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Title: Diabetes

  • Dwight Pargee, Fitness Coordinator
  • United Indian Health Services

Type 2 diabetes
  • Expanding horizons on diagnosis, treatment, and

Understanding Diabetes
  • What is diabetes? (Normal and abnormal sugar
    processing in the body)
  • Type 1 2 diabetes
  • Type 2 diabetes in American Indians

What is Diabetes?
  • A problem with the way your body uses food to
    store and make energy.
  • (and lots of other stuff)

What is Diabetes?
  • A chronic disease characterized by high blood
    sugar which can effect many organs and systems of
    the body
  • A disease which can damage tissues before an
    individual is diagnosed or has symptoms
  • An illness which may affect individuals
  • Some aspects of diabetes are still poorly

Understanding Diabetes
  • Glucose (a kind of sugar) is an important fuel
    for your body
  • Insulin (a hormone or messenger protein that is
    made in the pancreas) helps glucose get into many
    kinds of cells in the body
  • With diabetes, there is a problem with the
    glucose getting into the cell where it can be
    used for fuel

Understanding Diabetes
  • When the glucose cant get into the cell
    properly, it stays in the bloodstream
  • When the glucose level in the bloodstream rises,
    the glucose may attach to proteins or cause other
    imbalances leading to build-up of toxins in the
    body (and you dont feel a thing)

Understanding Diabetes
  • Over time, this can result in damage to the
    tissues (and you dont feel a thing)
  • Insulin resistance may also lead to tissue
    damage independent from that of high blood sugar
    (and you dont feel a thing)

A Key Player - Insulin
  • Insulin a hormone made by special cells in the
    pancreas gives signals to many tissues,
    including the signal to move glucose from the
    blood into the cells. Insulin mainly tells the
    body to store energy for the future.
  • Insulin Resistance - the decrease in the tissues
    ability to respond to insulins signal.

A Key Player - Insulin
  • Insulin a hormone made by the Beta cells in
    the pancreas gives signals to many tissues,
    including the signal to move glucose from the
    blood into the cells. Insulin mainly tells the
    body to store energy for the future.
  • Insulin Sensitivity - the ability of different
    tissues to respond to insulin.
  • Insulin Resistance - the decrease in the tissues
    ability to respond to insulins signal.

What Kind of Diabetes?
  • Type 1
  • Complete shutdown of cells that make insulin
  • Cannot live without insulin
  • Type 2
  • The body still makes some Insulin
  • The insulin signal is not as powerful
  • Gestational Diabetes or Diabetes of Pregnancy
    (like type 2 diabetes)

Feature Type 1 Type 2
(No Transcript)
Normal Glucose Metabolism
Nutrition Carbohydrates (starches sugars)
Tissues (Muscle and Fat)
glucose storage (glycogen) and production
What Goes Wrong in Diabetes?
Nutrition (carbohydrates)
Tissues (Muscle and Fat)
Type 2 insulin resistance
excess glucose production
Insufficient or no insulin
What is Insulin Resistance?
Insulin Resistance
  • Insulin is like a messenger-key to a lock on
    the cell, it opens the lock to let in glucose
  • Many cells, especially muscle and fat cells, need
    insulin to help get the glucose in the cell.
  • Folks with insulin resistance need more
    messenger-keys (insulin) to let the
    glucose into the cell

Insulin Resistance
  • Insulin resistance can also result in damage to
    blood vessels in the body that leads to heart
    attacks and strokes.
  • This damage usually starts before the
    blood sugar starts going up
  • (and you dont feel a thing
  • until your first heart attack.)

More Key Players
  • Pancreas - monitors levels of glucose in blood
    continuously and provides enough insulin to keep
    blood glucose level lt120mg/dL
  • Muscle - the tissue that is best able to burn
    glucose in its cells.
  • Fat stores excess energy, communicates with the
    liver, responds to signals given by insulin
  • Liver - stores and releases sugar, providing
    enough to keep blood glucose level gt60mg/dL.

The Epidemiology of Diabetes in the USA
  • Incidence
  • Type 1 30,000/year
  • Type 2 850,000/year
  • GDM 3-8 of pregnancies

10,000,000 (6,000,000 undetected)
Estimates based on U.S. population of 250 million
Global Epidemic Of Diabetes
  • More than 135 million people worldwide had
    diabetes in 1995 (4.0)
  • 300 million people are expected to have the
    disease by 2025 (5.4)
  • 42 increase in developed countries
  • 170 increase in developing countries
  • Urban dwellers more likely to have the disease
    than rural inhabitants

