A Guide for American Indians 

I CAN LOWER MY RISK FOR 

TYPE 2 DIABETES 

NATIONAL INSTITUTES OF HEALTH 

National Kidney and Urologic Diseases Information Clearinghouse 

U.S. Department 

of Health and 

Human Services 
A Native Physician’s Thoughts 

Dear Friends, 

As a Native physician practicing in Indian communities, I have seen the 

devastating changes diabetes has caused among our people. American 

Indians are more than twice as likely to develop diabetes than the rest of the 

U.S. population, and we are more likely to develop complications of diabetes 

once we have the disease. 

Despite these higher risks, Indian communities can work toward preventing 

diabetes with modest lifestyle changes. For years we have assumed that 

losing weight and exercising will lower our risk of developing diabetes. With 

the results of the Diabetes Prevention Program, we have not only confirmed 

that it is true, but we now know that the changes needed to reduce our risk 

of diabetes are not as big as we thought. We do not have to completely 

return to the lifestyle of our ancestors to prevent diabetes. We can take 

small steps toward achieving big rewards. 

Donald K.Warne, M.D, C.D.E, M.P.H. 

Oglala Lakota 
Research Gives Hope Diabetes Can Be Prevented 

Although people with diabetes can prevent or delay complications by 

keeping blood glucose (also called blood sugar) levels close to normal, 

preventing or delaying the development of type 2 diabetes in the first place 

is even better. The results of a major federally funded study, the Diabetes 

Prevention Program (DPP), give hope that we can prevent or delay the 

disease. This study of 3,234 people at high risk for diabetes showed that 

moderate diet and exercise, resulting in a 5- to 7-percent weight loss, can 

delay and possibly prevent type 2 diabetes. More than 170 American 

Indians participated in the DPP. 

Study participants were overweight and had higher-than-normal levels of 

blood glucose, a condition called pre-diabetes or impaired glucose tolerance. 

The participants were chosen because being overweight and having prediabetes increases a person’s risk of developing type 2 diabetes. 

The DPP tested two approaches to preventing diabetes: changing one’s 

lifestyle compared to taking a pill. People in the lifestyle change group 

exercised about 30 minutes a day, 5 days a week, usually by walking, and 

they lowered their intake of fat and calories. Those who took the diabetes 

pill metformin received standard information on exercise and diet, as is done 

in an Indian Health Service clinic or tribal physician’s office. 

The DPP results show that people in the lifestyle change 

group reduced their risk of getting type 2 diabetes by 

58 percent. Average weight loss in the first year of 

the study was 15 pounds. Lifestyle change was even 

more effective in those 60 years and older. They 

reduced their risk by 71 percent. People who took 

metformin and received standard information on 

exercise and diet reduced their risk by 31 percent. 

“After I started 

exercising and 

watching what I eat, my blood 

glucose levels returned to normal.” 

Contents
 

1 What is diabetes? 

2 What are the signs and 

symptoms of type 2 diabetes? 

2 What does pre-diabetes mean? 

3 What factors increase my risk 

for type 2 diabetes? 

4 Should I be tested for diabetes? 

4 How can I lower my risk for 

diabetes? 

12 Hope Through Research 

13 Daily Food and Drink Tracker 

13 Daily Physical Activity Tracker 

16 For More Information

What is diabetes? 

Diabetes causes blood glucose levels to be above normal. People with 

diabetes have problems converting food to energy. After food is eaten, it is 

broken down into a sugar called glucose. Glucose is then carried by the 

blood to cells throughout the body. The hormone insulin, made in the 

pancreas, helps the body change blood glucose into energy. People with 

diabetes, however, either no longer make insulin, or their insulin doesn’t 

work properly, or both. 

Type 2 diabetes 

Type 2 diabetes is the most common type in American Indians. It can occur 

at any age, even during childhood. People develop type 2 diabetes because 

the cells in the muscles, liver, and fat do not use insulin properly. 

Eventually, the body cannot make enough insulin. As a result, the amount 

of glucose in the blood increases while the cells are starved of energy. Over 

time, high blood glucose damages nerves and blood vessels, leading to 

problems such as heart disease, stroke, blindness, kidney failure, and 

amputation. 

