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University of Southern California Dissertations and Theses

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Reversing the transition away from traditional foods and culture: health care communications for a multicultural audience

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Reversing the transition away from traditional foods and culture: health care communications for a multicultural audience

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1

REVERSING THE TRANSITION AWAY FROM TRADITIONAL FOODS AND
CULTURE:
HEALTH CARE COMMUNICATIONS FOR A MULTICULTURAL AUDIENCE
by
Amber Miller

A Thesis Presented to the
FACULTY OF THE USC GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
MASTER OF ARTS
(STRATEGIC PUBLIC RELATIONS)

August 2014

Copyright 2014 Amber Miller

2

Dedication and About the Author
I am proud to be a member of the Choctaw Nation of Oklahoma. I find it important to
honor my heritage and cultural traditions by giving back. Many of my elders have dedicated
their lives to reuniting our people and their achievements thus far are great. My purpose is to
follow in their footsteps.
I have grown up living on or near American Indian reservations in the
Southwest where my father has spent his career working for the Bureau of Indian Affairs
(BIA). My mother has dedicated her career to improving education for American Indian
children. This lifetime of exposure thus far has allowed me to personally see the trials and
tribulations that many American Indians have persevered through. My views have been greatly
shaped by my environment and personal family struggles.
I believe my grandfather has faced some of the greatest struggles, as he has endured
severe health problems, relating to his heart and eating habits. He has undergone three open-
heart surgeries, the last being a quadruple bypass surgery, one that many people do not survive.
The emergency trips to the hospital served as the ultimate wake-up call, forcing my grandfather
to make dramatic lifestyle changes; I believe these changes are the reason he is still alive today.
My grandfather’s struggles have had a great impact on my life and influence the daily
choices I make. Recognizing that his hardships are similar to the hardships faced by many
American Indian people, especially in poverty-stricken areas, I felt a call to action. Therefore I
would like to dedicate my thesis research to my grandfather and I have written this paper as a
tribute to my heritage.

3

Acknowledgements
The following work would not have been possible without the unwavering support,
personal knowledge, and invaluable resources provided by my parents. While writing a thesis
can be overwhelming, the task is much less daunting with family encouragement along the way.
Thank you for your love and motivation through this rewarding experience.
I would like to offer a special thanks to my committee chair, Jennifer Floto for her
guidance, patience and vision for my work. Her reassurance, positive feedback, and belief in me
were a tremendous help throughout this process. I would also like to thank my committee
members Burghardt Tenderich and Daren Brabham for their much appreciated assistance and
review of my work.
Finally, I would like to thank my interview sources for their depth of knowledge, insight,
and the way they deeply care about their patients. Thank you for sharing your culture and
providing direction as I sought to find answers to an issue that is near and dear to my heart.

4

Table of Contents
Dedication and About the Author ....................................................................................................... 2
Acknowledgements ......................................................................................................................... 3
List of Figures ................................................................................................................................. 5
Abstract ........................................................................................................................................... 6
Preface ............................................................................................................................................. 7
Introduction ..................................................................................................................................... 8
Chapter One: A Growing Epidemic – Diabetes and Obesity in the United States ......................... 9
Chapter Two: Diabetes and Obesity Disparities Among Minorities ............................................ 15
Chapter Three: Diabetes and Obesity Plague Native America ..................................................... 20
Chapter Four: A Look at the Indian Health Service ..................................................................... 32
Chapter Five: Communicating Change ......................................................................................... 36
Chapter Six: Evaluation of Healthcare Materials ......................................................................... 41
Chapter Seven: Tribes in the Southwest Fight Back .................................................................... 51
Chapter Eight: Looking to the Future ........................................................................................... 55
Bibliography ................................................................................................................................. 58
Appendix ....................................................................................................................................... 63

5

List of Figures
Figure 1: Word Cloud ...................................................................................................................... 41
Figure 2: “My Native Plates for Your Family” ................................................................................... 42
Figure 3: “10 Tips to a Great Plate” .................................................................................................. 45

6

Abstract
There are many influences that have affected American Indian health. This thesis
examines some of the shortcomings of current healthy eating communications campaigns
targeting American Indian/Alaska Native populations in the United States. It begins with a
discussion of key issues affecting the United States population as a whole in Chapter 1, and then
examines the great health disparities experienced by minority populations in Chapter 2.
Narrowing in on issues specific to American Indian/Alaska Native communities, the author
investigates some of the root causes and drivers behind their current health trends in Chapter 3
and Chapter 4. Proceeding in Chapter 5, Chapter 6, and Chapter 7, is a closer look at current
communications efforts focused on health and healthy eating, including a content analysis of
current campaign materials. The thesis concludes with summary discussion and
recommendations for future campaigns.

7

Preface
Research Methodology
The author conducted both primary and secondary research in preparation for the
following thesis. Before commencing secondary research, the author conducted several
interviews for preliminary enlightenment and direction. Interviewees included Steven Williams,
Director of the Diabetes Department at Whiteriver Indian Health Services Hospital, David Noe,
Contact for the Whiteriver Healthy Heart Project at Whiteriver Indian Health Services Hospital,
and Wil Dubois, a diabetes educator formally associated with Project ECHO (Extension for
Community Healthcare Outcomes). Interviewees provided keen insight on health issues unique
to American Indian populations, and the quality and accessibility of healthcare and healthcare
communication and education today. Additionally, a content analysis was conducted of type 2
diabetes-related materials and promotional health material available online and utilized by health
care providers at Indian Health Services facilities. A focus on dietary guidelines provided by the
United States Department of Agriculture for American Indian/Alaska Native populations was of
particular interest to the author and the appropriateness of these guidelines for their intended
audience was examined.
Secondary research included review of academic journals, scholarly articles, health
studies and reports, news features, and accredited websites. Much of the information presented
herein stems from statistics provided by the American Diabetes Association, The Office of
Minority Health, and the Indian Health Service.

8

Introduction
What if a fatal disease affects 71% of your community? What if people you love are
affected with the seventh leading cause of death? What if the estimated cost of this disease was
$147 billion in the United States alone? What if this disease caused more health loss than
smoking, alcohol and drug use? What if every family you know has been affected by this
catastrophe? What if these appalling statistics are only getting worse? What if we could do
something about it?

9

Chapter One: A Growing Epidemic – Diabetes and Obesity in the United States
The prevalence of obesity and diabetes continues to increase in the United States.
Obesity and type 2 diabetes specifically are major causes of illness and mortality, sharing several
similar causes. These conditions are inter-related as evidence shows that obesity and weight gain
are associated with an increased risk of type 2 diabetes. Furthermore obesity, lifestyle, and
socioeconomic factors may raise or lower an individual’s lifetime risks for type 2 diabetes.
1

In discussing diabetes it is important to note and understand the distinctions between type
1, type 2, and gestational diabetes. Simply put, type 1 diabetes is caused by a body’s inability to
produce insulin. Type 2 diabetes occurs when a body is unable to use the insulin it produces.
Gestational diabetes is a condition that only occurs during pregnancy. Although high blood
sugar levels characterize all cases of diabetes, roughly 90 percent of all cases are type 2 and will
be the primary focus of this paper.
Diagnosis of type 2 diabetes usually occurs over age 40 however, with the increased
prevalence of obesity and the rise in the number of people living with diabetes, it is now being
diagnosed at all ages. As the numbers continue to grow, it is estimated that the number of people
living with what is now deemed “prediabetes” now totals 79 million.
2
According to the latest
statistics from the American Diabetes Association (ADA), 25.8 million children and adults in the
United States have diabetes - that number is equivalent to 8.3 percent of the United States
population. Diabetes is one of the most serious and devastating health problems in our country,
affecting the health and quality of life of entire communities.
As of 2011, diabetes was the seventh leading cause of death in the United States. Similar

1

Narayan, K. M. (2003). Lifetime Risk for Diabetes Mellitus in the United States. Jama-journal of The American
Medical Association, 290(14). doi:10.1001/jama.290.14.1884
2

Diabetes Statistics - American Diabetes Association®. (2013, June 6). Retrieved December 18, 2013, from
http://www.diabetes.org/diabetes-basics/diabetes-statistics/

10

to obesity, diabetes is associated with many health complications that can significantly lower
quality of life. The latest National Diabetes Statistics (2011) show that diabetes is the leading
cause of kidney failure, nontraumatic lower-limb amputations, and new cases of blindness
among adults in the United States.
3
Diabetes is also a major cause of heart disease and stroke.
As a result, more than 200,000 people die of diabetes-related complications each year.
4

The estimated lifetime risk of developing diabetes for individuals born in the United
States in 2000 was 32.8 percent for males and 38.5 percent for females.
5
Individuals diagnosed
with diabetes have large reductions in life expectancy. It is important to quantify this burden in a
way that is easily understood and communicated. For example, it is estimated that if an
individual is diagnosed at age 40, men will lose 11.6 life-years and 18.6 quality-adjusted life-
years and women will lose 14.3 life-years and 22.0 quality-adjusted life-years.
6
This realization
can be jarring and hopefully life changing. For individuals born in the United States in 2000, the
lifetime probability of being diagnosed with diabetes, especially type 2 diabetes is substantial,
however, it is questionable whether this information is being communicated effectively. To
recognize whether one is at exceptionally high risk for diabetes it is important to understand how
the onset of diabetes occurs.
According to the ADA, individuals inherit a predisposition to diabetes and then the
disease is triggered by something in the individual’s environment.
7
The ADA has stated that

3
National Diabetes Information Clearinghouse (2011, February). National Diabetes Statistics, 2011. Retrieved from
http://diabetes.niddk.nih.gov/dm/pubs/statistics/DM_Statistics_508.pdf
4

Obesity.org - your-weight-and-diabetes. (n.d.). Retrieved December 18, 2013, from
http://www.obesity.org/resources-for/your-weight-and-diabetes.htm

5

Narayan, K. M. (2003). Lifetime Risk for Diabetes Mellitus in the United States. Jama-journal of The American
Medical Association, 290(14). doi:10.1001/jama.290.14.1884
6

Narayan, K. M. (2003). Lifetime Risk for Diabetes Mellitus in the United States. Jama-journal of The American
Medical Association, 290(14). doi:10.1001/jama.290.14.1884

7

Genetics of Diabetes - American Diabetes Association®. (2014). Retrieved December 18, 2013, from
http://www.diabetes.org/diabetes-basics/genetics-of-diabetes.html

11

“genes alone are not enough” to cause diabetes.
8
As evidence of this, the ADA points to studies
conducted with identical twins, as they have identical genes. Studies have shown that when one
twin has type 1 diabetes, the other gets the disease at most only half the time. When one twin
has type 2 diabetes, the other twin’s risk is 3 in 4.
9
These studies are often conducted by first
identifying twin pairs with only one twin diagnosed with diabetes. Follow-up studies are
conducted years later to assess the number of initially undiagnosed twins who developed the
disease.
Although diabetes cannot be attributed to genetic factors alone, it has been shown to run
in families; the same is also true for obesity. Family lifestyle is recognized as a risk factor for
diabetes and obesity. Families tend to have similar eating and exercise habits and, as such, if one
or both parents are obese, the risk of a child being obese and/or developing diabetes is
increased.
10

Obesity rates have more than doubled in adults and children since the 1970’s. More than
one-third of adults in the United States are obese. Research also shows that the heaviest
Americans have become even heavier in the past decade.
11
According to the Centers for Disease
Control and Prevention (CDC), obesity-related conditions are some of the leading causes of
preventable death. Obesity-related conditions include diabetes, high blood pressure, high
cholesterol levels, stroke, heart disease, certain cancers and arthritis. Of these conditions,

8

Genetics of Diabetes - American Diabetes Association®. (2014). Retrieved December 18, 2013, from
http://www.diabetes.org/diabetes-basics/genetics-of-diabetes.html

9

Genetics of Diabetes - American Diabetes Association®. (2014). Retrieved December 18, 2013, from
http://www.diabetes.org/diabetes-basics/genetics-of-diabetes.html

10

Genetics of Diabetes - American Diabetes Association®. (2014). Retrieved December 18, 2013, from
http://www.diabetes.org/diabetes-basics/genetics-of-diabetes.html

11

Overweight and Obesity in the UNITED STATES « Food Research & Action Center. (2010).
Retrieved December 19, 2013, from http://frac.org/initiatives/hunger-and-obesity/obesity-in-the-us/

12

diabetes may be most closely linked to obesity.
12
The obesity epidemic is widespread and
continues to be a leading public health problem in our country. The estimated annual medical
cost of obesity in the United States was $147 billion in 2008.
13