King, et. al., Diabetes Care, 1998
Age-adjusted prevalence of diagnosed diabetes
among American Indians/Alaska Natives aged 20
years or older, by IHS area, 2001
Age-adjusted based on the 2000 U.S.
population. Source FY01 IHS APC file. Excludes
data from 39 service units (7 of the IHS user
Increase in diabetes prevalence among persons
aged 2059 years, by age U.S. general
population and American Indians/Alaska Natives,
1990 and 1998
Source Mokdad et al. Diabetes Care
200023127883, and Indian Health Service
outpatient data. 1829 years in U.S. general
Prevalence of diagnosed diabetes among children
and young people by age group, 1990-2001
Per 1000
79 increase
68 increase
106 increase
25 increase
Source IHS Diabetes Program Statistics
Mortality Rates in American Indians Alaska
Trends in Indian Health, 1997 Age adjusted rate
per 100,000
Burden of Diabetes in the U.S.
  • Increases the risk of heart attack and stroke by
    24 fold
  • The leading cause of new blindness, end stage
    renal disease, and amputations
  • 193,140 deaths from diabetes a year (7th)
  • Costs 98 billion or more per year

CDC National Diabetes Fact Sheet 1998
  • About 80 percent of people with type 2 diabetes
    are overweight.
  • Type 2 diabetes is often part of a metabolic
    syndrome that includes obesity, elevated blood
    pressure and high levels of blood lipids.
  • Unfortunately, as more children and adolescents
    become overweight, type 2 diabetes is becoming
    more common in young people.

Diabetes Why Me?
  • Its in your genes right?
  • NO.
  • Getting more calories than needed, over a
    healthy weight
  • Physical activity Sedan and screen lifestyle
  • Aging

Diabetes Why Me?
  • Psychosocial and Cultural trauma?
  • What evidence?
  • Other Diseases and conditions
    (e.g. smoking, medications)
  • We dont know everything! (not yet

Why is this happening in Children Adolescents?
  • Born to a mother who had gestational diabetes
  • High birth weight qualified
  • Low birth weight qualified
  • Less physical activity
  • More food, calories that we dont use, calories
    from things like saturated fats
  • Stress and depression?
  • We dont know all the answers

Diabetes in the American Indian community
  • The actual reasons for the increase in type 2
    diabetes remain both elusive and complex our
    work toward a complete understanding of this will
    no doubt continue for some time to come.
    However, several observations belie a simple
    genetic causation. Fifty to sixty years ago,
    type 2 diabetes was nearly nonexistent in
    American Indian populations. Lest we think this
    was merely a problem of poor diagnostic abilities
    or case finding, consider that type 2 diabetes
    prevalence increased 106 in the 15-19 year old
    American Indian/Alaskan Native populations alone
    from 1990-2001

Risk Factors in Children Adolescents
  • Family history of type 2 diabetes in first or
    second degree relative
  • Born to a mother who had gestational diabetes
  • High or low birth weight qualified
  • American Indian, Hispanics, Blacks
  • Hypertension, blood pressure
  • Dyslipidemia, cholesterol and fats in the blood
  • Acanthosis Nigricans
  • Polycystic Ovarian Syndrome

Insulin resistance
Diabetes Research
  • Diabetes Control Complication Trial (DCCT)
  • Type 1 Diabetes, 10 year study
  • Blood glucose control decreases complications

Diabetes Related Complications
  • Cardiovascular Disease
    (Heart attacks and Stroke)
  • Blood Vessel (Peripheral Vascular) Disease
  • Kidney Disease (Nephropathy)
  • Nerve Disease (Neuropathy)
  • Eye Disease (Retinopathy)
  • Dental/Peridontal Disease

Summary of (even more) Recent Research Findings
  • It is even more important to lower cholesterol
    and fats in the blood for patients with diabetes
    in order to prevent heart attacks and stroke
  • Good blood sugar control in pregnancy may reduce
    the risk of complications by 50.
  • Smoking increases your chance of getting diabetes

Type 2 Diabetes and Complications
High Blood Sugar
High Cholesterol
Excess calories and Insulin Resistance
High Blood Pressure
High Blood Levels of Insulin
Reaven GM, Am Heart J 19911211283-1288.
Natural History of Type 2 Diabetes
Environmental factors e.g. nutrition, more
calories than needed, physical inactivity
Onset of diabetes
susceptible physiology
High Sugar High Cholesterol High Blood Pressure
Kidney Eyes Nerves
Blindness Renal failure CHD Amputation
Insulin resistance Hyperinsulinemia Low HDL
FPG gt126 mg/dL CPG gt200 mg/dL
IFG 110-125 mg/dL IGT 140-199 mg/dL
Heart Attacks and Strokes
Foundations of Therapy
  • Education, Education, Education
  • Self management, individual learning styles
  • Simplicity (i.e. avoid complexity!)
  • Nutrition
  • Identify barriers to change
  • Family community support
  • Physical Activity

At least Two Approaches To Fitness
  • Traditional
  • Frequency 3-4 days/wk
  • Intensity 65-85 of maximum heart rate
  • Time Minimum of 20 minutes/session
  • Alternative
  • Physical activity every day.
  • Moderate intensity (brisk walking)
  • Accumulate 30 minutes or more every day

the all-American diet
Oh yeahNow That place was really a greasy
Type 2 Diabetes
  • The most important factor in caring for Type 2
    Diabetes that we can control
  • is our lifestyle.
  • We need to try to live in a way that matches how
    our bodies were made to live.

