Diabetes as a Disease of Civilization: The Impact of Culture Change on Indigenous Peoples 9783110853148, 9783110134742

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Diabetes as a Disease of Civilization

New Babylon

Studies in the Social Sciences

50

Mouton de Gruyter Berlin · New York

Diabetes as a Disease of Civilization The Impact of Culture Change on Indigenous Peoples

Edited by

Jennie R. Joe Robert S. Young

Mouton de Gruyter Berlin · New York 1994

Mouton de Gruyter (formerly Mouton, The Hague) is a Division of Walter de Gruyter & Co., Berlin.

® Printed on acid-free paper which falls within the guidelines of the ANSI to ensure permanence and durability.

Library of Congress Cataloging-in-Publication

Data

Diabetes as a disease of civilization : the impact of culture change on indigenous peoples / edited by Jennie R. Joe and Robert S. Young . p. c,. — (New Babylon, studies in the social sciences ; 50) Includes bibliographical references and index. ISBN 3-11-013474-8 (acid-free paper) 1. Non-insulin-dependent diabetes — North America. 2. Indians of North America — Diseases. 3. Non-insulin-dependent diabetes — Social aspects. I. Joe, Jennie Rose. II. Young, Robert S., 1942 — III. Series. RA645.D5D493 1993 616.4'62'008987—dc20 93-10649 CIP

Die Deutsche Bibliothek — Cataloging-in-Publication

Data

Diabetes as a disease of civilization : the impact of culture change on indigenous peoples / ed. by Jennie R. Joe ; Robert S. Young. — Berlin ; New York : Mouton de Gruyter, 1993 ISBN 3-11-013474-8 NE: Joe, Jennie R. [Hrsg.]

© Copyright 1993 by Walter de Gruyter & Co., D-10785 Berlin. All rights reserved, including those of translation into foreign languages. No part of this book may be reproduced in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission in writing from the publisher. Typesetting and printing: Arthur Collignon GmbH, Berlin. — Binding: Lüderitz & Bauer, Berlin. — Printed in Germany.

Contents

Jennie R. Joe, Robert S. Young Introduction

1

I. Diabetes prevalence in North America

19

T. Kue Young 1 Diabetes among Canadian Indians and Inuit: An epidemiological overview

21

James D. Brosseau 2 Diabetes and Indians: A clinician's perspective

41

II. Tribal and regional studies

67

James W. Justice 3 The history of diabetes in the Desert People

69

Martin Hickey 4 Many Farms revisited: Evidence of increasing weight and noninsulin dependent diabetes in a Navajo community 129 Benjamin R. Kracht 5

Diabetes among the Kiowa: An ethnohistorical perspective . . .

147

Cynthia D. Schraer 6 Diabetes among the Alaska Natives — The emergence of a chronic disease with changing life-styles 169 Neil Murphy 1 Diabetes and pregnancy among Alaska Natives: Prevalence and sociocultural aspects 195

VI

Contents

Emoke Szathmäry 8 Factors that influence the onset of diabetes in Dogrib Indians of the Canadian Northwest Territories 229 III. Cultural issues and health beliefs

269

Lillian Tom-Orme 9 Traditional beliefs and attitudes about diabetes among Navajos and Utes 271 Linda C. Garro, Gretchen Ch. Lang 10 Explanations of diabetes: Anishinaabe and Dakota deliberate upon a new illness 293 Jennie R. Joe 11 Perceptions of diabetes by Indian adolescents

329

Veronica Evaneshko 12 Presenting complaints in a Navajo Indian diabetic population

357

IV. Culture and diet

379

M. Yvonne Jackson 13 Diet, culture, and diabetes

381

Cynthia J. Smith 14

Food habit and cultural changes among the Pima Indians . . .

407

Wendy Wolfe 15 Dietary change among the Navajo: Implications for diabetes

435

V. Medical perspectives

451

Martin Hickey 16 Cultural barriers to delivering health care: The non-Indian provider perspective 453 Dianna Garcia-Smith 17 The Gila River Diabetes Prevention Model

471

Contents

VII

Robert Wilson, Carol Graham, Karmen G. Booth, Dorothy Gohdes 18 Community approaches to diabetes prevention

495

Contributors

505

Index of subjects

509

Introduction Jennie R. Joe, Robert S. Young

Because modern technology and medical advances have dramatically lowered the number of deaths world-wide due to communicable diseases, the attention of many international health leaders has in recent years turned to the alarming mortality and morbidity statistics associated with a number of noncommunicable diseases such as diabetes. Type II diabetes, or non-insulin dependent diabetes (NIDDM), is devastating the health and contributing to the early death of many indigenous peoples all over the world. Referencing a recent World Health Organization report, Grabauskas (1988) notes the following prevalence rates for NIDDM among young adults aged 20 and older: Fiji Indians, 13.5 percent; Naurau 24.3 percent; and Pima Indians (aged 25 and older), 25.5 percent. The prevalence rates noted here represent two to three times the rates (6.9 percent) in the general population of the United States for those between the ages of 20 and 74. High prevalence rates of NIDDM have also been observed for Australian Aborigines (O'Dea 1984; Cameron, Moffitt and Williams 1986); the Maoris of New Zealand (Prior and Tasman-Jones 1981); Polynesians and Micronesians (Zimmet et al. 1990); Mexican Americans (Gardener et al. 1984); and various ethnic groups in India (Gupta, Dave, and Joshi 1978). Because type II diabetes has affected greater numbers of people from non-European societies who have adapted or have become acculturated to western culture, diabetes for these people has been described by a number of researchers as the "price" of civilization (Prior 1971; Eaton 1977; Fatani, Mira, and El-Zebier 1987; Hagey and Bulles 1983; O'Dea, Spargo, and Akerman 1980; Stern etal. 1983; Urdaneta and Krehbiel 1989; West 1974). In the United States, type II diabetes has generally been associated with the Pima Indians, a tribe in south central Arizona whose adult population is known to have the world's highest rate of diabetes, i.e., over 50 percent of the adult population over age 35 are afflicted with the disease (Knowler et al. 1990). Prior to World War II, diabetes appears to have been rare in this tribe (Joslin 1940). Since that time the number of

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Jennie R. Joe, Robert S. Young

Pima Indians diagnosed and who have succumbed to the secondary complications of the disease has continued to rise. In the meantime, diabetes is also becoming a major health problem for other tribes as prevalence rates are steadily increasing among American Indians throughout the United States and Canada (Young et al. 1987; Gohdes 1986). The purpose of this book is to examine the changes that have occurred in the recent history of American and Canadian natives peoples in an effort to elucidate those environmental and sociocultural factors that have contributed to these extremely high prevalence rates of type II diabetes. The objective of the authors of the various studies is not only to draw attention to this fast growing inter-tribal epidemic, but also to present the experiences of a number of tribes that can serve as important bench marks for other indigenous populations throughout the world who, as a result of drastic cultural and lifestyle changes, may face a similar prospect with type II diabetes.

1. Diabetes: the disease process There are three primary forms of diabetes millitus: type I diabetes, type II diabetes, and gestational diabetes. The three forms of diabetes are similar in that they are characterized by hyperglycemia and by secondary complications that affect the vascular system. In type I diabetes, however, the hyperglycemia is the consequence of Beta cell destruction in the pancreas that results in a total or almost total lack of insulin. Patients with type I diabetes require exogenous insulin for maintenance of health; hence the medical description of the disorder — "insulin dependent diabetes mellitus" (IDDM). In type II diabetes (also known as "maturity onset diabetes"), which is the most frequent form of the disease being detected in indigenous populations throughout the world, the beta cells of the pancreas continue to produce insulin, and in fact in addition to being hyperglycemic, the patient may have hyperinsulinemia, i. e., an excess of insulin in the blood stream. The disease is characterized by "insulin resistance", i. e., although insulin is present in the blood stream, a post receptor defect in the cells inhibits the insulin-cell receptor interaction that facilitates cellular uptake of glucose (Bogardus 1987). The glucose accumulates in the blood stream, i. e., the person becomes "hyperglycemic", and the body's cells become energy starved. Fasting blood glucose levels of 90-140 mg per dl indicate

Introduction

3

impaired glucose tolerance. A fasting blood glucose level of 140 ml per dl or greater on two occasions is diagnostic of diabetes as is a random plasma glucose level of 200 mg per dl or more in conjunction with symptoms of diabetes (See Chapter 2). Type II diabetics are generally obese (120 + percent normal body weight). Loss of weight, appropriate dietary modifications, and hyperglycemic agents (for some patients) improve glucose tolerance. Insulin is not required for survival, and therefore the disease is medically described as "noninsulin dependent diabetes mellitus" (NIDDM). However, prolonged exposure of the pancreas to elevated blood glucose levels may result in increasing beta cell failure or exhaustion (Knowler et al. 1990), and the patient with type II diabetes (NIDDM) may eventually become dependent on exogenous sources of insulin for survival. Although less life threatening than type I diabetes, the consequences of type II diabetes are quite serious, especially since the disease can be present for years and not detected until the patient has developed the secondary complications characteristic of the disease. The third form of diabetes, gestational diabetes, is currently being detected in pregnant women from many of the tribes discussed in this book. Gestational diabetes is characterized by hyperglycemia during pregnancy that occurs in women who may not be hyperglycemic prior to pregnancy. If the elevated blood glucose levels during pregnancy are not reduced to normal levels, the unborn fetus is at risk for birth defects and fetal demise, and the mother is at risk for ketoacidosis, pyelonephritis, and toxemia. After delivery, the post-partum mother may return to a normoglycemic state.

1.1. Secondary complications Morbidity and mortality rates associated with both type I and type II diabetes manifest as secondary illnesses and complications, including: (1) cataracts, glaucoma, and the diabetic retinopathy leading to impaired vision and blindness; (2) diabetic nephropathy, which leads to end-stage renal disease (ESRD); (3) increased frequency of cardiovascular associated diseaes including coronary artery disease, stroke, hypertension, and lower limb vascular disease that may result in gangrene and lower limb amputation; (4) increased susceptibility to infection; (5) increased rates of periodontal disease; (6) increased rates of perinatal mortality and congenital abnormalities; and (7) neuropathy (Rhoades 1986; Bennett 1986).

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Jennie R. Joe, Robert S. Young

Because of these secondary complications, diabetes is a costly disease not only in terms of medical care costs but also in terms of human cost. Statistics complied by the National Institute of Health (NIH) for NIDDM patients, all races, reveal that approximately 20 percent have developed kidney disease 15 years after diagnosis of diabetes; 45 percent develop cardiovascular related diseases (coronary heart disease and ischemic heart disease) 20 years after diagnosis; and 50 percent suffer from hypertension (Sievers and Fisher 1985). Strokes occur two to six times as frequently in diabetics as in non-diabetics; peripheral vascular disease is present in 45 percent of patients after 20 years; 40-45 percent of all non-traumatic amputations are diabetes related, and length of survival after amputation for 40-70 percent of the patients all races is less than five years (IHS Factsheet 1989). Approximately 22 percent report visual impairment; 12 percent report cataracts; 11 percent report glaucoma (2-3 times the rates for the general population); and 5 percent report severe visual impairment (Sievers and Fisher 1985). Morbidity rates are even higher for American Indians. Approximately 50 percent of the American Indian patients with ESRD have diabetes, and the renal failure rate for Indians with diabetes is 3.5 times the rate for Caucasians (Hoffman and Haskell 1984; Rhoades 1986). For example, in 1986 there were 30 Pima Indian patients with ESRD on dialysis at the Sacaton hospital on the Gila River Indian Reservation; in 1989, that number had increased to 65 on dialysis and an additional 25 with ESRD. Ninety-five percent of the Pima patients on dialysis have diabetes associated end stage renal disease (See Chapter 17 in this book). Nationally, the Indian Health Service (IHS) Diabetes Control Program reports that between 1982 and 1983, diabetes was the second most frequent reason for an outpatient visit for Indian patients (15 years and older) at IHS facilities (Gohdes 1986). According to Rhoades (1986), 46.8 percent of Pima Indians suffering from diabetes for ten years or more had some form of retinopathy, and 29 percent suffering from ischemic heart disease also had diabetes listed as a discharge diagnosis. In the Tucson and Phoenix IHS regional areas, the amputation rates attributable to secondary complications from diabetes are 24.10 and 20.20 respectively per 1000 diabetics, compared with 5.97 per 1000 diabetics for the U.S., all races (IHS Factsheet 1989).

Introduction

5

2. Diabetes and cultural change: The price of civilization Unfortunately, despite vast technical and other biomedical advances, the etiology of diabetes remains elusive and the biochemistry of the disease process continues to be one of the most vexing research problems confronting modern medicine. To account for the rapid rise in the revalence of type II diabetes in some populations, Neel (1962) postulated the existence of a "thrifty gene". According to Neel's theory, early peoples existed through feast-famine cycles, and the "thrifty gene" would have had selective advantage because it increases the ability of the body to store fats (energy) that could later be metabolized during periods of food shortage. According to Neel (1962), the thrifty gene becomes a detrimental trait given a constant food supply, and may lead to obesity and ultimately diabetes. In a study of obesity among the Pima Indians, Knowler et al. (1983) suggest that the "thrifty gene" may enhance the ability of insulin to maintain fat stores in spite of resistance to glucose utilization. The "thrifty gene" as defined by Neel (1962) is not an "inborn error of metabolism" such as phenylketonuria or galactosemia, but describes a "genetic predisposition", i. e., environmental factors play the significant role in the expression of the gene or genes that contribute either directly or indirectly to the disease process. This is especially true for type II diabetes. Although a genetic predisposition may be a factor in the onset of the type II diabetes epidemic that now exists in "Indian country", the fact that prior to World War II diabetes was rare or non-existent in most Indian tribes suggests that certain environmental and sociocultural factors have played a major part in the manifestation of the disease in such epidemic numbers. For the past three centuries, extensive (and sometimes forcible) sociocultural changes have impacted on the lifestyle and culture of Native Americans. Each cycle of experience with non-Indians in each historical period has left an imprint on the health picture of American Indians. The path to civilization that Indian tribes were forced to take was set in motion by a rapid succession of events that accompanied episodes of depopulation and colonization. The depopulation process for American Indians began with European contact — a contact that brought devastating communicable diseases and widespread warfare. Communicable diseases such as smallpox decimated many tribes because most of these peoples had no immunity to these new infectious diseases. Over time, many of the native popuations, now reduced in numbers and unable to protect their land and their resources, found themselves

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Jennie R. Joe, Robert S. Young

not only dispossessed but also facing forced removal at gunpoint to unfamiliar and unproductive lands called reservations. Once resettled, most were left without tools to work the land and with no access to adequate food sources. The displacement and lack of food resources undoubtedly also contributed to the high mortality of the Indian people on the resettlement lands. In addition to the economic, social, and biological consequences of the conquest, there were also undetermined long-term psychological consequences, psychological scars that left many once proud Indian nations with a sense of hopelessness and powerlessness, and in most instances, a lifestyle colored by chronic, abject poverty. Unfortunately, despite the passage of time, healing has not occurred; instead, some of the long-term psychological consequences of many of these earlier traumas continue to plague the present generations of Indian people. In spite of government sponsored programs to improve the quality of life for Indian people and various other symbolic and/or political efforts pushing them towards assimilation into mainstream society, the results have not always rewarded native people with a better life. Today, it is not unusual to find tribal leaders attributing many of the social, economic, and health-related problems confronting native peoples to the rapid cultural changes that have been imposed on them. Included in this perspective is the cycle of poverty that is intertwined with the almost total dependency on federal and other governmental institutions — a powerlessness and dependency that to many has indirectly fostered such problems as alcoholism, suicide, homicide, low self-esteem, and the emergence of "new" health problems such as hypertension, cancer, and diabetes. Campbell (1989: 1) characterizes the medical history of the American Indians as "unnatural" because the health status of this population has been drastically altered under the hegemony of the European contact and continues to be shaped and re-shaped by subsequent interface with nonIndian institutions and the process of colonization. As a conquered people, the potential for survival and, in essence, the quality of life of Native Americans has become greatly dependent on the policies and generosity of the U.S. government. Thus the extent to which such colonized groups do or do not enjoy "good" health and/or have access to adequate medical care is determined by agencies and policymakers outside their society. Although the colonized Indian populations were rarely passive in the interaction with the institutions of colonization, the policies forcing civilization and assimilation did alter and influence the values, religion, and

Introduction

7

health resources for each generation after the European contact. Where some of these influences were minimal or not readily adopted, there are a number of Indian communities in the United States that still identify themselves as maintaining their "traditional" culture. Thus despite the incorporation of various European material goods and other conveniences of modern society, there are Native Americans who still speak their tribal language and utilize their indigenous health resources such as medicine men to aid them during times of illness. In addition to this segment of the Indian population, there are also a significant number who declare themselves to be "bicultural", that is, they have one foot in EuroAmerican culture and one foot in their tribal culture. This mix of cultural niches exists in most tribes, and therefore cultural or tribal health beliefs remain important variables, especially for those who must live with a chronic degenerative disease such as diabetes, which has not only an unclear etiology but is also not amenable to the miracles of modern medicine. According to Baer, Singer, and Johnson (1986), type II diabetes is becoming a major problem in societies and cultures, such as those of the American Indians, in which health status is influenced or generally shaped by outside socio-cultural, political, and economic forces. Type II diabetes, therefore, can be perceived as a disease of "modernization" and "civilization". For the American Indian tribes discussed in this book, civilization and modernization have brought about drastic cultural and lifestyle changes that carry a heavy burden in disease and suffering. Acutely aware of this burden, Urdaneta and Krehbiel (1989: 221), two medical anthropologists, conclude that one impediment to understanding diabetes has been the narrow focus taken by most researchers because diabetes does not easily "yield to the fine, precise, dissecting lens of modern medical science". Urdaneta and Krehbiel (1989) have called for a bicultural view that examines all determinants of the disease, i.e., environmental and sociocultural as well as biological. Only by understanding what these determinants are and how they have contributed to the diabetes epidemic will we be able to begin to control and eventually eliminate this most insidious and costly of modern epidemics.

3. Diabetes, cultural change and Native Americans The premise of this book is that diabetes is a new disease among Indian peoples and is the consequence of drastic lifestyle and cultural changes

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Jennie R. Joe, Robert S. Young

that have occurred since World War II. To substantiate this premise, the editors have sought to include studies about the relationship between cultural and lifestyle changes and diabetes from a number of tribes and regions in both the United States and Canada. Southwestern tribes in the United States that have been the subjects of study for this volume include the Pima, the Tohono O'odham, the Navajo, the Utes, and the Zuni. Plains Indian tribes that are discussed in the book include the Iowa, Kiowa Apache, Comanche, Sioux, Mandan, Hidatsa, Winnebago, Chippewa, Arikara, Omaha, and Sauk and Fox. Two chapters provide valuable information about the native peoples of Alaska, i. e., the Inuit, Eskimos, Athabascans, and Northwest Coastal tribes. The book also includes chapters about the problem of diabetes among the native peoples of Canada. In addition to a chapter discussing the epidemiology of diabetes in Canadian Indians, the book includes chapters with in-depth discussions of the relationship between health and culture for two Canadian tribes, the Dogrib and the Anishinaabeg. To illustrate the premise about the relationship between cultural and lifestyle changes and the rising prevalence rate of diabetes among native peoples, the editors have divided the book into the following five sections: (1) "Diabetes Prevalence in North America", which includes two chapters that review the epidemiology of diabetes in Canada and the United States; (2) "Tribal and Regional Studies", which includes chapters that look at the relationship of lifestyle change in terms of specific tribes and regions, and how these changes appear to have contributed to the onset of diabetes; (3) "Cultural Issues and Health Beliefs", which includes a number of studies that discuss the impact of culture on health beliefs; (4) "Culture and Diet", which includes studies analyzing the cultural meanings of food and the impact of diet change on the increasing prevalence of diabetes among Indian people; about diabetes and about food; and (5) "Medical Perspectives", which includes three chapters discussing the impact of culture in disseminating health care to patients with diabetes.

3.1. Diabetes prevalence in North America The opening section of the book comprises two chapters discussing the prevalence rates of diabetes among Indian peoples in the United States and Canada respectively. In Chapter 1 ("Diabetes among Canadian Indians and Inuit: An epidemiological picture"), the author, T. Kue Young, presents an overview and history of diabetes among the Canadian native peoples and includes

Introduction

9

recent statistical data about the prevalence of diabetes in this population native. According to a recent study (Young etal. 1987), there are 5324 cases of diabetes among native peoples in Canada. In the present chapter, the author notes that the highest rates of diabetes among native peoples occur in urban centers and in southern latitudes, and the lowest rates occur among peoples living in remote areas and in northern latitudes. The implications from this data are that contact between indigenous peoples and non-Indian cultures may lead to lifestyle changes that correlate with a rise in diabetes prevalence rates. The diabetes problem in native peoples in Canada is a decade or more behind the epidemic now occurring in the United States. According to an IHS Factsheet (1989), there are approximately 72,000 Indians with diabetes in the United States, and as noted above, Gohdes (1986) has stated that most tribes in the United States appear to have increasing rates of diabetes, regardless of cultural or linguistic groupings. The second chapter ("Diabetes and Indians: A clinician's perspective") presents a brief discussion of prevalence rates for diabetes in American Indians across the country by IHS region. The author, James Brosseau, then focuses on the Aberdeen region (Iowa, Nebraska, South Dakota, North Dakota), which includes a number of the northern plains tribes (Mandan, Sioux, Winnebago, Hidatsa, Arikara, Sauk and Fox) among whom the mortality rates from diabetes are the highest in the United States. The author concludes with a brief discussion of some of the sociocultural factors that have contributed to the epidemic of diabetes among these peoples. 3.2. Tribal and regional studies This section of the book focuses on the lifestyle and culture of several tribes in various locations around the United States and Canada who have been studied in order to eludicate the connections between diabetes and culture change. Chapter 3 ("The history of diabetes mellitus in the Desert People") presents a detailed discussion of the history of diabetes among the Tohono O'odham (formerly Papago), whom the author, James Justice, describes as "cousins" (culturally and linguistically) of the Pima. The author reviews medical data from the late nineteenth century as he traces the diabetes epidemic among the Tohono O'odham, which began in the post World War II period, and compares the prevalence rates of diabetes in the Tohono O'odham with the prevalence rates in the Pima. The author, who

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Jennie R. Joe, Robert S. Young

was an IHS physician working with the Tohono O'odham during the 1970s and 1980s, traces the evolution of obesity and diabetes in the Tohono O'odham beginning in the 1950s and discusses his research and that of others, which demonstrates that the rates of diabetes among the Tohono O'odham are equal to rates among the Pirnas. In .discussing the impact of cultural change on Tohono O'odham, the author postulates four stages in the development of diabetes among indigenous peoples as they make the transition from a feast-famine food cycle to one of constant food supply and, as a result of the introduction of technology, change from an active to a relatively sedentary lifestyle. For a number of years, some researchers believed that Athabascan peoples such as the Navajos were not as susceptible to diabetes as other Indian peoples because prevalence rates in these tribes were extremely low. Among the Navajo of the community of Many Farms during the 1950s, the Cornell University Medical Team, which provided care and conducted physical exams of the majority of the members of this community, found very few cases of type II diabetes among the residents. In 1988, Teri Hall, Martin Hickey, and Theresa B. Young, the authors of Chapter 4 ("Many Farms revisited: Evidence of increasing weight and non-insulin dependent diabetes in a Navajo community") returned to the Many Farms community to collect physical data for comparison with the earlier data obtained by the Cornell University medical team. The authors found that members of the community are now ten times more likely to have diabetes than they were thirty years ago, and they present an analysis of some of the changes in the lifestyle of community members in the last thirty years that may account for the rising prevalence rate of diabetes. The prevalence of diabetes among the Plains Indian tribes continues to increase at an alarming rate. In Chapter 5 ("Diabetes among the Kiowa: An ethnohistorical perspective"), Ben Kracht presents an analysis of the changes in lifestyle of the Kiowas, Comanches, and Kiowa Apaches residing in the KCA communities in Oklahoma. The author begins with a discussion of the consequences of the transition from a nomadic huntergatherer lifestyle to the settled pattern of the reservation, and then analyzes how the resulting lifestyle changes have contributed to the rising prevalence of diabetes among the Kiowa. The study concludes with a discussion of how some Kiowa people cope with the problem of diabetes. In contrast to the increasing prevalence of diabetes among Indian tribes in the Southwest and on the Plains, where diabetes has reached epidemic proportions in the adult population, the disease has only since

Introduction

11

the 1970s become a serious problem among the Alaska natives. In Chapter 6 ("Diabetes among Alaska Natives — The emergence of a chronic disease with changing life styles"), Cynthia Schraer discusses the rising prevalence of diabetes in the Eskimo, Aleut, Athabascan, and coastal Indians in Alaska, noting that those regions that have historically had the longest contact with Euro-American influences have the highest prevalence rates. In Chapter 7 ("Diabetes and pregnancy among Alaska Natives: Prevalence and sociocultural aspects"), Neil Murphy presents research indicating a high prevalence rate of gestational diabetes in Yup'ik Eskimos and discusses some of the sociocultural considerations that may account for this condition. This section concludes with Chapter 8 ("The factors that influence the onset of diabetes in Indians of the Northwest Territories"), which provides information on differences in acculturation between Dogrib communities in northern Canada and the impact of this acculturation on glucose tolerance and diabetes prevalence. The author, Emoke Szathmary, suggests the variables and the genetic mechanisms that should be examined in an indigenous population that is experiencing increasing cultural pressures and lifestyle changes. 3.3. Cultural issues and health beliefs While all the chapters in the book discuss diabetes within the context of cultural change, the chapters in this section focus on specific cultural issues and health beliefs that impact directly on diabetes diagnosis, management, and care. The importance of understanding cultural attitudes about health and diet, particularly with diabetes, cannot be overstated. The design of successful education and prevention programs as well as the delivery of optimum health care is dependent on understanding the client's frame of reference. This frame of reference includes cultural beliefs and attitudes that impact directly on the health and behavior of the client. The cultures and the belief systems of the native peoples of Canada and the United States differ in varying degrees from that of mainstream culture as well as from one another, and these differences have historically been the source of problems in the dissemination of health care. For example, when faced with a health problem with an "unknown" cause, some Indian patients turn to culturally determined explanations of illness to aid them in either accepting or coping with an illness. Native American beliefs about the etiology and treatment of illness are therefore

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Jennie R. Joe, Robert S. Young

important determinants in how they view the disease and how they respond to services offered by health care providers. The more traditional (or the less acculturated) an Indian patient is in their world view and lifestyle, the more likely he or she will seek explanations for their disease within their own cultural frame of reference. They may, or example, attribute diabetes to various acts of witchcraft such as object intrusion, spells or actions of malevolent spirits, or breech of tribal taboo. Therefore, in contrast to the mainstream biomedical doctrine of specific etiology, disease causality for many Indian patients can be attributed to an array of natural, social, or supernatural causes. When Indian patients with diabetes seek help from tribal healers or practitioners, they often seek the answer to why they were stricken with diabetes. The in-culture interventions that respond to "why" a misfortune or illness has befallen the patient may call for a series of elaborate ceremonies in some tribes, while in others the intervention may call for the use of specially prepared sacred herbs. A cure, therefore, is not always the prime objective, but the ceremonies often are seen as making amends with the source that brought on the illness in order to prevent or lessen the consequences of the disease and/or to enhance the healing power of the remedies prescribed. An understanding of the health beliefs of people receiving care is essential if that care is to be acceptable, and is particularly important for a disease such as diabetes that requires such major modifications in lifestyle. Four studies about health beliefs are included in this book. In Chapter 9 ("Traditional beliefs and attitudes about diabetes among Navajos and Utes"), Lillian Tom Orme presents a comparison of the beliefs about diabetes of people from two communities, one Ute and the other Navajo, and in Chapter 10 ("Explanations of diabetes: Anishinaabeg and Dakota deliberate upon a new illness"), Linda Garro and Gretchen Lang discuss the beliefs of the Anishinaabeg (Ojibwa) of Canada and the Dakota Sioux. The authors of both chapters explore beliefs about the perceived causes and treatment of diabetes, perceptions of western health care, and the role of traditional Indian medicine in the treatment of the disease. It is significant that respondents in both Chapters 9 and 10 express the belief that diabetes is a new disease that is the result of changes brought about by the white man's disruption of the "balance" or "harmony" in the world. The success of education and prevention programs depends on whether the programs have been designed to be compatible with both the knowledge and cultural background of the participants. Chapter 11 ("Percep-

Introduction

13

tions of diabetes by Indian adolescents") presents a unique study of the health beliefs about diabetes of a group of adolescents from four different southwestern tribes: Yaqui, Pima, Apache, and Navajo. The author, Jennie Joe, finds that most of the participants in the study have a very poor knowledge base about diabetes in spite of family experience and/or tribal experience with the disease. For example, most of the subjects in the study did not associate obesity or secondary complications with the disease process. The author thus raises some interesting questions about the cultural context of the design of current educational and prevention efforts among tribal groups who have a high prevalence rate of diabetes. Because of this very high rate of diabetes in these southwestern tribes, the author also suggests that education and primary prevention programs be introduced into the curriculum in reservation schools in a manner similar to the introduction of substance abuse prevention programs. The final chapter in this section is a discussion of a neglected area of health beliefs, the problem of symptom presentation. In Chapter 12 ("Presenting complaints in a Navajo Indian diabetic population"), Veronica Evaneshko discusses the nature of symptom presentation and the differences in perception between Indians and non-Indians about the physical symptoms of illness. Because most Indian peoples do not have the same set of expectations about health as do non-Indians, they frequently ignore symptoms or attribute them to other causes (e.g., aging) rather than consult a physician. Thus in communities that lack screening programs, diabetes is often diagnosed as a result of secondary complications such as gingivitis. The author presents an analysis of symptom presentation among Navajos and discusses some of the implications of this research in screening for diabetes and providing care to patients. 3.4. Culture and diet A diet consisting of refined carbohydrates and high caloric content has been implicated as a causal factor in obesity and ultimately diabetes among native peoples. Thus the subject of diet and its cultural implications are a significant focal point for any discussion about diabetes in native peoples. Although most of the chapters in the book mention diet as a contributing factor to the onset of type II diabetes, three of the chapters focus specifically on the impact of lifestyle changes on dietary habits. In Chapter 13 ("Diet, culture, and diabetes"), Yvonne Jackson reviews what is known about dietary changes among native peoples in North

14

Jennie R. Joe, Robert S. Young

American from pre-European contact to the present. The author discusses dietary changes and related diseases based on studies of several tribal groups and presents a history of the commodity foods program as well as a discussion of nutrient and energy intake. Certainly the single most studied tribe afflicted with diabetes has been the Pima Indians in south central Arizona. Chapter 14 ("Food habit and cultural changes among the Pima Indians") presents a detailed history and analysis of food habits and dietary changes among the Pima. The authors present a brief ethnohistory of the Pirnas and a detailed discussion of their ethnic foods. The study also compares the dietary intake of the Pimas as determined in a 1968 study with their dietary intake in 1988 as determined by the authors from a similar study cohort. The authors note that during the last twenty years, which has seen an increasing prevalence rate for type II diabetes among the Pimas, there has been a drastic reduction in use of native indigenous foods as well as a marked decrease in physical activity. Chapter 15 ("Dietary change among the Navajo") presents a similar history of changes in dietary patterns among the Navajo. The author, Wendy Wolfe, presents research showing how diet and lifestyle among the Navajos have changed gradually over the past 100 years, thus accounting for the increasing prevalence of obesity and diabetes within the Navajo population. 3.5. Medical perspectives The final section of this book is devoted to articles that discuss the role of culture as a factor in the dissemination of health care. Because diabetes is "new" to many native peoples, the etiology, treatment, and prognosis are not always clearly understood, thus making prevention and/or compliance with treatment regimens difficult and sometimes impossible. This situation is often troublesome for both the patients and the health care providers. An analysis of some of these problems as well as possible solutions is the subject of the three chapters in this section. Chapter 16 ("Cultural barriers to delivering health care: The nonIndian provider perspective") presents the perceptions of two physicians with extensive experience working with Indian patients. The authors, Janette Carter and Martin Hickey, discuss the impact of cultural differences on the patient-provider relationship. They discuss the possible differences in the frames of reference between the Native American patient and the provider and the impact of these differences in the dissemination

Introduction

15

of health care. The authors stress the need for the health care provider to understand not only the frame of reference of the patient, but also his/her own cultural background in order to communicate effectively, to provide treatment that is practical given the economic and geographic situation of the patient, and to facilitate compliance with treatment recommendations. Indeed, one of the most serious problems facing the medical practitioner is the poor level of compliance with treatment recommendations. The author of Chapter 17 ("The Gila River Diabetes Prevention Model") states that many providers fail to recognize that for most Indian clients, it is the treatment, not the disease itself, that is perceived as the problem. To meet the needs of their clients and to attempt to remedy the problem of compliance, the Gila River Indian tribe is currently implementing for the Pima Indians an innovative program called the Diabetes Prevention Model (DPM). Dianna Garcia-Smith, administrator of the program and author of this chapter, states that the basis of the DPM is the recognition that diabetes is "not simply a medical problem, but a complex lifestyle and health care delivery system issue". The Diabetes Prevention Model (DPM) program incorporates the traditional ways of the Pirnas into a primary, secondary, and tertiary prevention program based on an approach that the author describes as combining managed care with differentiated practice concepts. The health care providers most likely to be involved in the treatment of an Indian patient with diabetes in the clinics and hospitals are those affiliated with the federal Indian Health Service (IHS). The IHS is the primary health care provider on most Indian reservations in the United States and is part of the governmental structure under the U.S. Public Health Service in the Department of Health and Human Services. Prior to 1955, the IHS was part of the services provided by another federal agency — the Bureau of Indian Affairs (BIA) within the Department of Interior. The IHS provides health care, free of charge, to Indian patients who come into the IHS facilities and who are recognized by their Indian communities and/or who are enrolled members of federally recognized tribes. As a federal agency, the IHS has the responsibility to develop and operate a broad spectrum of preventive, curative, rehabilitative, and environmental services for Indian people. The overall scope of the health programs provided by the IHS, however, is dependent on the amount of money allocated by the U.S. Congress each year. As a result of special legislation, IHS has also been mandated to assist those Indian tribes with

16

Jennie R. Joe, Robert S. Young

the capability to contract and manage their own health programs. Periodically, major health initiatives have also been funded by Congress. Diabetes control programs, for example, have been one of these initiatives. Since 1979, the Indian Health Service has implemented a number of diabetes prevention and education programs aimed at primary and secondary prevention. Chapter 18, the final chapter in the book, briefly discusses three of these programs: the running programs at Zuni in New Mexico and at the Penobscot reservation in Maine, and the St. Peter's Program of dietary education for Pima youngsters of the Gila River Indian Reservation. The success of these primary prevention programs holds promise for eventually halting the increase in the prevalence of type II diabetes among Indian peoples. What can be learned from the experience of Indian peoples with diabetes? Type II diabetes among Indian peoples is perhaps unique as a health condition because its onset correlates with drastic changes in lifestyle and culture as a result of the influence of mainstream EuroAmerican culture. A similar situation of drastic cultural and lifestyle change exists for other indigenous populations throughout the world. The lessons to be derived from the Indian experience are clear: changes in lifestyle and culture may bring a heavy burden in disease, suffering, and despair. Only by the early identification of other populations at risk for the development of diabetes and by a thorough understanding the impact of cultural differences on lifestyle can we begin to develop the kinds of education and prevention programs that may prevent type II diabetes from becoming an epidemic among those third world indigenous populations not yet afflicted. References Baer, Η. Μ., H. Singer, and J. H. Johnson 1986 Towards a critical medical anthropology. Social Science and Medicine 23: 95-98. Bennett, Peter H. 1986 Statement before the Select Committee on Indian Affairs, United States Senate, April 15, 1986. Bogardus, Clifton 1987 Skeletal muscle and insulin action in vivo in man. Current Concepts. Kalamazoo, MI: Upjohn Co. Cameron, W. I., P. Moffat, and D. R. R. Wiliams 1986 Diabetes mellitus in the Australian Aborigines of Bourke, New South Wales. Diabetes Research and Clinical Practice 2: 307-314.

