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S. HRG. 110–19

DIABETES IN INDIAN COUNTRY

HEARING

BEFORE THE

COMMITTEE ON INDIAN AFFAIRS

UNITED STATES SENATE

ONE HUNDRED TENTH CONGRESS

FIRST SESSION

ON

DIABETES IN INDIAN COUNTRY, WITH PARTICULAR FOCUS ON THE

SPECIAL DIABETES PROGRAM

FEBRUARY 8, 2007

WASHINGTON, DC

(
COMMITTEE ON INDIAN AFFAIRS

BYRON L. DORGAN, North Dakota, Chairman

CRAIG THOMAS, Wyoming Vice Chairman

DANIEL K. INOUYE, Hawaii

KENT CONRAD, North Dakota

DANIEL K. AKAKA, Hawaii

TIM JOHNSON, South Dakota

MARIA CANTWELL, Washington

CLAIRE McCASKILL, Missouri

JON TESTER, Montana

JOHN McCAIN, Arizona

PETE V. DOMENICI, New Mexico

GORDON SMITH, Oregon

LISA MURKOWSKI, Alaska

RICHARD BURR, North Carolina

TOM COBURN, M.D., Oklahoma

SARA G. GARLAND, Majority Staff Director

DAVID A. MULLON JR. Minority Staff Director

(II)
(III)

C O N T E N T S

Page

Statements:

Baker, Biron, Primary Care Physician, MED, Center One ........................... 22

Brosseau, James, director, Altru Diabetes Center, member of the American Diabetes Association Native American Community .......................... 18

Dorgan, Hon. Byron L., U.S. Senator from North Dakota, chairman,

Committee on Indian Affairs ....................................................................... 1

Fradkin, Judith, director, Division of Endocrinology, and Metabolic Diseases, National Institute of Diabetes and Digestive and Kidney Disease,

National Institutes of Health, Department of Health and Human Services .................................................................................................................. 6

Grim, Charles W., director, Indian Health Service, Department of Health

and Human Services ..................................................................................... 3

Knowler, William, chief, Diabetes Epidemiology and Clinical Research

Section, Division of Intramural Research, National Institute of Diabetes

and Digestive and Kidney Disease, National Institutes of Health, Department of Health and Human Services ................................................... 6

McCracken, Sam, director, Nike Native American Business Program ........ 20

Moore, Kelly, clinical specialty consultant, Division of Diabetes Treatment and Prevention, Department of Health and Human Services ......... 3

Rolin, Buford, chairman, Poarch Band of Creek Indians, cochair, Tribal

Leaders Diabetes Committee, and cochair, National Steering Committee for the Reauthorization of the Indian Health Care Improvement

Act .................................................................................................................. 16

Thomas, Hon. Craig, U.S. Senator from Wyoming, vice chairman, Committee on Indian Affairs ............................................................................... 2

Vandall, Donna, director, Whirling Thunder Wellness Center .................... 26

APPENDIX

Prepared statements:

Baker, Biron ...................................................................................................... 33

Barnard, MD, Neal D., president, Physicians Committee for Responsible

Medicine (with attachment) ......................................................................... 43

Brosseau, James (with attachment) ................................................................ 69

Bursell, Sven-Erik, Joslin Diabetes Center .................................................... 90

Grim, Charles W. .............................................................................................. 93

Inouye, Hon. Daniel K., U.S. Senator from Hawaii ....................................... 35

Johnson, Jacqueline, executive director, National Congress of American

Indians (with attachment) ............................................................................ 102

Knowler, William (with attachment) .............................................................. 36

McCracken, Sam ............................................................................................... 40

Rolin, Buford ..................................................................................................... 107

Vandall, Donna (with attachment) .................................................................. 113

(1)

DIABETES IN INDIAN COUNTRY

THURSDAY, FEBRUARY 8, 2007

U.S. SENATE, COMMITTEE ON INDIAN AFFAIRS, Washington, DC.

The committee met, pursuant to notice, at 9:39 a.m. in room 485

Senate Russell Office Building, Hon. Byron Dorgan (chairman of

the committee) presiding.

Present: Senators Dorgan, Cantwell, Conrad, Smith, Tester, and

Thomas.

