1/5/07njm

**Discussion: Causes of Type 2 Diabetes: Old and New Understandings**

**Moderator: Ann Bullock M.D.**

We would like to hear your thoughts on the Causes of Type 2 Diabetes.

To begin with, please review the case below and tell us what could be
done at your facility now...

...then tell what you wish could be done in the future.

Our moderator is Ann Bullock, MD, Medical Director, Eastern Band of
Cherokee Indians

**Case Scenario**

A 9 year old girl was brought into the clinic by her family as she had
been having blurry vision and urinating frequently.  As there are
multiple family members with diabetes, including her father and older
sister, they had checked her sugars at home and found them to be well
over 200.  The symptoms started within a few days of her 46 year old
mother's death after a prolonged ICU stay, which capped about 5 years of
serious diabetic complications. 

The 9 year old's mother had been diagnosed with type 2 diabetes for 8
years when she was pregnant with the patient.  Exam was significant for
obesity (\>95^th^ percentile for age and height, BMI of 33), acanthosis
nigricans, and positive serum glucoses confirming the diagnosis of
diabetes.

-How would you manage this patient at your facility?

-What are some key points for possible intervention?

-Could some of this have been prevented?

Go here for a **Summary of the Key Points** on issues associated with DM
etiology

<http://www.ihs.gov/MedicalPrograms/MCH/F/documents/Question111606.doc>

**More Resources**:

<http://www.ihs.gov/MedicalPrograms/MCH/F/PCdiscForumMod.cfm#diabetes>

**Lamer, Chris CL (IHS/NAS) \[Chris.Lamer@ihs.gov\]**

**Sat 12/2/2006 6:44 AM**

Below are my comments and thoughts on this interesting case.  For as
much as we continue to learn about diabetes, it seems like the
management continues to increase in complexity and difficulty.\
\
Obviously the first step would be to gather more information first. As a
pharmacist and clinical coordinator, I do not have much opportunity to
intervene on a patient\'s treatment plan; however, I would consider the
elements listed at the end of my e-mail- and be totally overwhelmed!\
\
Realistically, (in a nutshell), I would expect this patient to be
thoroughly assessed and to be admitted to the hospital. Treatment would
consist of initiation of short acting insulin to lower the blood glucose
and initial diabetes education to the patient and the family, a hard
task as you is trying to target the child\'s level of understanding but
also raising the bar for the parents. After initial treatment, the next
steps would depend upon the child\'s assessment with an intervention
targeted at nutrition and exercise initiated with or without insulin
therapy and frequent visits to the diabetes clinic.\
\
I think one of the greatest difficulties in preventing this and other
chronic diseases is that it really involves transforming society. How
can we motivate a culture to change - how can we effectively implement
true public health measures to reduce chronic disease such as diabetes?
Do our health care teams contain the right people to implement these
changes - clinicians, outreach, community members, and
governmental/Tribal members?\
Chris\
\
Just as the development of diabetes, interventions for chronic diseases,
especially type 2 diabetes are multi-factorial. Elements I would
consider on the individual level for intervention:\
1) Thorough assessment of the patient (their lifestyle, history,
problems, concerns, beliefs, experiences\....\
\
2) Intensive education consisting of knowledge assessment, transfer of
knowledge, motivational interviewing and goal setting to encourage
change/intervention based on the education. Diabetes treatment is a time
and energy consuming force and as demonstrated by the DPT (and other
studies) continued patient assessment and motivation requires near
one-on-one interactions frequently.\
\
3) Identification of behavioral needs and barriers that may be necessary
for the patient to make appropriate health related decisions and
interventions. Behavioral health needs have skyrocketed as the
understanding of the development of chronic disease and mental
interventions that are necessary to elicit physical interventions have
been better understood.\
\
4) Interventions targeted at lifestyle. Traveling to different places
has made me aware that it is not always easy to get something to eat at
a restaurant that isn\'t fast food or fried in some locations or to even
get out and exercise. (not to mention the fact that the food tasted darn
good!). Social and public health changes are some of the hardest health
changes to initiate as there are so many variables and it is outside of
the realm of clinician training, experience, and expectations.
Incorporating community involvement is essential for interventions to
occur in the environment.\
\
5) Pharmacologic therapy still remains a cornerstone of treatment, and
we can expect this girl to be on 8-15 medications and to develop 2-4
more chronic diseases throughout her life. Currently no oral medications
are FDA approved for the treatment of type 2 diabetes in children,
although small trials have found them to be effective and to have
similar actions as that observed in adults; however, \"it is never too
early to start insulin,\" the only FDA approved treatment of diabetes in
children.\
\
6)  In addition to interventions on the disease, the clinician must also
consider assessment and improvement of health literacy to ensure the
patient and family understands the process for obtaining health care
resources (appointments, referrals, medications, reading labels) - which
we often take for-granted.\
\
7) In this case and others, clinicians do not only have to educate,
treat, and empower the patient; but also must do the same for those
people whose lives strongly influence the patient (family members, close
friends).