Introduction

17

Campbell, G. 1989 The changing dimension of Native American health: A critical understanding of contemporary Native American health issues. American Indian Culture and Research Journal 13 (4): 1-20. Eaton, C. 1977 Diabetes, culture change, and acculturation: A bicultural analysis. Medical Anthropology 1: 41-63. Fatani, H. H., S. A. Mira, and A. G. El-Zebier 1987 Prevalence of diabetes mellitus in rural Saudi Arabia. Diabetes Care 10:180-183. Gardner, L. I., M. P. Stern, S. M. Haffner, et al. 1984 Prevalence of diabetes in Mexican Americans in relationship to percent of the gene pool derived from Native American sources. Diabetes 33: 86-92. Gohdes, D. 1986 Diabetes in American Indians: A growing problem. Diabetes Care 9 (6): 609-613. Grabauskas, V. J. 1988 Glucose intolerance as contributing to noncommunicable disease morbidity and mortality. Diabetes Care 11 (3): 253-257. Gupta, O. P., S. H. Dave, and Μ. H. Joshi 1978 Prevalence of diabetes in India. In: R. Levine and R. Luft (eds.), Advances in Metabolic Disorders. Vol. 6 (pp. 13-28). New York: Academic Press. Hagey, R. and E. Bulles 1983 Drumming and dancing: A new rhythm in nursing care. The Canadian Nurse 19 (4): 28-31. Hoffman, Β. H., and A. J. Haskell 1984 The Papago Indians: Historical, social, and medical perspectives. Mt. Sinai Journal of Medicine 6: 707-713. IHS Factsheet. 1989 These factsheets were given to participants at the IHS-NIH joint conference, "Diabetes in American Indians and Alaska Natives" held at Mesa, AZ, Nov. 7-10, 1989. Joslin, E. P. 1940 The universality of diabetes. Journal of the American Medical Association 115: 2033-2038. Knowler, W. C., Pettitt, D. J., Bennett, P. H., and R. C. Williams 1983 Diabetes mellitus in the Pima Indians: Genetic and evolutionary considerations. American Journal of Physical Anthropology 62: 107-114. Knowler, W. C., D. J. Pettitt, Mohammed F. Saad, and Peter H. Bennett 1990 Diabetes mellitus in the Pima Indians: Incidence, risk factors and pathogenesis. Diabetes/Metabolism Reviews 6 (l):l-27.

18

Jennie R. Joe, Robert S. Young

Neel, J. V. 1962 Diabetes Mellitus: A "thrifty" genotype rendered detrimental by "progress"? American Journal of Human Genetics 14: 353-362. O'Dea, K. 1984 Marked improvements in carbohydrates and lipid metabolism in diabetic Australian Aborigines after temporary revisions to traditional lifestyle. Diabetes 33: 596-603. Ο Dea, K., R. M. Spargo and K. Akerman 1980 Some studies of the relationship between urban living and diabetes in a group of Australian Aborigines. Medical Anthropology 4:1-20. Prior, I. A. M. 1971 The price of civilization. Nutrition Today 6: 2-11. Prior, I. A. M. and C. Tasman-Jones 1981 New Zealand Maori and Pacific Polynesians. In: H. C. Trowell and D. D. Bunkitt (eds.), Western Diseases: Their Emergence and Prevention, 227-267. London: Edward Arnold Publishers. Rhoades, Everett 1986 Statement before the House Select Committee on Indian Affairs, United States Senate, April 15, 1986. Sievers, Maurice L. and Jeffrey R. Fisher 1985 Diabetes in North American Indian. In: Maureen I. Harris and Richard F. Hamman (eds.), Diabetes in America. Rockville, MD: U.S. Dept. of Health and Human Services. Stem, M. P., S. P. Gasskill, Η. P. Hazuda, L. I. Gardner, and S. M. Haffner 1983 Does obesity explain excess prevalence of diabetes among Mexican American? Results of the San Antonio Heart Study. Diabetologia 14: 272-277. Urdaneta, M. L. and R. Krehbiel (eds.) 1989 Anthropological perspectives on diabetes mellitus type II. Medical Anthropology 11 (3): 221-225. West, Κ. M. 1974 Diabetes in American Indian and other natives of the New World. Diabetes 23: 841-855. Young, T. Kue, and Chandrakant Shah 1987 Extent and magnitude of the problem. In: T. Kue Young (ed.), Diabetes in the Canadian Native Population: Bicultural Perspectives 11-25. Toronto: Canadian Diabetes Association. Zimmet, P., G. Dowse, C. Finch, S. Serjeanton, and H. King 1990 The Epidemiology and natural history of NIDMM: Lessons from the South Pacific. Diabetes!Metabolism Reviews 6(2): 91-124.

I. Diabetes prevalence in North America

Chapter 1

Diabetes among Canadian Indians and Inuit: An epidemiological overview T. Kue Young

1. Introduction In 1974, the late Dr. Kelly West, who can be considered the father of diabetes epidemiology, reviewed exhaustively the literature on diabetes among North American Indians as well as aboriginal populations in other parts of the world (West 1974). Since that time, the problem of diabetes has received the attention of many researchers and the literature on diabetes among North American Indians has grown substantially. A computerized bibliographic database maintained at the University of Manitoba revealed 285 entries (including abstracts) as of April 1988 (Rokala and Meiklejohn 1988). It is now generally recognized that type II noninsulin dependent diabetes mellitus (NIDDM) is an increasingly prevalent, serious, but relatively "new" disease in these population groups. The situation for native people in the U.S. is reviewed elsewhere (Sievers and Fisher 1985; Gohdes 1986). There are just under half a million Inuit, Indians, and Metis in Canada belonging to many linguistic and cultural groups. In this chapter, I shall summarize findings from both the published and unpublished literature on the extent, magnitude, and impact of diabetes among Native Canadians. I shall attempt to address the following questions: (1) Do Native Canadians suffer more from diabetes than the predominantly white "general" population of Canada? (2) Is there variation in disease risk among Native Canadians belonging to different geographical, cultural, and linguistic groups? (3) Is diabetes occurring more frequently in recent times as a result of lifestyle and environmental changes? The scanty data on Native Canadians currently available suggest that an excessive diabetes burden exists in part but not in all of this population.

22

Τ. Kue Young

The research that has been conducted with Native Canadians shows that prevalence rates vary widely, but the factors that contribute to these differences are not well understood. Table 1 summarizes several recent regionally based studies on physician-diagnosed diabetes cases: the Crees and Ojibwa of northwestern Ontario and northeastern Manitoba (Young etal. 1985); the Oneida, Ojibwa, and Delaware residents of the Oneida Settlement and Caradoc Reserve in southwestern Ontario (Evers et al. 1987); Mohawks in St. Regis, Ontario (Selikoff, Hammond, and Levin 1986), and Kahnawake, Quebec (Montour and Macaulay 1985); and Indians in six communities belonging to various Plains tribes in southern Saskatchewan (Joseph 1986). It should be emphasized that the methodologies used in these studies varied widely, and that no single set of diagnostic criteria was uniformly adhered to. Of the studies in Table 1, a comparative non-Native group was provided only in the Evers et al. (1987) study from southwestern Ontario, where the age-adjusted prevalence rate among Indians was 6.7 times that of whites using the same clinic. Nationally, prevalence data for Canadians existed only in the form of self-reports in the Canada Health Survey of 1978 and the General Social Survey of 1985. It can be seen that these limited data do suggest an excess of known diabetes cases among those Canadian Indians that have been studied. Hospital separation data also support the observation that certain Native groups suffer from a higher burden of diabetes than the nonNative population. A study among the Crees of northern Quebec demonstrated that the age-adjusted rate of hospitalization for diabetes was twice that of the total population of Quebec (Pelchat and Wilkins 1986). In Manitoba, analysis of all claims submitted by all physicians to that province's universal health insurance plan indicated that Indians had a 2.3 times higher rate of diabetes than non-Indians in the age group 15-64, and a rate 1.6 times higher for those aged 65 and above. For the under15 age group, however, the Indian rate was only 0.63 of the non-Indian group (Young and Shah 1987). Oral glucose tolerance surveys have rarely been done in Native Canadian communities. In epidemiological studies elsewhere it is recognized that for every known case of NIDDM, there may be at least one or two undiagnosed ones (Harris etal. 1987). In 1979 and 1985, Szathmary conducted extensive studies among the Dogribs, an Athapaskan (Dene) group in the Northwest Territories. In this population there had been no reported known case of clinical diabetes until about 1981. Yet, on oral glucose tolerance tests, 10 percent of subjects had 2-hour post-challange

1 Diabetes among Canadian Indians and Inuit

23

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0 26.8 180.7 436.4 571.4 663.5 635.7

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0 0 73.5 97.6 100.0 500.0 444.4

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Age 5-14 15-24 25-34 35-44 45-54 55-64 65 +

+ 62 119.6

* Diabetes diagnosed in volunteers by plasma glucose of 180 mg or more per 100 dl at one hour after 75 mg glucose load, or 160 mg or more per 100 dl at two hours (Niswander 1966). ** Diabetes diagnosed if plasma glucose of 200 mg or more per 100 dl at two hours post-load with 75 gm glucose (Bennett 1979). *** Diabetes diagnosed by a physician as explained in text. were full-blooded Tohono O ' o d h a m and were also reservation residents are included in this table. In 1965 the Phoenix field unit of N I A M D under the local direction of Tom Burch, M . D., and Peter Bennett, M. D., opened a diabetes research clinic at Sacaton on the Gila River Indian Reservation. They started blood glucose screening of all Pima Indians w h o volunteered to enter their clinic, which included those referred f r o m the Indian Hospital and Clinic located next d o o r to them. The results of their work by age

78

James W. Justice

and sex are also tallied in Table 1. They stated that "there can be no question that many diabetics, particularly among the [Tohono O'odham], are never seen by Indian Service physicians" (Miller, Bennett, and Burch 1968). Several Tohono O'odham who were closely related to the Pirnas and who were residents in Phoenix, on the G.R.I.R., on the Maricopa Reservation, or in one northernmost district of the main Papago Indian Reservation, were also tested. For the positive screening level, NIH used a plasma glucose concentration of 160 dl. or more from a sample of blood taken two hours following a 75 gm glucose load in the form of a cola flavored beverage. They reported a NIDDM rate of 42.3 percent among 365 Tohono O'odham over age 35 in testing conducted between 1965 and 1972. Not one case of type I diabetes (insulin dependent diabetes mellitus) was found. Reinhard and Greenwalt (1975) published the only other study of diabetes prevalence among the Tohono O'odham, although Strotz and Shorr (1973) did mention diabetes prevalence on the Papago Indian Reservation in their study of hypertension. Strotz and Shorr (1973) and Reinhard and Greenwalt (1975) used a newly developed computerized health information system that collected and arranged patient encounter data from all ambulatory care stations (i. e., home, community, clinics, health center visits to San Xavier or Santa Rosa Health Center, outpatient department of the Sells hospital, and referral visits to private specialists if paid for by the Federal program). Of course, inpatient visits to the IHS hospitals or referral centers were also included. Strotz and Shorr (1973) reported in their study group a prevalence rate of 16.2 percent for diagnosed diabetes among Tohono O'odham, aged 15 years or older, who had at least one blood pressure recorded from July 1969 to December, 1972. They also found that 42.7 percent of the diabetic patients had systolic hypertension (but not diastolic) compared to a rate of 15.2 percent among those who were not reported to be diabetic. Reinhard and Greenwalt (1975) used the same computerized health record systems to retrieve all records from 1970 to 1972 in which any Tohono O'odham or Pima had been recorded by a physician as having diabetes. They then dropped all those known to have died by December 31, 1972, and thereby arrived at the prevalence rates. These rates are shown in Table 2 and are compared with the rates found in this current report. In 1972, diabetes rates had been reported among the Pima/Tohono O'odham, over age five years, as 5.6 percent for males, and 8.4 percent for females, which represents an overall percent rate of

3

The history of diabetes mellitus in the Desert People

79

Table 2. The changing prevalence rates of reported diabetes in Tohono O'odham, 1972 compared to 1985, rates per 1000 Ages

1972 Pima/T. Ο. N. in Tucson Service Area (Reinhard, 1972)

Ages

Male (N = 248) 10-19 20-29 30-39 40-49 50-59 60-69 70 > Total

2.9 23.3 53.0 111.7 118.3 112.0 167.4 55.9

Ν = 454 5-14 15-24 25-34 35-44 45-54 66-64 65 + Total 25 yr. +

Female (N = 387) 10-19 20-29 30-39 40-49 50-59 60-69 70 > Total Both sexes

6.4 17.4 76.9 191.8 262.2 280.0 218.0 84.0 7.0

1985 Tohono O'odham reservations

0 7.9 106.8 307.1 427.1 341.8 265.8 113.7 257.8 (Ν = 702)

5-14 15-24 25-34 35-44 45-54 55-64 65 + Total 25 y r s . +

0 10.4 136.8 292.0 616.4 546.2 556.0 169.1 373.0

Both sexes, All ages 25 y r . +

141.8 317.0

7.0 percent. Because different age groupings were analyzed in these two studies, it appears that direct comparisons with the 1985 population study are not possible, but there is an indication that reported rates for diabetes had increased for both sexes and for every age group. On the other hand, there has been no question that the percent of type II diabetes has increased among the Pima residents of GRIR from 1967 to 1977 for all ages and both sexes because the data collected by Bennett and Knowler (1979) was directly comparable.

80

3.

James W. Justice

Diabetes on the Papago Indian Reservation, 1985

3.1. Methods and results A number of data sources were used for the 1985 survey, several of which were cross checked with one another to verify statistics. A description of how these prevalence rates were calculated has been published elsewhere (Justice 1993).

3.1.1. Case identification

results

Prevalence of diabetes by age group and sex reported in the Patient Care Information System (PCIS) computer data base among Tohono O'odham residents of the three reservations is shown in Table 3 and Figure 3. The total number of people with diabetes shown in Table 2 (1,156) represents only Tohono O'odham patients with unequivocal narrative statements coded to number 250 of the International Classification of Diseases (ICD 9), and patients whose medical summary or chart review indicated persistent diagnosis of diabetes over several visits subsequent to the first visit during which a diagnosis of diabetes by a physician was reported. In Table 3, the 1980 U.S. census estimation of the reservation population of "all Indians" was used in the denominators to calculate rates for Tohono O'odham only. By 1985, these numbers are probably too low (based upon a study of those using health services), which would give falsely higher rates. However, the Tohono O'odham represent 94 percent of all the Indians resident on these reservations, which may compensate for the error in these rates. Cases of diabetes have been diagnosed among other Native American tribal members resident on these reservations but are not listed in this report.

3.1.2. Reporting of cases

Table 4 shows the tabulations of the year in which the earliest diagnosis of diabetes was entered into the patient's data base. In this table, all known Tohono O'odham patients, regardless of their residence, were tallied. Therefore diabetics in Tucson, Ajo, Marana, Eloy, etc., and other off reservation communities were included inadvertently. So few of these people were outside the IHS Tucson Program Area (e. g., eight in Coolidge, Florence, Phoenix, etc.) that this listing is representative of the IHS

3 The history of diabetes mellitus in the Desert People

81

Table 3. Prevalence of diabetes January 1985 in Tohono O'odham Nation (formerly Papago) reservation residents, by age group and sex Sex

Age groups

Male

0-14 15-19 20-24 25-34 35-44 45-54 55-64 65-74 75 +

Number

Population

Rate per 1000

0 3 3 63 129 126 67 40 23

1501 416 347 590 420 295 196 142 95

0 7.21 8.65 106.78 307.14 427.12 341.84 281.69 242.11

Subtotal, Male all ages:

454

4002

113.4

Age 25 years + :

448

1738

257.8

0 2 13 80 120 196 142 102 47

1480 470 359 585 411 318 260 174 94

0 4.26 36.21 136.75 291.97 616.35 546.15 586.21 500.00

Subtotal, Female all ages:

702

4151

169.12

Age 25 years + :

687

1842

372.96

Both totals: all ages

1156

8153

141.79

Age 25 years +

1135

3580

317.04

Female

0 — 14 15-19 20-24 25-34 35-44 45-54 55-64 65-74 75 +

Rates per 1000; population from 1980 U. S. Census Tucson Program Administration Area plus the San Lucy Reservation near Gila Bend in Maricopa County. The largest relative increase that occurred in 1969 was the result of the first time inclusion of all outpatient diagnoses in the PCIS data base. Before 1969, only diagnoses for patients discharged from the Sells hospital were entered in the data base. The new Sells hospital was opened in 1961. The sudden increases in 1978-1979 and 1982-1984 may have been the result of increased emphasis upon diabetes by different medical staff assigned to the Sells service unit or may represent increasing prevalence of this disease.

82

James W. Justice 700 x. 600

500

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400

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200

100

0-U

15-19

20-24

25 - 3 4

35 - 44 Age groups

ο Male

4 5 - 54

5 5 - 64

6 5 - 74

7 5-»

χ Female

Figure 3. Prevalence of diabetes 1985 on Tohono O'odham reservations.

In Table 4, the number of people with diabetes recorded each year in the data base is shown. The second column, labeled "died", includes the earliest date diabetes was mentioned in the data base (not the date of their death) for those reported to have died as of January 1, 1985. Ninety four (20.4 percent) of the total patients who died had only one visit or date recorded. The total and the five year mean number of cases reported for each five year period starting from 1961 is shown in the last column. The large differences in the mean numbers of people with diabetes for each five years indicates that diagnosing and reporting practices by physicians were inconsistent, not that an increase or decrease in true incidence occurred. Although the incidence and prevalence of diabetes appears to be increasing, this conclusion cannot be verified from this data because of the uneven distribution of reporting peaks and lack of a consistently applied clinical definition of a case. The increase in reported prevalence of diabetes by age and sex (per 1000 population) in the 1965 survey and the 1985 report is shown in Figure 4.

3

The history of diabetes mellitus in the Desert People

83

Table 4. Number of patients with diabetes reported to the computer data system by years, Tohono O'odham only, all sites, on and off reservations Alive January 1985 Year

Number

Died*

Totals

1960 1961 1962 1963 1964

0 15 11 13 6

1 29 36 27 19

1 44 47 40 25

157

31.4

1965 1966 1967 1968 1969

6 13 15 13 113

23 10 24 15 64

29 23 39 28 177

296

59.4

205

248

453

1970 1971 1972 1973 1974

51 42 63 47 27

49 37 29 21 11

100 79 92 68 38

377

75.4

1975 1976 1977 1978 1979

43 36 44 74 80

14 14 9 9 10

57 50 53 83 90

333

66.6

507

203

710

28 35 164 211 134

3 0 6 0 0

31 35 170 211 134

581

116.2

572

9

581

1284

460

1744

Subtotal

Subtotal 1980 1981 1982 1983 1984 Subtotal Total

Five yr. Total

Mean no.

* "Died" number shows earliest date of diagnosis of diabetes in their computer record, not the date of their death before 12/30/85.

84

James W. Justice

u

ι 5-14

I

I

Μ 1965

Figure 4.

ι ·——r™——ι 15-24 O H

25 - 3 4

35-44 Ages

Μ 1985

\ΖΖΔ

r——^^ 45-54 F 1965

55-64 ES3

65. F 1985

Change of prevalence of diabetes for Tohono O'odham. 1965-1985.

3.1.3. Duration of diabetes (Table 5)

The major use of the numbers for those living as of 1985 was to construct Table 5, a frequency distribution by duration of reported diabetes. This is important because the frequency of complications increases greatly as the duration of diabetes increases. One should interpret Table 5 as follows: "at least" 4 percent of diabetics have had their disease for 20 or more years, 57.6 percent for five years or longer, and 37.2 percent for ten years or longer. Unfortunately, these are very crude estimates because the first reported date in the data base is most often many years after the silent onset of the disease, and frequently many years after the condition was first recorded in the patient's original written record. The method now in use of creating a problem oriented computer record was first started in 1971. Physicians infrequently indicated an earlier date of diagnosis when they entered diabetes on the problem list. When they did, the earlier date was tallied in Table 4 and used in Table 5.

3

The history of diabetes mellitus in the Desert People

85

Table 5. Duration of diabetes in Tohono O'odham (formerly Papagos). Alive by 1/1/85 (estimated by date of report). No. of years Per year %

No. of patients

Cummulative

Duration (years)

No.

Cum. %

24 23 22 21 20

15 11 13 6 6

1.17 0.86 1.01 0.47 0.47

20 +

51

4.0

19 18 17 16 15

13 15 13 113 51

1.01 1.17 1.01 8.80 3.97

15 +

256

20.0

14 13 12 11 10

42 63 47 27 43

3.27 4.91 3.66 2.10 3.35

10 +

478

37.2

9 8 7 6 5

36 44 74 80 28

2.80 3.43 5.76 6.23 2.18

5+

740

57.6

4 3 2 1

35 164 211 134

2.73 12.77 16.43 10.44

1+

1284

100%

Total

1284

100

1284

3.1.4. Deaths attributed to diabetes (Table 6) Since there is a question about the increasing prevalence of diabetes based upon a comparison of three different prevalence studies (Niswander 1966; Reinhard and Greenwalt 1975; Justice 1990) done at different times by three different teams using different methods, it was thought that one study of causes of death by one investigator using the same data base over a 23 year period may also show an increase in the frequency of diabetes as a listed cause of death.

86

James W. Justice

Table 6. Number of reported deaths and rates for Tohono O'odham Nation (formerly Papago) residents of Tohono O'odham Nation reservations from diabetes as underlying cause of death, 1961 through 1984 (22.75 years). (ICD 250.0-250.9) 5 year mean average

Population (estimated)

Crude death rate per 100,000

1 0 2 1 1

1.0

5047

19.8

1966 1967 1968 1969 1970

1 3 2 2 2

2.0

5744

34.8

1971 1972 1973 1974 1975

4 3 3 5 3

3.6

7231

49.2

1976 1977 1978 1979 1980

2 3 4 7 9

5.0

7600

65.8

1981 1982 1983 1984*

1 4 4 5

3.5

8600

40.7

Totals

72

Year

No.

1961 1962 1963 1964 1965

* 9 Months (4 deaths); annualized.

All copies of death certificates were reviewed where the decedent had been identified as an American Indian, and the certificate was copied by the Arizona State Health Department Bureau of vital statistics and sent to the IHS Tucson Program Office. Deaths from 1961 through 1977, listed in Table 6, occurred in those who used the health facilities of the IHS. Deaths since then have not yet been checked against the computer patient data base and may include a few who were not actual users of

3

The history of diabetes mellitus in the Desert People

87

services. All decedents were described as either "Papago" or "Tohono O'odham" on the certificate. The mid-interval popuations used in Table 6 to calculate the rates were determined from various sources (Tribal or U.S. census, or IHS user populations) over the years and were graphed. The estimates in this table were from straight line interpolations for the midyear of each five year period. These crude rates were per 100,000 population per year ("Crude", i. e., not adjusted for differences in the proportion by age from one period to the next). The rate of Tohono O'odham deaths coded to diabetes as the underlying cause appears to have increased by 300 percent since the decade of the 1960s. This increase could be due to better screening and identification of diabetes before death, or by better motivation of physicians to record diabetes on the certificates. This increase is not because of any change in the coding procedures of the Bureau of Vital Statistics since 1961 (personal communication with Mr. Alfonso Bravo, Arizona Department of Health, Bureau of Vital Statistics). The 72 deaths coded to diabetes in Table 6 are not all from the 460 persons with diabetes who died from all causes that are listed in Table 3. For example, from a total of 36 deaths reviewed from 1962 through 1977, six were not listed under their residence at time of death as ever having had diabetes. An in-depth study of diabetes deaths compared with a suitable control population may provide some valuable data but was beyond the scope of the present report. 3.1.5. Treatment of diabetes (Table 7) Although there is a debate about whether insulin is indicated in the therapy of N I D D M , most physicians prescribe it only for the more severe, or refractory patients. Severity of N I D D M is also possibly correlated with the duration of the disease, although there are many other indications for giving insulin such as pregnancy, prior to surgery, or the presence of infection. Table 7 is the result of the tabulation of only Papago Indian Reservation residents alive as of January 1985 and the medication they received on the latest date of their visit to an IHS facility in the Tucson Program Area. The pharmacists at each facility enter all prescriptions directly into the data base by entering the patients' record number and the code number, dose, frequency, and quantity of the drug prescribed. Each

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Table 7. Treatment of diabetes January 1985 for Tohono O'odham on reservations

1. 2. 3. 4. 5.

Insulin

%

Oral agents

%

249 106 87 69 645

82 34 22 27 173

32.9 32.1 25.3 39.1 26.8

93 38 43 16 264

37.3 35.8 49.4 23.2 40.9

1156

338

29.2

454

39.3

Number patients

Sites Sells San Xavier Santa Rosa San Lucy All other

Totals

patient is listed by name, birth date, sex, residence, date of visit, site of visit, and the medication prescribed. Each was checked against the active file and all were confirmed to have had a recorded diagnosis of diabetes. Oral agents as a group were more often prescribed (39.3 percent) than all types of insulin (29.2 percent). The oral agents prescribed were tolbutamide (31 percent) chlorpropamide (47.4 percent) and acetohexamide (20.8 percent). Tolazamide was prescribed for only two patients. Perhaps a few additional patients may be providing for their own medication through private or non-federal facilities, but IHS records indicated that in 1984 about 70 percent of diabetics (all type II) were being treated with medications and about 30 percent by other means such as diet, or not at all.

3.1.6.

Prevalence

of diabetes by

community

Table 8 presents the crude community rates for prevalence during the same five year period as was shown in Table 2. The population and the cases shown here are only Tohono O'odham who used IHS health services during this time. The range is from a high of approximately 23 percent to a low of 4-7 percent, with a mean rate of 13 percent. There does not seem to be any particular pattern of economics or grossly visible lifestyle associated with communities that have either a high or a low prevalence. However, these residences are those of the first recorded visit (active plus inactive, plus deceased files) and therefore may not represent the community of longest duration of residence before the onset of diabetes, or before the recording of diabetes in the data base. All communities with less than ten percent prevalence are those far from cities and far from the trading posts located on the reservation at

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Table 8. Diabetes period prevalence rates by community on reservations, Tohono O'odham only (Communities with 40 or more population) Time: 7/1/79-7/1/84 Diabetes patient

%

Reservation community

population (5 year users)

Kohatk Santa Rosa Ranch Coldfield Vamori Ventana San Pedro Akchin Covered Wells Cockleburr Charco 27 Fresnal Village Cowlic Queens Well Pisinimo Vaya Chin Topawa San Lucy ( + Gila Bend) Santa Rosa Kerwo Gunsight No. Komelik San Simon Anegam Choulic ChuiChu San Xavier Sells Little Tucson Cobabi Big Fields Menegers Dam Crowhang San Miguel Kaka Hickiwan So. Komelik Sil Nakya Kom Vaya Nolia

78 43 48 57 95 44 102 251 114 90 90 128 58 383 41 291 500 648 284 85 104 125 188 64 332 907 2308 213 46 234 163 104 105 161 254 110 46 59 48

21 10 11 13 19 8 18 42 19 15 14 20 9 57 6 42 72 92 40 12 14 16 24 8 39 105 262 24 5 25 17 10 10 15 23 8 3 3 2

26.9 23.3 22.9 22.8 20.0 18.2 17.6 16.7 16.7 16.7 15.6 15.6 15.5 14.9 14.6 14.4 14.4 14.2 14.1 14.1 13.5 12.8 12.8 12.5 11.7 11.6 11.4 11.3 10.9 10.7 10.4 9.6 9.5 9.3 9.1 7.3 6.5 5.1 4.2

Sub total

9001

1153

12.8

All other (28 sites) Totals

293 9294

59 1212

20.2 13.0

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James W. Justice

Seils, Santa Rosa, Pisinemo, and Covered Wells (See Figure 2). However, several small towns that appear to be similar to those with the lowest rates and are located far from urban areas and trading posts do have rates higher than the mean rate of 13 percent. Examples of some of these are: Coldfield (22.9 percent); Kerwo (14.1 percent); Pia Oik (20 percent); Kohatk (26.9 percent); and Santa Rosa Ranch (23.3 percent). Larger towns such as Sells and San Xavier that have been the centers of a wage economy and are near ample food supplies in stores and trading posts have rates between 10 percent and the mean rate, 13 percent, when they might have been expected to have higher rates if diabetes were assumed to be a consequence of acculturation. The methods used in this report could be too imprecise for the influence of diet, proximity of high caloric foods and alcohol, and differences of life style to be reflected in the prevalence rates of diabetes. 3.1.7. Complications

(per Hurtado's report 1985) during fiscal year 1983

The following figures for diabetic complication were derived from the study conducted by Hurtado (1985): 1. Amputation: There were 21 amputations during fiscal year 1983 (13 toes), 23 during nine months of the next fiscal year (31 if projected for the year). Undoubtedly, some of these were also counted twice in the PIMC data. 2. Diabetes was diagnosed in "8.5 percent of 294 total pregnancies" (time period not stated), "but only 2.7 percent of all pregnancies were true noninsulin dependent (Type II)." 3. Renal failure: 32 patients on dialysis. 4. Ketoacidosis: Only "one case reported in the past year." 5. Optic complications: 100 diabetics had cataracts seen and diagnosed by the ophthalmologist; 62 had retinopathy. In Tables 9 and 10, the full fiscal year 1984 has been used to establish a baseline without the use of statistical projections. An effort was made to check the residence code for each hospital admission and to separate Tohono O'odham into those resident within and without the IHS Tucson Program Administrative Area, plus those resident in District XI of the Papago Indian Reservation (i. e., San Lucy Village plus Gila Bend). Of the total number of Tohono O'odham hospital discharges (1719) for two years, only 658 (38.3 percent) had a residence within the Tucson Program Area. The rest resided in Pinal County, many upon the Gila River, Salt

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Table 9. Hospitalizations and average length of stay (ALOS) in fiscal year 1984 (10/1/83 — 9/30/84) related to diabetes diagnosis, Tucson program area (plus San Lucy Reservation) Code ICD 9

Hospital sites

No. Discharges

Days All tribes

ALOS (days)

12 Ν. Α. 0

2136 662 49

8.86 12.04 5.44

12

2847

9.30

2 0 0

35 0 23

4.38

2

58

4.46

2905

9.1

Papago Other 250.0 Series Diabetes Mellitus

1. Sells 2. PIMC 3. Contract (Tue)

229 56 9

Subtotal

294 306

648 Series (Not incld. Above) Diabetes and pregnancy

1. Sells 2. PIMC 3. Contract (Tue)

6 0 5 11

—

4.60

13 Total Tucson area, All Tucson program area San Lucy/Gila Bend Papago

305

14

305

Ν. Α.

24

Ν. Α.

301

12.54

Total

329

N. A.

3070

9.33

Table 10. FY 1984, Tucson program area only, diabetes related hospitalizations compared to all hospitalizations, diabetes days and average length of stay (ALOS) for hospitalization Hospital sites

Number related

1. Sells 249 2. PIMC 56 3. Contract 14

Total number

Percent D. M. hospitalized

Days ALOS diabetes

Total hospital ALOS days

1281 658 350

19.4 8.5 4.0

8.72 12.04 5.14

5.70 7.5* 5.10

* T. O. only mean discharges sites of residence only in Tucson Area (1983 — 85, two calendar years). ALOS for all PIMC admissions, all tribes, FY 1984, all sites of residence. (T. O. refers to Tohono O'odham, formerly Papago)

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River, and Ak Chin (Maricopa) reservations, and in surrounding towns such as Casa Grande. Others lived in Phoenix, Scottsdale, Tempe, Mesa, and Glendale in Maricopa County. For these tables, I chose to use all hospital discharges of persons diagnosed with diabetes regardless of the order of appearance of this diagnosis upon the hospital record face sheet. Previous comments notwithstanding, I believe this is more important than consideration of only hospitalizations where diabetes was listed first. There is no standard method or reason to list diabetes first on the hospital record. Some physicians start listing diagnoses as they are confirmed during the hospital stay. Others wait until they review the entire chart after the patient has been discharged, and they attempt to first list the most serious, or in some cases the underlying cause of the hospitalization. Some first list the most urgent cause for hospitalization, which is not necessarily the underlying cause. In addition, it became clear that by reading the other diagnosis and operations listed after discharge in those with diabetes that almost all hospitalizations were related to their diabetes. In other words, rarely (if ever) did diabetes seem to be only an incidental diagnosis. All information was derived from various computer generated reports, and no original hospital records were studied. Finally, it should be mentioned that the computer records used in this study indicate only those diagnoses appearing within the first six spaces of the hospital discharge summary form.

4.

Tohono O'odham and Pima comparisons

4.1. Prevalence by age and sex Prevalence rates for type II diabetes found in Pima Indians are shown in Table 1. The rates in the Tohono O'odham for 1985 (Figure 3) seem to be almost identical with the rates in the Pima for 1972. Both Arizona tribes show male prevalence rates that peak at age fifty years (at rates of between 30 percent and 40 percent) and then remain constant until age 70 years, when both drop, the Tohono O'odham rates for males being lower (25 percent) than the rate for Pima males (33 percent). The Pima female rate pattern by age, although very similar to that of the Tohono O'odham, shows a peak (70 percent) ten years later at age 60 years

3 The history of diabetes mellitus in the Desert People

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compared to the Tohono O'odham peak at age 60 years, which also shows a lower prevalence (60 percent). This peak falls to about 55 percent at age 70 years. Pima women at younger age groups seem to run about a 10 percent higher prevalence rate than the Tohono O'odham females (i. e., Pimas 20 percent at age 30 years, and Tohono O'odham, 10 percent; Pirnas 33 percent at 40 years, and Tohono O'odham, 25 percent). The age at which the female rate pattern "crosses over" the male rate pattern is also very similar in both groups, i. e., at approximately age 40. As mentioned earlier, when one considers that the Pimas have had the benefit of close proximity to a research team of epidemiologists and diabetologists who have followed a similar protocol for almost twenty years, it follows logically that by 1983 their prevalence rates should have been recorded at much higher levels than the rates for Tohono O'odham people. In the United States, many organized surveys using the same criteria for diagnosis of diabetes usually reported twice the number of diabetic people than had been diagnosed prior to the survey. This was also true for the first reported findings among the Pima from 1965 to 1967 (Miller, Bennet, and Burch 1968), when 40 percent of the 288 verified diabetics had been diagnosed by clinicians during routine health care operations. Forty-seven percent of the Maricopa diabetic patients surveyed by Justice (1967) were previously known to the medical staff. It follows, therefore, that if the Tohono O'odham people had had similar access to consistent screening for diabetes, that we would expect their age specific rates to be higher than the rates for Pimas for each age group and sex. 4.2. Duration The duration of diabetes in Pimas was reported to have been equal or greater than 14 years in 20.4 percent (43/211) of cases, between seven and fourteen years in 45.5 percent of cases, and less than seven years in 34.1 percent (72/211) of cases. From rather incomplete data, the comparative statistics for Tohono O'odham would be as follows: 14 years, 31.7 percent; between 7 and 14 years, 25.1 percent; and less than 7 years, 43.2 percent. Exact comparisons between these tribes cannot be done because of limitations in our data. The time of reported diagnosis after the onset of diabetes in Tohono O'odham was much more variable than in the Pimas, where duration of the diabetes was most often based upon known prior recording of negative plasma glucose test results followed by subsequent positive tests (Knowler et al. 1983).

