The diabetes epidemic in our Native communities is deeply personal to me: all of my siblings, one of whom died in part of complications from it; an aunt, dead long before I was born, of complications; the love of my life, who I help battle this disease every day; his beloved mother, dead of kidney failure and other complications because it went too long undiagnosed. (Lack of access to adequate medical care exacerbates the problem, and I will be devoting an upcoming diary to the Indian Health Service and its problems.) It is an epidemic whose seeds were planted 500 years ago, at first contact; we are now reaping the deadly harvest of its toxic fruit.

WHAT IS DIABETES?

Diabetes is a disorder that causes an imbalance in the body's blood glucose and insulin levels. Glucose powers the body's most basic functions, and provides fuel for energy. Insulin is a hormone, produced in the pancreas's islets of Langerhans, that regulates the uptake and processing of glucose, so that it can function as fuel, rather than simply being stored in fat cells. Without proper treatment and management, diabetes can lead to stroke, heart disease/failure, kidney disease/failure, renal disease/failure, blindness, limb amputation, and other disabling and often fatal conditions.

Type I diabetes (formerly, and mistakenly, called "juvenile diabetes" because it was then thought to occur only in children and teenagers) is generally an autoimmune disorder, in which one's own body turns on itself, effectively shutting down the pancreas's ability to produce insulin. Today, experts know that Type I is not limited to children, and it has been split into two sub-types: Type Ia, in which auto-antibodies are present (indicating an autoimmune cause), and Type Ib, in which auto-antibodies are not present, but the pancreas is completely unable to manufacture insulin (which may not be autoimmune). Type I patients are dependent on insulin, usually through standard injections or an insulin punp. Type I formerly was uncommon in communities of color, including Native communities; it appeared mostly in populations of ethnic European descent. However, with intermarriage and other factors, Type I is also increasing in Native and other communities of color.

Type II diabetes, on the other hand, is "acquired," in the sense that it results from a number of external factors, rather than a misfiring of the body's own immune system. Poor diet, lack of exercise, alcohol abuse, and, yes, genetics - all can play a role. With Type II, the pancreas produces insulin, but either 1) not enough, or 2) it produces enough, but the body is unable to process it effectively. Type II is rampant in Native communities (as well as African American communities), and the numbers are growing every day. Worse, it is now appearing at epidemic rates in our children and teenagers - age groups that not long ago were thought to be unable to develop Type II. Type II diabetics may be treated with oral medications, insulin injections, or both.

The American Diabetes Association (ADA) estimates that 95% of all diabetic American Indians and Alaska Natives have Type II diabetes, which will be the primary focus of this diary. The ADA also estimates that another 30% of all non-diabetic American Indians and Alaska Natives have a pre-diabetic condition, such as metabolic syndrome.

"Hybrid diabetes" contains characteristics of both Type Ia and Type II. There are also other less common forms: "untyped diabetes," that does not fall precisely into the Type I or II categories; "gestational diabetes," which occurs during pregnancy; and diabetes that occurs as a result of illness, trauma, medication, pancreatic disease, etc. These are beyond the scope of this diary.

ETHNIC INDICATORS

Only in recent years has the federal government become interested in funding research into ethnic disparities in the incidence of diabetes. Data are further limited by many of the same factors that skew research into any issue that affects underserved communities: poverty, lack of access to medical, lack of access to studies and clinical trials, language and cultural barriers, distrust of governmental and/or dominant-culture endeavors, and lack of effective outreach to such communities. However, the issue is now on the radar of the national Institutes of Health and the Department of Health and Human Services, which publishes the following 2006 statistics:

* American Indian/Alaska Native adults were 2.7 times as likely as white adults to be diagnosed with diabetes.

* American Indians/Alaska Natives were almost twice as likely as non-Hispanic whites to die from diabetes in 2006.

* American Indian/Alaska Native adults were 1.6 times as likely as White adults to be obese.

* American Indian/Alaska Native adults were 1.3 times as likely as White adults to have high blood pressure.

And an analysis of the 2005 patient population of the Indian Health Service produced the following statistics:

* Data from the 2005 IHS user population database indicate that 14.2 percent of the American Indians and Alaska Natives ages 20 years or older who received care from IHS had diagnosed diabetes. After adjusting for population age differences, 16.5 percent of the total adult population served by IHS had diagnosed diabetes, with rates varying by region from 6 percent among Alaska Native adults to 29.3 percent among American Indian adults in southern Arizona.

* After adjusting for population age differences, 2004 to 2006 national survey data for people ages 20 years or older indicate that 6.6 percent of non-Hispanic whites, 7.5 percent of Asian Americans, 10.4 percent of Hispanics, and 11.8 percent of non-Hispanic blacks had diagnosed diabetes. Among Hispanics, rates were 8.2 percent for Cubans, 11.9 percent for Mexican Americans, and 12.6 percent for Puerto Ricans.

Got that? American Indian/Alaska Native adults had a diabetes diagnosis rate of 16.5%. compared to 6.6% for non-Hispanic whites. The Pima in southern Arizona led the rate of diagnosis, at a staggering 29.3%. In practical terms, what these numbers mean is that Native Americans have the highest age-adjusted incidence of diabetes of any ethnic group. And these are just those who have been diagnosed. Thousands more go undiagnosed for years - often until they die from complications resulting from undiagnosed diabetes.