**N BURTON ATTICO** <BabyDoc53@msn.com>

**Sun 12/3/2006 7:00 AM**

I thought that these two articles below\* might add something to the
discussion on management of the child with diabetes.  At the present,
the oral medications utilized in adults are not approved for use in
children, and, as someone who has fought with this disease for more than
25 years; I think that this might add something.  No matter what \"the
calculation\" of dosage, it still usually amounts to mostly a guess as
to dose.  I manage to keep my A1c in the normal range, as I believe that
diabetes is a disease that reminds you in 10-20 years what you did
today, and I saw both my mother and a brother slowly destroy vital
organs and slowly kill themselves.  I am not fatalistic (as so many of
my patients were - they would answer \"I don\'t have that problem
yet\"), and believe that I can (must) beat the disease.  My
patients were usually afraid of both finger sticks and needles, but I
find that I cannot exist without them, and rationalize each time (blood
sugar 3-6x daily, insulin 3-4x daily).  My problem is forgetting to eat,
and resultant hypoglycemia, often unrecognized.  To make things worse, I
now live alone.  My patients trusted me because I \"challenged\" them,
and also told them that I was not asking them to do anything that I
didn\'t do myself.  When I was diagnosed with diabetes, the guys at NIH
teased me that I had proven that diabetes was a contagious disease.

 

I don\'t think we motivate our patients enough, for control of diabetes
is [entirely]{.underline} the responsibility of the patient.  \"The
patient is the one who [controls]{.underline} the disease; the doctor
only \'[monitors]{.underline}\' the degree of control.\"  Motivation
(internal) is the most important control factor, and has to be
*implanted*.  Pregnant women are the most highly motivated, especially
when they learn about what can happen.  Hospitalization for \"control\"
usually allows motivation and education, and gives staff time for that
education.  Education, education, education - and [more]{.underline}
education.  The PIMC staff knows how compulsive I am.  I want to be able
to bounce my grandchildren on my knee, and still have my knees, and be
able to see them!

 Burt Attico

**\* Refined Definition of Metabolic Syndrome Better Predicts Future
Diabetes**

A newly validated definition of metabolic syndrome that uses continuous
rather than categorical variables has better predictive power for future
diabetes, according to a report in the November issue of Diabetes Care.

\"The diagnosis of the metabolic syndrome should not be managed as a
categorical variable; a \'yes or no\' approach is not valid in
chronic-degenerative disorders such as this,\" Dr. Rosalba Rojas told
Reuters Health. A continuous variable concept \"results in a group of
subjects with a spectrum of long-term risk for having the final
outcomes.\"

Dr. Rojas from the National Institute of Public Health, Cuernavaca,
Morelos, Mexico and colleagues developed a definition that gave one
point per population decile for every component of the National
Cholesterol Education Program (NCEP) definition of the metabolic
syndrome, and tested the ability of the definition to predict diabetes
in a Hispanic population.

More than 60% of the patients identified by NCEP criteria as having
metabolic syndrome were in the upper quintile of the new definition\'s
scale, the authors report. However, 147 of 559 individuals in the upper
quintile had an adverse metabolic profile but met only two NCEP
criteria.