According to a 2013 news release from the Institute for Health Metrics and Evaluation
(IHME), poor diet and inadequate physical activity are two of the driving forces behind our
nation’s health. Findings were presented from ongoing research that showed unhealthy diet and
lack of physical activity in the United States caused more health loss than smoking, alcohol or
drug use in 2010. Researchers from this study, like many of their peers, believe that if the
United States can raise awareness for and reduce current health trends, we could see marked
reductions in health deterioration. Dr. Christopher Murray, IHME Director and one of the lead
authors on the study stated, “The U.S., particularly in certain communities, has shown what it
can do about addressing risk factors such as smoking, and if we can see that same type of energy
put into dietary risk factors, physical inactivity and other key areas of concern, we will see real
progress in health outcomes.”
14
Other key findings from this study show that overall disease
burden in the United States is now dominated by conditions that are more disabling than fatal.
Proving Dr. Murray’s point about the progress that has been made as a result of
addressing smoking and its health risks, a look at state-level public education campaigns to
reduce tobacco use clearly shows a link between effective healthcare public relations and health
improvement. In 1988 for example, California launched one of the first widespread state efforts
to implement strong anti-tobacco interventions after voters passed Proposition 99, which

12
Flegal, K. M., Carroll, M. D., Ogden, C. L., & Johnson, C. L. (2002). Prevalence and Trends in Obesity Among
US Adults, 1999-2000. The Journal of the American Medical Association, 288(14).
13

Obesity and Overweight for Professionals: Data and Statistics: Adult Obesity - DNPAO - CDC. (2013, August
16). Retrieved December 19, 2013, from http://www.cdc.gov/obesity/data/adult.html
14
Dietary risks are leading cause of disease burden in the US and contributed to more health loss in 2010 than
smoking, high blood pressure, and high blood sugar | Institute for Health Metrics and Evaluation. (2013, July
10). Retrieved from http://www.healthmetricsandevaluation.org/gbd/news-events/news-release/united-states-
losing-ground-other-countries-health-outcom

13

increased cigarette taxes. A portion of revenues from the tax hike was earmarked towards the
establishment of the California Tobacco Control Program (CTCP).
15
Specific CPTP elements
included a statewide mass-media campaign, competitive grants program, school-based
prevention and cessation programs, health care provider education, community programs and
coalitions, and restrictions on advertising and promotions.
16

According to The California Department of Public Health, before Proposition 99, tobacco
was a part of everyday life, “Not only did almost a quarter of the population smoke, but they
could smoke just about everywhere.”
17
Today the story is very different and strong protections
from dangerous secondhand smoke can be seen across California, in addition to efforts to expose
and fight the tobacco industry’s negative influences. Grassroots programs conducted by local
health departments, community groups, nonprofit organizations, and schools had a significant
positive impact on the health of millions of Californians. The CTCP (now recognized as the
longest-running comprehensive tobacco control program in the nation) states that since 1988 the
adult smoking rate has dropped 50 percent and California has saved more than $86 billion in
health care costs.
18
Furthermore, it is estimated that since Proposition 99 passed, smoking-
related cancer rates have decreased over three times faster in California than in the United States
as a whole.
19

Decreases in smoking rates and improved health have been shown to result from changes

15

Friend, K., & Levy, D. T. (2002). Reductions in smoking prevalence and cigarette consumption associated with
mass-media campaigns. Health Education Research,17(1), 85-98. doi:10.1093/her/17.1.85
16

Wakefield, M. and Chaloupka, F. (2000) Effectiveness of comprehensive tobacco control programmes in
reducing teenage smoking in the USA. Tobacco Control, 9,177–186.
17

California Department of Public Health (2014). History of Tobacco Control - TobaccoFreeCA.
Retrieved February 11, 2014, from http://www.tobaccofreeca.com/successes/history/
18

California Department of Public Health (2014). About - TobaccoFreeCA. Retrieved February 11, 2014, from
http://www.tobaccofreeca.com/about-us
19

Cowling, D.W., Yang, J. Smoking-Attributable Cancer Mortality in California, 1979-2005. Tobacco Control.
2010;19 (Suppl 1):i62ei67.

14

in social norms, and in knowledge, attitudes and beliefs regarding smoking. As mentioned by
Dr. Murray, if a similar level of energy and attention is put towards combating dietary risk
factors, physical inactivity, and other key areas of concern, real progress in positive health
outcomes could be realized. Community-focused efforts that spotlight risk factors such as
smoking increase the chances of reversing health trends. The United States has faced many
health problems in the past, but with a targeted focus, has shown the ability to turn a horrible
tide.
It is clear that obesity and diabetes substantially impair quality of life and increase
morbidity, however the numbers of people diagnosed with these conditions continue to rise.
Therefore communication and education about prevention of obesity and diabetes and their
complications should become public health priorities. Interventions are needed to increase
physical activity and improve diet in communities nationwide. Insight will be gained, however
by taking a closer look at these communities to understand how they are uniquely affected. Of
particular importance to the author is the broader community of racial/ethnic minorities, with
specific emphasis on American Indians.

15

Chapter
Two:
Diabetes
and
Obesity
Disparities
Among
Minorities

In the United States, the burden of diabetes, in specific, is greatest for racial and ethnic
minorities. According to the Agency for Healthcare Research and Quality, “Minorities have a
higher prevalence of diabetes than whites, and some minorities have higher rates of diabetes-
related complications and death.”
20
These populations, especially the elderly, are
disproportionately affected by this life-altering disease. Obesity as well is seen in substantially
high rates, especially among women, in these same ethnic/minority groups.
According to the Office of Minority Health (OMH), African Americans are twice as
likely to have diabetes as their Caucasian counterparts. The most recent national survey data
from the ADA (2007-2009) shows 12.6 percent of non-Hispanic blacks (age 20 years or older)
are diagnosed with diabetes.
21
The highest incidence of diabetes in African Americans occurs
between 65-75 years of age, with African American women being especially affected. In
addition, African Americans are more likely to experience complications of diabetes. End-stage
renal disease (kidney failure) and amputations of lower extremities (legs and feet) for example,
are more commonly seen in African Americans with diabetes than seen in the United States
population as a whole.
22
On average, African Americans are 1.5 times as likely to be obese as
non-Hispanic Whites as of 2011. African American women are 1.8 times as likely (or 80 percent
more likely) to be obese than non-Hispanic White women.
With similarly high numbers, 13.2 percent of Hispanic adults (age 18 years or older)
have diabetes (as of 2010). Diabetes is also more prevalent in older Hispanics with the highest

20

Diabetes Disparities Among Racial and Ethnic Minorities | Agency for Healthcare Research & Quality (AHRQ).
(2001, November). Retrieved from http://www.ahrq.gov/research/findings/factsheets/diabetes/diabdisp/index.html

21
Statistics About Diabetes: American Diabetes Association®. (2011, January 26). Retrieved from
http://www.diabetes.org/diabetes-basics/statistics/
22
Diabetes Data/Statistics - The Office of Minority Health - OMH. (2012, August 28). Retrieved January 16, 2014,
from http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=3&lvlid=62

16

rates amongst those 65 and older. In 2008 the death rate from diabetes in Hispanics was 50
percent higher than the death rate of non-Hispanic Whites.
23
On average, Hispanics are 1.7
times as likely to have diabetes and 1.2 times as likely to be obese as non-minorities in the
United States.
With the highest rate of diabetes, 16.1 percent of American Indians and Alaska Natives
(age 20 years or older) have been diagnosed with diabetes (as of 2011).
24
On average, American
Indians and Alaska Natives are twice as likely as non-Hispanic Whites of similar age to have
diabetes and sixty percent more likely to be obese. At the regional level, diabetes is least
common among Alaska Natives (5.5 percent) and most common among American Indians in
southern Arizona (33.5 percent).
25

A relationship undeniably exists between low-socioeconomic-status groups and obesity,
as well as diabetes. According to the Origins and Consequences of Obesity, the most thoroughly
studied measure of environmental influences is socioeconomic status.
26
Many studies have
shown not only a strong relationship between socioeconomic status and obesity but also
causation. In developed societies, socioeconomic status helps to determine the prevalence of
obesity: the lower the social class the more the obesity. The striking increase in the number of
obese Americans during the past decade has shed light on the importance of the environment
when discussing this epidemic. In addition, many medical literature articles indicate that
individuals’ health and behaviors are affected by their social and physical surroundings.

23

Diabetes Data/Statistics - The Office of Minority Health - OMH. (2012, August 28). Retrieved January 16, 2014,
from http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=3&lvlid=62

24

SPECIAL DIABETES PROGRAM FOR INDIANS: 2011 REPORT TO CONGRESS- Making Progress Toward a
Healthier Future. (2011). Retrieved from INDIAN HEALTH SERVICE website:
http://www.ihs.gov/MedicalPrograms/Diabetes/HomeDocs/Programs/SDPI/2011RTC_Layout_10102012_508c.pdf
25

Diabetes Data/Statistics - The Office of Minority Health - OMH. (2012, August 28). Retrieved January 16, 2014,
from http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=3&lvlid=62

26
Symposium on the Origins and Consequences of Obesity, C., Cardew, G., & Ciba Foundation (1996).
Socioeconomic status and obesity. In The origins and consequences of obesity (pp. 174-187). Chichester: John
Wiley.

17

In considering diet, studies have shown that poorer United States neighborhoods have
three times fewer supermarkets than wealthier neighborhoods but contain more fast food
restaurants and convenience stores – all known to offer high-sugar, high-fat food choices. As a
result, the availability of nearby healthy food choices is limited.
27
In considering physical
activity levels, neighborhood influence and environment may independently affect human
behavior and health as well. Safer neighborhoods, for example, that include a mixture of houses,
commercial, retail and recreation destinations, often result in more physical activity and social
capital and less obesity. Neighborhoods with low socioeconomic status, and ones where
residents may feel unsafe at times, usually have fewer physical activity resources than
neighborhoods with medium-to high socioeconomic status, leading to more inactivity of
residents.
28
The impact that environment may have on health will be further discussed in later
chapters, but it is important to note the relationship with socioeconomic status.
Higher rates of low socioeconomic status continue to be seen among all racial and ethnic
minorities in the United States. In discussing poverty alone, the data from recent years still
shows dramatic economic hardship for select populations. For example, in a 2011 article titled
“Minority Children Four Times More Likely to Start Poor, Stay Poor,” children of color in the
United States were reported to be four times more likely than their white peers to be born into a
poor family and suffer a lifetime of consequences.
29
The most recent American Community
Survey (5-year data on United States poverty rates by race and Hispanic or Latino origin from
2007-2011) by the United States Census Bureau, shows that by race, the highest national poverty

27
Morland, K., Wing, S., Roux, A. D., & Poole, C. (2002). Neighborhood Characteristics Associated with the
Location of Food Stores and Food Service Places. Am J Prev Med, 22, 23-29.
28
Booth, K. M., Pinkston, M. M., & Carlos Poston, W. S. (2005). Obesity and the Built Environment. Journal of the
American Dietetic Association, 105(5), 110-117.
29
Ross, J. (2011, June 6). Minority Children Four Times More Likely to Start Poor, Stay Poor.
Retrieved January 15, 2014, from http://www.huffingtonpost.com/2011/04/06/minority-children-start-poor-
stay-poor_n_845866.html

18

rates were for American Indians and Alaska Natives (27.0 percent). The American Community
Survey recognizes that poverty rates are an important indicator of community well-being and
points out that they are used by government agencies and organizations to allocate need-based
resources. Since the poverty rates were the highest for American Indians/Alaska Natives, this is
the population of gravest concern and therefore becomes the focus of this paper.
Low socioeconomic status has consistently been implicated as a risk factor for many of
the problems that plague communities.
30
Communities across the United States still experience
segregation according to socioeconomic status, resulting in compounded problems. Results from
a 2009 Risk Factor Survey conducted by the CDC in minority communities show that education
level and household income were markedly lower in black, Hispanic, and American Indian
communities than that among the general population. More residents in these minority
populations did not have health care coverage and did not see a doctor because of the cost.
31

Concurring studies show low socioeconomic status and race/ethnicity to be associated with
avoidable procedures, avoidable hospitalizations, and untreated disease.
32
The development and
implementation of effective strategies for treating minority populations have become both
clinical challenges and public health priorities. The Handbook of Obesity Treatment points out
that “some data suggest that conventional obesity treatment programs are less likely to be
successful in African Americans than in whites and this may be true for minority populations

30
Ethnic and Racial Minorities & Socioeconomic Status. (2014). Retrieved January 14, 2014, from
http://www.apa.org/pi/ses/resources/publications/factsheet-erm.aspx
31
Surveillance of Health Status in Minority Communities --- Racial and Ethnic Approaches to Community Health
Across the UNITED STATES (REACH UNITED STATES ) Risk Factor Survey, United States, 2009. (2011,
May 20). Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/ss6006a1.htm
32
Ethnic and Racial Minorities & Socioeconomic Status. (2014). Retrieved January 14, 2014, from
http://www.apa.org/pi/ses/resources/publications/factsheet-erm.aspx

19

overall.”
33
As these populations are disproportionately affected, it seems population based
programs and policies are needed.
It is important to understand that continually skewed distributions produce conditions that
ultimately affect our entire society. “Minority” status in the United States now refers to
approximately 37 percent of the United States population according to a press release from the
United States Census Bureau released in December 2012.
34
Projections show that the United
States population will continue to become more racially and ethnically diverse in the years to
come. Considering continuing trends, increased focus must be placed on socioeconomic
inequalities and its correlates. As the prevalence of obesity and diabetes continues to rise at
alarming rates, it is important to look at the unique factors affecting distinctive populations in
order to combat this grave epidemic.