The Diabetes Prevention Program (DPP)
  • 3,234 participants with impaired glucose
    tolerance (IGT)
  • Average age 51 yrs (range 25-85 yrs)
  • 45 from ethnic/minority groups (171 American
    Indian participants, 5 of the study)

DPP Goals Primary
  • To prevent or slow the development of type 2
    diabetes in persons with impaired glucose
    tolerance (IGT) and other high risk

Lifestyle Intervention
  • Intensive Lifestyle Modification
  • A comprehensive program using a Case Management
    approach with the following specific aims
  • Reduction of fat and calorie intake
  • Physical activity at least 150 minutes per
  • gt 7 loss of body weight

DPP Study Results
  • Participants from the lifestyle group reduced
    their risk of getting type 2 diabetes by 58

DPP Study Results
  • Lifestyle intervention worked very well in
    elderly (gt60 yrs), reducing development of
    diabetes by 71

What do the results of the DPP mean to our
  • Screening for diabetes AND for IGT in AI/AN
  • Create lifestyle programs for diabetes
    prevention case management approach
  • Purchase metformin for diabetes prevention

Type 2 Diabetes Prevention
  • The most important factor in caring for and
    preventing Type 2 Diabetes that we can control is
    our lifestyle.
  • We need to try to live in a way that matches how
    our bodies were made to live.

...youve got to be careful if you dont know
where youre going, because you wont get there.
  • ...when you come to a fork in the road, take it.

Yogi Berra
  • Anybody seen my magic wand?

Sandy Lake School Diabetes Prevention Program
  • The Sandy Lake First Nation School Diabetes
    Prevention Program was created during the 1998
    school year to help students in grades 3 and 4
    learn about and practice healthy eating and
    physical activity behaviours the only known ways
    to prevent diabetes. Developing healthy behaviors
    at a young age should give students the skills
    and motivation to continue these behaviors into
  • The program was designed to address the
    individual, social, and structural levels of
    influence on children's behaviors associated with
    making healthy food choices and physical
  • The 4 components of the Sandy Lake School
    Diabetes Prevention Program include a classroom
    curriculum, family outreach, peer activities, and
    changes in the immediate school and store

Sandy Lake program description
  • COMPONENTDESCRIPTIONClassroom Curriculum
  • 17 lessons on healthy eating and physical
    activity. Focus on the identification of healthy
    foods, skills building, behavior modeling, and
    food preparation.
  • Family
  • Information booths during school parent night
  • Letters sent home on healthy eating and physical
  • Weekly radio show topics
  • Articles in the local newsletter
  • Peer
  • Angel Cooking Video Club (kids cooking club)
  • Diabetes Kids interviews on the Sandy Lake Youth
    Radio show
  • Youth Radio Show, which focuses on healthy
    lifestyles, is now offered in collaboration with
    Sandy Lake's Brighter Futures Project
  • Environment
  • Board of Education Policy of no pop or chips on
    school grounds
  • School breakfast snack program
  • Healthy food promotion in local stores
  • Community-wide SLHDP diabetes prevention

Curriculum description
  • The Sandy Lake First Nation School Diabetes
    Prevention curriculum is a culturally appropriate
    healthy lifestyle curriculum for students in
    grades 3 and 4. The lessons draw upon social
    learning theory and traditional learning styles
    and includes role modeling, taste tests, skills
    building, goal setting, and games.
  • This is a 2 year curriculum which begins in grade
    3 and continues in grade 4. Each of the 17 units
    contains 2 lessons which are taught once a week
    for approximately 30 minutes each. The units of
    the Sandy Lake curriculum address three main
  • making healthy food choices (what are healthy
    food choices, encouragement for students to make
    healthy food choices, and providing students with
    the skills and opportunities to make healthy food
    choices in their daily lives)
  • daily physical activity (what are different kinds
    of physical activities, the health benefits of
    physical activity, and providing students with
    opportunities for doing more daily physical
    activities) and
  • learning about diabetes (basic information on
    diabetes and prevention)
  • Each unit begins with an introductory story from
    an imaginary community called Winding Lake and
    includes two lessons with activities that
    reinforce the concepts of the unit. The stories
    and lessons are sequenced and build upon one
    another. Each unit begins with an introductory
    story from an imaginary community called Winding
    Lake and includes two lessons with activities
    that reinforce the concepts of the unit.
  • www.sandylakediabetes.com

  • Pathways, a research study funded by the National
    Heart, Lung, and Blood Institute, is a
    school-based health promotion program that
    includes physical activity, nutrition, classroom
    curriculum, and family involvement. The primary
    purpose of the Pathways study is to prevent
    obesity among American Indian children by
    promoting increased physical activity and
    healthful eating behaviors.