STATEMENT OF HON. BYRON L. DORGAN, U.S. SENATOR FROM

NORTH DAKOTA, CHAIRMAN, COMMITTEE ON INDIAN AFFAIRS

The CHAIRMAN. Next, we will turn to the purpose of the hearing

this morning. Let me thank my colleagues for allowing us to pass

these four pieces of legislation early on. As I indicated, three of

them had previously gotten through the entire Senate, but did not

get through the House. We want very much for there to be an opportunity to move all legislation through the full Congress and get

them signed. That is why we wanted to start early on this occasion.

Let me talk about the oversight hearing today, diabetes in Indian

country. In 1997, as part of the Balanced Budget Act, Congress established what is called a designated fund to address diabetes in

Indian country. It created the Special Diabetes Program for Indians, along with a separate authorization for Special Diabetes Programs for children with type 1 diabetes; $30 million was authorized

for the Special Diabetes Program for Indians in each of 1998

through fiscal year 2002. The program has grown to $150 million per year. The Special Diabetes Program for Indians is administered by the IHS Division of

Diabetes Treatment and Prevention. It is recognized as the most

comprehensive rural system of care for diabetes in the United

States. Grants under this program have been awarded by the Indian Health Service to 400 Indian Health Service, tribal and urban

Indian programs within the 12 IHS areas and 35 States. The program now serves about 116,000 Native American people with various prevention and treatment services.

The committee has not held an oversight hearing on diabetes

since the Special Diabetes Program for Indians was established in

1997. The program will need to be reauthorized after fiscal year

2008, so today’s hearing is timely.

I wanted to just make a point that we are going to talk a lot

about health care on Indian reservations in this Congress. I believe
2

that there is health care rationing going on on reservations. Nobody talks much about it. We have a bona fide crisis in health care.

One part of that crisis has to do with diabetes, a very significant

problem, a scourge that we need to deal with. There are programs

underway, as I have just described, that provide some hope. We

want to find out how they work, what more we can do. But this

is an illness that afflicts Native Americans more than any other

group in our country.

I have been to the dialysis centers. I have been to the diagnostic

centers on reservations all across this country. The stories you hear

are just heartbreaking, of people who struggle, whose families

struggle with this.

Yesterday, I had a group of I believe 30 American Indians in my

office, some of them young college students. I asked how many of

them have in their family someone who is affected by diabetes. I

think 80 percent of them raised their hands.

We are going to have substantial testimony today from people

from around the country to talk about these issues. I want to thank

the witnesses who have decided to come at our invitation. I am

going to ask that when witnesses testify, they would summarize

their testimony. We have in almost all cases the testimony that has

been submitted, and all of the written testimony will be included

in full in the record. Our record will remain open for 2 weeks to

allow others who might wish to submit additional testimony for

this hearing.

I now want to recognize my colleague, Senator Thomas, the vice

chairman, for an opening statement.

Senator THOMAS. Thank you very much, Mr. Chairman. I appreciate your holding this hearing today.

STATEMENT OF HON. CRAIG THOMAS, U.S. SENATOR FROM

WYOMING, VICE CHAIRMAN, COMMITTEE ON INDIAN AFFAIRS

Senator THOMAS. I share the concerns about the high rate of diabetes in the Indian communities. Indians have the highest known

rate of type 2 diabetes in the world, according to the NIH. Type 2

diabetes is a major cause of blindness, kidney failure, cause of

death and lower limb amputations. And it is largely preventable,

according to IHS. So I think it is good that we move forward and

seek to take advantage of those potential possibilities for prevention.

I do encourage the Indian tribes to take the lead in fighting and

preventing this disease. I am pleased that partners such as those

we will hear from today have joined in the effort, particularly those

directed at Indian Youth, before diabetes has a stronghold in their

lives.

So welcome to the witnesses, and I look forward to the testimony.

The CHAIRMAN. Senator Thomas, thank you very much.

As I prepare to call the first panel, I want to just mention to you

the first story I think I told on the floor of the U.S. Senate, as I

talked about Indian health care and diabetes, was a story about a

man named Laidman Fox. He was a traditional Mandan, Hidatsa,

Arikara man who, like many other members of his family, had diabetes. He had his feet amputated, then he had his knees gone, and

then he had his legs gone. When the doctors finally told him that
3

he was going to lose his hands, he decided that he would go home

and prepare to die. He wanted to discontinue the dialysis machine

and go home, and he did. He had been on the pow-wow trail for

many years, so he had a lot of friends around the country, and they

came to see him as he stayed at home and his health deteriorated.

