ACTIVITY/MECHANISMS BUDGET SUMMARY

Department of Health and Human Services

Indian Health Service -- 75-0390-0-1-551

DIABETES

[Program Authorization]{.underline}

Program authorized by 111 STAT. 574, 1997 Balanced Budget Act (P.L
105-33) and H.R. 4577, Consolidated Appropriation Act 2001 (P.L.
106-554) and Interior Appropriation Indian Health Service National
Diabetes Program.

+-------------+-------------+-------------+-------------+-------------+
|             | 2002        | 2003        | 2004        | Increase    |
|             |             |             |             |             |
|             | Actual      | President's | Estimate    | or Decrease |
|             |             |             |             |             |
|             |             | Budget      |             |             |
+-------------+-------------+-------------+-------------+-------------+
| BA          | \$          | \$          | \$          | +\          |
|             | 100,000,000 | 100,000,000 | 150,000,000 | $50,000,000 |
+-------------+-------------+-------------+-------------+-------------+
| FTE         | 1           | 2           | 6           | +4          |
+-------------+-------------+-------------+-------------+-------------+

The Balanced Budget Act of 1997 (P.L. 105-33) provided that \$30 million
per year appropriated to the Children's Health Insurance Program (CHIP)
be transferred to Indian Health Service for diabetes prevention and
treatment for five years ending in FY 2002 called the *Special Diabetes
Program for Indians* grant program. An additional \$70,000,000/year was
provided under the Medicare, Medicaid, and SCHIP Benefits Improvement
and Protection Act of 2000 for FY 2001 and FY 2002, and \$100,000,000
was provided for FY 2003. These funds support the Secretary's initiative
to prevent diabetes and obesity, as well as a focus on healthier youth.
Total Indian Health Service (IHS) diabetes funding also includes the IHS
National Diabetes Program (NDP) with 12 Area Diabetes Consultants and 19
model diabetes sites (\$7.7 million per year) and, starting in FY 1998,
\$3 million was added to the diabetes grants.

The *Special Diabetes Program for Indians* grant funds will expire in
FY 2003, under the current legislation. The SDPI funding was
reauthorized in December 2002 at \$150 million per year, a \$50 million
per year increase, for five years (2004-2008).

**[PURPOSE AND METHOD OF OPERATION]{.underline}**

American Indian and Alaska Native (AI/AN) communities suffer a
disproportionately high rate of type 2 diabetes. The mission of the IHS
NDP is to develop, document, and sustain a public health effort to
prevent and control diabetes in AI/ANs. In FY 2002, with total funding
for IHS National Diabetes Program of \$110.7 million, the IHS NDP
promoted collaborative strategies for the prevention of diabetes and its
complications in the 12 IHS Service Areas (regions) through coordination
of a network of 19 Model Diabetes Programs and 13 Area Diabetes
Consultants. They in turn provided resource distribution, program
monitoring and evaluation activities, and technical support to 84
Service Units (local level), whether federal or tribal, in the delivery
of comprehensive health care to over 1.5 million American Indians and
Alaska Natives. The NDP continues to develop and operate the *Special
Diabetes Program for Indians* grant program with 318 grantees in 35
states.

[PROGRAM MISSION AND RESPONSIBILITIES]{.underline}:

The National Diabetes Program provides

-   **Comprehensive diabetes surveillance** (including total and
    age-specific prevalence rates of diabetes and diabetic complications
    across Indian country) at the local, regional and national levels
    through collaboration with CDC epidemiologists and use of contract
    epidemiologists and statisticians

-   **Research translation** through training and technical assistance
    provided via our extensive network

-   **Promotion of quality assurance / improvement activities** in
    clinical and community programs through updated Standards of Care
    for Diabetes, the annual Diabetes Care & Outcomes Audit, and the
    Integrated Diabetes Care and Education Recognition Program

-   **Technical support** to I/T/U sites nationwide through bulletins,
    updates and comprehensive website information

-   **Resource information** on a full complement of training
    opportunities including specialized training related to primary
    outpatient treatment models of diabetes management

-   Health care provider/ consumer **education resources and "best
    practices" information** to IHS, tribal and urban health programs

-   Development, field testing and distribution of **Native
    American-specific diabetes education** printed and audio-visual
    materials to IHS & tribal health centers. In FY 2002, over 5500
    diabetes education materials were sent to over 300 I/T/U programs
    nationwide

In addition, the NDP serves as the key IHS contact and source of
information for outside organizations and agencies working on issues of
diabetes and disparities related to diabetes.