33

Wadden, T. A., & Stunkard, A. J. (2002). Obesity Treatment in Minorities. In Handbook of obesity
treatment (p. 416). New York: Guilford Press.
34
UNITED STATES Census Bureau Projections Show a Slower Growing, Older, More Diverse Nation a Half
Century from Now - Population - Newsroom - UNITED STATES Census Bureau. (2012, December 12).
Retrieved from https://www.census.gov/newsroom/releases/archives/population/cb12-243.html

20

Chapter
Three:
Diabetes
and
Obesity
Plagues
Native
America

“American Indian/Alaska Native” status in the United States refers to those having
origins in any of the original peoples of North, South, and Central America, who maintain tribal
affiliation or community attachment. As of 2012, there were an estimated 5.2 million people
who were classified as American Indian/Alaska Native alone or American Indian/Alaska Native
in combination with one or more other races in the United States. The most current statistics
show this racial group comprises two percent of the total United States population.
35

Type 2 diabetes has been recognized as a significant public health problem in American
Indian communities for almost 50 years, and more recently in Alaska Native communities, but
like other minority groups and the United States population as a whole, the prevalence continues
to increase. Staggering statistics show that between 1990 and 1998, the recorded number of
American Indian and Alaska Native children, adolescents, and adults aged 35 years and younger
diagnosed with diabetes increased an astonishing 71 percent.
36
As diabetes is continually being
diagnosed at younger ages, it is estimated that by age 55, nearly half of all American
Indians/Alaska Natives will have the condition. As pointed out in the American Journal of
Public Health, this increase poses a major public health challenge for affected communities,
because young persons with diabetes will have more years of disease burden and a higher
probability of developing costly and disabling diabetes-related complications early in life – and
for a longer period of time.
37

35

The Office of Minority Health (2014, April 23). American Indian/Alaska Native Profile - The Office of Minority
Health - OMH. Retrieved June 1, 2014, from http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlID=52
36

Acton KJ, Burrows NR, Moore K, Querec L, Geiss LS, et al. (2002) Trends in diabetes prevalence among
American Indian and Alaska native children, adolescents, and young adults. Am J Public Health92: 1485–1490.
37

Acton KJ, Burrows NR, Moore K, Querec L, Geiss LS, et al. (2002) Trends in diabetes prevalence among
American Indian and Alaska native children, adolescents, and young adults. Am J Public Health92: 1485–1490.

21

The latest statistics from the OHM show that the median family income for American
Indians/Alaska Natives is $39,664, as compared to $67,892 for non-Hispanic Whites.
38
Similar
to other minority groups, high rates of poverty have been associated with high rates of
preventable health problems. However, unlike other minority groups, American Indians/Alaska
Natives continue to suffer significant disparities in health status despite the efforts of the federal
Indian Health Service (IHS) to improve quality of care in their communities. Most notably
American Indians have the highest prevalence of diabetes of any group in the United States, with
one tribe in particular, the Pima Indians of Arizona, suffering from the highest rate of diabetes in
the world. How is this possible?
In considering barriers to change and health improvement it is important to note that for
American Indians/Alaska Natives living on reservations or other trust lands (an estimated 22
percent in the United States)
39
issues related to geographic isolation may exist. These issues may
include lack of easy access to healthcare, jobs, healthier food options and/or recreational
facilities. Both Steven Williams and David Noe, who work for IHS, recognize geographic
isolation as a barrier to change for the American Indians living on the Fort Apache Reservation
in eastern Arizona. Displacement and cultural trauma, in addition to high rates of poverty have
also been attributed to poor outcomes for American Indians/Alaska Natives compared to other
groups. Related high obesity rates have had a great impact on health and it is estimated today
that 1 in 5 American Indians and Alaska Natives has two or more chronic health problems.
40

38

American Indian/Alaska Native Profile - The Office of Minority Health - OMH. (2012, September 17).
Retrieved January 19, 2014, from http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlid=52

39

American Indian/Alaska Native Profile - The Office of Minority Health - OMH. (2012, September 17).
Retrieved January 19, 2014, from http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlid=52

40

American Indians/Alaska Natives | womenshealth.gov. (2012, July 16). Retrieved from
http://womenshealth.gov/minority-health/american-indians/

22

Health trends have been impacted by the transition away from traditional foods and
culture, and this, in fact, may be the greatest contributor to the diabetes epidemic experienced by
American Indians. A look at recent history shows a significant change occurred during World
War II. Although industrialization had already swept America, many American Indians still
lived a traditional lifestyle with diets similar to their ancestors who had lived in these particular
locations for generations. During the war, however, many American Indians left the reservations
to fight in defense of the United States or seek work created by the war. While American
Indians financially benefited from new opportunities, these same opportunities disrupted ancient
patterns and lifestyles.
41

Following the war, many American Indians settled into the mainstream, adapting
permanently to the cities and to a non-Indian way of life. Thousands of others returned to the
reservation, but brought with them a taste for the "new" American high-sugar, high-fat diet.

As
happened to the United States population as a whole, a reliance on highly processed foods had
ramifications and took its toll on health.
The American high-sugar, high-fat diet, particularly when combined with poverty was
especially disastrous to the American Indian population. Providing insight, Williams points out,
“If I don’t have a lot of money, I can buy Ramen noodles and feed my family.” This fills the
stomach but provides little nutritional value. Access to nutritious foods is more difficult for
anyone living in poverty, and studies have shown this barrier to a healthy lifestyle is magnified
among American Indian populations. In Whiteriver, Arizona (located on the Fort Apache
Reservation, where Williams and Noe work), the employment rates are very low, and Williams
has seen first-hand the relationship with poverty and the type of foods people eat. He reiterates

41

Capps, R. (1996, July 1). Type 2 Diabetes Continues To Plague Indian Reservations, New Hopes Are Scarce -
Diabetes Health. Retrieved from http://diabeteshealth.com/read/1996/07/01/657/type-2-diabetes-continues-to-
plague-indian-reservations-new-hopes-are-scarce/

23

that limited funds mean limited ability to buy nutritious foods. This starts or renews a cycle: lack
of nutritious food leads to lack of proper nutrition, which leads to worsening health.
Noe tells another story about how poverty and employment rates have affected this
community, “We had a two year battle here [Whiteriver, Arizona] on whether to let Burger King
or Subway come to the reservation…. They ended up choosing Burger King because they can
employ more people.” Subway would have been a healthier choice, but this example sadly
shows how health takes a back seat to the economic hardship many people living on Indian
reservations continue to face. Now the current generation of Apaches living in Whiteriver,
Arizona has developed a taste for Burger King, the only available fast food chain in the
community. Had the decision gone the other way, thinner Apache “Jareds” might have been the
result.

The Food Distribution Program on Indian Reservations (FDPIR) is a federal program that
seeks to address the issue of poverty and food insecurity by providing commodity foods to low-
income households living on reservations, and to American Indian households residing in
approved areas near reservations or Oklahoma. The United States Department of Agriculture
(USDA) purchases and ships the foods in food packages each month to participating households.
Although the program provides hunger relief, food aid provided to tribes often receives
unfavorable scrutiny for being insufficient and often of little quality. The foods have also been
criticized for being non-traditional.
A United States study featured in Reuters Health in 2012 examined a single aspect of the
non-traditional diet consumed by many American Indians and reported that those who frequently
ate processed meat from a can (a common food on reservations and one subsidized by the United
States government) had a two-fold increased risk of developing diabetes compared to those who

24

ate little or none of what is generically known as spam. To conduct the study, researchers
writing for the American Journal of Clinical Nutrition surveyed 2,000 American Indians from
Arizona, Oklahoma and North and South Dakota.
According to Reuters, none of the participants, whose average age was 35, had diabetes
at the start of the study when they answered questions about diet and other health and lifestyle
factors. After five years, a follow-up survey found that 243 people had developed diabetes.
42

Even more alarming, among the 500 people in the study group who ate the most processed,
canned meat, 85 developed diabetes. In contrast, among the 500 people who ate the least amount
of spam, just 44 developed the disease.
43

Findings from the study featured in Reuters Health support an earlier analysis that tallied
the results from multiple studies examining the link between diabetes and processed meat. It was
found that processed meats were tied to a 19 percent higher diabetes risk, while unprocessed
meats were neutral.
44
Although a clear explanation for the link between processed meats and
diabetes has yet to be provided, some have pointed to the difference in sodium, as sodium
impacts blood pressure. People who ate the most processed meats also tended to be heavier,
raising the possibility that processed meats contribute to obesity, therefore increasing the risk of
diabetes. In addition, the possibility that sodium nitrite (a preservative used to cure processed

42

Grens, K. (2012, January 30). Spam linked to diabetes risk in Native Americans| Reuters. Retrieved February 17,
2014, from http://www.reuters.com/article/2012/01/30/us-diabetes-risk-native-americans-
idUSTRE80T1KU20120130

43

Grens, K. (2012, January 30). Spam linked to diabetes risk in Native Americans| Reuters. Retrieved February 17,
2014, from http://www.reuters.com/article/2012/01/30/us-diabetes-risk-native-americans-
idUSTRE80T1KU20120130
44

Grens, K. (2012, January 30). Spam linked to diabetes risk in Native Americans| Reuters. Retrieved February 17,
2014, from http://www.reuters.com/article/2012/01/30/us-diabetes-risk-native-americans-
idUSTRE80T1KU20120130

25

meats) plays a role in diabetes, was also considered. The truth is that all of the above are likely
contributing factors.
Results from this study indicate that a reduction in consumption of processed meats
should be a priority, especially among American Indians. Unfortunately, as many American
Indian communities are located in rural areas with limited access to grocery stores, many
residents continue to seek foods with a long shelf life. This issue is made worse by the ability to
receive discounted or free spam. People also develop a taste for what is readily available. These
factors alone and combined pose serious challenges for diet change. Therefore education and
effective healthcare communication is needed to promote the benefits of a healthy diet,
especially in managing diabetes.

Decrease in activity levels among American Indians/Alaska Natives has contributed to
obesity and diabetes as well. Although a fitness center was built in Whiteriver, Arizona with the
specific intention of helping those who are overweight and have diabetes, Noe says the people
that are already fit and in shape are the ones who visit. “Trying to get people there who aren’t fit
has been one of the biggest challenges.”
Noe is astonished by the change that has occurred over generations, especially among the
American Indians of the Southwest. “These people used to be the most fit people in the world,”
Noe says. “They could run around all day in the hot sun and not even swelter.” He points out
that past generations grew up collecting water and wood, and gathering the natural foods along
with small game native to their area. However, today the story is very different and the change
in lifestyle is dramatically apparent. “They look nothing like their great great grandparents,”
says Noe. When talking with his patients, this is something he often points out.