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4.3. Comparison of death rates from diabetes The most recent study of causes of death among the Pima, restricted to residents on the Gila River Indian Reservation, was by Carraher (1984). During a period of 13 years (1970-1982), a total of 75 deaths were attributed to diabetes as the underlying cause. Four other causes were more numerous. Ranked in order these causes were, first, diseases of the circulatory system (166), accidents (149), diseases of the digestive system (89), and diseases of the respiratory system (87). Cancer deaths were the same number (75) and tied with diabetes for fifth rank. Deaths for diabetes by sex were about equal. For diabetes, the standardized mortality ratios (SMR) among the Pima, compared to the state of Arizona all races, were more than ten times the expected numbers for both sexes together and for each sex. (The use of SMR's does correct for the different age and sex distribution of the GRIR residents from the state of Arizona.) The crude annual death rate from diabetes, both sexes, was 95 per 100,000 population. For this same period of time, 50 deaths with diabetes listed as the underlying cause were recorded for the Tohono O'odham. Their crude annual rate was 53.2 per 100,000. Since the age and sex distribution of the Tohono O'odham are very similar to that of the Pima, these crude rates can be compared. This rate has changed little during 1982 through 1986, when it was reported as 54 per 100,000 by the Indian Health Service (1987). Age adjusted Tohono O'odham diabetes deaths compared with all races in the U.S., 1978-1982, was 4.6 expected and 28 observed. The SMR was 6.1. Carraher (1984) suspected that some of the excess deaths attributed to diabetes in the Pirnas were due to a reporting bias. Since the NIH research team had been finding diabetes cases since 1965, there was a better chance that this diagnosis would appear on several death certificates whereas in the total Arizona population (and by extension, other Indian populations in Arizona), some may have died with undiagnosed diabetes. In Arizona, only one cause of death is coded upon the certificate. Whenever "diabetes" appears on the certificate — in any location — the underlying cause is coded as diabetes except if trauma, infection, or a cardiovascular disease is also listed, in which case those diagnoses take precedence. Deaths by cause comparisons of these very similar Indian peoples is complicated by another difference: In Pirnas residing in the GRIR, only 6.5 percent of deaths were coded to the catch-all category of "symptoms,

3

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ill defined, and unknown", but 11.2 percent of all Tohono O'odham deaths were coded to this category. This reflects the greater distances and relative inaccessibility to health services for the Tohono O'odham compared to the Pirnas. 4.4. Renal failure The evidence regarding renal failure from complications of diabetes very clearly indicates that an epidemic situation exists because after renal dialysis became available for IHS patients, this "end stage renal disease" diagnosis was recorded, and patients were evaluated for diabetes if not previously diagnosed prior to the onset of renal failure. Renal failure that results in the use of renal dialysis technology is the best documented complication of diabetes in this population and therefore has higher visibility in the record system than either retinopathy or amputations (retinopathy was difficult to diagnose in many older patients because their scarred corneas from decades of trachoma infection made visualization of their retina difficult or impossible). But this was not always the case. Renal failure was poorly reported as a cause of death or rarely even listed on a certificate until effective treatments became available to Indians in Southern Arizona. The first available dialysis machine was located in the Phoenix Indian Hospital in 1965 (Sievers 1985), and the first patient was a Tohono O'odham from Sells with diabetic nephrosclerosis. Diabetes was first recorded in this patient in 1961 and remained uncontrolled. Table 11 shows all Tohono O'odham patients with end stage renal disease treated with renal dialysis or kidney transplant during the five year period 1979-1984. Rates are shown for each sex and age group per 1,000 population in two categories: those resident on the Papago Indian Reservation, and those resident in nearby communities in Arizona. The ESRD prevalence rate curve resembles that for diabetes (shown in Figure 5), i.e., a plateau effect is evident. Male rates peak from 45 to 65 years of age, and then decline, while female rates plateau at 37 to 42 per 1,000 for those aged 55 through 74, and decline after age 75. Point prevalence as of January 1, 1985, can be calculated by substracting the 14 deaths from the 52 total reservation patients. The prevalence rate at January 1, 1985, was 3.2 per 1,000 population. In the United States for all races, a rate of 354 per million was reported by the U.S. Health Care Finance Administration. The crude Tohono O'odham rate is 3,242 per million, a multiple of 9.2 times the rate in the

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Table 11. Tohono O'odham, 1979 through 1984, treated '"end stage renal disease", 5 year prevalence rates, residents and users of services, by sex 1. On reservation (1 — 11 districts) Sex

Ages

Treated cases

Total

Estimated population

Rates per 1000

Deceased by 1/85 Male

0-14 15-19 20-24 25-34 35-44 45-54 55-64 65-74 75 + Sub total 25 yrs. Sub total

Female

0-14 15-19 20-24 25-34 35-44 45-54 55-64 65-74 75 + Sub total 25 yrs. Sub total

Both sexes 2. Off reservation Male Female 3. Totals 1

1 3 6 4 1 1

2100 051 555 852 553 395 228 162 104

1.17 5.43 15.19 17.54 6.17 9.62

16 16

2294 5600

6.97 2.86

3 2 8 11 10 3

2054 675 665 945 643 473 294 236 137

3.17 3.11 16.91 37.41 42.37 21.90

(7)

37 37

2728 6122

13.56 6.04

(14)

53

11,722

4.52

(1) (4)

7 7

n. a. n. a.

unknown unknown

(19)

67

n. a.

unknown

(2) (3) (2)

(7)

(2) (2) (2) (1)

— —

— — —

i. e.: Renal dialysis plus transplanted renal tissue during January 1979 to January 1985, ages of living as of January 1985, age of deceased at time of death.

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Age groups Residents & users of services by sex ο Male χ Female

Figure 5. Five year Arizona rates per 1000 Tohono O'odham, 1979-1984 treated "end stage renal disease" United States, all races. Ideally, the comparison should be with all those who had end stage renal disease both treated and untreated, but these statistics are not available. The Pirnas have had the same experience with renal failure among those with diabetes. In 1982, their rate was 2521 per million for those on dialysis for renal failure. A comparable rate for the total U.S. population in 1985 was 354 per million (IHS Diabetes Program, Sacaton, AZ, personal communication). Figure 6 shows the sharply rising epidemic curve for the number of patients each year, 1972 through 1984, who received treatment for their renal failure at some time during each year. This figure includes the fourteen new dialysis patients (including two patients not residing in Pima County and therefore not included in Figure 6) who entered into a treatment program during calendar year 1984, but were not included in Table 11. F o u r kidney transplant patients are included. Only two had successful outcomes. One died and one returned to hemodialysis after the transplant was rejected.

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Figure 6. Tohono O'odham diabetes patients entering renal dialysis

4.4.1

Incidence

Incidence of treated E S R D from diabetes increased from 15 patients during 1965 through 1979 (average 1.0 case per year) to an average of 7.3 cases per year during 1980 through 1982 (i. e., 22 patients in 3 years). Until 1983, there were 14 females (mean age 54.9 + / — 9.7 years) and 8 males (mean age 60.9 + / — 12.3 years). This age difference was not statistically significant at the 95 percent confidence level. The average annual crude incidence rate among the Tohono O ' o d h a m for 1980 through 1982 was 535.6 per million. This rate, age adjusted by the direct method to the 1970 U.S. standard population, is 917.5 per million per year. Renal failure as a result of nephrosclerosis from uncontrolled diabetes that has existed at least eight years (mean 10.4 yrs.) is the best evidence that the prevalence of diabetes has been increasing among the Tohono O ' o d h a m since 1965. If the diabetes rates stabilize or decrease after 1980, the effect of declining renal failure patients will not be evident until the 1990s. In summary, the E S R D data presented suggests that the prevalence of N I D D M is increasing among the Pima and the Tohono O ' o d h a m and

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that the rates in the Tohono O'odham for this disease are at least equal to the rates of their much studied Pima cousins.

4.5. Diabetes and infant child health It is remarkable that type I diabetes (insulin dependent diabetes mellitus) has never been recorded for the Tohono O'odham. Instances are recorded where fasting glucose blood levels of over 200 mg./dl. were found in two teenage males, ages 13 and 15 respectively (Adams et al. 1970; personal communication with physicians). However, no complications of diabetes have ever been reported in this population before age 25 years. Therefore the health effects of parental diabetes upon infants and children are manifest primarily through 1) the high rates for congenital defects, which are a direct result of maternal hyperglycemia (Miodovnik etal. 1988); and 2) by the early development of obesity, which is now known to predispose youngsters to develop hyperglycemia and eventually diabetes. 4.5.1.

Obesity and weight gain in children

The earliest data collected about young Tohono O'odham emphasized deficiencies in nutrition, including disproportionate numbers of young school children below growth and development "norms" for anglo children. Ross (1944) recorded the earliest physical measurement data for children aged five through sixteen. Using the Baldwin and Wood standard growth measurements (based upon White children in the eastern United States), Ross reported that 39 boys (of 72), and 45 girls (of 80) were below "normal" in their weights. She reported a mean weight of 43.9 Kg. for 13 boys, aged 11 to 16 years, and a mean weight of 43.7 Kg. for 13 girls, aged 11 to 14 (Ross 1944). The next measurements of school children were made in 1949 by Vavich, Kemmerer, and Hirsch (1954). Mean weights of boys had increased to 56 Kg. and of girls to 59 Kg. There is not enough information in either report to be sure that a representative sample of 11 to 16 year olds on the reservation had been measured. Neither study mentioned obesity as an observation or concern. The first observations that brought attention to the comparative obesity of Tohono O'odham school children (and also Pimas) were conducted by Kraus and Jones (1954). The authors converted heights and weights to growth channels as developed by Wetzel (1948). Their sample com-

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James W. Justice

prised anglo and Indian boys and girls aged 6-11. (Indian children compared were from members of the Apache [San Carlos], Pima, and Tohono O'odham tribes.) The authors note for the first time that compared to anglos and Apaches, the Pima and Tohono O'odham children show much greater obesity: in 40 percent of the Pima and 35 percent of the Papago (six year olds), "obesity is characteristic of the body builds of Pima and Papago boys and ... this obesity is already established at the age of six, if not earlier — the data on girls shows almost the same phenomena" (Kraus and Jones 1954). Similar data for 1965 was collected by Van Cleft (1965), but unfortunately her records of measurements of height and weight have not been found. Her sample included "beginners, first, third, and sixth grades" in all the schools in the San Xavier District and on the main reservations. She compared the weights of Indian children against weights listed in tables for white chldren published by Ross Laboratories in 1962 that were based on growth statistics of white children. Van Cleft concluded that "the results show that the Papago children are of average weight but that they tend to gain weight rapidly. Most of the beginners and the first graders are within the average weight ranges, but by the time they reach the third grade, they tend to be in the upper range. By the sixth grade practically all are well over the average and some above the high range on the chart." This impression was confirmed by a study conducted by Adams et al. (1970) during 1967-1968 for 929 Tohono O'odham school children. These children included more than 85 percent of all enrolled children on the main reservation. No differences are noted when heights in 1967 are compared to heights for school children recorded by Ross in 1941. However, weights were 1-2 kg. heavier for each sex and for each year of age in the 1967-1968 cohort of school children. The first age group to show a significant weight gain (4 kg.) was age nine. Through the pre-teen years, increases ranged from 5 to 12 kg. Those aged 13 and over showed increases of from 9 to 13 kg. Adams et al. (1970) concluded that "the growth of school age Papago children is remarkable in the early onset of obesity." They attributed this phenomena to their high carbohydrate diet but not to the high prevalence of diabetes in their parents. Adams made no reference to the dates on the studies of either Ross or Kraus. When the Women, Infants and Children program (a federally funded program hereafter referred to as W.I.C.) started in 1969, statistics for

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pre-school age children became available for the first time. Burkhalter (1979) tabulated birth weights for every year from 1968 through 1978. He defined underweight and overweight with reference to the StuartMeredith weight for age standard. Underweight was defined as a recording in the computer file of at least one weight in the first 12 months of life below the 10th percentile of this standard. Overweight was defined as the 90th percentile or above of the same standard. The average percentage of children overweight for this 11 year period was 27.7 percent, but the average of the first six years was 26.3 percent, compared to an average of 29.4 percent children overweight for the last five years. Since 1974, the percent overweight has increased for every year of age and ranges from 17 percent to 58 percent (age 13). Forty-two percent of the school age children (boys and girls) in 1976 were reported to be overweight at age seven years, 43 percent at 10 years, 58 percent at 13 years, and 37 percent by 17 years. An average of 44.7 percent across all ages were overweight; only 1.7 percent were underweight. By 1985, further weight gain of school children was recorded by the Tohono O'odham nutrition program, but gains were not significantly different for almost all ages and for both sexes over those recorded in 1968 by Adams (Adams etal. 1970). The maximum amount of weight gain in children appears to have occurred, and from the preceding evidence, it appears that the greatest weight gain for children, proportionately, began between 1941 and 1955, presumably closer to the latter date. 4.5.2.

Birth

weights

There are a few data about birth weights for the Tohono O'odham, but it was not as well studied as the growth and development of school-age children. There was some indication from 1965 to 1967 that Tohono O'odham infants were heavier at birth than infants from the few other tribes for which measurements were available. Adams etal. reported in 1970 that the mean birth weight for 125 Tohono O'odham infants was 117.93 ounces. Of eight tribes in Arizona where birth weights were measured, only Pirnas (mean 120.1 oz.) and Mohaves (mean 124.6 oz.) had heavier birth weights. Among the Tohono O'odham (as well as among the Pima), the birth weight varied directly with the plasma glucose levels measured within one hour after a 75 gm. glucose load was administered during a home visit following the birth. Sixteen percent of these 94 mothers tested above 150 mg. per dl. The

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James W. Justice

mean birth weight of their babies was 128.0 oz. compared with 117.6 oz. for those born to 79 mothers who tested less than 150 mg. per dl. These mothers' weights were obtained within a year of the birth. In 1979, the I.H.S. reported that for 1974-1977, 37.5 percent of Tohono O'odham babies weighed 3501 g. or more. This was a gain of 3.5 percent over the period 1972-1973. This proportion was compared with other tribes where diabetes is relatively lower, such as in the Navajo, among whom 31.3 percent of babies weighed 3501 g. or more during 1972-1977. The earliest birth weight data discovered to date was reported in a series of vital statistic reports on Arizona Indians in 1967,1968, and 1969 by the Public Health Service. Births were tabled by weight classification. For these three years, 1965-1968, 8.1 percent of all Tohono O'odham infants born during this period weighed over 4000 g. at birth. Only the Pima had a higher proportion (9.3 percent) of infants weighing over 4000 g. In all other Arizona tribes, less than 5 percent of the infants had weights over 4000 g. During this time period (1964-1966), Niswander and Adams (1973) did a more thorough study of birth weights for all Indians born in federal I.H.S. hospitals (i.e., 26 tribes in nine major linguistic groups in the U.S.). The birth weights of 14,376 single, live-born deliveries were analyzed. In those years the tribes with the heaviest newborns were the following with the percentage that weighed over 153 ounces (4338 grams): Omaha males, 12 percent; Cheyenne males, 9 percent; Commanche males, 7 percent; Mohave males, 8 percent; Chippewa males, 7 percent; Sioux males and Winnebago males, 6 percent; Papago (Tohono O'odham), Crow, Choctaw and Chickasaw males, 5 percent). The heaviest females were born to the Cheyenne, among whom 7 percent weighed over 153 ounces. Among other tribes, the percentage with birth weights over 153 ounces are as follows: Omaha, 5 percent; and Chippewa, Choctaw, Creek, Seminole, Sioux, Winnebago, Commanche, Kiowa, and Pima, 4 percent. The Tohono O'odham ranked 17th, tied with five other tribes at 1 percent (Adame et al. 1970). When tribes were ranked by mean birth weight, the Tohono O'odham were in 14th place for males with 3430 g. ( + / - 512 S.D.) and in 20th place for females, with a mean weight of 3251 g. ( + /— 455 S.D.). The Pimas were ranked for males in 8th place (3454 g. +/— 547), and for females in 16th place (3338 g. +/— 532). Ranking by birth weight does not correspond to ranking by the known prevalence of diabetes in each tribe.

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From these statistics it would not have been evident that there is a connection between diabetes in adults and either the mean birth weight or the proportion of births that weighed over 153 ounces in Pirnas and the Tohono O'odham. However, these statistics are hard to interpret. By 1984, 41.9 percent of all births to Indian Women in the U.S. were 3500 g. or more, and 0.3 percent were 5000 g. or more, numbers which are the same as for whites (NCHS, 1984). The proportion (41 percent) of all Indian births over 3500 gms. for 1972-1978 was unchanged (I.H.S., 1979), even though diabetes rates were presumably increasing. This discussion would be of interest only to those who equate birth weights and growth and development to nutritional status. However, in 1981 the NIDDK research team proved that obesity in children was directly related to maternal blood glucose levels during gestation (Pettitt et al. 1984). As Adams et al. (1970) had suspected, infants born to mothers with abnormally high glucose levels (i.e., either pre-diabetic or frankly diabetic) grew up to become obese adolescents, and we suspect that they will be obese adults. Pettitt et al. (1984) state that "at 15-19 years of age, (Pima) offspring on non-diabetics, pre-diabetics, and diabetics had obesity rates of 20 percent, 28 percent, and 71 percent, respectively" — which is a correspondence that is highly statistically significant. Although weight gain and obesity in infants and children could be attributed to dietary factors as well as to genetic predisposition, weight gain could also be more indirect evidence that the present epidemic of type II diabetes among the Tohono O'odham began after 1941 and was a highly prevalent metabolic disorder in the early 1950s. The evidence presented above does not contradict other data presented that adult onset diabetes developed rather suddenly among this population over a period of from 12 to 15 years and has continued to increase until the present. 4.5.3.

Birth defects (Table

12)

The other indirect evidence of undiagnosed hyperglycemia and frank diabetes in pregnancy is the rate of birth defects. Many studies (Comess etal. 1969; Miodovnik etal. 1988) have confirmed that these conditions during the prenatal period can cause from two to five fold more defects at birth than occur in children born to mothers with normal gestational glucose levels. Among the Pima from 1965 to 1967, diabetic mothers delivered 19.1 percent infants with anomalies compared to 3.5 percent of live born infants to mothers with normal glucose levels during their gestation (Comess etal. 1969). The defects in these Pima infants were

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found primarily in their cardiovascular system. The cardiovascular system was also affected in 9 of 14 infants in the study conducted by Miodovnik et al. (1988). The available statistics for the Tohono O'odham were searched to calculate rates for congenital defects with attention to the cardiovascular system. Prior to 1964, Indian infant deaths due to congenital defects in Pima County, Arizona, were rarely even mentioned. However, the death rates due to these causes from 1964 through 1982 for Tohono O'odham mothers resident upon the Papago Indian Reservations was 80.9 per 1,000 live births. This rate was 2.5 times the rate for all U.S. Indians and 2.7 times the rate for live births, all races, in the U.S. (p = .0001, a highly significant increase by Chi Square Statistics). The rate in the Tohono O'odham has remained statistically unchanged during 1964-1970 (82.1), 1971-1976 (90.5), and 1977-1982 (70.0) (Justice 1983). However, the infant death rate from congenital defects in those born to Tohono O'odham mothers resident in urban Tucson did increase from 25.0 per 1,000 during 1964-1970 to a range of 46.5-55.1 per 1000 during 1977-1982. Birth defects entered into the I.H.S. computer patient care information system were collected for the period 1960 to 1979. Infants were categorized as having a single major defect or multiple defects. The definitions used were those described by Niswander, Barrow, and Bingle (1975) in their national study of birth defects in 43,526 Indians born in 44 federal hospitals during 1964-1969. The rates from this study were applied to the numbers of single births to Tohono O'odham mothers from 1960-1969 and from 1970-1979 to calculate the "expected" number of infants with birth defects. The "expected" number is the number that would result if the Tohono O'odham had the same rates as that for all U.S. Indians. For the first time period, 87 infants had single major defects (compared to 28 expected), and 29 had multiple defects (only 2.7 were expected). The next decade also produced many times more defects than expected based on the all U.S. Indian rates: 140 single defects compared to 32 expected, and 36 multiple defect infants compared to 3.2 expected. Clearly, these results cannot implicate hyperglycemia as the cause for all the differences, but the high rates of diabetes among women of childbearing ages among the Tohono O'odham are a major distinguishing factor compared to rates in all other U.S. Indian tribes. Specific defects in the Tohono O'odham were compared with the Niswander study rates as well as with published rates for birth defects in

3

The history of diabetes mellitus in the Desert People

107

Atlanta and Nebraska (please see Table 12) by the U.S. Public Health Service, Center for Disease Control (1979). These results show that the differences between expected defects and observed numbers were statistically significantly higher in the Tohono O'odham for the following categories: microencephalies, encephalocele, and total central nervous system (p = .002); dislocation of the hip, (p = .0001); trisomy 21, also called Downs' syndrome (p = .01); and total defects of the cardiovascular system (p = .001), which included ventricular septal defects and patent ductus, both at the ρ = .001 level of significance (the Chi Square test was used to calculate probability values). These comparisons were repeated for birth defects reported only on birth and death certificates, with almost identical results. All comparisons support the finding that the Tohono O'odham resident in Pima County had greater than expected numbers of infants with birth defects since 1960 compared with those either in the U.S. population, all races, or the all U.S. Indian population. 4.6.

Obesity in Tohono O ' o d h a m adults

4.6.1. Women As suggested in the last section, hyperglycemic pregnant females give birth to obese infants who grow up to become obese adults. To prove this progression is a difficult task because so few measurements of weights together with heights were located for adult Tohono O'odham. It would be most interesting to compare body mass indices (BMI) where both measures for this calculation are known, or even weights alone for women throughout the last 50 years. However, the earliest weight (without heights) among both men and women were collected by this author at the San Xavier district of the Papago Indian Reservation in 1965. These were weights recorded in women's medical records chosen at random but matched for age ( + 5 years) to women listed as having diabetes diagnosed by a physician who considered fasting blood glucose levels of 150mg. per dl. as diagnostic. There were 19 women in each group, i.e., with diabetes and with normal results (i. e., below 130 mg. per dl. of glucose in a fasting specimen of blood). The mean weights were 160.9 and 161.3 lbs. respectively, which were not significantly different from one another. The total mean weight of the two groups was 161.1 lbs.

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James W. Justice

A random sample of women's computer records were chosen in 1985 and matched to those in 1965 by age group plus or minus five years. The mean for the 1985 group was 189.6 lbs., which represents a gain of 28.5 lbs. (or 17.7 percent) over the mean weights obtained in the 1965 study. When analyzed by age group, the entire average weight gain was in those subjects under 44 years of age in 1985. Those under 34 years gained 82.6 lbs., (a 53 percent increase over the 1965 group); those aged 40 to 44 gained 16.2 lbs. (or 8.5 percent). All the weight changes for each five year age group after age 44 showed only small gains or losses compared with the 1965 study (see Table 13). Table 13. Tohono O'Odham change in weight, 1965 compared to 1985, females Years

Ages

#

Mean weight (lbs.)

lbs.

Change % of 65 base

1965 1985

30-34 30-34

4 9

158.0 240.6

+ 82.6

+ 153%

1965 1985

40-44 40-44

10 4

191.6 207.8

+ 16.2

+ 8.5%

1965 1985

45-49 45-49

2 3

173.0 165.0

-12.0

-6.9%

1965 1985

50-54 50-54

2 3

169.0 162.0

-7.0

-4.1%

1965 1985

55-60 55-60

8 3

167.5 169.3

+ 1.8

+ 1.1%

1965 1985

65-70 65-70

2 2

183.0 146.5

-36.5

-19.9%

1965 1985

70 + 70 +

6 3

145.0 149.3

+ 4.3

+ 3.0%

38 31

161.1 189.6

+ 28.5

+ 17.7%

Totals 1965 1985

In 1983, the residents of one Papago Indian Reservation, San Lucy (District 11, located in Gila Bend, Arizona) were the subject of a special study on the possible effects on hypertension and cardiovascular disease of drinking water with a high sodium content (Welty etal. 1986 a). Seventy-one Tohono O'odham females aged 25 and over were interviewed. Heights and weights, among other data, were collected and analyzed. Scales were calibrated before each use, and all weights were recorded

3

The history of diabetes mellitus in the Desert People

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over a three month period in 1983. This data had been collected but not reported by the team involved in this study under the direction of Dr. Welty from the PHS Center for Disease Control in Atlanta, Georgia (Welty, Freni-Titulaer, and Zack 1986 b). This sample was 54 percent of the total number of females 25 years and over, using the I.H.S. clinic facility located on this reservation. Their group mean weight was 178.1 lbs., but those 44 years and younger had mean weights of 190.5 ( + / - 38.2) lbs. (age 25-34), and 195.7 ( + / - 30.6) lbs. (35-44yrs.). Those 10 year age groups over 45 years had mean weights of 164.7 +/— 44.0 (45-54yrs.), 164.0 + / - 23 (55-64yrs.), and 158.3 + / - 20.6 lbs. (65-74 yrs.), respectively. This pattern is very similar to that reported for the Tohono O'odham random sample of weights obtained in 1985 by the author. 4.6.2.

Men

Heights and weights of Tohono O'odham men recorded in 1938 were discovered serendipitously in the basement of the Anthropology Department at the University of Arizona where they had been stored. Dr. Norman Gabel in 1938 took a number of measurements of 219 men who desired employment in projects of the Work Projects Administration (WPA) (Gabel 1949). He published his findings only as the means for each measurement for the entire group, but his raw data allowed for comparisons to be made by each age group. Since both heights and weights became available, the body mass index (BMI) could be calculated for each age group from 18 to 75 years. The BMI is found by converting all measurements to metric equivalents and dividing the weight in kilograms by the height in meters, squared. A random sample of 1985 computer medical records were chosen for comparison of heights and weights using 371 men in the same age span. The mean weight for the 1938 group was 157.8 lbs. ( + /— 24.4) compared with a mean weight of 201.9 lbs ( + / - 49.8) for the 1985 sample, a gain of 46 lbs., or a 29.2 percent increase. However, when the age groups are compared, a pattern similar to that of the female emerges. The 18 through 44 year age group showed the greatest average weight gain. As indicated in Table 14, the youngest age group, 18-24 years, gained an average of 57 lbs. The next group, 25 to 34 years gained an average of 49.3 lbs., and those 35 to 44, gained an average of 49.7 lbs. The next three age groups changed as follows: 45-54 gained 7.3 lbs.; 55-64 gained 24.4 lbs.; and 65-74 lost 3.6 lbs.

James W. Justice

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111

As noted above in reference to female weights in the San Lucy survey of 1983 (Welty et al. 1986 a; Welty, Freni-Titulaer, and Zack 1986 b), the weight for 61 males compared to the random sample weights of males recorded in this same study showed similar trends. Their mean weights in pounds (and standard deviations), starting with the 25-34 year group and ending with the 65-74 year olds, were as follows: 219.3 (+/— 45.7), 212.2 ( + / - 58.8), 178.0 ( + / - 37.3), 153.6 ( + / - 17.5), 149.8 ( + / — 37.5). Again, the heaviest men of San Lucy were those born from 1949 to 1958. Their group mean was 197.9 bs. This sample represented 55 percent of all males in those age groups that had been counted as local clinic users. These means are very close to those calculated for males in the 1985 random sample, which did not happen to include any residents of the San Lucy district. The average heights for each age group was practically unchanged over the years. The group mean in 1938 was 1688 (+/— 23 mm.) and in 1985 was 1698 ( + /— 80 mm.). In fact there was very little difference in height in males based on the earliest measurements located, which were taken over 100 years ago. In 1888, Ten Kate (1892) reported a mean height for 17 Tohono O'odham men as 1695 mm. He also measured five women and calculated a mean height of 1576 mm. Table 15 and Figure 7 show the increase in male BMI by age group from 1938 to 1985. A detailed analysis of this data has been published elsewhere (Justice 1993). The effects of obesity (which is a BMI of 20 or more) upon this population have not been studied for differences in either causes, age of death, or illnesses, other than for the increased risk of developing diabetes shown by Pettitt et al. (1982) to be positively correlated in the Pirnas with weight gain, measured by the BMI, as well as for familial prevalence of NIDDM. One study of the Pimas did suggest that mortality rates for males increased significantly only when their body mass index equaled 40 or more. Α BMI of 20 or more is considered obese. However, in females there was no association of mortality with obesity (Pettitt 1982). In summary, the available data on weights and obesity among the Tohono O'odham suggest that the first physical sign of the approaching epidemic of NIDDM was weight gain in children and young adults, beginning during the time period of 1941 to 1954. The data presented about diabetes prevalence, fragmentary and incomplete as it is, suggests that diabetes was first recognized in 1957 and was established by 1965. Since then, the prevalence rates have increased in each age group, have involved more persons at younger ages in each decade since 1957, and

112

James IV. Justice 34 32 30

0-17

18-24

25-34

35-44 Ages

I 7 7 Λ Male 1938

Figure 7.

45-54 1

55-64

65-74

75 *

Male 1985

Statistics on BMI per age group

correspond to an increase in obesity among the pre-adolescent age group. The Tohono O'odham pattern seems to duplicate their better studied Pima cousins to the north.

5. Theoretical stages of the development of diabetes among the Desert People In 1962, J. V. Neel postulated that the pattern of a fluctuating food supply and feast and famine cycles would lead to the accumulation of a gene or genes favorable for the storage of energy in the form of body glycogen during the times of food scarcity. This so called "thrifty gene", or genes, would have a selective advantage in an environment characterized by a fluctuating food supply. However, the thrifty gene becomes detrimental in an environment where there is a constant and plentiful food supply. Such may be the case for the Tohono O'odham. Abetting the accumulation of genes that favor the storage of energy in the body was the relative homogeneity of the gene pool in Southwestern Arizona. The historical isolation of the Tohono O'odham has been documented

3

The history of diabetes mellitus in the Desert People

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by Fontana (1982) and Hackenberg (1982). The relative drift of the gene pool was studied by Niswander (1970), who stated that "the Papago (Tohono O'odham) are relatively undisturbed genetically by admixture either with other unrelated Indian groups or with Caucasians." Indeed, there is also evidence (Fish 1989) that the probable distant ancestors of the present day O'odham did not experience gene mixing through violent invasion or regional warfare, which did befall other ethnic populations in the American Southwest (e. g., the Pueblo cultures, Navajo, Apache, Yavapai, and Yuman tribes). However, while genetics may be a factor that explains the predisposition to NIDDM in this population, it does not account for the recent onset (last 40 years) and extraordinarily high prevalence rates for NIDDM in the Tohono O'odham and the Pima. It may be practical to hypothesize definitions of various states by which a genetic pool of related individuals, living in a similar geopolitical and social environment, pass from a very low or non-existent prevalence of diabetes to a situation in which 50 percent of those over forty years of age are afflicted. The following four theoretical stages are postulated. 5.1. Firststage During the first stage, food supplies are sometimes scarce; food production such as from small family gardens, wild food gathering, and hunting and fishing takes much energy to accomplish, and prepared or refined goods high in carbohydrates are not available. During this state, NIDDM is practically absent except for a few thin persons over 65 years of age. Periodic famine among the Tohono O'odham has been documented by several reseachers (Hackenberg 1982; Fontana 1968). For example, Underbill's (1938 a) informant, Jose Santos from the San Xavier district, interpreted his markings on the calendar stick history as indicating that crops were bad and people were hungry in 1875 and in 1889. A drought with famine during 1889-1890, and again in 1921, was also indicated on a calendar stick from Covered Wells interpreted in 1936 by Sevilla Juan (Juan 1978). The difficulties faced by upland desert farmers who depend upon unpredictable flash floods have been discussed by Joseph, Spicer, and Chesky (1949) and by Castetter and Bell (1942). No one has taken measurements of the amount of energy needed by all members of the extended family to avoid starvation, but it takes little imagination to conclude that planting five or more scattered fields in the hope that at

114

James W. Justice

least one will receive the necessary moisture to produce corn, squash, melons, wheat, peas, lentils, and garbanzos is an exhaustive undertaking. Additional food sources included wild desert plants such as the fruit of the cholla cactus, prickly pear, and saguaro, as well as acorns, wild greens, and mesquite pods. In spite of the constant search for food, Joseph, Spicer, and Chesky (1949) reported that as late as 1941, "almost half the children (43.4 percent) appeared underfed — were thin or emaciated. About the same percentage showed sighs of malnutrition " This report was based upon an examination of 58 boys and 55 girls at two schools and may not be representative of the entire population. In their 1954 report in which obesity trends for Pima and Papago youth were first mentioned, Kraus and Jones felt that "diet and other environmental factors play a minor role, if any, in the growth differntials found among these (i.e., Pima, Papago, Apache, and white children) ethnic groups." Kelly as late as 1962 wrote that "flood water farming still persists, however, in spite of periodic drought, back breaking work, and low yields." Food obtained from farming, although declining, was still needed to supplement the meager cash income from cattle, which averaged less than $ 400 per year per family (Kelly 1963). Papago income sources in 1937 were described by Nichols (1949) as: Cattle, 36 percent; Labor, 27 percent; and "Subsistence", 32 percent. In contrast he reported that income for reservation residents by 1947 was 56 percent from labor, 27 percent from cattle, and only 17 percent from subsistence. By 1962, although subsistence farming was practiced in 37 of the 47 villages studied by Jones (1962), the average size of the fields was only 3.0 to 10.2 acres per person engaged in farming. The most distinguishing feature about the Tohono O'odham food supply for the period before the 1950s was the "seasonal flux in nutrient availability" (Nabhan 1982). Nabhan (1982) goes on to say that "Except for a few easily stored mainstays such as mesquite pod flour, roasted corn, dried beans, and chilies, most foods were available only for brief periods each year". Nabhan's studies give many illustrations that show that the desert people are an excellent example of a population that was exposed to feast and famine during seasonal cycles as well as to periodical cycles of years of fluctuating rainfall. Nabhan (1982) states further that "there are historic accounts of the Tohono O'odham gorging themselves on saguaro fruit for weeks, gaining weight rapidly during that time. They then went back to their fields and sometimes lived on bloodroot amaranth greens until the crops ripened."

3 The history of diabetes mellitus in the Desert People

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5.2. Second stage The second stage begins when there is an increase in food supply availa b l y , i.e., food is available to be eaten each day, every day, and thus periods of food scarcity affect only a minority of the extended families in the community. Energy output begins to decline. Snack food, soda pop, candy, refined flour, and sugar begin to be sold in stores accessible to the community, which means that most families have cash income that enables them to make these purchases. Adults in their mid-life begin to gain weight rapidly, especially women following menopause, and diabetes begins to appear first in the 45 years and older age group among those who are obese. Finally, the school children and teen-agers begin to gain weight, and abnormally high blood sugars begin to appear in obese women of childbearing age. The effects of the contacts between the O'odham and Europeans since the first Spanish visit in 1687 have been to increase their food supply. At first, this increase was achieved by reducing the cyclic seasonality of wild foods. The Spanish introduction of cattle and winter wheat provided meat all year round and grain in early spring before other crops were ripe (Hackenberg 1982). In the arid environment of the Sonoran Desert, well drilling provided a hedge against seasonal and cyclic food variations. Well water was first available in 1870 from the abandoned silver mining towns (Kelly 1963), and later the U.S. Bureau of Indian Affairs in 1908 began an ambitious well drilling and reservoir building program that was eventually to affect the entire reservation (Bryan 1925; Heide etal. 1961). In 1933, 32 deep wells were finished, and by 1953 there were 160 domestic water sources from deep wells, and an additional 23 irrigation wells (Heide et al. 1961). The steady change from a farming, hunting, and gathering society to one in which most individuals become wage earners occurred very slowly until the 1930s. During the 1930s, cotton farming off reservation needed manual labor, and by 1939, one third of all dollars earned by reservation residents came from this work (Spicer 1962). By 1950, 25 percent of all families had some cash income from cattle sales, but most were employed by the cotton industry (Waddell 1969). School children received at least one meal per day through various federal government and private school nutrition programs, but it was not until 1958 that for the first time nearly all children attended school regularly (Spicer 1962), where most received a nutritious lunch (Vavich, Kemmerer, and Hirsch 1954).

