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Diabetes Care in American Indians in North Carolina


tight-knit social/family networks. Lots of resources as well! ... tight-knit social networks - respect for the 'traditional way' ... – PowerPoint PPT presentation

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Title: Diabetes Care in American Indians in North Carolina

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Diabetes and the Eastern Band of Cherokee
  • Anthony Fleg
  • Deanndria Seavers
  • Che Smith
  • Brad Wright

  • American Indians (AI) and Their Health
  • The Eastern Band of Cherokee and Their Health
  • AI Disparities A Historical Perspective
  • Video
  • Diabetes Overview National, State, Cherokee
  • Group Discussion Activity
  • Cultural Competency with American Indians
  • Small Group Activity
  • Current Diabetes Programs in Cherokee, N.C.
  • Q A

American Indians in the United States
  • 2.5 - 4.1 million persons
  • 569 Federally recognized tribes 300 State
    recognized tribes
  • 10 speak lndigenous language in the home
  • Major U.S. historical markers
  • 1492 First encounters with Europeans
  • 1830 Indian Removal Act
  • 1924 Indian Citizenship Act
  • 1930s-1960s Boarding schools

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American Indians in North Carolina
  • There are more American Indians in North Carolina
    ( 100,000) than in any other state east of the
    Mississippi River
  • Nearly 60 of the AI population in NC belong to
    the Lumbee Tribe
  • There are 8 Tribes represented in NC
  • 7 are state recognized
  • 1 is federally recognized

North Carolinas Tribes
State vs. Federal Recognition
  • Federally recognized tribes have access to the
    Indian Health Service (IHS) blessing or curse?
  • ? Traditionally, IHS was run 100 out of
    tribes control
  • ? IHS spends about 50 of what it would
    take to offer what the average health plan offers
  • ? Other major issue is that HIS spends 1 of
    its budget on urban AI, despite the reality that
    2/3 of AI live off reservations
  • State tribes have no guaranteed access to health
    care services ? AI in NC have similar access to
    care barriers as other poor, minority, and rural
  • What are other consequences (positive and
    negative) to being a state recognized tribe?

American Indian Health in NC
  • Lots of needs
  • - lack of tribal health system
  • - invisibility of AI population
  • - data gap
  • - few health interventions
  • - little political presence
  • - lack of culturally competent care
  • - problems of the rural poor

  • Lots of resources as well!
  • - tight-knit social/family networks

  • Lots of resources as well!
  • - tight-knit social/family networks
  • - respect for the traditional way

  • Lots of resources as well!
  • - tight-knit social/family networks
  • - respect for the traditional way
  • Ex Tobacco and the AI Not on Tobacco program
  •  For us, tobacco is sacred. In the older
    teachings of what it was all about, it was very
    important to see that it was sacred. A lot of us
    have forgotten the sacred purposes of tobacco,
    for various reasons.
  • - Dennis Nicholas, Kanehsatake Elder, March

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  • Lots of resources as well!
  • - tight-knit social/family networks
  • - respect for the traditional way
  • Ex Tobacco and the AI Not on Tobacco program
  •  For us, tobacco is sacred. In the older
    teachings of what it was all about, it was very
    important to see that it was sacred. A lot of us
    have forgotten the sacred purposes of tobacco,
    for various reasons.
  • - Dennis Nicholas, Kanehsatake Elder, March
  • - strong, central role of faith/churches

  • Lots of resources as well!
  • - tight-knit social networks
  • - respect for the traditional way
  • Ex Tobacco and the AI Not on Tobacco program
  •  For us, tobacco is sacred. In the older
    teachings of what it was all about, it was very
    important to see that it was sacred. A lot of us
    have forgotten the sacred purposes of tobacco,
    for various reasons.
  • - Dennis Nicholas, Kanehsatake Elder, March
  • - strong, central role of faith/churches
  • A plug for community asset mapping the
    resources are as important as the needs when
    designing programs/interventions

American Indian Health in the U.S.
  • 2002 CDC Mortality Data for the United States
    Top 10 leading causes of death
  • U.S. population American Indian
  • 1. Heart disease 1. Heart disease
  • 2. Cancer 2. Cancer
  • 3. Stroke 3. Unintentional Injuries
  • 4. COPD 4. Diabetes
  • 5. Unintentional injuries 5. Stroke
  • 6. Diabetes 6. Liver Disease
  • 7. Influenza/pneumonia 7. COPD
  • 8. Alzheimers 8. Suicide
  • 9. Kidney disease 9. Influenza/pneumonia
  • 10. Sepsis 10. Homicide
  • Of note (1) Liver disease, suicide, homicide
    present only in AI list
  • (2) Diabetes and Unintentional
    injuries higher up in AI list

American Indian Health in the U.S.
  • Centers for Disease Control (CDC) office has
    identified a disproportionately high prevalence
    of health inequalities in 4 areas
  • Mental health
  • Substance abuse
  • Obesity
  • SIDS
  • http//www.cdc.gov/omh/Populations/AIAN/AIAN.htm.