The Burden of Type 2 diabetes in AI/AN communities

Diabetes was the most frequently identified health problem in the IHS
Area I/T/U budget formulation workshops for FY 2001.

![](media/image1.png){width="3.0in" height="2.0805555555555557in"}Type 2
diabetes occurs at dramatically higher rates among AI/AN adults who are
over 3 times as likely to have diabetes than the general U.S.
population.

![](media/image2.wmf) A recent alarming trend is the increase in
prevalence of type 2 diabetes in young AI/AN. Over an eleven-year
period, from 1990-2001, the prevalence of diabetes rose 25 percent in
children and 106 percent in AI/AN adolescents.

Complications of diabetes lead to much higher incidence rates of
blindness, vascular insufficiency leading to amputation, and End Stage
Renal Disease (ESRD) than in the general U.S. population. Most recent
data show that diabetes mortality is 4.3 times higher in the AI/AN
population than in the U.S. population.

Special Diabetes Program for Indians

The Balanced Budget Act (BBA) of 1997 provided \$30 million per year for
5 years through the *Special Diabetes Program for Indians*. On December
15, 2000, Congress passed PL 106-568, the Consolidated Appropriations
Act of 2001, which included a provision for supplemental funding of the
*Special Diabetes Program for Indians*. PL 106-568 authorized an
additional \$70 million in FY 2001, \$70 million in FY 2002 and \$100
million in 2003. In December 2002, the President signed PL 107-360
authorizing \$150 million per year from 2004 - 2008 for grants to
eligible tribes and organizations. Key aspects of the *Special Diabetes
Program for Indians* include:

-   *Tribal Consultation* A Tribal Leaders Diabetes Workgroup was
    established in 1998 to review the Area tribal input and make
    recommendations on the administration and distribution of the
    diabetes funds. Based on their recommendations, funds were awarded
    through non-competitive grants for a five-year project term. The
    Workgroup recommended that IHS distribute the funding by IHS Area
    according to a formula based primarily on disease burden and user
    population with an adjustment to increase funding for very small
    tribes. They also recommended that \$1.5 million be set aside for
    the urban programs who were to be exempt from the distribution
    formula process. In addition, 5 percent of the overall funds were
    reserved for improved data collection to enhance the evaluation
    process. An Area-wide consultation process determined distribution
    of the grant funds within each Area to local IHS and tribal
    programs. An evaluation process was created for national and
    regional levels.

-   *Grant Program Evaluation* There were 286 grants representing 333
    separate sites awarded each year. The CDC's Framework for Public
    Health Evaluation, using a mixed methods approach (both qualitative
    and quantitative methods), has been implemented. Tribal programs
    determined at the local level how their funding was to be used.

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-   *Prevention Efforts* Sixty-six percent of programs have chosen to
    focus on primary prevention, such as offering exercise and nutrition
    programs to prevent the onset of diabetes. Sixty-five percent of
    programs are also devoting some of their grant funds toward
    secondary prevention efforts (managing diabetes to prevent
    complications such as kidney failure, amputations, heart disease and
    blindness) and 33 percent of programs decided to implement tertiary
    prevention efforts to reduce morbidity and disability in those who
    have complications from diabetes.