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Allotments to the American Smelting and Refining Company were worth over one million dollars to those families who owned this land (Fontana 1960). He indicates that "many Papago (in the San Xavier district) received enough income from that source that many worked less than before." Reduction of effort and physical exertion was present by the 1950s. Kelly (1963) also documented the decrease in small, flood water farming efforts as irrigation of the larger plots of community crops became available as a result of the deep water wells. Kelly (1963) quotes an early report by Clotts in 1914 that a total of "5537 acres" were farmed by the labor intensive flood water methods. Kelly states that by 1953, only 536 of these same acres were farmed in that manner. By 1962, irrigation farming had produced a $ 95,000 income from sale of crops. Most of the planting, fertilizing, and harvesting was mechanized. By 1960, most of the dollars earned by reservation Papagos came from off reservation work or from allotments paid by outside agencies, including the Bureau of Indian Affairs Welfare Program (Kelly 1963). In 1970, fully 50 percent of all registered Papagos were employed wage earners living at least part of the year off the reservation in Tucson, Phoenix, Casa Grande, and the mining town of Ajo (Dobyns 1972). Once wage earning became the primary source for food purchasing, the six trading posts on or near the reservations changed their inventories. As late as 1949, most stores carried only beans, syrup, sugar, flour, coffee, lard, and powdered or canned milk (Vavich, Kemmerer, and Hirsch 1954; Ross 1944). By the early 1960s, these same on-reservation stores started to carry high caloric pre-packed sweets, such as carbonated beverages (i. e., "soda pop"), candy, potato chips, and cakes. None of these foods were mentioned by Ross in her 1941 survey of dietary habits nor by Van Cleft (1955 b), who in 1954 calculated an in-depth survey of the buying habits of 16 families at "the trading posts". Van Cleft (1955 b) concluded that "the Indians no longer depend upon the desert for their food — but depend upon the trading posts for their staples." One thorough but unpublished report in 1962 about the largest reservation trading post (at Sells, the Papago "Capital") stated that "sweets play a large role in the Papago diet. Candy in bulk packages, bars, and penny form is found in most shopping baskets — chocolate and chocolate covered bars are by far the favorite winter and summer — Soda pop is used in immense amounts — over a thousand bottles a week are sold" (Dyer 1962).

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As noted earlier in this chapter, weight gain and obesity were first described in children by Kraus and Jones (1954) in the early 1950s. Therefore, this trend toward obesity in children must have been due largely either to the consistency of seasonal eating or to the quantity of staples available rather than because of the sudden appearance of high calorie foods that came to the trading posts sometime between 1954 and 1962. Finally in 1959, large quantities of refined flour, sugar, and canned fruits high in sugar became available from the U.S. Department of Agriculture surplus commodity food program, and by 1965 were being distributed widely (Van Cleft 1965). Apparently from the incomplete but available data about the Tohono O'odham, weight gain in women and children beginning in the mid-1950s precede the diabetes epidemic. This weight gain can be attributed to both the constant availability of food, particularly refined carbohydrates, and to a reduction in physical activity. However, in the absence of data regarding blood sugar levels or the diagnosis of clinical diabetes during this period, this conclusion cannot be confirmed. 5.3. Third stage The third stage appears when infants born to obese, hyperglycemic (if not frankly diabetic) mothers survive their increased risk of injury at birth and death from congenital defects and grow up as obese children. As these generational changes occur, the proportions of those adults with uncontrolled diabetes for ten or more years increases. Amputations, cataracts, renal disease, and arteriosclerotic peripheral vessel disease appear for the first time. Food supply has remained constant, cash income has increased, expended energy has decreased, and high caloric foods are available to all, especially to children. For the Tohono O'odham, this third stage continued during the 1960s. It should also be mentioned that the use of alcohol apparently soared during this time period, although it had always been present in this culture and was first described by the Spanish, who observed an annual tribal rainmaking ceremony during which they consumed a native alcoholic beverage made from saguaro fruit (Crosswhite 1980). Drunkenness in adult males was observed by Pfefferkorn in 1795 to have occurred from overindulgence in fermented saguaro fruits during the rainmaking ceremony (Ross 1944).

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Although the concordance of alcoholic cirrhosis and the diagnosis of diabetes could not be proven by Reinhard etal. (1977), deaths from cirrhosis first became a serious problem only as late as 1968 (Justice et al. 1975). From this later study, it appeared that the mass exposure of adults to large amounts of alcohol was also a relatively recent event among the reservation desert people. However, alcohol abuse had been a problem for Papagos who lived in urban areas starting in the early 1950s (Waddell 1975). Certainly the effects of alcohol upon a population with a propensity for diabetes could only worsen attempts for blood sugar control and hasten the development of the diabetic complications discussed previously. In a study of risk factors for renal failure, 36 percent of those on dialysis had a history of alcohol abuse (Justice 1982). The above factors of: 1) a constant food supply — or at least the elimination of seasonal food shortages; 2) increased cash income (although the median income remains well below the poverty level in 1980 — 62 percent earn less than § 5,000 per year); 3) eating of refined and high caloric foods; and 4) decreasing physical exertion continue to occur as the hypothetical fourth stage begins. 5.4. F o u r t h stage The fourth stage is characterized by: 1) the constancy of prevalence rates (constant, that is, at a high level) for diabetes for those 45 years and older; 2) increasing prevalence rates among the younger age groups, 15 to 35 years; 3) increasing numbers and rates of diabetic complications and conditions associated with either obesity or diabetes or both (such as uterine cancer and gall bladder cancer; see Justice 1992) plus other diseases; 4) obesity in high proportions (25 percent and above) of primary school children; and 5) the appearance for the first time of adult onset diabetes in those under 15 years of age. This stage began for the Tohono O'odham in the mid-1970s and continues today.

6. Conclusion The preceding information summarized a large number of socio-economic studies about the desert people in order to provide a partial explanation for the appearance of diabetes in the Tohono O'odham in the mid-1960s.

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Weight gain from: 1) a change from cyclic food availability to a constant supply; 2) a reduction in physical effort; and 3) the sudden introduction of high caloric, refined food products, is presented as the environmental changes that have brought about this ongoing tragedy of NIDDM in Indian peoples. What biological evidence is present to support this hypothesis? From the NIH studies on the related Akimel O'odham (The Pima, or literally, the "River People"), several truths that may also apply to the Tohono O'odham seem to be relevant. First, the NIH studies show that obesity per se exposes one to a higher risk of developing type II diabetes by a factor of three to four times (Knowler etal. 1981). In addition, Pettitt etal. (1984) reported that intrauterine exposure of the fetus to high maternal blood sugar levels leads to obesity at a younger age than occurred in the parents and also increases the risk of an individual becoming diabetic at a younger age than the parents. This latter biological mechanism appears to be of sufficient force to partially explain the increasing weight of adolesent children and the increasing prevalence of both diabetes (Bennett and Knowler 1980) and the complications of diabetes in younger aged persons. The alternative explanation offered by Neel (1982), i.e., changes in immune system functions result in an autoimmune reaction against one's self-produced insulin, has not been confirmed frequently enough in any population to be an explanation for the epidemic among this population. There is also increasing evidence that the replacement of the complex carbohydrates found in desert plants (both wild — mesquite and acorns — and domesticated — beans, such as limas, and white and yellow teparies) with refined, high caloric, single carbohydrates does produce a very slowly rising blood glucose level and the corresponding insulin levels in non-diabetic subjects. These low glycemic responses contrasted greatly with those measured following the eating of potatoes, bread, and processed cereal products (Brand et al. 1990). Brand et al. (1990) hypothesize that "the nature of the starch in traditional foods was an important factor in protecting indigenous populations from developing diabetes". Supposedly similar changes in both food availability and the starch content in new or processed foods have been reviewed by Bennett et al. (1984) for many diverse populations such as migrating Yemenite Jews, Australian Aborigines, and many insular native populations of the South Pacific. Bennett et al. (1984) state that their Pima studies do indicate that the incidence of diabetes (NIDDM) among those who consumed complex carbohydrates (starch) was higher than those who increased their simple

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sugar intake (sucrose). However, their study did not include starch from traditional food sources and did not consider the frequency of consumption. There are some indications that similar socio-economic and dietary changes have been associated with the appearance, or the increase, of type II diabetes in other Native American groups such as the Pima (Knowler et al. 1983), the Zuni Pueblo people in New Mexico, and the confederated tribes of Warm Springs, Oregon (Justice 1989). The coincident changes from hunter-gatherer societies to a wage economy and the diagnosis of diabetes in Africa, Asia, and India have been reviewed by Eaton (1977). If the preceding hypothetical arguments are shown to be true after further research, then many diverse ethnic groups in the world may be at similar risk should their lives and food supply change in a manner similar to that of the desert peoples of Arizona. Genetically homogenous groups that have been exposed to cyclic, seasonal variations in food supply for generations, and who have recently been subject to an increasing food supply as well as to processed or refined carbohydrates, would be at especially high risk for diabetes in the space of only one or two generations. Weight gain of women, infants, and children may be the preceding signs. These simple measurements of height, weight, and circumference could be monitored for presumably susceptible populations on a worldwide scale. It is suggested that the more expensive random blood sugar determinations would then be made upon only those peoples that show the weight changes similar to those presented in this report of the Tohono O'odham. Other measures such as the use of the euglycemic clamp technique for the determination of insulin resistance are expensive and impractical for the screening of populations. Even if recent findings (Modan et al. 1985) that suggest "it is insulin resistance and not primarily obesity that leads to glucose intolerance and subsequently diabetes" (Bennett 1986) are confirmed, the measurement of obesity would still remain the most practical screening objective, especially for rural populations. Once high risk populations have been identified who have a high probability of increased fasting blood sugar levels, educational efforts could be implemented at an earlier stage before hyperglycemic complications become manifest in a large segment of the population. This study suggests that cultural and environmental changes were the principle instruments through which diabetes appeared among the Tohono O'odham, although genetic predisposition would need to be present

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in order to explain why only some special populations have developed the highest rates of diabetes as compared with Europeans. Although no one has yet reported a reversal of the stages of diabetes development in a population, there is some evidence that weight loss (Henry, Wallace, and Olefsky 1986), increased physical exertion (Heath et al. 1987), substitution of indigenous and traditional foods for modern refried and high caloric foods (Brand etal. 1990), and the reduction of the total amount of food consumed may have a desirable outcome in halting the spread of this diabetes epidemic among high risk ethnic groups.

References Adams, M. S., K. S. Brown, Β. Y. Iba, and J. D. Niswander 1970 Health of Papago Indian children. Public Health Reports 85 (12), 1047-1061. Bennett, Peter H. 1986 More about obesity and diabetes. Letters to the editor. Diabetologia 29: 753-754. Bennett, Peter, and W. C. Knowler 1980 Increasing prevalence of diabetes in the Pima (American) Indians over a ten year period. In: W. K. Waldhand (ed.), Proceedings of the 10th Congress of the IDF (pp. 507-511). Amsterdam: Excerpta Medica. Bennett, Peter H., William C. Knowler, H. R. Baird, M. J. Butler, David J. Pettitt, and J. M. Reid 1984 Diet and development of noninsulin dependent diabetes mellitus: An epidemiological perspective. In: G. Pozza (ed.), Diet, Diabetes, and Atherosclerosis. New York: Raven Press. Brand, James C., B. Janelle Snow, Gary P. Nabhan, and A. Stewart Truswell 1990 Plasma glucose and insulin responses to traditional Pima Indian meals. American Journal of Clinical Nutrition 51, 416-420. Bryan, Kirk 1925 The Papago Country Arizona: A geographic, geologic, and hydrologic reconnaissance with a guide to desert watering places. U.S. Geological Survey. Washington, D.C.: U.S. Dept. of Interior. Burkalter, Β. R. 1979 Investigations of rapidly changing Papago tribal health programs. Sells, AZ: Papago Tribal Health Department. Carraher, Michael J. 1984 Causes of death in Indians on the Gila River Indian Reservation of Arizona, 1970-1982. Master of Public Health Thesis. Unpublished. Seattle: University of Washington.

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Castetter, Edward F., and Willis H. Bell 1942 Pima and Papago Indian agriculture. Albuquerque: University of New Mexico Press. (Reprinted AMS Press, New York, 1980). Cohen, Β. M. 1954 Diabetes mellitus among Indians of the American Southwest: Its prevalence and clinical characteristics in a hospitalized population. Annals of Internal Medicine 40, 588-599. Comess, L. J., P. H. Bennett, T. A. Burch, and Μ. M. Miller 1969 Congenital anomalies and diabetes in the Pima Indians of Arizona. Diabetes 18 (7), 471-477. Crosswhite, Frank 1980 The annual saguaro harvest and crop cycle of the Papago. Desert Plants 2 (1), 3-63. Dobyns, Henry F. 1972 The Papago people. Phoenix, AZ: Indian Tribal Series. Dyer, Louise 1962 Buying habits of the modern Papagos. Unpublished manuscript. Eaton, Cynthia 1977 Diabetes, culture change and acculturation: A biocultural analysis. Medical Anthropology 1 (2), 41-63. Fish, Paul R., and Suzanne K. Fish 1989 Hohokam warfare from a regional perspective. In: Diana C. Tkaczuk and Brian C. Vivian (eds.), Proceedings of the 20th Annual Chacmool Conference (pp. 112-119). Calgary, Canada: University of Calgary Press. Fontana, Bernard 1960 Assimilative change: A Papago Indian case study. Thesis for doctor of philosophy. Tucson, AZ: University of Arizona, Department of Anthropology. 1968 Man in arid lands: The Piman Indians of the Sonoran Desert. In: George W. Brown (ed.), Desert Biology, Vol. 2 (pp. 489-528). New York: Academic Press. 1982 History of the Papago. In: William C. Sturtevant (ed.), Handbook of North American Indians, Vol. 10 (pp. 137-148). Washington, D.C.: Smithsonian Institution. Gabel, Norman 1949 A Comparative racial study of the Papago. University of New Mexico publications in anthropology. Number 4. Albuquerque, NM: University of New Mexico Press. Hackenberg, Robert A. 1967 The parameters of an ethnic group. A method for studying the total tribe. American Anthropologist 69 (5), 478-492. 1982 Pima and Papago ecological adaptation. In: William C. Sturtevant (ed.), Handbook of North American Indians, Vol. 10 (pp. 161-177). Washington; D.C.: Smithsonian Institution.

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Heath, Gregory W., Bruce E. Leonard, R. H. Wilson, J. S. Kendrick, and Κ. E. Powell 1987 Community-based exercise intervention: Zuni diabetes project. Diabetes Care 10 (5), 579-584. Heide, L. Α., Ο. J. Cosner, H. G. Page, C. A. Armstrong, and L. R. Kister 1961 Summary of occurrence of ground water on the Papago Reservation, Arizona. United States Department of Interior Geological Survey. Tucson, AZ: U.S. Dept. of Interior. Henry, R. Ε., T. A. Burch, P. H. Bennett, and M. Miller 1969 Diabetes in the Cocopah Indians. Diabetes 18, 33-37. Henry, R. R., P. Wallace, and J. M. Olefsky 1986 Effects of weight loss on mechanisms of hyperglycemia in obese noninsulin-dependent diabetes mellitus. Diabetes 35, 990-998. Hurtado, Felix 1985 Report on Diabetes on the Papago Reservation. Unpublished manuscript. Tucson, AZ: IHS Tucson Program Office. Indian Health Service 1979 Selected Vital Statistics for Indian Health Service Areas and Service Units 1972 to 1977. Rockvill, MD: Dept. of Health, Education and Welfare, pp 25-39. (Pub. No. (HSA) 79-1005). Jones, Delnos J. 1962 Human ecology of the Papago Indians. Thesis for Master of Arts, Department of Anthropology. Tucson, AZ: University of Arizona. Joseph, Alice, Rosamond B. Spicer, and Jane Chesky 1949 The desert people. Chicago: University of Chicago Press. Juan, Sevilla 1978 Papago 208 project water quality report and management plan. Tucson, AZ: Office of Environmental Health, Indian Health Service, O.R.D., DHHS, pp. 130-148. Justice, James W. 1965 San Xavier survey of diabetic Papago population and controls compared for family history, weight, and blood pressure. Unpublished manuscript. Phoenix, AZ: Indian Health Service, Epidemiology Training Program. 1967 Carbohydrate intolerance among the Gila River Tribes of Arizona (abstract). Proceedings of the Second Joint Meeting of the Clinical Society and Commissioned Officers' Association of the United States Public Health Service, Atlanta, GA. Rockville, MD: United States Public Health Service, p. 7. 1982 Renal failure in a Southwestern Indian tribe. Abstract in Proceedings of the 17th Annual Meeting of the USPHS Professional Association, Orlando, FL. Rockville, MD: United States Public Health Service, p. 20.

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A preliminary survey of birth defects among Papago Indians. Unpublished Report. Tucson Program Office. Tucson, AZ: Indian Health Service. 1989 Twenty years of diabetes on the Warm Springs Reservation, Oregon. American Indian Culture and Research Journal 13 (3 & 4), 49-81. 1993 How diabetes came to the desert people. Monograph. N.A.R.T.C. Univ. of Arizona, Tucson, AZ. (In preparation) Justice, James W., K. R. Reinhard, R. S. Klappenbach, Ε. W. Rogg, and D. A. Rabin 1975 Alcohol-related mortality and morbidity in a Southwestern Unted States Indian Population. Abstract, in: Proceedings of the 10th Joint Meeting of the professional associations of the U.S. Public Health Service, Las Vegas, Nevada., Rockville, MD: U.S. Public Health Service, p. 38. Kelly, William H. 1963 The Papago Indians of Arizona: A population and economic study. Tucson, AZ: The Bureau of Ethnic Research, Department of Anthropology, University of Arizona. Knowler, W. C., D. J. Petitt, P. J. Savage, and P. H. Bennett 1981 Diabetes incidence in Pima Indians: Contributions of obesity and parental diabetes. American Journal of Epidemiology 113 (2), 144-157. Knowler, William, D. J. Pettitt, Peter H. Bennett, and R. C. Williams 1983 Diabetes mellitus in the Pima Indians: genetic and evolutionary considerations. American Journal of Physical Anthropology 62, 107-114. Kraus, Bertram S., and Bonnie M. Jones 1954 Indian health in Arizona. Second annual report of the Bureau of Ethnic Research. Tucson, AZ: Univ. of Arizona. Pp. 94-95. Miller, Max, P. H. Bennett, and Thomas A. Burch 1968 Hyperglycemia in Pima Indians: A preliminary appraisal of its significance. Biochemical challenges presented by the American Indian. Washington, D.C.: W.H.O., Pan American Health Organization, pp. 89-104. (Scientific Publication No. 165) Miodovnik, Menacham, F. Mimouni, P. Dignan, M. Berk, J. L. Ballard, T. A. Siddiqi, J. Khoury, and R. C. Tsang 1988 Major malformations in infants of IDDM women: Vasculopathy and early first-trimester poor glycemic control. Diabetes Care 11 (9), 713-717. Modan, Μ., H. Halkin, S. Almog, A. Lusky, A. Eshol, M. Shefi, A. Satnt, and Z. Fuchs 1985 Hyperinsulinemia — a link between hypertension, obesity, and glucose intolerance. Journal of Clinical Investigation 75, 809. Nabhan, Gary P. 1982 The desert smells like rain. A naturalist in Papago Indian country. San francisco: North Point Press.

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Diabetes mellitus: A "thrifty" genotype rendered detrimental by "progress"? American Journal of Human Genetics 14 (3091), 353-362.

The thrifty genotype revisited. In: J. Koeblerling and R. Tattersall (eds.), The genetics of diabetes mellitus. Serono Symposium, No. 47. New York: Academic Press. Nichols, J. R., Burton A. Ladd, and Thomas A. Segundo 1949 The Papago development program. Sells, AZ: U.S. Dept. of Interior, Bureau of Indian Affairs. Niswander, Jerald 1966 Prevalence of diabetes on the Papago Indian Reservation. Annual Project Report of NAIMD 1967-68. Bethesda, MD: National Institute of Health, National Arthritis, Intestinal, and Metabolic Disease. Niswander, J. D., K. S. Brown, Β. Y. Iba, W. G. Leyohon, and P. L. Workman 1970 Population studies on Southwestern Indian tribes. History, culture, and genetics of the Papago. American Journal of Human Genetics 22 (1), 7-23. Niswander, Jerald, and M. S. Adams 1973 Birthweights of North American Indians: A correction and amplification. Human Biology 45 (3), 351-357. Niswander, Jerald, Μ. V. Barrow, and A. J. Bingle 1975 Congenital malformations in the American Indian. Social Biology 22 (3), 203-215. Parks, J. H., and E. Waskow 1961 Diabetes among the Pima Indians of Arizona. Arizona Medicine 18, 99-106. Pettitt, D. J., J. P. Lisse, W. C. Knowler, and P. H. Bennett 1982 Mortality as a function of obesity and diabetes mellitus. American Journal of Epidemiology 115 (3), 359-366. Pettitt, David J., H. R. Baird, M. J. Carraher, and W. C. Knowler 1984 Genetic and intrauterine environmental effects (offspring of nondiabetes mellitus, diabetes mellitus, and pre-diabetes mellitus and obesity) in transmission of diabetes mellitus. (Abstract). American Journal of Epidemiology 120 (3), 477-482. Prusnitz, L. R., L. R. Mandell, and G. L. Mandell 1967 Diabetes mellitus among Navajo and Hopi Indians: The lack of vascular complications. American Journal of Medical Sciences 253, 700-705. Reinhard, Karl, and Ν. I. Greenwalt 1975 Epidemiological definition of the cohort of diseases associated with diabetes in southwestern American Indians. Medical Care 13 (2), 160-173.

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Reinhard, Karl, Ν. I. Greenwalt, A. L. Todd, M. A. Madden, and D. A. Rabin 1977 Diabetes mellitus and alcoholic liver cirrhosis in an American Indian population. Unpublished manuscript presented at the 105th annual meeting of the American Public Health Association. Ross, Winifred 1944 The present day dietary habits of the Papago Indians. Master of Science Thesis. University of Arizona: School of Home Economics. Seltzer, R. A. 1963 Multiphasic screening project in an Indian school. Public Health Reports 78 (11), 971-76. Sievers, Maurice 1985 Former Chief of Medicine, Phoenix Indian Medical Center. Personal Communication. Sievers, Maurice, and Jeffrey Fisher 1985 Diabetes in American Indians. In: Maureen I. Harris and Richard F. Hamman (eds.), Diabetes in America, Nat'l Diabetes Data Group. (Chapter XI). Rockville, MD: Dept. of Health and Human Services. (NIH Pub. No. 85-1468) Smith, C. G. 1970 Culture and diabetes among the Upland Yuma Indians. Unpublished doctoral thesis. University of Utah: Department of Anthropology. Spicer, Edward 1962 Cycles of conquest: The impact of Spain, Mexico, and the United States on the Indians of the Southwest. 1533-1960. Tucson, AZ: University of Arizona Press. Spier, Leslie 1930 From notebooks. "Maricopa — Haldchidoma". Informant, Ida Redbird. Unpublished field notes provided by Mrs. Spier. Strotz, Christopher, and Gregory Shorr 1973 Hypertension in the Papago Indians. Circulation 48 (6), 1299-1303. Ten Kate, Herman 1892 Somatological observation on Indians of the Southwest. Journal of American Ethnology and Archaeology (3) 2, 121. Underhill, Ruth M. 1938 a A Papago calendar record. Anthropological Series Vol. 2, No. 5, Albuquerque, NM: University of New Mexico Bulletin, No. 322. 1938 b Singing for power. New York: Ballantine Books Inc., pp. 19-25. Van Cleft, Kathleen 1955 a Annual report: Fiscal year 1955. Unpublished manuscript. 1955 b Nutritional deficiencies among school children on the Pima and Papago reservations. Unpublished report. Public Health Service. Phoenix Area Public Health Unit, Casa Grande, AZ. 1965 A comparison of nutritional deficiencies among school children on the Papago reservation in 1954 and 1965. Unpublished manuscript.

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Vavich, M. G., A. R. Kemmerer, and J. S. Hirsch 1954 The nutritional status of Papago Indian children. Journal of Nutrition 54, 121-131. Waddell, Jack O. 1969 Papago Indians at work. Anthropological Papers of the 2000University of Arizona, No. 12. Tucson, AZ: University of Arizona Press. 1975 For individual power and social credit. The use of alcohol among Tucson Papagos. Human Organization 34 (1), 9-16. Welty, Thomas, Lambertina Freni-Titulaer, Matthew M. Zack, Peter Weber, Jeffrey Sippel, Nina Huete, James W. Justice, Dan Dever, and Mary Ann Murphy 1986 a Effects of exposure to salty drinking water in an Arizona community. Journal of the American Medical Association 255 (5), 622-626. Welty, Thomas, L. W. Freni-Titulaer, and M. Zack 1986 b Prevalence of hypertension, diabetes, and health risk factors in Papago Indians and non-Indian populations living in Gila Bend, Arizona. Unpublished manuscript. Atlanta, GA: USPHS, Center for Disease Control. Wetzel, Norman C. 1948 The role of the grid technique in a physical fitness program. Medical Woman's Journal, p. 18.

Chapter 4

Many Farms revisited: Evidence of increasing weight and non-insulin dependent diabetes in a Navajo community Teri R. Hall, Martin E. Hickey, Terry B. Young

1. Introduction The treatment of choice for non-insulin dependent diabetes mellitus (NIDDM) is weight loss and exercise; however, for most diabetic patients, shedding pounds and engaging in vigorous activity are difficult. Also, many patients apparently question whether losing weight will be of significant benefit. However, if it could be demonstrated that diabetes did not exist in a population when that population was trim and highly active, then the current overweight population which is afflicted with diabetes might be more responsive to a weight loss regimen in order to return to the non-diabetic state. While many anecdotal reports exist from various Native American tribes that diabetes did not exist in the past, and memories of parents and/or grandparents are of trim and highly active individuals, the data to document this in any Native American group is sketchy at best (West 1974). Recently, specific historical medical information about one particular group of Indians was discovered in the form of charts that were preserved from the famous Navajo-Cornell Field Health Research Project (Cornell Project) in the 1950s. The availability of this information presented a unique opportunity to compare in individuals from essentially the same population the prevalence of NIDDM and obesity of thirty years ago with the prevalence of those same problems today. Thus, we undertook a review of the old clinic charts and at the same time estimated the current prevalence of NIDDM through a field sample of the same community. What was learned from that chart review and field study, and why those results may have occurred in such a short time frame (thirty years), is the subject of this chapter.

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In 1955 a unique cooperative project to establish a primary care clinic in the Many Farms-Rough Rock area of the Navajo Reservation (see map in fig. 1) was undertaken by the Navajo Tribe, Cornell University Medical School, and the U.S. Public Health Service. The purpose of the clinic was to experiment with innovations in the delivery of Western allopathic health care in a non-Western traditional culture before the Public Health Service's establishment of an extensive network of clinics on the Reservation. The genesis for this experiment was based on the experiences in 1952 of Cornell University Medical School Staff, who were called upon to investigate an outbreak of infectious hepatitis at the Tuba City BIA school. The results of their experience demonstrated that simply providing acute health care services without any attempt to accommodate traditional Navajo beliefs could doom those services to failure. Thus a medical team lead by Dr. Walsh McDermott, which included physicians, anthropologists, nurses, and local Navajo leaders such as Annie Wauneka, established a clinic to deliver primary care and to educate local people in disease prevention. The Many Farms-Rough Rock community was chosen because of its general representativeness of the reservation terrain, culture, demography, and socioeconomic status. The experiment was unique because the medical team created bridges with the local culture and traditional healers. Specifically, the concept of Community Health Representatives was pioneered, and requirements for various types of health professionals and support personnel in such an environment were developed. One of the most important consequences of the program was the development of mutual appreciation by both patients and health professionals for each other's approach to illness.

2.

Many Farms then and now

2.1. The 1950s Members of the Many Farms-Rough Rock community in the 1950s were considered to be living fairly "traditionally", residing in hogans within family "camps". The Navajo people then were primarily herders and farmers living in widely dispersed, seasonal, extended family-based camps. These camps were generally located in remote areas, which required extensive travel by wagon and horseback. Activity levels were described

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as moderate to heavy, including much walking and horseback riding (Fulmer and Roberts 1963). Most families depended on their gardens for staple foods, which included corn, melons, and squash. Farming activities also demanded moderate to heavy labor. Electricity and running water were non-existent, and transportation was difficult, all of which significantly influenced health patterns on the Reservation. At the time of the original project, average life expectancy was 30-40 years (U.S. average 70 years); infant mortality was 108.6/1000 (26.6/1000 U.S. average); and TB mortality was 53/10,000 (10.5/10,000 U.S. average) (Adair, Deuschle, and McDermott 1957). Seventy-six percent of the community health problems were the result of microbial disease, with pneumonia and infant diarrhea the major causes of death (McDermott etal. 1960). The Cornell project was well-received by the community, resulting in a high level of participation (Adair, Deutshle, and Barnett 1988). By the end of the project, approximately 1600 subjects of all ages had been included in the study (90 percent of the area population), with two thirds of that total using the clinic frequently (McDermott, Deuschle, and Barnett 1972). The clinic made a significant impact on tuberculosis in the area; the success of the clinic was attributed to extensive health education about how to treat and prevent the disease. This education was accomplished primarily through the use of the Navajo community health workers trained by the program. The research team was committed to improving the health status of the Navajo people, particularly by impacting on the infectious diseases and by building the aforementioned cultural bridges. But as they came to know the community and particularly its health problems, they began to have a concern that the Navajo people might merely exchange their particular pattern of disease for that of the dominant culture. As Fulmer and Roberts (1963: 762) warned: " . . . we would do well to exercise caution and not inflict these people with our disease pattern along with our civilization." Unfortunately that concern was well founded, particularly in regard to diabetes. 2.2. The 1980s In 1988, the Many Farms-Rough Rock Health Survey Project was conducted under a grant from the Indian Health Service to determine the current prevalence of NIDDM and overweight status in the community. During that survey, we observed that most community residents continued

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Figure 1. Map of the Navajo and Hopi reservations, and location of the Many Farms-Rough Rock Chapters

to live in remote areas in the traditional family camps, with most camps continuing the same family lineage. But major changes were noted to have occurred in lifestyle. In particular these were found to be in the new found ease of transportation (trucks, cars) and in the direct local access to plentiful, prepared, and preserved foods (including commodity foods). As such, the level of energy expenditure to maintain daily living requirements became significantly reduced at the same time access to energy (food) was significantly increased. As will be noted later, these changes have had a significant impact on the development of NIDDM in this community. Other changes consistent with the diffusion of Anglo culture into the reservation include the increased access to electricity, television, and shopping centers in nearby Chinle and Kayenta.

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3. Methods A comparative study was undertaken by reviewing data in the medical records from the Cornell Project and comparing it to data collected from the recent filed survey and current medical charts at the Chinle Comprehensive Health Care Facility. Medical records compiled during the project are currently under the supervision of Dr. Clifford Barnett, who was a member of the Cornell Medical School research team. Permission was obtained from Dr. Barnett to review these records for biomedical data from this historic community cohort. These data included: sex, age, and diabetes status for 827 adults, 20 years and older. Complete height and weight data were available for a subsample of 509 adults. Due to the difficulty of obtaining a representative sample in this community using conventional sampling methods, a geographically-based cluster sampling designed by the World Health Organization was utilized (Henderson and Sundaresan 1982). An aerial map of family camps was used as the sampling frame to randomly select 34 camps from in the 117 camps identified during the original Navajo-Cornell Project. Field-based data collection was assisted by a Navajo interpreter as many adults speak Navajo exclusively or by preference. Data collected on 231 individuals, 20 years and older (17 percent of the estimated adult population) included: age, sex, height, and weight. Capillary blood samples were also collected and analyzed at the Chinle Comprehensive Health Care Facility (Chinle, AZ) for serum glucose content. Individuals with elevated random serum glucose values ( > 140mg/dl) were recalled for further evaluation. This evaluation consisted of drinking a 75 gram glucose load and a serum glucose test two hours later. Those with a serum glucose greater than 200 mg/dl were classified as diabetic as per the World Health Organization (1985) diagnostic criteria for NIDDM. In addition to field data collection, medical records at the Chinle Comprehensive Health Care Facility were reviewed to verify self-reported diabetes status. Those who were currently diagnosed and treated for diabetes were not tested further. A description of the historic and current Many Farms-Rough Rock community cohorts is given in Table 1. A more detailed description of the study methods is reported in Hall, Hickey, and Young, 1992.

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Tab. 1. Summary statistics: Many Farms-Rough Rock community historic and current cohorts Historic cohort

Current cohort

Subjects

Number

%

Number

%

Female Male Total

441 386 827

53.3 46.7 100

140 91 231

60.6 39.4 100

Age

years

years

mean range

41.2 + 17.0 20-92

44.7 + 18.7 20-98

BMI

kg/m2*

kg/m2*

Female mean ( + SD) range

24.6 + 4.8 16.3 - 41.6

27.7 + 5.2 16.6 - 45.8

Male mean (+ SD) range

23.4 + 3.6 15.5 - 37.2

26.0+ 4.7 17.2 - 40.0

(all differences between historic and current cohorts significant at ρ < .01) * based on complete information on 281 females and 228 males in historic cohort

4. Results and comparison In the original Cornell Project only 8 cases of diabetes out of a sample of 827 adults were documented in the charts. An addtional review of urinalyses from the old charts for 593 individuals did not turn up any unknown diabetic patients from that group. In contrast, twenty-nine diabetic patients (22 currently diagnosed and 7 newly discovered through the sampling process) were identified out of the 231 adults participating in the recent survey. The age-adjusted prevalences and risk ratios of overweight and NIDDM for the two cohorts are shown in Table 2. As can be seen, the increased prevalence of NIDDM in the community is quite striking. The prevalence in the current cohort is 12.4 percent compared to 1.2 percent in the historic cohort. Thus a member of the current Many Farms-Rough Rock community is 10 times more likely to be diagnosed with NIDDM than a member of the historic group. For males this increased risk, which is eighteen times that of the historic cohort, is particularly remarkable.

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Table 2. Age-adjusted prevalence of N I D D M and overweight3 in the Many Farms-Rough Rock community historic and current cohorts (standardized to 1980 US general population)

NIDDM Total Female Male

Risk ratiob

Current cohort

Historic cohort

prevalence (95% CI)

prevalence (95% CI)

12.4% 14.3% 10.8%

(8.1, 16.7) (8.5, 20.1) (4.4, 17.2)

1.2% 1.7% 0.6%

Overweight 43.7% Total Female 50.7% Male 33.1%

(37.3, 50.1) (42.4, 59.0) (23.4, 42.8)

18.9% 26.3% 12.6%

(0.5, (0.5, (-0.2,

1.9) 2.9) 1.4)

10.3 8.4 18.0

(15.5, 22.3) (21.2, 31.4) (8.3, 16.9)

2.3 1.9 2.6

(all current cohort prevalence values significantly greater than historic cohort prevalence, ρ = .0001) 1

BMI (kg/m 2 )

b

Risk Ratio =

equivalent to > 120% Ideal Body Weight Current cohort prevalence Historic cohort prevalence

Overweight is defined as Body Mass Index (BMI equals weight in kilograms/height measured in meters squared: kg/m 2 ) equivalent to > 120 percent Ideal Body Weight, using the criteria of the National Health and Nutrition Examination Survey II (National Center for Health Statistics 1987). The estimated increase in the proportion of overweight individuals in this community is dramatic. The overall prevalence rate has more than doubled from 19 percent in the historic cohort to 44 percent in the current cohort. The trend of increasing BMI in the community over the last thirty years is illustrated in Figures 2 and 3. The mean BMI for each 10 year age interval has increased in both females and males. This increase is particularly evident at younger ages. Current cohort females have significantly greater mean BMI at all age intervals, except the 30-39 years age group and those over age 80. Current cohort males have significantly greater mean BMI at ages 20-50 than older males. The trend of higher mean BMI in young to middle-aged males may be the result of a cohort effect, i.e., older males (over 50 years of age) in the current cohort represent the slim, young, and middle-aged males in the historic cohort. These older men have apparently maintained their slimness with aging.