\"Therefore,\" the investigators assert, \"the population-based method
provides complementary information for individuals with no more than 2
NCEP components.\"

The prevalence of hyperinsulinemia increased as the total number of
points increased, the results indicate, and the incidence of diabetes
was directly proportional to the total number of points accumulated.

\"The clinical application of our method may be limited by the necessity
for a decile distribution of the variables,\" the researchers admit.
\"The main value of this report may be in research studies.\"

Meanwhile, \"a large cohort study is under way to assess the performance
of our definition (and other prognostic scales) for the prediction of
cardiovascular outcomes,\" Dr. Rojas said. \"In addition, we are
applying our population-based definition in several genetic studies
designed to identify type 2 diabetes susceptibility genes.\"

[Aguilar-Salinas
CA](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Aguilar-Salinas+CA"%5BAuthor%5D)
et al Design and validation of a population-based definition of the
metabolic syndrome. [Diabetes
Care.](javascript:AL_get(this, 'jour', 'Diabetes Care.');) 2006
Nov;29(11):2420-6

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17065678>

[**Insulin Therapy: Indications, Insulin Types, and Treatment
Design**](http://www.medscape.com/viewprogram/6309)

<http://www.medscape.com/viewarticle/548385>

**From Ann Bullock, MD**

**Tue 12/5/2006 5:30 AM**

Understanding what is causing the diabetes epidemic which causes so much
suffering and early death in our AI/AN communities should be among the
most important discussions we in Indian Health can have.  Many of us
have been combating this epidemic for years and feeling more frustrated,
even burned out, from the sense that it just never ends.  Prevention
programs seem to have little effect and offer small hope that the tide
will ever be turned.  Fortunately, research coming out in the last few
years is starting to give us a better glimpse into the complex and
fascinating physiologic/behavioral entity that is type 2 diabetes.

 

The case study of the 9 year old child Dr. Murphy sent out is a real
case from here in Cherokee.  It was chosen to illustrate the many
factors that are known to contribute to diabetes.  So that our
discussion can focus on applying newer understandings of diabetes
etiology from the literature, I've pasted the "summary of key points"
below for your consideration.  If these issues are of interest, click on
the "More Resources" link for articles which discuss them further.

 

Questions we might discuss include:

-How successful are we with diabetes prevention using our current
models? 

-What do the studies (e.g. DPP, Finnish Diabetes Prevention Study)
showing the ability to prevent /delay diabetes onset teach us? 

-Why, really, do we have almost 2 ½ times as much diabetes in our Indian
communities as in the general population?

-How does poverty affect this so profoundly? 

-How do prenatal and early life environments/experiences help set a
"trajectory" toward future obesity and diabetes?

-How do adult life experiences continue to affect that "trajectory"?

-How might these newer understandings change the way we think about the
causes of diabetes? 

-How might our diabetes treatment and prevention programs evolve in
response to the science showing the breadth and depth of the
multifactorial nature of type 2 diabetes?

>  

I'm looking forward to what I'm sure will be an interesting discussion
about the roots of the obesity and diabetes epidemics in Indian
Country.  Thanks to Drs Lamer and Attico for making many good points to
start us off!

 Ann Bullock, MD

 

**Summary of key points:**

Type 2 diabetes is increasingly understood to be multifactorial in
origin.  The International Diabetes Federation convened a conference in
2002 to examine the literature on this issue and identified 4 etiologies
defensible at a level of evidence of either A or B: (1) Genetics, (2)
Fetal Origins, (3) Lifestyle, and (4) Stress (see IDF Consensus Document
in the "More Resources" link).  "Fetal origins" refers to how the
prenatal nutritional status of the mother affects the risk for diabetes
in her offspring. This category would also include the increased risk to
offspring who are the products of diabetic pregnancies.  The case study
illustrates a 9 year old child who had all 4 of these etiological risk
factors contributing to her diabetes.  Other risk factors which have
been associated with developing obesity or diabetes, even if not yet
proven to be causative, include smoking, depression, adverse childhood
experiences, poverty, prenatal alcohol and/or smoking exposure, and
environmental pollutants.

