# **IHS Report to Congress:**

## **Obesity Prevention and Control**

**for American Indians and Alaska Natives**

**April 2001**

### 

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Presented to the President of the United States of America and to the
Congress of the United States of America

Prepared by the Secretary of Health and Human Services

with the assistance of the Indian Health Service and the

American Indian and Alaska Native People

# Acknowledgements

*Writing Team:*

## Jean Charles-Azure, MPH RD

### Principal Nutrition Consultant

Indian Health Service Headquarters, Rockville, MD

Elizabeth Warren-Boulton, RN MSN

President, Health Education Consulting Associates

Washington, D.C.

Brenda Broussard, RD MPH MBA CDE

Principal, Brenda Broussard Consulting

Albuquerque, NM

***Contributors***

*(includes contributors of articles, writings, reviewers, and*

*focus group participants in IHS meeting of Oct. 23-24, 2000, Rockville,
MD):*

### Chief Allan

### National Congress of American Indians

Washington, DC

### 

### Carol Ballew, PhD

### Epidemiologist, CDC Division of Nutrition

###  and Physical Activity

Atlanta, GA

James Bresette, Pharm. D.

Indian Health Service

Rockville, MD

Martina Callaghan, MPH RN

Principal Nursing Consultant

Indian Health Service Headquarters, Rockville, MD

Aaron Carrell, MD

University of Wisconsin Children's Hospital

Ho-Chunk Youth Fitness Program, Madison, WI

John Cheek

##### National Indian Education Association

Alexandria, VA

Jamie Davis-Hueston, PhD

Principal Psychology Consultant

Indian Health Service Headquarters,Rockville, MD

William Deitz, MD PhD

Director, CDC Division of Nutrition

and Physical Activity

Atlanta, GA

### Karen Donato, MS RD

### Coordinator, Obesity Education Initiative

### National Heart, Lung, and Blood Institute, NIH

Bethesda, MD

Abby Ershow, Sc.D.

National Heart, Lung, and Blood Institute, NIH

Bethesda, MD

Jan Frederick, RD MS

Acting Phoenix Area Nutrition Consultant

Indian Health Service

Phoenix, AZ

### Charmaine Garry, MES, CKPT

Fitness Director

Rural Health Outreach Grant

Ho-Chunk Nation

Baraboo, WI

### 

### Tim Gilbert, MPH RD

Health Systems Network Specialist

Alaska Native Tribal Health Consortium

Anchorage, AK

Van Hubbard, MD PhD

Director, NIH Division of Nutrition Research

Coordination

### Bethesda, MD

M. Yvonne Jackson, PhD RD

### Office for American Indian, Alaskan Native, 

###  Native Hawaiian Programs

Administration on Aging, DHHS, Washington, DC

Tony Kenrick

Director, Public Affairs

Indian Health Service

Rockville, MD

Theresa Kuracina, RD MS CDE

Chief Dietitian

Indian Health Service Albuquerque Indian Hospital,

Albuquerque, NM

Michael Mahsetky, Senior Legislative Analyst

Indian Health Service

Rockville, MD

Melvina McCabe, President

Association of American Indian Physicians

### Oklahoma City, Oklahom*a*

Kathryn McMurry, MS

Nutrition and Food Science Advisor

US Department of Health and Human Services

Washington, DC

Laura McNally, RD, MPH, FADA

HRSA , Center for Quality

Rockville, MD

Leo Nolan, Senior Policy Analyst

Indian Health Service

### Rockville, MD

Glen Revere, MS, RD

Indian Health Service

Fort Washakie, WY

Charlene Sanders, Public Health Nutritionist

Division of Nutrition and Physical Activity

Centers for Disease Control and Prevention

Atlanta, GA

Patricia Schumacher, MS RD

Nashville Area Nutrition Consultant

Indian Health Service

Nashville, TN

Phillip L. Smith, MD

Director, Office of Public Health Support Services

Indian Health Service

Rockville, MD

Elaine Stone, PhD MPH

National Heart, Lung, and Blood Institute, NIH

Bethesda, MD

Mary Story, PhD, RD

Associate Professor, Division of Epidemiology

University of Minnesota, Minneapolis, MN

Karen Strauss, MS RD

Consumer Safety Officer

Office of Special Nutritionals, FDA, Washington, DC

Nancy Theodore

Food and Nutrition Service, USDA

Washington, DC

Mindy Tomkins, RD

Nutrition Education Coordinator

Inter Tribal Council of Arizona, Inc., Phoenix, AZ

William Craig Vanderwagen, MD

Director, Division of Clinical and Preventative Services

Indian Health Service Headquarters, Rockville, MD

Mary Wachacha, Acting Health Education Chief

Indian Health Service

Nashville, TN

Lorraine Whitehair, MPH RD RN

Chief Dietitian

Indian Health Service A/C/L Hospital, San Fidel, NM

### Cheryl Wilson, MS

IHS Diabetes Prevention Consultant

Albuquerque, NM

Wynona Woolf, MPH RD

Public Health Nutritionist

IHS Blackfeet Community Hospital, Browning, MT

Elenora Zephier, MPH RD

Chief, Nutrition and Dietetics Branch

Indian Health Service Aberdeen Area, Aberdeen, SD

Amy Zibble, RD, CD

Department of Health, Ho-Chunk Nation

Baraboo, WI

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*The grandfathers and grandmothers taught us things. They ate according
to what they should eat, the Indian way, the traditional way. They
taught us how to gather these foods and eat them. And they were
strong...My grandfather, No Two Horn was 107 when he died. And he had a
cane but he used it just now and then. And he would take it and put it
above his head and run in the mornings**.*** **Zona Loans Arrow,
Standing Rock Sioux, 72 years old, diagnosed with diabetes at age 34.**

**Table of Contents**

> **Executive Summary**
> ........................................................................
> 6
>
> **1.
> Introduction**...............................................................................
> 9

2.  **The Magnitude of the Problem**
    ....................................................... 9

####### A. The Prevalence of Obesity in AI/AN Communities

B.  Morbidity and Mortality Associated with Obesity

C.  Economic Cost of Obesity

D.  Behavioral and Lifestyle Factors Affecting Obesity

> **3. IHS Plan to Reduce the Obesity Epidemic Among AI/AN**
> ...................... 14

A. Obtaining AI/AN Input to Identify Issues

B.  IHS Recommendations

C.  Activity Details

**4. Available Guidelines for Physical Activity and Provider/Patient
Interactions**

**Concerning Obesity**
.......................................................................
21

> A. Physical Activity Recommendations

B.  Recommendations for Provider/Patient Interaction Concerning Obesity

C.  Mental Health And Obesity Issues in AI/AN

> **5. Risks of Obesity Treatment**
> ............................................................ 23
>
> **6. Studies of Dietary Intake**
> ............................................................... 24
>
> A. Studies Reporting Nutrient Intakes for AI/AN

B.  Traditional and Contemporary Foods

C.  Food Assistance Programs

> **7. Nutrition-Related Intervention Studies**
> ............................................. 26
>
> **8. Local Tribal Community Intervention Programs**
> ................................. 27
>
> A. Ho-Chunk Nation Youth Fitness Program, Wisconsin

B.  "Community Mobilization to Beat Diabetes" in Five Tribal Communities

C.  St. Regis Mohawk Tsitewatakari:tat "Let's Get Healthy" Program

**9. Current National Program Activities**
................................................ 30

A. IHS Special Diabetes Program for Indians Interim Report to Congress,

January 2000

B.  IHS Head Start Initiative "Healthy Children, Healthy Families,
    Healthy Communities: A Focus on Diabetes and Obesity Prevention"

C.  NIH Diabetes Prevention Program (DPP)

**10. Summary**
...................................................................................
32

> **References**
> .......................................................................................
> 33
>
> **Appendices**

1\. Senate Report No. 106-312 on FY 2001 Interior Appropriations
................ 37

2\. Obesity in AI/AN Children
............................................................. 38

> 3\. IHS Planning Conference to Reduce Obesity Among AI/AN:
>
> Conference Invitees
> .....................................................................
> 41
>
> 4\. Inter Tribal Council of Arizona Programs -- Input into the October
> 2000
>
> Planning Conference
> ................................................................... 43

5.  Input From the Planning Conference and Current Diabetes Programs
    .......... 44

6.  CDC Division of Nutrition and Physical Activity Proposal to
    Collaborate

> with IHS
> .................................................................................
> 49
>
> 7\. CDC Recommendations to Promote a Lifetime of Healthy Physical
> Activity .. 50

8\. Mental Health Issues and Obesity in AI/AN
........................................ 51

9\. Traditional and Contemporary Foods
................................................ 53

10\. Nutrition Intervention Studies
........................................................ 55

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*I know that Education is the key and we need more money for education.
This wasn't done (education) in my younger time. I really didn't know
what diabetes was, how it affects you in the later years. I guess if I
had a little more education on it, I probably wouldn't be sitting here
without my limbs.* **Lawrence Bedeau, Red Lake Band of Chippewa, 55
years old.**

*Knowledge is more powerful than pharmaceuticals.* **Former Surgeon
General Everett Koop, MD.**

## **Obesity Prevention and Control**

**for American Indians and Alaska Natives**

**Executive Summary**

The prevalence of obesity in American Indian and Alaska Native (AI/AN)
populations has increased dramatically over the past 30 years and in AI
preschool and school-age children, is up to three times higher than the
rate in the U.S. population. About 40 percent of AI children are
overweight. Obesity is a risk factor for diabetes that now affects over
one quarter of the adult AI population and the number of AI people with
diabetes has doubled in the past 5 years. Precise data on obesity rates
among AI/AN populations are limited partially because there are over 500
federally recognized tribes in the United States. The current epidemics
of obesity in children and adults and obesity-associated morbidity,
including type 2 diabetes, cardiovascular disease, and some cancers,
have profound implications for AI/AN communities.

Although genetic factors may create a predisposition toward obesity,
behavioral and lifestyle conditions related to diet and physical
activity play a critical role in the development and extent of obesity.
Most AI/AN populations developed obesity only in the past few
genera­tions -- a change probably related to the relative abundance of
modern foods, accompanied by relatively rapid changes from an active to
a sedentary lifestyle.

Diets historically high in complex carbohydrate/high fiber foods have
been replaced by foods that are high in refined carbohy­drates
(especially sugars), fat, and sodium, and low in fruits and vegetables.
The recent proliferation of fast-food restaurants and convenience food
stores on and near reservations also encourages the consumption of foods
high in fat and sugar.

The poverty rate for AI/AN is higher than any other racial/ethnic
category. Consequently, Federal nutrition assistance has become an
integral part of life on and off the reservation. Approximately 68
per­cent of AIs living on reservations receive either food commodi­ties or
food stamps. The foods offered meet or exceed the RDA for food energy
and many key nutrients, and the USDA has made significant improvements
to the nutritional profile of these foods. An important missing element,
however, is education that would build participant skills in healthy
food selection and preparation, and participation in physical activity.

Obesity is very difficult to treat. Research data on effective ways to
prevent and treat obesity in AI/AN communities is limited. Comprehensive
obesity-prevention programs beginning early in childhood are necessary
if the epidemics of obesity and diabetes among AI/AN populations are to
be reversed. Research-based school and community interventions that are
culturally oriented and family centered are needed to encourage lifelong
healthy eating and regular physical activity. Expanded partnerships to
maximize the use of available resources will avoid duplication of
efforts and services.

Several promising obesity prevention or diabetes management programs
have been implemented in AI/AN communities to promote physical activity
and weight loss through fitness events and nutrition education. Although
evaluative research to determine program effectiveness on health
outcomes is lacking, an analysis of these and other programs has helped
determine components of this IHS plan for obesity prevention and
control. Local tribal community intervention programs to address these
problems have developed a number of successful strategies that include
"ownership" of a project to foster local leadership and community
support, coalition building for sharing resources, training leaders
about program goals, content, and implementation, family involvement in
school programs to reinforce healthy messages for children, and a
long-term outlook.

The need for these strategies was confirmed by tribal input during eight
regional meetings conducted to help create an action plan to reduce
diabetes as part of the planning work for the IHS Special Diabetes
Program for Indians. In addition, evaluation of the diabetes program
provides planners with recommendations to better address the physical
activity and nutrition components of community programs.

**Major Recommendations**

1.  Recognize Tribal governments and work collaboratively with Tribal
    governments to:

-   Address obesity prevention and treatment in AI/AN children and
    adults.

-   Enable Tribal governments, communities, and tribal members to take
    ownership of health and obesity interventions, possibly including
    the development, implementation, and evaluation of obesity treatment
    and prevention, and weight loss maintenance programs.

-   Develop cross-program initiatives at the national, state, regional,
    and tribal community levels to reach AI/AN.

2.  Develop a "Healthy Weight and Physical Activity Program for American
    Indians and Alaska Natives" to potentially plan, implement, and
    evaluate obesity prevention and control programs in AI/AN
    communities.

3.  Work with other government agencies and departments to possibly
    develop interventions to reduce obesity among AI/AN communities:

-   Collaborate with the CDC Division of Nutrition and Physical Activity
    to potentially

    -   expand use of the IHS Resource Patient Management System (RPMS)
        for

> basic surveillance of obesity and related health status markers (e.g.,
> serum cholesterol, blood pressure, diabetes management).

-   Collaborate with CDC to target interventions to reduce obesity among

> AI/AN communities.

-   Develop a joint strategic plan with NIH to collaborate on new
    research and to evaluate the success of ongoing and new activities.

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-   Collaborate with HRSA programs, including Bright Futures in
    Practice, Bureau of Primary Health Care, Community/Migrant Health
    Centers.

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-   Partner with the USDA's Food and Nutrition Service, Department of
    Interior, and Department of Education, and other departments, to
    develop collaborative projects.

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-   Coordinate whenever possible this IHS plan with both Healthy People
    2010 and the pending National Action Plan on Overweight and Obesity.

4.  Maintain or increase health care provider expertise and access to
    nutrition services:

-   Train health care professionals and community health workers about
    obesity prevention and management.

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-   Maintain efforts to recruit and retain dietitians to serve AI/AN.

-   Maintain or increase current nutrition services for the AI/AN.

5.  Consider implementation of "best practices" regarding obesity
    prevention and management in AI/AN communities:

-   Identify and disseminate a kit of research-based best practices.

-   Select and build upon successful components of the Pathways Study,
    Diabetes Prevention Program, National Diabetes Education Program,
    Weight Information Network, and other effective NIH, CDC, or other
    programs.

6.  Support or encourage clinical behavioral research and evaluation of
    public health approaches in partnership with tribes by NIH, CDC, and
    IHS to prevent and treat obesity in AI/AN populations.

7.  Establish a yearlong planning period to develop a detailed plan to
    address the obesity epidemic in AI/AN populations.

**1. Introduction**

> The Indian Health Service (IHS) was instructed to prepare a report to
> the Congress that presents the magnitude of the obesity problem among
> American Indians and Alaska Natives (AI/AN) and recommends
> interventions to reduce the toll of obesity and to improve health in
> these populations (**see Appendix** **1**).
>
> Although genetic factors may create a predisposition toward obesity,
> behavioral and lifestyle conditions related to diet and physical
> activity play a critical role in the development and extent of
> obesity.^1^ Most AI/AN populations developed obesity only in the past
> few genera­tions, and this change is believed to be related to the
> relative abundance of foods high in fat and sugar, accompanied by
> changes from an active to a sedentary lifestyle.^2^ ^1^
>
> Health education interventions are vital to public health efforts to
> prevent dis­ease and promote healthy behaviors particularly since most
> of the major health problems of AI/AN are preventable through diet
> modification and increased physical activity. Relatively few
> interventions, however, have focused on healthful behaviors or obesity
> among AI/AN, or have been reported in the literature.^3^ Studies are
> usually of specific tribes, often with small sample sizes. Although
> there are similarities among tribes regarding nutrition-related
> behaviors and health concerns, there are also differences, and we must
> be aware of tribal heterogeneity. This report presents known limited
> data about obesity and associated morbidity and mortality in AI/AN
> populations. IHS recommendations to address the problem, and
> strategies to accomplish goals are outlined. Budgetary considerations
> are not included. Summary information about existing programs that
> could guide the development of "best practices" for implementation in
> AI/AN communities is presented.

**2. The Magnitude of the Problem**

**A. The Prevalence of Obesity in AI/AN Communities**

> The prevalence of obesity in AI/AN populations has increased
> dramatically over the past 30
>
> years. **Table 1** presents a review of selected studies of the
> prevalence of overweight and obesity in AI/AN compared to the total
> U.S. population. Overall, these studies demonstrate that obesity
> begins early for AI/AN children and also is a significant problem for
> the adult population.
>
> Over 60 percent of AI/AN adult women under 60 years of age are likely
> to be overweight or obese, compared to 55 percent of the total adult
> U.S. population. In AI/AN preschool and school-age children, the
> prevalence of obesity is up to three times higher than the rate among
> other children in the United States at all ages and both sexes. In
> 1990, 40 percent of school age AI/AN children were found to be obese
> compared to 11 percent in the total population of children in the
> U.S.^4^ Since obesity in childhood often persists into adulthood and
> is associated with significant morbidity, this has major implica­tions
> for the health of AI/AN populations.
>
> Both maternal obesity and high birth weight have been shown to be
> strong predictors of obesity in early childhood.^5^ Breast-feeding is
> associated with a lower prevalence of type 2 diabe­tes in breast-fed
> Indians.^6^ Both non-pregnant and pregnant breast-fed Pima In­dians
> studied had lower plasma glucose concentrations at ages 20-24 years.
> Breast-feeding, therefore, could be viewed as a potential preventive
> strategy for type 2 diabetes.