He sang Indian songs and prepared to die. And he died 21⁄2 years

ago.

But it is not a unique or unusual story. It is happening all the

time all over this country, and it is a devastating illness that we

need to continue to battle.

So let me, with that, ask Dr. Charles Grim, director of Indian

Health Service, to come forward, accompanied by Dr. Kelly Moore.

Is Dr. Grim here? Dr. Grim. Dr. Kelly Moore is a clinical specialty

consultant from Albuquerque, NM.

Mr. William Knowler is the chief, Diabetes Epidemiology and

Clinical Research Section, at the NIH, accompanied by Dr. Judith

Fradkin, director of the Division of Diabetes, also at the NIH.

Let me thank the four of you for being here.

Let me mention that the second panel today will be Buford Rolin,

chairman of the Poarch Band of Creek Indians; Dr. James

Brosseau, Altru Diabetes Center; Sam McCracken, director, Nike

Native American Business Program; and Donna Vandall, director,

Whirling Thunder Wellness Center.

Let me thank all of you for being here.

With our first panel, Dr. Grim, let me ask you to proceed.

STATEMENT OF CHARLES W. GRIM, DIRECTOR, INDIAN

HEALTH SERVICE, DEPARTMENT OF HEALTH AND HUMAN

SERVICES, ACCOMPANIED BY KELLY MOORE, CLINICAL SPECIALTY CONSULTANT TO THE DIVISION OF DIABETES

TREATMENT AND PREVENTION

Mr. GRIM. Good morning, Mr. Chairman and Mr. Vice Chairman.

My name is Dr. Charles Grim, director of the Indian Health Service. As you mentioned, I am accompanied today by Dr. Kelly Moore,

who is our Clinical Consultant at our National Diabetes Program

in Albuquerque.

We are pleased to be here to testify on behalf of Secretary

Leavitt on the Special Diabetes Program for Indians. We are very

appreciative of the committee taking time to have an oversight

hearing on this important issue.

Diabetes has quickly emerged as one of the most serious and

devastating health problems of our time. American Indians and

Alaska Natives, as you noted in your opening statement, carry the

heaviest burden and suffer from among the highest rates of diabetes in the world. In some of our communities, more than one-half

of adults have diabetes, with prevalence rates reaching as high as

60 percent.

American Indians and Alaska Natives have the highest age-adjusted rates of diabetes, at 16.3 percent, among all U.S. racial and

ethnic groups. On average, American Indians and Alaska Natives

are 2.3 times as likely to have diabetes as non-Hispanic whites of

similar age.

The rates of diabetes in our communities vary across the country.

The lowest rates are found among the Alaska Natives, while the
4

highest are found among our Nashville and Tucson area tribes.

Yet, while Alaska has the lowest prevalence, the data from our systems show that the increases in adults in Alaska from 1997 to 2002

show that they have had the greatest increase in that time period.

Alarmingly, the disease is increasingly affecting our American

Indian and Alaska Native youth. I know you have seen over the

years that our statistics show in a 14-year period from 1990 to

2004, we have seen an increase of 128 percent among 15 to 19 year

olds and a 77-percent increase was seen among American Indian

and Alaska Native children and youth less than 15 years of age.

As you noted in your opening statement, Senator, in 1997 Congress passed the Special Diabetes Program for Indians in recognition of the enormity of the problem in Indian country. You all recognized that should be a grant program that would provide funding

for diabetes prevention and treatment at IHS, tribal and urban Indian health programs across the Nation. That program has now

been in operation for almost 10 years, and recognized as one of the

most comprehensive health programs ever developed for American

Indian and Alaska Natives, reaching nearly all federally recognized

tribes around the Country.

The Indian Health Service, as directed by Congress, established

three major components of that program. I just want to briefly

point them out for you. There is a community-directed program

that provides grants to 333 IHS tribal and urban programs in 35

States to begin or enhance diabetes prevention and treatment programs. These grant programs make up the community-directed diabetes program, and those grant programs are designed to carryout

interventions that will best address the problems of diabetes in

their individual communities.

The second area is the targeted demonstration projects. In 2004,

Congress directed the Indian Health Service to develop and implement a comprehensive grant program which was to prevent diabetes in high-risk individuals, and then to prevent cardiovascular disease, one of the most compelling complications of diabetes. We have

now established competitive grants in those two areas and have 66

of those that are awarded across the country.