American Indian Health in NC
  • Limited data, non-existent tribe specific data
  • AI rates of chronic disease, infectious disease,
    and unintentional injuries are roughly twice as
    high as for other North Carolinians

American Indian Health in NC
  • 2002-3 BRFSS data touted as a solution to the
    data gap
  • On 17 of 20 age-adjusted health indicators, there
    was a significant health disparity between AI
    and whites
  • - Diabetes 14 vs. 7
  • - HTN 40 vs. 27
  • - Unable to see a doctor due to cost 29 vs.
  • - Disabled 39 vs. 25
  • Most of the differences persisted after
    controlling for sociodemographic factors
  • Prevalence rates similar for AI and African
    American population in NC
  • Methods 16,203 respondents, 434 American Indians

Framing the numbers…
  • One way to frame it (the biomedical disparities
    approach) Why are AI experiencing health
  • Intervention Study AI, and then tailor a program
    to address AI risk factors
  • Another framework What social and health
    inequities, shared by AA, AI and other
    underserved groups lead to similarly high rates
    of disease?
  • ? Intervention Study all affected groups, and
    address the larger structures of inequities
    shared by AA, AI, etc.

American Indian Health in NC
  • Recommendations for improving AI health in NC
  • Data, Information and Gaps
  • Sovereignty, Governance and Systems
  • Access to Prevention and Care Services
  • 2004-5 DHHS NC Commission of Indian Affairs
    Joint Task Force on Indian Health

Eastern Band of Cherokee
  • Trace their people back 11,000 years
  • Once controlled 140,000 square miles (much of
    current-day 8 southern states)
  • Each village governed itself, and had a peace
    chief, a war chief, and a priest
  • Matriarchal system
  • Sequoyah created an alphabet for Tsalagi
    (Cherokee language)

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  • There are 7 Cherokee clans
  • -Wolf
  • -Deer
  • -Wild Potato
  • -Long Hair
  • -Blue
  • -Bird
  • -Paint

Trail of Tears
  • Cherokee had served as important allies for the
    U.S. against the French and British, but their
    land became increasingly desired (for
    plantations, possible gold)
  • In 1838, 17,000 Cherokee were forcibly marched
    westward by U.S. Army
  • On the 6 month journey to Oklahoma, 1 in 4 died
  • Those who hid from the Army, along with those who
    returned, became the Eastern Band of Cherokee

Eastern Band of Cherokee Today
  • 13,000 live in/around Qualla boundary (56,000
    acres) in Cherokee, NC
  • Thriving casino and tourism industry
  • Tribe has taken control of the IHS hospital ?
    Cherokee Indian Hospital

Cherokee Health
  • Poverty rates are falling 31 down to 22 since
    Casino opened
  • Obesity rates twice the state average, close to
    50 (2003)
  • 60 of 6-11 year old youth were overweight or
    obese (2003)
  • Surprisingly, data is still hard to find!
  • Source http//www.cdc.gov/pcd/issues/2006/jul/p

  • Understanding the persistence
  • of American Indian
  • Health Inequalities

Historical influences on Health and Health Care
  • Health
  • Foreign diseases
  • Economic and social discrimination
  • ?
  • Health care
  • Mistrust of Providers
  • Mistrust of Health care institutions
  • ?

Havasupai Tribe vs. Arizona State University
  • Professors worked with members of the tribe to
    design a project to study a pressing medical
    issue of the tribe -- diabetes -- in 1989.
  • The resulting "Diabetes Project" was supposed to
    offer three components Diabetes education,
    collecting/testing blood samples from members to
    identify diabetics or people who are susceptible
    to the disease, and conducting genetic testing
    "to identify an association between certain gene
    variants and diabetes.
  • In 2003, a tribal member approached ASU
    administrators and asked if the blood samples had
    been used for research other than that agreed to
    by the tribal members.
  • Source Arizona Daily Sun

  • The independent investigation uncovered "...
    numerous unauthorized studies, experiments and
    projects by various universities and laboratories
    throughout the United States ..." that resulted
    in at least 23 scholarly papers, articles and
    dissertations that involved the Havasupai blood
    samples. Fifteen of those publications dealt with
    subjects that had nothing to do with diabetes --
    like schizophrenia, inbreeding and theories about
    ancient human population migration to North
    America. -Arizona Daily Sun article