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Teri R. Hall, Martin E. Hickey, Terry B. Young 40

Γ

35

30 : 120·/. IBW

\

>5

25 20

d Historic cohort

15

• 10 0

10

20

30

40

50 Age

Λ 60

I 70

I 80

L 90

Current cohort

100

Figure 2. Mean BMI (kg/m 2 ) by age intervals: females (*p < .01)

40

35

30

^ 1 2 0 ° / . IBW

5 25 ID 20

15

10

J 10

L 20

30

J 40

I 50 Age

I 60

L 70

J 80

L 90

δ

Historic cohort

*

Current cohort

100

Figure 3. Mean BMI (kg/m 2 ) by age intervals: males (*p < .05).

The higher overall mean BMI of young males in the current cohort, however, implicates the effects of lifestyle changes occurring during the last thirty years. These results indicate that there has been a dramatic increase in the prevalence of both obesity and NIDDM in this community (Figure 4 and Figure 5). Furthermore, both obesity and NIDDM prevalence in this group exceed that of the US general population. A current member of

4

Diabetes mellitus in a Navajo community

•

Total

Ε

Female

•

Male

137

* ρ=.0001 Historic cohort

Current cohort

Figure 4. Comparison of age-adjusted prevalence of overweight (BMI kg/m2 > 1 2 0 percent IBW) in the Many Farms-Rough Rock community

20

15

10

•

Total

0

Female

•

Male

*

ρ = .0001

frzCl—, Historic

Current

cohort

cohort

Figure 5. Comparison of age-adjusted prevalence of NIDDM in the Many Farms-Rough Rock community

the Many Farms-Rough Rock community has almost twice the risk of being overweight (43.7 percent compared to 25.6 percent) or diabetic (12.4 percent compared to 6.8 percent) than the U S general population (National Center for Health Statistics 1987).

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Teri R. Hall, Martin E. Hickey, Terry B. Young

Discussion: Why N I D D M and obesity have increased

5.1. Environmental factors in changing societies NIDDM has drastically increased in many groups experiencing recent, rapid lifestyle changes but is rare or non-existent in traditional living groups. This trend in the expression of the disease suggests the importance of environmental factors that apparently "unmask" an underlying genetic susceptibility (Knowler et al. 1983; Mohs, Leonard, and Watson 1988; Sievers and Fisher 1981; Szathmary, Rittenbaugh, and Goodby 1987; Weiss, Ferrell, and Hanis 1984; World Health Organization 1985; Zimmet 1979; Zimmet 1988). The genetic susceptibility, or defect, is the development of resistance to the action of insulin at the cellular level, which then leads to an increase in serum glucose. The expression of this susceptibility seems to be stimulated by the onset of obesity and exacerbated by a decrease in the level of physical activity. NIDDM seems to emerge in groups undergoing a rapid shift from a subsistence to a wage economy. This shift often causes drastic social, cultural, economic, and environmental disruption. Factors relating this lifestyle shift to the development of NIDDM include dietary changes (both an increase in total caloric intake and changes in dietary composition) and a reduction in activity level. Either one or both of these factors may lead to the development of increasing body mass and, in turn, NIDDM. In addition, the role of emotional stress accompanying this lifestyle shift may be implicated in an as yet undetermined manner (King et al. 1984; Szathmary, Ritenbaugh and Goodby 1987; World Health Organization 1985; Zimmet 1988).

5.2. The "Thrifty Gene" Neel (1962) first proposed the "thrifty genotype" hypothesis to explain the increasing prevalence of obesity and NIDDM in American Indians. During times of fluctuating food availability, the capacity for efficient energy storage would be an advantageous adaptation. This adaptation would become detrimental, however, during times of more constant food supplies by contributing to the development of obesity and eventual NIDDM in genetically pre-disposed individuals. While much of human evolutionary success may be due to our nutritional adaptability, many of the chronic health problems currently affecting us may be diet-related (Brown and Konner 1987; Eaton and

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Konner 1985). Because chronic diseases are usually expressed at postreproductive ages, natural selection provides an inadequate mechanism for adaptation to the recent changes in food availability and diet composition. Successful adaptation to these conditions must therefore involve changing previous behavioral patterns, such as not eating any and all food when it is available in order to increase energy stores for when it is not. 5.3. Obesity and culture Obesity is implicated as the main environmental determinant of and most powerful risk factor for NIDDM (Bray 1987; Salans, Knittle, and Hirsch 1983; Van Itallie 1985). This risk factor is modulated through the influence of obesity on the development of insulin resistance. As body mass index increases and as activity decreases, more insulin resistance is produced, leading to even higher serum glucoses in the NIDDM patient. That is, the more obese and sedentary an individual, the more profound the insulin resistance and NIDDM (Reaven 1988). Obesity is often a consequence of lifestyle, and therefore is subject to the influence of cultural patterns and socioeconomic factors (Bray 1979; Mohs, Leonard, and Watson 1988; National Institutes of Health 1987). Socially accepted and culturally determined levels of food intake may act permissively and/or facilitatively in the development of obesity. In Navajo culture this is particularly true as food and feasting play a prominent role in how clans and individuals relate to one another. Also, various socioeconomic factors have been found to influence food choices. Low socioeconomic status has been associated in many studies with caloriedense, high fat and refined carbohydrate diets (Mohs, Leonard, and Watson 1985). Cultural traditions may also greatly influence attitudes toward food and fatness. Fatness is still considered a sign of health and well-being among many Native Americans, while weight loss may be a cause of concern (Lee et al. 1985). In addition, traditional diet patterns that were well-adapted to cyclical food availability with few food choices may now contribute to obesity. This tradition may encourage individuals to eat excess amounts of whatever food is available, whenever it is available (Mohs, Leonard, and Watson 1985). In describing Navajo eating patterns during the early 1940s, Kluckhohn and Leighton (1974: 93) noted: "Most Navahos (sic) are accustomed to tightening their belts and going for days on nothing more than coffee and a little bread, but they will gorge when

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opportunity offers. They pride themselves on being able to go a long time without food. The whole pattern is that of alternation between eating a little and eating a lot". This pattern was obviously a useful adaptation to the challenge of fluctuating food availability in a farming, gathering, and herding lifestyle. Continuing this behavioral pattern in a time of greater access to a more constant food supply can obviously lead to over-consumption and consequent obesity. This can be particularly troubling when the available food has as high a fat content as did the initial commodity food programs on the Navajo Reservation (Wolfe and Sanjur 1988). During the Cornell Project, researchers noted that the "traditional" diet was still commonly consumed. This diet was based on mutton, bread, potatoes, and coffee consumed 2-3 times a day, when available. While more variety was possible because of the increased availability of foods at trading posts, the overall diet was not significantly affected because of transportation and economic limitations (Fulmer and Roberts 1963). More recently, though, food is much more available due to government commodity food allocation and more accessible local commerce and shopping centers. Over-consumption, especially of refined carbohydrates and "junk foods", has now become a major concern of health-care providers on the Reservation (Broudy and May 1983). In a recent survey of contemporary Navajo diet, Wolfe and Sanjur (1988) reported that the most frequently consumed foods are fry bread, potatoes, eggs, and sugar added to beverages (1988). Soda pop or other sweetened drink mixes are also commonly consumed. "Traditional" foods eaten include mutton, tortillas, and fry bread. While 52 percent of the households sampled grow corn, squash, and melons in household gardens, most gardens are small and are no longer a major source of food. During the survey, respondents reported eating several meals at the fast food restaurants that are found in many of the larger Reservation communities. No fast food restaurants existed in the Many Farms-Rough Rock region at the time of the Cornell Project. 5.4. Reduced physical activity During this same survey, Wolfe and Sanjur (1988) found that although 63 percent of the sample of females 20-90 years of age were overweight ( > 1 2 0 percent IBW), the mean caloric intake was only 82 percent of the Recommended Daily Allowance. The investigators thus suggest that the

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low physical activity levels observed during their study were likely an important explanation for the high prevalence of the overweight state. Reduced physical activity is another environmental factor that influences the development of N I D D M directly through metabolic mechanisms and indirectly by contributing to increasing body mass. Exercise programs for diabetics have demonstrated that increased activity even without accompanying weight loss results in increased insulin sensitivity and improvement of glucose tolerance (National Institutes of Health 1987; Reaven 1988, Taylor et al. 1984; World Health Organization 1985). This has recently been demonstrated in diabetics from several populations, including the Zuni (Heath et al. 1987). Further evidence of the importance of physical activity was reaffirmed during an unusual experiment utilizing a temporary reversion to a traditional foraging lifestyle in a group of diabetic Australian Aborigines (O'Dea 1984). This lifestyle alteration included both an increase in physical activity as well as a favorable change in dietary composition and reduction in total caloric intake. The group showed an overall improvement in insulin secretion and action, two of the major metabolic defects in N I D D M (O'Dea 1984; Zimmet 1988). Quantification of actual energy expenditure is generally difficult in field studies. Most observations of changing activity levels are based an anecdotal information regarding historical changes in physical activity patterns. It is clear, however, that daily subsistence activities and transportation needs have until recently required moderate to heavy energy expenditure in most tribal groups (Sievers and Fisher 1981). The farming and herding activities of the Navajo people living in remote areas formerly demanded a great deal of physical labor. Walking and horseback riding have only recently been replaced by motor vehicle transportation for most Navajos. The implication of this decreased activity level is well understood by many elderly Navajos, who blame reduced physical activity rather than greater food consumption for increasing obesity on the Reservation.

5.5. Sociocultural disruption A nurse with the Navajo Area IHS, who lived in the Many Farms area during the Cornell Project, provided additional historical information on the impact of socio-cultural changes on the community. This informant attributed current health problems, including obesity, to socio-cultural disruptions beginning in the early 1960s. Historically, families in the

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Many Farms area had engaged in considerable gardening and farming, producing corn, beans, squashes, melons, peaches, and apricots, major components of the family diet. Family sheep herds provided a fairly reliable source of meat. Both farming and herding demanded a great deal of physical activity. Grandparents cautioned young family members against becomg "fat and lazy", exhorting them to "keep busy" tending livestock and gardening. By the early 1970s, reliance on farming and herding had declined as the wage economy became the primary economic base in the community. In addition, fewer elders lived within the extended family, which decreased their influence on family diet and activity patterns. At the same time, pick-up trucks became the preferred and more available mode of transportation. The informant further suggested that the increased reliance on motor vehicles has had a strong relationship to many current health concerns. Not only is there less walking, horse-back riding, and herding on the Reservation, but also people have greater access to food stores and fast food restaurants, which has resulted in an overall increase in consumption of "junk food". Thus significant socioeconomic changes due to a shift from a primarily subsistence economy to a wage economy have occurred on the Navajo Reservation in the past thirty years (Broudy and May 1983). This transition has led to lifestyle alterations, including changes in diet and physical activity patterns, which in turn have contributed to increasing rates of obesity in the Many Farms-Rough Rock community. This obesity, in conjunction with the decreased energy expenditure, has in turn lead to the physiologic expression of NIDDM in individuals who are genetically susceptible to insulin resistance. Clearly, the concerns expressed by the Cornell Project team that the diffusing Anglo culture would also bring changes in disease patterns were indeed justified.

6. Conclusions and significance for the future This study has clearly demonstrated that unlike today, NIDDM was not the major affliction of the Navajo people in the Many Farms-Rough Rock community of thirty years ago. During the past thirty years, there have been significant environmental changes (a change in diet and a decline in energy expenditure), resulting in obesity and in an increasing prevalence of NIDDM. There are essentially two options available for

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reversing this increase. The first is to somehow intervene in the genetics of the disease to eliminate the underlying predisposition to insulin resistance. To do this will require extensive resources to fund genetic engineering experiments. But even if the aberrant gene can be found and altered, it is highly doubtful that entire Native American population groups will be willing to subject themselves to such alterations. The second approach is to influence behaviors through education and by altering factors that support maladaptive behavior. While this approach may seem as difficult as that of changing genetics material, it is certainly much more efficient as well as more practical. Examples of such educational approaches include the possibility of using social marketing techniques to reach and educate patients about the role of overeating and inactivity in the development of NIDDM. Another approach is to utilize the techniques pioneered by the Zuni project to change the activity ethic of a community. Finally, there is much promise in working with school age children, teaching them new eating and activity patterns. The results of this study, which have clearly demonstrated that the Navajo people previously were more trim, led a more active lifestyle, and did not have NIDDM, suggest that environmental influences can be significant in the control of the disease. The Navajo people described in the Cornell Project are a role model to be emulated by today's people, i.e., that they should become more active and not consume excessive quantities of food. Finally, returning to the basic concepts and discoveries of the original Navajo-Cornell Project may hold many of the keys to finally achieving a behavioral-environmental intervention that successfully reduces and controls NIDDM in the Navajo people. As was initially noted, the project was founded on the concept that any medical interventions had to be culturally amenable and understandable to the target population, and that such interventions were best implemented when the Navajo people and their "healers" were involved in the delivery of health care and health education. This was how tuberculosis was overcome in the late fifties and early sixties, and will likely be the way the NIDDM will be overcome in the nineties.

A cknowledgmen

ts

We are indebted to Melvin Harris; Bill Gloyd, M. D.; Sue Savage, M. D.; and Esther Frazier and other staff members of the Chinle Comprehensive Health Care Facility for their advice and assistance. We especially thank the members

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of the Many Farms and Rough Rock communities who participated in this study. This study was supported by an IHS 437 Grant, NAR-87-11.

References Adair, John, Deuschle, Kurt, and McDermott, Walsh 1957 Patterns of health and disease among the Navajos. Annals of the American Academy of Political and Social Science 311, 80-94. Adair, John, Deuschle, Kurt, and Clifford Barnett 1988 The peoples' health: Anthropology and medicine in a Navajo community (Rev. ed.), Albuquerque: Univ. of N. Mexico Pr., pp. 143-160. Bray, G. A. 1979 Obesity in America: an overview. In: George Bray (ed.), Obesity in America. National Institutes of Health. Bray, G. A. 1987 Overweight is risking fate: Definition, classification, prevalence and risks. Annals of the New York Academy of Sciences 499, 14-28. Broudy, D. W. and P. A. May 1983 Demographic and epidemiological transition among the Navajo Indians. Social Biology 30, 1-16. Brown, P. J. and M. Konner 1987 An anthropological perspective on obesity. Annals of the New York Academy of Sciences 499, 29-46. Eaton, S. B. and M. Konner 1985 Paleolithic nutrition: a consideration of its nature and current implications. The New England Journal of Medicine 312, 283-289. Fulmer, H. S. and R. W. Roberts 1963 Coronary Heart Disease — among the Navajo Indians. Annals of Internal Medicine 59, 740-764. Hall, Τ., M. Hickey and T. Young 1992 Evidence for recent increases in obesity and non-insulin dependent diabetes mellitus in a Navajo community. American Journal of Human Biology 4, 547-553. Heath, G., B. Leonard, R. Wilson, J. Kendrick and K. Powell 1987 Community-based exercise intervention: Zuni Diabetes Project. Diabetes Care 10, 579-583. Henderson, R. H. and T. Sundaresan 1982 Cluster sampling to assess immunization coverage: A review of experience with a modified cluster-sampling method. Bulletin of WHO 60, 253-260. King, H., P. Zimmet, L. R. Raper and B. Balkau 1984 Risk factors for Diabetes in three Pacific populations. American Journal of Epidemiology 119, 396-409.

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Kluckhohn, C. and D. Leighton 1974 The Navaho. Cambridge: Harvard University Press. Knowler, W. C., D. J. Pettitt, P. H. Bennett and R. C. Williams 1983 Diabetes mellitus in the Pima Indians: genetic and evolutionary considerations. American Journal of Physical Anthropology 62, 107-114. Lee, E. T., P. S. Anderson Jr., J. Bryan, C. Bahr, Τ. Coniglione and M. Cleves 1985 Diabetes, parental Diabetes and obesity in Oklahoma Indians. Diabetes Care 8, 107-113. McDermott, W., K. Deutschle, J. Adair, H. Fulmer and B. Laughlin 1960 Introducing modern medicine in a Navajo community, Parts I and II. Science 131, 197-205 and 280-287. McDermott, W., K. Deuschle and C. Barnett 1972 Health care experiment at Many Farms. Science 175, 23-31. Mohs, Μ. Ε., Τ. K. Leonard and R. R. Watson 1985 Selected risk factors for Diabetes in Native Americans. Nutrition Research 5, 1035-1045. Mohs, Μ., T. Leonard and R. Watson 1988 Interrelationships among alcohol abuse, obesity and Type II diabetes mellitus: focus on Native Americans. World Review of Nutrition and Dietetics 56, 93-172. National Center for Health Statistics 1987 National health and nutrition survey II. National Institutes of Health 1987 Consensus development conference on diet and exercise in noninsulin dependent diabetes mellitus. 10, 639-644. Neel, J. A. 1962 Diabetes mellitus: a "thrifty genotype" rendered detrimental by "progress?" American Journal of Human Genetics 14, 353-362. O'Dea, K. 1984 Marked improvement in carbohydrate and lipid metabolism in diabetic Australian Aborigines after temporary reversion to traditional lifestyle. Diabetes 33, 596-603. Reaven, G. M. 1988 Role of insulin resistance in human disease. Diabetes 37, 1595-607. Rolland-Cachera, M. and F. Bellisle 1986 No correlation between adiposity and food intake: Why are working class children fatter? Journal of Clinical Nutrition 44, 779-787. Salans, L. B., J. L. Knittle and J. Hirsch 1983 Obesity, glucose intolerance and Diabetes Mellitus. In Ellenberg, Μ. and Η. Rifkin (eds.) Diabetes mellitus: Theories and practice. New Hyde Park, NY: Medical Examination Publishing Co., Inc. Sievers, M. and J. Fisher 1981 Diseases of North American Indians. In: Henry Rothschild (ed.) Biocultural Aspects of Disease. New York: Academic Press.

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Szathmary, E., C. Ritenbaugh and C. S. Goodby 1987 Dietary change and plasma glucose levels in an Amerindian population undergoing cultural transition. Social Science and Medicine 24, 791-804. Taylor, R., R Ram, R Zimmet, L. R. Raper and H. Ringrose 1984 Physical activity and prevalence of diabetes in Melanesian and Indian men in Fiji. Diabetologia 27, 578-582. Van Itallie, T. 1985 Health implications of overweight and obesity in the United States. Annals of Internal Medicine 103 (6 pt 2), 983-988. Weiss, K. M., R. E. Ferrell and C. L. Hanis 1984 A new world syndrome of metabolic diseases with a genetic and evolutionary basis. American Journal of Physical Anthropology 127, 153-178. West, Κ. M. 1974 Diabetes in American Indians and other Native populations of the new world. Diabetes 23, 84-855. World Health Organization 1985 Diabetes Mellitus. Geneva: WHO. Wolfe, Wendy S. and D. Sanjur 1988 Contemporary diet and body weight of Navajo women receiving food assistance: An ethnographic and nutritional investigation. Journal of the American Dietetic Association 88 (7), 822-827. Zimmet, R 1979 Epidemiology of diabetes and its macro vascular manifestations in Pacific populations: The medical effects of social progress. Diabetes Care 2, 144-153. Zimmet, P. 1988 Primary prevention of diabetes mellitus. Diabetes Care 11, 258-262.

Chapter 5

Diabetes among the Kiowa: An ethnohistorical perspective Benjamin R. Kracht I have heard that you intend to settle us on a reservation near the [Wichita] mountains. I don't want to settle. I love to roam over the prairies. There I feel free and happy, but when we settle down we grow pale and die. (Set'aide "White Bear," cited in Mooney

1979: 208)

White Bear's prophetic speech in 1867 at the Medicine Lodge Treaty sessions accurately predicted the fate of the Kiowa and other Southern Plains tribes — Cheyenne, Arapaho, Comanche, and Plains Apache — assigned to reservations the following year. The fact that these people were not amenable to a sedentary existence until their military subjugation in 1875 attests to their devotion to a lifestyle based on gathering and pursuing the migratory bison herds. As prophesied by White Bear, settling on a reservation not only brought about the demise of the horse and buffalo culture of the Southern Plains but also affected Kiowa health and general well-being. The purpose of this chapter is to examine the historic literature about the settlement of the Kiowa, Comanche, and Plains Apache (KCA Indians) Reservation in an effort to define the conditions responsible for the emergence of "diseases of civilization" such as type II diabetes mellitus (non insulin dependent diabetes mellitus). The major premise of this chapter is that dietary change, obesity, a sedentary lifestyle, and the lack of exercise have provided the necessary conditions for the emergence of type II diabetes mellitus as a major health problem among the Kiowa. Although it is impossible to account for the initial appearance of diabetes among the Kiowa population, the historic sources do provide both Indian and non-Indian interpretations of the factors deemed most responsible for the increase in diabetes. Once this historic baseline has been established, I will then describe some of the spiritual means the Kiowa are using to help them cope with this disease.

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1. Historie perspective The rates of type II diabetes mellitus are higher among American Indians than in the U.S. population in general (Leonard and Leonard 1985: 17). Recent statistics released by the Oklahoma City Area Indian Health Service indicate that diabetes mellitus is indeed a serious health problem facing Oklahoma Indians. In 1988, the IHS tabulated 272,962 Oklahoma Indians registered in the nine areas serviced by the IHS hospitals. In the 1987 fiscal year, there were 37,015 outpatient visits for diabetes, ranking diabetes second only to hypertension for visits to IHS. The Lawton Service Unit serves the Kiowa, Comanche, Plains Apache, Fort Sill Apache, Caddo, Delaware, and Wichita tribes. Altogether, these tribes are represented by a resident population of 16,783; clinics available for them include the Lawton Indian Hospital, Anadarko Health Center, Carnegie Health Center, and the Riverside Indian School Health Station (the latter two have no full-time staff, only outreach services). Between 1983 and 1985, the Lawton Service Unit reported 19 deaths from diabetes mellitus (6.7 percent of total deaths), ranking it as the fifth leading cause of death among the resident population. The other leading causes of death in descending order were heart disease (22.5 percent of total deaths), malignant neoplasms (16.5 percent), accidents and adverse effects (10.5 percent), and chronic liver disease and cirrhosis (7 percent). It is thus apparent that diabetes mellitus is a major health problem among the Kiowa and affiliated tribes (Oklahoma City Area Indian Health Service 1988: 43, 48, 20, 54). A number of researchers have documented a strong correlation between obesity and diabetes in American Indians (Leonard and Leonard 1985: 17; Joos 1984: 218) and in other indigenous groups throughout the world that "have undergone major socioeconomic changes accompanied by increasing obesity" (Knowler et al. 1983: 109; see Smith 1970:134-135, 164). Increased obesity has been attributed to a change from "diets high in fiber and unrefined carbohydrates to diets high in refined carbohydrates and sugar and low in fiber" (Lang 1982: 4) and to changes in energy expenditure, e. g., changing from a hunting and gathering lifestyle to a sedentary lifestyle (Eaton 1977: 42, 44-46). Some researchers believe that James Neel's (1962) "thrifty genotype" hypothesis explains the emergence of diabetes among American Indians; the "thrifty" genotype and a steady food supply introduced by modernization, compounded by inactivity caused by a sedentary existence, have led to increased fat storage and

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insulin production, resulting in obesity, and ultimately, diabetes (Knowler etal. 1983: 113; Smith 1970: 126-127, 134-135, 137). A study of diabetes among the Florida Seminole (Joos 1984) suggests that diabetes is a recent phenomena for the Seminoles that can be traced to changes in the "social, economic, and subsistence spheres of life ... twenty to thirty years ago" (Joos 1984: 218). Another· study among the Inuit of Canada, confirms this claim (Schaefer 1971: 13). Moreover, Joos states that contemporary studies of diabetes mellitus among North American Indians "have neglected to examine the influence of both the historical background and the contemporary social situation on changes in diet and health status in these populations" (Joos 1984: 218). With this in mind, it is necessary to determine the earliest evidence if the conditions reponsible for the emergence of diabetes, i.e., changes in diet and lifestyles.

1.1. Pre-reservation f o o d s eaten by the K i o w a Prior to forced settlement on the KCA Reservation, there were approximately ten to twenty prominent Kiowa kindreds to which the rest of the tribe was affiliated; each of these "primary political unitfs]" (Richardson 1940: 6) constituted a band. In a pre-reservation population of approximately 1600, each band numbered between twelve and fifty tipis at any given time. These flexible bands, or topadoga, were led by the most prominent Kiowa band chiefs, or camp chiefs, esteemed men who selected camping locations as the bands followed the migrating bison herds. During the mid-nineteenth century, the Kiowa bands hunted buffalo between the Arkansas River in Southwest Kansas and the Staked Plains in the Texas Panhandle (Kracht 1989: 366-367, 371). Kiowa social organization was analogous to that of the bison herds: the herds aggregated in mid-June during the summer rut, the same time the Kiowa bands coalesced for the Sun Dance and the summer hunt; afterwards the Kiowa split into topadoga that pursued the mating herds until they dispersed in the late fall and early winter. At that time, the Kiowa topadoga fragmented into nuclear and extended family groups that hunted the small, scattered, male and female herds. Springtime brought on the calving season, which marked the upcoming summer rut when the herds and the Kiowa again coalesced. Such was the annual cycle of Kiowa buffalo hunting (McHugh 1979: 156-157; Levy 1961; Kracht 1989: 376).

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Besides buffalo, pre-reservation game included deer and elk. The Kiowa also ate turtle, turkey, and quail. Boys were known to hunt rabbit and to fish for recreation, but these meats were never eaten by adults, except during times of food scarcity. In addition, certain meats and internal organs were taboo for priests, warriors, and curers with particular medicine powers, and the Kiowa particularly avoided eating bear meat. Indeed, some Kiowa still remember the bear meat taboo and claim that the Kiowa "are brothers to the bear" (I have been told that a bear carcass with the fur removed resembles a human being). Although the Kiowa were very fond of their horses, they were known to consume horse flesh, particularly when war parties ran out of food. Young puppies were also eaten at times. A large variety of wild vegetables and fruits supplemented the Kiowa diet, including turnips, onions, mesquite beans, skunkberries, plums, grapes, hackberries, currants, and "chokingberries". Berries gathered in the late summer and early fall were eaten fresh or else boiled, pounded, dried, then placed in parfleche bags for winter consumption along with dried and jerked meat. Some roots and tubers were consumed as well. In general, the Kiowa had a rich and varied diet.

1.2. Kiowa subsistence during the Reservation Period, 1868-1901 Following their defeat, the Kiowa, Comanche, and Plains Apache subsisted entirely on government rations in 1875 and 1876, for they were not permitted to leave the reservation without a military escort (Mooney 1979: 339; Annual Report of the Commissioner of Indian Affairs [hereafter ARCIA] 1878: 610-611). Like many Indian tribes fed by the government, the Kiowa were issued such commodities as "beef, salt pork, coffee, rice, beans, flour, sugar, and dry corn" (Powers and Powers 1984: 61). Before 1868, the Kiowa had been issued rations as an inducement to come to the Indian agencies, but in 1868, Congress ratified the Medicine Lodge Treaty with the provision that rations would be distributed to the KCA Indians for a thirty year period. After 1875, these foods became a major part of the Kiowa diet (Kracht 1989: 380, 445). At first, the Kiowa did not care for the foods provided at the agency. For instance, when issued rice for the first time, some individuals thought the tiny white grains were dried maggots, so the camp criers were told to notify the people; as a result, the rice was discarded on the ground. Likewise, they mistook slab bacon for bear meat and refused to accept it. Government efforts in 1875 to introduce the Kiowa to raising sheep

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and goats failed because the Kiowa did not care for the meat. The animals were turned loose on the prairie where they were killed by young boys and coyotes (Nye 1983: 249-250). Similar efforts to turn the Kiowa into swine herders were also fruitless (Crawford 1915). Early attempts to transform the Kiowa into farmers also were unsuccessful primarily because the Kiowa were not agriculturally inclined, especially since they had no oral traditions concerning agriculture. They resisted all pressures to become farmers, prompting their Indian agent to report in 1892 that of all the tribes in the area, they were the most "backward in agricultural pursuits" (ARCIA 1892: 386). The Comanche and Plains Apache — sharing a hunting traditiion with the Kiowa — also refused to farm, but the Wichita, Caddo, and Delaware, who occupied the same reservation, successfully grew crops near the Kiowa Agency. In 1937, Colonel Wilbur S. Nye, who wrote a history of the Kiowa Agency, summed up as follows the efforts to turn the Kiowa into farmers: "The attempt to make farmers of these people was not a success, and remains a failure to this day" (Nye 1983: 258). Because the government did not transform the Kiowa into farmers and stock raisers, starvation conditions often prevailed during the early years of the Reservation Period. The extirpation of the Southern Plains bison herds by 1881 greatly exacerbated the problem, particularly because Congress appropriated rations with the intent that they supplemented buffalo meat (Kracht 1989: 449). Beef had become the major meat consumed on the KCA Reservation, and the government tried to promote tribal cattle herds to eliminate the ration system. However, Congress failed to allocate sufficient rations to compensate for the disappearance of the bison herds, so the Kiowa were compelled to slaughter their breeding herds in order to survive. For instance, rations were issued weekly in 1881, but the Kiowa frequently went two to three days a week with little or no food, and according to Agent George Hunt, hunger was a major problem at the Kiowa Agency: "About three years ago (1878) the buffalo disappeared, and instead of the government ration being increased, it has been reduced about one-fourth by insufficient appropriations" (ARCIA 1881: 138). Because food rations were decreased, the Kiowa were compelled to subsist on the scanty rations available; they had a steady, albeit inadequate food supply that was consumed within a few days. Thus, consuming all available foods at once became a pattern attributable to inadequate ration distributions. More new foods were introduced to the Kiowa in 1878 when their agency was moved from Fort Sill (north of present-day Lawton), thirty

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miles north to Anadarko, situated on the Washita River. At this time, traders obtained government licenses to peddle their goods to the Indians from stores located at the agency (Methvin n.d.: 53-56). In 1886, the Kiowa and Plains Apache began receiving lease payments — "grass money" — from Texas cattlemen renting pasturage on the KCA Reservation (the Comanche accepted their payments a year earlier because the other tribes refused any rent monies until driven by starvation; they thought the payments were for the sale of their reservation, which they opposed [Mooney 1979: 220, 350-351, 354-355, 358-359; Methvin n.d.: 80; ARCIA 1886: 348]). Since the Indians economically were in the process of adopting a cash economy, the traders responded by offering a credit system at their stores. Hence the Kiowa and affiliated tribes began purchasing new foods on credit (Sneed 1936: 152). A trader operating one of the four government-licensed stores listed the foods they liked best as follows: "The Indians were very fond of fruit, such as prunes, figs, dates, raisins, etc., and large quantities of these were purchased in nearly every consignment; also the best grade of canned goods.... The stock [also] included staple and fancy groceries, canned goods, cured meats, etc" (Sneed 1936: 139). As evidenced by the above data, Kiowa subsistence patterns within a matter of twenty years shifted from hunting and gathering to a cash economy and dependence on government rations and store bought goods. Once buffalo eaters, they now consumed beef and packaged commodities. 1.3. Living in houses: The Kiowa become sedentary In the spring of 1875, the Kiowa, treated as prisoners of war, camped in a single village along Cache Creek under the watchful eye of the U.S. Army at nearby Fort Sill. Life in this consolidated village was not conducive to Kiowa well-being due to the lack of sanitation and because of the unhealthy conditions that prevailed in the crowded camp. For these reasons, the Kiowa Agency was moved from Fort Sill to Anadarko in 1878; by that time, it had been suggested that the best way to remedy the Kiowa living situation was to move them into houses. As early as the fall of 1877, the government built houses for the ten Kiowa chiefs deemed most "peaceful" toward the government during the recent Kiowa and Comanche "outbreak" (ARCIA 1878:777; 1878:457). Not accustomed to living in "boxes", the chiefs camped nearby in tipis, which they found more accommodating. Dogs, snakes, and other creatures inhabited the houses instead (Nye 1983: 250; Kracht 1989: 469-70).

