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Nebraska Anthropologist Anthropology, Department of

1997

Native Americans and Diabetes

Kristina K. Lee

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Lee, Kristina K., "Native Americans and Diabetes" (1997). Nebraska Anthropologist. 108. https://digitalcommons.unl.edu/nebanthro/108

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Kristina K. Lee

Type II diabetes has reached Almost all Native Americans with epidemic proportions among Native diabetes have Type" diabetes. Americans. It Is estimated that 12.2 There are many warning signs of percent of all Native Americans in the Type " diabetes. These physical U.S. have Type II diabetes. This ailments include: compares with 5.2 percent of the general U.S. population (Diabetes • fatigue Statistics 1997). The highest rate of • initability diabetes in the world is in the Pima • increased thirst or hunger • extreme weight loss Nation. Half of all Pima Indians age 35 • blurred vision and older have diabetes (West 1974). • increased urination Diabetes causes severe health • sore gums complications and is a major cause of • sores that do not heal or are slow to death for Native Americans. heal • frequent infections (skin, gum, bladder) What is Diabetes? • numbness in the hands or feet Diabetes is a chronic disease in (Diabetes and American Indians 1997; which the body does not produce insulin The Dangerous Toll 1997) or properly use insulin. There is no cure. Insulin is a hormone that is needed by One of the most significant the body to convert sugar, starches, and problems associated with diabetes is other food into energy needed for daily that over half of the people with the life. There are two main types of disease, do not know they have it Many diabetes, Insulin Dependent (100M) and people learn they have the disease only Non-Insulin Dependent Mellitus after they develop serious diabetes (NIDDM). Between 80 and 90 percent of related complications. Late diagnosis people with diabetes have Type 11 and increases the risk for more serious this will be the focus of this paper. health problems. Four of the most Non-Insulin dependent diabetes common life-threatening complications mellitus is also known as Type II of diabetes are: blindness (retinopathy), diabetes. It is charaderized by elevated kidney disease (nephropathy) and plasma glucose and plasma cholesterol ultimately, kidney failure, amputations of in blood and urine This is the more digits and limbs, heart disease, and common type of diabetes. Type " strokes. Heart disease is 2 to 4 times diabetes is a metabolic disorder in which more common in people with diabetes. the body produces insulin, but cannot The disease may cause damage to the use it efficiently or does not produce nervous system (neuropathy) and the enough. NIDDM affects carbohydrate, blood vessels (cerebrovascular). fat and protein metabolism, and Between 60 and 65 percent of diabetics insufficient insulin secretion or insulin develop high blood pressure resistance. Type " diabetes (hypertension). This increases the risk disproportionately affects minority of strokes with diabetics having a 2.5 populations and the prevalence of higher risk than a non-diabetic diabetes among minorities is increasing. (Diabetes Statistics 1997).

108 Research has indicated three diabetes among African Americans is primary fadors for the prevalence of comparable to the Hispanic population diabetes among Native Americans. (Diabetes Among Hispanics 1997). These factors are genetic For African Americans, it is predisposition, diet and obeSity, and estimated that over 2 million have phYSical activity level. Stress has also diabetes. They are 1.6 times more likely been indicated as a possible factor, but to have diabetes than the general U.S. very little research or documentation population. Almost 6 percent of African relates it to diabetes (Urdaneta 1989). American men have diabetes and The interrelationship between these almost 8 percent of African American fadors appears to cause Native women have diabetes. They often Americans to be more susceptible to experience higher rates of serious diabetes. Other factors that may complications such as blindness, increase the prevalence of diabetes amputation, and kidney failure (Diabetes include: high blood sugar during Among African Americans 1997). pregnancy, women with high birth . The average prevalence of weight babies (over 9 pounds at birth), diabetes among Native Americans is and ethnic background. more than twice as high as the general The following chart presents the U.S. population (West 1974, 1978a,b). percent of adults with diabetes in Overall prevalence of Type II diabetes various ethnic groups. These among Native Americans is 12.2 percentages, prepared by Diabetes percent as compared to 5.2 percent of Statistics, not only include figures of the general U.S. population (Diabetes diabetes patients, but also estimates of ·Statistics 1997). In less than thirty years, those individuals that are undiagnosed diabetes went from being unranked in the ethnic populations. The (1951) as a leading cause of death for percentages of adults (diagnosed and Native Americans to becoming the undiagnosed) with diabetes can be seventh leading cause of death by 1980 divided by ethnicity as follows: (Campbell 1996). Diabetes is the second most common diagnosis for African Americans 9.6 percent Native Americans admitted to the Mexican Americans 9.6 percent hospital (West 1974). If current rates Cuban Americans 9.1 percent continue, Type II diabetes will eventually Puerto Rican Americans 10.9 percent affect one-half of all Native American White Americans 5.2 percent adults. For the U.S. population as a Native Americans 5 to 50 percent whole, less than 10 percent of people (Diabetes Statistics 1997) age 45 or older have diagnosed or For Hispanics in the U.S., one in undiagnosed Type II diabetes (Harris every ten adults has diabetes. For 1985). For many Native American Cuban American and Mexican American nations, this figure jumps to 25 percent populations, almost· 10 percent have or more. For Pima adults age 35 or diabetes. For Mexican Americans and older, the rate is an astounding 50 Puerto Ricans ages 45-74, percent (Sievers and Fisher 1985). approximately 25 percent have These figures are staggering when diabetes, and in this same age group, recognizing that diabetes was rare in all 16 percent of Cuban Americans have Native American nations prior to 1940. diabetes. Hispanic women with diabetes The percentage of Native have a greater risk of death and American adults with diabetes, both complications during pregnancy than the diagnosed and undiagnosed, ranges U.S. average. The prevalence of from 5 to 50 percent Prevalence rates vary among different Native American