Other kinds of diabetes 

Type 1 diabetes 

Type 1 diabetes is rare in American Indians. People develop type 1 diabetes 

when their bodies no longer make any insulin. Type 1 is usually first 

diagnosed in children or young adults, but it can develop at any age. 

Gestational diabetes 

Gestational diabetes is first diagnosed during pregnancy. It occurs when the 

body doesn’t use insulin properly. Having an American Indian family 

background raises the risk of developing gestational diabetes. Although this 

form of diabetes usually goes away after the baby is born, a woman who has 

had it is more likely to develop type 2 diabetes later in life. 

1 
What are the signs and symptoms 

of type 2 diabetes? 

Many people have no visible signs or symptoms of diabetes. Symptoms can 

also be so mild that you might not notice them. More than 5 million 

people in the United States have type 2 diabetes and do not know it. 

Look for 

➜ increased thirst 

➜ increased hunger 

➜ fatigue 

➜ increased urination, 

especially at night 

➜ unexplained weight loss 

➜ blurred vision 

➜ sores that do not heal 

What does pre-diabetes mean? 

Pre-diabetes means your blood glucose is higher than normal but not high 

enough for a diagnosis of diabetes. When you have pre-diabetes, you’re at 

risk of getting type 2 diabetes and heart disease. There are no visible 

symptoms of pre-diabetes. The good news is, if you have pre-diabetes, you 

can lower your risk of getting diabetes. With modest weight loss and 

moderate physical activity you may even return to having normal blood 

glucose levels. 

2 
What factors increase my risk 

for type 2 diabetes? 

If you have certain conditions, you’re more likely to develop type 2 

diabetes. The more of these conditions you have, the higher your risk. 

Check each item that is true for you. Then show this list to your doctor. 

My mother had diabetes when I was born. 

I am overweight. 

I have a parent, brother, or sister with diabetes. 

My family background is American Indian. 

I have had gestational diabetes, or I gave birth to at least one baby 

weighing more than 9 pounds. 

My blood pressure is 140/90 or higher, or I have been told that I 

have high blood pressure. 

My cholesterol levels are higher than normal. My HDL 

cholesterol (“good” cholesterol) is below 35, or my triglyceride 

level is above 250. 

I am fairly inactive. I exercise fewer than three times a week. 

“I didn’t know I had diabetes until I 

had a blood test at the clinic.” 

3 
Should I be tested for diabetes? 

Anyone 45 years old or older should consider getting tested for diabetes. If 

you are 45 or older and overweight, getting tested is strongly recommended. 

If you are younger than 45, overweight, and have one or more of the risk 

factors, you should consider testing. Ask your doctor for a fasting blood 

glucose test or an oral glucose tolerance test. Your doctor will tell you if you 

have normal blood glucose, pre-diabetes, or diabetes. 

How can I lower my risk for 

diabetes? 

You can do a lot to lower your risk. 

The small steps you take can lead to 

big rewards. 

➜ Reach and maintain a reasonable 

body weight. 

➜ Make wise food choices most 


of the time.
 

➜ Be physically active every day. 

➜ Take your prescribed medicines. 

Doing these things can reduce your risk of 

developing type 2 diabetes. Keeping your 

blood pressure and cholesterol on target also 

helps you stay healthy. 

“My 

great grandmother told me 

to breastfeed my child so the 

baby would be healthy.” 

If you are pregnant, plan to breastfeed your baby. Ask your doctor for 

the names of people to call for help learning to breastfeed. Besides 

being good for your baby, breastfeeding is good for you. Studies done 

with the help of Pima Indian volunteers have shown that breastfeeding 

may lower the baby’s risk of becoming overweight and getting diabetes. 

4 
Getting Started 

Making changes in your life such as eating less can be hard. You can make 

the changes easier by taking these steps: 

➜ Make a plan to change something that you do. 

➜ Decide exactly what you will do and when you will do it. 

➜ Plan what you need to get ready. 

➜ Think about what might prevent you from reaching your goal. 

➜ Find family and friends who will support and encourage you. 