  • Pathways includes four components. This
    intervention was designed so that all four
    components are to be implemented together. We
    highly recommend that you implement Pathways in
    this way. The four components of Pathways are
  • Curriculum
  • Family
  • Food Service
  • Physical Activity
  • Each of these components and accompanying
    materials has been included for the use of
    interested teachers, school personnel, and health
    promotion practitioners. These materials can be
    viewed and printed.
  • http//hsc.unm.edu/pathways

  • Regular physical activity is associated with a
    healthier, longer life and with a lower risk of
    heart disease, high blood pressure, diabetes,
    obesity, and some cancers. Despite all the
    benefits of physical activity, most school-aged
    children in this country are sedentaryonly one
    in four gets the recommended amount of physical
    activity each day (30 minutes of moderate
    activity or 20 minutes of vigorous activity).
    Lack of physical activity has also contributed to
    a sharp rise in childhood obesity over the last
    20 years. Given that regular physical activity
    will help young people stay healthier, it is
    important to know what strategies work best to
    increase physical activity.
  • A systematic review of published studies,
    conducted on behalf of the Task Force on
    Community Preventive Services by a team of
    experts, found that physical education (PE)
    classes taught in schools that included which
    enhance the length or activity levels, are
    effective in improving both physical activity
    levels and physical fitness among school-aged
    children. Based on this review, the Task Force
    issued a recommendation to implement programs
    that increase the length of, or activity levels
    in, school-based PE classes based on strong
    evidence of effectiveness.

Physical education in schools
  • Background on the Interventions
  • To increase the amount of time students spend
    doing moderate or vigorous activity in PE class,
    these programs seek to change PE curricula by
    making classes longer or having students be more
    active during class.
  • Interventions reviewed included changing the
    activities taught (e.g., substituting soccer for
    softball) or modifying the rules of the game so
    that students are more active (e.g., in softball,
    have the entire team run the bases together when
    the batter makes a base hit). Many interventions
    also included health education.
  • Findings from the Systematic Review
  • In all 14 studies reviewed, students physical
    fitness improved.
  • In 5 studies measuring activity levels during PE
    class, all recorded increases in the 1) number of
    minutes spent in moderate or vigorous physical
    activity, 2) percentage of class time spent in
    moderate or vigorous physical activity, and/or 3)
    intensity level of physical activity during
  • The median estimates from the reviewed studies
    suggest that modifying school PE curricula as
    recommended will result in an 8 increase in
    aerobic fitness among school-aged children.
  • Modifying school PE curricula was effective
    across diverse racial, ethnic, and socioeconomic
    groups, among boys and girls, elementary- and
    high-school students, and in urban and rural
  • In a separate literature review, having students
    attend school PE classes was not found to harm
    academic performance.

Social support
  • A systematic review of published studies,
    conducted on behalf of the Task Force on
    Community Preventive Services by a team of
    experts, found that efforts made in community
    settings to provide social support for increasing
    physically activity are effective. Based on this
    review, the Task Force issued a strong
    recommendation to implement these efforts.
  • Background on the Interventions
  • These interventions focus on changing physical
    activity behavior through building,
    strengthening, and maintaining social networks
    that provide supportive relationships for
    behavior change (e.g., setting up a buddy system,
    making contracts with others to complete
    specified levels of physical activity, or setting
    up walking groups or other groups to provide
    friendship and support).
  • Interventions included in the review involved
    either creating new social networks or working
    within existing networks in a social setting
    outside the family, such as in the workplace.
  • Findings from the Systematic Review
  • In all 9 studies reviewed, social support
    interventions in community settings were
    effective in getting people to be more physically
    active, as measured by various indicators (e.g.,
    blocks walked or flights of stairs climbed daily,
    frequency of attending exercise sessions, or
    minutes spent in physical activity).
  • The median estimates from the reviewed studies
    suggest that social support interventions in
    community settings can result in a 44 increase
    in time spent being physically active and a 20
    increase in the frequency of physical activity.
  • These interventions also improved participants
    fitness levels, lowered their percentage of body
    fat, increased their knowledge about exercise,
    and improved their confidence in their ability to
  • These interventions were effective in various
    settings including communities, worksites, and
    universities, among men and women, adults of
    different ages, and both sedentary people and
    those who were already active.
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