 

The tremendous impacts of an individual's life experiences and
environment on health behaviors and outcomes are starting to be realized
and defined.  The prenatal and early life periods are generating
particular attention as health "trajectories" are affected by life
experiences most profoundly while the organism is undergoing
development.  These trajectories, if left unaltered, set a life course
through their physiologic and behavioral effects, including brain
development and synaptic complexity, hypothalamic-pituitary-adrenal
(HPA) axis sensitization, autonomic nervous system reactivity,
sensitivity to hunger/satiety signals, imprinting of parentally modeled
eating behaviors, and others---all of which combine and accumulate to
set a course toward obesity and eventual diabetes.  Given this and that
it has been shown that high fat/high calorie foods turn off the HPA axis
stress response and that carbohydrates modulate brain serotonin levels,
overeating can be seen as an adaptive stress coping mechanism, which
would reframe much of the context for "lifestyle education".  Even the
genetic component of diabetes risk is affected by life experience---as
the emerging field of epigenetics is now revealing, it is not just a
matter of which genes are *inherited*, but also which genes are being
*expressed* in response to environmental stimuli.

 

Perhaps it is time to expand our models to incorporate these newer
scientific perspectives. 

**More Resources**:

<http://www.ihs.gov/MedicalPrograms/MCH/F/PCdiscForumMod.cfm#diabetes>

**North, Charles (IHS/ALB) \[Charles.North@ihs.gov\]**

**Fri 12/8/2006 10:05 AM**

I appreciate the comments of Dr.'s Attico and Lamer.  The summary of key
points is a very concise and profound reduction of the state of our
knowledge and the literature that has increased exponentially.  I would
like to respond to Dr. Bullock's questions listed below from my clinical
experience.

 

1.  How successful are we with diabetes prevention using our current
    models?  *Our current models include community and clinically based
    interventions.  We know intensive education and groups that discuss
    common interests work from the DPP study but the durability of the
    effect is not known.  We need better effectiveness studies for both
    clinical and community interventions.  Anecdotally, my patients are
    much more aware of the risk from diabetes and are much more
    interested in weight loss, diet and exercise than just a few years
    ago.  Whether this will translate into primary prevention, delayed
    diagnosis, earlier treatment, fewer complications and longer life
    remains to be seen.*

2.  What do the studies (e.g. DPP, Finnish Diabetes Prevention Study)
    showing the ability to prevent/delay diabetes onset teach us?  *They
    teach us that it will take a lot of time and money to make a
    difference without major government intervention to regulate the
    food, transportation and health care industries.  The same can be
    said for global warming, no?*

3.  Why, really, do we have almost 2 ½ times as much diabetes in our
    Indian communities as in the general population?  *Poverty and the
    current stress from being a small misunderstood minority in a
    society managed by the descendents of conquering European immigrants
    have to be significant factors.  I find my patients are often
    anxious and stress about financial and family issues without the
    resources to address them.  Prejudice and discrimination are less
    than in earlier times, but subtle forms of racism can be very
    stressful still.*

4.  How does poverty affect this so profoundly?  *Poverty makes healthy
    food choices difficult, exacerbates educational challenges and feeds
    depression and loss of hope.  Alcohol abuse, drug use and somatic
    disorders are exacerbated by poverty.  Families have fewer options
    for housing, less privacy, more crowding and health falls lower on
    the agenda behind shelter, food and finding enough cash to make it
    day to day.*

5.  How do prenatal and early life environments/experiences help set a
    "trajectory" toward future obesity and diabetes?  *"Stress or
    comfort" eating, adverse childhood experiences, exercise habits and
    food choices are all factors.  The prenatal environment has profound
    impacts on the adrenal cortical system.  Will prolonged
    breastfeeding compensate? *

6.  How do adult life experiences continue to affect that "trajectory"? 
    *Many of my morbidly obese adults were victims of childhood sexual
    abuse and suffer currently from chronic mental disorders.  They tend
    to overeat when stressed.  Even discussing weight loss and diet can
    be stressful and paradoxically lead to overeating and weight gain. 
    Alcohol abuse, family disruption, intimate partner violence, poor
    educational and work experiences, and external threats to
    communities can continue the cycle of trauma and stress.*