➜ Decide how you will reward yourself—with a nonfood item or 

activity—when you do what you have planned. 

Your doctor, a nutritionist, or a counselor can help you make a plan. 

Reach and Maintain a Reasonable 

Body Weight 

Your weight affects your health in many ways. Being overweight can keep 

your body from making and using insulin correctly. The extra weight may 

also cause high blood pressure. The DPP showed that losing even a few 

pounds can help lower your risk of developing type 2 diabetes, because 

weight loss helps your body use insulin more effectively. Every pound you 

lose lowers your risk of getting diabetes. In the DPP, people who lost 5- to 

7- percent of their body weight lowered their risk of developing type 

2 diabetes. A 5- to 7-percent weight loss for a 150-pound person, for 

example, would be about 7 to 10 pounds. If you’re overweight, choose 

sensible ways to lose weight. 

➜ Don’t use crash diets. Instead, eat smaller servings of the foods you 

usually have, and limit the amount of fat you eat. 

➜ Increase your physical activity. Aim for at least 30 minutes of exercise 

most days of the week. Do something you enjoy, like biking or 

walking with a friend. 

➜ Set a reasonable weight-loss goal, such as losing about a pound a 

week. Aim for a long-term goal of losing the number of pounds 

that’s right for you. 

5 
Choosing My Weight Loss Goal 

Losing 5- to 7- percent of your total weight can help lower your risk of 

getting type 2 diabetes. You are more likely to lose weight if 

➜ you’re physically active 

➜ you cut down on fat and calories 

Use these steps to choose a goal. Talk with your doctor and your 

nutritionist about your goal and how to reach it. 

To find your weight loss goal for losing 5 percent of your weight, fill 

in the blanks. 

My weight _________ multiplied by .05 is __________ pounds. 

To find your weight loss goal for losing 7 percent of your weight, fill 

in the blanks. 

My weight _________ multiplied by .07 is __________ pounds. 

Write your goal here: 

To lower my risk of getting type 2 diabetes, my goal is to lose 


about ___________ pounds.
 

Write down what you will do to lose weight. I will:
 

Choose a date to start your plan for losing weight and write it here: 


Start date: ___________________
 

Look ahead to when you think you can meet your goal. Allow about a
 

week for each pound or half-pound you’d like to lose. Write the date for
 

meeting your goal here:
 

End date: ___________________
 

6 
Make Wise Food Choices Most of The Time 

What you eat has a big impact on your health. By making wise food choices, 

you can help control your body weight, blood glucose, blood pressure, and 

cholesterol. 

➜ Keep track of what you eat and drink. People who keep track are more 

successful in losing weight. You can use the Daily Food and Drink 

Tracker form on page 14 to write down what you eat and drink. 

➜ Take a close look at the serving sizes of the foods you eat. Limit serving 

sizes of main courses (such as meat), desserts, and other foods high in 

fat. Increase the amount of fruits and vegetables at every meal. See 

page 8 for tips on choosing sensible serving sizes. 

➜ Limit your fat intake to about 25 percent of your total calories. Your 

doctor or nutritionist can help you figure out how many grams of fat to 

have every day. You can check food labels for fat content. For example, 

if your food choices add up to about 2,000 calories a day, try to eat no 

more than 56 grams of fat. See page 9 for ways to lower the fat in your 

meals and snacks. 

➜ Cut down on calories by eating smaller servings and by cutting back on 

fat. People in the DPP lifestyle change group 

lowered their daily calorie total by an 

average of about 450 calories. Your 

doctor or nutritionist can work with 

you to develop a meal plan that 

helps you lose weight. 

➜ Choose healthy commodity foods
 

(items provided by the
 

government to help people
 

consume a nutritious diet),
 

including those lower in fat.
 

➜ When you meet your goal, reward 


yourself with something special, like a 


new outfit or a movie.
 

“Having 

fruit for dessert 

instead of sweets has helped 

me lose weight.” 