In 2006, diabetes was the seventh-leading cause of death in the United States. However, Native Americans constitute a disproportionately high percentage of members of that particular demographic: Diabetes-related mortality rates are substantially higher in Native populations: 39.6 per 100,000, compared to 1.9 per 100,000 for non-Hispanic whites. Keep in mind, however, that these number are almost certainly much lower than the reality: A study of 1986 data found that, on death certificates, Native American ancestry was underreported at a rate of 65%. The same analysis concluded that diabetes was 4.3 times more likely to be the underlying cause of death for those listed on their death certificates as Native American than for whites.

And the rates are getting worse, not better. Part of this may be attributable to higher rates of diagnosis, but the largest part is undoubtedly higher actual incidence.

CHILD AND TEEN GROWTH RATES

The American Diabetes Association reports that the decade between 1994 and 2004 saw a 68% increase in Type II diabetes among self-identified American Indians and Alaska Natives between the ages of 15 and 19.

Read that again for a moment: nearly a 70% jump in diabetes among older teenagers - in one decade.



According to the Indian Health Service:

American Indian and Alaska Native children have obesity rates of 40%, four times the rate for the general population.

Obesity is one of the greatest risk factors for developing Type II diabetes - and obesity among children and teenagers is rampant among American society generally, as well as in Native communities particularly.

WHY NATIVE POPULATIONS ARE AT GREATER RISK

We are a mere 100 years removed from living as hunter/gatherers, our ancestral methods of sustaining our peoples. Indeed, experts often describe us as coming from "hunter-gatherer societies", and as having a "thrifty" genetic type, biologically engineered to store food as fat during times of plenty, to provide fuel and sustenance during extended periods when food was scarce, such as winter, drought, or migration. In other words, our bodies had adapted perfectly to our physical environment.

But with contact came the reservation.

With the reservation came deprivation: of our traditional hunting grounds, including the wanton destruction of the buffalo herds; of the environments where we harvested food, herbs, and medicine; of our ancestral lands when many of our tribes engaged in sophisticated farming and crop rotation practices; of access to many of our cultural and spiritual traditions and methods of healing.

And with the reservation came new dangers: of previously-unknown infectious agents and disease; of tobacco (not the old asemaa of our medicine persons, consisting of herbs such as red willow bark, bearberry, and mullein, but the modern asemaa of tar and nicotine); of alcohol (not the fermented medicine and ceremonial drinks of our ancestors, but whiskey, rum, and moonshine); of a diet restricted to non-indigenous foods, that would eventually become a diet consisting almost entirely of refined, processed foods low in protein and complex carbohydrates but high in simple carbs and trans fats.

And residents of modern reservations, with median household incomes well below the federal poverty line (often well below $10,000 per year) and with staggering rates of unemployment (as much as 85%), often must rely almost wholly on government welfare programs, including refined and processed commodity foods. Whole grains, fresh produce, and other healthy foods are far too expensive, and on many reservations, there are no grocery stores or markets that carry such items anyway. And over the years, refined ingredients have infiltrated the recipes for our traditional foods, so that here in the Southwest, for example, people have for decades used bleached, refined white flour in their tortillas - because it is both available and affordable. And thus is a staple of the traditional diet converted into an instrument of disease.

ACTION: WHAT YOU CAN DO

On the personal level:

* If you're of Native ancestry, get tested. It only takes a pinprick on the end of a finger. * If you have loved ones of Native ancestry, encourage them to do the same. * If you or a loved one gets a diagnosis of diabetes, enroll in a diabetes management program. * Eat right. Exercise. Don't smoke; don't drink. Monitor your glucose levels, and take charge of your own health.

On the local level:

* If you live on or near a reservation, encourage the development of tribal diabetes education and management programs. * Support related culturally-appropriate non-profit efforts and local businesses that serve such populations. * Encourage cultural education and sensitivity.

On the national level:

* Contact your members of Congress; demand that they fulfill the nation's statutory obligation to fund the Indian Health Service (IHS) fully. * Lobby for additional funding for culturally-appropriate diabetes research and prevention programs through IHS. * Lobby for federal funding for tribal initiatives to maintain diabetes management and traditional treatment programs, including tobacco and alcohol cessation programs. * Lobby for federal funding for investment and development dollars to bring healthy food initiatives and businesses to reservations. * Demand that federal assistance programs distribute healthy foods, such as whole grains, and provide access to fresh fruits and vegetables. * Lobby for funding for research and development, through the National Institutes of Health, the Indian Health Service, and the Association of American Indian Physicians, dedicated to prevention, treatment, and education programs in Native populations.

One final set of requests: Please also visit the most recent South Dakota rez donation diary to find out how to help buy propane and other basic necessities for families in desperate need as a result of the extreme weather conditions there. Go to these diaries to find out who you can call and/or e-mail to get federal dollars and other relief flowing. And please tip and rec today's Haiti and ShelterBox diaries, and donate if you can.