7.  How might these newer understandings change the way we think about
    the causes of diabetes?  *I think we need to use an approach that
    includes the understanding of the community environment, family,
    social and psychological factors in the development of diabetes and
    morbid obesity.*

8.  How might our diabetes treatment and prevention programs evolve in
    response to the science showing the breadth and depth of the
    multifactorial nature of type 2 diabetes?   *We need to find new
    ways to empower communities to find new ways to control their
    destinies.  I would like to hear from our diabetes program leaders
    who know examples of communities that are using new approaches.*

 

*Thanks for raising these important questions.  I would like to hear
from others who care for patients like this 9 year old.*

**Neil Murphy**

**Mon 12/11/2006 2:52 PM**

Here is a message that was sent in f/u to Dr. North's 12/6/06 message,
above

"So true.

Helping patient\'s manage \"medical conditions\" within the everyday
socioeconomic context of their lives casts a whole different light on
strategies and priorities. Ten years of clinical practice has taught me
that the forces of poverty (little money to spend on feeding families =
forced subsistence on cheap starchy (potatoes) + fatty (spam) diets,
jobs that require long hours and limited access to healthy food choices)
are under appreciated \"risk factors.\" Yes, we\'re lucky in the IHS to
be able to offer patients access to medications, but I would agree our
next goal is to focus on community-based initiatives that increase ready
access to affordable, healthy foods, and family-oriented recreational. "

**Long, Bernard BNL (IHS/ABR) \[Bernard.Long@ihs.gov\]**

**Tue 12/12/2006 3:02 PM**

So many things to do...so little resources....and we are running out of
time, for so many. 

All of the communities that we serve have striking similarities, but are
vastly different. While our need (unmet) for direct clinical service is
increasing; our Public Health infrastructure also suffers. I have
patients that totally rely upon or demand the Indian Health Service meet
all their health needs and yet there are equal number of people who know
that this in not possible.  The social-economic condition must improve
for more people to be engaged in their own health.  I feel we must
create or strengthen the "partnership" bonds so a tribal and community
infrastructure can be more supportive to personal and public health
indicators. Our mission statement uses the word partnership and the
principle is still fundamentally sound. These can be either just words
or something we actually do.

  [^1]**MISSION: **

> ***The mission of the Indian Health Service, in partnership with
> American Indian and Alaska Native people, is to raise their physical,
> mental, social, and spiritual health to the highest level.***

**\*GOAL: **

> ***To assure that comprehensive, culturally acceptable personal and
> public health services are available and accessible to American Indian
> and Alaska Native people.***

**\*FOUNDATION: **

> ***To uphold the Federal Government's obligation to promote healthy
> American Indian and Alaska Native people, communities, and cultures
> and to honor and protect the inherent sovereign rights of Tribes.***

I sense there is a lot of untapped or non-directed energy throughout the
Service.  I hope we all can find or create avenues to assist our
communities and support current infrastructure.  Although economic
development is not our mission, it is part if the fabric whereby we
perform our mission.

Remember the greatest strength to make change exists internally in all
of us.

**Placide, Frances fpp (IHS/NAS) \[Frances.Placide@ihs.gov\]**

**Tue 12/12/2006 6:24 PM**

This is a fantastic discussion. While the case presented identifies DM
as the primary diagnosis, I believe we can assign the diagnosis of any
number of chronic diseases (prevalent in Indian Country) and end up with
very similar issues relative to self and disease management in minority
communities.

Why is it that Indian communities, in which the population has
considerable access to medications, continue to be challenged by raising
rates of DM and other chronic diseases? I applaud Dr. North
comments:\...the answers are obviously not in the medications-alone.
Rather, it most likely lies within addressing the issues relative to
poverty, early negative childhood experiences, historical trauma, grief,
and persistent lack of emotional and environmental support.

I think our diabetes treatment and prevention programs must be directed
towards addressing more of these emotional/environmental/ behavioral
issues with the involvement of comprehensive, community-based and
non-traditional behavioral approaches if we are to decrease the
incidence of and get ahead of DM and other chronic diseases in Indian
Country.