26

Helping to further illustrate the effects of dramatic lifestyle change are the Pima Indians
of Arizona, who have the highest reported prevalence of diabetes of any population in the
world.
45
These people in particular have been the focus of decades of research, with studies
dating back to 1965. According to an article published by the ADA, the current diagnostic
criteria for type 2 diabetes adopted by the World Health Organization were initially established
in this American Indian population.
46

The Pimas present a unique opportunity for study as Pima Indians are divided between
Arizona and Mexico. Therefore researchers have the ability to compare the health and lifestyles
of tribal members living in the United States to those dwelling in Mexico. By looking at people
with roughly the same genetic make-up but greatly differing lifestyles, researchers have sought
to find answers as to why the Pimas in Mexico suffer from far fewer health problems, especially
related to obesity, than those living in the United States.
Some researchers have hypothesized that the Pimas, like other desert-dwelling Indians,
may have genetically developed for their systems to be more “thrifty” when it comes to
metabolizing food. Many scientists use the thrifty gene theory to help explain why many Pima
Indians are overweight. This theory is based on the fact that for thousands of years populations
who relied on farming, hunting and fishing for food, such as the Pima Indians, experienced
alternating periods of feast and famine. According to the theory, to adapt to extreme changes in
caloric needs, these people developed a thrifty gene that allowed them to store fat during times of
plenty so they would not starve during times of famine.
47

45

Knowler WC, Bennett PH, Hamman RF, Miller M: Diabetes incidence and prevalence in Pima Indians: a 19-fold
greater incidence than in Rochester, Minnesota. Am J Epidemiol108 :497 –505,1979
46

Baier, L. J., & Hanson, R. L. (2004). Genetic Studies of the Etiology of Type 2 Diabetes in Pima Indians:
Hunting for Pieces to a Complicated Puzzle. Diabetes, 53(5), 1181-1186. doi:10.2337/diabetes.53.5.1181

47

NIDDK (n.d.). Obesity Associated with High Rates of Diabetes in the Pima Indians. Retrieved February 13,
2014, from http://diabetes.niddk.nih.gov/dm/pubs/pima/obesity/obesity.htm

27

This gene was helpful as long as there were periods of famine. But when these Indian
populations adopted the typical Western lifestyle, the theory goes with a high fat diet, access to a
constant supply of calories, and less physical activity, the gene began to work against them,
continuing to store calories in preparation for famine. Some scientists believe that the thrifty
gene that once protected people from starvation might also contribute to their retaining unhealthy
amounts of fat.
A study published in the United States National Library of Medicine titled “Effects of a
Traditional Lifestyle on Obesity in Pima Indians,” recognizes a parallel with abrupt changes in
lifestyle and the prevalence of obesity and diabetes in the Pima Indians of Arizona. To assess the
impact of the environment on the prevalence of obesity and diabetes, data were collected on
members of Pima ancestry living in a remote location in northwestern Mexico, with a lifestyle
distinctly contrasting with that in Arizona. Results showed that Mexican Pimas were shorter and
lighter in weight, with lower body mass indexes, lower plasma total cholesterol levels, and lower
rates of diabetes than Arizona Pimas.
48

Researchers from the study attributed living in a “traditional” lifestyle versus living in an
“affluent” environment to the difference in results. According to the study, “These findings
suggest that, despite a similar potential genetic predisposition to these conditions [obesity and
diabetes], a traditional lifestyle, characterized by a diet including less animal fat and more
complex carbohydrates and by greater energy expenditure in physical labor, may protect against
the development of cardiovascular disease risk factors, obesity, and NIDDM [non-insulin-
dependent diabetes mellitus, or type 2 diabetes].”
49

48

Ravussin, E., Valencia, M. E., Esparza, J., Bennett, P. H., & Schulz, L. O. (1994). Effects of a traditional lifestyle
on obesity in Pima Indians. Diabetes Care, 17(9), 1067-1074. doi:10.2337/diacare.17.9.1067

49

Ravussin, E., Valencia, M. E., Esparza, J., Bennett, P. H., & Schulz, L. O. (1994). Effects of a traditional lifestyle
on obesity in Pima Indians. Diabetes Care, 17(9), 1067-1074. doi:10.2337/diacare.17.9.1067

28

Similarly, a 2010 study published in the Journal of Clinical Endocrinology &
Metabolism, which accounted for obesity, age and sex, found that Pimas living in the United
States were more than six times as likely to develop insulin resistance as those living in Mexico.
Researchers again concluded that lifestyle differences were likely to blame for this occurrence.
50

The American Indian Health and Diet Project, a website devoted to recovering the health
of Indigenous peoples, also recognizes that American Indians have been especially hard hit by
the processed American diet. “Diabetes, obesity, and all the ailments that result from them are
commonplace among our people. Instead of turning to the foods that sustained our ancestors, we
tend to prefer the foods and destructive lifestyles that are actually killing us.”
51
The extent to
which transitions away from traditional foods have occurred likely vary by tribe, but it is clear
that current Native diets overall are drastically higher in fat and caloric intake than they used to
be while the daily required caloric expenditure of modern life has decreased.
Recently, “fry bread” (a flat dough fried or deep-fried in oil, shortening or typically lard)
has become the topic of conversation and a hot button issue. Once described as a “traditional”
food by many, efforts have been made to shed light on the controversial history of fry bread and
change attitudes toward a food that is far from indigenous. Drawing great attention to the issue,
TV personality and famed weight loss coach Jillian Michaels took “Losing It with Jillian”
viewers to the Yavapai Apache Nation, located in the Upper Verde Valley of central Arizona, in
an episode that aired in 2010. Plagued with diabetes and obesity, community leaders of the
Plunkett-Marquez family hoped to inspire their tribe to get healthy and to return to their roots.

50

BArizonaell, R., & Carroll, L. (2011, December 9). Indian tribe turns to tradition to fight diabetes - Health -
Diabetes | NBC News. Retrieved from http://www.nbcnews.com/id/43257536/ns/health-diabetes/t/indian-tribe-turns-
tradition-fight-diabetes/#.Ueg3YGAro38\

51

Mihesuah, D. (2013). Health Problems – Reasons Indigenous People are Unhealthy. Retrieved January 25, 2014,
from http://www.aihd.ku.edu/health/lactose_intolerant.html

29

Viewers watched as a shocked Jillian was welcomed with a “traditional” meal of fried
bread, processed cheese and fried beans. The history of fry bread was discussed and although
tribal members initially defended the food as a part of their heritage, it became apparent that the
original ancestors of the Yavapai Apache tribe did not eat bleached white flour dough fried in
lard or processed cheese. Jillian referred to the food as poison and went so far as to say, “Fry
bread is, seemingly, a representation of everything horrible that’s ever happened to your
people.”
52

Jillian is very blunt and her message was not at first well received, especially after she
dramatically dumped all of the tribe’s fry bread in the trash before a tribal picnic. Although
Jillian was trying to illustrate how unhealthy the food is, the elders were very offended and upset
by her wastefulness.
Later, when four members of the Plunkett-Marquez family took Jillian’s advice on diet
and exercise, they lost an incredible combined 143 pounds in six weeks.
53
One member cut her
blood sugar level by 30 percent, and another dropped six dress sizes. While the episode shows
the dramatic turnaround that can occur with diet and exercise, it also underscores the importance
of message delivery in combating the American Indian health epidemic.
Williams and Noe spoke specifically about the diet they see daily on the reservation
where they work. Around lunchtime a “tailgate” is set up where people sell food from the back
of their pick-up trucks. Foods that are considered more traditional can be found here, but these
foods are too often extremely high in fat and the associated calories. Usually the Apache

52
Sklar, B. (2010, July 7). Losing It With Jillian: Toss the Indian Fry Bread - That's Fit. Retrieved from
http://www.thatsfit.com/2010/07/07/losing-it-with-jillian-toss-the-indian-fry-bread/
53

Losing It With Jillian (2010). Losing It With Jillian TV Show, Families, Plunkett-Marquez Family. Retrieved
from http://www.jillianmichaels.com/losing-it-families/plunkett-marquez-family.aspx

30

“hamburger” or Navajo “taco” that is sold consists of greasy fry bread with various toppings
including cheese.
Considering another single aspect of the non-traditional diet, the consumption of dairy
products has received scrutiny. Lactose, the sugar found in milk and foods made with milk, has
been shown to affect some populations more adversely than others. According to the Werner
Medical Center at Ohio State University, seventy-five percent of all African-American, Jewish,
Mexican-American and American Indian adults are lactose intolerant. On the other hand, lactose
intolerance is least common among people with a northern European heritage.
54
As three of the
four minority populations just mentioned have experienced the highest rates of diabetes in the
United States, it seems logical that a relationship between dairy consumption and diabetes may
exist. Nemours, a non-profit children’s health organization, states, “Some ethnic groups are
more likely to be affected [by lactose intolerance] than others because their diets traditionally
include fewer dairy products.” Nemours points out, “Their ancestors did not eat dairy foods, so
their bodies were not prepared to digest dairy, and they passed these genes on from generation to
generation.”
55
Ironically commodity cheese provided free by the government is a staple on many
American Indian reservations.
The Physicians Committee for Responsible Medicine has warned about the health
concerns with dairy products and also acknowledges the great disparity in lactose intolerance
amongst minority populations and their Caucasian counterparts. Due to the common nature of
lactose intolerance amongst minority populations, the group states that milk consumption is not
recommended. The Committee recognizes that many Americans still consume substantial

54
The Ohio State University Wexner Medical Center (n.d.). Lactose Intolerance. Retrieved January 20, 2014, from
http://medicalcenter.osu.edu/patientcare/healthcare_services/digestive_disorders/lactose_intolerance/Pages/ind
ex.aspx
55
Nemours (2014). Lactose Intolerance. Retrieved from
http://kidshealth.org/teen/food_fitness/nutrition/lactose_intolerance.html

31

amounts of dairy products, and government policies still promote them, despite scientific
evidence that questions their health benefits and indicates their potential health risks.
56

The American Indian Health and Diet Project made the following statement on the issue:
“An example of how out of step nutrition ‘experts’ are with the needs of Natives is a study
conducted in 1977 in Gastroenterology that revealed 100 percent of Natives tested were lactose
intolerant, which is a food intolerance to the sugar lactose that is found in milk products. Yet,
the Dietary Guidelines advises that everyone eat two or three servings of dairy foods, despite the
reality that other foods such as green leafy vegetables (collards, turnips greens, spinach, kale,
bok choy), oatmeal, tofu, soy milk, almonds, beans, salmon, herring, sardines, trout, tuna, and
dried smelt also offer calcium.”
57

The much-adopted Standard American Diet and the fast food culture exact an increasing
toll on minority populations and especially American Indians. Unwise food choices sometimes
forced upon the population because of economic status have increased preventable health risks.
The belief that some of these especially unhealthy foods, such as fry bread and spam, are
“traditional” presents additional obstacles for educational healthcare communication.

56

PCRM (n.d.). PCRM | Health Concerns about Dairy Products. Retrieved February 12, 2014, from
http://www.pcrm.org/health/diets/vegdiets/health-concerns-about-dairy-products
57
Mihesuah, D. (2013). American Indian Health - Health. Retrieved January 25, 2014, from
http://www.aihd.ku.edu/health/lactose_intolerant.html

32

Chapter Four: A Look at the Indian Health Service
Working to improve health, federally recognized tribes in the United States are provided
health and educational assistance through a government agency called Indian Health Service
(IHS). Established in 1955, the IHS grew out of the special government-to-government
relationship between the federal government and Indian tribes. This relationship has been given
form and substance by numerous treaties, laws, Supreme Court decisions, and Executive
Orders.
58
The mission of today’s IHS is “to raise the physical, mental, social and spiritual health
of American Indians and Alaska Natives to the highest level.” This mission is built on the IHS
foundation, “to uphold the Federal Government’s obligation to promote healthy American Indian
and Alaska Native people, communities, and cultures and to honor and protect the inherent
sovereign rights of Tribes.”
59
Today, the agency provides a comprehensive health service
delivery system for American Indians and Alaska Natives who are members of 566 federally
recognized tribes across the United States.
Either the IHS or, more recently, tribes, under P.L.93-638, the Indian Self-Determination
and Educational Assistance Act, manage hospitals and clinics in the Indian health system. Over
the past few decades, the management of Indian health programs has shifted from the IHS to
tribes, with more than half of the current IHS budget now managed by tribal health programs.
60

58

Indian Health Service (n.d.). Agency Overview | About IHS. Retrieved February 12, 2014, from
http://www.ihs.gov/aboutihs/overview/

59

Indian Health Service (n.d.). Agency Overview | About IHS. Retrieved February 12, 2014, from
http://www.ihs.gov/aboutihs/overview/

60

Roubideaux, Y. (2004). A REVIEW OF THE QUALITY OF HEALTH CARE FOR AMERICAN INDIANS AND
ALASKA NATIVES. Retrieved from The Commonwealth Fund website:
http://www.commonwealthfund.org/usr_doc/roubideaux_qualityhltcare_aians_756.pdf