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The trend established by the peace chiefs of not living in houses applied to the rest of the Kiowa, for during the next twenty years, houses were built for everyone, especially in 1900-1901 when the KCA Reservation was parceled into allotments. Perhaps the biggest encumbrance faced by the Indian agents, government field matrons, and missionaries between 1877 and 1917 was inducing the Kiowa to live in their houses (ARCIA 1885: 310; 1886: 346; 1887: 164). For instance, in 1890 the Kiowa camped in four different parts of the reservation, prompting their agent to write: "Comparatively few have permanent homes; the camp being moved from season to season to suit the comfort and convenience of the family" (ARCIA 1890:186). One of the initial problems associated with constructing homes for the KCA Indians was that the Indian agents expected the Indians to provide their own labor; it took a great deal of effort to induce them to help out (Mooney 1979: 342; ARCIA 1878: 557). The situation changed after the fall of 1892, when the KCA Indians were cajoled into signing the Jerome Agreement, thus agreeing to the breakup of their reservation through individual allotments of 160 acres apiece (see Hägen 1985: 11-30). Allotment did not occur until 1900-1901, primarily due to the "great uneasiness of the Indians ... caused by the treaty)" (ARCIA 1896: 257). Their agent wrote in 1896 that they were not ready for "civilized surroundings", and that assigning them individual allotments and forcing them to live in houses was analogous to "confining the wild deer to a pen" (ARCIA 1896: 257). Another problem with the houses was sanitation. Accustomed to moving frequently between camps, the Kiowa had never experienced the accumulation of refuse and human waste to the extent that it created health problems (except when they were confined near Fort Sill after the "outbreak"). In 1895, field matrons were hired to visit Indian homes and to help the women with cooking, cleaning, and basic home repairs. Much credit goes to these devoted individuals, many of them women missionaries (see Crawford 1915; n.d.), for helping to improve sanitation within the homes, thereby benefiting Indian health conditions (Kracht 1989: 483; ARCIA 1895: 252; 1896: 257; 1897: 232-233). Finally, once the Kiowa were settled into their houses after the turn of the century, the Indian agents still had difficulty dissuading them from periodically living in camps. The Kiowa love for camping could not be easily broken, as evidenced by the Ghost Dance movement of 1894-1916. Unlike the earlier Ghost Dance movement that swept the Oklahoma Territory in 1890-1891, this version of the Ghost Dance was a syncretic

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blend of Christian and Kiowa beliefs. In short, the revived Ghost Dance was the Kiowa interpretation of Christianity, with emphasis on the trance state so popular during the earlier movement (Mooney 1896: 924; Kracht 1989: 803-815). The Indian agents and Christian missionaries did everything in their power to break the Ghost Dance, which concomitantly rekindled an interest in war dancing and was partially responsible for spawning the modern powwow (Kracht 1989: 808-810). Hence the campaign between 1909-1934 to outlaw Indian dances (in particular those of the Kiowa) stemmed from complaints by non-Indians about the Indians leaving their houses unoccupied to participate in tribal and intertribal dances. It was also a common complaint that those Kiowa not adhering to the "dance crowd" often left their houses vacant while attending Christian camp meetings, which usually lasted from several days to a couple weeks (Kracht 1989: 821-846). Thus, compelling the Kiowa to become sedentary was not an easy task. 1.4. Inactivity and lack of exercise Of all the conditions conducive to the emergence of diabetes as a major health problem, the imprisonment of the Kiowa prisoners of war following the "outbreak" of 1874-1875 clearly produced a period of inactivity which led to the decline of their health. In May 1875, Kicking Bird, one of the Kiowa "peacefuls", was asked to select twenty-six "hostile" Kiowa to serve prison terms at Fort Marion, Florida. Twenty Kiowa and six Mexican captives — the Kiowa and Comanche frequently kidnaped children from Texas, New Mexico, and Mexico; the children were raised by couples who had lost their own children to epidemics and other causes (see Corwin 1959) — were chosen to serve prison terms (Mooney 1979: 215). On M a y l , 1878, thirteen of the Kiowa and Mexican captives were released from Fort Marion and returned to the KCA Reservation (Nye 1983: 250-251; Mooney 1979: 216; Levy 1959: 40). Thus, only half of the original twenty-six Kiowa prisoners came home; five (all Kiowa) died in Florida, and eight stayed east to attend the first Indian boarding schools in Hampton, Virginia, and Carlisle, Pennsylvania (Mooney 1979:216). Agent P. B. Hunt noticed vast changes in the men: "There has been a very great change in these people, not only in their appearance, but a complete and thorough reformation in every particular" (ARCIA 1878: 555). Sixteen years later, Mooney noted that compared to the Mexican prisoners, the Kiowa had suffered greatly from confinement and

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inactivity: "It is notable, as showing the comparative vitality of the races under new conditions, that of the twenty Indians on the list (of prisoners) only five are still alive, and one of these is dying of slow consumption, while all of the six Mexican captives are still in vigorous health" (Mooney 1979: 216). Paul Zotom, one of Mooney's principal Kiowa informants "returned (from the east coast) in the summer of 1881, but has sadly fallen from grace" (Mooney 1979: 216). Photographs of Paul Zotom taken by Mooney show that obesity had become a major health problem for him (Kracht 1989: 471; see photograph in Ewers 1978). Another collaborator, Setk'opte, or "Mountain Bear", returned to the KCA Reservation in 1882, "nearly dead from consumption contracted in the east, and although of more manly charcater than Zotom is now almost helpless for any practical purpose, being a confirmed invalid" (Mooney 1979: 216). It is difficult to discern from Mooney and Hunts' descriptions that the Fort Marion prisoners actually suffered from a disease such as diabetes, especially since Mountain Bear's symptoms, described as "consumption", are problematic. Nevertheless, the photographs of Paul Zotom definitely indicate that he was extremely overweight, which undoubtedly affected his health. That five out of twenty Kiowa died while prisoners in Florida and only five were living in 1896 suggests that the stress of separation from their people and their confinement directly influenced their wellbeing. Future archival research may shed more light on this topic. 1.5. Further dietary changes in the nineteenth century The first solid evidence suggesting that a change in diet, lifestyle, and perhaps to a lesser extent, the stress of acculturation were affecting Kiowa health comes from an unpublished manuscript entitled "Autobiography of a Kiowa Indian". Transcribed by Weston LaBarre in 1936, this manuscript relates the life history of Charlie Apekaum (Charcoal), who served as translator and principal collaborator for the Santa Fe field school in 1935 (LaBarre n.d.). The following statement by Apekaum reflects that the Kiowa perceived that a new lifestyle was responsible for their health problems (LaBarre n.d.: 17): I don't know what accounts for this, but we've had more people sick, and more operated on for different reasons at the present time. And the Indians think probably it is the food, canned goods and too much of the white man's food and way of living, diet and so on, where they used to have their own dried fruit. According to the last statistics from the Kiowa Agency

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the Indians are increasing — it is because they are becoming accustomed to live in houses, but it took a long time, hardship and sickness, caused a lot of death. But since they have learned hygiene and sanitation they have become accustomed to it. Apekaum's insightful statement acknowledges that by 1936, the Kiowa had devised their own explanatory models blaming the prevalence of sickness on new foods and living in houses. Apekaum's testimony prompted me to discuss the first known appearance of diabetes among the Kiowa with one of my principal collaborators, who is in her early eighties. She informed me that she first heard of diabetes as well as tuberculosis shortly before 1930. Moreover, like many Kiowa over the age of 45 whom I have interviewed over the last several years, her parents died when she was a child, and she emphasized that her grandparents, born in the 1870s, were quite healthy and lived to old age. She specifically indicated that the change in diet beginning with the distribution of government rations "did them (the Kiowa) in". This and other interviews I have conducted in Carnegie and Anadarko, Oklahoma coincide with the "Dakota narratives of illness" collected by Gretchen Lang (1989). As with the Devils Lake Sioux, the Kiowa with whom I have discussed diabetes contend that a change in diet is largely responsible for its prevalence among tribal members over 40 years of age. One woman even went so far as to say that the problems with Kiowa health derive from the fact that they are now "beef eaters"; she said that beef is higher in fat than buffalo. It is important to point out that some of the currrent Kiowa "delicacies" include bote, or "tripe", liver, and kidneys. These organs are savored particularly by Kiowa elders and are usually consumed at meals served during Kiowa Ceremonials. It should be noted that according to pamphlets distributed by the Indian Health Service Hospital in Lawton, consumption of internal organs by diabetics must be carefully monitored (Becton Dickinson and Company 1985: 30-31). Further changes in Kiowa diet occurred during the years of the Great Depression, and several collaborators have described how their families subsisted on fried squirrel and rabbit during the 1930s and 1940s. It appears that by this time, the local deer population was severely depleted by over-hunting, so smaller rodents — meats formerly avoided by the Kiowa — became the principal sources of meat. According to an informant who grew up in a Kiowa community near Saddle Mountain, .22 rifles were a rarity in his area, so the boys manufactured slingshots from forked sticks and rubber from old tire inner tubes; squirrels and rabbits which ended up on the family dinner table were skillfully killed with this weapon.

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In addition, despite a history of antipathy toward farming, some Kiowa began cultivating small garden plots to feed their families. Tomatoes, beans, and potatoes were the principal cultigens. Significantly, potatoes became a major part of the Kiowa diet, although they were almost always fried. One collaborator even mentioned that non-Indians residing in the same area (after allotment, Indian and non-Indian lands in Oklahoma represented a patchwork mosaic) also consumed fried potatoes. It is noteworthy from statements by informants that fried foods were well-established among the Kiowa by the 1930s. Of course, frybread is still a popular item in the Kiowa diet, as it is among other tribes. Frybread, also called "fried bread", dates back to the Reservation Period when the Kiowa began receiving government rations. The basic recipe to feed a family of four or five calls for three cups of flour, a pinch of baking powder and salt, and lukewarm milk (or water). After kneading the mixture slowly to allow the proper amount of air to be worked into the dough, small pieces are pulled off and rolled into small balls, which are then flattened into a doughnut shape. The pieces are then deep-fried in Crisco shortening or lard. That frybread is considered an "Indian food" can be observed by attending tribal ceremonies in Oklahoma as well as intertribal powwows in Oklahoma and Texas. Food stands always have an ample supply ready for sale, and the great demand for this item keeps the vendors busy. Evening meals ( a common phrase is that the powwow committee will "sponsor a feed") typically feature frybread, along with beef stew, canned and baked beans, and cupcakes. Sometimes "Indian tacos", or "Navajo tacos", i.e., frybread topped with ground beef, lettuce, and shredded cheese, are featured at the food booths and evening meals (see Lang 1989: 456; 1985: 254). The standard joke usually announced by the emcee or arena director is that the concession stands are selling "low calorie" frybread. Understandably, most diabetics know that they cannot eat frybread because of the flour, the lard, and the high caloric content. To summarize, it should be mentioned that foods consumed by the Kiowa are very similar to those eaten by the Devils Lake Sioux, as recorded by Gretchen Lang (1989: 455; 1985: 254), especially since many low income Kiowa families qualify for government commodities, which are distributed from the Kiowa Tribal Complex. Lang noted that the Sioux receive "canned or storable shelf products not intended to provide a balanced diet" (Lang 1989: 455). The same commodities are received by needy Kiowa families.

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In addition, patterns of eating beyond fullness exist among the Kiowa, and several Kiowa with whom I have discussed this matter also claim that overeating is an Indian trait. On one occasion in which I visited some elderly Kiowa, I gave them a large bag of meat and groceries, which I assumed was several days worth of food; I was rather surprised when most of it appeared on the dinner table that evening. In fact, after two weeks in the field, I gained ten pounds! I was well fed by everyone, even non-Kiowa. The practice of eating all available foods coincides with patterns from the Reservation Period, when the Kiowa consumed their rations in a matter of a few days, and when they slaughtered their breeding herds when confronted by starvation conditions. Research among other tribes will undoubtedly present parallel patterns of food consumption.

2. Diabetes among the contemporary Kiowa: A spiritual concern When I conducted my dissertation research in the vicinity of Carnegie and Anadarko, Oklahoma, between January and May, 1987, I had no idea that I would collect data concerning the prevalence of type II diabetes mellitus among the contemporary Kiowa. Nevertheless, since I was recording data related to Kiowa belief systems, I found that Indian health issues (and general well-being) could not be ignored, particularly because in American Indian societies, curing and religion are intricately related (Hultkrantz 1989: 7-8; 1981: 59; Vogel 1970: 27). I increasingly became aware of the prevalence of diabetes among the Kiowa after interviewing Kiowa who were Christian and who were attending services at several Kiowa churches. Christian missionaries initially sojourned to Kiowa country between 1869 and 1887, but were largely unsuccessful in converting the Kiowa to Christianity. After 1887, Methodists, followed by Baptists, Catholics, and several smaller denominations, established missions and contract boarding schools among the KCA Indians. Gradually, they converted a handful of Kiowa, and by 1941, most Kiowa claimed affiliation in Christian churches. Today, there are numerous Christian Kiowa who attend Methodist, Baptist, and Pentecostal churches, and significantly, church services (and prayer meetings held in homes) frequently feature tearful testimonies. In historic Kiowa society, the Kiowa believed that the spirit forces were best approached

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in a pitiful manner, so it was not unusual for them to cry while praying. When the early Kiowa converts attended camp meetings held under tents and arbors, they quickly blended the tradition of crying and praying when they placated the Christian God; tearful invocations fit in well with the testimonials (Kracht 1989: 704). Witnessing testimonials, therefore, was the best way to learn about particular diseases among the Kiowa. During the testimonials, I learned about some of the diseases afflicting people; aside from excessive drinking, diabetes was the most frequently cited health problem (as will be demonstrated, some Kiowa correlate heavy drinking with diabetes). After attending several church services and prayer meetings where testimonials occurred, I observed that many people depended on spirituality to help control their diabetes. For instance, when Kiowa — typically, those over the age of 40 who are most vulnerable to diabetes — talk about their diabetes with one another, they express it in terms of blood glucose counts. A woman might say: "My sugar's up 200", meaning that her blood sugar levels are elevated. On several occasions, I listened to testimonials in which the individuals stated that their faith in the healing power of God caused their sugar levels to drop. In one testimonial, a man claimed that his doctor expressed amazement at how rapidly his blood sugar levels fell. Another woman who experienced severe diabetic symptoms of fatigue and drowsiness, attended an all night prayer meeting against the wishes of her doctor, who finally acquiesced to her request on the grounds that her religious beliefs kept her alive anyway. Her testimonial that evening attested that her strong faith solely was responsible for her ability to attend. On two occasions, I witnessed the "laying on of hands" to help diabetics cope with their symptoms. The first healing episode occurred at a Methodist church. A number of women claiming the ability to heal by passing their hands over the person's afflicted areas welcomed all people attending a prayer service to approach the altar for "faith healing". Many people went up at the same time and the woman immediately went to work employing this tactile healing technique while simultaneously chanting prayers. I do know that one of the people who went forward is a severe diabetic. While this ritual occurred, the room was filled with chants and tearful exhortations, representing a syncretic blending of Kiowa and Christian prayers. Since diabetes is not a curable disease, it is doubtful that the diabetic woman was "cured", albeit the temporary relief brought about by the prayer meeting and faith healing were well worth her efforts; the efficacy of healing resides in her belief system.

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The second time I observed the laying on of hands was at a prayer meeting held in the home of a person who had recently incurred a foot amputation caused by a wound that never healed and had turned gangrenous due to diabetic complications. The purpose of the meeting was to procure a speedy recovery for the patient. People from all three major Christian denominations among the Kiowa were in attendance as well as a prominent Kiowa Methodist minister. When everybody had taken seats on chairs situated around the perimeter of the room, the purpose of the meeting was announced by the patient's mother so that everybody's prayers would be "in accordance". After the introduction, Kiowa hymns were sung and followed by a short sermon from the minister. More Kiowa hymns interspersed by testimonials preceded the main event — healing through the laying on of hands. The healing episode was performed by the Methodist minister, who placed his hands on the patient's head and then shoulders while praying out loud. Toward the end of the episode, with his hands on the patient's shoulders, the minister asked the evil spirits causing the illness (in this case the malevolent spirit was perceived as alcohol) to depart. Concomitantly — analogous to similar healing rituals performed in Pentacostal churches — most people in attendance prayed in unison. At one point during the healing episode, the minister appeared to be speaking in tongues, although it was difficult to discern because so many people were praying at once. The session ended with more Kiowa songs and a light meal of sandwiches and cake. Prohibition of alcohol consumption (alcohol consumption is considered by some of my informants to be a major health concern among the Kiowa), is one of the most salient features of the Kiowa Christian churches. It is not my intent to provide a detailed account of Kiowa drinking behaviors, but to note that several Kiowa have indicated that they believe that excessive drinking is linked to diabetes, a belief that parallels some of Lang's findings among the Devils Lake Sioux (Lang 1989: 459, 461). Although the American Diabetic Association has not specifically stated that alcohol should be avoided by diabetics (Becton Dickinson and Company 1985: 23), most Kiowa I have talked to about drinking believe that alcohol consumption is deadly to diabetics. Perhaps the best information I obtained concerning this belief derives from a conversation between two diabetics, a drinker and an ex-drinker. The individual who quit drinking said he did so at the request of his doctor because alcohol (beer was the alcoholic beverage discussed) is derived from "sugar like products". He said: "Man, you've got to stop drinking beer because what

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you're doing is putting sugar on top of sugar. That sugar will burn you right up." In other words, drinking exacerbates the problem of elevated blood sugar levels by adding more sugar to the bloodstream, thereby complicating glucose metabolism. I recently discussed this matter with a drug and alcohol counselor in Oklahoma, and he confirmed that most of his clients over the age of 40 who are classified as alcoholics also have diabetes; these people therefore have two diseases. Members of the Kiowa Christian churches campaign aginst alcohol consumption on a regular basis. In general, Baptists, Methodists, and Pentecostals oppose drinking anyway, so the Kiowa who belong to these churches typically adhere to church doctrines, particularly those that call for temperance. Women members of these churches are usually the strongest opponents of drinking, and on several occasions, I have heard them scold men for drinking. (An individual who enters a non-drinking Kiowa woman's home with beer, or is under the influence of alcohol, takes his life in his own hands!) A number of Kiowa women (nondenominational) meet every Thursday morning for prayer meetings in their homes to pray for the well-being of the Kiowa people; alcoholism (and drug abuse) is the top priority on their prayer list. Once as I was driving through rural Carnegie, I passed a Kiowa church with a sign in the front yard which read: "If you booze, you lose." Membership in the Christian churches, therefore, puts a lot of pressure on people not to drink, a prohibition which undoubtedly helps those individuals who are diabetic. Any discussion of Kiowa spirituality and its efficacy in coping with diabetes cannot overlook the other religious system operating in Kiowa country — the Native American Church. The North American Indian peyote rite — there are actually two versions of the ceremony today — originated on the KCA Reservation in the 1870s (see LaBarre 1938; Stewart 1987), and although there are fewer Kiowa peyotists around today, there are still a handful of peyote doctors who administer to the needs of those who adhere to the peyote religion. It should be mentioned that most Christian Kiowa abhor the use of peyote. Thus, the opinions regarding the use of peyote as a cure for diabetes differ, depending on who is asked. For example, I heard about a Kiowa man in Texas who drinks a "cactus juice", claiming it acts as a diuretic to flush excess sugar from the bloodstream. Without correlating "cactus juice" with peyote tea (often used by peyotists as a panacea for ailments), I asked a Christian Kiowa if she knew anything about this remedy. She responded by saying that the individual in question is a " 'peyot' man", and that the use of

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peyote is opposed by the Christian churches (Although many Christians believe the peyote religion to be a "false" religion, the peyotists acknowledge that they are merely praying to God [and Jesus] in their own way [Kracht 1989: 935-940]). Since conducting my fieldwork in 1987, I have learned that the Native American Church of Oklahoma has passed a resolution requesting its members not to discuss the peyote religion with outsiders. Nevertheless, I wanted to know if peyote doctors have treatments for diabetes, so I asked a peyote collaborator if patients came to him for help. He said that peyote doctors do treat diabetics. Peyote doctors have been known to treat strokes, Bell's palsy, heart attacks, and other maladies, so I was not surprised to find out that diabetic patients go to them for treatment. The usual procedure is to come to the peyote doctor's house, offering him a ritual smoke, then telling him about the purpose of the visit. After listening to the problem, the peyote doctor states whether or not he can cure it. Out of respect for these people (the peyote religion has been persecuted and written about in great detail by others), I did not ask any further questions. What is important is that diabetics sometimes come to peyote doctors for treatment, usually after they have sought medical treatment elsewhere. Finally, it is noteworthy that participation in tribal ceremonials relates to Kiowa spirituality because Kiowa powwows (and to a larger extent, Southern Plains tribal and intertribal powwows) have a sacred character; that is, since the period of the revived Kiowa Ghost Dance (1894-1916), Kiowa powwows have transformed into sacred ceremonies (Kracht 1989: 44-50, 976-977). One who attends Kiowa ceremonials, especially the warrior societies revived in 1958 — the Kiowa Gourd Clan and the Black Leggings — can observe many Kiowa religious symbols during these events. The dances themselves display a great deal of religious sycretism, blending symbols from Christianity and the peyote religion with traditional Kiowa beliefs. Normally, Christian prayers, war songs, peyote symbolism, and a few "traditional" practices such as blessing dancers with cedar smoke (an act of purification to keep away all evil influences) appear in the same warrior society ritual (Kracht 1989: 46). The emcee at the Kiowa Gourd Clan dance held July 4,1989, even mentioned that stepping into the dance circle (the sacred circle) not only brings about a good feeling for the dancers, but moreover, that being inside the circle is also a healing ritual in and of itself. Those dancers entering the dance circle do so to help overcome personal problems, including illness. Participation in this and other dances

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is essential in building self-esteem in individuals afflicted by diseases that are debilitating.

3. Conclusion As stated in the introduction, the purpose of this chapter was to examine the ethnohistorical background of the conditions conducive to the emergence of type II diabetes mellitus among the Kiowa, and to delineate the contemporary Kiowa attempt to deal with this disease through their spirituality. Based on historic evidence, the conditions necessary for the emergence of diabetes began with the period of inactivity that affected the Fort Marion prisoners, who were deemed unhealthy first by their Indian agent and then again by James Mooney in 1896, eighteen years after their return to Oklahoma. If the prisoners were in fact suffering from diabetes (or something very similar), then the period of time it took for inactivity to affect them was much shorter than the twenty to thirty years it took for a change in diet and other factors to enable diabetes to emerge among the Florida Seminole (Joos 1984: 218). At any rate, confinement in a different environment and a drastic change in diet were the primary factors shortening the lifespans of the Kiowa prisoners. Aboriginally, the Kiowa enjoyed a rich and varied diet, but the Reservation Period witnessed a tranformation to foods extremely high in refined carbohydrates and sugar. As noted by Lang (1982: 4), the same diet was introduced to the Devils Lake Sioux. Because of periods of food scarcity and starvation, the Kiowa would eat all available foods within several days of distribution, a tendency that became prevalent during the Reservation Period. A totally inefficient ration distribution system can be blamed for this behavior, because most KCA Indians who did not live near the agency at Anadarko were compelled to travel long distances just to pick up one or two weeks worth of food. By the time they made the journey (in most instances, a three day round trip for a week of rations) their supplies were practically exhausted. Today, low income families that cannot afford to buy groceries also depend on government commodities. These families are compelled to stock their pantries with foods not intended to constitute a balanced diet by themselves. This implies that many people subsist on an improper diet. Finally, the increased consumption of fried foods has also contrib-

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uted to the prevalence of diabetes, and "frybread", symbolic as a modern "Indian" food, is probably the most unhealthy item in the Kiowa diet. A sedentary lifestyle and lack of exercise also are responsible for the onset of diabetes among the Kiowa. Even the noted chief White Bear predicted that settling down in one place was not healthy for his people. Kiowa resistance to a sedentary lifestyle and to living in houses indicates that White Bear was right; the nineteenth century Kiowa were a healthier people when they lived as nomads following the migrating buffalo herds. Charlie Apekaum mentioned this in 1936 when Weston LaBarre recorded his autobiography. Apekaum was emphatic that living in houses in conjunction with an unhealthy diet were ultimately responsible for high mortality rates among his people. One of my principal collaborators confirmed this claim. That a sedentary lifestyle and a lack of exercise were responsible for the onset of diabetes among Kiowa prompted me to look more closely at the time period mentioned by my principal informant, who said she first really noticed diabetes among the Kiowa shortly before 1930. At that time, many Kiowa were still enjoying the benefits of living solely from rents paid by non-Indian farmers leasing Indian allotments for farming and ranching. The rent system really paid off between 1901 and 1945 because many of the original allotees were still living, and their allotments had not been divided into smaller parcels among their heirs. One of my informants once told me that the main reason why so many Kiowa were able to spend a month camping at the Christian churches around Christmas was because they did not have to work, based on the fact that they were living off their lease monies. In fact, he further stated that prior to World War II, anyone who had to work for a living was criticized for lavishly having spent their lease monies, which was presumably why they had to work. Perhaps this period of inactivity coincides with the increased prevalence of diabetes among the Kiowa; was this period of socio-cultural change largely responsible for spawning a larger number of diabetics? Conditions are not much better today, especially in rural Carnegie, heartland of the Kiowa, where unemployment and underemployment rates are extremely high; do the large unemployment rates in the Carnegie area exacerbate these health problems? Regardless of the causes of the onset of diabetes among the Kiowa, their spirituality is probably the best approach to coping with it today. Most diabetics realize that controlling the amount of carbohydrates, sugar, and alcohol is the only way they can stabilize their diabetes, and there are even a few Kiowa who take daily insulin injections to curb their

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blood sugar levels. Despite their compliance or non-compliance with the medical model of good health, the Kiowa are generally a spiritually motivated people; they recognize that religion is an important dimension of everyday life. With this in mind, during austere times they often turn to their religious beliefs, whether they are Christians, peyotists, or a combination of the two. They recognize that problem solving is best done through religion and through compliance with the regimens requested by their doctors; the diabetics I know seek medical treatment most of the time, which provides strength to Kiowa society. In conclusion, I discussed this matter with a peyote doctor, who said that anyone can come to terms with their diabetes if they merely comply with what their religion dictates. He then told me a story about a Sioux friend from the north who once visited him to ask a similar question — how could he help solve his people's problems? The answer the old man gave him was that religion is the only way to approach their problems, even if it meant reviving the Ghost Dance: "As long as the religion has something to do with God, then it is the most important thing to which they can turn; if they believe in God, then they can find a cure." However, he said they must also follow the orders of their doctor (medical or peyotist). Perhaps more Kiowa diabetics should heed the old man's advice.

References Annual Reports of the Commissioner of Indian Affairs (ARCIA) 1878-1898 Washington, D.C.: Congressional Serial Set. Becton Dickinson and Company 1985 Managing diabetes at home. Rochelle Park, New Jersey: Becton Dickinson Consumer Products. Corwin, Hugh D. 1959 Comanche & Kiowa captives in Oklahoma & Texas. Guthrie, Okla.: Cooperative Publishing Company. Crawford, Isabel n.d. From tent to chapel at Saddle Mountain. Chicago: The Woman's Baptist Home Mission Society. 1915 Kiowa. The history of a blanket Indian mission. New York: Fleming H. Revell Company. Eaton, Cynthia 1977 Diabetes, culture change, and acculturation: A biocultural analysis. Medical Anthropology 1 (2), 41-63.

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Ewers, John C. 1978 Murals in the round. Painted tipis of the Kiowa and Kiowa-Apache Indians. Washington, D.C.: Renwick Gallery. Hagan, William T. 1985 Adjusting to the opening of the Kiowa, Comanche, and Kiowaapache Reservation. In: Peter Iverson (ed.), The Plains Indians of the twentieth century (pp. 11-30). Norman: University of Oklahoma Press. Hultkrantz, Ake 1981 Belief and worship in native North America. Syracuse: Syracuse University Press. 1989 The religious life of Native North Americans. In: Lawrence E. Sullivan (ed.), Native American Religions (pp. 3-18). New York: Macmillan Publishing Company. Joos, Sandra K. 1984 Economic, social, and cultural factors in the analysis of disease: Dietary change and diabetes mellitus among the Florida Seminole Indians. In: Linda K. Brown and Kay Mussel (eds.), Foodways in the United States. The Performance of Group Identity (pp. 217-237). Knoxville: The University of Tennessee Press. Knowler, William C., David J. Pettitt, Peter H. Bennett, and Robert C. Williams 1983 Diabetes mellitus in the Pima Indians: Genetic and evolutionary considerations. American Journal of Physical Anthropology 62, 107-114. Kracht, Benjamin R. 1989 Kiowa religion: An ethnohistorical analysis of ritual symbolism, 1832-1987. Ann Arbor: University Microfilms. LaBarre, Weston n.d. Autobiography of a Kiowa Indian. Unpublished Manscript, Smithsonian Institution, National Anthropological Archives. 1938 The Peyote Cult. Yale University Publications in Anthropology, No. 19. New Haven, Conn.: Yale University Press. Lang, Gretchen 1982 "Sugar" is new to Indian people. Plainswoman 6 (4), 4-6. 1985 Diabetes and health care in a Sioux community. Human Organization 44 (3), 251-260. 1989 "Making sense" about diabetes: Dakota narratives of illness. Medical Anthropology 11, 449-471. Leonard, Carol, and Bruce Leonard 1985 Zuni diabetes project. The Indian Health Service Primary Care Provider 10 (4), 17-19. Levy, Jerrold E. 1959 After Custer: Kiowa political and social organization from the reservation period to the present. University of Chicago: Ph. D. Dissertation.

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Ecology of the South Plains. Pp. 18-25 in AES Proceedings of the Annual Spring Meetings. Seattle: American Ethnological Society. Methvin, John J. n.d. In the limelight, or history of Anadarko [Caddo County] and vicinity from the earliest days. Anadarko, OK: Ν. T. Plummer Printing Company. McHugh, Tom 1979 The time of the buffalo. New York: Alfred A. Knopf, Inc., 1972; reprinted, Lincoln: University of Nebraska Press, 1979. Mooney, James 1896 The Ghost-Dance religion and the Sioux outbreak of 1890. Fourteenth Annual Report of the Bureau of Ethnology, 1892-93, Part 2. Washington, D.C. 1979 Calendar history of the Kiowa Indians. Seventeenth annual report of the Bureau of American Ethnology, 1895-96. Reprinted, Smithsonian Institution, 1979. Washington, D.C.: Smithsonian Institution Press. Neel, James V. 1962 Diabetes mellitus: A "thrifty genotype" rendered detrimental by "progress"? American Journal of Human Genetics 14, 353-362. Nye, Wilbur S. 1983 Carbine and lance: The story of Old Fort sill. 3d ed. Norman: University of Oklahoma Press. Oklahoma City Area Indian Health Service 1988 Oklahoma area Indian Health Service, service unit profiles, FY 1987. Oklahoma City, Oklahoma. Powers, William K., and Maria Powers 1984 Metaphysical aspects of the Oglala food system. In: Mary Douglas (ed.), Food in the social order. Studies of food and festivities in three American Communities (pp. 40-96). New York: Russell Sage Foundation. Richardson, Jane 1940 Law and status among the Kiowa Indians. American Ethnological Society Monograph No. 1. Schaefer, Otto 1971 When the Eskimo comes to town. Nutrition Today 6, 8-16. Smith, Charline G. 1970 Culture and diabetes among the Upland Yuman Indians. Ann Arbor: University Microfilms. Sneed, General R. A. 1936 The reminiscences of an Indian trader. The Chronicles of Oklahoma 14 (2), 135-155. Stewart, Omer C. 1987 Peyote religion. A history. Norman: University of Oklahoma Press. Vogel, Virgil J. 1970 American Indian medicine. Norman: University of Oklahoma Press.

Chapter 6

Diabetes among the Alaska Natives — The emergence of a chronic disease with changing life-styles Cynthia D. Schraer

To understand the interplay of life style, health, and disease among the various Alaska Native groups, one needs to become familiar with the subregions of Alaska and with the unique environment each offers to its inhabitants. Because diabetes in the past was rare among Alaska Natives, this chapter will focus on the pre-contact characteristics of each regional environment and its people, the life-style changes that have occurred as a result of Euro-American contact, and the effects these changes have had with respect to diabetes.

1. The land and its people Alaska, the 49th State, is in reality a subcontinent of 586,112 square miles (Naske and Slotnick 1979: 5). This is approximately two-thirds the area of all the states east of the Mississippi River. As Naske and Slotnick (1979) have noted, "the diversity of this lonely and lovely subcontinent is just as incredible as its size" (p. 6). The diversity and richness of cultural history among Alaska's native peoples are no less impressive, for they have developed cultures and life styles consistent with their love and respect for the land, the waters, and the animals with whom they share their existence. Because the many natural environments of Alaska are so intense with respect to climate and other conditions, the ingenuity and resourcefulness of its people have blossomed forth in a wide array of fascinating adaptations. The stereotype of Alaska as a perpetually cold and snowy land is fiction. So, too, is the notion that all Alaska Natives are Eskimos. Alaska can be geographically divided into six broad regions

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that range from the mild coastal environment of the southeastern panhandle to the frigidity of the arctic coast. The Native people of Alaska can be grouped very broadly as Eskimos, Aleuts, and Indians. For purposes of discussion, we will review the life-style changes for these three specific groups based on geographical area (Fig. 1).

Figure 1. Geographic distribution of Alaska native groups

1.1. Southeastern Alaska The southeastern panhandle of Alaska encompasses densely forested islands, a labyrinth of bountiful fiords, numerous channels and bays, and glacier-cloaked mountains reaching to altitudes over 18,000 feet. This region is homeland to three groups of Coastal Indians: the Tlingits, Haidas, and Tsimshians.

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The Tsimshians are a group of about 1100 individuals who inhabit Annette Island, which is situated near the southern tip of the panhandle. Their village, Metlakatla, was founded in 1887 when their forebears arrived at this site following a religious migration from their old village near Prince Rupert, British Columbia (Morgan 1979: 239). The community of Metlakatla is known for its independent thinking, its ability to deal successfully with the white man's world, and its cohesiveness and cultural pride. The Tlingit Indians comprise the majority of Southeast Alaska's 11,000 Native people. Their ancestors are thought to have migrated into their present-day homeland 7,000 to 10,000 years ago as the glaciers of the last ice age were retreating from the coastal mountains and islands. Tlingit legends tell of ancient migrations along river valleys and from presentday British Columbia northward along the coast. The ancestors of the Haida Indians migrated to Alaska from British Columbia's Queen Charlotte Islands during the past few hundred years. While today's Tlingits and Haidas share certain cultural patterns, their languages and ethnic identities are distinct (Langdon 1987: 60). The life-style and cultures of the Coastal Indians developed in a land of relative abundance. The climate is moderate and rainfall is heavy, producing a thick growth of large evergreen trees, including spruce, hemlock, and cedar. The rivers provide salmon and eulachon (hooligan); the hooligan are rendered to an oil to be eaten with salmon and herring eggs. Moose, deer, and mountain goats provide meat, while the sea is a source of shellfish, chitons (gumboots), seaweed, halibut, and seals. The land also provides several kinds of berries and greens (Langdon 1987: 61). All three groups of southeast coastal people developed a complex system of social organization and used their abundant resources to develop elaborate and intricate art forms, tools, and dwellings. 1.2. Southcentral Alaska Southcentral Alaska is a varied region bounded on the North and West by the Alaska Range, a chain of mountains that includes North America's highest peak, Mt. McKinley. The eastern reaches of this area are also mountainous and glacier-clad. The Gulf of Alaska moderates the climate of much of southcentral Alaska, although the inland areas often experience winter temperatures below 0 °F. This region is the home to several ethnic groups, including the Koniag of the Kodiak Island region, the Athabascan Indians of the Cook Inlet and Copper River subregions, and

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the people of the northern coast of the Gulf of Alaska. This latter group as well as the Koniags identify themselves today as Aleut and are regarded by anthropologists as Pacific, or Sugpiaq Eskimos. Their language is a dialect of the Eskimo Language (Dumond 1987: 21). The Pacific Eskimos and Coastal Athabascans, always marine-oriented, have traditionally depended on fish, sea mammals, shellfish, and seaweed for much of their diet, which also included greens, roots, and berries. (Langdon 1987: 38). The Athabascans of the inland areas depend also upon freshwater fish, including salmon, and on moose, caribou, and waterfowl. Their existence was more nomadic than that of the coastal inhabitants. 1.3. The Aleutian and Pribilof Islands The Aleutian Island Chain stretches roughly 1500 miles from its origin at the tip of the Alaska Peninsula, to Attu, the westernmost island. This archipelago, which reaches into the eastern hemisphere, is buffeted by winds and rain that originate at the turbulent interface between the cold arctic air masses of the Bering Sea and the warmer, humid air masses of the Pacific. The native people of this region are the Aleuts, who share a common ancestry with the Eskimos (Dumond 1987: 20-24). The Aleuts depended primarily upon the sea for food and materials. Seal, whale, and fish provided much of the nutrition, supplemented by berries, other plant products, birds, and caribou in some locations. These people have become masters at living in a rainy and treeless land. They made waterproof clothing from seal gut, constructed partially subterranean sod houses, and still produce the most finely woven grass basketry in the world. The Pribilof Islands north of the Aleutian Chain, which are the breeding grounds for vast herds of fur seals, were originally uninhabited by humans. In the late 18th century, Russian fur traders rounded up a number of Aleuts and transported them to these treeless, remote islands to provide labor for the seal harvest. The descendants of these Aleut and Russian individuals inhabit the Pribilofs to this day and have come to rely on the seals as the mainstay of subsistence activities. 1.4. Southwestern Alaska Southwestern Alaska consists of hilly, sparsely wooded land and tundra that borders on the Bering Sea. The vast majority of the roughly 20,000 inhabitants of this region are Yup'ik Eskimos. The life-styles developed

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by these people varied, depending upon whether they lived inland or near the coast. Inland groups faced a generally colder winter environment and relied primarily upon salmon and other river fish, caribou, waterfowl, and sometimes moose. The diet of the coastal people is predominantly salmon and other fish, but seals and sometimes whale products are also eaten. Greens, roots, and berries are also plentiful throughout much of this region. 1.5. The interior The interior of Alaska, which lies inland to the north and west of the Alaska Range, experiences some of the most severe temperature extremes of any inhabited locations on earth. Winter temperatures frequently drop below — 60 °F, and summer temperatures often rise into the 80s and 90s. This region is marked by hilly terrain and river valleys, generally covered with spruce forests. This region is less richly endowed with the necessities for human life than the other areas previously discussed (Naske and Slotnick 1979: 17). This relative paucity of resources plus the severe climate have encouraged flexibility and cultural resourcefulness among the Athabascan Indians who are the inhabitants of the region. These people, now numbering roughly 10,000, are linguistically related to the Apaches and Navajos of the American Southwest (Langdon 1987: 48). Hunting for caribou, moose, waterfowl, and small game governed much of the activity and life-style of these people. Along rivers, salmon and other fish species constitute a major portion of the diet that was traditionally supplemented by roots and berries. Periods of starvation were probably not uncommon in this harsh land (Naske and Slotnick 1979: 18). 1.6. The Arctic and Northwest Alaska The northernmost regions of Alaska have been mainly responsible for the stereotype of a cold, dark, snow-clad world peopled by Eskimos and their dogs. This region does have long, dark winters, but it also features summers of perpetual daylight and an abundance of marine mammals, fish, waterfowl, caribou, and small game. The tundra in summer is a veritable jungle, albeit only a few inches high, of willow, grasses, tiny flowers, moss, and other plant life. The summer temperatures, which even in the cool coastal regions may reach into the 60s, banish the "frozen wasteland" to several inches or feet under the surface, where it persists as permafrost the year round. The people who inhabit this fascinating

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land are the Inupiaq Eskimos. Depending upon the exact location of their villages, these people have lived and developed cultures primarily dependent upon marine mammal hunting, mixed hunting and fishing, or caribou hunting (Langdon 1987: 25). The Inupiaq, who currently number roughly 15,000, probably did not experience starvation as frequently as might be expected (Langdon 1987: 24).