A third area was strengthening our diabetes data infrastructure.

We have used the administrative funding from the Special Diabetes Program for Indians to strengthen our diabetes data and to use

on the expansion and implementation of our electronic health

record.

The Indian Health Service has been evaluating the program ever

since Congress gave us the money. In two interim reports in both

2000 and 2004, we presented extensive data to Congress that evaluated those programs. In fact, I have given to your staff today

about a half dozen copies of that 2004 report, if any of you would

like additional copies of that.

We have used well established public health evaluation methods

to document the accomplishments of that program. I think you will

find some of the results in there remarkable and outstanding. Just

to mention a few, we have increased the number of people with diabetes that are screened for kidney disease. We have increased the

number of people who are screened for diabetic eye and foot disease. We have improved blood sugar control at the population level
5

with mean A1C levels decreasing from 8.9 percent to 7.9 percent.

We have decreased population mean blood levels. We have decreased population mean cholesterol levels, as well as triglyceride

levels.

Just a few of the programmatic accomplishments, we have striking results in almost every area that you can look at. As an example, we have seen improvements in physical activity programs, now

with 92 percent of the grant programs having community walking

or running, as opposed to 20 percent before the program started.

About 80 percent now offer some sort of exercise class, compared

with 16 percent before. There are huge numbers of percentage improvements like that, both before and after the program.

We have tracked how we have spent the money and shown that

$48 million has been spent going toward primary prevention of diabetes, one of the most cost effective methods known. We have invested approximately $57 million of that toward screening and

treatment activities for complications of diabetes. We are consistently using best practices around the country in our programs, utilizing some of the most cost effective interventions that are known

in the country.

In closing, the Special Diabetes Program for Indians has brought

tribes together over these past nine years to work toward a common purpose and sharing information and lessons learned along

the way. We have shown in public health evaluation activities that

these programs have been very successful in improving diabetes

care and outcomes, as well as launching primary prevention efforts

on reservations and in urban areas where none existed.

Our evaluation of the program and its clinical measures suggest

that population levels of diabetes health is better than ever among

our American Indian and Alaska Native patients since the implementation of the program. In its 9 years, we have demonstrated

positive public health impact is possible when the tribes and congressional initiatives are focused on a common outcome, which is

building a diabetes-free future for our American Indians and Alaska Natives.

Mr. Chairman, that concludes my comments. I would be pleased

to answer any questions that you or members of the committee

have.

[Prepared statement of Dr. Grim appears in appendix.]

The CHAIRMAN. Dr. Grim, thank you very much.

Next, we will hear from Dr. William Knowler, chief, Diabetes Epidemiology and Clinical Research Section at the National Institutes

of Health.

Mr. Knowler, thank you for being with us.
6

STATEMENT OF WILLIAM KNOWLER, CHIEF, DIABETES EPIDEMIOLOGY AND CLINICAL RESEARCH SECTION, DIVISION OF

INTRAMURAL RESEARCH, NATIONAL INSTITUTE OF DIABETES AND DIGESTIVE AND KIDNEY DISEASES, NATIONAL INSTITUTES OF HEALTH, DEPARTMENT OF HEALTH AND

HUMAN SERVICES, ACCOMPANIED BY JUDITH FRADKIN, DIRECTOR, DIVISION OF DIABETES, ENDOCRINOLOGY, AND

METABOLIC DISEASES, NATIONAL INSTITUTE OF DIABETES

AND DIGESTIVE AND KIDNEY DISEASES

Mr. KNOWLER. Thank you.

Mr. Chairman, members of the committee, I am Bill Knowler, as

you heard, from the NIDDK. Our institute has the primary responsibility for diabetes research at the National Institutes of Health.

I am accompanied by Dr. Judith Fradkin, director of NIDDK’s extramural Division of Diabetes, Endocrinology and Metabolic Diseases.

I am pleased to testify today regarding NIDDK’s efforts to combat diabetes in American Indians, the population with the highest

known rates of type 2 diabetes in the world.

For the past 31 years, I have conducted diabetes research with

the Gila River Indian Community at the NIDDK’s Phoenix branch

in Arizona, a part of NIDDK’s intramural research program. Our

goals are to gain greater knowledge of the genetic, environmental

and behavioral factors that lead to type 2 diabetes, obesity and

their complications, and develop more effective treatments and

ways to prevent these diseases.