-   *CDC/National Diabetes Prevention Center* \$1 million of the BBA
    funds were allocated to CDC Division of Diabetes for the development
    of a National Diabetes Prevention Center (NDPC) in Gallup, NM. The
    NDPC agreement was originally awarded to the University of New
    Mexico (UNM). In 2001, UNM redefined the NDPC's area of impact from
    that of a national perspective to a southwest regional focus. UNM
    will continue to work primarily with the Zuni Pueblo and Navajo
    Nation as originally legislated and will keep a solely southwest
    focus. The IHS NDP and the CDC Division of Diabetes are working
    collaboratively to expand the national focus of the NDPC through the
    dissemination of diabetes technical assistance resources and other
    diabetes data. The Tribal Leaders Diabetes Committee, established as
    a result of the BBA funds to advise IHS on diabetes-related issues,
    advises the IHS and CDC on these national expansion efforts.

-   *Tribal Management of Local Grant Programs* The number of tribally
    managed programs continues to grow steadily. 81 percent of the SDPI
    grant recipients are tribal programs. To responsibly manage a health
    program requires data that supports an assessment of the health
    needs of the population. To meet this need, tribal programs were
    well represented in the IHS 2002 Diabetes Care and Outcomes Audit of
    AI/AN with diagnosed diabetes and will have the opportunity to
    participate in the 2003 survey. Data gathered by these surveys
    provides tribes information from which to make rational decisions
    regarding their diabetes programs.

The IHS National Diabetes Program has a long and distinguished history
of serving as a benchmark of diabetes clinical and public health
excellence including:

-   Development of the IHS Standards of Care for Diabetes in 1985, prior
    to those published by the American Diabetes Association in 1986,
    that are updated every 2 years based on the latest diabetes science

-   Leader in developing a diabetes care surveillance system, the Annual
    Diabetes Care and Outcomes Audit, carried out voluntarily in Indian
    health facilities, to track clinical performance. This audit:

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-   measures 87 quality improvement indicators / outcomes yearly, and
    allows IHS to assess trends in these outcomes over time,

    -   monitors use of standards and outcomes of diabetes care,
        including blood sugar and blood pressure control, screening for
        complications, and preventive health services and

    -   in FY 2002 reviewed over 17,000 charts representing care to
        almost 90,000 patients with diagnosed diabetes at 190 IHS /
        tribal health facilities in the 12 IHS Areas.

## This diabetes care surveillance system has been instrumental in the improvement of diabetes care practices in many Indian health settings. For example, in a special program in Alaska and in northern Minnesota from 1989-2002, lower extremity amputation rates were reduced by 60 percent in people with diabetes who received complete foot screening and protective footwear. This same system enabled IHS to measure significant improvements in blood sugar control nationwide and in blood pressure control in Montana after an intensive intervention.

## 

## FINDINGS INFLUENCING THE FY 2004 REQUEST

The 1997 BBA Special Diabetes Program for Indians (SDPI) provided IHS
\$30 million per year for 5 years for the prevention and treatment of
diabetes. The amendment to the 1997 BBA SDPI through H.R. 4577, the
Consolidated Appropriations Act, 2001 provided additional funding for FY
2001, 2002 and 2003. On Dec 17, 2002 a second amendment, through
H.R.5738, was signed into law, which provides \$1.5 billion for the
Special Diabetes Program for Indians over the next five years (\$150
million each year for FY 2004 -- FY 2008).

SDPI funds originally provided "seed money" to 318 new programs to begin
or enhance diabetes prevention programs in Indian communities as well as
to address diabetes treatment. The result has been the creation of
innovative, culturally appropriate strategies that address diabetes. The
SDPI funds have significantly enhanced diabetes care and education in
AI/AN communities, as well as built desperately needed infrastructure
for diabetes programs.

The IHS distributed SDPI funding for FY 2003 to eligible I/T/U grantees
utilizing a formula determined with input from tribes through an
extensive Area tribal consultation process. Funds were distributed to
each Area based on a formula using the following components:

-   *disease burden* (defined as 75% diabetes prevalence, 25% diabetes
    mortality),

-   *user population* (defined through HIS data collection efforts) and

-   *a tribal size adjustment*.