109 nations (see Weiss 1984, Appendix 1). Environmental change occurred as food At this point in diabetes research, it resources become increasingly dense seems that diabetes is not uniformly and available. Since the environment distributed across all Native American today, does not match the past groups. The extent of acculturation may environment, Native Americans have play a role in this pattern and needs to developed problems with adaptations. be researched further. Many nations of These environmental changes in such the southwest (Pima, Navajo, Tohono aspects as diet and activity level O'odham) have extremely high occurred rapidly in many Native prevalence rates and, as with the Pima, American communities. Most of these have been researched for many years. changes were imposed on them by a Unfortunately, few other nations have dominant outside culture. been examined for incidence of diabetes and significant cross-cultural data is not Genetic Explanations available. Another important factor to and the Thrifty Gene consider with the wide range of diabetes Many researchers think that prevalence is that almost half of those diabetes in Native Americans is a with diabetes are still undiagnosed with problem in human adaptation and the disease. genetics is strongly linked. One of the Diabetes has become a growing possible explanations of this health problem among Native evolutionary adaptation was developed Americans since the 1940s (West by Neel (1962,1982). In 1962, Neel was 1974). There is little documentation of the first to argue that diabetes was a diabetes prior to this time period. genetic adaptation that dealt with According to reports, diabetes was rare changes in lifestyle. His theory was in the first part of the twentieth century called the "thrifty genotype" hypothesis. (Hrdlicka 1908; Sievers 1981). By the People with a thrifty gene were better 195Os, diabetes was found in many able to store food as -fat during feast nations. By the 1970s, it was found in periods. The thrifty genotype hypothesis epidemic proportions in many nations, involves quick insulin discharge after a West (1974) discovered that within a meal, which granted a survival short period of time, diabetes had advantage during times of food spread throughout the Native American shortages. Evidence for seasonal stress populations. is widespread among hunters and One possible way to examine or gatherers in various environments. explain the change in the occurrence of "Near1y all hunters and gatherers living diabetes among Native Americans is in seasonal environments continued to using mismatch theory. It is noted that be affected by the seasonality with diabetes and obesity were rare in Native some degree of episodic stress" (yesner American populations historically. 1994:167). Unfortunately, this one-time Diabetes became increasingly apparent advantage has now become a after the 194Os. As living organisms, maladaptation which is detrimental humans are adapted to live in a certain giving rise to insulin resistance and environment We presume that eventually Type II diabetes. Today's biological adaptations humans have are new environment with high food from past environments. Mismatch availability and consumption patterns, theory examines the consequences of combined with decreased physical diet change. Humans, specifically activity, may lead to diabetes. Neel hunters and gatherers, seek out caloric theorized that the "thrifty" gene probably rich foods in areas of limited resources. accounted for the high prevalence of Today, food stress is not a problem. Type II diabetes in Native American