  • Editorial in Nature
  • Leaders from both communities need to reach out
    to each other to bridge the gap between their
    cultures. The National Human Genome Research
    Institute is funding work to do precisely this.
    One group in a unique position to help are Native
    American scientists they too can support
    dialogues to create a research environment to
    match the genetic opportunities of the times.
  • Source http//www.nature.com/nature/journal/v4

Health Inequities in the American Indian
  • A 500 year history
  • First explained by providential explanations

Providential explanations
  • If God were not pleased with our inheriting
    these parts, why did he drive out the natives
    before us?
  • -Winthrop (1634)

Providential (cont.)
  • Foreign disease introduced (intentional and
  • Where we were most welcome, where we baptized
    most people, there it was in fact where they died
    the most
  • -Lalement (1640)

Behavioral explanations
  • Behavioral explanations for disease
  • Explaining smallpox, which reduced tribal nations
    by 50-95 (e.g. 5-50 were left), destructive
    Indian behaviors were blamed indifference to
    cleanliness, reckless use of sweat baths and the
    vicious and dissolute life caused by alcohol
  • Disease became a tool of moral exhortation

Behavioral (cont.)
  • According to missionaries, if vice brought
    disease to American Indians, then acceptance of
    Christian morality and lifestyles would bring
    them health
  • -Jones DS, AJPH 2006

  • In the 19th century, health theories moved to
    consider the effects of government policies
  • Reservation system enacted in 1830s-1870s…there
    was faith that civilization would eventually
    bring health to the American Indians

Disparities in health and health resources
  • In 1890, govt. was spending 1.25 per Indian (vs.
    20-40 per military personnel)
  • 1917 as spending on AI health began to
    increase, this was the first year in 50 years
    where birth rate death rate
  • 1925 TB rates (per 100,000) U.S. (87), AI
    (603), Arizona AI (1510)

Recent and current frameworks
  • Environmental factors
  • Genetic explanation of disease rates
  • SES as proxy for social determinants of health
  • Recognition that increased tribal control of
    health services is necessary
  • Race/discrimination rarely considered

Another perspective historical trauma as a
health risk
  • Featuring Ann Bullock, MD

Diabetes Basics
  • Chronic disease that affects the bodys ability
    to properly produce or use insulin
  • Four major types of diabetes type 1, type 2,
    gestational and prediabetes.
  • Type 2 diabetes (non-insulin dependent diabetes
    mellitus), is the adult-onset condition
    accounting for 90-95 of diagnosed cases
  • Risk factors family history of diabetes,
    previous gestational diabetes, impaired glucose
    metabolism, physical inactivity and

Diabetes Complications
  • heart disease
  • stroke
  • kidney disease
  • nerve damage
  • eye problems
  • skin conditions
  • foot complications
  • depression

Depression Diabetes
  • Rates of depression are nearly twice as high
    among diabetics than non-diabetics
  • Depression reduces quality of life and is
    associated with increased morbidity, mortality,
    and health care costs
  • Not a statistically significant difference by
    race/ethnicity (p0.08)
  • Source Bell RA et al. Prevalence and correlates
    of depressive symptoms among rural older African
    Americans, Native Americans, and Whites with
    diabetes. Diabetes Care 28(4) 823-829

Depression Diabetes (cont.)
  • Definite physiological and behavioral links
  • Questions remain as to causal order
  • Hard to quantify the prevalence in AI compared to
    other populations
  • Dx by responses to a set of questions
  • Historical trauma and stress make differences in
    baseline likely
  • Depression may be the norm for AI, so it wont
    show up as easily (underdiagnosed)
  • Cultural Biases The classic AI is NOT stoic
    This is the result of a coping mechanism for

  • The NIH, CDC and the American Diabetes
    Association show that about 40 of Americans
    between ages 40 and 74 have pre-diabetes
  • Type 2 can be prevented

  • Improving glycemic and blood pressure control
    have shown to be effective
  • Improved glycemic control can be achieved through
    regular physical activity
  • Pre-diabetes shown preventable through regular
    exercise and a proper diet

  • Link between obesity and the increased chance of
    developing diabetes
  • 2005 CDC estimates show between 25-29 of
    population obese
  • 2002 North Carolina Diabetes Summary showed that
    21.8 of NC is obese
  • Obesity trend may increase rate of

National and State Data
  • In US
  • In 2005, the national prevalence of all types of
    diabetes was at 20.8 million Americans, or 7 of
    the population, with 6.2 million who have been
  • In NC
  • In 2004, an estimated 584,000 people with
  • Between 1995 and 2000, the prevalence of diabetes
    in adult population increased 42

