Diabetes in Diabetes in American Indian/Alaska Native American Indian/Alaska Native

CommunitiesCommunities

Yvette Roubideaux MD MPHYvette Roubideaux MD MPH

Assistant ProfessorAssistant Professor

College of MedicineCollege of Medicine

The University of ArizonaThe University of Arizona

OverviewOverview

Diabetes in American Indians and Diabetes in American Indians and Alaska NativesAlaska Natives

Traditional foodsTraditional foods

DiabetesDiabetes

A group of disease characterized by high A group of disease characterized by high levels of blood glucose (blood sugar)levels of blood glucose (blood sugar)

Common types of diabetesCommon types of diabetes Type 1 diabetes – 5-10%Type 1 diabetes – 5-10% Type 2 diabetes – 90-95%Type 2 diabetes – 90-95% Gestational diabetes – 7% of all pregnanciesGestational diabetes – 7% of all pregnancies

Diabetes is common and seriousDiabetes is common and serious can lead to serious health conditions and can lead to serious health conditions and

premature deathpremature death

NIDDK, National Diabetes Statistics fact sheet. HHS, NIH, 2005.

U.S. Diabetes PrevalenceU.S. Diabetes Prevalence

In 2005In 2005 20.8 million people have 20.8 million people have diabetesdiabetes

14.6 million diagnosed with diabetes14.6 million diagnosed with diabetes 6.2 million undiagnosed6.2 million undiagnosed

54 million US adults age 20 and older have 54 million US adults age 20 and older have pre-diabetes

increased risk for diabetes and cardiovascular diseaseincreased risk for diabetes and cardiovascular disease

Prevalence is increasing over timePrevalence is increasing over time

NIDDK, National Diabetes Statistics fact sheet. HHS, NIH, 2005.

Age-Adjusted Prevalence of Diagnosed Diabetes by Age-Adjusted Prevalence of Diagnosed Diabetes by

Race/Ethnicity and Sex, United States, 1980–2005Race/Ethnicity and Sex, United States, 1980–2005

Data Source: Centers for Disease Control and Prevention, National Center for Health Statistics, Division of Health Interview Statistics, data from the National Health Interview Survey. U.S. Bureau of the Census, census of the population and population estimates.

Diabetes in American Indians Diabetes in American Indians and Alaska Nativesand Alaska Natives

Overall – 4-8 times more commonOverall – 4-8 times more common Prevalence varies by Area, TribePrevalence varies by Area, Tribe Prevalence of diabetes is increasingPrevalence of diabetes is increasing Prevalence of diabetes is increasing in youthPrevalence of diabetes is increasing in youth

0

5

10

15

20

Year

Per

cen

t

AIAN

US

Source: IHS Program Statistics and National Diabetes Surveillance System. Age-adjusted to the 2000 US standard population with the exception of 1981–1993 data for AIAN, which was age-adjusted to the 1980 US standard population.

1980- 20041980- 2004

Prevalence of Diagnosed DiabetesPrevalence of Diagnosed DiabetesAI/ANs compared to U.S. populationAI/ANs compared to U.S. population

Prevalence of diabetesAdults, by age, race/ethnicity, and sex,

United States, 2003

0

10

20

30

40

50

20-44 45-64 65+ 20+*

Per

cent White men

White women

Black men

Black women

Hispanic men

Hispanic women

AI/AN men

AI/AN women

*Age-adjusted based on the 2000 U.S. populationSource: 2002-03 National Health Interview Survey and 2003 Indian Health Service outpatient data.

Prevalence of diagnosed diabetes among AIAN Prevalence of diagnosed diabetes among AIAN children and young people, by age group, children and young people, by age group,

1990-20041990-2004

0

10

20

30

40

50

1990 1994 1998 2001 2004

<15

15-19

20-24

25-34

Per 1000

Source: IHS Diabetes Program Statistics

Year

160% increase

94% increase

128% increase77% increase

ComplicationsComplications

Higher rates of complications for AIANsHigher rates of complications for AIANs ESRD from diabetes – 6.8 times higherESRD from diabetes – 6.8 times higher Lower Extremity Amputations – 3 times higherLower Extremity Amputations – 3 times higher Cardiovascular disease – 2 times higherCardiovascular disease – 2 times higher Age-adjusted death rates – 4.3 times greaterAge-adjusted death rates – 4.3 times greater

Diabetes is the 4Diabetes is the 4thth leading cause of death leading cause of death

Risk Factors for DiabetesRisk Factors for Diabetes

Older ageOlder age Overweight (BMI ≥ 25)Overweight (BMI ≥ 25) Family HistoryFamily History Race/ethnicityRace/ethnicity History of gestational History of gestational

diabetesdiabetes Signs of insulin Signs of insulin

resistanceresistance Pre-diabetes Pre-diabetes

IGT or IFGIGT or IFG

HypertensionHypertension Abnormal lipid levelsAbnormal lipid levels History of vascular History of vascular

diseasedisease PCOSPCOS Inactive lifestyleInactive lifestyle

American Indians and American Indians and Alaska NativesAlaska Natives All of the above andAll of the above and Degree of Indian blood Degree of Indian blood

quantumquantum

American Diabetes Association. Diabetes Care 2007; 30;(Suppl.1):S4-41.; Strong Heart Study

Why is the prevalence of diabetes Why is the prevalence of diabetes so high in AIANs?so high in AIANs?