**Table 1**

Review of selected studies on the prevalence of overweight and obesity
in American Indians and Alaska Natives, compared to U.S. all races.

> [Percentage overweight or obese]{.underline}

Population, year, and reference Age of subjects Sample size Male Female
Both

+-----------------------------+---------+-------+------+------+------+
| # **Preschool children**    |         |       |      |      |      |
+-----------------------------+---------+-------+------+------+------+
| American Indian, AZ,        | 1-4     | 622   | --   | --   | 1    |
| 1990^7^                     |         |       |      |      | 2.0* |
|                             |         |       |      |      | ^a^* |
+-----------------------------+---------+-------+------+------+------+
| American Indian, national,  | 2-4     | 2     | --   | --   | 1    |
| 1994 ^8^                    |         | 3,009 |      |      | 1.9* |
|                             |         |       |      |      | ^a^* |
+-----------------------------+---------+-------+------+------+------+
| Mohawk, Akwesasne, NY^9^    | 2-5     | --    | --   | --   | 24   |
|                             |         |       |      |      | -39* |
|                             |         |       |      |      | ^b^* |
+-----------------------------+---------+-------+------+------+------+
| U.S. all races, 1994^10^    | 2-4     | --    | --   | --   | 8.1* |
|                             |         |       |      |      | ^a^* |
+-----------------------------+---------+-------+------+------+------+
| # **School-age children**   |         |       |      |      |      |
+-----------------------------+---------+-------+------+------+------+
| Winnebago and Omaha, NE,    | 7-17    | 499   | 3    | 3    | --   |
| 1990 ^11^                   |         |       | 2.7* | 4.4* |      |
|                             |         |       | ^b^* | ^b^* |      |
+-----------------------------+---------+-------+------+------+------+
| American Indian, national,  | 5-18    | 9,464 | --   | --   | 3    |
| 1990-91^8^                  |         |       |      |      | 9.3* |
|                             |         |       |      |      | ^a^* |
+-----------------------------+---------+-------+------+------+------+
| Navajo Health and Nutrition | 12-19   | 160   | 3    | 4    | --   |
| Survey, 1991-1992 ^12^      |         |       | 5.0* | 0.0* |      |
|                             |         |       | ^b^* | ^b^* |      |
+-----------------------------+---------+-------+------+------+------+
| Winnebago and Omaha, NE,    | 3-19    | 1,141 | --   | --   | 2    |
| 1992^13^                    |         |       |      |      | 7.0* |
|                             |         |       |      |      | ^b^* |
+-----------------------------+---------+-------+------+------+------+
| American Indian, SD, ND,    | 5-17    | 1     | 39   | 38   | --   |
| IA, NE 1995-96 ^14^         |         | 2,559 |      |      |      |
+-----------------------------+---------+-------+------+------+------+
| U.S. all races, 1988-94^10^ | Scho    | --    | --   | --   | 1    |
|                             | ol-aged |       |      |      | 3.7* |
|                             |         |       |      |      | ^d^* |
+-----------------------------+---------+-------+------+------+------+
| U.S. all races, 1988-94^10^ | Adol    | --    | --   | --   | 1    |
|                             | escents |       |      |      | 1.5* |
|                             |         |       |      |      | ^d^* |
+-----------------------------+---------+-------+------+------+------+
| # **Adults**                |         |       |      |      |      |
+-----------------------------+---------+-------+------+------+------+
| Navajo Health and Nutrition | 20-39   | 380   | 3    | 6    | --   |
| Survey, 1991-1992 ^15^      |         |       | 7.0* | 2.0* |      |
|                             |         |       | ^b^* | ^b^* |      |
+-----------------------------+---------+-------+------+------+------+
| Navajo Health and Nutrition | 40-59   | 233   | 5    | 6    | --   |
| Survey, 1991-1992 ^15^      |         |       | 0.0* | 9.0* |      |
|                             |         |       | ^b^* | ^b^* |      |
+-----------------------------+---------+-------+------+------+------+
| Navajo Health and Nutrition | [\>]    | 164   | 9.0* | 6    | --   |
| Survey, 1991-1992 ^15^      | {.under |       | ^b^* | 1.0* |      |
|                             | line}60 |       |      | ^b^* |      |
+-----------------------------+---------+-------+------+------+------+
| Alaska Natives              | \>40    |       | 3    | 56*  | \_   |
| (Eskimo/Athabascan)         |         |       | 1.5* | ^b^* |      |
| 1992^16^                    |         |       | ^b^* |      |      |
+-----------------------------+---------+-------+------+------+------+
| Alaska Natives              | [\>]    | --    | 36.2 | 27.9 | --   |
| (Inupiat/Yupik/Eskimo)      | {.under |       |      |      |      |
| 1994^17^                    | line}25 |       |      |      |      |
+-----------------------------+---------+-------+------+------+------+
| Strong Heart Study          | 45-74   | 1446  | 67.0 | 80.0 | 75.0 |
| 1989-1992^18,\ 19^          |         |       |      |      |      |
|                             | 45-74   | 1449  | 65.0 | 71.0 | 70.0 |
| Pima, Maricopa/Papago, AZ   |         |       |      |      |      |
|                             | 45-74   | 1409  | 54.0 | 66.0 | 62.0 |
| 7 Oklahoma Tribes, OK       |         |       |      |      |      |
|                             |         |       |      |      |      |
| 3 Lakota Tribes, ND, SD     |         |       |      |      |      |
+-----------------------------+---------+-------+------+------+------+
| U.S. all races              |         | 1     |      |      | 47.0 |
| 1976-1980^20^               |         | 1,207 |      |      |      |
+-----------------------------+---------+-------+------+------+------+
| U.S. all races, 1988-94^10^ | [\>]    | --    | --   | --   | 5    |
|                             | {.under |       |      |      | 4.9* |
|                             | line}20 |       |      |      | ^d^* |
+-----------------------------+---------+-------+------+------+------+

*^a^*Weight-for-height \> 95^th^ percentile of National Center for
Health Statistics (NCHS) reference population^21^

*^b^*BMI \> 85^th^ percentile of Second National Health and Nutrition
Survey reference population^20^

*^c^*Self-reported height and weight

*^d^*BMI \> 85^th^ percentile of Third National Health and Nutrition
Survey reference population^10^

**B. Morbidity and Mortality Associated with Obesity**

> Poor nutrition contributes substantially to the burden of preventable
> illness, disability, and premature death in the United States. Of the
> six leading causes of death among AI/AN adults -- heart disease,
> malignant neoplasms, accidents/injury, diabetes mellitus, chronic
> liver disease and cirrhosis, and cerebrovascular disease -- all are
> diet-related except for accidents/injury.^22^
>
> Among the general U.S. population, and probably among AI/AN, the
> health risks of obesity increase with severity and reach significance
> at a body mass index (BMI) greater than 27.^23^ Known obesity-related
> health risks for adults include type 2 diabetes, hypertension,
> cardiovascular disease, and problems with lipid levels.^24^ These
> risks are higher for people with centralized body fat than for people
> with peripheral fat distribution.^25^ ^26^ Mortality from gallbladder
> cancer, endometrial cancer in women, and colorectal cancer in men is
> also increased.^24^
>
> **Diabetes**
>
> The diabetes epidemic among AI/AN populations is strongly associated
> with the increasing prevalence of obesity.^18^ ^2^ A striking example
> is seen with the Pima Indians, who have the highest rates of type 2
> diabetes in the world, with a prevalence of about 50 percent in adults
> older than 35 years.^27^ Obesity is also more common among children of
> diabetic parents.^27^ Obesity and parental diabetes increase diabetes
> incidence rates synergistically, with the highest rates occurring in
> obese subjects with at least one parent with diabetes.
>
> A study by the Centers for Disease Control and Prevention (CDC) of the
> IHS national outpatient database found a nearly 30 percent increase in
> diabetes diagnoses among the AI/AN populations between 1990 and 1997.
> During this time period prevalence among women was higher than among
> men, but the rate of increase was higher among men than women (37
> percent v. 25 percent). The increase in prevalence was highest in
> Alaska, where it rose 76 percent, and lowest in the Northern Plains
> region of the United States, where it rose by 16 percent.^28^ Another
> study in AN found that the prevalence of diabetes increased for Yupik
> from 1.7 percent in 1962 to 4.7 percent in 1992 and for Indians in
> Alaska from 1.8 percent in 1969 to 10.0 percent in 1992.^16^
>
> A study of AI/AN elders who receive Federal nutrition services, found
> that 54 percent had a BMI in excess of 27, and 42 percent of
> congregate meal participants and 32 percent of home delivered meal
> participants had been diagnosed with diabetes.^29^
>
> It is estimated that half of all type 2 diabetes is preventable by
> obesity control.^30^ A recent study found that intentional weight loss
> reduced mortality by 26 percent in overweight people with
> diabetes.^31^
>
> **Cancer and fat and alcohol intake**
>
> It is estimated that approximately 35 percent of cancer deaths may be
> related to diet.^24^ A high intake of fat has been associ­ated with
> cancers of the breast, colon, rectum, and prostate and possibly with
> those of the pancreas, uterus, and ovary. Populations consuming diets
> rich in vegetables, fruits, and grain products have significantly
> lower rates of cancer of the colon, breast, lung, oral cavity, larynx,
> esophagus, stomach, bladder, uterine cervix, and pancreas. High
> alcohol consumption has been associated with can­cers of the buccal
> cavity, pharynx, larynx, esophagus, liver, large bowel, breast, head,
> and neck.^24^

########  Obesity-related Risk Factors in Children

> Child health and nutritional status in AI/AN communities have changed
> markedly over the past 30 years. Childhood under-nutrition, a problem
> prior to 1970, has now been replaced with obesity, that presents a
> major health problem among AI/AN children.^11,\ 32^ ^33^
>
> A few studies have examined risk factors for type 2 diabetes and
> cardio­vascular disease in AI children and adolescents. Gilbert et al.
> reported high normal (\>90th percentile) blood pressures in 10 percent
> of adolescent Navajo boys and 6 percent of girls.^34^ There was a
> positive relationship between body weight and blood pressure. Of those
> with high normal blood pressure, 36 percent of the boys and 64 percent
> of the girls were overweight. Data from another study suggest that
> obesity associated with elevated lipid levels begins at an early age
> in AI children.^35^ For more information about childhood obesity in
> AI/AN children see **Appendix 2.**
>
> ![](media/image4.jpeg){width="2.8048611111111112in"
> height="2.498611111111111in"}

**C. Economic Cost of Obesity**

> Although the cost burden of obesity for AI/ANs is not known, this cost
> for the general population has been estimated. Over \$68-70 billion
> are spent each year on direct health care related to obesity,
> representing 6 to 9.4 percent of total U.S. health care
> expenditures.^36^ ^37^
>
> Gorsky et al. used an incidence-based analysis to estimate the 25-year
> direct health care and medication costs associated with women who are
> currently 40 years of age and who will remain overweight through age
> 65 years.^38^ The analysis compared the expected rates of coronary
> heart disease, diabetes, and other conditions, and their associated
> costs. The authors estimated that when compared with the
> non-overweight cohort of 10,000 women, the cohort of 10,000 women who
> were overweight over a 25-year period incurred excess costs of \$22
> million and 212 excess deaths. They estimated that \$16 billion would
> be spent during the next 25 years treating health outcomes associated
> with overweight in middle-aged women in the United States.
>
> A study by Oster et al. concluded that sustained modest weight loss
> (10 percent of fat weight) among obese persons would yield substantial
> health and economic benefits. Expected lifetime medical care costs for
> hypertension, elevated cholesterol, type 2 diabetes, cardiovascular
> disease, and stroke would decrease by about \$3,300 to \$3,800 per
> person.^39^ Using these figures, the potential cost saving for
> sustained modest weight loss among obese AI/AN is \$30.7 -- 35.3
> million. Additionally, quality of life would be likely to improve.

**D. Behavioral and Lifestyle Factors Affecting Obesity**

> Although moderate physical activity reduces the risk of coronary heart
> disease, diabetes, and colon cancer,^40,\ 41^ more than 60 percent of
> American adults are not sufficiently active.^42^ Approaches to
> encourage sedentary people to exercise are becoming better understood.
> Applying the model of the stages and processes of change to exercise
> adoption and maintenance can provide guidance for both individual and
> public health physical activity programs.^43^
>
> A recent study by Ravussin et al. assessed the probable effect of the
> environment on the prevalence of obesity and type 2 diabetes.^44^ The
> Pima Indians of Arizona were compared to members of a population of
> Pima ancestry who separated 700-1,000 years ago, living in a remote
> mountainous location in north­western Mexico, whose lifestyle contrasts
> markedly with that of Arizona Pimas. The authors found that both
> obesity and possibly type 2 diabetes were less prevalent among people
> of Pima heritage living a \"traditional\" lifestyle than among Pimas
> living in an \"affluent\" environment. These findings suggest that,
> despite a similar potential genetic predisposition to these
> conditions, a more traditional lifestyle, characterized by a diet
> including less fat and more complex carbohydrates and by greater
> energy expenditure, may protect against the de­velopment of obesity,
> type 2 diabetes, and cardiovascular disease.
>
> Gilbert et al. documented that Navajo adolescents consumed sugared
> carbonated beverages at more than twice the national average.^34^ A
> recent study found one group of overweight AI/AN children consumed 402
> more calories per day than children who were not overweight.^9^ Other
> researchers assessed physical activity in Pima and Caucasian children
> and found that Pima children spent more time watching television and
> were less involved in sports than Caucasian children.^45^

Behavioral interventions in the treatment of obesity have been
successful in helping individuals lose weight, but most people gradually
regain to baseline weight.^46^ A promising obesity treatment strategy
involves shifting the primary focus in behavior modification programs
from weight loss to optimizing long-term psychological and physical
health.^47^ The most promising weight maintenance program appears to be
a combination of behavioral methods with extended therapist contact,
social influence in peer groups, and aerobic exercise. The skills of
registered dietitians and psychologists or behavioralists are important
for program development and implementation.

## 

**3. IHS Plan to Reduce the Obesity Epidemic Among AI/AN**

**A. Obtaining AI/AN Input to Identify Issues**

> **Planning Conference Held**
>
> On October 23-24, 2000 a planning conference was held to identify
> issues and concerns, and to select priorities for addressing obesity
> in AI/AN populations. A list of individuals invited to the conference
> is in **Appendix 3**. At the conference, the Inter Tribal Council of
> Arizona Program presented an issue paper which is summarized in
> **Appendix 4.** The Council's recommendations are reflected throughout
> this IHS report to Congress. On December 18, 2000 a draft of the IHS
> report was mailed to all persons invited to the conference for review,
> and comments were incorporated into the report.
>
> **Input from the Planning Conference and Current Diabetes Programs**
>
> The participants in the October 2000 planning conference made a number
> of recommendations to IHS concerning a national obesity plan. In
> addition, Tribal recommendations for a national obesity plan were
> obtained during eight regional meetings conducted in the fall of 2000
> by the IHS Special Diabetes Program for Indians. The planner of the
> National Diabetes Prevention Center located in Gallup, New Mexico also
> sought tribal input concerning obesity prevention and management. The
> recommendations from the October planning conference, the regional
> diabetes meetings, and the Gallup Program were consistent and are
> combined and summarized in **Appendix 5.** These groups identified the
> following major issues that the IHS plan to reduce obesity could
> address.

-   Obesity prevention is the concern of highest priority, and
    interventions should target young children, because of the alarming
    increase in obesity in this age group in AI/AN. Promotion of
    breastfeeding should be a primary intervention.

-   Schools and communities are integral to the prevention of obesity as
    vehicles for reaching the young with healthy meals and physical
    activity programs, coupled with messages about healthy eating,
    exercise, and not smoking. Currently there are no comprehensive
    school health programs; school cafeterias often serve fast foods;
    school vending machines offer unhealthy food choices; and
    convenience and fast food outlets are often located near schools.

-   Developing a community and school relationshipfor non-tribal schools
    which could assist in coordinating existing educational objectives
    with desired health initiatives.

-   Interventions need to enhance empowerment and self-determination in
    participants.

-   Strategies to reach adults and children should be multidisciplinary
    and include Tribes, community members, registered dietitians,
    behavioral scientists, educators, exercise physiologists, housing,
    law enforcement, health care providers, outreach workers, public and
    private nutrition assistance providers, grocers, restaurant owners,
    parks and city/village planners, and others.

-   Tribally directed community interventions that interact with
    non-Tribal agencies, organizations, and facilities, hold the
    greatest promise for success. Because tribes are heterogeneous,
    strategies should be tailored for the specific tribes targeted. The
    specific assets and barriers to achieving and sustaining healthy
    behaviors must be assessed for each community.