33

Even though this health system serves as a valuable resource for the health care needs of
American Indians and Alaska Natives, disparities in access and utilization persist.
61
According
to the OMH, the majority of those who receive IHS services live mainly on reservations and in
rural communities in 36 states. Most of these communities are in the 11 continental western
states and Alaska.
62
However as mentioned before, it is estimated that about 22 percent of
American Indians still live on reservations, with the majority now living in urban areas.
63

Additionally, Williams notes that some tribes and/or individuals are still very ambivalent toward
the United States government and, as a result, some tribal members prefer to receive care outside
of the IHS.
IHS has stated that diabetes prevention efforts are an urgent priority, as is diabetes
management to prevent complications.
64
Taking action, Congress established a Special Diabetes
Program for Indians (SDPI) in 1997 in response to the diabetes epidemic among American
Indians and Alaska Natives. This $150 million annual grant program provides funds for diabetes
treatment and prevention. Funds have been specifically allocated for diabetes prevention in
high-risk individuals and cardiovascular disease prevention in people who already have diabetes
(also known as the Healthy Heart Initiative).
65
The SDPI has established the IHS Diabetes Care
and Outcomes Audit as a process for assessing care and health outcomes for American Indians

61

Roubideaux, Y. (2004). A REVIEW OF THE QUALITY OF HEALTH CARE FOR AMERICAN INDIANS AND
ALASKA NATIVES. Retrieved from The Commonwealth Fund website:
http://www.commonwealthfund.org/usr_doc/roubideaux_qualityhltcare_aians_756.pdf
62

American Indian/Alaska Native Profile - The Office of Minority Health - OMH. (2012, September 17).
Retrieved January 19, 2014, from http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlid=52

63

Roubideaux, Y. (2004). A REVIEW OF THE QUALITY OF HEALTH CARE FOR AMERICAN INDIANS AND
ALASKA NATIVES. Retrieved from The Commonwealth Fund website:
http://www.commonwealthfund.org/usr_doc/roubideaux_qualityhltcare_aians_756.pdf

64
Indian Health Service (2014, January). Diabetes | Fact Sheets. Retrieved from
http://www.ihs.gov/newsroom/factsheets/diabetes/
65
Division of Diabetes - Programs - Special Diabetes Program for Indians (SDPI). (2014). Retrieved January 25,
2014, from http://www.ihs.gov/MedicalPrograms/Diabetes/?module=programsSDPI

34

and Alaska Natives with diagnosed diabetes. In addition the IHS has provided access to two
reports submitted to Congress on the activities and outcomes of this program.
In the most recent report, 2011 Report to Congress: Making Progress Toward a
Healthier Future, insights from the SDPI Diabetes Prevention Program are highlighted. These
show that an intensive lifestyle intervention can dramatically reduce the incidence (rate of new
cases) of type 2 diabetes in people at high risk. Proving this point, the results of one study are
shown where such interventions began with numerous awareness activities to inform
communities about a new diabetes prevention program. Events such as health fairs, with blood
sugar screenings to identify American Indian and Alaska Native people at high risk for diabetes
were held. These people were then recruited for lifestyle balance classes and lifestyle coaching
sessions where they were taught about the importance of eating healthy. For example,
participants in this study learned about the direct effects of weight loss on blood sugar levels.
Participants were also encouraged to meet a goal of at least 150 minutes of physical activity per
week.
66

The study reports that many participants indicated they had made important lifestyle
changes following the intervention. More people reported eating healthy food more often and
eating unhealthy food less often, while more than twice as many people achieved the goal of at
least 150 minutes of physical activity per week compared to their baseline assessments.
67

According to the report, the landmark National Institutes of Health-led Diabetes Prevention
Program (NH DPP) clinical trial was the first study in the United States to show that an intensive

66

SPECIAL DIABETES PROGRAM FOR INDIANS: 2011 REPORT TO CONGRESS- Making Progress Toward a
Healthier Future. (2011). Retrieved from INDIAN HEALTH SERVICE website:
http://www.ihs.gov/MedicalPrograms/Diabetes/HomeDocs/Programs/SDPI/2011RTC_Layout_10102012_508c.pdf

67

SPECIAL DIABETES PROGRAM FOR INDIANS: 2011 REPORT TO CONGRESS- Making Progress Toward a
Healthier Future. (2011). Retrieved from INDIAN HEALTH SERVICE website:
http://www.ihs.gov/MedicalPrograms/Diabetes/HomeDocs/Programs/SDPI/2011RTC_Layout_10102012_508c.pdf

35

lifestyle intervention could reduce the incidence of type 2 diabetes by 58 percent in people at
high risk for diabetes compared to a placebo group.
68

The report to Congress also notes that each case of diabetes that is delayed or prevented
translates to a reduction in diabetes-related complications and health care costs required to treat
the disease. According to the report, “It has been estimated that Medicare could save between
$1.8 to $2.3 billion over the next 10 years if community-based lifestyle intervention programs
(such as the SDPI DP) were made available nationwide to overweight people ages 60-64 years
who have prediabetes.” Most importantly, each case of type 2 diabetes that is prevented means a
better quality of life for American Indian/Alaska Native people, their families and their
communities.
69

As mentioned earlier in this chapter, tribal health programs now compliment or take the
place of IHS provided care. With the respect to diabetes, my own tribe has a specific Diabetes
Wellness Center, whose mission is to, “Prevent and effectively treat diabetes, provide education,
and training for better living.” Their webpage states that, “We have diabetes educators available
to provide many forms of education, including diabetes prevention education, and diabetes self-
management training. Our Registered Dietitian is eager to share her knowledge of healthy eating
and the fitness assistance are happy to work with you to develop an exercise plan tailored to your
particular needs.”
70

68

SPECIAL DIABETES PROGRAM FOR INDIANS: 2011 REPORT TO CONGRESS- Making Progress Toward a
Healthier Future. (2011). Retrieved from INDIAN HEALTH SERVICE website:
http://www.ihs.gov/MedicalPrograms/Diabetes/HomeDocs/Programs/SDPI/2011RTC_Layout_10102012_508c.pdf
69

SPECIAL DIABETES PROGRAM FOR INDIANS: 2011 REPORT TO CONGRESS- Making Progress Toward a
Healthier Future. (2011). Retrieved from INDIAN HEALTH SERVICE website:
http://www.ihs.gov/MedicalPrograms/Diabetes/HomeDocs/Programs/SDPI/2011RTC_Layout_10102012_508c.pdf

70

Choctaw Nation of Oklahoma (2010). Health Services | Choctaw Nation. Retrieved from
http://www.choctawnation.com/services/departments/health-services/

36

Chapter Five: Communicating Change
Wil Dubois has unique experience promoting care in underserved areas. As a diabetes
educator he worked for five years with the University of New Mexico and Project ECHO
(Extension for Community Healthcare Outcomes). The mission of Project ECHO is to develop
the capacity to safely and effectively treat chronic, common, and complex diseases in rural and
underserved areas, and to monitor outcomes of this treatment.
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Specifically, Dubois helped to
train community health workers to aid doctors and serve as ambassadors for their local
communities. Although his work was primarily focused on the diabetes epidemic experienced
by Hispanic populations in New Mexico, he believes similar practices may be useful for
American Indian communities.
Community health workers, or ambassadors, having the specific purpose of helping
doctors understand the needs and lifestyles of local communities may be able to improve patient
compliance. Dubois believes that American Indians may be more receptive to receiving
information or instruction from someone whom they closely identify with, such as members of
their own tribe or community. Both patients and doctors have the ability to benefit from this
approach as a person who is already familiar with traditional habits and customs would likely
have an easier time teaching. Furthermore, a third party ambassador may also serve as a
translator, eliminating any language barriers that may exist.
The issue of language barriers was also brought up in conversations with Williams and
Noe, proving that it is relevant today. It is an issue faced by many health care providers, as a
direct translation for medical terms does not always exist. This problem is compounded by the
fact that there is a lack of educational materials printed in American Indian/Alaska Natives
languages. According to the OMH, in 2010, more than one fourth of American Indians/Alaska

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Project ECHO | The University of New Mexico. (2014). Retrieved January 26, 2014, from http://echo.unm.edu/

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Natives spoke a language other than English at home.
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With more than 500 federally
recognized American Indian/Alaska Native tribes in the United States, these represent numerous
distinct languages and cultures.
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As patient compliance is highly dependent on comprehension,
and with the tremendous number of complications that come with diabetes, this issue is of grave
importance.
Education is key to reverse diabetes trends. Williams believes it is imperative for
medical providers to know how their patients understand information given to them and gauge
how much of their discharge instructions is retained. As Williams points out, “We already know
there is a large percentage of people that only retain a small number of instructions that they are
given.” The consequences of misunderstanding or having instructions lost in translation can be
dire. According to Noe, “There have been people admitted to the hospital when they didn’t need
to be just because they didn’t understand our instructions.” Once again, effective
communication is key to reduce the rate of preventable health problems and achieve the best
possible outcome.
When community health workers or ambassadors are not available (which is often the
case at IHS facilities today) it is important for health care providers to take the time to
understand cultural and traditional practices. As pointed out by Noe, two of the greatest virtues
recognized by the American Indian community he works most closely with are patience and
listening. Therefore, Noe, who is American Indian himself, believes it is especially important for
health care providers to take the time to really hear and comprehend their patient’s issues and

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American Indian/Alaska Native Profile - The Office of Minority Health - OMH. (2012, September 17).
Retrieved January 19, 2014, from http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlid=52

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Roubideaux, Y. (2004). A REVIEW OF THE QUALITY OF HEALTH CARE FOR AMERICAN INDIANS AND
ALASKA NATIVES. Retrieved from The Commonwealth Fund website:
http://www.commonwealthfund.org/usr_doc/roubideaux_qualityhltcare_aians_756.pdf

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concerns before providing instructions. He understands that in the community in which he
works, patients may be hesitant to speak up if a doctor overlooks symptoms that have worsened
over time. This is because their culture seeks to avoid embarrassing conflict. “They learn things
by saying this is the way it’s done, and they don’t question it,” states Noe. In order to encourage
patients to speak up, Noe has found that it is important to be non-judgemental and respectful,
especially when speaking with the elders.
Issues to consider when relating to patients also include literacy levels. Williams
mentioned that sometimes even though doctors begin speaking with a patient at a fifth or sixth
grade level, it is easy to creep up too high. Noe points out that especially when English is not a
patient’s first language, instructions can easily become too complicated. Doctors, trained in
medical terminology and scientific thought, continually struggle to figure out how to
communicate properly so that their patients understand and are therefore more prone to be
successful in preventing further diabetes related complications.
In considering educational materials, Williams said there is some positive information
people can gain from a brochure and handout on their own, but quite often it is better for health
care providers to walk patients through the material and provide explanations. This is especially
beneficial when it can be done in the patient’s native language. He recognizes that many of the
patients he sees are more visual, hands-on learners and as a result, efforts have been made to
tailor communications for this specific audience to increase effectiveness.
Digital stories relating to health issues have recently been introduced at the Whiteriver
IHS and include highly visual slide shows. Williams and his team are currently looking at
different ways to use photos. Story maps and conversational maps are also being used with story
lines related to different health topics, including diabetes. Health providers are encouraged to

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use these materials by showing them to their patients and asking, “Where do you want to go on
this map?” and “What do you want to talk about?” Williams reports that the digital stories and
story maps have been working well.
Using a similar approach, The Choctaw Nation of Oklahoma Health Services website
shares stories written in a blog format. In one post titled “A Journey Called Diabetes,” readers
are reminded that diabetes is not inevitable and that their health truly is in their own hands.
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Lifestyle modification in terms of dietary change and exercise is encouraged.
Small attainable goals are promoted to help eliminate feelings of inadequacy while
increasing chances of success. The post reminds readers that exercise does not have to be a full
gym membership or an intense program and that, “Almost all activities such as walking the dog
or raking leaves can be beneficial.” The Choctaw Nation Health Services recognizes that more
than anything it’s important to get people moving, in any way possible. The tribe reminds
people that the proverb states, “A journey of a 1000 miles starts with one small step.”
Staying healthy and managing diabetes, however, requires increased efforts. To help
with this, the Choctaw Nation Health Services acknowledges that people with strong support
systems are better able to cope with the demands on their time and energy to prevent or manage
diabetes. As a result, the Choctaw Nation of Oklahoma has publically dedicated itself to be part
of this support system. By establishing the “Going Lean” initiative in 2010, the Choctaw Nation
created a program to promote healthy communities. On its Health Services blog, the tribal
leaders announced, “The Choctaw Nation and the Going Lean team will make this journey with
anyone who is willing to take control of their health one step at a time.”
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A JOURNEY CALLED DIABETES. (2011, November 18). Retrieved from http://www.cnhsa.com/a-journey-
called-diabetes.aspx
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A JOURNEY CALLED DIABETES. (2011, November 18). Retrieved from http://www.cnhsa.com/a-journey-
called-diabetes.aspx