110 populations. The thrifty genotype current environmental conditions. became a liability after adopting a According to Weiss, Eskimos have a modem lifestyle. lower prevalence to the New World Another related theory is Weiss's Syndrome because of their later (1984) "New World Syndrome." This migration to the New World. The New theory states that there is one World Syndrome presents itself in fundamental mechanism for the high Native American populations with the prevalence of certain diseases among onset of obesity sometime after puberty. Native Americans, diabetes and obesity Later, diabetes develops in adults. The included. Weiss suggests that Native underlying cause for diabetes and Americans have a genetic susceptibility obesity seems to be the interaction to the New World Syndrome due to between the environment and positive natural selection or genetic drift susceptible genotypes. during the early peopling of the New Ritenbaugh and Goodby World. Certain traits were perpetuated (1989:228) suggest "with northern by natural selection which provided hunting adaptations, rapid changes in survival advantages when Native lifestyle among this group could lead to Americans were hunting and gathering. the NIDDM seen in present day Weiss states that the New World American Indians and other New World Syndrome is connected to female populations." Diet for northem hunting reproduction. This "suggests that groups consists mainly of animal . possibility of a gene or genes related to resources. These sources are low in food storage in the form of fat, whose carbohydrates, low in dietary fiber, selective advantage pertained to the moderate in fat, and high in protein. ability of a woman to become fertile, to People living in northern latitudes of carry a child successfully to term, or to North America have a high metabolic nurse an infant" (WeiSS 1984:172). rate for the production of body heat and Wiedman (1983) also proposed a theory blood flow to extremities. Their reliance relating female reproduction to the thrifty on animals for their food base suggests gene, called the "muitiparity" hypothesis. irregularity of food availability and He suggested that the thrifty gene possible health problems related to the allows females to gain weight for excessive ingestion of protein. successful pregnancies. The ability to Ritenbaugh and Goodby (1989:230) gain weight would increase the birth suggest that "in this context, preferential weight of a child and increase the child's storage of fat would provide a distinct survival rate (Wiedman 1983). Today, survival advantage." Therefore, fat could this thrifty gene causes problems by the be preferentially stored. As with Neel's relative ease of significant weight gain. thrifty genotype hypotheSiS, this This may lead to obesity and diabetes. preferential fat storage would be a Weiss (1984) argued that the "thrifty survival factor during this period of genotype" must represent some form of hunting. altered metabolism. He stated that since World War 11, there has been a Dietary Change and Obesity significant increase in diabetes and Several researchers have obesity and he argues that it is from the examined the relationship between diet, interplay of certain Native American culture, and diabetes (Jackson 1994; genotypes and changes in their Smith 1994; Thorbum 1987; Wolfe environment, most notably, changes in 1994). From food quality to food intake, their diet The diseases that are food plays an important role in the becoming rampant today did not present health of a population, both physically a problem in the past This is because of and psychologically. In many Native

III American cultures, food plays an loss of traditional lifestyle. Thus, important role in social situations from although some individuals in some everyday life to religious ceremonies tribes still eat at least a limited amount and celebrations (Jackson 1994; Lang of traditional foods, purchased items 1989). have generally replaced traditionally Dietary and cultural changes hunted, gathered, or cultivated foods. " arose after contact with Euroamericans Feskens (1992) discusses diet and these changes impaded the overall and how carbohydrates, fiber, refined health of Native Americans (Jackson sugars, starches, fats, and proteins help 1994). New plants and animals were or hinder the development of diabetes. introduced and many traditionally used Most traditional foods are high in plants and animals were destroyed. complex carbohydrates, while With the relocation and reservation processed foods are high in simple period in the mid to late nineteenth carbohydrates, sugar, and fat. Thorburn, century, the U.S. government began et al (1987) suggests that diabetes was limiting Native American access to not found historically because traditional traditional foods and them with food "bushfoods" digested slowly due to the rations and commodities. These goods amount of complex carbohydrates. often consisted of flour, baking soda, "There is increasing evidence that the sugar, rice, canned meat, bacon, lard, replacement of the complex and coffee (Jackson 1994). "Dietary carbohydrates found in desert plants changes usually involve the with refined, high caloric, Single replacement of high fiber and complex carbohydrates does produce a very carbohydrate foods with high fat and . slowly rising blood glucose level and the simple carbohydrate foods" (Jackson corresponding insulin levels in 1994:393). The U.S. government also non-diabetic subjects" (Justice strongly encouraged many traditional 1994:119). Swath mary (1986) also hunter and gatherer groups to take up hypothesized that the high prevalence of agriculture and become farmers. NIDDM among Native Americans was Today, diets are generally high related to proper digestion of in refined carbohydrates, fat, and carbohydrates. sodium with very few fruits and Brand, et al (1990) conducted vegetables as part of the diet. "In a research on traditional Pima Indian recent Survey of contemporary Navajo meals and found that these starchy diet, Wolfe and Sanjur (1988) reported foods digested slowly and contributed to that the most frequently consumed the protection of the group from foods are fry bread, potatoes, eggs, and diabetes. The Pima diet before 1930 sugar, in addition to beverages of soda consisted of legumes (wild and pop or other sweetened drink mixes. cultivated), cacti, fish, seeds, mesquite, "Traditionar foods eaten include mutton, and com. Through acculturation and tortillas, and fry bread. While 53 percent adoption of government commodity of the households sampled grow corn, foods, these traditional foods lessened squash, and melons in household in use, as wheat, lard, sugar, and other gardens, most gardens are small and processed foods became the bulk of the are no longer a major source of food" Pima diet. The traditional foods (Hall 1994:140). Jackson (1994:390) contained carbohydrates that digested states that "contemporary food choices slowly and they have low glycemic and of American Indians reflect historical ties insulin responses. as well as many changes. A decreased in available variety and quantity of wild animals and plants has paralleled the