Some genetic/familial factorsSome genetic/familial factors Large role of environmental/lifestyle factorsLarge role of environmental/lifestyle factors

Lifestyles have changed over timeLifestyles have changed over time

Traditional ----------------------------Traditional ---------------------------- Western Western Increased ObesityIncreased Obesity

Decreased physical Decreased physical activityactivity

Example: Pima IndiansExample: Pima Indians

Pima Indians – Mexico vs. USPima Indians – Mexico vs. US

Pima Indians in Pima Indians in MexicoMexico Similar genetically to Similar genetically to

US Pima IndiansUS Pima Indians More “traditional” More “traditional”

lifestylelifestyle Lower obesityLower obesity Higher physical Higher physical

activityactivity Lower prevalence of Lower prevalence of

diabetesdiabetes

Schulz LO et al. Diabetes Care 29(8);2006

Obesity Obesity Trends1990 2001

Diabetes Trends1990 2001

BRFSS, 1990- 2001NIDDK, National Diabetes Statistics fact sheet. HHS, NIH, 2005.

We’re Eating More!We’re Eating More!

Daily caloric intake Daily caloric intake increased by increased by 523523 calories from 1970 to calories from 1970 to 2003. 2003.

-- Bigger portion sizes Bigger portion sizes

-- More eating out/fast food More eating out/fast food consumptionconsumption

-- Fat-free foods perceived Fat-free foods perceived as low calorie as low calorie

Ernst N. Am J Clin Nutr 1997;66(suppl):965S-72S.

We’re Moving Less!We’re Moving Less!

More automation / More automation / less activity at less activity at work.work.

Less energy to get Less energy to get to work, school & to work, school & shop.shop.

Remote controls, Remote controls, drive-through drive-through windows, garage windows, garage door openers, etc.door openers, etc.

Risk Factors for DiabetesRisk Factors for Diabetes

Dependence on market or commercially Dependence on market or commercially prepared foodsprepared foods U.S. Commodity Food ProgramU.S. Commodity Food Program Special Supplemental Nutrition Program for Special Supplemental Nutrition Program for

Women, Infants and Children (WIC)Women, Infants and Children (WIC) Senior MealsSenior Meals School MealsSchool Meals Fast food restaurants, convenience storesFast food restaurants, convenience stores RestaurantsRestaurants

Why is the prevalence of diabetes Why is the prevalence of diabetes so high in AIANs?so high in AIANs?

Some genetic/familial factorsSome genetic/familial factors Large role of environmental/lifestyle factorsLarge role of environmental/lifestyle factors

Lifestyles have changed over timeLifestyles have changed over time

Traditional ----------------------------Traditional ---------------------------- Western Western Increased ObesityIncreased Obesity

Decreased physical Decreased physical activityactivity

Example: Pima IndiansExample: Pima Indians

Public Health Approaches to Public Health Approaches to DiabetesDiabetes

Special Diabetes Program for IndiansSpecial Diabetes Program for Indians

Balanced Budget Act 1997Balanced Budget Act 1997 $30 million per year x 5 years$30 million per year x 5 years Grants for prevention and treatment of diabetesGrants for prevention and treatment of diabetes IHS, tribal and urban Indian programsIHS, tribal and urban Indian programs Funded over 300 programsFunded over 300 programs

Funding increased and extended three timesFunding increased and extended three times $150 million per year through 2011$150 million per year through 2011 Variety of prevention and treatment activitiesVariety of prevention and treatment activities Outcomes – improved care for individuals with Outcomes – improved care for individuals with

diabetes, increased access to services, including diabetes, increased access to services, including prevention activitiesprevention activities

Special Diabetes Program for IndiansSpecial Diabetes Program for Indians

Two types of programs in placeTwo types of programs in place1) Community-directed programs (333)1) Community-directed programs (333)

Some programs chose to do prevention activitiesSome programs chose to do prevention activities

2) Competitive Demonstration Projects (66)2) Competitive Demonstration Projects (66) SDPI Diabetes Prevention ProgramSDPI Diabetes Prevention Program SDPI Healthy Heart ProjectSDPI Healthy Heart Project

Developing Nutrition Models to Tell the Story of Food-Developing Nutrition Models to Tell the Story of Food-System Change – Kibbe M. Conti RD CDESystem Change – Kibbe M. Conti RD CDE

Conti KM. Journal of Transcultural Nursing, July 2006

Developing Nutrition Models to Tell the Story of Food-Developing Nutrition Models to Tell the Story of Food-System Change – Kibbe M. Conti RD CDESystem Change – Kibbe M. Conti RD CDE

Conti KM. Journal of Transcultural Nursing, July 2006

Diabetes in AIANsDiabetes in AIANs

Serious problem for AIANsSerious problem for AIANs Risk factors include genetic and Risk factors include genetic and

environmental factorsenvironmental factors Changing lifestylesChanging lifestyles Change in physical activity, dietChange in physical activity, diet

Strategies to prevent and treatStrategies to prevent and treat Lessons from healthy traditionsLessons from healthy traditions Education about healthy foods/eating and Education about healthy foods/eating and

physical activityphysical activity

QuestionsQuestions

Contact InformationContact Information

Yvette Roubideaux MD MPHYvette Roubideaux MD MPH

The University of ArizonaThe University of Arizona

500 N. Tucson Blvd., #110500 N. Tucson Blvd., #110

Tucson AZ 85716Tucson AZ 85716

520-318-7280 phone520-318-7280 phone

yvetter@u.arizona.eduyvetter@u.arizona.edu