2. Early Western contact and cultural changes The first non-natives to document their interaction with Native Alaskans were members of Vitus Bering's expedition who landed in the Aleutians in 1741 (Naske and Slotnick 1979: 27). This "discovery" of Alaska led to a century-long invasion by Russian fur hunters and business men, and later by other Europeans and Americans, culminating in the sale of Alaska to the United States in 1867 (Naske and Slotnick 1979: 55). The first Alaska Native people to be affected by outsiders were the Aleuts, who "were the first Alaskan inhabitants to succumb to the ruthless actions of the Russian fur hunters, who killed whole families and overran their hunting grounds" (Morgan 1979: 15). History books are replete with tales of horror during these early days of contact, which resulted in a drastic reduction of the Aleut population. Estimated at 10,000 people prior to 1760, the population of the eastern Aleutians declined by 1790 to 1900 Aleuts, with possibly 50 percent of this decline occurring in the first ten years of Russian colonization (Laughlin 1980: 15). Needless to say, the culture of the Aleuts was forever altered, and the diet of survivors and their descendants changed to include rice, flour, sugar, and other foreign items. The Russians, having depleted the sea otter population in the Aleutians, moved eastward to Kodiak Island and the coastal regions of Southcentral Alaska; by 1795 they had reached southeastern Alaska (Naske and Slotnick 1979: 27-40). Thus by the beginning of the 19th century, Russian influence had altered the life-styles and diets of the Aleuts, the Sugpiaq Eskimos, and the Coastal Indians. Not until the mid-19th century did the Athabascan Indians of the interior begin to experience an influx of outside goods and people. The Hudson Bay Company had established a post on the Yukon River. This was subsequently taken over by the Alaska Commercial Company, which expanded its commercial enterprises throughout the Yukon Valley as well as to Kodiak, the Aleutians, and the Pribilofs (Naske and Slotnick

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(1979: 61). In the 1890s, the Klondike gold rush in Canada led to an invasion of would-be miners through Southeastern Alaska and to migrations following gold strikes in the interior and at Nome (Naske and Slotnick (1979: 71-77). Thus the Indians of the interior were further introduced to western diet and commercial activities, which led to substantial changes in life-style. Another group of Alaskans beset by venturesome outsiders during the 19th century were the Inupiaq Eskimos. They came in contact with the Yankee whalers and were exposed to their trade goods, foods, and diseases (Langdon 1987: 74). An 1889 description of the Eskimos of Point Hope in northwestern Alaska stated that the people were "in a most degraded state, physically, mentally, and spiritually" due to the "riot and drunkenness" caused by the whalers and their socially disruptive behavior (Morgan 1979: 39). In response to the plight of Alaska Natives during this period, missionary activity became widespread, not only among the Inupiaqs, but also throughout many regions. Native children began to be educated in the American style, resulting in further cultural changes occurring (Morgan 1979: 39-40). Also in response to an increasing Eskimo population and a supposedly declining food availability, reindeer herding was introduced in northwestern Alaska in 1891. This project evolved into a new and profitable industry for the people (Fortuine 1989:155-156). The Yup'ik Eskimos of southwestern Alaska, although exposed to early Russian exploration and outposts, did not experience any massive economic changes. This region was not particularly attractive to outsiders, and therefore the Yupik Eskimos have been able to preserve their language and much of their culture and dietary practices to the present day.

3. Dietary changes and their consequences Traditionally, the diets of Alaska Natives and Canadian arctic people, though quite varied from one region to another, were generally low in carbohydrates. The pre-contact Eskimo diet was believed to contain only about 10 grams of carbohydrate per 2,500 calories, or only about onetenth the daily glucose requirement of the human brain. Hence, the high protein content of the diet was necessary not only for calories, but also for the conversion of amino acids to glucose by the human body (Draper 1977). Prior to Caucasian influence in Alaska, carbohydrate sources were "negligible" and were obtained primarily from liver, fish roe, whale

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muktuk, herbivore stomach contents, greens, roots, and berries (Heller and Scott 1967: 43). This lack of carbohydrate in the diet was noted in northern Canada as recently as 1935. At that time, Dr. Urquhart, a general practitioner, described the Natives as " ...people who live and eat differently from those of a more civilized part of the country, and who in spite of the apparent deficiencies in their diet, not only continue to live and keep well, but apparently escape many of the ills of their more civilized brethren" (Urquhart 1935). However, the cultural changes associated with outside contact brought about a drastic departure from this remarkable balance between human nutritional needs and diet. An Alaskan survey begun in 1956 of four Inupiaq (northern) Eskimo villages, five Yup'ik (southwestern) Eskimo villages, and two Athabascan villages found that the proportion of calories from fish and meat was highest in the older age groups, lower in adolescents, and lowest of all in young children (Heller and Scott 1967: 35). Calculations based on the survey data show that the proportion of calories derived from local sources ranged from 20-45 percent. Among adults, carbohydrates suplied approximately one-third of the calories, largely in the form of bread, cereal, and other grain products (Heller and Scott 1967: 43-45). Further calculations based on this data show that the proportion of carbohydrates consumed in the form of candy and soft drinks ranged from 15-32 percent, or roughly 5-10 percent of the total calories (Heller and Scott 1967: 37-43). In 1978 another survey among Yupik villages noted several interesting changes (Knapp and Panruk 1978). The average calorie intake had decreased by 7 percent across all age categories without a change in growth. The authors speculated that increased use of human energy saving devices may have accounted for this. They found that 50 percent of the calories were consumed in the form of carbohydrates, that highly refined, low fiber products comprised most of the carbohydrate sources, and that high sugar cereals constituted most of the cereal sold outside of the regional commercial center of Bethel. The intake of protein and fat in grams had decreased by 46 percent and 25 percent respectively, and the fats were more likely to be saturated (Knapp and Panruk 1978: 6-9). The studies cited above have shown that association with Caucasians has brought about major dietary increases in both saturated fat and carbohydrates, with a decrease in total fat and protein. Protein sources now include chicken, beef, and pork, often in prepared and frozen forms. Carbohydrates are often consumed in the form of rice, pasta, pilot bread, pancakes with syrup, and cereal (Halderson 1993). However, simple forms

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of carbohydrate such as soda pop and candy are also major constituents of the modern diet. A 1985 survey of dietary intake of teen-agers in 14 Eskimo villages in the Yukon-Kuskokwim region indicated that the teens consumed three to four times the amount of soft drinks consumed by teens in the general U.S. population (Thiele 1989). A recent comprehensive survey of foods consumed by Alaska Natives in various regions of the state indicates that overall, the most frequently consumed beverages are coffee, water, tea, and carbonated soft drinks (sweetened with sugar as opposed to non-caloric sweeteners). The most frequently consumed foods are sugar, bread, margarine, and rice. On the average, the diet of Alaska Native men now consists of 38 percent fat, 19 percent protein, and 41 percent carbohydrates; women's diets consist of 37 percent fat, 18 percent protein, and 44 percent carbohydrates. These proportions are essentially the same as for the United States general population (Nobmann 1989). The data in this study was obtained from 24-hour dietary recall interviews (900 interviews, 358 adults) conducted by trained local interviewers in Anchorage and in villages all around the state. The health effects of these changes in nutrition have been varied, and as Draper (1977) has concluded, are generally not favorable: The modern Eskimo has for the first time the opportunity to make significant food choices. Presented with an array of exotic new foods which he is not equipped by personal experience or education to evaluate, he tends to choose badly. In general, the items he selects are below the average quality of the U.S. mixed diet and of the foods they replace in his native diet. His nutritional status is deteriorating, in terms of both undernutrition and overnutrition, in direct relation to the proportion of processed foods in his total diet. In the subarctic, where dietary acculturation is extensive, the Eskimo has the full complement of diet-related diseases that are characteristic of other segments of the U.S. population of low socioeconomic status: obesity, cardiovascular disease, hypertension, and tooth decay.

Of particular interest in the diabetes arena is the occurrence of obesity. Artist's drawings at the time of initial Caucasian contact and early photographs depict most people in heavy clothing, making it difficult to discern body habitus; extreme obesity, however, does not appear to be present. A few descriptions from the early history of Caucasian contact survive. As noted by Fortuine (1989: 27), "These writings must be used with caution since they usually resulted from short meetings with Native leaders or hunting parties, and probably did not reflect conditions as they were in the villages and homes where the sick and disabled would tend to congregate." In 1741, Georg Steller, the naturalist on the Bering

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expedition, described nine Aleuts as being "of average height, strong, and stocky, but rather well proportioned and fleshy on arms and legs .... they have short necks, broad shoulders, and a thick yet not paunchy torso" (Steiler 1988:103). The Kodiak Island people were described in 1784 as "tall, healthy, well-fleshed" (Shelikhov 1981: 53). Early comments on the body habitus of Eskimos include the observation that the Chugach Eskimos (southcentral Alaska) were "fat and jolly, as if they lived well" (Ellis 1782: 1: 236) and that the Yupik near Kuskokwim Bay were "tall, well-made and wild fierce looking people" (Ledyard 1963: 85). Other observations of the Yup'ik people noted that "In times when food, and especially fats are plentiful, their faces are puffed out and their bodies grow chubby, but they are never obese" (Zagoskin 1967: 211). Northern Eskimos were described in 1782 as "very plump and full of flesh" (Ellis 1782:2: 12-13). In Barrow an early observer measured and weighed a number of men and found their height to be between five feet one inch and five feet ten and a half inches, with their weights ranging from 125 to 195 pounds (Simpson 1855: 920). A summary of observations on the stature of the Athabascans note them to be of variable height, healthyappearing, and generally vigorous and energetic (Fortuine 1989: 30). In 1791 the Tlingits of southeastern Alaska were noted to be of medium height but robust and strong (Suria 1936: 254). Hence, it seems reasonable to conclude, based on early observations and drawings, that Alaska Natives were probably well-nourished and sometimes "plump", but that marked obesity, if it occurred at all, was not common. There is little recent information about obesity among Alaska Natives. In 1958, Heller and Scott showed that over half of the Eskimo and Athabascan individuals surveyed consumed fewer calories than the intake recommended by the National Research Council (Heller and Scott 1967: 31-11). A 1958 study among Eskimos and Athabascans found that obesity, if defined as weight above 120 percent of the "standard" weight for height, was not present on a population basis. In fact, on average, southern Eskimo women over 45 years old were below "standard" weight, and no group was found to have average weights above 114 percent of "standard" (Mann et al. 1962). But the picture was changing, and by 1971-1972 a comparison of specific Eskimo villages with differing degrees of dietary cultural change revealed that the increased use of processed foods and the "decay of the traditional life style" correlated with the prevalence of obesity, hypercholesterolemia, and hypertension (Draper 1977). Two comparative studies among Eskimos documented an increase in the prevalence of "overweight" persons, and an increase in the pro-

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portion of subjects with two-hour whole blood glucose levels over 150 mg/ dl, which would indicate impaired glucose tolerance (Mouratoff, Carroll, and Scott 1967; Mouratoff and Scott 1973). These authors commented that by 1972, snowmobiles, chain saws, and fuel oil were replacing the more labor-intensive dog teams, hand saws, and wood heating. Numerous unpublished observations by Alaska Native villagers from multiple regions of the state attest to an increase in the prevalence and magnitude of obesity over the past two or three decades. Villagers comment on the marked decline in physical activity and attribute some of this to the adoption of mechanized transportation in the form of automobiles, snowmobiles, three-wheelers, and small aircraft. A more recent development has been the introduction of television and videocassette recorders into the villages. Many villagers note that when they were children twenty to forty years ago, entertainment and social contact often involved physical activity such as games, walking for pleasure, dancing, and other events. By contrast, watching television programs and videotapes now occupy a prominent place in the social and entertainment arena. Most villages have either video rental shops or ready access to mail order video supply sources. A survey performed in 1987 in the same Eskimo villages studied by Mouratoff et al. in 1962 found that the proportion of persons ages 40 years or older who were "overweight" had increased from 3% to 16% for men, and 6% to 27% for women (Murphy et al. 1992). Over a decade ago, Mouratoff and Scott (1973) concluded that the rarity of diabetes among Eskimos was probably due to a high level of physical activity rather than genetic factors. They further suggested that glucose intolerance might become more frequent if Eskimo life conformed increasingly to the "standards of western civilization" (Mouratoff and Scott 1973). As we shall see, this was a prophetic statement.

4. The occurrence of diabetes among Alaska Natives Prior to 1985, no systematic efforts to define or describe diabetes among all Alaska Natives had been conducted, and this disease was thought to be unusual among Alaska Natives and other Eskimo groups (Davies and Hanson 1965; West 1974; Kromann and Green 1980, Sagild etal. 1966; Urquhart 1935; Mouratoff, Carroll, and Scott 1967; Mouratoff and Scott 1973). A survey among Alaskan Eskimos conducted in 1957 revealed not more than six known cases, which represents a prevalence of 0.4/1000

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(Scott and Griffith 1957). A study among Alaskan Athabascan Indians completed during the 1960s identified only 3 cases among 306 subjects over 20 years old, for a prevalence of 9.8/1000 (Mouratoff, Carroll, and Scott 1969). Among the Aleuts of the Pribilof Islands, a 1973 survey revealed that 10 percent of those over 25 years of age had diabetes (Dippe et al. 1975). Hence, data gathered during the late 1950s through the early 1970s indicate that diabetes was rare among Eskimos and Athabascans but relatively common among the Pribilof Aleuts. Anecdotes from Southeast Alaska suggest that diabetes was not uncommon among the southeast Coastal Indians as early as the 1950s. There is, however, no documentation of rates in Southeast Alaska prior to 1985. During the 1980s, several health care providers in the Alaska Native Health Service (ANHS), a division of the Indian Health Service, felt that more Alaska Natives were developing diabetes. Because of this impression, and given the knowledge of the devastating history of diabetes among other Native Americans, a project was initiated in 1986 to establish a patient registry. The registry was formed by searching the computerized medical records system of the ANHS for patients with a history of diabetes. Charts were subsequently audited to identify patients who met the 1985 World Health Organization clinical criteria for diabetes, and the patients' names, demographic data, and audit results were entered into the registry. This registry was then used to determine prevalence rates of diagnosed diabetes among the different subgroups of the Alaska Native population as of December 1985 (Schraer et al. 1988). It must be kept in mind that this study determined rates of clinically recognized diabetes in a population in which screening was not routine. Nevertheless, 610 patients were identified for an overall age adjusted rate of 15.7/1000 (all rates cited are age-adjusted to the 1980 U.S. all races population). The rates per 1000 were found to vary among the major ethnic groups: the age adjusted prevalence was 27.2 among Aleuts (Sugpiaq Eskimos included), 22.0 among Indians (Athabascan and Coastal), and 8.8 among Eskimos (Yup'ik and Inupiaq). These rates can be compared with the U.S. all-races rate of 24.7/1000 in 1980 (National Diabetes Data Group 1985: VI-4). Rates further varied by subdivision of each ethnic group and by region of the state. Figure 2 shows the prevalence data for various regions in 1985. Comparison of the 1985 data with that from the prior studies indicates that the prevalence of diabetes among Eskimos and Athabascans has increased over the past two to three decades. Table 1 shows a comparison of rates at different points in time.

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14

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Norton Sound 1 6.7

Yukon/ Kuskokwim Delta

r

V

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Figure 2.

Diabetes prevalence, Alaska, 1985, age adjusted rates/1000

The six-fold variation in prevalence among regions prompts the question of why it should occur. Screening practices from one region to another have not differed significantly over time; hence they are unlikely to provide the explanation. The observations of this author are that two other theories about the differences in diabetes prevalence from one group to another are often put forth by Alaskans: one is that genetic susceptibilities vary according to ethnic group; the other is that life style factors are the major determinant of the occurrence of diabetes. Figure 2 represents an attempt to look graphically at the rates of diabetes. One may see that the areas showing the highest rates are the Aleutian and Pribilof Islands, and southcentral and southeastern Alaska. The ethnic groups in these regions include Aleuts, Sugpiaq Eskimos, a few Athabascans, and the Coastal Indians. The areas showing the next highest rates are the interior and northern regions, which are inhabited by Athabascans and Inupiaq Eskimos. The lowest rates occur in regions inhabited by Yup'ik Eskimos (the rate of 6.7 in the Norton Sound Service Unit may represent underascertainment of cases as they do not use a computerized record

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Table 1. Diabetes prevalence among Alaskan Eskimos and Athabascan Indians Eskimos, all Alaska Year

Number of cases

Crude rateb

1957 1958 1987

3 to 6 179 216

0.2 to 0.4 per 1000 4.6 per 1000 5.2 per 1000

(Scott and Griffith 1957) (Schraer et al. 1988) (Schraer et al. 1991)

Eskimos, Barrow service unit" Year

Number of cases

Crude rate b

1972 1985 1987

7 23 29

3.0 per 1000 7.6 per 1000 9.0 per 1000

(Fischer 1974) (Schraer et al. 1988) (Alaska Native Health Service Program Data)

Athabascan Indians Year

Number of cases

Crude rate" (over 20 years old)

1969 1985

3 62

9.8/1000 14.2/1000

(Mouratoff et al. 1969) (Schraer et al. 1988)

a. "Service unit" refers to a geographic region served by each subdivision of the Alaska Native Health Service. See Figure 2. b. Changes are statistically significant using a test for linear trend in proportions. c. Change is not statistically significant (x2 = 0.40, ρ = .53, df = 1). However, 1969 data was based on a screening study; 1985 data was based on clinically recognized cases only. retrieval system). Looking at the history of Caucasian contact with Alaska Natives, one can see that regions of higher prevalence are those with a longer history of contact with outside influences. One cannot rule out the possibility that genetic differences among groups account for different prevalence rates. Nevertheless, the fact that the highest prevalence rates occur in three distinct populations, i.e. Aleuts, Sugpiaq Eskimos, and Coastal Indians, and furthermore that the prevalence rates among the Eskimo-Aleut population who share a common though distant ancestry, spans the range from lowest prevalence (Yupik, 5.8/1000) to highest (St. Paul Aleut, 69.0/1000), may indicate that life style factors are as important as genetic background in determining diabetes risk. In the past, speculations were made that when diabetes occurred in an Eskimo individual, it was due to Caucasian ancestry (Quick 1974). As

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Table 2. Native blood quantum among people with Type II diabetes Alaska, 1987a Indian

Eskimo Number

Number

(%)

Aleut

(%)

Number

(%)

1/2 1/2-7/8 full

9 29 144

(5%) (16%) (79%)

28 69 129

(12%) (31%) (57%)

25 46 46

(21%) (39%) (39%)

Total

182

(100%)

226

(100%)

117

(99%) b

a. Only those Alaska Natives with specified quantum and specified type of diabetes are included in this table. b. Does not add to 100% due to rounding.

Annette Island Mt. Edgecumbe Anchorage InteriorKotzebue

Ethnic group • Yupik s Inupiaq s Mixed n Indian

BarrowBristol 212222MSL V///////////A Bay Norton Sound Y u k o n - 7Ζ7ΖΛ Kuskokwim '/••'/////AVA

0

5

10

15

20

25

30

35

40

Figure 3. Diabetes in Alaska natives, age adjusted prevalence per 1,000 by service unit, December 1985, December 1987

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the distribution of Native blood quanta in the non-diabetic Native population is not known, blood quantum as a risk factor cannot be analyzed. Table 2 shows the distribution of blood quanta among Type II diabetic patients for whom blood quantum information is available. It can be seen that the overwhelming majority of Eskimo patients are full blooded, and a significant proportion of the Indians and Aleuts are full blooded. While there may be many errors in the blood quantum data, it seems reasonable to infer that diabetes is not solely due to the presence of Caucasian ancestry. This conclusion is consistent with data obtained in several studies that examined degree of Native American ancestry as a risk factor for type II diabetes (Gardner et al. 1984; Drevets 1965; Stein et al. 1965). The prevalence of diabetes has been followed through periodic analysis of the registry. The most recent data indicates that overall, the prevalence among Native people increased 11 percent from 1985 to 1987, to an ageadjusted rate of 17.4 per 1000 in 1987 (Schraer et al. 1993). Tables 3 and Table 3. Diabetes prevalence per 1000 among Alaska Natives age-adjusted to 1980 U. S. population" 1987

1985

All Alaska Natives Alaskan Eskimo Alaskan Indian Alaskan Aleut

% Change

Number of cases

rate

Number of cases

rate

Over 2 yearsb

610 179 292 139

15.7 8.8 22.0 27.2

708 216 335 157

17.4 10.2 24.0 28.6

+ 11% + 16% + 9% + 5%

U.S. all races, 1980 = 24.7 (National Diabetes Data Group 1985) a Schraer et al. 1993 b These changes are not statistically significant using the Mantel-Haenszel test adjusting for age.

4 show the rates for various groups in 1985 and 1987 (Schraer et al. 1985; Schraer et al. 1993; Alaska Native Health Service Program Data); figure 3 shows the service unit-specific prevalence rates in graphic form. Over this brief period of observation, only the increase in the Yukon-Kuskokwim Service Unit was statistically significant. At this time, one can only speculate as to whether the increases are due to increased case finding and better documentation, or to an actual increase in the prevalence of

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Table 4? Diabetes age-adjusted prevalences per 1000 by service unitb, Alaska Natives, 1985 and 1987 1985 Service unit

Annette Island Mt. Edgecumbe Anchorage Interior Kotzebue Barrow Bristol Bay Yukon-Kuskokwim Norton Sound a b c

1987

% Change

cases

rate

cases

rate

Over 2 years

P-valuec

21 154 193 78 47 23 23 48

31.1 27.2 20.7 16.7 16.6 14.0 10.4 5.8

28 177 219 81 48 29 26 76

40.8 29.5 22.0 19.1 16.3 17.0 12.1 8.9

+ 31% + 8% +6% + 14% 0% + 21% + 16% + 53%

0.33 0.45 0.56 0.40 0.93 0.50 0.61 0.02

23

6.7

24

6.7

0%

1.00

Schraer et al. 1988; Alaska Native Health Service Program Data. "Service unit" refers to a geographic region served by each subdivision of the Alaska Native Health Service. See Figure 2. P-values were calculated using a t-test with variance calculated by the method of Chiang. Only the Yukon-Kuskokwim service unit showed a statistically significant change over this brief period. Over 90 percent of the native residents of this region are Yupik Eskimos.

the disease, or to random variation in numbers. However, a summary of the prevalence among Eskimos (presented in table 1 and table 4) shows that the increase is of a magnitude difficult to explain by improved record keeping. With time and continued observation, it is hoped that the causes of the increase will become clear.

5. The impact of diabetes on Alaska Natives Information about public knowledge and attitudes regarding diabetes was obtained in a survey of 20 village health aides in various stages of training (Hedlund 1988). In general the health aides indicated that people do not know much about diabetes and do not care to know much about any disease until they get it (Hedlund 1988: 57-60). As diabetes has been

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relatively rare until recently, it has not made a large impact on Alaska Native life-styles in general. Many diabetic patients are unaware of the significance of early symptoms and are diagnosed only when obvious problems arise, such as nonhealing of foot or leg sores, rapid weight loss, or severe general debility. Others are prompted to seek help when family members notice problems; for example, one elderly man was diagnosed when his wife complained that his urine was difficult to clean off the toilet rim due to its sticky consistency! This patient was found to be losing large amounts of sugar in the urine due to uncontrolled diabetes. Another patient, who successfully lost weight after being diagnosed with diabetes, noted that prior to receiving health education, he had not viewed himself as overweight. He had viewed other individuals of similar build as markedly obese, but did not see himself in the same light. The facts about diabetes and its complications must be faced because patients throughout Alaska are now beginning to experience secondary complications: approximately 3-6 diabetes-related amputations occur each year; 13 patients have required dialysis because of end-stage renal disease; and at least 96 patients have had documented retinopathy, many requiring laser treatments and at least 4 becoming blind. Many patients have neuropathies and recurrent foot ulcers. While the general Alaska Native public is just beginning to learn what diabetes is, those who have the disease and their families and friends, have been profoundly affected by it. One Alaska Native patient educator has made a number of interesting observations on the difficulties caused by diabetes and the change in life style it requires, based on several years of working with Native patients from all regions of the state (Augusta Reimer, letter to the author, January 1989): It has been said that when one has diabetes the whole family has diabetes. Often times the diabetes patient simply cannot get the family to cooperate and accept diabetes within itself. Thus, with such resistance, the patient has to struggle alone while others eat what they want, drink, smoke, and cause stress. Indeed, the whole community can be so trauma-oriented that the patient has no motivation and support for a healthier life style.

This observation has been confirmed by other health care providers who observe that patients frequently do not acknowledge the need for diabetes treatment and control until complications begin to arise. This can be a problem particularly for men. Men often project a sense of bravado and deny that diabetes presents any problem to them. Moreover, their life styles, often involving irregular hours in commercial fishing, trapping, and other endeavors, do not lend themselves to smooth glucose control.

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Meals are irregular, insulin is difficult to use, and exercise may be intense but sporadic. Hence, they often come face-to-face with the realities of the disease only when complications suddenly and severely limit their ability to function within the scope of their normal life-style, or when illness directly challenges their "rough and tough" self image. Women also face extreme difficulties. In many cases, diabetes asserts itself in middle-aged women facing difficult home situations. Reimer (1989) notes that often there are grown children still living in the parental home, participating in arguments and other activities that cause stress. Sometimes the patient's husband has an alcohol problem that prompts family violence. In some circumstances finances are often a major problem, with income being insufficient to allow purchase of adequate footwear, fresh produce (which is often unavailable at any price in the villages), and othe diet items recommended for diabetes management. In some individuals, the chaotic home life fosters feelings of self-pity and hopelessness. The situation can cause the patient to rely subconsciously on diabetes as a means to elicit concern from the family or to justify limitations and dependency. A positive aspect of women's lives that makes diabetes difficult to control is the nurturing role. Alaska Native women tend to be friendly and hospitable individuals who are ready offer food to visitors and family. In one community with a high prevalence of diabetes, many women are renowned for their cooking skills. In visiting this village, the author has sometimes eaten several large meals each day as food is such an important medium for social interaction (moreover, their reputations as good cooks are well deserved!). Middle-aged women also tend to be sedentary. Many of these women do traditional beadwork, needlework, and basketry, which by necessity are sedentary activities. In addition, the long winters, marked by either slippery snow and ice, or heavy, frequent rainfall, are not conducive to regular exercise. In general, people use motorized transportation: cars, snowmobiles, and three or four-wheelers are used even for traveling short distances. Walking is encouraged by health care providers, but it must be acknowledged that risks associated with falls and cold or wet conditions are not to be ignored. In addition, urban Native people, particularly women, are often afraid to go out walking in the dark because of fear of criminal activity in the low-income parts of the cities in which many Native people live. This is a definite limitation because winter darkness prevails most of the day in much of Alaska. Thus the life-style changes necessary to treat diabetes can involve some fundamental conflicts with the cultural values and life-styles of both men

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and women. As diabetes complications are still relatively rare, most diabetic patients are not aware of the devastating effects of the disease. It is therefore a challenging task to motivate them for difficult life-style changes. Some elderly patients have a very hard time understanding what diabetes is, what the treatment involves, and why the treatment is important. Some feel that they will die sooner or later anyway, and therefore choose not to live their lives any differently (Reimer 1989). Some observers feel that individual autonomy is a major issue in the treatment of diabetes, and that authoritarian approaches by medical care professionals are counterproductive. For example, family members and health aides have pointed out that some patients almost seem to demonstrate independence by gaining weight, eating "forbidden" foods, etc. One health aide observed that it is difficult for patients to learn to control their diets because, in the past, there have not been many things that needed to be controlled. It had been a "do-what-you-want kind of life" (Hedlund 1988: 58). There is, however, a more optimistic side to the picture. In recent years there has developed a renewed pride in traditional Native foods and ways of life. As diabetes appears to have been very rare prior to westernization, the recommendations made by health care providers often harken back to traditional life-style features that are a source of cultural pride. Activities such as Native dancing and sports are still frequent and joyful events in many communities and offer an opportunity for exercise, social contact, and perpetuation of tradition. Native foods offer a much more nutritious alternative to pop, candy, chips, dips, and prepared foods. The traditional fat sources, largely fish and sea mammals, appear to offer potential protection from atherosclerotic diseases, although more research is required to substantiate this. Thus nutritionists feel that dietary advice may be given to patients often without conflict with cultural tradition (Halderson, personal interview, January 1989). Such advice, however, has to be given with the acknowledgment of certain limitations. Native people point out that a return to a total subsistence life-style is not possible in the modern world, and that in some regions, traditional food has become relatively scarce and therefore quite expensive.

6. A look to the future Alaska may offer a unique opportunity for chronic disease prevention because at present the Native population has relatively small numbers of

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have non-profit branches which have increasingly empowered the Native people to control their own health care and to set related priorities. The Indian Health Service and these Native Health Corporations have joined forces to deliver optimum care to diabetes patients through a network of specialty clinics and patient education programs. In addition, training sessions are offered to health care providers, stressing key elements necessary for prevention of complications. The recent occurrence of diabetes among Eskimos, who only thirty years ago were essentially free of the problem, is cause for concern. So, too, is the fact that overall, the age-adjusted prevalence of diagnosed diabetes among Alaska Natives appears to have risen from 15.7/1000 to 17.4/1000 over two years, an increase of eleven percent (Schraer etal. 1993). A look at the magnitude of the problems caused by this disease among other Native Americans has led Alaskan health workers and various native leaders to believe that a major public education campaign is needed about the life-style risk factors. Since 1986, diabetes has become a focus in workshops, health board discussions, health aide (village medical care provider) training, and various village-based activities. Posters, pamphlets, videotapes, radio talk shows, news articles, health fairs, and group discussions have served to make the general public aware of the disease, its detrimental effects, and its preventable nature. A 1987 screening campaign in one service unit demonstrated that among the cases of diabetes in the screened population, about 28 percent did not know they had diabetes prior to the screening (Murphy et al. 1992). This campaign served as a basis for village health fairs; subsequently four villages in the region established exercise and nutrition programs. While these projects represent a good start, the task is a formidable one. There are over 170 villages in Alaska which are remote from hospitals and urban centers. The day to day health care in each village is provided by a health aide, who is on call 24 hours a day, 7 days a week. Thus the tasks of public education and life style intervention must compete with acute illness and injury for the attention and energies of relatively few trained people. It is hoped that Alaska's Native people, who so successfully rose to the challenge of surviving in several extreme environments, will be equally successful in overcoming the detrimental effects of the western life style while still receiving the advantages of the modern world.

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Acknowledgments The author thanks Robert Fortuine, M.D.; Betty Baker, R. N.; Neil Murphy, M. D.; Clarence Gohdes, Ph. D.; Karen Thompson and Martha Edwards, C. Η. P, for their comments; Anita Vogt and Alice Muller, A.A., for manuscript and graphics preparation; and Lisa Bulkow, M. S., for statistical analysis. References Davies, L. E. C., and S. Hanson 1965 The Eskimos of the Northwest Passage: A survey of dietary composition and various blood and metabolic measurements. Canadian Medical Association Journal 92, 205-16. Dippe, S. E. et al. 1975 Lack of causal association between Coxsackie B4 virus infection and diabetes. The Lancet 1, 1314-17. Draper, Η. H. 1977 The Aboriginal Eskimo diet in modern perspective. American Anthropologist 79, 309-16. Drevets, C. C. 1965 Diabetes mellitus in Choctaw Indians. Oklahoma State Medical Association Journal 58, 322-29. Dumond, D. E. 1987 The Eskimos and Aleuts. London: Thames and Hudson Ltd. Ellis, William 1782 An Authentic Narrative of a Voyage Performed by Captain Cook and Captain Clerke in His Majesty's Ships Resolution and Discovery During the Years 1776, 1777, 1778, 1779 and 1980; in Search of a North-West Passage Between the Continents of Asia and America. Two volumes. Reprinted in 1969. New York: Da Capo Press. Fisher, Q. A. 1974 Diabetes in Eskimos. Letter to the editor. Journal of the American Medical Association 227, 1383. Fortuine, Robert 1989 Chills and fever: Health and disease in the early history of Alaska. Fairbanks: University of Alaska Press. Gardner, L. I., M. P. Stern, S. M. Haffner, S. P. Gaskill, H. P. Hazuda, J. H. Relethford, C. W. Eifler 1984 Prevalence of diabetes in Mexican Americans: Relationship to percent of gene pool derived from Native American sources. Diabetes 33, 86-92. Halderson, K. 1993 Alaska Native food practices. Chicago: American Dietetics Association· (In press).

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1989 Personal communication. Hedlund, M. 1988 Perceptions of susceptibility, severity and consequences of diabetes mellitus by a sample of Alaskan community health aides. Unpublished Masters thesis, Anchorage, Alaska: University of Alaska, Anchorage. Heller, C. Α., Ε. Μ. Scott 1961 The Alaska dietary survey 1956-1961. Anchorage: U.S. Public Health Services. (Public Health Service Publication No. 999-AH-2) Knapp, Β. and Peter Panruk 1978 Southwest Alaska Eskimo dietary survey of 1978. Report for the Yukon Kuskokwim Health Corporation, Bethel, Alaska. Kromann, N., and A. Green 1980 Epidemiologic studies in the Upernovik District, Greenland. Acta Medica Scandinavia 208, 401-406. Langdon, Steve J. 1987 The Native People of Alaska. Anchorage: Greatland Graphics. Laughlin, W. S. 1980 Aleuts: Survivors of the Bering Land Bridge. New York: Holt, Rinehart, and Winston. Ledyard, John 1963 John Ledyard's Journal of Captain of Cook's Last Voyage. Edited by James Kenneth Mumford. Corvallis: Oregon State University Press. Mann, G. V. et al. 1962 The health and nutritional status of Alaskan Eskimos. A survey of the Interdepartmental Committee on Nutrition for National Defense — 1958. American Journal of Clinical Nutrition 11, 31-76. Mouratoff, G. J., Ν. V. Carroll, and Ε. M. Scott 1967 Diabetes mellitus in Eskimos. Journal of the American Medical Association 199, 107-12. Mouratoff, G. J., Ν. V. Carroll, and Ε. M. Scott 1969 Diabetes mellitus in Athabascan Indians in Alaska. Diabetes 18, 29-32. Mouratoff, G. J., and Ε. M. Scott 1973 Diabetes mellitus in Eskimos after a decade. Journal of the American Medical Association 226, 1345-1346. Morgan, Lael (ed.) 1979 Alaska's Native People. Alaska Geographic vol. 6, No. 3 Murphy, N. J., C. D. Schraer, L. R. Bulkow, E. J. Boyko, A. P. Lanier 1992 Diabetes Mellitus in Alaskan Yup'ik Eskimos and Athabascan Indians after 25 years. Diabetes Care 15, 1390-1392. Naske, Claus-M., and Herman Slotnick 1979 Alaska, A History of the 49th State. Grand Rapids: Wm. B. Eerdmans Publishing Company.