112 Obesity conducted by the Indian Health Service, In 1978, West, a prominent diabetes indicated that 77 percent of all subjeds scholar, concluded that obesity was the were obese and 84 percent of all single most important nutritional factor in persons with diabetes were obese the cause of diabetes. He stated that (Diabetes Nutrition Education Materials Type II diabetes is genetically 1989). It is unclear with this data how detennined, with close ties to age and the Indian Health Service defined obesity Records and observations of obese. It is possible that the figures Native American body type in the 19th include people who are simply and early 20th century, suggest that "overweight' and not obese as defined most Native Americans were generally by other researchers (Broussard et al lean, healthy individuals (West 1978a). 1991). There was little historical documentation Obesity and diabetes seem to be of obese Native Americans. Today, highly correlated in Native American obesity is very common in Native populations. Diabetes incidence is American populations (West 1978a,b). A greater in obese people than in those medical survey in 1987 documented the who are not obese. "The most prevalence of overweight and obese frequently encountered explanation for Native Americans and Alaska Natives the increased incidence of NIDDM is and compared those figures to the that obesity increases insulin resistance general U.S. population. For Native which results in high circulatory levels of American males, 18 years and older, the glucose" (Ritenbaugh and Goodby prevalence of obesity was 13.8 percent 1989:233). It is not known whether This figure jumps to 28.2 percent for obesity brings out diabetes sooner in men ages 45 to 54. For non-Indian men people already predisposed to the of the same age group, the prevalence disease or if it is adually causal (Bennet of obesity is 14. 1 percent, For Native etaI1976). American women, 18 years old and Lifestyle choice is often one of older, the prevalence of obesity is 16.6 the leading factors in weight gain. percent This compares to only 8.2 Weight gain may come from a the percent prevalence for non-Indian constant supply of food, a decrease in women in the some age group physical exertion, and an increased (Broussard at al 1991; see Appendix 2). availability of high caloric foods. Cultural The extent of obesity in Native traditions playa role in ideas of food and American populations is not well fatness. Lee et al (1985) found that in understood or documented, Most some Native American communities, national health surveys do not include fatness is a sign of well-being and that Native Americans. Documentation and Significant weight loss may be sign of researdl is sketchy and exad research concem for people. These views may methods of various surveys are often promote feasting behavior but no not known. There are problems with the corresponding fasting behavior. Food use of tenns, "over-weight" and "obese." and feasting often play an important role Obesity is defined using, body mass in Native American communities ties. In index (BMI) as the indicator. For adults, addition, socioeconomic conditions may obesity prevalence is defined as having playa role in the types of food available a BMI greater than or equal to the 95th to certain groups. Studies have shown percentile and overweight is defmed as that low socio-economic groups often those with a BMI greater than the 85th have diets that have significant amounts percentile (Broussard et aI1991). A of calorie-dense, high fat, and refined screening of more than 2000 .Native carbohydrates (Molls, Leonard, and Americans representing 15 tribes Watson 1985).

