Battling Diabetes
Alliance for Diabetes
Diabetes is one of the toughest health challenges facing American Indian communities.

Battling Diabetes on Reservations: A Two-Part Look at Coalitions and Culture

Catherine Keene

Editor’s note: This is the first of two articles by the author—a healthcare specialist and former facility director at the Indian Health Service.

Diabetes is one of the toughest health challenges facing American Indian communities, and it’s a problem that has troubled me deeply for many years. I grew up on the Wind River Reservation in Wyoming and I’ve spent most of my professional career trying to improve health conditions for people of the Eastern Shoshone and Northern Arapaho Tribes.

Among American Indian and Alaskan Native adults, the diabetes prevalence rate is nearly 16 percent, according to the Centers for Disease Control and Prevention (CDC). That’s the highest prevalence we see among all U.S. racial and ethnic groups, and is more than double the rate for non-Hispanic whites.

Mortality rates linked to the condition are also soaring, especially among the Northern Plains Tribes. From the years 2000 to 2009, these communities had the highest age-adjusted death rate from diabetes of all the regions covered by the Indian Health Service (IHS).

The good news is that there are proven methods for slowing the spread of the epidemic. The most common form of the disease, known as type 2 or non-insulin-dependent diabetes, can often be prevented through diet, exercise and controlling body weight. Even after being diagnosed with diabetes, many people can manage the illness with the same lifestyle approaches.

On many reservations, health authorities are already promoting such modifications. To date, they have encountered obstacles in getting the message out, but I believe we are finally beginning to gain traction.

At Wind River, our biggest breakthrough has been our ability to build trusted relationships through collaboration with people and organizations on and off the reservation. Many of the steps we’ve implemented could be adopted in other Indian communities. These are described in a new guide titled “A Comprehensive Strategy for Prevention and Management of Diabetes for American Indians.”

Since the late 1990s, IHS and groups on the ground at Wind River have been battling the epidemic. It has been an uphill struggle, in part, because different groups were working in silos. At the IHS facility where I served as director at the time, we recognized the issue and even put together an informal “diabetes coalition.” However, we lacked the kinds of structures and incentives that might encourage better coordination.

Our efforts saw a significant boost in 2009 when we received support from the Merck Foundation’s Alliance to Reduce Disparities in Diabetes (Alliance). This support allowed us to forge strong working relationships with the Wind River Indian Health Service, the Tribal Health Departments of the Eastern Shoshone and Northern Arapaho tribes, and the non-profit Sundance Research Institute, which provides technical support and services to Tribes in several regions.

The steps we’ve employed fall broadly into three categories. Most important was the improved coordination I described above. Secondly, we emphasized sharing of health information, making it easier to identify and track the progress of people at risk and those already sick. The third pillar was the use of “lay health educators” to provide culturally relevant education on diabetes self-management.

To work effectively, we needed to enroll participants whose improved health status would draw in other recruits. Initially, some doctors working on the reservation were reluctant to refer their patients because they wanted to see data showing that our approach would be effective. With the Alliance’s support, we compiled persuasive data, allowing us to reach more than 25 percent of tribal members with diabetes—sharing tips and information on how to manage their disease.

Over the next five years, we would go on to document improvements in eating and exercise habits, and also in clinical measures such as blood pressure, body weight and blood glucose levels. Ultimately, collaboration would set the stage for even more profound shifts in community attitudes toward illness and the importance of a healthy lifestyle.

Check out this video about reducing diabetes disparities in American Indian communities:

In the second half of this two-part series, we’ll explain how the program produced results and the lessons this may hold for programs on other reservations.

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