7 
Choose Sensible Serving Sizes 

Amount of food Types of food Size of one serving (the same size as:) 

3 ounces meat, chicken, turkey, or fish the palm of a hand 

1 cup cooked vegetables 

salads 

casseroles or stews, such as 

chili with beans 

milk 

an averagesized fist 

1/2 cup fruit or fruit juice 

starchy vegetables, such as 

potatoes or corn 

pinto beans and other dried beans 

rice or noodles 

cereal 

half of an averagesized fist 

1 ounce snack food one handful 

1 Tablespoon salad dressing the tip of a thumb 

1 teaspoon margarine a fingertip 

8 
Ways to Lower The Amount of Fat in Your Meals 

and Snacks 

1 Choose lower-fat foods.
 

Example:
 

Instead of sunflower seeds (20 grams of fat), 


choose pretzels (1 gram). 


Savings: 19 grams. 


2 Use low-fat versions of foods.
 

Example:
 

Instead of regular margarine (5 grams of fat), 


use low-fat margarine (2 grams).
 

Savings: 3 grams. 


3 Use low-fat seasonings.
 

Example:
 

Instead of putting butter and sour cream on your baked potato 


(20 grams of fat), have salsa (0 grams).
 

Savings: 20 grams. 


4 Cook with less fat.
 

Example:
 

Instead of making fried chicken (31 grams of fat), 


roast or grill the chicken (9 grams).
 

Savings: 22 grams.
 

Remember that low-fat or fat-free products still contain calories. Be 

careful about how much you eat. In fact, some low-fat or fat-free 

products are high in calories. Check the food label. 

9 
Be Physically Active Every Day 

Regular exercise tackles several risk factors at once. Activity helps you lose 

weight; keeps your blood glucose, blood pressure, and cholesterol under 

control; and helps your body use insulin. If you are not very active, start an 

exercise program slowly. Talk with your doctor first about what kinds of 

exercise would be safe for you. Then make a plan to increase your regular 

physical activity. 

➜ Keep track of what you do for exercise and how long you do it. Use 

the Daily Physical Activity Tracker form on page 15 to keep track of 

your physical activity. 

➜ Aim for at least 30 minutes of physical activity
 

a day most days of the week.
 

➜ Incorporate physical activity into
 

plans with family and friends.
 

Set a good example for your
 

children. Play softball on
 

weekends. Go on a family
 

hike.
 

➜ Be active every day. For
 

example, walk to the store,
 

clean the house, or work in the
 

garden, rather than watch TV.
 

Getting Started on a Walking 

Routine 

Walking is a great way to be physically active. Before you get started, talk 

with your doctor about whether it’s OK for you to walk for exercise. Then 

get comfortable shoes that provide good support. You can use the chart on 

page 15 to start your routine gradually. Try to walk at least 5 times a week. 

Build up little by little to 30 minutes a day of brisk walking. 

“Walking makes 

me feel good.” 

10 
My Walking Program 

Week 

number 

Warm up time 

(minutes) 

Walk slowly 

Fast walk time 

(minutes) 

Walk briskly 

Cool down time 

(minutes) 

Walk slowly 

Total 

(minutes) 

1 5 5 5 15 

2 5 8 5 18 

3 5 11 5 21 

4 5 14 5 24 

5 5 17 5 27 

6 5 20 5 30 

7 5 23 5 33 

8 5 26 5 36 

9+ 5 30 5 40 

Source: Small Steps. Big Rewards. Your GAME PLAN for Preventing Type 2 

Diabetes. A publication of the National Diabetes Education Program. 

Take Your Prescribed Medicines 

Some people need medicines to help control their blood pressure or 

cholesterol levels. If you do, take your medicines as directed. Ask your 

doctor if you should take any medicines to prevent type 2 diabetes. 

11 
Hope Through Research 

With the help and participation of many Pima Indian volunteers over the 

years, scientists at the National Institutes of Health have been able to 

identify several ways health care providers can take better care of people 

with diabetes. We know keeping blood glucose, blood pressure, and blood 

cholesterol under control is very important. We know pregnant women 

with diabetes need to keep their blood glucose under control so their babies 

will be healthy and have a lower risk of getting diabetes. We know 

breastfeeding, even for a few weeks, helps protect babies from becoming 

overweight and developing diabetes. 