US Prevalence of Diabetes
Diabetes Prevalence in AI
  • American Indians in North Carolina are three
    times more likely to die from diabetes than are
    whites in the state
  • Between 1990 and 1997 the prevalence of diagnosed
    diabetes among American Indians increased by
    roughly 30
  • Diabetes rates in the Lumbee are more comparable
    to those among the general NC population perhaps
    because they do not live on a reservation but are
    more integrated in their local community
    (primarily Robeson County)
  • Source Levin S et al. Geographic variation in
    cardiovascular disease risk factors among
    American Indians and comparisons with the
    corresponding state populations. Ethnicity
    Health 7(1) 57-67

2002 2003 CDC Data www.cdc.gov/pcd/issues/2006/j
  • Obesity
  • Diabetes

Trends in Diabetes??
  • A good news, bad news situation
  • Achieving targets, realizing better medical care
  • But longer lives spent with diabetes leads to
    multiple complications (morbidity)
  • Compounded by earlier age of diabetes onset ( 30
    years old)
  • This is more expensive for the system

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Group Discussion
Program Challenges
  • Barriers
  • cultural misunderstandings
  • poor dissemination of diabetes knowledge to
  • underutilization of current information
  • insufficient clinical care, financial restraints,
  • no single best practice

Decreasing Barriers
  • Increase social support and self-efficacy for
    patient adherence
  • Increase patient education and include behavioral
    change education
  • Change diabetes research from ideal, clinical
    settings with those at highest risk, to more
    community-based research and interventions

AI Beliefs about Diabetes
  • Most of the population is well-educated and knows
    the cause(s) of diabetes, BUT
  • There is are feelings of fatalism
  • I am going to get diabetes because I am a Native
    American and Native Americans have such a high
    prevalence of diabetes.
  • …Because the disease is so rife, it has
    unfortunately created an almost fatalistic
    acceptance of diabetes as an inevitable fact of
    Cherokee life, and a widespread belief that the
    disease is not preventable. -

Cultural Competency Tribes
  • It is important to keep in mind that each AI
    tribe has its own unique culture and heritage and
    its members consider themselves a distinct
    Indian Nation
  • Therefore, clinicians and others must respect
    these differences to provide culturally competent
  • E.g., Tobacco is considered sacred by most if not
    all tribes....thus, smoking cessation
    interventions may pose a challenge

Implementing Cultural Competency in Interventions
  • Clinicians caring for the AI population must be
    empathetic towards the long history of stress and
    trauma suffered by AI
  • Clinicians must realize that unlike the dominant
    western view of individualism, AI prioritize the
    family and the tribe
  • Interventions must be tailored accordingly

Challenges for Implementing Cultural Competency
  • Two-Pronged Approach to Health Professions
  • Cultural Competency Curriculum
  • Increase AI enrollment (Offer experiential
    learning to peers during school More likely to
    serve their own after graduation)
  • But Whose Lead To Follow?
  • These types of changes are made from the top down
  • Not a single American Indian on UNCs health
    professions faculty

Small Group Activity
  • Thinking Outside the Box

Cherokee Choices
  • Cherokee Choices (Sept. 2001 Aug. 2004 )
  • Primary and Secondary Diabetes Prevention
  • Education in Elementary Schools
  • Worksite Wellness
  • Faith-based Wellness
  • Native Lifestyle Balance
  • Social Marketing Campaign
  • Goals 7 weight loss 150 minutes of exercise
  • Funded by a Reach 2010 Grant

Cherokee Choices
  • Successes
  • Increased worksite knowledge about diabetes
  • Increased physical activity of students and staff
  • Changes in school lunch menus
  • Increased parental involvement in student
  • Evaluation
  • Last reviewed in January 2007
  • REACH Information Network evaluation tools

Cherokee Diabetes Program
  • State of the Art Program
  • Uses Evidenced-Based Medicine
  • Acupuncture
  • Massage
  • Yoga
  • Used to have traditional healer, but has not been
    replaced since last one left
  • Funded by IHS Grant

Wound Care Program
  • To treat foot injuries prevalent in diabetics
  • Tribe-funded
  • All American Indians are eligible

Special Thanks To
  • Ann Bullock, MD
  • Medical Director of Cherokee Health and Medical
    Division since January 2000
  • With HMD since 1990
  • Ronny Bell, PhD
  • Epidemiology professor at Wake Forest
  • Lumbee Indian
  • AI Task Force member
  • Mary Anne Farrell, MD, MPH
  • Clinical Director of Indian Health Service,
    Nashville Area
  • Susan Leadingfox
  • Deputy Health Officer for the Cherokee Tribe

  • For a subject worked and reworked so often in
    novels, motion pictures, and television, American
    Indians are…the least understood, and the most
    misunderstood Americans of us all
  • -John F. Kennedy (1963)
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