Each IHS Area had the flexibility to further define distribution to
tribes and IHS grant programs locally. Urban Indian health programs,
administrative and data improvement support costs were also funded
through a set-aside determined by the IHS Director.

In order to support grant programs in planning for use of the
supplemental grant funds in FY 2001 -- FY 2003, the application process
included a community assessment tool and 14 suggested "Best Practice"
approaches. Grantees were given the option to strengthen clinical
diabetes and complications prevention and/or to develop and strengthen
primary diabetes prevention programs.

The IHS used administrative funding to strengthen diabetes
infrastructure at the Headquarters and Area office levels to maintain
and improve diabetes surveillance, technical assistance, provider
networks, clinical monitoring and grant evaluation activities. Support
for the Area Diabetes consultants, who serve a crucial role in
coordinating these functions at the Area level, was also strengthened.
Funding for the past 5 years has served to provide much needed
infrastructure within IHS and tribal administrations that will enable
continued development of diabetes programs to address treatment and
prevention of diabetes.

Tribes have had to make choices about how to best use their local SDPI
funding because, while it is a significant increase in funding, it is
not enough to address the entire problem of diabetes in AI/AN
communities. Managed care studies have estimated that it costs
\$5000-9000 per year to care for one person with diabetes. Based on
current IHS figures, a conservative estimate is that it costs the agency
\$425 million per year to care for those who are diagnosed today. These
figures do not include those with undiagnosed diabetes or those in whom
we could prevent the disease. The Indian health care system recognized
from the start of this program that we would have to make careful
choices about where to best invest these funds. And we knew these
choices would best be made locally.

# 

# Tribes have had to make decisions about whether to focus on: 

# 

# treatment (such as supporting pharmacy budgets, hiring eye or foot specialists, hiring nurse educators and nutritionists, etc), 

# prevention (such as creating physical activity programs for youth, community cooking classes, weight management programs, etc), or 

# divide the funding between both treatment and prevention. 

The SDPI has brought tribes together over these past 5 years, working
toward a common purpose and sharing information & lessons learned along
the way. The IHS has shown through its public health evaluation
activities that these programs have been very successful in improving
diabetes care and outcomes, as well as the start of primary prevention
efforts, on reservations and in urban clinics. The FY 2001 GPRA
performance for the diabetes indicators showed improved clinical
outcomes for the four diabetes outcome indicators. In addition, through
innovative collaboration and sound public health techniques, there were
significant accomplishments reached in eye exam rates and reductions in
lower extremity amputations for some programs.

*Eye Disease:* The IHS has partnered with the Joslin Diabetes Center to
implement the Joslin Vision Network (JVN), a tele-ophthalomolgy state of
the art technology in several IHS clinics. This allows for an eye exam
to be done through equipment operated on site in the clinic and then
evaluated by an eye care specialist in another facility. IHS has been
evaluating this technology and comparing it to its other sites with
"regular" eye care. Eye exams are a very important part of the care for
the person with diabetes as diabetic eye disease is usually "silent"
until its late stages, but if discovered early through regular eye
exams, can be readily treated and blindness prevented.

Data shows eye exam rate outcomes following implementation of the JVN in
one IHS site compared to a site with no JVN. Eye exam rates improved in
one year from 48 percent to 79 percent of all people with diabetes at
the JVN site while in the site with no JVN the eye exam rates remained
unchanged.

![](media/image3.wmf)

Several studies have suggested that 75 percent of lower extremity
amputations (LEA) due to diabetes can be prevented through the use of
public health techniques and low-tech strategies to categorize patients
by risk. Programmatic changes were used in the Bemidji and Alaska Area
to implement foot care practice guidelines through a process called
Staged Diabetes Management (SDM) in partnership with the International
Diabetes Center. SDM uses a local consensus process to customize the
guidelines to promote acceptance by providers and the community. SDM
also stresses the importance of system changes**.** The IHS continues to
partner with IDC, and to date, the SDM process for improving overall
diabetes care has been implemented in over 50 facilities IHS-wide.