I too am eager to hear from the DM program leaders who are using new
community-based approaches to combat not just the disease but also the
social issues relative to its effective management.

Frances Placide, PA-C

**Mckittrick, Katherine km (IHS/NAS) \[Katherine.Mckittrick@ihs.gov\]**

**Wed 12/13/2006 4:49 AM**

Good Morning,

I feel compelled to respond to this case which cuts to the heart of our
work. This child has just lost her mother to diabetic complications. I
doubt that I can begin to understand how that might affect her. Sheer
terror might be a place to begin. Why would she ever come to believe
that she could control a disease that killed her mom? How can we provide
education and support without implying that her mother might have
survived if she had only followed medical advice? Her remaining parent
and a sibling are also threatened. My gut suggests that a common enemy
could provide a base from which these family members might come together
to create and implement a strategy for survival but reframing this
tragedy into an opportunity will take a mighty effort and it is the
family, not the health care providers, who are the key players.

This case makes me think of a patient here who is in her thirties and
almost blind from diabetic retinopathy. Her 13 year old son draws up her
insulin for her because she can\'t see well enough to do it correctly. I
wonder what the future holds for him. How does the daily experience of
helping his mother who has not been able to care for herself influence
his sense of the possibility of controlling diabetes (which he will
probably have eventually)?

There are many challenges in health care but the one that puts my back
up against the wall more than any other is responding to a sense of
futility and impotence (masquerading as apathy) among patients. I have a
lot to learn about helping others to understand that they are more
powerful than they know\...

My experience in another setting suggests that a different messenger
(rather than a different message) may be an effective strategy.

Kate McKittrick, PA-C

Cherokee Indian Hospital

**Saltclah, Rose (FDIH) \[Rose.Saltclah@ihs.gov\]**

**Wed 12/13/2006 2:16 PM**

Katherine,

I appreciated your thoughts and recommendations.

It is rather difficult emotionally to deal with a diabetic in a
household and daily interaction of seeing a loved one with such disease
and its complications. Children learn fast and amazingly grow up fast.

I believe healthcare providers and DM educator coaching the family
during and after the fact, will guide a family thru.

Such tragedy.

Depending on what population we work with; I strongly believe and
practice the cultural integration of traditional perspective of
healthcare vs contemporary healthcare approach in dealing with chronic
disease.

That seems to work in my clinical practice working with the Navajo
population.

On the positive note; children that experience such tragedy may grow up
with better understanding of their own health; some day have better
weight control of their health, exercise and focus on prevention. I have
known some youth (natives) that have selected a health care profession
as a career because of their love ones medical issues.

Thanks CDR Saltclah

**Attico, Burton <nbattico@POL.NET>**

**Fri 12/15/2006 7:01 AM**

I think that the reaction (that this child will eventually get diabetes)
is fatalistic, which is not the way to talk to this child about
diabetes.

There are several things that can be done as far as prevention, proven
by the Diabetes Prevention Program Trials, some of them done right here
in the Phoenix Area. Today, there are a number of things that can be
done with the patient who has diabetes, so that that patient is included
within their family. Desserts can be a piece of fruit, and doesn\'t have
to be a brownie or a piece of cake. There are now \"no-sugar-added\"
pies and cookies, as well as diet drinks. In some stores (like Trader
Joe\'s), ice cream that the patient with diabetes can have are
available.

Also, we do not \"deal with a diabetic,\" but rather, help a person with
diabetes. The personhood is far more important than the disease, and we
should not label the patient by a disease entity with which he might be
afflicted. If we look optimistically at things, give hope rather than
gloom, our patients might respond differently to this disease, and with
some thoughts at \"beating it,\" rather than fatalistically succumbing,
and developing all the complications. Treatment today is far different
than 30-40 years ago. I don\'t want to hear a patient say \"\... I
haven\'t gotten that \... yet.\" Remember, that person must be motivated
to control the disease, for the provider is nothing more than an
advisor, educator, motivator, and monitor. Insulin is not the most
horrible thing, and eventually most people with diabetes wind up using
insulin. Nasal insulin is an available alternative that has not been
tried much in our IHS system.