113 Weiss (1984: 157) states that activities of the Navajo demanded a "while obesity is a cardinal risk factor for great deal of physical labor. People diabetes in New World populations, often walked long distances to their there is evidence that the prevalence of herds and fields. Today, many Navajo diabetes ... cannot be explained by have motor vehides to get from one obesity alone." Obesity and its place to another. "The implication of this subsequent relationship to diabetes is a decreased activity level is well serious medical problem for many understood by many elderly Navajos, Native American populations. KnowIer who blame reduced physical activity et al (1991) stress the importance of rather than greater food consumption for research on how obesity increases the increasing obesity on the Reservation" incidence of diabetes and whether (Hall 1994:141 ). weight loss programs and preventive Diabetes has drastically weight control programs will reduce the increased in Native Americans possibly incidence of diabetes. due to recent, rapid lifestyle changes. Diets have changed and activity levels Reduced Physical Activity have decreased, both ofwhich seem to One of the most common contribute to the prevalence of diabetes. statements made about Native Research suggests that these Americans is that they do much less environmental changes "unmask" an physical activity now that they are not underlying Native American genetic hunting and gathering. Many hunting susceptibility to diabetes (Knowler et al and gathering groups spent significant 1983; Mohs et al 1988; Sievers and amounts of physical activity in their lives Fisher 1981; Weiss et al 1984; Hall for the procurement of food. This 1994; Zimmet et aI1982). decrease in physical activity and increase in sedentism has led to an A Look at Diabetes in increase in obesity, which in tum, might Several Native American Nations lead to diabetes. Another possible fador Kiowa in the reduction of physical activity Kracht (1994) presents the among Native Americans deals with changes that occurred for the Kiowa that urban living versus rural living. Urban have led to a high prevalence of populations are often more sedentary diabetes. They indude changes in diet than rural populations. Urban Native and lifestyle, development of obesity, Americans make up over 63 percent of and a decrease in exercise. This the total Native American population. situation is similar to many other Native Urban Native Americans have three American nations. times the national rate for diabetes Kiowa diet changed significantly. (Urban Indian Fad Sheet 1997). One of the important pre-reservation "Quantification of adual energy foods eaten by the Kiowa was bison expenditure is generally difficult in field meat Other foods included deer, elk, studies. Most observations of changing wild fruits, and vegetables. During the activity levels are based on anecdotal reservation period, 1868-1901, Kiowa information regarding historical changes subsistence and diet changed from wild in physical activity pattems. It is dear, plant and animal resources to an however, that daily subsistence increased dependence on govemment activities and transportation needs have commodities of beef, salt pork, flour, until recently required moderate to and sugar. Due to unsuccessful heavy energy expenditure in most tribal attempts of the U.S. govemment to groups" (Sievers and Fisher 1981). For transform the Kiowa into farmers and by example, traditional farming and herding the reduction of govemment rations,