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The P.A.C.E. Club, which stands for Promoting Active Communities Everywhere, is one
of the many health initiatives set forth by the Going Lean taskforce. P.A.C.E. promotes the
importance of regular physical activity through walking or running for a healthier lifestyle. The
program provides the registration fee for selected walk/runs throughout Oklahoma and contact
information for walking/jogging groups. Currently there are 32 walk/runs listed on the 2014
P.A.C.E. race schedule including the Happy Heart 5k in February and the Diabetes 5k in
October. It is encouraging that Native communities across the country are taking positive steps
to alleviate the devastating effects of diabetes on their members.
Noe, who is a tribal member of one of the Oklahoma tribes, believes he has been
successful in communicating change because he has formed relationships with his patients and
has worked to genuinely understand their ways. “I understand their humor and I share it with
them frequently. I’ve learned their languages and practices and they really respect that.”
Although he admits he cannot speak their language perfectly, he says that in his experience,
“When you try to speak their language, they help you.” To incoming health care providers Noe
says, “You need to fold into the mold, like water and putty.”
According to Noe it is important to point out the positive differences that have been made
in order to continue to encourage continued change. “People tend to focus on the bad things and
even when good things happen they are missed or not recognized,” Noe said. He recalls a time
he watched a six year old read a nutritional label on a box of cereal and point out the calories and
grams of sugar to him - This, he says is an example of what other people aren’t seeing.

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Chapter Six: Evaluation of Healthcare Materials
Disparities in access to health care may exist, but what about access to information about
health care? Williams comments that most Native communities are able to receive the exact
same information as the majority of Americans, “Many have smart phones or access to the
Internet… how well they understand the information though, that’s a whole other story.” In
order to assess the likelihood of comprehension, it is important to evaluate the information
widely available online, in addition to the information published with an intended American
Indian/Alaska Native audience, such as the material that is distributed by IHS.
The Word Cloud below consists of the information provided online by the top 25 Google
search results for “American Indian/Alaska Native and Diabetes.”
Figure 1
Word Cloud courtesy of: Wordle

The cloud provides greater prominence for the words that appeared more frequently in a
Google search conducted in April of 2014. The words most frequently used are at a moderate
reading level and of a balanced tone (not extremely negative or positive). This cloud provides a

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simplistic view of the words most commonly associated with American Indians/Alaska Natives
and diabetes. However, the many diabetes complications and necessary lifestyle modifications,
including dietary guidelines are not so simplistic.
To better communicate the changes necessary to maintain a healthy lifestyle, IHS
provides many teaching tools to its health care providers. The following graphic is a perfect
example of the type of visuals being employed in current diabetes campaigns:

Figure 2
“My Native Plate” and “My Native Plates for Your Family,” produced by IHS Division
of Diabetes Treatment and Prevention, and based on the USDA “My Plate,” is a printable

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material that IHS health care providers are encouraged to use.
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In addition to the visual seen
above, IHS also provides a teaching manual titled “Eating Issues and Nutrition Tips for
Educators Using My Native Plate.”
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This document introduces My Native Plate as a visual
guide to help clients and patients eat balanced meals of reasonable portion sizes. It is
recommended to be a starting point for nutrition education, a daily reminder, and a way to
introduce healthy eating to family members of all ages. Importantly, IHS recognizes that there
are “Issues to Consider” prior to using the My Native Plate visual. Below are the suggested
points to keep in mind to discuss My Native Plate in a positive, supportive way (taken directly
from “Eating Issues and Nutrition Tips for Educators Using My Native Plate”):

1. Emotions and stress can impact your clients’ food selection and portion sizes. The
reasons why people eat certain foods, and why they overeat, are often linked to depression,
anxiety and stress.
§ Ask your clients what they are eating, how much and possible reasons why.
§ Refer them to other health care professionals, spiritual leaders or counselors if needed.

2. Not consistently having enough money to buy good quality food will affect your clients’
eating habits. Food insecurity can cause your clients to overeat available foods, skip meals
and/or choose unhealthy foods that are less expensive.
§ Find out if your clients have consistent access to nutritious foods and are getting enough
nutrition from the foods they usually eat.
§ Refer them to community food resources program if needed.

3. Family and social gatherings are important to your clients and can affect healthy eating.
Not eating foods brought to gatherings, potlatches and potlucks can be considered rude. Suggest
ways your clients can enjoy social eating while using My Native Plate as a guide.
§ Explain how a small portion of several dishes from one food group (corn, pasta salad,
potatoes) can be combined to make up one My Native Plate quadrant (grains/starch).
§ Talk about the importance of stacking food no higher than 1 - 1½ inches.

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Indian Health Service, Division of Diabetes Treatment and Prevention (2012). My Native Plate - An Easy Way to
Help Your Family Know How Much to Eat. Retrieved from
http://www.ihs.gov/MedicalPrograms/Diabetes/HomeDocs/Resources/InstantDownloads/MyNativePlate1_508c.pdf
77

IHS Division of Diabetes Treatment and Prevention (2012, August). Eating Issues and Nutrition Tips for
Educators Using My Native Plate. Retrieved from http://www.choosemyplate.gov/food-
groups/downloads/TenTips/DGTipsheet1ChooseMyPlate.pdf

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4. Incorporating traditional foods into the plate can help your clients eat healthier.
§ Talk about traditional foods and how they fit into the plate.
§ Consider copying the design of My Native Plate using traditional foods from your region
and providing this version to your clients.

5. Eating out at fast food restaurants and convenience stores may be common and can
make up a large percentage of what your clients eat.
§ Ask your clients how often they eat out and the types of foods they eat.
§ Suggest ways to use My Native Plate when eating at places with very limited menus.
§ Keep in mind that healthier menu options are often more expensive and encourage your
clients to ask that their choices be prepared in healthier ways.

Within the same document, educators are also encouraged to also use “10 Tips to a Great Plate”
for additional nutritional information. Provided by www.ChooseMyPlate.gov, this additional
material provides tips on how to limit portion sizes, foods to avoid and foods to eat more often.
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“Eating Issues and Nutrition Tips for Educators Using My Native Plate” positively
addresses the great majority of the eating issues facing American Indian/Alaska Native
communities today. Each of these issues were touched upon and their importance reiterated in
conversations with Williams, Noe and Dubois. The advice given to practitioners is considerate
and necessary for the target audience (both practitioners and patients). However it is difficult to
say the same for the visual material, arguably the more important material, provided for the
patients.
Taking a closer look at the recommended foods pictured on My Native Plate, the protein
section of each plate always consists of an animal product. The visuals, therefore, ignore
healthier protein options including leafy greens, grains, beans, lentils, nuts, seeds etc. Ironically,
especially in the southwest, beans, squash, and wild nuts like piñon nuts, acorns and mesquite
beans have been traditional foods for generations, various combinations of which are considered
traditional foods for American Indian tribes.

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United States Department of Agriculture (2011, June). Choose MyPlate - 10 Tips to a Great Plate. Retrieved
from http://www.choosemyplate.gov/food-groups/downloads/TenTips/DGTipsheet1ChooseMyPlate.pdf

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My Native Plate can be interpreted as a tool that teaches animal products are necessary,
healthy and furthermore synonymous with protein. In the “3 steps to remember to help families
eat in a healthy way” section, patients are taught to reserve ¼ of their plate for meat, fish or
poultry. Additionally, a form of dairy is encouraged in the “Tips” section next to each plate.
Under “Lunch Tips” readers are told to add one slice of cheese to add calcium and vitamins.
Positively, in the “Pictured Here” section it is noted that dairy should be low-fat, nonfat, lactose-
free or soy milk. However, non-dairy calcium sources including dark-green, leafy vegetables,
beans and fortified orange juice are absent from the recommendations.

Figure 3

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Looking closer at “10 Tips to a Great Plate” (encouraged for use by IHS health care
providers for additional nutrition education), a color-coded plate is pictured in the top right
corner of the informational flyer. The plate again is divided into four sections, for fruits, grains,
vegetables and protein. In addition, a side plate or bowl is promoted for dairy. In relation, Tip 6
teaches patients to switch to fat-free or low-fat milk, stating, “They have the same amount of
calcium and other essential nutrients as whole milk, but fewer calories and less saturated fat.”
The visual next to the tip depicts a mother reading the label on a milk bottle. It appears she is
with her child in the dairy aisle of a grocery store, and the photo seems to suggest that buying
milk is what good mothers do.
Other visuals depict a plate with fish, grains and salad, two grocery bags with fresh fruits
and vegetables, and another mother with her child choosing bread at a grocery store. Tip 4, titled
“Foods to eat more often” says, “Eat more vegetables, fruits, whole grains, and fat-free or 1%
milk and dairy products. These foods have the nutrients you need for health- including
potassium, calcium, vitamin D, and fiber. Make them the basis for meals and snacks.”
“10 Tips to a Great Plate” was published in June 2011, with “My Native Plate” and “My
Native Plates for Your Family,” following in 2012. It is important to note the USDA Center for
Nutrition Policy and Promotion has provided the recommendations included in these materials.
Although they may be deemed appropriate recommendations by some nutritionists, these
recommendations may have significant consequences for American Indian populations.
Neal D. Barnard, M.D., author of Foods That Fight Pain and Eat Right, Live Longer,
along with Derek M. Brown, a writer in Rockville, Maryland have called for an end to racially
biased federal food guidelines. They have received support from the Association of American
Indian Physicians and the National Indian Health Board. According to Barnard and Brown,

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previous dietary guidelines for Americans push a “Westernized” diet and ignore the health needs
and cultural practices of American Indians and other minorities. They have stated,
“Unfortunately, the Dietary Guidelines, which govern all federal and many private nutrition
efforts, poorly reflect what we know about health.”
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In an article titled United States Dietary Guidelines Unfit for Native Americans, Barnard
and Brown point out that that United States Dietary Guidelines still promote two to three
servings of dairy, advice dating to the first federal food guides in 1916. Yet they ignore ample
research on lactose intolerance among racial minorities, which has been available since the mid-
1960s.
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Taking a look at the “Indian Health Diabetes Best Practice – Nutrition for Diabetes
Prevention and Care” guide (revised April 2011), clear direction is given to health care providers
about nutrition recommendations for patients, and strengthens the argument made by Barnard
and Brown. Under the “Definition of Nutrition for Diabetes Prevention and Care” section, the
opening sentence states: “Optimal nutrition is provided by breastfeeding early in life and by the
consumption of a diet rich in fruits, vegetables, whole grains, legumes, low-fat dairy products,
lean meats, fish and/or poultry, and healthy fats from early childhood through adulthood.” The
guide recognizes that there is no one set of nutrition recommendations that apply to all
individuals with or without diabetes, but it seems illogical to encourage dairy consumption for a
group of people whose majority is lactose-intolerant. Taking a closer look, the nutritional
recommendations follow the general recommendations made by the American Diabetes
Association, and the American Dietetic Association.

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Barnard, M.D., N. D., & Brown, D. M. (n.d.). UNITED STATES Dietary Guidelines Unfit for Native Americans.
Retrieved February 13, 2014, from http://www.dontgotmilk.com/nativeamericans.html
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Barnard, M.D., N. D., & Brown, D. M. (n.d.). UNITED STATES Dietary Guidelines Unfit for Native Americans.
Retrieved February 13, 2014, from http://www.dontgotmilk.com/nativeamericans.html

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Further recommendations throughout the document are made based on what is referred to
as “The Mediterranean Diet,” and also the Dietary Approaches to Stop Hypertension (DASH)
diet. An excerpt from the DASH diet recommendations appears in exact as follows:
In addition to emphasizing fruits, vegetables, whole grains, nuts and legumes, the DASH
diet also emphasizes the inclusion of three servings of low-fat or fat-free dairy
products daily as sources of calcium to reduce blood pressure. If individuals do not
consume cow’s milk, fortified soy products are available, or calcium supplements may be
an option.
Health providers are encouraged to recommend a dairy alternative as a second option “if”
individuals do not consume cow’s milk. Again, the recommendations are made for all persons
seeking to improve their diet and reduce blood pressure, and are not specific to the dietary
concerns of American Indian/Alaska Native populations.
On the positive side, the guide recommends conducting a community needs assessment to
assess the learning needs and preferences of each community. Suggestions include:
• Partner with local schools to improve school food and physical activity programs.
• Partner with cultural programs and faith-based organizations to provide information on
the prevention and management of diabetes.
• Work with programs, groups, and faith-based organizations to offer healthier choices at
community gatherings and events.
• Encourage clinical and community staff to participate in events and programs such as
health fairs, youth wellness camps, diabetes camps, Native food gathering outings, food
prevention sessions, Tribal garden projects, and other programs that encourage and
support active participation in nutrition-related activities.