*Amputation prevention:* Data shows that following implementation of
SDM, amputation rates were reduced by half, compared with the baseline
period.

![](media/image4.wmf)

As part of an effort to build on this program, vascular surgery and
pedorthic (specialty preventive shoes) outreach services were added, and
the LEA rate was further reduced by half. These latter efforts were made
possible through support from the *Special Diabetes Program for Indians*
grant program.

*Blood sugar control:* IHS has been able to demonstrate significant
improvements in blood glucose control over time, greater than 1
percentage point drop for each age group, as measured by A1C.

![](media/image5.wmf)

Large clinical trials have shown that a 1 percentage point drop in A1C
in people with diabetes should result in:

\* 14% decrease in total mortality \* 21% decrease in diabetes-related
deaths

\*14% decrease in heart attacks \* 12% decrease in strokes

\* 43% decrease in amputations \* 24% decrease in kidney failure

\* \$800 reduction (per person) in annual health care costs.

Continued funding beyond FY 2003 will provide for continuation of all
current diabetes programs in AI/AN communities and provide resources
needed to establish more primary prevention activities in AI/AN
communities based on proven lifestyle programs and pharmaceutical
interventions, as well as address the rise in cardiovascular disease.
The IHS, in collaboration with the CDC NDPC, will disseminate the new
"promising practices" learned from these grant programs to other tribal
communities for adaptation and implementation. A compendium of grant
program descriptions is being compiled for dissemination nationwide. An
in-depth analysis and interim evaluation of grant program activities
will provide a compilation of "best practices" developed and outcomes of
these activities which will provide a basis for planning and future
direction.

###### ACCOMPLISHMENTS

## Primary Prevention of Diabetes

Two thirds of the 318 *Special Diabetes Program for Indians* grant
programs are focused on primary prevention projects. Analysis of our
most recent survey results, done in March 2002, showed that compared
with before the grants were awarded:

-   More diabetes prevention efforts now focus on elders(86%),
    adults(89%), young adults(73%), adolescents(65%), school age(55%),
    and preschool children (39%),

-   More diabetes prevention activities now focus on screening(85%),
    nutrition(84%) and physical activity(69%).

-   Programs now report that they focus more on clients with newly
    diagnosed diabetes (87%), family members of people with diabetes
    (74%) and on pregnant women (48%) as a result of the grant funds.

-   More emphasis is now placed on addressing preventive measures in
    adults who are overweight (73%), people with high blood pressure
    (63%), children and youth who are overweight (67%), and on tobacco
    users (40%) than before they received their grant funds.

-   Some important impacts now focused on are diabetes prevention
    efforts (92%), increase in healthy behaviors of individuals (95%),
    and increase I healthy behaviors of the community (88%).

-   70 percent of grantees report being able to develop or greatly
    improve nutrition counseling for people with diabetes.

As a result of the SDPI grant funds, programs have both enhanced
existing diabetes activities and developed new activities. Many of these
activities have been shown in studies to improve diabetes care. For
example:

-   83 percent of programs now track their diabetic patients through
    diabetes registries,

-   81 percent have diabetes teams in place to provide better care,

-   66 percent of programs report that basic diabetes care is now
    available for people with diabetes in their communities,

-   87 percent of programs now have diabetes education services
    available.

Many grant programs are using traditional approaches in their new
diabetes activities, including:

-   story-telling (34%),

-   talking circles (35%),

-   use of traditional herbs or medicines (28%).

Traditional approaches can help support and influence positive diabetes
self-management behaviors within communities.

The diabetes grant funds have afforded tribes the opportunity to address
diabetes prevention where it needs to be addressed -- at the tribal
community level.

-   89 percent of programs now solicit and receive feedback from their
    local communities on what their diabetes goals and priorities are,
    and then use this information to design their diabetes care
    programs.