114 there were periods of starvation and Diabetes among Alaskan famine in the Kiowa community. Hunger Natives was rare in the past, but was a major problem at the Kiowa according to Schraer (1994), it is Agency. "The Kiowa were compelled to becoming more common. Why is it subsist on the scanty rations available; becoming more common? Schraer they had a steady, albeit inadequate argues it is because of lifestyle changes. food supply that was consumed within a Traditional foods for Alaskan Natives few days. Thus, consuming all available vary according to the environment in foods at once became a pattem which people live. Traditional foods attributable to inadequate ration range from salmon, moose, deer, distributions" (Kracht 1994:151). shellfish, seals, halibut, berries, Activity levels also changed for seaweed, whales, and birds. As with the Kiowa. First, the Kiowa were forced most Native American groups, cultural to stay on the reservation. They were changes occurred after Westem not allowed to move camp or migrate to contact. The traditional diet of many other areas. Secondly, by the end of the Alaskan Natives was low in nineteenth century, the Kiowa were carbohydrates and high in protein. being forced to live in govemment built Research has shown that their houses, thus compelling them to traditional diet was fairly balanced for become more and more sedentary. The human nutritional needs. By the mid-20th Kiowa were forced into inactive Century, food resources were changing lifestyles. At the same time, their diet as well as energy expenditure. was changing to heavily refined foods. Technology has given Alaska Natives This combination could easily lead to important labor saving devices such as Increased obesity and possibly snowmobiles, chain saWs, and fuel oil. diabetes. Saturated fat and carbohydrates have increased in their diet These changes Eskimo/Alaskan Natives have unfavorably affected the health of Previously, researchers have Alaska Natives. presented the relatively rare occurrence The occurrence of diabetes of diabetes among Alaskan Natives among Alaska Natives was thought to (Mouratoff et aI1972). Recently though, be rare up to 1985. In 1985 the Alaska this position has been challenged by Native Health Service was concemed Schraer (1994). Mouratoff (1972) that Alaska Natives were developing concluded that diabetes was probably diabetes. In the following year, the rare among the Eskimo because of their health service started a project to high level of physical activity which register diabetic patients. It was found hindered the development of diabetes. that diabetes prevalence (age adjusted Another reason for the rarity of diabetes rates/1000) varied between Alaskan was thought to be the lack of obese ethnic groups: 27.2 among Aleuts, 22.0 people in the population. The group among Indians, and 8.8 among Eskimos Mouratoff (1972) researched was not (Schraer 1994). Schraer suggests two extremely obese. A survey (Shraer theories for the differences in diabetes 1994) conducted in 1987 of an Eskimo prevalence from one Alaska group to village found that in a span of fifteen another. First, these differences may years (1962 to 1987), the number of reflect different genetic susceptibility overweight (BMI>85%) men increased among ethnic groups. Second, lifestyle from 3 percent to 16 percent and for factors may be the most Significant women it increased from 6 percent to 27 component of the occurrence of percent. diabetes. Schraer points out that those regions with the longest contact with

115 outsiders, are those regions that have obesity. Pima children today are much the higher prevalence of diabetes. heavier in weight than Pima children earlier in the twentieth century. Obesity Pima among the Pima can be traced through Type II diabetes is epidemic families and seems to be connected to among the Pima of Arizona. The Pima the development of diabetes. were a hunting and gathering group who Neel's thrifty genotype theory had successfully adapted to desert life. has been applied to the Pima to explain Euroamerican settlement into their area the high incidence of diabetes in disrupted their traditional hunting, research by Bennet et al (1976) and gathering, and agricultural lifestyle. Two Knowler et al (1981,1983). Knowler's enormous health problems among the findings (1983) are consistent with the Pima today are diabetes and obesity. basic principles of Neel's theory. 'When According to KnowIer (1978), the Pima food supplies are steady and abundant, have the highest reported diabetes as they are for the Pimas today, incidence in the world. Approximately 50 increased fat storage is detrimental, percent of adults over the age of 35 leading to increased obesity, insulin years have diabetes. The Pima have resistance, and eventually diabetes" been participating in longitudinal (Knowler 1983:113), This increased epidemiological research studies as far incidence of diabetes coincides with the back as 1965. These studies on increased availability of food resources. diabetes and obesity hope to rand the Bogardus et al (1989:1423) cause(s) of the astronomical rates hypothesizes that among the Pima, (Bennett 1976). "insulin resistance is determined by a Obesity among the Pima is single gene with a co-dominant mode of phenomenal (see Appendix 3 ). For the inheritance." Bogardus suggests that first half of this century, obesity among obesity is not the major factor of MaxM the Pima was relatively rare (Hrdlicka (maximal insulin-stimulated glucose 1908; Knowier 1983). Obesity among uptake rates) and that other the Pima has increased significanUy environmental factors are not significant during the 20" Century. According to factors of MaxM. His research suggests body measurements, when compared to that there is a strong factor among the the general U.S. population, aU Pima, Pima that MaxM is a familial trait that is regardless of age, tend to be more not related to obesity. age, and sex. obese (Knowier 1983). At all ages, the "Family membership was a more Pima exceed the U.S. age-specific important determinant of MaxM than all medians of body mass index. In 1981 of the other covariates combined" the National Center for Health Statistics (Bogardus 1989-1423). According to indicated that almost 60 percent of Bogardus, environmental determinants Pimas 20 to 34 years old) exceeded the have only a weak connection to the 90th percentile for the body mass index. development of diabetes. This compares with 10 percent of the general U.S. population (Berg 1990). Tohono O'odham The highest body mass index in the Justice (1994) compares population is in the young adults. There diabetes prevalence rates of the Tohono have been some increases in age- and O'odham to the Pima and finds similar sex-specific mean body mass index for rates. As with other groups, the rates the past 25 years. According to Knowler, have increased significantly over a short this would indicate that older members period of time. For the Tohono of the population have been less O'odham, the prevalence of diabetes is exposed to those factors that lead to 141.79 per 1000 for all ages. The rate