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• Increase access to healthful foods at home by monitoring foods available at local grocery
and convenience stores. Make recommendations to business owners to improve selection
for consumers.
• Partner with local restaurants to provide healthier food options and to label healthier
foods on menus (for example, identify entrees on menus with less than 500 calories, or
those that contain whole grains).
• Increase access to healthier options in the workplace by making fruits and vegetables
available for snacks, offering nutrient-rich foods at meetings, and in vending machines,
and making changes in cafeteria menus.
The guide also notes that many American Indian and Alaska Native communities are interested
in consuming traditional foods and encourages health care providers to recommend traditional
eating patterns and food because “they are associated with improved diabetes management.”
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Barnard and Brown also cite the Diabetes Care study that showed diabetes and obesity to
be much less prevalent among Mexican Pima Indians living a “traditional” lifestyle than among
Arizonan Pimas in an “affluent” environment. Learning from this, they believe that switching to
a plant-based diet, and consuming much less fat than United States Dietary Guidelines suggest,
could greatly cut diabetes rates.

“In the public mind, shaped by Hollywood Westerns, a typical Native American was a
big meat-eater – a ‘killer of buffalo’ but few tribes in what is now the United States hunted much
(though some fished) before whites came.” Barnard and Brown write that hunting went from an

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IHS (2011, April). Indian Health Diabetes Best Practice – Nutrition for Diabetes Prevention and Care. Retrieved
from http://www.ihs.gov/MedicalPrograms/Diabetes/HomeDocs/Tools/BestPractices/2011_BP_Nutrition_508c.pdf

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exception to a widespread steady activity after Spanish conqueror Francisco Coronado’s 16
th
-
century explorations of the United States Southwest introduced horses and guns.
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Indeed, the 19 pueblos of New Mexico, the Tohono O’odom, Pimas, and Hopi Indians of
Arizona were all agrarian people whose diet mainstays were beans, squash, and corns (maize) –
sometimes referred to as the three sisters. The tradition of interplanting these three foods is a
sophisticated, sustainable system that provided long-term soil fertility and the staples of a healthy
diet to generations. Considering this, it seems possible that a look back at history and a return to
traditions may aid in solving some of the health problems faced by these people today.

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Barnard, M.D., N. D., & Brown, D. M. (n.d.). UNITED STATES Dietary Guidelines Unfit for Native Americans.
Retrieved February 13, 2014, from http://www.dontgotmilk.com/nativeamericans.html

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Chapter Seven: Tribes in the Southwest Fight Back
The Tohono O'odham tribe of southern Arizona has one of the highest rates of adult onset
diabetes in the world. Many of the tribe's 28,000 members live on the lands of the Tohono
O’odham Nation, which is the third largest Indian reservation (area wise) in the United States.
Just a few generations ago, diabetes was unknown,

however, over the past several decades, type
2 diabetes has exploded, striking half of the adults living there.
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Many attribute the skyrocket
in diabetes rates to diet change.
Traditionally, the Tohono O'odham, which means the desert people, were farmers who
harvested food from native plants and grew crops that could withstand desert heat. The Spanish
conquistadors referred to this tribe as Papago, literally meaning “Tepary bean-eater” but the tribe
has largely rejected this name. Now unfortunately, instead of eating a traditional diet that
includes foods made from tepary beans, cholla buds, mesquite flour, saguaro fruit syrup, squash
and corn (all native to the southwestern United States), tribal members today tend to eat foods
found in a typical mainstream diet, including highly-processed federal commodity foods.
While poor eating habits have led to bulging waistlines on many Americans, their impact
seems to be magnified for a people who traditionally lived on parched land, described as land
that needed to be worked with vigor just to produce a sparse harvest.
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Since the 1960s obesity
and with it, type two diabetes have become commonplace among tribal members. Half to three

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BArizonaell, R., & Carroll, L. (2011, December 9). Indian tribe turns to tradition to fight diabetes - Health -
Diabetes | NBC News. Retrieved from http://www.nbcnews.com/id/43257536/ns/health-diabetes/t/indian-tribe-
turns-tradition-fight-diabetes/#.Ueg3YGAro38\
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BArizonaell, R., & Carroll, L. (2011, December 9). Indian tribe turns to tradition to fight diabetes - Health -
Diabetes | NBC News. Retrieved from http://www.nbcnews.com/id/43257536/ns/health-diabetes/t/indian-tribe-turns-
tradition-fight-diabetes/#.Ueg3YGAro38\

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quarters of all adults are diagnosed with the disease and about one third of all the tribe’s adults
require regular treatment.
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In order to save their tribe and combat this modern problem, the Tohono O’odham
Nation has sought to encourage its members to return to old tribal ways and an indigenous diet.
They have organized a way to bring back the tribe’s traditions.
The Tohono O’odham Community Action group is dedicated to this cause. They
encourage people to see that traditional foods have meaning, that they are medicine for the body
and that they can keep their tribe healthy. They have drawn attention to lifestyle changes as
well, ones that have led to more sedentary habits and have impacted the health of the Tohono
O’odham Nation. They point out that tribal members no longer have to physically work as hard
to gather their food. The ability to drive up to a window for fast food has had consequences on
their tribal nation’s health.
Even with scientific evidence in hand, those pushing for change still have obstacles to
overcome. The loss of taste for traditional foods, for example, has presented a challenge. For
this reason, chefs at the Desert Rain Café, located on the reservation, have worked to put a new
spin on old foods to make them more interesting and appealing. Serving “Contemporary Tohono
O’odham Cuisine,” each dish contains at least one traditional food from plants that grow on the
reservation.
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The “rich and wonderful flavors of the desert” are promoted at the Desert Rain
Café, which chefs believe are provided to sustain the “People of the Desert.”
Ned Norris, chairman of the Tohono O’odham Nation, has weighed in on the current
efforts being made, “I think as a tribal community, if we start to re-educate ourselves about the
nutritional value of those foods that are natural and that grow naturally around here, then we’re

85

Tohono O'odham Community Action (2014). OUR COMMUNITY. Retrieved from
http://www.tocaonline.org/our-community.html
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Desert Rain Cafe. (2014). Retrieved from http://www.desertraincafe.com/

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going to make much greater headway in addressing diabetes and heart issues that are so
prevalent with our people today.”
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Interestingly, the same compounds that help native plants survive desert conditions have
been found to regulate blood sugar levels. These foods have the ability to aid in keeping blood
sugar levels even, help prevent diabetes and keep people with diabetes healthier.
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Supporters of
the Desert Rain Café hope their tribe will begin to eat more traditional foods again, and become
more aware of what they're putting in their bodies.
With similar goals, a nonprofit organization called Native Seeds/SEARCH (Southwest
Endangered Arid Lands Resources Clearing House) has also been working with American
Indians in Arizona to curb the rate of diabetes. Based in Tucson, Arizona, Native Seeds aims to
implement a logical approach to tackling diabetes by having tribes return to traditional foods.
This organization also promotes foods native to the desert because of their significant blood
sugar control qualities. "Today we are learning that the same gooey substances which keep
cactus from drying up and dying during drought also slows down the digestion and absorption of
foods,"
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states their website. This organization offers recipes for cooking with ingredients like
prickly pear cactus, cholla cactus buds, saguaro, chia, and native beans. They also offer
resources for those who wish to grow these native foods in their gardens. In this way they
encourage people to return to traditional farming of foods, therefore increasing activity and
improving diet.

87

BArizonaell, R., & Carroll, L. (2011, December 9). Indian tribe turns to tradition to fight diabetes - Health -
Diabetes | NBC News. Retrieved from http://www.nbcnews.com/id/43257536/ns/health-diabetes/t/indian-tribe-turns-
tradition-fight-diabetes/#.Ueg3YGAro38\

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Block, D. (2009, December 5). Native American Tribe Has Highest Rate of Adult Onset Diabetes Worldwide.
Retrieved January 20, 2014, from http://www.voanews.com/content/native-american-tribe-diabetes-
73628337/415922.html

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Capps, R. (1996, July 1). Type 2 Diabetes Continues To Plague Indian Reservations, New Hopes Are Scarce -
Diabetes Health. Retrieved from http://diabeteshealth.com/read/1996/07/01/657/type-2-diabetes-continues-to-
plague-indian-reservations-new-hopes-are-scarce/

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With a mission of strengthening food security in the Greater Southwest by conserving the
region’s unique crop diversity and teaching others to do the same, Native Seeds/SEARCH is
leading the way in a growing movement. To connect with their members and non-members
alike, Native Seeds/SEARCH publishes an official tri-annual newsletter, shares recipes and
progress on their blog and hosts community events. They have been successful in educating the
public, both Indian and non-Indian, on the value of using truly traditional desert foods to help
combat the diabetes epidemic and unhealthy eating habits.

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Chapter Eight: Looking to the Future
The relationship between dramatic lifestyle change and diabetes and obesity rates among
American Indians and Alaska Natives presents a complex and dynamic problem that cannot be
ignored. Because of situational and cultural factors, effective communication efforts about
obesity and diabetes must be created on an ethnicity-specific basis.
After completing a content analysis of healthy eating campaign materials targeted to
American Indian/Alaska Native communities and considering the specific needs of these
communities, it is clear to the author that some of the current United States Dietary Guidelines
are unfit for this population, especially when the majority of the population is lactose intolerant.
A blanket guideline cannot be applied to people with differing needs. The great disparity in
health amongst minorities in this country has proved this point.
A more traditional diet may be the prescription for avoiding much of the suffering
experienced by American Indian/Alaska Native people today. It seems a natural and logical
choice that foods native to a region are healthy for people who lived and evolved in that region.
However, American Indians and Alaska Natives have been receiving mixed messages,
promoting a “Western” lifestyle and diet.
Increased attention to obesity as it occurs in and affects diverse ethnic groups can help to
address critical minority health issues, including diabetes. Such efforts can also broaden and
enrich aspects of research for which models based on white populations are inappropriate or
limited. It has been shown that people with a history of diabetes in their families are at higher
risk than those whose families do not have that unfortunate legacy. Therefore the responsibility
is not only to take care of oneself, but to also include generations to follow and this should be
communicated.

56

As was succinctly described by Williams, Noe, and Dubois, it is important to recognize
barriers to change and adapt communications efforts to the specific needs of differing
populations. Local community members may provide invaluable knowledge and the utilization
of community ambassadors should be considered to reach multicultural audiences. Language
barriers must also be recognized and native languages should be integrated into educational
materials. From personal conversations with Williams, Noe, and Dubois it is clear to the author
that stronger connections with target audiences can be made with keen insight about cultural
traditions and a better understanding of community practices and values.
Native people have always had a connection to the earth for spiritual reasons as well as
reasons for living sustainable lives. Efforts that have been seen in the recent awakening to
reverse health trends show there is an interest and desire to return to tradition. Noe also
recognizes that changes are happening, “They’re just not coming as fast as we would like.” But
he says, “You can’t just keep harping about the bad stuff.” He believes it is important to grasp
the good changes that have been made and encourage American Indian/Alaska Native
communities to continue on the path to greater health. He believes in cultivating change. In
talking about his patients he says, “I keep telling them you didn’t get this way overnight and it
comes over time.”
It is important to understand and communicate that change does not occur overnight,
however the seriousness of the situation should not be understated. Genetics, culture, lifestyle
and habits all play a part in this current health crisis. It is encouraging to see significant strides
being made by American Indian tribes in the Southwest, the IHS, and non-profit organizations
such as Native Seeds. People such as Steven Williams, David Noe, and Wil Dubois are working
hard to educate people about their health. As more and more organizations and people jump on

57

this education bandwagon and take seriously the devastating impacts of non-healthy lifestyles,
the expectations should be that this worsening trend in the continuing downward health spiral
will be able to switch direction.