-   Build tribal capacity to recruit and retain health professionals,
    especially registered dietitians. Build the capacity of tribes to
    utilize local role models (for examples individuals, who have
    successfully lost weight) to promote healthy behaviors that
    encourage healthy weight. Health care providers may need training in
    diabetes prevention strategies and risk factor reduction, including
    obesity management.

-   Obesity should be viewed as a chronic disease and weight loss
    maintenance should be managed long-term. Regaining weight should be
    viewed as a failure of treatment rather than an individual's
    personal failing.

-   There is a lack of proven strategies for effective prevention and
    treatment of obesity. Nutritional and weight data on AI/AN that
    programs can utilize in planning and evaluation is limited. Future
    plans should evaluate program success, therefore maintain current
    efforts to build the capacity of tribes in the area of program
    evaluation.

> **B. IHS Recommendations**
>
> Seven recommendations are proposed by IHS to address the obesity
> epidemic and achieve healthy weights and healthy lifestyle habits in
> AI/AN communities Each recommendation is followed by a list of
> proposed strategies to accomplish goals.

**Recommendation 1**

> **Work collaboratively with Tribal governments to:**

**a. Address obesity prevention and treatment**

**in AI/AN children and adults.**

> **b. Enable Tribal governments, communities, and tribal members to
> take**
>
> **ownership of health and obesity interventions, including the
> development, implementation, and evaluation of obesity treatment and
> prevention, and weight loss maintenance programs.**

**c. Develop cross-program initiatives including non-Native services
and**

> **populations, at the national, state, regional, and tribal community
> levels to reach**
>
> **AI/AN.**

########  Strategies

-   Conduct formal tribal consultation through local/regional meetings
    with AI/AN Tribal leaders, and for meetings with scientific advisors
    on the science and intervention research on obesity prevention and
    control. Seek guidance and advise from tribal leadership and AI/AN
    communities related to obesity prevention and treatment.

-   Continue to build and support tribal capacity by providing
    consultation, technical assistance, training, coordination, and
    collaboration among various partners including tribal schools and
    Head Start, public schools, law enforcement, housing, health care
    facilities, worksites, breastfeeding promotion programs, childcare
    programs exercise facilities, grocery stores, restaurants/food
    service, tribal enterprises, federal/state/local agencies and
    others.

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-   IHS Headquarters will continue to provide consultation to regional
    and local programs.

-   Partner agencies and communities could receive training to develop
    the ability to take over and manage programs for themselves and
    foster local tribal leadership, including leadership in young
    people. Trainers may be trained to implement community mobilization
    efforts. Networking and collaborative efforts will be promoted.

> *We may never see the results of what we're doing here today as tribal
> leaders, but... we are here for the future good of the tribes we
> represent...How can we best do something for the future generations?
> That's what we're here to talk about...There are some people that are
> already gone, we've lost them. But it's those that we can stop (from
> getting this disease) that we can help, we can talk about prevention.
> Those are the ones we need to be thinking about...that group of young
> people.* **Alvin Windy Boy, Chippewa Cree, Councilman, Chair, Tribal
> Leaders Diabetes Committee**

**Recommendation 2**

> **Develop a "Healthy Weight and Physical Activity Program for American
> Indians and Alaska Natives" to potentially plan, implement, and
> evaluate obesity prevention and control programs in AI/AN
> communities.**
>
> **Strategies**

-   The design of this program should complement the Special Diabetes
    Program for American Indians and Alaska Natives.

-   Results of the NIH NIDDK Diabetes Prevention Program may be reviewed
    and may be utilized in ongoing planning when released in 2002.

-   NIH Clinical Guidelines on the Identification, Evaluation, and
    Treatment of Overweight and Obesity in Adults: The Evidence Report
    may be used or adapted as appropriate for the development of
    initiatives for the AI/AN populations.^48^

-   Obesity Evaluation and Treatment: Expert Committee Recommendations,
    may be used or adapted as appropriate for the development of
    initiatives for AI/AN children and adolescents.^49^

-   Research-based interventions for AI/AN children and adolescents may
    be developed in collaboration with CDC and NIH.

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-   A multidisciplinary behavioral intervention for an obesity/physical
    activity program that includes behavioral methods, dietary
    strategies, social influence/peer support, and moderate aerobic
    exercise may be selected and implemented.

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-   A cost-effective screening program may be developed to identify and
    provide services to children and their families, who are at high
    risk for becoming obese or developing diabetes.

-   Culturally appropriate behavior modification programs incorporating
    traditional foods for both AI/AN adults and children/families may be
    developed. Food preparation demonstrations will be part of the
    programs. Strategies for life-long weight loss maintenance may be
    identified and incorporated.

-   A plan for prenatal care to provide breastfeeding, infant feeding,
    and child nutrition information to expectant and young families may
    be established.

> **Recommendation 3**
>
> **Work with other government agencies and departments to potentially
> develop interventions to reduce obesity among AI/AN communities:**
>
> **a. Collaborate with the CDC Division of Nutrition and Physical
> Activity to potentially expand use of the IHS Resource Patient
> Management System (RPMS) for basic surveillance of obesity and related
> health status markers (e.g., serum cholesterol, blood pressure,
> diabetes management).**

-   **Collaborate with CDC to possibly target interventions to reduce
    obesity among**

> **AI/AN communities.**

b.  **Develop a joint strategic plan with NIH to possibly collaborate on
    new research and to evaluate the success of ongoing and new
    activities.**

c.  **Collaborate with HRSA programs, including Bright Futures in
    Practice, Bureau of Primary Health Care, Community/Migrant Health
    Centers.**

d.  **Partner with the USDA's Food and Nutrition Service, Department of
    Interior, and Department of Education, and other departments, to
    potentially develop collaborative projects.**

e.  **Coordinate whenever possible this IHS plan with both Healthy
    People 2010 and the pending National Action Plan on Overweight and
    Obesity.**

> **Strategies**

-   Ask each DHHS and USDA agency or program, such as USDA WIC, DHHS CDC
    and NIH, etc. to indicate what is being done now to help AI/AN
    populations prevent and treat obesity, and what is being planned to
    address disparities in obesity prevention and treatment in these
    populations in the FY 2001-2003.

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-   Develop interventions to further improve the nutritional quality of
    government food assistance programs.

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-   Partner, whenever possible, with the CDC Division of Nutrition and
    Physical Activity (DNPA) to address obesity in AI/AN populations.

> DNPA proposes to develop a surveillance system based on the existing
> RPMS system for those tribes that participate in RPMS.

-   Collaborate with CDC to target interventions to reduce obesity among
    AI/AN communities.

> Projects could include interventions focused on physical activity,
> diet, or a combination of the two, with the explicit goal of primary
> prevention of weight gain, weight loss, or maintenance of target
> weight in a defined target segment of the population.
>
> Applicants could be required to include a mechanism for start-up and
> continuation of interventions, such as the development of partnerships
> in the community to sponsor programs supporting the interventions. In
> all cases, developing community commitment and capacity to
> independently maintain interventions would be a primary goal.

**Recommendation 4**

> **Maintain or increase health care provider expertise and access to
> quality nutrition services:**

a.  **Train health care professionals and community health workers about
    obesity prevention and management.**

b.  **Maintain efforts to recruit and retain registered dietitians to
    work with AI/AN people.**

c.  **Maintain or increase current level of access to nutrition services
    for the AI/AN.**

> **Strategies**

-   Maintain or increase the number of health professionals who work
    with AI/AN by maintaining or increasing recruitment and mentoring
    efforts in tribal schools/colleges, and maintaining or increasing
    the number of scholarships and loan repayment slots in public health
    nutrition.

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-   Continue efforts to partner with Indian Tribal colleges and
    universities to offer health education, nutrition, and physical
    fitness courses either on-site or satellite to tribal community
    health care providers.

-   Continue efforts to partner with AI/AN educational organizations and
    agencies to promote physical activity and good nutrition in schools
    serving AI/AN.

-   Partner with HRSA's provider training programs in Maternal Child
    Health Bureau and Bureau of Health Professions.

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-   Maintain or increase the current professional nutrition services by
    registered dietitians employed or contracted nationwide by the IHS,
    Tribes, or Urban Programs to provide fully qualified and culturally
    competent nutrition services to 15 percent of AI/AN or approximately
    207,000 AI/AN.

> **Shorterm:** Plan to conduct training of health care professionals
> and community health
>
> workers about obesity prevention and management.

**Longterm:** Maintain or increase AI/AN access to qualified nutrition
services.

-   Conduct training of health care professionals and community health

> workers about obesity prevention and management.

-   Expand nutrition services as planned and arranged by individual
    tribes.

-   Continue to use the loan repayment program as an incentive to fill
    positions in remote and isolated locations.

-   Continue to provide scholarships for bachelor level AI/AN registered
    dietitians and/or masters level public health nutritionists, who
    would return to their communities or other tribal communities (often
    remote and isolated) after completing their college coursework and
    clinical or field internships. A long-term goal is to have one AI/AN
    community member trained as a registered dietitian per tribal group.

**Recommendation 5**

> **Support or encourage the implementation of "best practices"
> regarding obesity prevention and management in AI/AN communities:**
>
> **a. Identify and disseminate a kit of research-based best
> practices.**

b.  **Select and build upon the successful components of the Pathways
    Study, Diabetes Prevention Program (DPP), National Diabetes
    Education Program, Weight Information Network (WIN) and other
    effective NIH, CDC, or other programs.**

> **Strategies**

-   Continue to collaborate with the IHS Head Start's Healthy Children,
    Healthy Families, Healthy Communities Initiative's pilot sites.

-   Identify best practices in the national programs noted above as well
    as in current local tribal community intervention programs, and
    nutrition intervention studies such as the Zuni Pueblo program, the
    Southwestern Cardiovascular Curriculum in New Mexico, The Intensive
    Lifestyle Intervention, and Minnesota's Work Out Low Fat program.
    These programs are discussed in sections 7 and 8 in this report.

-   Prioritize for possible implementation available guidelines for
    physical activity and provider/patient interactions concerning
    obesity discussed in section 4 of this report.

**Recommendation 6**

> **Support clinical behavioral research and evaluation of public health
> approaches conducted in partnership with tribes by NIH, CDC, and IHS
> to prevent and treat obesity in AI/AN populations.**
>
> **Strategies**

-   **National Institutes of Health (NIH)**

> Tribes, IHS and NIH could create a strategic plan to reduce obesity
> among AI/AN communities. Potentially, this could include research at
> multiple sites throughout the United States. The research would
> investigate the effectiveness of specific innovative obesity
> prevention strategies that target schools, worksites, housing,
> groceries, restaurants, media, law enforcement, health centers, and
> other environmental factors that have an effect on weight and health.

-   In collaboration with tribes, IHS and others could collect national
    actual height and weight data from AI/AN school-aged children,
    preschoolers, toddlers, and infants, in order to provide follow-up
    data to the 1991 AI/AN School-age Height/Weight Survey. This
    information could assist in planning and evaluation of obesity
    prevention and treatment services and strategies.

-   Provide epidemiological training to select IHS, Tribal, and Urban
    Program nutritionists and health professionals to participate in the
    national height weight survey of AI/AN children.

"It is impossible to blaze a new trail when we are unsure of where we
are. Nutritional surveillance is crucial for effectively targeting the
health care resources available to AI/ANs, so that we can effectively
impact the escalating rates of obesity and diabetes. A national AI/AN
Height/Weight Study would be timely, in that it would indicate what
changes have occurred (if any) since that last national height/weight
study. It would also provide data utilizing real measures of a
representative sample with clear quality assurance parameters rather
than existing data such as the Indian Health Service\'s RPMS data**."
Tim Gilbert (Unupiaq/Tsimpsiam), MPH, Health Systems Network Specialist,
Anchorage, Alaska**

**Recommendation 7**

> **Develop a more detailed plan to address the obesity epidemic in
> AI/AN populations.**
>
> **Strategies**

-   Create a planning committee to conduct tribal consultation meetings
    and obtain comments from scientists, lay experts, AI/AN people,
    AI/AN children/adolescents, and representatives from other U.S.
    agencies through a series of conferences and workshops.

-   A multidisciplinary planning group should include: health
    professionals, registered dietitians, mental health professionals,
    public health educators, public health nurses, exercise
    physiologists, school teachers, school administrators, food service
    managers, students, and parents.

-   Planning meetings should be conducted in multiple locations to
    obtain tribal input into a comprehensive plan.

########  C. Activity Details 

########  Nutrition Staff Capacity: Direct Care

> Currently, approximately 95 registered dietitians (RD) work for the
> Indian Health Service and another 45 RDs work for tribal or urban
> Indian health programs. Additionally, about 90 RDs work with
> tribal/USDA Women, Infants, and Children's Supplementary Food
> Programs. A total of approximately 230 RDs, therefore, serve Indian
> people. It should be noted that tribal RDs might work part-time -- for
> example, a few days per month. Although national data is lacking on
> the exact number of obese and overweight AI/AN, 40 percent AI/AN
> school-age children were found to be obese in 1991. It is estimated
> that these RDs can currently provide nutrition services to
> approximately 15 percent of the AI/AN population or about 207,000
> individuals. It appears that 600,000 AI/AN people (40 percent of the
> population) may need medical nutrition therapy that can be provided by
> an RD.
>
> Access to professional nutrition services is important. Studies show
> that people with diabetes have improved control of their blood glucose
> when an RD counsels them. There are also studies that show that
> nutrition counseling from an RD helps people improve their blood lipid
> levels. Results of the Diabetes Guidelines Cost Effectiveness Study
> show that over 60 percent of the people with type 2 diabetes who
> received medical nutrition therapy from an RD, achieved a 20 percent
> reduction in their blood sugar. People who saw an RD more often had
> the best results. There was also a significant weight loss noted and
> an improvement in lipid levels.
>
> Results from the 1994--1998 Hyperlipidemia Outcomes of Medical
> Nutrition Therapy Survey which was conducted on the Warm Springs
> Indian Reservation in the northwest, highlight the fact that nutrition
> therapy by an RD was effective in improving blood lipids in 74 percent
> (45/61) of the patients. The average decrease in total cholesterol/HDL
> ratio was 18 percent. Importantly, the Warm Springs Tribe's Health
> Center is currently staffed by two IHS masters level RDs. These
> reductions in blood sugar, cholesterol levels, and weight help prevent
> illness, improve quality of life and well being, and decrease health
> care costs. Increasing access to nutrition services may be an
> important step in reversing the escalating rates of obesity among
> AI/AN. There is a paucity of evaluative data on community obesity
> interventions.
>
> In addition to providing medical nutrition therapy, RDs teach group
> classes, develop nutrition education materials, and organize community
> programs to help individuals, families, and communities to improve
> their nutrition and exercise habits.
>
> **Nutrition Staff Capacity: National Headquarters**
>
> AI/AN obesity and diabetes rates have been escalating. Consistent with
> the tribal self-determination policy, IHS Headquarters and Area
> ability to provide nutrition consultation/ technical assistance to
> tribes and to build tribal capacity has been delegated to local
> communities. Since the early the 1990s, IHS Headquarters nutrition
> staff has been reduced from 5 to 1 full-time staff. (The national
> diabetes nutrition specialist, deputy national nutrition consultant,
> national nutrition and dietetics training program chief, public health
> nutrition training officer, and dietetics training officer positions
> were not filled when vacant.) During this same period, IHS regional
> nutrition staff decreased by 93 percent (14 regional nutritionists
> decreased to one). Building tribal capacity to provide nutrition
> services is a pressing priority, particularly in the area of diabetes
> and obesity.
>
> The planning group named obesity prevention as the highest priority
> for this plan. A "Healthy Weight and Physical Activity Center" for
> American Indians and Alaska Natives" is one possible strategy that
> would build and support tribal capacity by providing consultation,
> technical assistance, training, coordination, and collaboration among
> various partners including tribal schools and daycare, public schools,
> law enforcement, housing, health care facilities, worksites,
> breastfeeding promotion programs, exercise facilities, grocery stores,
> restaurants, tribal enterprises, and others. Consultation and
> technical assistance activities could include coordinating the
> national height/weight survey of AI/AN school-age/preschool children
> with partners, potentially CDC and NIH. Increasing the knowledge of
> health care providers who serve AI/AN people in the area of pediatric
> and adult obesity treatment, as well as public health obesity
> prevention strategies could also be offered by such a center. Offering
> nutrition and physical activity education/training for
> paraprofessionals primarily through grants and partnerships with
> American Indian Community Colleges is also a possible strategy.