116 for age 25 years and older is 317.04 per between epidemiologists and 1000 (Justice 1994). Justice suggests anthropologists can contribute that Neel's "thrifty gene" theory may substantially to our knowledge of the explain these rates for the Tohono genetic, metabolic, social, and cultural O'odham. determinants of the disease" (Young Justice (1994) gives four 1994:34). theoretical stages of the development of Another important aspect is the diabetes among the Tohono O'odham. need to change behavioral patterns to The first stage includes periods of deal with conditions that increase the periodic famine and food scarcity. risk of diabetes. Dramatic improvements People are hunting and gathering, which can occur with proper treatments takes considerable amounts of energy. (charige in diet, weight loss and For the most part, diabetes is absent exercise) for Type II diabetes. Glucose during this first stage. The second stage levels improve with moderate physical is when the availability of food increases exercise. Exercise also helps lessen and it is available virtually every day. secondary complications of diabetes. Food scarcity only affects a small Management of diabetes relies heavily number of people on the outskirts of the on behavior modification on the part of community. Energy output decreases the patient. Cultural norms must be with the availability of storebought taken into consideration when foods. Because of the previous factors, developing these changes. A treatment weight gain increases and diabetes program that advocates changes which begins to occur in adults. In the third are not only difficult, but also culturally stage, obese, diabetic mothers are unacceptable, will likely not be followed giving birth, their children are surviving by the patient. The Gila River Diabetes and the children are becoming obese Prevention Model combines community adolescents. The availability of food is experiences and diabetes research into still abundant and energy output has a culturally relevant intervention continued to decrease. The last stage is framework for this community the continual decrease of physical (Garcia-Smith 1994). The model is activity and continued high prevalence based on the idea that if the cultural rates in all age groups. According to ways of the Pima are incorporated into Justice, the Tohono O'odham have the preventionltreatment program, those been in the fourth stage since the afflicted will be more likely to follow the 1970s. program and it will be more effective. Adherence to a diabetes treatment Implications for Diabetes Treatment program depends a great deal on The high prevalence of diabetes developing management programs among Native Americans has significant which include the patienfs culture, implications for their health care. One of rather than ignoring the patienfs culture. the most important steps in developing Diabetes prevention and appropriate treatment is the need for treatment programs must combine health care professionals to adapt their historical and contemporary information treatment to include cultural values and about the population when designing ideas of their patients. Education these programs. Each must be tailored programs need to have cultural to the specific cultural group. The knowledge of the targeted groups to Lorelei DeCora's Porcupine Clinic on better transmit information and assist Pine Ridge Reservation is teaching people with preventing and managing diabetics about beneficial diets, illness and disease. "Diabetes is one exercises, and how to control diabetes. field where a collaborative. approach DeCora is attempting to recover