(I tried responding to this last evening, and my system \"signed\" me
off while I was writing. I hope this gets through. Any disagreements,

folks?)

Burt Attico

**Kate McKittrick \[mckitk@yahoo.com\]**

**Sat 12/16/2006 10:51 AM**

Thanks for the responses from Commander Saltclah and Dr. Burton.  I\'d
like to clarify that my comment regarding the teenage boy who will
\"probably have diabetes eventually\" was based on the science mentioned
in Dr. Bullock\'s last email.  She reminded us that \"the International
Diabetes Federation convened a conference in 2002 to examine the
literature on this issue and identified 4 etiologies defensible at a
level of evidence of either A or B: (1) Genetics, (2) Fetal Origins, (3)
Lifestyle, and (4) Stress.\"  Like the 9 year old girl of the original
case study, this 13 year old boy has elements from all four
etiologies contributing to his risk for diabetes.  Clearly he is at
risk.

 

As our understanding of the causes of diabetes deepens, our challenge
becomes translating that understanding into effective action.  I did not
mean to imply that I felt fatalistic about this kid\'s future.  On the
contrary, I am looking realistically at his risks and thinking about
ways that we might empower him to take charge of his life and his
health.  Before any education about diet and exercise can be effective,
however, he must believe that he is capable.  Without this foundation,
all other efforts are futile.

 

I would like to hear more about coaches, the traditional approach to
health care, and the DPP.  I believe that the most powerful tool I have
as a clinician (and a human being) is a caring relationship.  I continue
to wonder if we need a change in paradigm.  What would happen if
community members, both with and without diabetes, became the recognized
teachers and mentors and our focus turned toward providing them with the
resources they need to step into this role?  A change in role has an
interesting way of changing perspective and community members will be
there to provide support, encouragement, and guidance long after our 20
minute office visits have ended.   It seems to me that, although we know
some things about how to eat, exercise, and use medicine, it is
community members who are the experts on life in the community and how
we might, together, face the challenges of diabetes. 

 

Kate McKittrick, PA-C

Cherokee Indian Hospital

**Ann Bullock, MD
[[ANNBULL@nc-cherokee.com]{.underline}](mailto:ANNBULL@nc-cherokee.com)**

**Mon 12/18/2006 2:13 PM**

Thanks for all the wonderful comments!

As we are starting to realize how profoundly poverty, stress and other
life experiences contribute to obesity and diabetes risk, some clinical
providers become frustrated because they \"can\'t fix poverty\" or
otherwise change the life circumstances of their patients. We in
clinical care deal simultaneously with both the macro and the
micro\--both the community-wide issues as well as how they affect the
patient sitting in front of us. 

How can our prevention and treatment programs support patients in the
life situations they find themselves in?

The Diabetes Prevention Program (DPP) was successful in
preventing/delaying diabetes, including in the American Indian
subgroup\--focus groups with the AI participants after the study was
completed clearly indicated that the tremendous amount of individual and
group support built into the intervention played a large role in their
success.  Similarly, the DPP Lifestyle Coaches have told story after
story about how they first needed to listen to participants talk about
the difficult things going on in their lives before they could start
discussing weight loss or exercise minutes.  In infectious disease,
eradicating the infection is preferable, but if that\'s not possible, we
can strengthen the person\'s immune system so they can better combat the
infection themselves.  Perhaps it\'s similar with poverty and
stress\--maybe we don\'t always have to \"fix\" the difficult life
circumstances many of our patients live with in order to make a
difference.