4.  **Available Guidelines For Physical Activity and Provider/Patient
    Interactions Concerning Obesity**

######## A. Physical Activity Recommendations 

> Physical activity is a key factor in the prevention of obesity and
> chronic disease. Many children, adolescents, and adults are sedentary.
> Goals for evidence-based obesity prevention interventions in children
> involving physical activity and improved eating would be to:

-   Help children reap immediate health and societal benefits by
    preventing stress on their metabolic and skeletal systems

-   Affect critical growth periods and improve adult health

-   Modify risk factors in childhood and result in reduced risk factors
    in adulthood

-   Carry over healthy behaviors of childhood into adulthood.^50^

> Multifaceted approaches to increase physical activity and improve
> eating habits may have the greatest chance for success. The Child and
> Adolescent Trial for Cardiovascular Health (CATCH) demonstrated that
> school based health promotion can increase physical activity among
> children and improve their dietary intakes.^51^ ^52^ The CATCH
> intervention's strategy included changes in teacher training, school
> lunch program, student physical education classes, and family
> intervention classes. Schools are key players in a community
> intervention for obesity prevention.
>
> CDC in collaboration with experts from universities from national,
> federal, and voluntary agencies and organizations has developed
> recommendations to promote a lifetime of healthy physical
> activity.^42^ These recommendations will guide the IHS strategies to
> increase the level of physical activity among AI/AN populations and
> are in **Appendix 7.**
>
> **B. Recommendations for Provider/Patient Interactions Concerning**

**Obesity**

> The Maternal and Child Health Bureau, Health Resources and Services
> Administration, Department of Health and Human Services convened a
> conference in Washington, DC on March 18-19, 1997 to develop guidance
> for health professionals and others who care for overweight children.
> The Expert Committee for Childhood Obesity Evaluation and Treatment
> noted the value the dominant U.S. society places on physical
> appearance and the common belief that obesity results from laziness or
> lack of willpower. As a result, overweight children and their families
> often feel embarrassed and ashamed. The Committee made the following
> recommendations concerning the language and demeanor of clinicians
> that will guide planned obesity interventions:

-   Clinicians who care for these families must treat them with
    sensitivity, compassion, and a conviction that obesity is an
    important, chronic medical problem that can be treated.

-   Questions about food consumption and activity should be framed in
    objective, non-accusatory language.

-   Clinicians can create an alliance with the family by focusing
    questions on behaviors rather than on the characteristics of the
    child or family.

-   By taking the time to understand each family's particular living
    situation, schedule, and values, clinicians can refine treatment
    recommendations and provide sympathetic support to the family's
    efforts.

-   Because obesity is a chronic disease, frequent visits, continuous
    monitoring, and reinforcement enhance the likelihood for success.

-   Clinicians who lack the time required to implement these
    suggestions, or find themselves annoyed or easily frustrated by
    obese children, or the parents of obese children, should refer these
    patients elsewhere for care to avoid the potential adverse effect
    the clinician's response may have on the child and family.^49^

> Clinicians should be offered training opportunities to enhance their
> interviewing and teaching skills with obese patients and their
> families.

######## C. Mental Health and Obesity Issues in AI/AN 

> An area that has been relatively overlooked by researchers is the
> impact of psychological factors on obesity as well as the effects of
> obesity on mental health. A review of the limited published literature
> on the subject is summarized below and discussed in more detail in
> **Appendix 8**.
>
> Kozak examined health attitudes and perceptions of people with type 2
> diabetes and suggested that the impact of history and culture has been
> overlooked in biomedical research, thus leaving an incomplete model
> for understanding the disease process and experience of illness in
> AI/AN communities.^53^ The author speculated that this may be the
> reason that clinical interventions to manage diabetes have generally
> failed. The author suggested that attention to symbolic meaning and
> emotion is warranted and proposed that instilling an understanding
> that the disease is preventable and treatable as well as developing
> multidisciplinary and community-based collaboration will increase
> treatment efficacy.
>
> Huttlinger also noted the importance of cultural beliefs and
> sociological understanding of the chronic disease process in
> AI/ANs.^54^ The author suggested that better understanding is needed
> of tribes' difficulty integrating the disease concept of diabetes into
> their lives -- a difficulty that often leads to AI/AN being termed
> "noncompliant" with medical treatment.^54^ ^55^ ^56^ ^57^ Study
> results indicated that a sample of Navajos described diabetes as a
> disease that results from "forces beyond the individual that come from
> the realm of the supernatural."^54^
>
> A body of research examines the importance of culture in the healing
> process, and includes the wide acceptance of traditional healers'
> roles in medical and psychological treatment.
>
> Neumark-Sztanier, et al. found that very overweight children perceived
> their health as fair or poor. Differences in body dissatisfaction, low
> body pride, and weight concerns were also noted in these children.^58^
> These findings suggest that it is important for obese youth to be both
> convinced and enabled to make successful lifestyle modifications to
> prevent excessive weight gain. The authors suggest that culturally
> sensitive educational and environmental interventions that take
> psychosocial factors into account are paramount for behavior change.

*Just don't assume that we know. We don't. You need to show us. You have
to show me. You can tell me. You can give me brochures to read. I'll
read those later and suddenly say "well what is this doing in here or
where did I get this?" The diabetes is a constant struggle because my
husband never did believe that he was sick. He says "There is nothing
wrong with me," but the toll that diabetes has taken on him...He's
blind, he has an amputation below the knee, and lost a toe on the other
leg.* **Juanita Atone, Kiowa, husband has diabetes, married 52 years**

########  5. Risks of Obesity Treatment

> The prevention and treatment of obesity is a multifaceted, long term
> process with potential risks that should be taken into account.
> Physical activity and playing sports may include health risks for
> injury; however, the health risks of obesity are greater.^59^ Weight
> loss also holds some health risk.^60^ The most aggressive medical
> strategies for weight loss, such as pharmacological treatment,
> surgery, and liquid diets, do carry some degree of health risk,
> including death. Popular diets implemented without sufficient
> scientific evidence or qualified medical supervision, also carry an
> unknown degree of health risk.

Some individuals practice dangerous weight control techniques, such as
smoking. Smoking cessation and tobacco education should be part of a
comprehensive school health curriculum and health center patient
education programs.

People with eating disorders such as bulimia, and anorexia often "diet"
unnecessarily to lose weight. A national survey by Story, et al. of
13,454 seventh- through 12th-grade AI youth found that AI youth,
particularly girls, are dissatisfied with their weight and are worried
about being overweight, and that unhealthy weight control practices are
common. In the year surveyed, 48 percent had been on a weight-loss diet,
and 27 percent reported that they had self-induced vomiting at some time
to try to lose weight. The high prevalence of body weight
dissatisfaction and the potentially harmful weight-loss practices
underscore the importance of ensuring appropriate weight management
practices among adolescents.^61^

> People who are not overweight and/or those with eating disorders
> should be screened from weight loss programs and directed to
> appropriate medical and mental health resources. Current scientific
> evidence supports the practice of healthy dietary and exercise habits
> to increase an individual's likelihood of having a healthier life.^49^

###  **6. Studies of Dietary Intake**

######## A. Studies Reporting Nutrient Intakes for AI/AN

> Despite widespread obesity in AI/AN, there is a paucity of data on
> dietary and exercise patterns among these groups and on the
> relationships among physical activity, dietary patterns, and
> obesity.^11^ Several dietary practices may contribute to obesity,
> including the wide use of butter, lard, whole milk, fry bread, and
> fried meats and vegetables, as well as the generous use of fats in the
> preparation of beans. Sweets and snacks may account for high calorie
> intakes in some groups.^34^
>
> An extensive review of the 1980-98 literature by Story et al,^62^
> found 13 studies reporting nutrient intakes in 20 tribal groups.
> Dietary intake informa­tion was collected using 24-hour dietary
> recalls, multiple-day food records, and food frequency questionnaires.
> All of the studies used visual guides such as pictures, cardboard
> shapes, or measuring utensils to quantify serving sizes. Nutrient
> values for traditional native foods, when available, were used in the
> analysis. Major findings were as follows:

-   Dietary fat intake was high.

-   In all of the studies, mean protein intake met the RDA.

-   Vitamin C was adequate in all groups except adolescent Cherokee
    (North Carolina) boys.

-   Mean intakes of vitamin A were below the RDAs for all age groups and
    both genders in

> the Navajo Health and Nutrition Survey.

-   The RDA for iron was not met for most of the groups of females.

-   Calcium intake was below the RDA for most of the groups.

> In all of the studies, dietary fat intake was above the recommended
> level of 30 percent of total calories, ranging from 31 percent to 47
> percent. In the 11 studies in which dietary fat was reported, half of
> the study groups had intakes of 30-35 percent of calories from fat and
> half had intakes greater than 35 percent from fat. In one study the
> percentage of calories from fat exceeded 40 percent.

## **B. Traditional and Contempory Foods**

> During the past century, dietary patterns among the various AI/AN
> tribes have changed drastically. Diets historically high in complex
> carbohydrate/high fiber foods have been replaced by high-fat modern
> foods.^63^ Concomitant with these dietary changes have been dramatic
> increases in obesity and diabetes. Before the turn of the twentieth
> century, however, the diabetes was vir­tually nonexistent. During the
> past fifty years, the amount of wild and homegrown foods in the AI/AN
> diet has greatly diminished, and a significantly greater propor­tion of
> food is processed and commercially prepared, a trend also seen among
> the general U.S. population.
>
> In general, the diets of AI/AN today are high in refined carbohy­drates
> (especially refined sugars), fat, and sodium, and low in fruits and
> vegetables.^64^ ^65^ The Navajo Health and Nutrition Survey found that
> fruits and vegetables were each consumed less than once per day per
> person, as were dairy products. Fry bread and Navajo tortillas,
> home-fried potatoes, mutton, bacon and sausage, soft drinks, coffee
> and tea provided 41 percent of the energy and 15 -- 46 percent of the
> macronutrients consumed.^66^
>
> Traditional foods are an integral part of numerous celebrations, feast
> days, powwows, and religious ceremonies. Most traditional foods are
> low in fat and sugar, with relatively high nutritive value. Today,
> AI/AN populations are being encouraged to incorporate more of their
> traditional foods into their diet. For further information about
> traditional and contemporary food see **Appendix 9.**

###  

###  **C. Food Assistance Programs**

> The poverty rate for AI/AN (25.9 percent) is higher than any other
> racial/ethnic category. Consequently, federal nutrition assistance has
> become an integral part of AI/AN life on and off the reservation.
> Low-income households living on or near Indian reservations are able
> to receive supplemental nutrition assistance from several programs
> administered by USDA. These programs include the School Lunch and
> Breakfast Programs, the Supplemental Food Program for Women, Infants,
> and Children (WIC), the Food Distribution Program on American Indian
> Reser­vations (FDPIR), and the Food Stamp Program. Federal nutrition
> services are also pro­vided to AI/AN elders through both Title III and
> Title VI of the Older Americans Act. These include both congregate and
> home-delivered meals. Collectively, these programs contribute
> significantly to AI/AN diets.

FDPIR and the Food Stamp Program are most widely used by AI.
Approximately 68 per cent of the tribes located in the continental
United States participate in FDPIR, a program not available in Alaska.
In 1999, an average of 129,466 individuals received commodities under
FDPIR each month, while approximately 103,500 AI/AN participated monthly
in the Food Stamp Program.^67^ Eligible households may participate in
either FDPIR or the Food Stamp Program each month, but they cannot
participate in both programs simultaneously.

Congress established FDPIR in1977 as a replacement for the Needy Family
Program, which was created in 1936 to distribute commodity agricultural
products to households in need of food assistance. Although national
participation in the Needy Food Program had declined as the Food Stamp
Program expanded in the 1960's and early 1970's, Congress was concerned
that AI/AN nutrition assistance needs could not be adequately addressed
by the Food Stamp Program. The focus of concerns was that the remote
location of many reservations made it difficult for many AI/AN to
participate in the Food Stamp Program, either because of the distance to
food stamp offices, or if certified to receive food stamps, the
difficulty of using them due to the scarcity of authorized food stores
or the distance to them. Thus, FDPIR represents an alternative to the
Food Stamp Program for households living on or near reservations where
access may be a problem.

> A 1990 report evaluating FDPIR addressed the nutrition-related health
> problems among FDPIR households. ­­^72^ More than half (53.9 percent) of
> all FDPIR household had at least one adult (over 16 years of age) with
> one or more nutrition-related health problems (e.g., diabetes,
> hypertension, obesity, heart disease, or cancer). One out of four
> FDPIR households reported having at least one member who was
> prescribed a special diet (e.g., sugar free, low salt, low
> cholesterol, or low fat). As a result, USDA has made significant
> improvements to the nutritional profile of commodities offered under
> FDPIR. The level of fat, sodium and sugar has been reduced in many of
> the products.

In addition, USDA is continuing to work closely with the tribes and
health professionals to provide a food package that includes a variety
of nutritious foods while appealing to the food preferences of tribes
with distinct cultures and traditions. Participants may select from a
monthly food package that contains over 70 products, including frozen
and canned meats, canned fruits and vegetables, ready-to-eat and cooked
cereals, evaporated and nonfat dry milk, low-sodium canned soups,
macaroni and cheese, spaghetti sauce, pasta and rice, flour and bakery
mix, peanut butter and peanuts, low-sodium crackers, dehydrated
potatoes, dried fruit, canned juices, dry and canned beans, all purpose
egg mix, cheese, shortening, oil and corn syrup. Recently, bison meat
has been provided to program participants. Also, tribes may opt to
receive fresh produce, which is distributed to households in lieu of
canned fruit and vegetables each month. To date, approximately 72
percent of the Indian Tribal Organizations participating in FDPIR have
elected, and been approved, to participate in the fresh produce program.
Increased nutrition education for participants that promotes utilization
of these improved food items in healthy recipes is desirable.

### 

### **7. Nutrition-Related Intervention Studies** 

> Comprehensive obesity-prevention programs beginning early in childhood
> are necessary if the epidemics of obesity and diabetes among AI/AN
> populations are to be reversed. School- and community-based
> interventions are needed to encourage lifelong healthy eating and
> regular physical activity. IHS and tribal nutritionists have conducted
> community-based nutrition edu­cation activities including adult
> diabetes camps, cooking classes, community fun walks, youth health
> camps, and nutrition education via the supermarket, community aerobic
> classes, and 100*-*mile walking clubs.^68^ While these activities tend
> to be culturally appropriate, their effectiveness has not been
> established. Promising programs are summarized below. For more
> information on the Zuni Pueblo and Pathways programs see **Appendix
> 10**.

-   The Zuni Pueblo, a southwest AI community with high rates of obesity
    and diabetes, has succeeded in developing community-based diabetes
    and wellness programs to promote physical activity and weight loss
    through fitness events, nutrition education, and weight loss
    com­petitions in adults.^69^ The results showed improved metabolic
    control in individuals with type 2 diabetes and modest weight loss.

-   The South­western Cardiovascular Curriculum Project in New Mexico was
    a compre­hensive, culturally oriented curriculum designed to increase
    knowledge and promote healthy behavior changes in fifth-grade Navajo
    and Pueblo Indian chil­dren. Preliminary results show a significant
    increase in overall knowledge and self-reported physical
    activity.^70^ ^71^

-   The Intensive Lifestyle Intervention is one of three interventions
    to be examined by the NIH conducted Diabetes Prevention Program
    (DPP). It focuses on dietary changes and increased physical activity
    to promote weight loss in adults with impaired glucose tolerance.
    Each participant receives individual and group training in diet,
    exercise, and behavior modification skills. Goals are personalized
    to meet individual needs and be flexible and sensitive to cultural
    differences. Four AI tribal communities are participating in the
    national DPP trial. Results are anticipated in 2002.

-   \"Pathways\" is a school ­based primary prevention study of obesity
    in AI school children funded by the NIH. This six-year multi site
    study involves seven AI Nations/Tribes, five universities, 41
    schools, and families.^72^ Results from the study are anticipated
    early in 2001. The intervention involved:

> 1). A classroom curriculum focused on healthy lower-fat eating
> patterns and
>
> increased physical activity.
>
> 2). Modification of school meals.
>
> 3). A physical education program in school.
>
> 4). Family in­volvement.

-   Minnesota's Work Out Low Fat -- WOLF program is an eight-week
    curriculum for children in grades 1-4 that promotes AI traditional
    lifestyle to encourage greater physical activity and less
    consumption of dietary fat. The program began with funding from the
    National Institute of Diabetes, Digestive, and Kidney Diseases of
    NIH for primary prevention of diabetes for AI youth. In 1997, the
    Minnesota state legislature funded a Tribal Task Force to take the
    WOLF program to AI communities throughout the state.

> Although intervention studies such as these are promising, more effort
> is needed to develop and evaluate other culturally appropriate health
> education interventions. The active involvement of the AI/AN com­munity
> is critical when planning, conducting, and evaluating interventions.

**8. Local Tribal Community Intervention Programs**

> A select number of innovative local tribal strategies were reviewed
> when preparing this IHS plan.
>
> **A. Ho-Chunk Nation Youth Fitness Program, Wisconsin**
>
> The Ho-Chunk Nation's Youth Fitness Program, located in Wisconsin, was
> funded by a HRSA Office of Rural Health Policy grant. In 2000, the
> program was initiated to address increasing rates of diabetes and
> obesity. The aim of the program is to empower 6-18 year olds and their
> families to improve their fitness and nutritional habits with a
> strategy that combines fun and exercise. The health program works
> closely with local schools that refer participants to the program. The
> staff includes an exercise specialist and pediatric registered
> dietitian. The program involves nutritional assessment and counseling;
> healthy habit activities; low fat cooking classes; fitness classes;
> nutrition and health education; and encouragement. Participants
> receive incentives and also earn rewards while working toward their
> goals. Students earn extra points for parental involvement. Cultural
> sensitivity has been key to the program, which has received support
> from elders in the community.