We also know that many people who might otherwise develop type 2 

diabetes can prevent it by exercising regularly, lowering the amount of fat 

and calories they eat, and losing weight. Researchers are also studying the 

genetic and environmental factors that can lead to pre-diabetes and 

diabetes. As they learn more about the events that lead to diabetes, 

researchers hope to develop more ways to prevent diabetes and take care of 

those who already have diabetes. People with diabetes and those at risk for 

it can be part of research studies that test promising new approaches to 

prevention and treatment. For information about current studies, see 

www.ClinicalTrials.gov or call the National Diabetes Information 

Clearinghouse at 1–800–438–5383. 

12 
Keeping Track 

Daily Food and Drink Tracker 

Use the form on page 14 to keep track of everything you eat and drink. 

Make a copy of the form for each day. Write down the time, the name of the 

food or drink, and how much you had. For a free booklet with information 

on fat grams and calories, call the National Diabetes Education Program at 

1–800–438–5383 and request a copy of the Game Plan Fat and Calorie 

Counter. Or view it online at www.ndep.nih.gov/diabetes/pubs/GP_FatCal.pdf. 

SAMPLE 

DATE December 1, 2006 DAILY FOOD AND DRINK TRACKER 

Time Name Amount Fat Grams Calories 

8:00 am oatmeal 1/2 cup 1 80 

fat-free milk 1 cup 0 90 

Daily Physical Activity Tracker 

Use the form on page 15 form to keep track of your physical activity. Make 

a copy of the form for each day. Write down what you do and for how long. 

SAMPLE
 

DATE December 1, 2006 DAILY PHYSICAL ACTIVITY TRACKER
 

Type of Activity Minutes 

Walking 20 

Gardening 10 

13 
Daily Food and Drink Tracker 

DATE 

Time Name Amount Fat Grams Calories 

TOTALS 

14 
Daily Physical Activity Tracker 

DATE 

Type of Activity Minutes 

TOTAL 

15 
For More Information 

National Diabetes Education Program 

1 Diabetes Way 

Bethesda, MD 20892–3600 

Phone: 1–800–438–5383 

Fax: 703–738–4929 

Internet: www.ndep.nih.gov 

National Diabetes Information Clearinghouse 

1 Information Way 

Bethesda, MD 20892–3560 

Phone: 1–800–860–8747 

Fax: 703–738–4929 

Email: ndic@info.niddk.nih.gov 

Internet: www.diabetes.niddk.nih.gov 

The National Diabetes Information Clearinghouse (NDIC) is a service of the 

National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). 

The NIDDK is part of the National Institutes of Health under the U.S. 

Department of Health and Human Services. Established in 1978, the 

Clearinghouse provides information about diabetes to people with diabetes and 

to their families, health care professionals, and the public. The NDIC answers 

inquiries, develops and distributes publications, and works closely with 

professional and patient organizations and Government agencies to coordinate 

resources about diabetes. 

Publications produced by the Clearinghouse are carefully reviewed by both 

NIDDK scientists and outside experts. The original version of this booklet 

was reviewed by Donald K. Warne, M.D., C.D.E., M.P.H.; William C. 

Knowler, M.D., Ph.D., M.P.H.; and Mary Hoskin, M.S., R.D. It was also 

reviewed by American Indian health care providers who work with the 

National Diabetes Education Program. Comments from members of the 

Indian Health Service, the Gila River Indian Community, and other American 

Indian communities have also been included. 

This publication is not copyrighted. The Clearinghouse encourages users of this 

booklet to duplicate and distribute as many copies as desired. This booklet is also 

available at www.diabetes.niddk.nih.gov. 

16 
The authors and reviewers of this prevention information wish to thank 

the tribal leaders, American Indian Communities, health care facilities 

that supported the DPP, and the many American Indians who 

participated in the DPP. Their generous gifts of time and energy are 

bringing the message that small steps result in big health rewards for all 

American Indians. 

17 
U.S. DEPARTMENT OF HEALTH 

AND HUMAN SERVICES 

National Institutes of Health 

National Institute of Diabetes and 

Digestive and Kidney Diseases 

NIH Publication No. 06–5337 

December 2005