Another study which raises a lot of issues here is the \"Pima Pride\"

study (Narayan et al, Diabet Med 15:66-72, 1998).  This was a pilot
study for the lifestyle intervention used in the DPP.  This study
recruited obese, normoglycemic participants and randomized them to the
lifestyle intervention (\"Pima Action\") and to a control group (\"Pima
Pride\").  The control group for the study received no diet/exercise
instruction; instead they met to discuss Pima history and culture.  At
the end of the study, the \"Pima Pride\" control group had more positive
outcomes than did the intervention group on all biological measures
studied.  In commenting on this study, the Principal Investigator and a
colleague stated, \"\...it is also intriguing to consider the
possibility that social support has a more direct effect on diabetes
control or perhaps influences glycemic control in ways that extend
beyond our current paradigm of diabetes management\" (Gregg and Narayan,
Diabetes Care 21(5):875, 1998).  Maybe social support, celebration of
community identity, acknowledging our history and honoring cultural
knowledge are even more powerful tools to prevent diabetes than
diet/exercise training!

 

How would that change our diabetes prevention programs?  Please share
your thoughts.

Ann Bullock

**Pena, Dennis (IHS/PHX) \[Dennis.Pena@ihs.gov\]**

**Thu 12/21/2006 9:55 AM**

The premier expert/author on leadership is John C. Maxwell u can find
his books by searching on Amazon he is one of their top selling authors

Mr. Maxwell simply defines leadership as influence in his book \"the 21
irrefutable laws of leadership\" he discusses the law of connection
stated thus, \"people don\'t care how much you know, until they know how
much you care\"

People feel loved when they feel heard

Dennis Pena

Podiatrist, Phoenix Indian Med Ctr

Pain Specialist

**Satterfield, L. Dawn (CDC/CCHP/NCCDPHP) \[dxs9@cdc.gov\]**

**Fri 12/22/2006 8:03 AM**

Thank you for including me on this listserv for this important
discussion.  The recommendations, compassion for this child and her
family, and recognition of the context of the situation and the
complexity that contributed to its development have been so instructive
and insightful.  The point that Dr. Bullock made on Monday about the key
role of social support in the success of the lifestyle arm in the DPP is
so well stated.  This observation provides direction not only an
individual and family counseling/care level but as we consider local,
state, and national policies in our collaborative efforts to prevent
diabetes and its complications across generations.  I am going to put
this observation to use right away in my work. Thank you!  Dawn

 

Dawn Satterfield RN PhD

Native Diabetes Wellness Program

Division of Diabetes Translation

Centers for Disease Control and Prevention

2858 Woodcock Boulevard Mailstop K-10

Atlanta, Ga. 30341

770-488-5285

**Attico, Burton** <BabyDoc53@msn.com>

**Sat 12/23/2006 10:20 AM**

Shortly before the Pima Pride part of the DPP intervention, there was a
group that noted that obesity was not present in the Pima at the turn of
the century (1900s), verified from old pictures. There were folks who
started a \"move back,\" restoring native foods rather than the \"empty
calories\" of today\'s processed foods, which factor seemed to be part
of the reason(?) for increasing rates of obesity.

In the DPP, it was noted that lifestyle changes had more of an effect on
prevention/delay than did medications. Thus, in both situations,
creating a motivation to change seemed to be the most important factor.
Diabetes has a large/huge behavioral factor, and while this may not be
there (or

apparent) in every case, it certainly is overwhelmingly important once
the disease actually starts.

Again, once the disease actually starts, motivation of the patient is
the most important factor, for it is that patient who is the one who
will actively control the disease, not the provider. The provider must
educate and motivate the individual patient to feel that they \"can
beat\" the disease.

Burt Attico

**Pena, Dennis (IHS/PHX) \[Dennis.Pena@IHS.GOV\]**

**Tue 1/2/2007 8:16 AM**

Re: Motivation

A Dr. told me that he had learned that if you want the \"cure\" more
than the pt. does, then you are doomed to failure

Another way to look at motivation is this:

You really do not help someone when you do something that they can do
for themselves.... to echo Dr. Burton\'s comment that the pt. must
control the disease, not the Dr.

**bich-hoa nguyen \[heohoa@hotmail.com\]**

**Fri 12/29/2006 4:02 PM**

Dear Ms. Bullock,

Thank you for bringing the subject on type 2 DM together. It\'s
comforting to know what little success I\'ve had with this disease, is
the norm.

Happy New Year to you too.

B.Hoa Nguyen, DO

(ex-Winslow IHS FP)

[^1]: ^^