This initiative brings together a network consisting of the Ho-Chunk
Nation Department of Health, Black Falls Health Care Center, Wisconsin
Dells House of Wellness, Ho-Chunk Nation Youth Services Program, The
University of Wisconsin Madison Pediatric Fitness Clinic, Baraboo School
District, Black River Falls School District and Wisconsin Dells School
District.

> Representatives from the Ho-Chunk Nation Department of Health
> participated in the IHS Nutrition and Dietetics Training Program
> Community Mobilization Workshop addressing diabetes prevention and
> control in AI communities, in 1997.

**B. "Community Mobilization to Beat Diabetes" in Six Tribal**

**Communities**

> This 1997 project began with the development of a workshop to train a
> number of key community people about the art of community
> mobilization. Attendees included community members, registered
> dietitians, health educators, tribal government and school employees,
> emergency medical service workers, and social workers.
>
> Tribal community and individual ownership of the project is a key
> feature, as community members identify problems and act upon common
> goals. This approach fosters local leadership development. Community
> members are enlisted to develop health strategies to reduce the
> escalating rates of diabetes. Community mobilization is consistent
> with tribal self-determination. Untilizing existing resources to
> target a pressing health issue among community members and coalition
> building is emphasized. The project planners look at community assets
> to draw upon and select strategies to overcome the barriers to healthy
> habits and exercise. Sustaining behavior change is an underlying goal
> of the program. The strategy builds and supports local health programs
> and the "Gathering Of Native Americans" (GONA) programs.
>
> Coordination occurs at all levels and between divisions and programs
> within the IHS including: Nutrition, Tribal Affairs, Health Education,
> Community Health Representatives, Nursing, and the Diabetes Program.
> Health care providers are utilized as advisors and consultants. An AI
> instructor was recruited to teach the training workshop. The IHS
> Headquarters Nutrition and Dietetics Training Program coordinated the
> workshop arrangements.
>
> Six tribal communities were selected for the project: Jemez (New
> Mexico); Ho-Chunk (Wisconsin); Blackfeet (Montana); Eastern Band of
> Cherokee (Nashville); Seminole (Nashville); and Kayenta (Navajo). The
> training may have been instrumental in increasing the success of
> future projects, for example, the IHS Nashville area nutrition
> consultant observed that the community mobilization efforts provided
> structure for the community's efforts when grant dollars were
> received. Participants requested further help, for example in grant
> writing.

**Tribal participants in the "Community Mobilization to Beat Diabetes"
program in six tribal communities made the following comments about the
program:**

"Returns a sense of hope"

> "Can plan with co-workers"
>
> "Used small tasks"
>
> "Modified to our needs"
>
> "Emphasized responsibility on others"
>
> "Don't have to do all alone"
>
> "Going home with a plan -- not just information"
>
> "Useful in many life and work situations"
>
> "High caliber, concerned (faculty) staff"

######## C. St. Regis Mohawk Tsitewatakari:tat "Let's Get Healthy" Program

> This program began in 1993 as a collaborative activity by the
> Akwesasne Tribe of NY and University of Vermont health scientists,
> with funds from NIH NIDDK, as a school-based primary prevention of
> obesity and diabetes program, Pre-K to Grade 6, and a community-based
> intervention. The initiative includes a comprehensive range of
> interventions including a curriculum, community exercise classes,
> diabetes education in-services, teacher interviews, and body fat
> measurements. At the start of the program in 1994, more than 50
> percent of children were overweight, and at the end of the program in
> 1998, 90 percent of those children continued to be overweight (10
> percent became less and 18 percent became more overweight). The
> investigators concluded that a healthy lifestyle involving an energy
> balanced diet with enough activity to avoid excessive weight gain has
> not been achieved for at least half the children in Akwesasne.
>
> In 1998, the program was expanded to a community and clinic-based
> intervention to target people with or at risk for type 2 diabetes,
> using funds from the Special Diabetes Grants for Indians.

*The Tsitewatakari:tat-Let's Get Healthy Program is a long-term
initiative to enable Mohawk people to sustain community wide programs
that promote healthy lifestyles among Mohawk children as they become
adolescents. It is a genuine commitment by many hearts working to
improve the health of our Mohawk children and families at Akwesasne.
Some of the benefits have been the formation of a community-wide
coalition to promote nutrition and fitness activities including
increased fruit and vegetable consumption, neighborhood walks, and
reduced soda pop and television viewing campaigns*. **Janine Rourke, RN,
BSN, Diabetes Grant Coordinator, St. Regis Mohawk Tribe, Akwesasne,
NY**.

**9. Current National Program Activities**

> A. IHS Special Diabetes Program for Indians Interim Report to
> Congress,
>
> January 2000
>
> The Balanced Budget Act of 1997 provided \$150 million over 5 years to
> the IHS to establish a Special Diabetes Program for Indians focused on
> the prevention and treatment of diabetes. The Consolidated
> Appropriations Act of FY2001 extended and increased the diabetes
> funding for IHS to FY 2003 at \$100 million per year. The findings of
> the interim report to Congress for the diabetes program will be
> helpful during the planning phase recommended by this obesity report
> to Congress.
>
> The IHS was instructed to conduct an evaluation of the grant program
> and provide an interim (Year 2000) and final (Year 2002) report to
> Congress. The accomplishments noted in the interim report include
> tribal consultation with full participation from tribes, urban AI
> organizations, and IHS staff; and 318 grants were awarded. The grant
> programs place emphasis on addressing preventive health measures in
> adults who are overweight (71.4 percent), people with high blood
> pressure (70 percent), children who are overweight (56 percent), and
> tobacco users (42.6 percent). The magnitude of the diabetes epidemic
> among AI/AN has prompted many tribes to first address urgent diabetes
> treatment and care issues, including the high cost of medications,
> availability of staff to treat patients with diabetes, access to
> equipment and supplies for self-monitoring of blood glucose, and
> specialty medical care. The need for primary prevention, such as
> obesity prevention, remains crucial. The report states that the grant
> opportunities have allowed tribal communities to move further along
> their paths to wellness and diabetes prevention. However, the report
> also states that five years is not nearly enough time to accomplish
> the goal of diabetes prevention.
>
> Most of the grant programs include components for young people,
> especially children and teenagers. Many programs for children and
> adolescents are designed to teach awareness of the health dangers
> associated with obesity. Goals are to improve dietary habits and
> encourage physical activity. Currently, 21 percent of the programs
> propose classes to promote physical fitness; 18 percent of the
> programs propose individual training; 17 percent intend to use grant
> funds to purchase exercise equipment; and 6 percent propose programs
> to train exercise instructors. Further strengthening of these physical
> activity and nutrition education components of grantee programs may be
> instrumental in decreasing obesity rates.
>
> Nutrition activities are important for grant programs. Currently, 32
> percent are targeting the whole community with healthy cooking
> classes, and 60 percent report developing or enhancing individual
> nutrition sessions for people with diabetes. More than half of the
> grant programs (56 percent) are providing education in the healthy use
> of commodity foods. About one-third of grantees used group or
> individual sessions with Head Start and WIC families. Many grantees
> used traditional approaches in their diabetes programs, including
> story telling (34 percent), talking circles (35 percent), and use of
> traditional herbs or medicines (28 percent). Traditional approaches
> help support and influence positive diabetes self-management behaviors
> within communities.

Few programs (3.2 percent) are targeting infants. However, promising
research shows that infants who are breastfed for at least two months
are at reduced risk for developing type 2 diabetes later in life, even
if one or both of their parents have type 2 diabetes. About nineteen
percent of the grant programs target Head Start or preschool children.
This is important because children ages 0-5 years of age are a key group
for obesity prevention interventions, because of the high rates of
obesity seen in AI/AN children 6-18 years of age.

> Programs report that personnel barriers affect their programs.
> Remoteness of locations, salary scales, and recruitment techniques,
> may play a role in the ability of tribes to hire and retain fully
> qualified staff. Hiring new staff has been a barrier for 126 (45.5
> percent) of the reporting programs. Ninety-two (33 percent) tribal
> grantees report difficulty obtaining nutrition services from a
> registered dietitian. Sixty-nine (24.9 percent) tribal grantees report
> that staff turnover is a barrier for their program. Almost half of the
> reporting grantees (44.4 percent) report that office space is a
> problem for their programs. One recommendations is to implement a
> Healthy Weight and Physical Activity Program to address the need for
> primary prevention.
>
> **B. IHS Head Start Initiative "Healthy Children, Healthy Families,
> Healthy**
>
> **Communities: A Focus on Diabetes and Obesity Prevention"**
>
> A new diabetes and obesity prevention initiative targets AI/AN Head
> Start Programs, which serves ages 0-5 years. In 1998 the planning
> process for this initiative began when twenty people representing
> tribal Head Start Programs, IHS, USDA, and university public health
> advisors met to draft a plan to address escalating obesity and
> diabetes rates in AI/AN communities. The group agreed that long-term
> interventions to promote healthy living would be appropriate, while
> interventions that label and target overweight individuals would be
> inappropriate.

The focus, therefore, is long term, and stresses healthy habits. These
habits include nutritionally sound food choices and regular physical
activity. Community mobilization and ownership of the program is key to
the program's success. Each local Head Start program and community will
be charged with the development of its own program. Continuing or
establishing partners to collaborate on this effort will be an important
part of the program.

> In October 2000, five pilot Head Start grantees were selected to
> participate\*. In November 2000 an orientation for pilot sites was
> held in Albuquerque, NM. Sites outlined the type of technical
> assistance they would require to begin work on the initiative. Two
> nutrition workshops have been held for the pilot sites*.* The workshop
> attendees were provided a booklet, [Bright Futures in Practice:
> Nutrition,]{.underline} for a reference.^73^ The pilot sites will
> operate programs for at least two years, be evaluated, be revised as
> necessary, and introduced nationwide to all IHS Head Start grantees.
> Because this is a joint tribal/IHS initiated initiative,
> collaborations and partnerships are vital.

\* -Cherokee Tribal Childcare Services, Qualla Boundary Head Start
Program, Cherokee, NC

> -Northern Cheyenne Head Start Program, Lame Deer, MT
>
> -Red Cliff Tribal Early Head Start Program, Bayfield, WI
>
> -San Felipe Pueblo Head Start Program, NM
>
> -Winnebago Head Start and Whirling Thunder Diabetes Prevention
> Program, NE.

C. NIH Diabetes Prevention Program (DPP)

NIDDK is conducting the DPP to investigate whether the onset of type 2
diabetes can be prevented or delayed. Four AI tribes are participating
in the DPP multicenter study, which includes an intensive diet and
physical activity component and medication. The Pima Indian population
of Gila River Indian Community of Arizona is expected to participate in
a 2001 NIDDK Study of Health Outcomes of Weight-Loss (SHOW) clinical
trial -- a national multi-center, randomized study to determine whether
interventions designed to produce sustained weight loss in obese
individuals with type 2 diabetes improve health and prevent
complications.

**10. Summary**

> The escalating costs of obesity in terms of dollars and human
> suffering in AI/AN populations demand that action steps are taken. The
> proposed IHS national strategy to reduce the epidemic among AI/AN
> includes prevention, treatment, and weight loss maintenance as part of
> a long-range plan. Most resources would be targeted for prevention -
> the most cost effective strategy. Promoting healthy eating and
> exercise in AI/AN communities, particularly in young people, has the
> greatest potential for a lasting effect. This prevention strategy
> requires the partnership of numerous key players who need to be
> involved in the development, planning, implementation, and evaluation
> of the IHS plan.
>
> Interventions must be culturally sensitive, grounded in cultural
> values and traditions that promote health and well being, and
> developed with full participation of the AI/AN communities. This
> report to Congress therefore recommends that a nationwide plan involve
> collaborative partnerships among Tribal governments, local native and
> non-native communities, and government agencies. Developing a Healthy
> Weight and Physical Activity Program for AI/AN would enable sound,
> coordinated planning, implementation, and evaluation of obesity
> prevention and control programs in AI/AN communities.
>
> Expanded recruitment and retention of registered dietitians would
> increase access to nutrition services. The identification and
> implementation of "best practices" would enable local communities to
> implement effective obesity prevention and management programs.
> Clinical behavioral research, and evaluation of public health
> approaches, would provide new information and methods for reducing
> obesity and related morbidity. A yearlong planning period would enable
> planners to obtain input from all partners to develop detailed plans
> to address the obesity epidemic.
>
> ![](media/image5.jpeg){width="3.223611111111111in"
> height="2.1256944444444446in"}
>
> **References**

1\. Bouchard C. Current understanding of the etiology of obesity:
genetic and nongenetic factors. Am J Clin Nutr 1991; 53:1561S-1565S.

2\. Welty TK. Health implications of obesity in American Indians and
Alaska Natives. Am J Clin Nutr 1991; 53:1616S-1620S.

3\. LeMaster PL, Connell CM. Health education interventions among Native
Americans: a review and analysis. Health Educ Q 1994; 21:521-38.

4\. Strauss K. American Indian school children height and weight survey.
Primary Care Provider 1993; 18:137-42.

5\. Gallaher MM, Hauck FR, Yang-Oshida M, Serdula MK. Obesity among
Mescalero preschool children. Association with maternal obesity and
birth weight. Am J Dis Child 1991; 145:1262-5.

6\. Pettitt DJ, Roumain J, Hanson R, al e. Lower glucose in pregnant and
nonpregnant Pima Indians who were breast fed as infants. Diabetologia
1995; 38 (suppl 1):A61.

7\. Maternal and Child Health Branch, Division of Nutrition, Centers for
Disease Control and Prevention. Pediatric Nutrition Surveillance System
Annual Report, 1994. Atlanta, GA: Centers for Disease Control and
Prevention, 1996.

8\. Jackson MY. Height, weight, and body mass index of American Indian
schoolchildren, 1990-1991. J Am Diet Assoc 1993; 93:1136-40.

9\. Harvey-Berino J, Wellman A, Hood V, Rourke J, Secker-Walker R.
Preventing obesity in American Indian children: when to begin. J Am Diet
Assoc 2000; 100:564-6.

10\. National Center for Health Statistics. The Third National Health
and Nutrition Examination Survey. Hyattsville, MD: National Center for
Health Statistics, Centers for Disease Control and Prevention, 1996.

11\. Broussard BA, Johnson A, Himes JH, et al. Prevalence of obesity in
American Indians and Alaska Natives. Am J Clin Nutr 1991;
53:1535S-1542S.

12\. Freedman DS, Serdula MK, Percy CA, Ballew C, White L. Obesity,
levels of lipids and glucose, and smoking among Navajo adolescents. J
Nutr 1997; 127:2120S-2127S.

13\. Stuart CA, Smith MM, Gilkison CR, Shaheb S, Stahn RM. Acanthosis
Nigricans among Native Americans: an indicator of high diabetes risk. Am
J Public Health 1994; 84:1839-42.

14\. Zephier E, Himes JH, Story M. Prevalence of overweight and obesity
in American Indian School children and adolescents in the Aberdeen area:
a population study. Int J Obes Relat Metab Disord 1999; 23 Suppl
2:S28-30.

15\. White LL, Ballew C, Gilbert TJ, Mendlein JM, Mokdad AH, Strauss KF.
Weight, body image, and weight control practices of Navajo Indians:
findings from the Navajo Health and Nutrition Survey. J Nutr 1997;
127:2094S-2098S.

16\. Murphy NJ, Schraer CD, Bulkow LR, Boyko EJ, Lanier AP. Diabetes
mellitus in Alaskan Yup\'ik Eskimos and Athabascan Indians after 25 yr.
Diabetes Care 1992; 15:1390-2.

17\. Risica PM, Ebbesson SO, Schraer CD, Nobmann ED, Caballero BH. Body
fat distribution in Alaskan Eskimos of the Bering Straits region: the
Alaskan Siberia Project. Int J Obes Relat Metab Disord 2000; 24:171-9.

18\. Lee ET, Howard BV, Savage PJ, et al. Diabetes and impaired glucose
tolerance in three American Indian populations aged 45-74 years. The
Strong Heart Study. Diabetes Care 1995; 18:599-610.

19\. Welty TK, Lee ET, Yeh J, et al. Cardiovascular disease risk factors
among American Indians. The Strong Heart Study. Am J Epidemiol 1995;
142:269-87.

20\. National Center for Health Statistics. Anthropometric reference
data and prevalence of overweight: United States, 1976-80. Washington,
DC: US Government Printing Office, 1987.

21\. Hamill PV, Drizd TA, Johnson CL, Reed RB, Roche AF, Moore WM.
Physical growth: National Center for Health Statistics percentiles. Am J
Clin Nutr 1979; 32:607-29.

22\. Indian Health Service Program Statistics Team. Trends in Indian
Health. Rockville, MD: Indian Health Service, 1997.

23\. Pi-Sunyer FX. Health implications of obesity. Am J Clin Nutr 1991;
53:1595S-1603S.