117 traditional tribal ways of preparing food. Program. This program conducts dietary She enlists the help of tribal elders in guidance workshops that assist tribal her programs (Sandrick 1997). Health program cooks to make changes in their programs need to incorporate cultural cooking and menu preparation. It adaptations for individual tribal diabetes emphasizes the U.S. Dietary Guidelines programs. One such program is the and how to cook more healthily (Pelican Intemational Diabetes Center and its 1995). Native Seeds/SEARCH Staged Diabetes Management (SOM) (Southwest Endangered Arid Lands program which has helped curb Resources Clearinghouse) provides diabetes on several Navajo reservations native desert seed packets free to (Innovations 1996). The International Native Americans. It supports the idea Diabetes Center has also developed a that native foods have health benefits partnership with the Indian Health and encourages people to plant and Service and serves many different harvest foods of the past. Some Tohono Native American nations. O'odham have retumed to a traditional There is often a gap that needs diet consisting of prickly pear and other to be bridged between the patients desert plants. Many of these desert cultural understanding of diabetes and plants are high-fiber foods and assist the medical doctor's clinical or westem the body in regulating glucose levels understanding of the disease. Carrese (Zastaury 1996). and Rhodes (1995) discuss the possible Reverting to a "traditional" diet is detrimental implications of discussing not as simple as it seems. Many advance care plaming, treatment risks, questions are raised regarding these and disease complications with ideas. What is the definition of traditional Navajo patients. Westem "traditional" foods? Are they the foods bioethics which is a common part of eaten during the period of first contact Westem medicine is seen as dangerous with Non-Native Americans? Who will to these Navajo. "The Navajo way of have access to these traditional foods? thinking embraces positive thinking, How will urban Native Americans gain beauty, harmony, and goodness. If a access to these foods? What images physician discusses the complications of are being projected by a "retum" to a disease such as diabetes, the Navajo "traditional"? On one hand, the use of patient may believe that he or she will traditional foods might be part of a become afflicted with those culture's revitalization. DeCora's use of complications. Health care providers the knowledge of tribal elders seems should consider the Navajo ethical beneficial. On the other hand, does perspective when offering treatment" stressing the retum to "traditional" foods (Carrese and Rhodes 1995:826). perpetuate stereotypes of Native Diet is central to the treatment of Americans as living in the bush or living diabetes. Food has important cultural off the land as pristine hunters and significance for many Native Americans. gatherers. Does it project an idea that These two ideas can cause much Native Americans should remain (or controversy in communities regarding retum) to "traditional" ways regardless of the treatment of diabetes. Diet plays an the ability of cultures to change and important rule both in the etiology and adapt? management of diabetes. This also Hall (1994) suggests two options challenges some Native American for dealing with the detrimental diabetes socio-cultural norms. One program that problem. He suggests the possibility of is attempting to change dietary genetic engineering to find the aberrant behaviors is the Indian Health Service gene and to alter it Unfortunately, this Nutrition and Dietetics Training process would be extremely costly and

118 time consuming. Native Americans also have caused such an explosion of might not be willing to be a part of a diabetes, but combined, they "trigger" genetic engineering experiment. The the onset of diabetes, like has never second option would be to condud been seen before. Mismatch theory and behavior modification. If behaviors that the thrifty genotype hypothesis are encourage or support the maladaptive plausible arguments for the high gene could be changed, this would prevalence of diabetes in Native significantly decrease the numbers of American populations. Research has Native Americans with diabetes. strongly suggested that a major gene(s) Educational programs would have to be influences the risk of Type II diabetes. culturally specific. The focus of this The manifestation of this gene may education would be twofold. First, depend on environmental facets that modification of the diet of many Native have become more prevalent In recent Americans must be made by decreasing times. The maladaptive trait and the the amount of high-caloric, high fat, and hereditary nature to develop diabetes high sugar foods. The second part appears to be the most significant would stress the importance of exercise factor, but other fadors such as diet and and energy expenditure. physical activity level muddle a strictly genetic analysis. The environmental Conclusion fadors should continue to be Understanding the nature and researched. Until diabetes is linked to a hiStory of diabetes is important. The specific gene(s) in Native American interaction between genetic and cultural populations, speculation will continue factors must be considered when about the phenomenal prevalence of researching the disease. Effective diabetes in those populations. treatment of diabetes patients needs to be researched further. What are the most important things needed for people With etiological roots that span an with diabetes or those at high risk? unusually broad range Of Subjects -from Programs must be established that are man's prehistory and evolution, to culturally sensitive and relevant to each endocrine function and subcellular group. These programs should involve interactions to behavioral psychology - diabetes does not yield to the fine, dietary changes and increased physical precise, dissecting lens of modem activity. According to newspaper medical science. The more columnist Don Finley (1996), some encompassing biocultural view by Pima have resigned themselves to medical anthropology provides an getting diabetes and living their life with additional perspective on this disease. the disease. They see diabetes as just a Only by examining the interactions "normal" part of their life and expect to between all the detenninants of the get it. Medical practitioners are worried disease - environmental, cultural, and about this fatalistic view and rightfully biological - can we hope to understand so. For researchers and the people with and solve the diabetes problem. (Urdaneta and Krehbiel 1989:221) the disease, diabetes continues to be a frustrating disease. Type II diabetes is found in REFERENCES CITED epidemic proportions in many Native American populations. Research has shown that the primary fadors in the Bennett, Peter H., Norman B. Rushforth, Max prevalence of diabetes are: genetic Miller, Philip M. Compte 1976 Epidemiological studies of Diabetes in predispoSition, diet, and activity levels. the Pima Indians. In Recent Hormone Individually, a single fador may not

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