58

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63

Appendix

Interview
with
Steven
Williams

What
do
you
believe
to
be
the
best
method
of
communicating
information
about
diabetes

and
other
health
issues
for
a
Native
American
audience?

There
is
some
positive
information
people
can
get
from
a
brochure
or
a
handout,
but
quite

often
they
are
more
visual
and
hands
on.

It’s
better
to
walk
them
through
a
pamphlet
and

explain.

We’ve
also
been
doing
some
digital
stories
and
we’re
looking
at
different
ways
to
use

photos.

Right
now
we
use
story
maps.

They
have
a
story
line
in
them
related
to
health
called

“conversational
maps,”
which
are
related
to
different
topics.

They
have
cards
you
can
pull

related
to
your
discussion.

So
we
ask
patients,
“Where
do
you
want
to
go
on
this
map?”

“What
do
you
want
to
talk
about?”

The
staff
has
used
this
technique
and
it
has
worked
well.

It’s
important
to
always
ask,
how
do
you
communicate?

And
can
you
be
communicating

better?

Do
you
believe
there
is
a
language
barrier
that
exists?

Sure.

For
example,
how
do
you
say
certain
medical
terms
and
body
parts
in
the
native

language
so
that
people
will
understand?

You
can’t
you
always
do
this.

Also,
you
have
a
big
mix
of
people
who
don’t
speak
the
native
language.

Then
there
are
those

people
who
understand
it
but
don’t
speak
it.

So
doctors
wonder,
if
I
say
a
certain
body
part,

do
they
have
that
word
in
their
native
language
and
understand
what
that
is?

What
other
barriers
to
change
do
you
believe
exist?

Well
some
tribes
are
still
very
ambivalent
toward
the
U.S.
government.

For
some
people,
they

may
prefer
to
go
to
somewhere
else
other
than
IHS.

Then
there’s
transportation
-‐
If
people

are
Medicaid
eligible,
which
some
are,
they
need
to
have
transportation
for
that.
But
the

biggest
barriers
are
probably
the
social
barriers.

Do
you
feel
that
your
patients
are
motivated?

Do
you
see
your
patients
carrying
out
what

they
are
supposed
to
do
and
making
the
changes
that
are
necessary
to
improve
their

health?

Well
you
can
be
very
motivated
but
if
you
have
difficulty
doing
something,
you
might
not

carry
through.

If
I
have
an
appointment
to
come
in
and
see
my
doctor
but
I
have
a
number
of

things
pushing
on
me,
for
instance,
I
might
not
do
it.

If
I
need
to
take
care
of
my

grandchildren,
or
watch
other
people’s
children….

If
one
of
the
kids
is
sick
I’m
not
going
to

come
into
the
clinic.

And
then
it’s
really
hard
to
get
back
into
the
[hospital]
system.

The

priority
is
the
day
to
day.

How
do
I
take
care
of
my
family?

Sometimes
that
has
a
priority

over
health.

As
far
as
seeing
people
make
changes…
they
do
make
significant
changes
sometimes.

A
lot

depends
on
their
social
backing.

Do
they
have
the
people
at
home
to
support
them?

Every

64

time
they
go
to
a
church
potluck,
what’s
available?

Down
here
there
are
a
lot
of
different

community
events.

Wakes,
Sun
dances…

and
you
have
to
consider
what
kind
of
food
they
are

bringing
in.

Here
the
people
are
considered
stingy
if
they
only
put
a
little
bit
of
food
on
their

plate.

I
went
to
one
church
where
they
were
encouraging
people
not
to
bring
fry
bread,
but

whole
wheat
bread.

Some
of
it
with
Native
American
communities
is
working
within
the

infrastructure.

That’s
all
part
of
people,
social
issues.

What
other
issues
are
there
to
consider
in
order
to
increase
patient
compliance?

One
thing
to
look
at
is
how
people
understand
the
information
given
to
them,
how
much

information
they
retain
from
their
discharge
instructions.

We
already
know
there
are
a
large

percentage
of
people
that
only
retain
a
small
number
of
instructions
that
they
are
given.

But

how
they
follow
through
on
their
care
is
very
important.

For
diabetes-‐
diet,
exercise
and

medication
is
most
important.

Trying
to
help
people
understand
these
3
components
and

following
through
is
our
priority.

Some
of
the
common
things
seem
to
be
the
language

spoken.

Sometimes
even
though
we
[doctors
and
health
care
providers]
are
speaking
at
a
fifth

or
sixth
grade
level,
we
sometimes
creep
up
too
high.

It’s
a
matter
of
how
do
you

communicate?

How
do
you
communicate
properly
so
that
people
understand?

Are
there
recreational
facilities
available
in
Whiteriver?

Have
efforts
been
made
to

increase
physical
activity?

There
is
one
available
and
run
by
the
tribe.

Periodically
they
will
have
different
walks

accompanied
by
the
Apache
diabetes
program
or
other
programs.

In
some
of
the
outlying

communities
there
is
less
available.

One
of
the
churches
offers
fitness
aerobics
for
the
ladies.

Some
of
the
tribes
are
better
than
others.

The
different
tribes
have
different
levels
of
activity.

What
do
you
believe
to
be
the
greatest
contributing
factor
in
the
rise
of
diabetes
rates

among
Native
American
tribes?

The
change
in
the
culture
and
then
the
change
in
the
food….

the
change
in
lifestyle.

If
you
go
to
Bashas
down
in
Whiteriver
before
lunchtime
you’ll
see
their
“Tailgate.”
Often
you

find
food
considered
more
traditional.

It’s
extremely
high
in
fat,
extremely
high
in
calories.

It

could
be
that
people
are
not
as
well
versed
on
how
to
select
foods
and
how
to
prepare
foods.

Then
you
have
to
consider
that
if
I’m
poor
and
I
don’t
have
a
lot
of
money,
I
can
buy
Ramen

noodles.

There’s
a
relationship
with
poverty
and
the
type
of
foods
people
eat.

There’s
a

relationship
with
poverty
and
disease….
and
Whiteriver
has
very
low
employment
rates.

Where
would
you
begin
your
research
on
this
topic?

You
might
want
to
look
at
other
minority
groups
and
some
of
the
difficulties
they
have
had.

I

would
then
see
if
those
difficulties
have
been
documented
in
the
Native
American
cultures.

You
may
also
want
to
focus
on
the
explosion
of
diabetes.

I
would
look
at
the
associations
of

diet,
lifestyle,
and
changes
in
behavior
patterns.

For
instance
the
Apaches
were
hunters,

gathers
and
raiders.

There
was
a
physical
aspect
to
getting
food.

In
the
past
they
used
to

have
to
collect
their
water
and
bring
it
back.

Things
of
course
are
very
different
today.

65

Interview
with
David
Noe

What
advice
do
you
have
for
incoming
health
care
providers
who
primarily
serve
Native

American
patients?

Two
of
their
greatest
virtues
are
patience
and
listening.

With
the
elders
it’s
especially

important
to
be
non-‐judgmental.

Their
culture
is
to
avoid
conflict.

They
learn
things
by

saying
this
is
the
way
it’s
done,
and
they
don’t
question
it.

I’m
genuine
in
the
way
I
am
and

why
I’m
here.

For
other
people
coming
in,
I’d
say
don’t
do
as
I
do
though.

I
can
get
away
with

things
that
other
people
can’t.

You
need
to
fold
into
the
mold.

Like
water
and
putty.

Why
do
you
believe
you
have
been
successful
in
forming
positive
relationships
with
your

patients?

I
understand
their
humor
and
I
share
it
with
them
quite
frequently.

I’ve
learned
their

languages
and
practices
and
they
really
respect
that.
When
you
try
to
speak
their
language

they
try
to
help
you.

There
are
differences
in
languages
in
different
areas.

They
know
where

people
are
from
just
by
the
way
they
speak.

Do
you
believe
there
is
a
language
barrier
that
exists?

And
if
so,
how
do
you
overcome
this

obstacle?

There
is
absolutely
a
language
barrier.

I
can
say
something
in
English
to
someone
who
speaks

English
to
me
but
they
may
not
understand
it
because
English
is
not
their
first
language,
or

because
what
I’m
saying
is
too
complicated.

We
have
a
clerk
here.

We
can
ask
her
to
come
in
and
translate
but
sometimes
we
don’t
use
a

translator
enough
and
things
are
lost.

There
have
been
people
admitted
into
the
hospital

when
they
didn’t
need
to
be
just
because
they
didn’t
understand
our
instructions.

Can
you
tell
me
about
the
fitness
center
on
your
reservation?

Do
you
see
it
being
utilized

by
your
patients?

The
fitness
center
was
built
with
the
specific
intention
of
helping
people
that
are
overweight

and
have
diabetes...

But
mostly
the
people
that
are
fit
and
in
shape
make
the
most
use
of
it.

Trying
to
get
the
people
who
aren’t
fit
to
the
center
has
been
one
of
the
biggest
challenges.

I’ve
had
better
luck
with
trying
to
get
people
to
change
their
diet.

How
do
you
communicate
the
importance
of
change
and
overcome
resistance
to
change?

Well
they
look
nothing
like
their
great
great
grandparents.

I
point
this
out
to
them
all
the

time.

These
people
used
to
be
the
most
fit
people
in
the
world!

They
could
run
around
all
day

in
the
hot
sun
and
not
even
swelter.

They
grew
up
collecting
water,
collecting
wood.

They

grew
up
gathering
the
natural
foods
that
grow
here
and
the
small
game.

So
I’ve
gone
out
and

collected
the
foods
they
used
to
gather.

There
is
some
interest
by
some
individuals….
I
try
to

do
things
out
of
the
box-‐
do
nature
walks,
have
speakers
come
down
and
invite
people
out

66

who
are
experts
on
things.

I
try
to
get
people
from
the
tribe
to
come
and
talk
about
cultural

things
and
make
a
connection.

What
cultural
barriers
are
preventing
change
on
the
reservation?

And
what
are
your

suggestions
for
overcoming
these
barriers
to
create
change?

Changes
are
happening.

They
are
just
not
coming
as
fast
as
we
would
like.

If
you
go
to
a

wake,
wedding,
grad
celebration…
you’ll
see
the
food
they’re
eating.
When
I
first
got
here
the

only
choices
to
drink
were
soda.

Now
they
choose
diet
coke
instead
of
coke.

I’ve
found
I
need

to
offer
an
alternative
that
appeals
to
them,
start
with
the
lesser
of
two
evils.

It
doesn’t
work

if
you
keep
harping
about
the
bad
stuff.

You’ve
got
to
grasp
the
good
stuff;
you’ve
got
to

encourage
them.

You
have
to
cultivate
relationships.

I
keep
telling
them
you
didn’t
get
this

way
overnight
and
change
comes
over
time.

What
are
some
of
the
favorite
foods
on
the
reservation
today?

Fry
bread
and
fried
potatoes
are
eaten
probably
two
or
three
times
a
week
if
not
more
for
at

least
half
the
population
here.

A
lot
of
it
has
to
do
with
financial
constraints.

They’re
having

to
feed
five
or
more
per
house-‐
that’s
the
average
here.

If
you
look
at
the
median
income
per

household
there’s
a
whole
new
poverty
level
here
that
people
just
don’t’
realize.

How
accessible/prevalent
is
fast
food
on
the
reservation?

Well
we
had
a
two-‐year
battle
here
on
whether
to
let
Burger
King
or
Subway
come
to
the

reservation.

They
ended
up
choosing
Burger
King
because
they
can
employ
more
people.

That’s
the
only
fast
food
restaurant.

There’s
just
the
Burger
King
down
here
right
now.

But

there
is
a
deli
at
Bashas…
they
go
there
for
the
fried
food.

Can
you
tell
me
about
any
health
education
efforts
that
are
currently
being
made?

We
have
cooking
classes
where
we
promote
healthy
cooking
and
bring
in
a
dietitian.

We
are

trying
to
get
them
to
eat
healthier
in
that
way.

When
we
do
our
annual
physicals
we
do
know

that
individuals
are
starting
to
cut
back
on
fry
bread
and
are
making
less
unhealthy
choices.

We
also
have
crafting
classes
where
we
invite
people
to
come
in
and
talk
about
issues
like

smoking
cessation.

People
are
actually
good
multi-‐taskers
when
their
creative
side
is

engaged.

So
we
have
topics
covered
when
they
come
to
our
workshops.

And
then
we
try
to

help
people
put
in
gardens.

We
have
put
in
at
least
80
gardens
here.

Abstract (if available)

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