-   53 percent have developed community walking programs

-   42 percent have created diabetes awareness programs for high-risk
    family members of people with diabetes.

[Translation of the Diabetes Prevention Program (DPP).]{.underline} The
study results published in the Feb 7, 2002 issue of the [New England
Journal of Medicine]{.underline} (which included 171 AI participants)
showed conclusively that type 2 diabetes could actually be prevented or
delayed through lifestyle changes (58 percent reduction) or use of the
medication metformin (31 percent reduction).

The DPP has provided a road map for diabetes prevention that was not
available to us before. Many of our SDPI grant programs were working on
diabetes prevention interventions prior to the publication of this
study. Thus, these SDPI funds have allowed us a much more advantaged
position, with a much stronger diabetes infrastructure and good ideas
about what works and what doesn't work, to launch diabetes prevention
activities in AI/AN communities to translate the exciting news. Since
February 2002 the NDP has organized a workgroup to adapt the DPP
materials for use in the field by IHS and tribal sites. American Indian
DPP participants have been interviewed and a special issue of our
magazine Health for Native Life focusing on their accomplishments was
published in December 2002.

[Diabetes and Obesity Prevention Initiative]{.underline}. This
partnership between the Head Start Bureau and the IHS, initiated in
1997, has provided an opportunity to address the increasing trend of
obesity and diabetes in children and youth. The goal is to promote
healthy lifestyle development and change among Head Start children,
families, staff, and their communities and to develop / sustain local
community partnerships. Five Tribal Head Start pilot sites, in
collaboration with their respective community health partners, have
developed local obesity and diabetes prevention interventions. Each Head
Start site community action plan includes multifaceted program
activities and milestones focusing on healthy eating, physical activity,
healthy behavior and community partnerships. These efforts are the
foundation of the success of the initiative and the development of new
resources for the Head Start community

Other Accomplishments

-   [IHS Diabetes Education Recognition Program]{.underline} approved by
    CMS and announced in the March 22, 2002 issue of the Federal
    Register as a National Accreditation Organization for diabetes
    self-management education programs. The IHS NDP joins the American
    Diabetes Association as the only other agency with this authority,
    allowing certified AI/AN programs to bill Medicare for diabetes
    education services.

-   Developed a tool to assess use of 14 Identified Best Practices by
    the grant programs. Results available in July.

-   Completed Tribal consultation for FY03 SDPI funding.

-   Collaborated with the NDPC in Gallup, NM to develop 8
    diabetes-related monographs on grant activities and GIS mapping of
    diabetes complications for dissemination later in the year.

-   Program Director serves as a Steering Committee member on the
    National Diabetes Education Program and attended a Steering
    Committee meeting in May 2002 and a NDEP Evaluation Committee
    meeting in April to determine a national evaluation plan for the
    NDEP. Other staff serves on the NDEP American Indian and the DPP
    Lifestyle Tools Workgroups.

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-   The IHS diabetes prevalence and complications surveillance system
    has been automated through the assignment of a CDC Epidemiologist to
    the program. The 1999 -- 2001 diabetes prevalence data were
    calculated and adjusted in May 2002 and have been disseminated to
    the Tribal Leaders Diabetes Workgroup, Area Directors, Area Diabetes
    Consultants, and others. The data are now available by region on our
    website.

-   Workgroup established with CDC, IHS, the American Academy of
    Pediatrics and the American Diabetes Association to address the
    growing concern about type 2 diabetes in AI/AN children. IHS staff
    are leading the effort. The committee recently published draft
    screening protocols, standards of care and treatment recommendations
    for these children which were distributed to the field in January
    2002.

-   The IHS NDP has begun a collaborative effort to provide I/T/U's with
    information on the CMS reimbursement process for Medical Nutrition
    Therapy for diabetes / kidney disease through area trainings. An
    article published in the IHS Provider.

-   The IHS NDP published an article in the December 2002 issue of the
    professional journal Diabetes Care on its successful lowering of A1C
    levels (indicating better blood sugar control) in the past decade.