24\. National Research Council Committee on Diet and Health. Diet and
Health: Implications for Reducing Chronic Disease. Washington, DC:
National Academy Press, 1989.

25\. Knowler WC, Pettitt DJ, Saad MF, et al. Obesity in the Pima
Indians: its magnitude and relationship with diabetes. Am J Clin Nutr
1991; 53:1543S-1551S.

26\. Howard BV, Lee ET, Cowan LD, et al. Coronary heart disease
prevalence and its relation to risk factors in American Indians. The
Strong Heart Study. Am J Epidemiol 1995; 142:254-68.

27\. Knowler WC, Saad MF, Pettitt DJ, Nelson RG, Bennett PH.
Determinants of diabetes mellitus in the Pima Indians. Diabetes Care
1993; 16:216-27.

28\. Burrows NR, Geiss LS, Engelgau MM, Acton KJ. Prevalence of diabetes
among Native Americans and Alaska Natives, 1990-1997: An increasing
burden. Diabetes Care 2000; 23:1786-90.

29\. United States Department of Health and Human Services. Serving
Elders at Risk: The Older Americans Act Nutrition Program\'s National
Evaluation of the Elderly Nutrition Program, 1993-1995. Washington, DC:
Office of the Assistant Secretary for Aging, Office of the Assistant
Secretary for Planning and Evaluation, July 1996.

30\. McGinnis JM, Foege WH. Actual causes of death in the United States.
Jama 1993; 270:2207-12.

31\. Williamson DF, Thompson TJ, Thun M, Flanders D, Pamuk E, Byers T.
Intentional weight loss and mortality among overweight individuals with
diabetes. Diabetes Care 2000; 23:1499-504.

32\. Owen GM, Garry PJ, Seymoure RD, Harrison GG, Acosta PB. Nutrition
studies with White Mountain Apache preschool children in 1976 and 1969.
Am J Clin Nutr 1981; 34:266-77.

33\. Story M, Strauss KF, Zephier E, et al. Nutritional concerns in
American Indian and Alaska Native children: Transitions and future
directions. Journal American Dietetic Association 1998; 98:170-6.

34\. Gilbert TJ, Percy CA, Sugarman JR, Benson L, Percy C. Obesity among
Navajo adolescents. Relationship to dietary intake and blood pressure.
Am J Dis Child 1992; 146:289-95.

35\. Blackett PR, Taylor T, Russell D, Lu M, Fesmire J, Lee ET.
Lipoprotein changes in relation to body mass index in Native American
adolescents. Pediatr Res 1996; 40:77-81.

36\. Wolf AM. What is the economic case for treating obesity? Obes Res
1998; 6 Suppl 1:2S-7S.

37\. Colditz GA. Economic costs of obesity and inactivity. Med Sci
Sports Exerc 1999; 31:S663-7.

38\. Gorsky RD, Pamuk E, Williamson DF, Shaffer PA, Koplan JP. The
25-year health care costs of women who remain overweight after 40 years
of age. Am J Prev Med 1996; 12:388-94.

39\. Oster G, Thompson D, Edelsberg J, Bird AP, Colditz GA. Lifetime
health and economic benefits of weight loss among obese persons. Am J
Public Health 1999; 89:1536-42.

40\. Hu FB, Sigal RJ, Rich-Edwards JW, et al. Walking compared with
vigorous physical activity and risk of type 2 diabetes in women: a
prospective study. JAMA 1999; 282:1433-9.

41\. Andersen RE, Wadden TA, Bartlett SJ, Zemel B, Verde TJ, Franckowiak
SC. Effects of lifestyle activity vs structured aerobic exercise in
obese women: a randomized trial. JAMA 1999; 281:335-40.

42\. U.S. Department of Health and Human Services. Physical activity and
health: A report of the Surgeon General. Atlanta, GA: Centers for
Disease Control and Prevention, National Center for Chronic Disease
Prevention and Health Promotion, 1996.

43\. Marcus BH, Rossi JS, Selby VC, Niaura RS, Abrams DB. The stages and
processes of exercise adoption and maintenance in a worksite sample.
Health Psychol 1992; 11:386-95.

44\. Ravussin E, Valencia ME, Esparza J, Bennett PH, Schulz LO. Effects
of a traditional lifestyle on obesity in Pima Indians. Diabetes Care
1994; 17:1067-74.

45\. Fontvieille AM, Kriska A, Ravussin E. Decreased physical activity
in Pima Indian compared with Caucasian children. Int J Obes Relat Metab
Disord 1993; 17:445-52.

46\. Goodrick GK, Foreyt JP. Why treatments for obesity don\'t last. J
Am Diet Assoc 1991; 91:1243-7.

47\. Foreyt JP, Goodrick GK. Behavioral interventions in the management
of obesity. Clinical Diabetes 1995.

48\. National Institutes of Health. Clinical Guidelines on the
Identification, Evaluation, and Treatment of Overweight and Obesity in
Adults: The Evidence Report. Bethesda, MD: National Institutes of
Health, National Heart Lung, Blood Institute, September, 1998.

49\. Barlow SE, Dietz WH. Obesity evaluation and treatment: Expert
Committee recommendations. The Maternal and Child Health Bureau, Health
Resources and Services Administration and the Department of Health and
Human Services. Pediatrics 1998; 102:E29.

50\. Baranowski T, Mendlein J, K. R, Frand E, Cullen K, Baranowski J.
Physical activity and nutrition in children and youth: An overview of
obesity prevention. Preventive Medicine 2000; 31:S1-S10.

51\. McKenzie TL, Nader PR, Strikmiller PK, et al. School physical
education: effect of the Child and Adolescent Trial for Cardiovascular
Health. Prev Med 1996; 25:423-31.

52\. Lytle LA, Stone EJ, Nichaman MZ, et al. Changes in nutrient intakes
of elementary school children following a school-based intervention:
results from the CATCH Study. Prev Med 1996; 25:465-77.

53\. Kozak DL. Surrendering to diabetes: An embodied response to
perceptions of diabetes and death in the Gila River Indian community.
Omega 1997; 35:347-59.

54\. Huttlinger. A Navajo perspective of diabetes. Family and Community
Health 1995; 18:9-16.

55\. Allen SN. Psychological assessment of post-traumatic stress
disorder. Psychometrics, current trends, and future directions.
Psychiatr Clin North Am 1994; 17:327-49.

56\. Duran E. Considerations of dealing with suicide as a front line
health provider in Indian country. Suicide Handbook: Prevention and
Intervention with Native Americans. San Francisco: Indian Health
Service, 1989.

57\. Ellis A. Post-traumatic stress disorder (PTSD): A rational emotive
behavioral theory. Journal of Rational Emotive Cognitive Behavior 1994;
12:3-19.

58\. Neumark-Sztainer D, Story M, Resnick MD, Blum RW. Psychosocial
concerns and weight control behaviors among overweight and nonoverweight
Native American adolescents. J Am Diet Assoc 1997; 97:598-604.

59\. Berg FM. Special report: Health risks of obesity. Obesity and
Health 1993.

60\. Berg FM. Health risks of weight loss. Healthy Weight Journal 1995.

61\. Story M, Hauck FR, Broussard BA, White LL, Resnick MD, Blum RW.
Weight perceptions and weight control practices in American Indian and
Alaska Native adolescents. A national survey. Arch Pediatr Adolesc Med
1994; 148:567-71.

62\. Story M, Strauss K, Gilbert TJ, Broussard B. Nutritional Health and
Diet-Related Contitions. In: Rhoades ER, ed. American Indian Health.
Baltimore, MD: The Johns Hopkins University Press, 2000.

63\. Boyce VL, Swinburn BA. The traditional Pima Indian diet.
Composition and adaptation for use in a dietary intervention study.
Diabetes Care 1993; 16:369-71.

64\. Porter J. Native Americans: Nutrition and Diet-Related Diseases.
Washington, D.C.: Congressional Research Service Report for Congress,
July, 1987.

65\. Pearce J. Dietary changes in a northern Minnesota Indian community
in the last fifty years. IHS Primary Care Provider 1990; 15:127-31.

66\. Ballew C, White LL, Strauss KF, Benson LJ, Mendlein JM, Mokdad AH.
Intake of nutrients and food sources of nutrients among the Navajo:
findings from the Navajo Health and Nutrition Survey. J Nutr 1997;
127:2085S-2093S.

67\. U.S. Department of Agriculture FaNS. Participation in Food Programs
by Race (FNS-101 Report). Washington DC: U.S. Department of Agriculture,
1999.

68\. Burhansstipanov L, Dresser C. Documentation of the Cancer Research
Needs of American Indians and Alaska Natives. Bethesda, MD., National
Institutes of Health, 1993.

69\. Heath GW, Wilson RH, Smith J, Leonard BE. Community-based exercise
and weight control: diabetes risk reduction and glycemic control in Zuni
Indians. Am J Clin Nutr 1991; 53:1642S-1646S.

70\. Davis S, Gomez Y, Lambert L, Skipper B. Primary prevention of
obesity in American Indian children. Ann N Y Acad Sci 1993; 699:167-80.

71\. Davis S, Lambert L, Gomez Y, et al. Southwest cardiovascular
curriculum project: study findings for American Indian elementary
students. Journal Health Education 1995; 26:S72-S81.

72\. Caballero B, Davis S, Davis CE, et al. Pathways: A school-based
program for the primary prevention of obesity in American Indian
children. Journal Nutrition and Biochemistry 1998; 9:535-43.

73\. Story M, Holt K, Sofka D. Bright Futures in Practice: Nutrition.
Washington, DC: National Center for Education in Maternal and Child
Health, Georgetown University, 2000.

74\. Sugarman JR, White LL, Gilbert TJ. Evidence for a secular change in
obesity, height, and weight among Navajo Indian schoolchildren. Am J
Clin Nutr 1990; 52:960-6.

75\. Centers for Disease Control and Prevention. 1994 Pediatric
Nutrition Surveillance System. Atlanta, GA: US Department of Health and
Human Services, 1996.

76\. Goran MI, Kaskoun M, Johnson R, Martinez C, Kelly B, Hood V. Energy
expenditure and body fat distribution in Mohawk children. Pediatrics
1995; 95:89-95.

77\. Hauck FR, Gallaher MM, Yang-Oshida M, Serdula MK. Trends in
anthropometric measurements among Mescalero Apache Indian preschool
children. 1968 through 1988. Am J Dis Child 1992; 146:1194-8.

78\. Pettitt DJ, Baird HR, Aleck KA, Bennett PH, Knowler WC. Excessive
obesity in offspring of Pima Indian women with diabetes during
pregnancy. N Engl J Med 1983; 308:242-5.

79\. U.S. Department of Health and Human Services. Healthy People 2010.
In National Health Promotion and Disease Prevention Objectives.
Washington, D.C.: U.S. Government Printing Office, January 2000.

80\. Bhadha H. Mimicry and/as identity: Cultural poetics of the habitus.
Mapping Colonialism. Berkeley: Universtiy of California Press, 1988.

81\. U.S. Department of Agriculture Food and Nutrition Service.
Evaluation of the Food Distribution Program on Indian Reservations. Vol
1, Final Report. Washington, D.C.: USDA, Food and Nutrition Service
Office on Analysis and Evaluation, 1990.

82\. Broussard BA, Sugarman JR, Bachman-Carter K, et al. Toward
comprehensive obesity prevention programs in Native American
communities. Obes Res 1995; 3 Suppl 2:289s-297s.

83\. Aspenland S, Pelican S. Traditional food practices of contemporary
Taos Pueblo. Nutrition Today 1992; 27:6-12.

84\. Wolfe WS, Weber, C.W., Arvisto KD. Use and nutritent composition of
traditional Navajo foods. Ecol Food Nutr 1985; 17:323044.

85\. Terry RD, Bass MA. Food practices of families in an eastern
Cherokee township. Ecol Food Nutr 1984; 14:63-70.

86\. Brown AC, Brenton B. Dietary survey of Hopi Native American
elementary students. J Am Diet Assoc 1994; 94:517-22.

87\. Nobmann ED, Byers T, Lanier AP, Hankin JH, Jackson MY. The diet of
Alaska Native adults: 1987-1988. Am J Clin Nutr 1992; 55:1024-32.

88\. Lang GC. \"Making sense\" about diabetes: Dakota narratives of
illness. Medical Anthropology 1989; 11:305-27.

**APPENDIX 1**

**Senate Report No. 106-312 on FY 2001 Interior Appropriations**

The Committee notes that obesity and related health disorders from heart
disease to diabetes to colon cancer is a leading killer of Americans,
and is a particular problem among Indian and Native populations. The
Committee directs the Indian Health Service to work with the National
Institutes of Health to develop a multi-disciplinary, long-range plan to
address this public health problem. The plan, which would be submitted
to the House and Senate Committees on Appropriations no later than March
1, 2001, should address nutrition and physical education for both
children and adults to prevent obesity; treatment programs including
medical and psychological support; and maintenance programs for those
who successfully lose weight.

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height="4.979166666666667in"}

**APPENDIX 2**

**Obesity in AI/AN Children**

### **1. Health Risks of Obesity in Children**

As in adults, overweight has emerged as the major nutrition-related
health issue affecting AI/AN children.^8^ ^11^ ^74^ In 1990, 40 percent
of school age AI/AN children were found to be obese.^4^ Since obesity in
childhood persists into adulthood and is associated with significant
morbidity, this has major implica­tions for the health of AI/AN adults.

### 

###  **A. Increasing Trend of Obesity in Children**

> Data suggest that there has been a secular change in height, weight,
> and obe­sity among AI/AN children.^11^ Over the past 35 years, obe­sity
> has increased in Navajo schoolchildren. Compared with data from 1955,
> mean weights increased 29 percent among boys and 19 percent among
> girls across all age groups.^74^ Pima children are also significantly
> heavier than children measured at the turn of the century. In 1905,
> Pima boys who were 165 cm in height weighed an average of 58 kg.
> During the period 1981-88, Pima boys of the same height weighed an
> average of 69 kg, an increase of approximately 11 kg.^25^

#### 

####  B. Obesity in Preschool Children

> A high weight-for-height (greater than the 95th National Center for
> Health Statistics percentile) is indica­tive of being overweight. AI
> children have consistently exhibited the highest prevalence of
> overweight of all ethnic groups in the Pediatric Nutrition
> Surveillance System (PedNSS) of the Centers for Disease Control and
> Prevention (CDC). In the 1994 PedNSS, 11.9 percent of AI children two
> to four years old were overweight. This rate is similar to that for
> same-age Hispanic children (11.7 percent ) but considerably higher
> than that for White children (6.2 percent ).^75^ Other studies have
> also indicated a high prevalence of overweight among young AI
> children.^76^ ^11^ ^77^ Overall, these studies demonstrate that
> obesity begins early for AI children.

###  **C. Obesity in School-aged Children and Adolescents**

> In 1990, a national survey of the height and weight status of 9,464 AI
> schoolchildren ages 5-18 living on or near AI reserva­tions was
> conducted by the IHS, CDC, and tribal nutrition programs in nine IHS
> areas.^8^ Data for height, weight, and body mass index (BMI) of the
> schoolchildren were compared with two national reference data sets,
> the second National Health and Nutrition Examination Survey (NHANES
> II) and the Mexican-American population of the Hispanic Health and
> Nutrition Ex­amination Survey (HHANES-MA).
>
> Although the three populations were simi­lar in height, the AI children
> had significantly higher BMIs for nearly every age and sex group
> compared to the reference populations. The overall preva­lence of
> overweight in the AI children (exceeding the 85th percentile of the
> reference population) was 39.3 percent compared with the NHANES II
> popula­tion and 28.6 percent compared with the HHANES-MA population.
> These data indicate that overweight is much more prevalent among AI
> children than among other children in the United States at all ages
> and in both sexes.
>
> In 1995-1996, a regional survey of AI children in South Dakota, North
> Dakota, Iowa, and Nebraska was conducted by IHS to estimate the
> prevalence of overweight and obesity. Thirty-nine percent of males and
> 38 percent of females were found to be overweight in this
> comprehensive survey of 12,559 children aged 5-17 years. Even at the
> youngest school ages, overweight is more than twice as likely as
> national patterns and obesity is more than three times as
> prevalent.^14^

**2. Relationships Between Weight and Chronic Disease Risk Factors in
Children**

A few studies have examined risk factors for type 2 diabetes and
cardio­vascular disease in AI children and adolescents. Gilbert et al.
reported high normal (\>90th percentile) blood pressures in 10 percent
of adolescent Navajo boys and 6 percent of girls.^34^ There was a
positive relationship between body weight and blood pressure. Of those
with high normal blood pressure, 36 percent of the boys and 64 percent
of the girls were overweight.

Data from another study suggest that obesity associated with elevated
lipid levels begins at an early age in AI children.^35^ Blackett and
colleagues explored the interrelation­ships between weight, BMI, lipids,
apolipoproteins, insulin, and glucose in 103 Oklahoma Indian children
between the ages of 4 and 19 years.^35^ BMI increased with age in boys
and girls and tended to be higher than in Caucasian children. Children
10 to 14 years old in the highest quartile for BMI had higher
triglyceride levels and lower high-density lipoprotein cholesterol when
compared with those in the lower quartiles. In contrast, 15-19-year olds
in the highest quartile for BMI had higher cholesterol and
apolipoprotein B levels. The mean fasting insulin levels were not
related to BMI.

