Facts at-a-Glance. 2008. Retrieved January 6, 2009 from

Paradis G, Levesque L, Macaulay AC, Cargo M, McComber A, Kirby R, et al. Impact of a diabetes
prevention program on body size, physical activity, and diet among Kanien’keha:ka (Mohawk)
children 6 to 11 years old: 8-year results from the Kahnawake Schools Diabetes Prevention
Project. Pediatrics 2005;115(2):333€“339. [PubMed: 15687441]
Prucha, FP. The Great Father: The United States Government and the American Indians. Abridged,
editor. Lincoln, NE: University of Nebraska Press; 1986.
Saksvig B, Gittelsohn J, Harris S, Hanley AJG, Valente T, Zinman B. A pilot school-based healthy
eating and physical activity intervention improves diet, food knowledge, and self-efficacy for
native Canadian children. Journal of Nutrition 2005;135(10):2392€“2398. [PubMed: 16177202]
Szathmary E. Non-Insulin Dependent Diabetes Mellitus among Aboriginal North Americans. Annual
Review of Anthropology 1994;23(1):457€“482.
Thompson J, Allen P, Helitzer D, Quails C, Whyte A, Wolfe V, Herman C. Reducing Diabetes Risk in
Ameri can Indian Women. American Journal of Preventive Medicine 2008;34(3):192€“201.
[PubMed: 18312806]
United States Commission on Civil Rights Report to Congress. Broken promises: Evaluating the
Native American Health Care System. 2004. Retrieved January 24, 2009 from

http://www.usccr.gov/pubs/nahealth/nabroken.pdf

Edwards and Patchell Page 7
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