Following are the funding levels for the last 5 fiscal years: (without
accrued)

+----------------+-----------------------------------+-----------------+
| # Year         | [Funding]{.underline}             | [F              |
|                |                                   | TE]{.underline} |
+----------------+-----------------------------------+-----------------+
| 1999           | \$30,000,000                      | 0               |
+----------------+-----------------------------------+-----------------+
| 2000           | \$30,000,000                      | 0               |
+----------------+-----------------------------------+-----------------+
| 2001           | \$100,000,000                     | 0               |
+----------------+-----------------------------------+-----------------+
| 2002           | \$100,000,000                     | 1               |
+----------------+-----------------------------------+-----------------+
| 2003           | \$100,000,000                     | 2               |
+----------------+-----------------------------------+-----------------+

**[PERFORMANCE MEASURES]{.underline}**

[Indicator 1:]{.underline} During FY 2004, continue tracking (i.e., data
collection and analyses)

Area age-specific diabetes prevalence rates to identify trends in the
age-specific prevalence of diabetes (as a surrogate marker for diabetes
incidence) for the AI/AN population.

[Indicator 2:]{.underline} During FY 2004, increase the proportion of
I/T/U clients with diagnosed diabetes that have demonstated improved
glycemic control by 2 percent over the FY 2003 level.

[Indicator 3:]{.underline} During FY 2004, increase the proportion of
I/T/U clients with diagnosed diabetes who have achieved blood pressure
control standards by 2 percent over the FY 2003 level.

[Indicator 4:]{.underline} During FY 2004, increase the proportion of
I/T/U clients with diagnosed diabetes assessed for dyslipidemia (i. e.,
LDL cholesterol) by 2 percent over the FY 2003 level.

[Indicator 5:]{.underline} During FY 2004, increase the proportion of
I/T/U clients with diagnosed diabetes assessed for nephropathy by 2
percent over the FY 2003 level.

[Indicator 6:]{.underline} During FY 2004, increase the proportion of
American Indian/Alaska Native diabetics who receive an annual diabetic
retinal examination at designated sites by 3 percent over the FY 2003
rate.

In addition, the IHS NDP has developed a set of short-term, intermediate
and long-term outcome measures for evaluation of the Special Diabetes
Program for Indians, using the CDC's Framework for Public Health
Evaluation methodology. The 2003 Interim Report on the SDPI will provide
data on IHS' accomplishments thus far on the short-term and intermediate
outcomes, and provide a description of the baseline long-term outcomes
that will be measured over the next decade.

**[RATIONALE FOR BUDGET REQUEST]{.underline}**

[TOTAL REQUEST]{.underline} \-- The request of \$150,000,000 is a net
increase of \$50,000,000 over the FY 2003 President's Budget request of
\$100,000,000.

[Program Increase: +\$50,000,000]{.underline}

In consultation with the tribes, the IHS proposes to let these grants
out as a combination of competitive and non-competitive RFAs to I/T/Us
with emphasis in the following areas:

-   assure continuation of all current diabetes grant programs in AI/AN
    communities;

-   provide additional resources to establish more focused diabetes
    primary prevention activities in AI/AN communities (both proven
    lifestyle programs as well as pharmaceutical interventions) based on
    findings from the Diabetes Prevention Program (DPP) model. For
    example, these communities would be able to hire additional physical
    activity specialists, registered dieticians, nurses and
    psychologists; add/improve Wellness facilities for physical activity
    and prevention activity; and purchase the medication metformin
    (GlucophageR) for pharmaceutical prevention of type 2 diabetes;

-   address the rising tide of cardiovascular disease in AI/AN with
    diabetes through translation of established risk factor reduction
    practices; and

-   devoted additional resources to provide adequate infrastructure,
    administrative oversight, monitoring, data improvement, educational
    resources and program evaluation activities related to these grants
    as well as to disseminate comprehensive diabetes-related information
    to the field in a timely way.