Centrally distributed body fat is associated with several chronic
diseases, including hypertension, heart disease, gallstones, diabetes,
and some types of cancer. Two studies have shown that AI/AN children
have increased central body fat.^34^ ^76^ Whether the pattern of central
distribution of body fat continues from childhood to adulthood is not
well established, but it is reasonable to expect that it does.

### **3. Determinants of Childhood Obesity**

### **A. Maternal Obesity** 

Both maternal obesity and high birth weight have been shown to be strong
predictors of obesity in early childhood.^5^ It has also been speculated
that the metabolic milieu of the intrauterine environment may play a
role in the etiology of obesity. Infants born to Pima mothers who were
diabetic during pregnancy were much more likely to later become obese
than were their siblings born before the full manifestation of their
mother\'s diabetes.^78^

###  **B. Breast-feeding and Type 2 Diabetes in Offspring**

Breast-feeding is associated with a lower prevalence of type 2 diabe­tes
in breast-fed AI.^6^ Both non-pregnant and pregnant breast-fed Pima
In­dians studied had lower plasma glucose concentrations at ages 20-24
years. Breast-feeding, therefore, could be viewed as a potential
preventive strategy for type 2 diabetes.

Data from the 1994 PedNSS indicate that 36 percent of low-income
children were breast-fed on hospital discharge, and 18 percent were
consuming some breast milk at six months of age. Across the ethnic
groups, AI and Asian mothers had the highest prevalence of
breast-feeding initia­tion and duration, with 44 percent of AI mothers
breast-feeding at hospital discharge and 24 percent breast-feeding at
six months postpartum.^75^ This is still below the Healthy People 2000
and 2010 goals: at least 75 percent of mothers breast-feed their babies
in the early post­partum period, and at least 50 percent breast-feed
through 5-6 months of age.^79^ Greater effort is needed to promote
breast milk as the preferred source of nutrition for young infants.

**APPENDIX 3**

**IHS Planning Conference to Reduce Obesity Among AI/AN**

October, 2000

Conference Invitees

**Facilitators:**

Jean Charles-Azure, MPH, RD

Principal Nutrition Consultant

Indian Health Service

5600 Fishers Lane, 6A-38

Rockville, MD 20857

PHONE: (301) 443-0576

FAX: (301) 594-6135

EMAIL: jcharles@HQE.ihs.gov

Brenda Broussard, MPH, RD, CDE, MBA

Health Care Consultant

18 Berm Street NW

Albuquerque, NM 87120

PHONE: (505) 792-0065

EMAIL: broussar@flash.net

**Attendees:**

Carol Ballew, Epidemiologist

Nutrition and Physical Activity

National Center of Chronic Disease Prevention

And Health Promotion

Centers for Disease Control and Prevention

3005 Chamblee Tucker Road

Atlanta, Georgia 30341

PHONE: (770) 488-6042

James Cussen, Director UIHP

Indian Health Service

5600 Fishers Lane, Rm 6A-55

Rockville, MD 20857

Jamie Davis-Hueston, PhD

Principal Psychology Consultant

Indian Health Service

12300 Twinbrook Metro Plaza Rm 605

Rockville, MD 20852

PHONE: (301) 443-0104

EMAIL: jdavis@hqe.ihs.gov

Martina Callaghan, MS, RN

Principal Nursing Consultant

Indian Health Service

5600 Fishers Lane, 6A-44

Rockville, MD 20857

PHONE: (301) 443-1840

Karen Donato, MS, RD

Coordinator, NHLBI Obesity Education Initiative

National Heart, Lung, and Blood Institute

National Institutes of Health

31 Center Drive, MSC 2480

Building 31, Room 4A16

Bethesda, MD 20892

PHONE: (301) 496-1051

EMAIL: donatok@nhlbi.nih.gov

Pat Schumacher, Director

Nutrition Services

Nashville Area Indian Health Service

711 Stewarts Ferry Pike Lane

Nashville, TN 37214

Phil Smith, MD

Principal MCH Consultant

Indian Health Service

Twinbrook Metro Plaza Rm 450

12300 Twinbrook Parkway

Rockville, MD 20852

PHONE: (301) 443-4644

Nancy Theodore

Food Distrib. Prog. on Indian Reservations

United States Department of Agriculture

3101 Park Center Drive, Room 510

Alexandria, Virginia 22302

EMAIL: nancy.theodore@fns.usda.gov

Craig Vanderwagen, MD

Director, DCPS

5600 Fishers Lane, Rm 6A-55

Rockville, MD 20857

PHONE: (301) 443-4644

Lorraine Whitehair, MPH, RD, RN

Chief Dietitian

ACL PHS Indian Hospital

PO BOX 130

San Fidel, NM 97049

PHONE: (505) 552-5320

Cheryl Wilson, Diabetes Prevention Consultant

National Diabetes Program

Indian Health Service

5300 Homestead RD NE

Albuquerque, NM 87110

Elenora Zephier, MPH, RD

Aberdeen Area Nutrition Consultant

Aberdeen Area Indian Health Service

Federal Building

115 4^th^ Avenue

Aberdeen, SD 57401

PHONE: (605) 266-7458

**Others:**

Dr. Kelly Acton

Director, National Diabetes Program

Indian Health Service

5300 Homestead RD NE

Albuquerque, NM 87110

PHONE: (505) 248-4182

Chief Allan

The National Congress of American Indians

1301 Connecticut Avenue NW, Suite 200

Washington, DC 20036

PHONE: (202) 466-7767

EMAIL: <chief_allan@ncai.org>

Roger Gollub, MD

Albuquerque Area Office

Indian Health Service

5300 Homestead RD NE

Albuquerque, NM 87110

Jan Frederick, RD, MS

Phoenix Area Indian Health Service

2 Renaissance SQ 40 N Central Ave. Suite 600

Phoenix, AZ 86004

PHONE: (605) 364-5251

William Freeman, MD

IHS Research Program

Twinbrook Metro Plaza Rm 450

12300 Twinbrook Parkway

Rockville, MD 20852

PHONE: (301) 443-4644

Stan Griffith, MD

Indian Health Service

5300 Homestead RD NE

Albuquerque, NM 87110

Yvette Joesph-Fox, Executive Director

National Indian Health Board

1385 So. Colorado Blvd. Suite A-707

Denver, CO 80222

PHONE: (303) 759-3075

Laura McNally, MPH, RD, FADA

Senior Advisor

HRSA/Center for Quality

5600 Fishers Lane

Room 9-05

Rockville, MD 20886

\(301\) 443-0569

FAX (301) 443-9795

**APPENDIX 4**

**\*Inter Tribal Council of Arizona Programs (ITCA) -- Input into the**

**October 2000 Planning Conference**

ITCA presented an issue paper to the planning group for this report at a
meeting held October 23-24, 2000 in Rockville, MD, and the Council's
recommendations are summarized here.

1). The Department of Health and Human Services must recognize tribal
communities as the critical arena for effective public health
interventions. Cross-program initiatives should be developed at the
national, state and tribal levels to better reach target populations.

2). Targeted funds to adequately address obesity in AI throughout the
United States need to be allocated. Tribes must be allowed access to
funds for obesity prevention and treatment that are made available to
states so that community-directed, community-based strategies can be
developed, implemented, and evaluated in tribal communities.

3). Public health organizations such as CDC should integrate their
programs with tribal governments.

4). Strategies for obesity prevention by government programs should
address:

-   Breastfeeding of infants throughout the first year of life.

-   Wellness counseling for the postpartum women and infants.

-   Coordination of efforts with tribal, government, and other health
    programs

5). Technical assistance is needed from the IHS, CDC, NIH, state health
departments, and other agencies to develop appropriate community-based
prevention programs.

6). Research efforts that focus on identified behavioral and social
barriers to effective interventions should be developed and funded.

7). There is a need for specialized staff in each AI community in the
areas of nutrition, physical activity, education, parent-child
interactions and community change to develop, implement, manage, and
evaluate obesity prevention programs.

8). Obesity prevention projects could incorporate obesity prevention
programs into existing programs, expand school curricula to include
health promotion information, work with school food service programs to
provide recommended foods, create community and family-based programs,
identify and work with high-risk groups, such as children of parents who
are overweight, children from a diabetic pregnancy, and people with a
family history of diabetes. 9). Obesity treatment projects could
include:

-   Monitoring growth in children to identify at-risk children at an
    early age.

-   Developing educational programs for weight management that include
    family involvement for adults and children.

-   Developing tracking systems to ensure appropriate follow-up
    management.

-   Implementing clinically based activities such as Staged Diabetes
    Management to improve diabetes care and prevent complications.

-   Establishing weight management teams that include physicians,
    dietitians, family therapists, etc.

\*This paper represents the views of the ITCA and do not necessarily
reflect the views of the US Government or Indian Health Service.

**APPENDIX 5**

> **Input from the Planning Conference and Current Diabetes Programs**
>
> The IHS planning group for this report to Congress agreed that an
> action plan to reduce obesity should capitalize on the assets present
> in AI/AN communities, as well as be cognizant of the existing
> barriers, and address those barriers when possible. An assessment of
> both assets and barriers would assist planners to match needs and
> resources appropriately to address the obesity epidemic. As a result,
> a planning conference was held October 23-24, 2000. The participants
> in the October 2000 planning conference made a number of
> recommendations to IHS concerning a national obesity plan.
>
> Similarly, the IHS National Diabetes Program held eight regional
> meetings during the fall of 2000 to obtain tribal input from centers
> supported by funding from the IHS Special Diabetes Program for
> Indians. These eight regional meetings identified successes as well as
> gaps or problems in diabetes prevention efforts. Obesity prevention
> and treatment is a key strategy in diabetes prevention.
>
> In addition, the planner of the National Diabetes Prevention Center
> located in Gallup, New Mexico sought tribal input concerning obesity
> prevention and management.
>
> The recommendations from the October planning conference, the regional
> diabetes meetings, and the Gallup Program were consistent and are
> combined and summarized below**.**

**Obesity Prevention And Treatment**

# **1). Potential Assets**

### **Infrastructure Assets**

-   Partners with whom collaborative relationships could be developed
    include: Universities, Native American Fitness Alliance, American
    Council on Exercise, American Association Indian Physicians,
    Schools, Tribal Health Departments, IHS DM Program, Head Start,
    Rehabilitation Programs, Exercise Centers, American Indian Colleges,
    YWCA, Weight Watchers.

-   Schools have a captive audience, provide at least one meal per day
    to students, and have the ability to incorporate a healthy lifestyle
    curriculum into ongoing classes.

-   Community members who are supportive to health promotion efforts can
    be identified.

-   Ann Wolf has done research on the cost of obesity, and perhaps
    Navajo or Pasqua Yaqui data exist.

-   The Resource Patient Management System (RPMS) data surveillance
    system is available and used at many tribal health care facilities
    and can provide obesity prevalence and incidence data. Many tribes
    now use this database to report obesity prevalence and incidence
    data for the Special Diabetes Grants Program for Indians.

-   Casinos have provided increased revenue for some tribes, thereby
    increasing economic resources for communities. Available resources
    include social services, mental health services, alcohol treatment
    programs, financial assistance programs, temporary assistance for
    needy families, Head Start, WIC, child support, Medicaid, elders,
    CIHS services,

### **Community Assets** 

-   AI/AN communities have possible celebrity and local role models
    including Notah Begay, Billy Mills, Vanessa Shortbull, and Seminole
    leader James Billie.

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-   Some AI/ANs have been trained as fitness instructors.

-   Some tribes have exercise facilities.

-   Traditional stories involving physical fitness and strength could
    help motivate AI/AN communities.

-   Traditional forms of exercise that could generate interest in
    physical activity include traditional or fancy dancing, and games
    such as stickball, canoe racing, and running.

-   Community health promotion and obesity prevention programs in
    schoolchildren include CATCH, Pathways, IHS Head Start Initiative,
    "Healthy Children, Healthy Families, and Healthy Communities.

-   The Pascui Yaqui tribe has a model diabetes intervention and risk
    reduction program.

-   Successful community programs that have been documented include:
    Community Gardens (Billings, MT); Strong Women Stay Slim
    (Blackfeet); St Regis Mohawk Community Program; Zuni Program; Gila
    River Program; Holiday Eating Learning Plan (HELP); and numerous
    summer camps that promote healthy behaviors.

-   Tribal health fairs offer collaborative health promotion
    opportunities.

-   Tribal runs or walking events include Pow Wows, Breast Cancer
    Prevention, Walk Across TX or AZ, and Outrun Diabetes.

-   Many AI/AN enjoy sports such as Native American basketball teams,
    golf, cross country, and bowling.

**Media**

-   AI/AN media outlets include *Health for Native Life Magazine*, and
    *Native America Calling Radio Talk Show.*

-   A popular program in Nashville called "Telling My Story" involves
    tribal members who have overcome barriers.

### **Data and Research**

-   RPMS collects data from some tribes.

-   The Strong Heart Study has published results.

-   The National Diabetes Center in Gallup potentially can provide
    research opportunities.

-   The NIH/USDA/IHS is conducting nutrient analysis of
    indigenous/traditional foods.

-   Obese people can have positive health benefits with a 10 or 15 pound
    weight loss.

# 

# **2). Potential Barriers** 

### **Limited Research and Data**

-   There is a lack of science upon which community strategies or
    individual interventions can be based. Programs are rarely
    pre-tested before implementation. Many tribes do not have the data
    they need to plan and evaluate local programs.

-   There is no national, standardized AI/AN database, and outcome
    evaluation is limited.

-   AI/ANs on reservations are not included in CDC's NHANES and BRFSS
    national surveys; AI/ANs are not included in the USDA's CSFII
    survey.

-   Local tribal resources available to dedicate to data collection are
    limited.

-   Clients who are very obese with very high BMIs of 40 or 45, may not
    qualify for study assessments or data collection.

-   Indian communities may have had limited study input in the past and
    are suspicious of being studied.

-   RPMS data is collected from clinic patients, rather than the total
    AI/AN population

-   RPMS anthropometric measures are not standardized

######## 

######## Birth Control Pills

-   Use of the birth control pill is associated with weight gain.

-   Young girls using birth control pills increase their risk for weight
    gain.

### **Self Efficacy and Denial**

-   AI/ANs believe that they will get diabetes no matter what they do,
    and that diabetes is not preventable.

-   AI/ANs who have diabetes, or at high risk for diabetes, don't want
    to take diabetes seriously.

-   Some have difficulty accepting diabetes until complications make it
    a "visible" disease.

-   Many people at risk for diabetes feel hopeless and helpless.

-   Making behavioral changes is difficult.

-   The community should have ownership of health behavior programs.

### **Health Provider Challenges** 

-   Providers do not consider obesity an urgent problem.

-   Some providers have a negative attitude toward obesity.

-   Many health care providers need to know how to empower patients for
    self-care.

-   Many health care providers are unable to incorporate early screening
    or intervention into their practices.

-   More training in diabetes prevention, treatment, and obesity
    managementwould have a positive effect.

-   . In some locations health professionals, for example, Registered
    Dietitians, are not available, which effects multidisciplinary
    health care.

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-   Diabetes educators are usually overworked mbursed.

-   

-   More could be done to train current staff on cultural competence.

-   There is a shortage of health professionals in nutrition, nursing,
    dentistry and medicine, who work with American Indian/Alaska Native
    people.

-   Registered dietitians may not be perceived as valuable or necessary
    by health administers.

######## 

######## School Challenges

-   There is no comprehensive school health program involving nutrition,
    exercise, and smoking cessation.

-   Health is a low priority in school curricula with few physical
    education classes offered.

-   There are [no]{.underline} home economics classes in schools that
    teach life skills, time management, or money management classes.

-   School cafeterias often serve fast food; school vending machines
    offer unhealthy food choices; and convenience and fast food outlets
    are often located near schools.

-   School facilities are not available at night or weekends for student
    or community use.

-   American Indian Colleges are not utilized or involved in healthy
    lifestyle interventions.

######## Physical Activity Issues

-   Competitive sports do not serve the needs of all children and
    adolescents.

-   Many Indian families and tribal communities do not have resources
    for sports equipment and uniforms.

-   Qualified leaders to organize sports or games are lacking.

-   IHS is a health care organization, therefore, staff does not include
    coaches and exercise specialists.

######## 

######## Parental Issues

-   Parental issues include conflicting priorities; work priorities;
    lack of control of children; child abuse; and child neglect.

-   Lack of parental knowledge about healthy lifestyles and nutrition,
    cooking, breast feeding, and infant feeding.

-   Alcohol and substance abuse are significant problems in some
    families.

-   Opportunities or places to exercise, play basketball, or other
    sports are limited.

-   Safety is an issue when there are no sidewalks, no street lights,
    and roads must be shared with cars, walkers, bikers, gangs, and
    unleashed dogs.

-   Cost is a barrier for families.

-   Television and video games reduce children's participation in sports
    or physical activity.

######## Psychosocial Factors

-   Depression, eating disorders, family stress, and emotional issues
    are all concerns for the AI/AN population.