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National Diabetes Data Group 1985 Diabetes in America, Diabetes Data Compiled 1984. In: Maureen I. Harris and Richard Hamman (eds.), Washington, D.C.: U.S. Dept. of Health and Human Services. (N.I.H. Pub. No. 85-1468) Nobmann, E. D. T. Byers, A. P. Lanier, J. H. Hankin, Μ. Y. Jackson 1989 The diet of Alaska Native Adults. American Journal of Clinical Nutrition 55, 1024-1032. Quick, W. W. 1974 Diabetes in Eskimos. Letter to the editor. Journal of American Medical Association 227, 1383. Reimer, Augusta 1989 Letter to the author, January, 1989. Sagild, V., J. Littauer, C. S. Jespersen, and S. Andersen 1966 Epidemiologic studies in Greenland 1962-1964. Diabetes mellitus in Eskimos. Acta Medica Scandinavia 179, 29-39. Schraer, C. D. Alaska Native Health Service Program Data, (unpublished). Schraer, C. D., A. P. Lanier, E. J. Boyko, D. Gohdes, N. J. Murphy 1988 Prevalence of diabetes mellitus in Alaskan Eskimos, Indians, and Aleuts. Diabetes Care 11, 693-700. Schraer, C. D., L. R. Bulkow, N. J. Murphy, and A. P. Lanier 1993 Diabetes: Prevalence, incidence, and complications among Alaska natives, 1987. Diabetes Care 16, suppl. I, pp. 257-259. Scott, Ε. M., and I. V. Griffith 1957 Diabetes mellitus in Eskimos. Metabolism 6, 320-25. Shelikhov, Grigorii I. 1981 A Voyage to America 1783-1786. Edited by Richard A. Pierce, and translated by Marina Ramsay. Kingston, Ontario: Limestone Press. Simpson, John 1855 Further Papers Relative to the Recent Arctic Expeditions in Search of Sir John Franklin in the Cruise of the H.M.S. "Erebus" and "Terror". London: Admiralty, Great Britain, Η. M. Stationery Office. Stein, J. Η., Κ. M. West, J. M. Robey, D. F. Tirador, G. W. McDonald 1965 The high prevalence of abnormal glucose tolerance in the Cherokee Indians of North Carolina. Archives of Internal Medicine 116, 842-45. Steller, Georg Wilhelm 1988 Journal of a voyage with Bering 1741-1742. Ed. by O. W. Frost, translated by Margritt Α. Engel and O. W. Frost. Stanford, CA: Stanford University Press. Suria, Tomas de 1936 Journal of Tomas de Suria of his voyage with Malaspina to the Northwest coast of America in 1791. Translated and edited by Henry R. Wagner. Glendale, CA: Arthur Η. Clark Co.

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Thiele, Μ. C , and C. J. Boushey 1989 Soft drink consumption among Yupik Eskimo teenagers. Alaska Medicine 31, 1-3. Urquhart, J. A. 1935 The most northerly practice in Canada. Canadian Medical Association Journal 33, 193-96. West, Κ. M. 1974 Diabetes in American Indians and other native populations of the New World. Diabetes 23, 841-55. Zagoskin, L. A. 1967 Lieutenant Zagoskin's travels in Russian America, 1842-1844; The First Ethnographic and Geographic Investigations in the Yukon and Kuskokwim Valleys of Alaska. In: Henry N. Michael, (ed.), Artie Institute of North America, Anthropology of the North: Translations from Russian Sources No. 7. Toronto. University of Toronto Press.

Chapter 7

Diabetes and pregnancy among Alaska Natives: Prevalence and sociocultural aspects Neil J. Murphy

1. Introduction* Glucose intolerance among Yup'ik Eskimo has risen from a virtual rarity in the 1950s to double the prevalence rate of gestational diabetes mellitus (GDM) in the U. S. today, all races (Scott and Griffith 1957; Mouratoff, Carroll, and Scott 1967; Mouratoff, Carroll, and Scott 1969; Murphy etal. 1991; 1993; Schraer etal. 1988). During the same period, Alaska Natives have greatly increased their intake of refined carbohydrates and increased the mechanization of subsistence activities. During this period the proportion of overweight women and men increased by factors of 4 and 5 times, respecively (Murphy et al. 1992). This report documents the increasing prevalence of GDM among the Yup'ik Eskimo in the Yukon Kuskokwim Delta Service Unit (YKDSU), which traditionally has had the lowest prevalence of non-insulin dependent diabetes mellitus (NIDDM) among Alaska Natives (Schraer et al. 1988). This study also compares the prevalence rate of GDM from the YKDSU to that of the Alaska Coastal Indian population of the Southeast Alaska Regional Health Corporation at Mt. Edgecumbe Hospital (SEARHC-MEH), which has the second highest prevalence rate of NIDDM among Alaska Natives. Diabetes in pregnancy is both a symptom of sociocultural change and a harbinger of future problems for the women in whom NIDDM may develop and for their offspring, who may suffer from obesity and NIDDM. Fortunately, GDM does offer a unique opportunity to provide primary, secondary, and tertiary prevention to the pregnant woman and her family during a period of relatively high compliance with medical

* Abbreviations, please see page 218.

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management. Our goal should be to develop culturally sensitive preventive strategies for NIDDM and GDM that will complement the Alaska Native health belief system.

2.

Background

2.1. Sociocultural factors Traditionally, Alaska Natives gathered all their food and materials for shelter from the harsh Arctic environment. The aboriginal lifestyle required the ability to adapt to a constantly changing environment and demanded a large amount of physical energy. Much of this energy was spent in food gathering activities to insure even the barest survival. The Arctic summer is a short frenzy of plant and insect life. The large biomass of insects and plants attracts birds like the Arctic tern (Sterna paradisaea) from as far away as Antarctica. The abundance of flora and fauna supports a food chain that includes: arctic hare (Lepus arcticus); salmon (Onocorhynchus sp); whistling swan (Olor columbianus); caribou (.Ranger arcticus)·, moose (Alces Alces); seal (Phoca vitulina); and bowhead whale (Balaena mysticetus) (Heller and Scott 1962; Morehouse 1981). Though the summer harvest was generally rich, late spring could be the traditional "hungry time" because winter food stores were depleted and none of the traditional protein sources from hunting were yet available. In addition, winter was frequently a nine month period of meager resources interspersed with periods of starvation (Heller and Scott 1962; Morehouse 1981). Gradual changes in food gathering and subsistence began in the 1700s with the arrival of the Russian fur merchants and subsequently the American whalers and gold miners, who provided a stable influx of refined carbohydrates, cereals, canned goods, and alcohol (Urquhart 1935). Recent North American Arctic dietary surveys document the change of diet from predominanty protein and virtually no carbohydrates (Urquhart 1935; Nicolaysen 1980; Morehouse 1981; Heller and Scott 1962) to a diet more dependent on refined carbohydrates (Davies and Hanson 1965; Schaefer 1970; Mann et al. 1962; Knapp and Panruck 1978; Szathmary, Ritenbaugh, and Goodby 1987). Heller reports that in aboriginal times the only carbohydrate sources available to most Eskimos and Indians were fish roe; fish liver; whale fat

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or muktuk; berries, i. e., salmonberry (Rubus spectabilis), and low bush cranberry (Vaccinium oxycoccus); wild greens, i. e., marsh marigold (Caltha palustris)', wild celery {Angelica lucida)\ and small quanitities of vegetable material from the stomach contents of moose and caribou (Heller and Scott 1962; Nicolaysen 1980). These carbohydrate sources constituted no more than 3-5 pervent of the total dietary intake of calories. By 1958 carbohydrate sources had increased to 31 percent of the total caloric intake (Heller and Scott 1962). Knapp and Panruck (1978) reported carbohydrate intake had increased to half of the total caloric intake of the Yup'ik Eskimos from the YKDSU. Current carbohydrate sources are frequently highly refined products with low fiber, vitamin, and mineral content. Thiele and Boushey (1989) report Yup'ik Eskimo teenagers consume three to four times the sweetened soft drinks consumed by the general population of U.S. Teenagers. These changes in cultural and nutritional status have been hastened by various supplemental food programs, including the United States Department of Agriculture Special Supplemental food Program for Women, Infants and Children, which began in 1973 (Pelto 1982). In a ten year follow-up study, Petersen (1984) documented the contribution of environmental factors, including diet, arguing against genetic variability with increasing stature and decreasing anemia among Alaskan Eskimo. The indigenous people of the North American Arctic have had all aspects of their culture modified by European culture. Long distance travel is accomplished by jetliner or propeller-powered aircraft. Common methods of local transportation include: trucks, automobiles, motorcycles, all-terrain vehicles, and outboard boat engines. Subsistence hunting activities are now aided by chainsaws, high powered rifles, monofilament line fishing nets, and metal traps. The current lifestyle is frequently sedentary, with life centered around school systems, post offices, stores, and transportation facilities. Petroleum-based products or electricity provide home heating. Potable water is delivered either by truck or by centralized plumbing, and sewage is removed in similar ways. In remote villages the most desirable grocery items are those with the longest shelf life. These food items are high carbohydrate, low protein, and low vitamin- or mineral-containing foods. These changes have eliminated some of the positive aspects of the subsistence lifestyle, i. e., limiting the physical and mental sense of well being promoted by the process of procuring and consuming traditional subsistence foods (Hurwitz 1977). The North American Arctic people did not have an intoxicating drink before the introduction of alcohol by the explorers and frontiersmen

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(Hild 1987). Once introduced, alcohol rapidly progressed to uncontrolled use by many people. The intermittent nature of alcohol delivery to small isolated communities via air transportation or seasonal barge shipments reinforced a binge drinking pattern. Suicide is frequently alcohol related, and suicide rates among Alaska Natives are the highest in the U.S. Kraus and Buffler (1979) report that inpatient and outpatient visits for psychiatric illness and alcohol abuse have been rising steadily. The prevalence rates for these psychiatric diagnoses exceed rates for other American Native and non-Native groups. Rates among Alaska Natives for violent death, suicide, homicide, and accidents are higher than rates for Alaska non-Natives, American Indians, and the U.S., all races (Kraus and Buffler 1978). Though traditional medicine men and women continue to offer the aboriginal remedies, the problems related to this cultural transition are frequently beyond the resources offered by the traditional medicine men and women (Baker et al. 1987; Kirchner 1982; Fortuine 1984; Book, Dixon, and Kirchner 1983; McGregor 1981; Anderson 1988). 2.2. Historical Alaskan and Arctic Native diabetes prevalence Studies from the 1950s and 1960s documented the virtual rarity of NIDDM among Alaska Natives (Scott and Griffith 1957; Mouratoff, Carroll, and Scott 1967; Mouratoff and Scott 1973; Fisher 1974). Scott and Griffith (1957) reported a crude rate of 0.2-0.4/1000 after finding three to seven persons with diabetes in oral glucose tolerance testing (OGTT) screening of 1227 Alaskan Eskimos and a statewide review of medical record and vital statistic information from a total of 16,000 Eskimos in 1957. Among the Yup'ik Eskimo of Southwestern Alaska, Mouratoff, Carroll, and Scott in 1967 found eight persons in a population of 705 (from a total population of 2167) with two-hour plasma glucose levels exceeding 200mg/dl, for a crude rate of 11.3/1000. Mouratoff and Scott (1973) found no additional cases in a follow-up study in the same region 10 years later. Fisher (1974) reported seven new clinical cases among 2,313 Inupiat Eskimos in Northern Alaska between 1966 and 1973 for a crude rate of 3.0/1000. In the 1960s, an OGTT screening study of Alaskan Athabaskan Indians, reinterpreted with 1985 World Health Organization (WHO) diagnostic criteria, identified three cases of NIDDM among 306 persons greater than 20 years old from a population of roughly 612, for a crude rate of 9.8/1000 (Mouratoff, Carroll, and Scott 1969). These very low prevalence rates of NIDDM in Alaska Natives have also been found among the Canadian Inuit and Athabaskans (Davies and

7 Diabetes and pregnancy among Alaska Natives

199

Hanson 1965; Schaefer 1968 a; Schaefer 1968 b; Schaefer 1970; Urquhart 1935), and among Greenland Eskimos (Kromann and Green 1980; Sagild etal. 1966). Recent surveys of Alaska Natives have found increased prevalence rates of NIDDM (Schraer etal. 1988, Dippe etal. 1975). Dippe etal. (1975) report in an OGTT screening study among the Aleut people of St. Paul island in the Bering Sea that 20 of the 355 islanders ages ten years and older had two-hour plasma glucose levels greater than 200 mg/ dl after a 75 gram glucose load for a crude prevalence rate of 59.7/1000. Fifty-three additional islanders (158.2/1000) displayed two-hour glucose levels exceeding 140 mg/dl. Schraer et al. (1988) report that from a statewide search of computerized medical records, inpatient medical record data, and clinical reports, the overall age adjusted prevalence of diabetes mellitus for all Alaska Natives was 15.7/1000. The age adjusted prevalence varied considerably by ethnic group. The prevalence among the Coastal Indians of the Mt. Edgecumbe Service Unit was 27.2/1000, yet was only 8.8/1000 for Alaska Eskimos. Rates among the Eskimo subgroups varied by a factor of four with the smallest age adjusted prevalence rate (5.8/ 1000) found among the Yup'ik Eskimo of the YKDSU. The majority of the NIDDM patients were full blooded. Murphy et al. (1992 b) reported an age adjusted prevalence rate of 47.0 per 1000 and 100.0 per 1000 in Yup'ik Eskimos and Athabascan Indians in a 25 year follow-up project that re-examined the same villages studied by Mouratoff in 1967. During this period the proportion of overweight women and men increased by factors of 4 and 5 times respectively (Murphy et al 1992). Schraer et al. (1988) suggested that the difference in rates of NIDDM between the Alaska Native groups correlated with the length of time each group experienced the influence of Caucasian contact. Increased rates of NIDDM have also been reported from various groups of Canadian Native people (Montour and Macaulay 1985; Young et al. 1985; Evers etal. 1987) and associated atherosclerotic complications (Macaulay, Montour, and Adelson 1988). Despite a prevalence slightly less than the US, all races, the rates of diabetic complications among Alaska Natives are as high as those in other populations (Schraer et al 1993).

2.3. Impact of global sociocultural change Studies from around the globe have illustrated increased prevalence rates of NIDDM among populations with increasing urbanization, mechanization of subsistence activities, and caloric intake, i. e., the new immigrant

200

Neil J. Murphy

Yemenites in Israel (Cohen et al. 1979); the Micronesian population of Kiribati (King etal. 1984); Australian Aborigines (O'Dea, White, and Sinclair 1988; Wise et al. 1970); the Micronesian population of Nauru (Zimmet 1979); and the Polynesian population of Western Samoa (Zimmet et al. 1981). The low prevalence rates of the Arctic Eskimo and Athabaskan Indian are in sharp contrast to the dramatically increased prevalence rates among other Native populations on the North American continent, i.e., Pima (Knowler et al. 1983); Cocopah (Henry et al. 1969); Seneca (Frohman, Doeblin, and Emerling 1969) and Cherokee (Stein 1965). West and Kalbfleisch (1971) in a review of eleven Central American countries report a positive correlation between elevated body mass index, dietary intake of fat and sugar, and prevalence of diabetes. The magnitude of NIDDM and its complications among these North American Natives raises serious questions for global medical care and future priorities given limited medical resources (Pyke 1969; Zimmet 1982).

2.4. GDM: Global perspective Comparison of the international prevalence rates of GDM is difficult due to differences in diagnostic testing (Second International WorkshopConference on Gestational Diabetes Mellitus 1985; WHO Expert Committee on Diabetes Mellitus 1980; Carpenter and Coustan 1982). Prevalence rates of GDM vary worldwide with Tunisia at 0.5 percent (Khalifia 1986); Chile at 1.0 percent (Mella 1986); Sweden at 2.0 percent (Persson 1986); Belfast at 2.2 percent (Hadden 1980) (see Figure 1). The GDM prevalence figure for the U.S. overall, all races, is 2-3 percent (Sepe 1985; O'Sullivan 1976). The prevalence of GDM among American Indians has been reported at 3.2 percent among the Northern Cheyenne (Dillard et al. 1988), 4.6 percent among the Navajo (Sugarman 1989), and 9.7 percent among the Pima (Pettitt et al. 1980).

2.5. Clinical aspects of GDM Prior to insulin therapy, diabetic women rarely delivered of a viable pregnancy. In one of the earliest collected series on diabetes in pregnancy, Williams (1909) reports a maternal mortality rate of 30 percent and overall fetal loss rate of 65 percent. Since 1921, the availability of insulin has markedly improved the outlook for both mother and fetus. Among pregnant women with insulin dependent diabetes mellitus, fetal mortality continues at rates of 3-5 percent, and major congenital anomalies occur

7

Diabetes and pregnancy among Alaska Natives

Pima (Pettit 1980)° Yup'ik E s k i m o Y K D S U 1987 b Navajo ( S u g a r - m a n 1989] b A l a s k a n C o a s t a l Indian S E A R H C - M E H 1987 b Northern C h e y e n n e ( D i l l a r d 1988) b

V / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / 7 7 7 7 7 A 9.7·/. V / / / / / / / / / / / / / / / / / / / / / / / A 6.1 V.

V / / / / / / / / / / / r f 7 7 7 7 A t-6·/. V////////////A^u '////////////Am.

U S All R a c e s ( 0 ' S u l l i v a n 1976)

'//////////Aw.

Belfast ( H a d d e n 1980)

'////////λ*.!·,.

Sweden (Persson1986)

201

7777777Λ1*·!.

Tunisia ( K h a l i f a 1986) J 2

3

L 4

J 5

I

6

Percent P o s i t i v e

Figure 1. Prevalence rates of gestational diabetes mellitus

in 6-12 percent of offspring, three times the rate in the general population (Freinkel 1980). In the past, fetal deaths in utero, neonatal respiratory distress syndrome, birth trauma, and asphyxia resulting from fetal macrosomia were responsible for the increased morbidity and mortality and could all be linked to fetal hyperinsulinemia. Perinatal mortality in GDM patients with optimal care approaches the rate found in normal women (Gabbe 1977). Patients with GDM and their offspring have an increased risk of subsequent NIDDM (O'Sullivan 1982; Pettitt etal. 1988). O'Sullivan (1982) reported in a 16-year follow-up study of GDM patients that 46.7 percent of overweight patients and 25.6 percent of normal weight patients developed NIDDM. Pettitt et al. (1987) notes that after 19 years of follow-up, offspring of diabetic women were heavier than offspring of nondiabetic women, regardless of birth weight, even after accounting for the effect of maternal body size. Pettitt et al. (1988) also report that

202

Neil J. Murphy

NIDDM during pregnancy in Pirna Indian women results in offspring who have a higher prevalence of NIDDM (45 percent) at age 20-24 years than in comparably aged offspring of nondiabetic women (1.4 percent).

2.6. Early evidence of gestational glucose intolerance in the Arctic In 1968 Schaefer (1968 a) reported 13 diabetics (pregnant and nonpregnant) among 13,000 Canadian Eskimos from medical records and vital statistics for a crude rate of 1.0/1000. Re-examination of Schaefer's data using 1985 WHO diagnostic criteria suggests higher levels of glucose intolerance may have existed than originally reported; however, it is very difficult to interpret this data because the techniques are nonstandard by current criteria. It would appear that more than 70 percent of Schaefer's pregnant patients had glycosuria (Schaefer 1968 a). In addition, six of the seven pregnant patients studied would have met current criteria for impaired glucose tolerance (IGT) by WHO criteria (Schaefer 1968 b). Schaefer (1968 b) further reports that four of the 13 (30.7 percent) total clinically recognized cases of diabetes mellitus from 1953-1967 were pregnant and had received medical therapy or induction of labor. Full term birth weights recorded at three different facilities in northern Canada revealed statistically significant increases in birth weight within the ten year period 1958-1968, with a mean weight at one facility of 3.65 kilograms (S.D. = ± 530 gms) (Schaefer 1970).

3. Methods Comprehensive medical care is available to all Alaska Natives directly through the Indian Health Service (IHS) or by contract with regional native health corporations. The Alaska statewide IHS system is divided into nine Service Units. The groups studied consist of the predominantly Yup'ik Eskimo from the YKDSU of Southwest Alaska and the Alaska Coastal Indians (Tlingit, Haida, and Tsimshian) from the SEARHCMEH of Southeast Alaska. The YKDSU contains approximately 20,000 Alaska Natives and is served by a 50-bed Yukon Kuskokwim Delta Regional Hospital (YKDRH) in Bethel, Alaska. The YKDSU has been influenced by Caucasian contact for the shortest time among the Alaska

7 Diabetes and pregnancy among Alaska Natives

203

Native Groups because the Yup'ik Eskimo did not undergo major cultural changes until the late 1800s and early 1900s. The SEARHC-MEH contains approximately 8,000 Alaska Natives and is served by the 75-bed Mt. Edgecumbe Hospital (MEH) in Sitka, Alaska. The MEH is administered by a native health corporation, the Southeast Alaska Regional Health Corporation. The SEARHC-MEH have been influenced by Caucasian contact for the longest period with heavy influence since the mid 1700s. Sitka served as the capitol of Russian America until 1867. The people supplement their subsistence lifestyle with income from tourism, forest products, commercial fishing, and government employment. IHS physicians act as referral resources for village clinics staffed by Community Health Aides and/or midlevel practitioners. The 170-bed Alaska Native Medical Center (ANMC) in Anchorage is a tertiary referral center. IHS medical care is free of charge, including prescription medications. It is estimated that 90 percent of the Alaska Native population uses the IHS system in some way for medical care. Patients were ascertained by review of birthlogs for consecutive deliveries at YKDRH, MEH, ANMC, and the YKDSU Maternal Child Health village delivery log (Murphy etal. 1991; 1993). Deliveries from the YKDSU were identified for 12 consecutive months from March 1, 1987, through February 29, 1988. Deliveries from the SEARHC-MEH were identified during 24 consecutive months from January 1, 1987, through December 31, 1988. Contract care records were also reviewed from Alaska's only Level III perinatal unit that is located in a nonfederal hospital in Anchorage, Alaska. Those reporting a race other than Alaska Native were excluded. All pregnant patients were encouraged to obtain GDM screening with a 50 gram GST between 24 and 28 weeks gestation. These patients were screened by obtaining a plasma glucose one hour after ingesting a 50 gram glucose load without regard to time of last meal. A three-hour 100-gram OGTT was recommended for all patients with GST results greater than or equal to 140 mg/dl. All glucose measurements were done by the hexokinase method. YKDRH was a Dupont Automated Chemistry Analyzer-5, and MEH used a Hitachi 704. The diagnosis of GDM was accepted if the records contained evidence of pregnancy and if the three-hour OGTT met the O'Sullivan criteria after a 100 gram oral glucose load. Patients were also accepted if they had previously met W.H.O. diagnostic criteria (Harris et al. 1985; Second International Workshop-Conference on Gestational Diabetes Mellitus

204

Neil J. Murphy

1985). Birthlog information was also obtained on maternal age, gravidity, parity, estimated gestational age, and birth weight. Chart review revealed the GST, any repeat GSTs, and results of the three-hour OGTT. Patients with risk factors were encouraged to obtain a GST on their first visit, at 24-28 weeks gestation, and at 32 weeks gestation if the previous screening tests were negative (First International ConferenceWorkshop on Gestational Diabetes Mellitus 1980). Risk factors for G D M include: history of previous glucose intolerance outside of pregnancy or GDM; family history of diabetes; previous poor obstetrical history inTable 1. Study population by region, Yukon Kuskokwim Delta Service Unit (YKDSU) and South East Alaska Regional Health Corporation-Mt. Edgecumbe Hospital (SEARHC-MEH), 1987-1988"

Records reviewedb Excluded non-Alaska Native Alaska Native

YKDSU

SEARHC-MEH

Total

630 25 605

243 43 200

873 68 805

a. Time periods: YKDSU: March 1, 1987-February 29,1988; SEARHC-MEH: January 1, 1987-December 31, 1988 b. Total pregnancies (twin births counted once) Table 2. Characteristics of the study population by average value and region, number of patients in parenthesis YKDSU

SEARHC-MEH

Total

Significance

Maternal age (years)

25.6 (605)

24.6 (200)

25.3 (805)

ρ = .04

Gravida

3.4 (604)

2.8 (200)

3.3 (804)

ρ < .001

Para

1.9 (585)

1.3 (198)

1.7 (783)

ρ < .001

Birth weight + SD grams3

3567 + 434 (493)

3722 + 512 (177)

3608 + 461 (670)

ρ < .001

Glucose screen test (GST)

125.3 (545)

108.7 (167)

121.4 (712)

ρ < .001

a. Restricted to term, live, singleton births SD = Standard Deviation

7

Diabetes and pregnancy among Alaska Natives

205

eluding habitual abortion, previous stillbirth, congenital anomalies, previous infant with birth weight greater than 4000 grams or polyhydramnios; or conditions during current pregnancy including maternal age greater than 35 years, initial weight greater than 165 pounds, glycosuria, and polyhydramnios or suspected large-for-gestational-age infant. GDM management category was based on White's Classification (White, Gillespie, and Sexton 1956). The data was analyzed by the two sample ttest, and comparison of rates was done with χ 2 techniques on Fisher's exact test. Multiple two sided ρ values are repeated, with ρ less than .05 set as the level of statistical significance.

4. Results Eight hundred seventy-three consecutive deliveries of patients were reviewed. Sixty-eight patients were excluded because of race other than Alaska Native (Table 1). Six hundred and five Alaska Native patients were identified from the YKDSU and 200 Alaska Native patients from the SEARHC-MEH. The mean age of the 805 Alaska Native patients studied was 25.3 years (Figure 2). The mean gravidity was 3.3 and parity 0.25c O) 0.20Ε ο ί 0.15ο c ο 0.10ο α. 0.05ο

(L

50

4fl

100

1

150

0.25-, M E Η

ΤΤΓΐ-π f=r 6 ST

200

~l I I Γ Ί 250

I 0.20* 0.15.2

0.100.05-

fl

50

100

150

GST

f=Fl· 200

l-1 I I I I I 250

Figure 2. Distribution of GST among Alaska native women

206

Neil J. Murphy

was 1.7 (Table 2). The Y K D S U study population had a significantly greater gravidity, parity, and GST values compared to the SEARHCM D H study population (Table 2). The SEARHC-MEH study population had a significantly greater birth weight compared to the Y K D S U (p < distribution by age (Figure 3), week of gestation at time of screening (Table 3), and proportion of repeat GST (Table 4). G D M was diagnosed by O'Sullivan criteria among 35 patients (5.8 percent) at Y K D S U and five patients (2.5 percent) at SEARHC-

Table 3. Weeks of pregnancy when initial glucose screen test (GST) was measured by region, percent of total in parenthesis YKDSU Weeks of pregnancy 10 10-14 15-19 20-24 25-29 30-34 35 +

9 16 26 103 139 100 152

Total

545 (100.0)

SEARHC-MEH

(1.7) (3.0) (4.8) (18.9) (25.5) (18.3) (27.9)

9 9 7 18 63 33 28

Total

18 25 32 121 202 133 180

(5.4) (5.4) (4.2) (10.8) (37.7) (19.8) (16.8)

167 (100.0)

(2.5) (3.5) (4.6) (17.0) (28.4) (18.7) (25.3)

712 (100.0)

Table 4. Repeat glucose screen tests (GST) by region, percent of total GST in parenthesis YKDSU

SEARHC-MEH

Total

Total pregnancies

605

200

805

Number of patients screened

545

167

712

Number of patients with repeat glucose screen test (GST)

50 (9.2%)

46 (27.5%)

96 (13.5%)

Initial GST Repeat GST Repeat GST

139 mg/dl 139 mg/dl 140 mg/dl

39 24 15

43 35 8

82 59 23

Initial GST Repeat GST Repeat GST

140 mg/dl 139 mg/dl 140 mg/dl

11 6 5

2 2 0

13 8 5

7

Diabetes and pregnancy among Alaska Natives

207

MEH (X 2 = 2.77, df = 1, ρ = 0.09) (Table 6). The total number of patients affected by diabetes during their pregnancies, including those meeting WHO criteria for NIDDM, was 37 patients (6.1 percent) from the YKDSU and seven (3.5 percent) patients from the SEARHC-MEH (X 2 = 1.52, df = 1, ρ = 0.22) (Table 6). GDM patients in the YKDSU had a statistically greater maternal age, gravidity, and parity compared to those YKDSU patients without GDM (p = 0.001) (Table 7). These relationships were not found among the SEARHC-MEH group, but birth weights were statistically greater among the SEARHC-MEH GDM group compared to the SEARHC-MEH patients without GDM (p = .003). Thirty-eight (86.3 percent) of the 44 patients with diabetes affecting their pregnancies were able to maintain a fasting plasma glucose consistently less than 105 mg/dl and/or two-hour post prandial plasma glucose consistently less than 120 mg/dl after inpatient diet therapy and were managed as Class A without insulin therapy (Table 6). Six (13.6 percent) patients were unable to maintain a fasting plasma glucose consistently

Table 5. Results of glucose screening in pregnancy by region, percent of total pregnancies, percent of total patients with glucose screening test (GST) measured, percent of positive GST, and percent of oral glucose tolerance tests (OGTT) measured in parenthesis YKDSU

SEARHC-MEH

Total

605

200

805

Number of patients with 545 (90.1%) GST measured (Percent of total pregnancies)

167 (83.5%)

712 (88.4%)

GST 140 mg/dl (percent of total GST)

179 (32.8%)

32 (19.2%)

211 (29.6%)

GST 139 mg/dl (percent of total GST)

366 (67.2%)

135 (80.8%)

501 (70.4%)

Number of patients with OGTT measured (Percent of patients with GST 140 mg/dl)

156 (87.2%)

30 (93.8%)

186 (88.2%)

O'Sullivan criteria (percent of total OGTT)

35 (22.4%)

5 (15.7%)

40 (21.5%)

Negative OGTT (percent of total OGTT)

121 (77.6%)

25 (83.3%)

146 (78.5%)

Total pregnancies

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Neil J. Murphy

Table 6. Diagnostic and management classification among pregnancies with diabetes by region. Percent of total pregnancies and percent of total diabetic pregnancies in parenthesis

Total pregnancies Diagnostic

SEARHC-MEH

Total

605

200

805

Criteria

O'Sullivan criteria (percent of toal pregnancies) Previous W. H. O. criteria NIDDMa Total pregnancies with diabetes Management

YKDSU

35

(5.8%)

5

(2.5%)

2

(0.3%)

2

(1.0%)

4

(0.4%)

37

(6.1%)

7

(3.5%)

44

(5.4%)

40 (4.9%)

criteria

b

Class A (percent of total diabet pregnancies) Class B b

34 (91.8%) 3

(8.1%)

4 (57.1%)

38 (86.3%)

3 (42.8%)

6 (13.6%)

Fisher's exact test ρ = 0.042 a. Harris 1985 b. Class Α-diet therapy adequate to consistently maintain fasting plasma glucose less than 105 mg/dl and 2 hour post parandial glucose less than 120 mg/dl. Class B-insulin therapy necessary to maintain levels noted above after inpatient diet therapy.

less than 105 mg/dl and/or a two-hour post parandial plasma glucose consistently less than 120 mg/dl after inpatient diet therapy, and therefore received insulin therapy and were classified as Class B. Three (8.1 percent) of the 37 patients in the YKDSU and three (42.8 percent) of the seven patients in the SEARHC-MEH group were classified as class Β (ρ = 0.042) (Table 6). Seven hundred and twelve GST results could be documented among 805 (88.4 percent) pregnancies (Table 5). Five hundred and forty-five (90.1 percent) YKDSU patients and 167 (83.5 percent) SEARHC-MEH patients had a documented GDM. Fifty (9.2 percent) repeat GST were documented among the YKDSU group, and 46 (27.5 percent) repeat GST were documented among the SEARHC-MEH group (Table 4). One hundred seventy-nine (32.8 percent) GST greater than or equal to 140 mg/

7

Diabetes and pregnancy among Alaska Natives

209

Table 7. Characteristics of patients with diabetes in pregnancy, patients with positive glucose screen tests (GST) and negative oral glucose tolerance test (OGTT), and patients without glucose intolerance by average value and region. Number of patients in parenthesis YKDSU

SEARHC-MEH

Total

O'Sullivan criteria

29.9

(35)

25.0

(5)

29.3

GST > 140 mg/dl but OGTT negative

26.8 (144)

25.9

(27)

26.7 (171)

24.8 (426) ρ < .001

24.4 (168) Ρ = .280

24.7 (594) ρ < .001

Maternal age, years

GST < 139 mg/dl

(40)

Gravida O'Sullivan criteria

4.9

(35)

2.0

(5)

GST > 140 mg/dl but OGGT negative

3.9 (144)

3.1

(27)

3.8 (171)

3.2 (425) ρ < .001

2.8 (168) Ρ == 1.0

3.0 (593) ρ < .001

2.9

0.8

(5)

2.7

1.6

(27)

2.2 (167)

1.7 (411) ρ < .001

1.2 (166) ρ = .753

1.5 (577) ρ < .001

3678 ± 389 (31)

4322 + 335 (3)

3735 ± 423 (34)

3647 + 412 (117)

3775 + 427 (23)

3668 ± 4 1 5 (140)

3529 ± 441 (345) ρ = .004

3702 + 521 (151) ρ = .003

3582 ± 473 (496) ρ = .010

GST < 139 mg/dl

4.5

(40)

Para O'Sullivan criteria GST > 140 mg/dl but OGTT negative GST < 139 mg/dl

(34)

(39)

2.4 (140)

Birth weight, + SD grams 3 O'Sullivan criteria GST > 140 mg/dl but OGTT negative GST < 139 mg/dl

a. Term, live, singleton SD = standard deviation

210

Neil J. Murphy

dl were recorded among the YKDSU group, and 32 (19.2 percent) were recorded among the SEARHC-MEH group. One hundred and fifty-six (87.2 percent) OGTT were performed on the YKDSU group and 30 (93.8 percent) OGTT were performed on the SEARHC-MEH group. The mean positive GST for GDM patients at YKDSU was 164mg/dl and at SEARHC-MEH was 155 mg/dl (p = 1). The mean birth weight for live singleton term infants (live infants born after 37-41 completed weeks of gestation) among GDM patients at YKDSU was 3768 ± 389 grams and at SEARHC-MEH was 4322 ± 335 grams (p = .009) (Table 7). The mean term singleton birth weight among patients with a positive GST but a negative OGTT was 3647 ± 412 grams at YKDSU and 3775 ± 427 grams at SEARHC-MEH (Table 7). There were eight fetal deaths among the study infants, all from YKDSU. Glucose screening was done on three of the mothers. All three GSTs were positive, but the three follow-up OGTTs were negative.

5. Discussion The prevalence of GDM in this study is probably underestimated. Sugarman (1989) reports that 20-40 percent of cases of GDM can be missed by use of delivery log or prenatal registry alone. In addition, it is estimated that at least 10 percent of the Alaska Native population receives medical care outside the IHS. There were also 11.6 percent of patients who received no GST, and 11.8 percent who received no follow-up testing after an abnormal GST. The most frequent reasons for not receiving a GST were: no prenatal care, late prenatal care, no records available, premature delivery, and intolerance of the oral glucose load. The demographic characteristics of the two groups are slightly different. The YKDSU study population has statistically greater maternal age, gravidity, and parity (Table 2). After adjusting for the differences of the overall study population at each facility, only gravidity attains statistical significance among the two groups of GDM patients. The proportion of Class A to Class Β patients at YKDSU was consistent with findings in other population studies (Gabbe etal. 1977). The groups were screened similarly by weeks of pregnancy (Table 2) and by maternal age (Figure 3) when the initial GST was conducted. The prevalence of maternal diabetes among the Yup'ik Eskimo is 6.1 percent, which is twice the rate for the U.S., all races (O'Sullivan

7

Diabetes and pregnancy among Alaska Natives

0.25-

0.25-

MEH

YKDSU

S °· 20 "

g