Hard road to walk: Native Americans and diabetes

Combination of genes and Western lifestyle

Lorraine Valdez, RN, CDE, remembers her days as a nurse in an Indian Health Service hospital in New Mexico all too well. Amputation was part of treating patients with advanced diabetic complications.

She remembers literally "chopping people up, piece by piece. First some toes, then a foot, then a leg. Then we’d start on the other leg."

Valdez, a member of the Isleta and Laguna Peublo tribes, is now national nursing coordinator for the Indian Health Service (IHS) Diabetes Program based in Albuquerque, NM, and co-chairwoman of the Native American project team for the American Diabetes Association.

In the last 20 years, Valdez has seen yet another cruel blow dealt to Native Americans.

In modern civilization, diabetes runs rampant, affecting nearly every family, and in the case of one Arizona tribe, striking half the adult population.

"I just grew up with it. Everybody knows somebody who has diabetes — family members, friends. It’s a way of life, having diabetes," she says. The latest figures show Native American adults have a 12.2% incidence of diabetes. But health care professionals in the field say that is probably underreported, since people living on reservations are not included in the national health surveys. Also, about half the Native American population lives in urban areas, where many are resistant to participation in government studies. Most of the data is obtained from IHS facilities where care is provided free to residents on reservations.

The rising number of Native Americans being diagnosed with Type II diabetes is blamed on two factors: genetics and the intrusion of Western civilization. The new culture brought with it poor diet and motorized transportation, giving obesity and a sedentary lifestyle a strong foothold.

"Obviously, Native Americans have a genetic predisposition to the disease," says Barbara Ramsey, MD, medical director of the Native American Health Center in Oakland, CA, whose patients include about 5,000 urban Native Americans each year.

Ramsey says she is a subscriber to the "thrifty gene" theory of survival of the fittest — that ancestors of Native Americans and other high-risk ethnic groups were those who could store fat and therefore survive long periods of famine. "Now they live in the most food-abundant country in the world and the least physically active. It’s no wonder they have the highest incidence of any ethnic group."

Ramsey and several fellow health care professionals point out that access to food is not usually a problem in the United States; the problem is knowing how to spend limited resources on the most nutritious food possible. Full-blooded Native Americans and Indian women are at particularly high risk, according to a 1995 study by Dorothy Gohdes, MD, former IHS medical director in Albuquerque (published in Diabetes in America by the National Institutes of Health and the National Institute of Diabetes and Digestive and Kidney Diseases in Bethesda, MD).

"Both diet patterns and physical activity have changed markedly in Native American communities over recent decades," Gohdes writes. "Although detailed longitudinal surveys are not available for most tribes, the disruption of traditional agriculture and hunting has resulted in an increased consumption of fat, typical of the contemporary Western diet."

Interestingly, the prevalence of diabetes lessens with tribes living farther north and farther west, presumably away from the more direct influences of Western society. According to 1980 census figures, the rate among Alaska natives and indigenous residents of the Yukon and Northwest territories is far below that of white society at four to 17 per 1,000.

"For now, their rates are low, but we are already seeing them start to climb as the oil industry brings more Western culture and the snowmobile and videos," says Gohdes.

Members of the Pima tribe in southern Arizona have the highest incidence of diabetes ever studied at half of all adults and as high as 85% of women over 55 and 75% of men over 55. The vast majority are diagnosed between the ages of 35 and 44, according to Gohdes’ study.

"It’s not just the Pimas that have such high prevalence rates," Gohdes says. "It’s just that they have been studied more than anybody else. It’s everywhere. It’s of epidemic proportions."

Ramsey says there are unique challenges to treating Native Americans, not because they aren’t aware of diabetes. "They know about it. The Native American community is totally aware because it is so familiar with it in their families because they have a sister who is blind and a cousin who is on dialysis and a father with an amputation," she says.

Ramsey says some of her patients are so imbued with that sense of fatalism they refuse to believe it when she tells them they don’t have the disease. They’re equally skeptical when they are diagnosed because they don’t believe it can be controlled, Ramsey says.

She says their skepticism about controlling their diabetes may be well-founded. "When a primary care physician tells you all you have to do is totally change your lifestyle and you’ll be OK, that’s not realistic," Ramsey says.

Valdez says there is a sense of fatalism among Native Americans because most believe they will eventually get the disease, "So the attitude is, I’m going to eat and live the way I want because when I get it, everybody will tell me what to do.’"

Valdez, however, cautions health care practitioners against placing blame on people who have the disease or are obese or sedentary. "Diabetes is not a character flaw. Neither is obesity or a sedentary lifestyle," she says.

Community intervention against the disease is perhaps the best method of containing the problem, says Gohdes.

The IHS has granted $150 million over the next five years to Native-American communities to determine for themselves how to approach the problem. Most tribes are expected to opt for primary intervention through fitness programs and school and community nutrition education projects.

The key to helping people, Valdez says, is to make role models of those who are controlling their disease and living a healthier lifestyle.

"It’s an overwhelming problem," she says. "It’s such an enormous problem, sometimes I wonder how people get by day to day."

[Lorraine Valdez can be reached at (505) 248-4182. Barbara Ramsey can be reached at (510) 261-1962.]