-   Learning styles of AI/ANs differ from those of the general
    population.

-   Behavior change is difficult.

-   Peer or social support is limited.

-   Trust and confidentiality must be present for interventions to be
    effective.

-   Culturally appropriate materials and community programs are needed
    for AI/ANs.

-   Fear or poor self-esteem are not motivating factors for weight loss
    or control.

### **Media Issues**

######## There are very few AI/AN role models to encourage healthy lifestyles.

######## Healthy practices are not shown on TV or in movies.

-   Fast food and soda advertisements encourage poor nutrition.

### **Community Issues** 

-   Although tribes have some similarities, values and traditions are
    heterogeneous and interventions need to be tailored to meet tribal
    needs.

-   No centralized data have been compiled for American Indian Colleges
    that offer nutrition courses.

-   Lack of coordination between programs can lead to duplication of
    efforts, conflicting messages, gaps in content, unawareness of
    resources, and lost opportunities for collaboration.

-   Community members may not see obesity as a problem.

-   Many individuals often smoke to lose or control weight.

-   Opportunities or space to exercise are limited.

-   Communities have no knowledge or skills regarding research or
    evaluation methods.

-   Community change is complex and time consuming.

-   AI/AN populations are unfamiliar with strategies that engage tribal
    communities.

### 

### **Infrastructure**

-   Only 33 percent of IHS diabetes grant programs focus on
    preschoolers, and 32 percent focus on

> tertiary diabetes prevention.

-   Shortage of trained nutrition professionas and health care providers
    to mentor in order to cultivate career development of AI/AN youth,
    who may later serve their own communities.

-   Commission Corp dietitians are not mobile and often work in urban
    areas rather than in remote (high need) locations, e.g., Santa Fe,
    NM or Phoenix, AZ, rather than Eagle Butte or Rosebud, SD.

-   Insurance companies do not reimburse obesity prevention or weight
    maintenance services.

-   Staff time for nutrition education competes with Children's Health
    Insurance Program, and voter registration, in programs such as the
    Supplemental Food Program for Women, Infants .

-   The IHS scholarship program does not reserve paybacks for registered
    dietitians in remote locations.

-   There are few treatment programs for the morbidly obese in IHS.

-   There are no national standards or guidelines for pharmacological or
    surgical interventions for obesity within the IHS.

-   Healthy foods in remote locations may be limited and high cost.

### **Economic Barriers**

-   Significant poverty is present on reservations.

-   Literacy levels must be considered.

-   Employers do not allow time off for medical appointments.

-   Fast food is low cost and popular.

-   

-   Few health interventions or materials target low-income populations.

-   Self-prescribed weight control efforts are low cost, unproven, or
    unsafe, such as over-the-counter pills, smoking, and skipping meals.

-   Competent childcare to enable clinic visits or exercise is limited
    for low-income families.

-   Absence of transportation may limit access to clinic services.

-   Healthy food may be more expensive than unhealthy foods.

-   Outreach is difficult when families do not have phones.

> ![](media/image7.jpeg){width="5.759722222222222in"
> height="3.2263888888888888in"}

**APPENDIX 6**

**CDC Division of Nutrition and Physical Activity (DNPA)**

**Proposal to Collaborate with IHS**

IHS could partner with DNPA to address obesity in AI/AN populations.
Potential collaboration may include:

1). Use the IHS Resource Patient Management System (RPMS) for basic
surveillance of obesity and related health status markers (e.g., serum
cholesterol, blood pressure, diabetes management) for tribes that
participate in RPMS.

DNPA could develop a surveillance system based on the existing RPMS
system for those tribes that participate in RPMS. The CDC is committed
to helping AI/AN partner agencies or communities develop the ability to
take over and manage programs for themselves.

**2). Targeted interventions to reduce obesity among AI/AN
communities.**

The interventions could include the collection of
community-representative baseline data that would contribute to the
surveillance goals of the IHS and would serve as baseline for evaluation
of the interventions. Successful baseline and follow-up data collection
activities could serve as templates for developing surveillance systems
in other tribes or regions.

Projects could include interventions focused on physical activity, diet,
or a combination of the two, with the explicit goal of (1) primary
prevention of weight gain, (2) weight loss, or (3) maintenance of target
weight in a defined target segment of the population. DNPA would require
each applicant to include a mechanism to cover start up costs and
continuation of interventions after the end of the intervention period,
such as the development of partnerships in the community to sponsor
programs supporting the interventions. In all cases, developing
community commitment and capacity to independently maintain
interventions would be a primary goal of the interventions.

DNPA views this program as an opportunity for capacity building in AI/AN
communities. The CDC-sponsored Physical Activity and Public Health
Training Course, or other appropriate training programs, could be
attended by tribal people. A goal of the interventions could be to
permit the communities to continue surveillance and evaluation
activities after the completion of the intervention. CDC would provide
both data management and analysis support and training to enable
communities to become more competent in data management and analysis.

**APPENDIX 7**

**CDC Recommendations to Promote a Lifetime of Healthy Physical
Activity**

**Recommendations For School And Community Programs Promoting Physical
Activity Among Young People:**

1\. Policy: Establish policies that promote enjoyable, lifelong physical
activity

> among young people.

2\. Environment: Provide physical and social environments that encourage
and

> enable safe and enjoyable physical activity.

3\. Physical Education: Implement physical education curricula and
instruction that

> emphasize enjoyable participation in physical activity and that help
> students to develop knowledge, attitudes, motor skills, behavioral
> skills, and confidence needed to adopt and maintain physical active
> lifestyles.

4\. Health Education: Implement health education curricula and
instruction that help

students develop the knowledge, attitudes, behavior skills, and

> confidence needed to adopt and maintain physically active lifestyles.

5\. Extracurricular Activities: Provide extracurricular physical
activity programs that

> meet the needs and interests of all students.

6\. Parental Involvement: Include parents and guardians in physical
activity

> instruction and in extracurricular and community physical activity.
> programs and encourage them to support their children's participation
> in enjoyable physical activities.

7\. Personnel Training: Provide training for personnel in education,
coaching, recreation,

> health-care, and other school and community personnel that impart the
> knowledge and skills needed to effectively promote enjoyable, lifelong
> physical activity among young people.

8\. Health Services: Assess physical activity patterns among young
people, counsel

> them about physical activity, refer to them to appropriate programs,
> and advocate for physical activity instruction and programs for young
> people.

9\. Community Programs: Provide a range of developmentally appropriate

> community sports and recreation programs that are attractive to all
> young people.

10\. Evaluation: Regularly evaluate school and community physical
activity

> instruction, programs, and facilities.

**APPENDIX 8**

### **Mental Health Issues and Obesity in AI/AN**

An area that has been relatively overlooked by researchers is the impact
of psychological factors on obesity as well as the effects of obesity on
mental health. Following is a review of the limited published literature
on the subject.

Kozak examined health attitudes and perceptions of people with type 2
diabetes and suggested that the impact of history and culture has been
overlooked in biomedical research, thus leaving an incomplete model for
understanding the disease process and experience of illness in AI/AN
communities.^53^ The author speculated that this may be the reason that
clinical interventions to manage diabetes have generally failed. In
discussing how a community at risk of becoming sick perceives health and
well being, the author considered how type 2 diabetes has led to changes
in the individual and collective emotional response to the disease that
can be defined as "surrender." This term is not to be confused with
learned helplessness or a fatalistic response. The author defined
surrender as the creation by people with diabetes of a "hypothetical
life history of themselves where they expect to be sickened by, and to
die from, diabetes because the weight of day-to-day experience
throughout their lifetime reveals this to be an appropriate and accurate
assessment of reality."

Kozak conducted qualitative thematic and narrative analysis. Four
categories of a "death theme" were delineated: inevitability,
uncontrollability, inheritability, and death sentence. Results indicated
that participants attached symbolic and sociocultural meaning to the
type 2 diabetes disease process. The author suggested that further
attention to symbolic meaning and emotion is warranted and proposed that
instilling an understanding that the disease is preventable and
treatable as well as developing multidisciplinary and community-based
collaboration will increase treatment efficacy.

Huttlinger used ethnographic interview techniques to study Navajos, and
also noted the importance of cultural beliefs and sociological
understanding of the chronic disease process in AI/ANs.^54^ The author
suggested that better understanding is needed of the tribe's difficulty
integrating the disease concept of diabetes into their lives -- a
difficulty that often leads to Navajos being termed "noncompliant" with
medical treatment. Huttlinger correlated diabetes mellitus with
postcolonial activities, and with posttraumatic stress disorder in
Navajos. Colonialism refers to the establishment of Western thought as
legal, institutional, and cultural domination over others.^80^ ^56^
Posttraumatic stress disorder can be defined as the "result of a
dramatic environmental change, including involuntary displacement or
relocation or a natural disaster; as a result of physical, sexual,
emotional, or spiritual assault, abuse or neglect; as a result of
war-like conditions, including experience in battle, internment as a
prisoner of war, civil imprisonment, involuntary subjugation at a
boarding school, internment in a concentration camp, or experience as a
hostage; or as a result of the death of a close friend or relative."^54^
(page 13) ^55^ ^56^ ^57^ Study results indicated that this sample of
Navajos described diabetes as a disease that results from "forces beyond
the individual that come from the realm of the supernatural."^54^ (p.
14).

Neumark-Sztanier, et al. conducted a cross-sectional survey assessing
psychosocial, health, and weight-specific concerns; disordered eating;
and health-promoting behaviors.^58^ Of particular interest are the
results from the psychosocial concerns measure - an 11-item scale.
Perception of health status differed significantly for non-overweight,
moderately overweight, and very overweight boys and girls. Very
overweight children perceived their health as fair or poor. Differences
in body dissatisfaction, low body pride, and weight concerns were also
noted among these groups. These findings suggest that it is important
for obese youth to be both convinced and enabled to make successful
lifestyle modifications to prevent excessive weight gain. The authors
suggest that culturally sensitive educational and environmental
interventions that take psychosocial factors into account are paramount
for behavior change.

A body of research examines the importance of culture in the healing
process, and includes the wide acceptance of traditional healers' roles
in medical and psychological treatment. The importance of
culture-specific beliefs for the treatment of diabetes and obesity
warrants further study.

> **APPENDIX 9**

### **Traditional and Contemporary Foods**

During the past century, dietary patterns among the various AI/AN tribes
have changed drastically. Diets historically high in complex
carbohydrate/high fiber foods have been replaced by high-fat modern
foods.^63^ Concomitant with these dietary changes have been dramatic
increases in obesity and diabetes. Before the turn of the twentieth
century, however, the diabetes was vir­tually nonexistent. For at least
500-1,000 years, the Pima lived in the Sonoran Desert, cultivating crops
irrigated by an intricate canal system, hunting, fishing, and gathering
foods from the desert. As the area became more settled in the 1880s, the
upstream waters of the Gila River were diverted and farming in the
desert was no longer possible. Eventually, food from subsistence
farming, hunt­ing, and gathering was replaced with food from trading
posts and government food programs. It has been estimated that the
traditional Pima diet of one hundred years ago was 70-80 percent
carbohydrate, 8-12 percent fat, and 12-18 percent protein. By the 1950s
the Pima diet comprised about 61 percent carbohydrate, 24 percent fat,
and 15 percent protein. The current diet of the Pima is about 47 percent
carbohydrate, 35 percent fat, 15 percent protein, and 3 percent
alcohol.^63^

During the past fifty years, the amount of wild and homegrown foods in
the AI/AN diet has greatly diminished, and a significantly greater
propor­tion of food is processed and commercially prepared, a trend also
seen among the general U.S. population. However, many AI/AN families are
still involved in some aspect of home food production. A 1990, U.S.
Department of Agricul­ture study of program participants in the Food
Distribution Program on Indian Reservations, found that about half of
all households reported produc­ing some of their food themselves,
including growing fruits and vegetables, maintaining livestock for dairy
and meat, raising poultry for eggs, and hunting and fishing.^81^

In general, the diets of AI/AN today are high in refined carbohy­drates
(especially refined sugars), fat, and sodium and low in fruits, and
vegetables.^64^ ^65^ The Navajo Health and Nutrition Survey found that
fruits and vegetables were each consumed less than once per day per
person, as were dairy products. Fry bread and Navajo tortillas,
home-fried potatoes, mutton, bacon and sausage, soft drinks, coffee and
tea provided 41 percent of the energy and 15 -- 46 percent of the
macronutrients consumed.^66^ Traditional preparation over direct heat
has been replaced with pan frying or deep fat frying. The recent
proliferation of fast-food restaurants and convenience food stores on
and near reservations also encourages the consumption of high-fat,
high-sugar foods.^82^ It is generally conceded that poverty in Indian
commu­nities further limits access to a healthy food supply.

Several reports have examined both traditional and contemporary food use
among tribal groups.^65^ ^83^ ^63^ ^84^ ^85^ Al­though all report use of
traditional foods, most of these foods seem to be consumed only
occasionally. The declining use of traditional foods among the Hopi was
noted by Brown and Brenton,^86^ who found that less than 25 percent of
dietary recalls from 420 children and female homemakers included at
least one traditional food in the daily diet. The most popular
Hopi-grown traditional foods continue to be corn and beans, which are
ancient dietary staples.^86^ Nobmann and colleagues found that native
foods such as salmon and other fish were used frequently by Alaska
Natives.^87^ Traditional fermented foods, including seasonally consumed
heads and eggs of salmon and other fish, seal, beaver, caribou, and
whales were re­ported by 23 percent of those surveyed.

For many AI/AN, foods regarded as traditional often have particu­lar
spiritual and social value and represent purity, healthfulness, and
strength­ - symbols of a pre-reservation (and pre-European contact) life
and culture. These foods are held in high regard and are seen as having
healthful properties, in con­trast to the modern-day diet.^88^
Traditional foods are an integral part of numerous celebrations, feast
days, powwows, and religious ceremonies. Most traditional foods are low
in fat and sugar, with relatively high nutritive value. Today, Indian
populations are being encouraged to incorporate more of their
traditional foods into their diet.

Many traditional belief systems include the concepts of harmony and
balance respecting food, and these can be useful concepts in motivating
individuals and communities to increase their use of traditional foods
and adopt healthier lifestyles. It is possible to reproduce the
composition of the native diet reasonably well with traditional foods
and certain commercially available foods.^63^ When traditional foods are
not available, healthy substitutes may be suggested, such as carrots for
wild roots, spinach for wild greens, and fresh fruit for wild berries.

![](media/image8.jpeg){width="5.793055555555555in"
height="3.6534722222222222in"}

**APPENDIX 10**

> **Nutrition Intervention Studies**

**Zuni Pueblo**

The IHS has partnered with Zuni Pueblo, NM, a southwest AI community
with high rates of obesity and diabetes, to develop community-based
diabetes and wellness programs to promote physical activity through
fitness events, healthful eating through nutrition education, and weight
loss through weight loss competitions in adults*.*^69^ The results
showed improved metabolic control in individuals with type 2 diabetes
and modest weight loss. The exercise program consisted of several 1-hour
aerobic sessions offered during the week. Zunis who were trained in
exercise and group leadership methods helped coordinate the program and
build community ownership. After participating in aerobic sessions
through the program, 43 percent of the participants began and maintained
an at-home exercise program, whereas only 18 percent of a comparison
group of previously sedentary non-participants with type 2 diabetes did
so*.*^69^ The Zuni Diabetes and Wellness Program continues today, and a
picture of the Tribal Wellness Center, Lea Lewis, MPH Director, is
featured in the US News and World Report, Dec 25, 2000 issue and an
article about the Zuni Center, under the heading of \"Innovations 2001:
The Best Minds at Work.\"

**Pathways**

Pathways is a school based primary prevention study of obesity in AI
third, fourth, and fifth grade children funded by National Heart, Lung,
and Blood Institute of NIH. After three years' implementation of the
feasibility study in four schools, NHLBI extended funding to expand the
program to 41 schools for a three-year intervention. The project is the
result of a unique collaboration among AI nations, universities,
schools, and families. This multi site study involves seven American
Indian Nations/Tribes and five universities.^72^ The seven AI nations
are the (Dine) Navajo Nation, the Gila River Indian Community, the
Tohono O'odham Nation, the White Mountain Apache Tribe, the San Carlos
Apache Tribe, the Oglala Lakota Nation, and the Sicangu Lakota Nation.
Results from the study are anticipated early in 2001. The intervention
program promotes increased physical activity and healthful eating
behaviors for AI children through the following:

**1). Curriculum.** The Pathways curriculum consists of culturally
appropriate school-based lessons that promote healthful eating behaviors
and increased physical activity.

**2). Physical Activity.** The intervention is focused primarily on
increasing children's activity and energy expenditure in school by
increasing the frequency and quality of physical education classes and
activity breaks, including recess periods.

**3). School Food Service.** The goal is to lower the amount of fat in
the breakfast and lunch school meals to a healthful level of fat.

**4). Family.** Pathways builds a supportive collaboration for obesity
prevention among teachers, food service personnel, school administrators
and family. Pathways involves a school-family advisory team, Family Fun
Nights at each school, and Family Packs -- education materials taken
home by students to their parents.