Most of our research is conducted in collaboration with the Pima

Indians of the Gila River Indian Community near Phoenix. Some

of our programs also include other American Indians in Arizona

and New Mexico. In our longitudinal population study in the Gila

River Community, begun in 1965, we conduct periodic examinations focused on diabetes and its risk factors and complications.

This study has contributed much to the world’s current understanding of the causes and consequences of type 2 diabetes and its

complications, including the serious long-term consequences of

childhood obesity and type 2 diabetes, the importance of obesity in

the development of type 2 diabetes, and the concept that type 2 diabetes and its complications can be prevented or delayed by modifying or treating factors that put people at high risk. We are all

indebted to this community for these advances in medical knowledge.

Our research has also facilitated improved treatment and prevention services in this community, leading to improved hemoglobin A1C, the main measure of glucose control in patients with

diabetes, and lower blood pressure.

In fact, attainment of American Diabetes Association treatment

goals for diabetes is better in this community than in the Nation

as a whole, thanks to the diligent efforts of the tribal health program in implementing research-based standards of care.

Another example of a successful intervention is the Diabetes Prevention Program, or DPP, that was stimulated by the results of research suggesting that type 2 diabetes is preventable. The findings

of the DPP are among the most encouraging to come from diabetes
7

research in the past decade. I would like to tell you briefly about

this clinical trial.

Our branch, along with 22 university sites, conducted the DPP

to examine the effects of a lifestyle-based weight loss intervention

and drug treatment on the development of type 2 diabetes in adults

at high risk. The weight loss intervention resulted in a 58 percent

reduction in the rate of developing type 2 diabetes. The drug

metformin reduced diabetes risk by 31 percent.

These interventions worked equally well in men and women and

in all ethnic groups studied, including American Indians. These results convey an important message to American Indians and others

at high risk for type 2 diabetes: You can prevent or delay diabetes.

The DPP participants continue to be followed in the DPP outcome study to assess the long-term effects of the interventions on

preventing type 2 diabetes and diabetes complications. The DPP

was primarily funded by NIDDK, but also had substantial personnel and financial support from the IHS. It is an outstanding example of collaboration between NIDDK and the IHS in a research

study, the results of which greatly influence clinical practice in Indian country and throughout the world.

The complications of diabetes affect the eyes, kidneys, heart, feet,

gums and blood vessels. Poor control of blood glucose and blood

pressure, long duration of diabetes, and genetic factors increase the

risk of diabetes complications, such as those affecting the kidneys,

a major problem for Southwestern American Indians and a focus

of our research.

I am pleased to report that the rate of progression to kidney failure among diabetic Gila River Indian Community members at least

45 years of age has declined since 1990, suggesting that newer

treatments for diabetic kidney disease are slowing its progression.

Since 1999, a similar decline in the rate of diabetic kidney failure

has been seen nationally in American Indians, but not in other racial or ethnic groups.

Unfortunately, the frequency of kidney failure is increasing

among younger Gila River Indian Community members because of

the increasing rate at which diabetes develops in youth.

Most of the research I have described has had a large and immediate impact on prevention and treatment of type 2 diabetes. To

achieve even greater progress or to eliminate the disease altogether, we believe that a more fundamental understanding of its

causes and biological mechanisms is needed. To this end, we have

also pursued research in the genetic susceptibility factors for obesity, type 2 diabetes, and its complications.

Our research to date suggests that some genetic factors important for obesity and diabetes in Pima Indians are the same as in

other racial or ethnic groups, but some are different. Understanding the genetic factors contributing to type 2 diabetes in different

populations will help us understand the biologic mechanisms causing diabetes, which will lead to better ways of predicting those at

highest risk and preventing onset of the disease or its progression.

A minute ago, I described the successful Diabetes Prevention

Program, or DPP. To disseminate its important findings to people

at risk for diabetes, the National Diabetes Education Program, or

NDEP, developed the ‘‘Small Steps, Big Rewards, Prevent Type 2
8

Diabetes’’ education campaign. The NDEP is sponsored by the

NIDDK, CDC, IHS, and over 200 partners. Dr. Kelly Moore, who

is here today, chairs the NDEP’s American Indian/Alaska Native

Work Group.

In addition to the diabetes prevention campaign, the NDEP has

developed culture-specific material for American Indians with diabetes. The NIDDK is committed to continuing these educational efforts to disseminate the positive results of its clinical trials to benefit public health.

I am pleased to report that the NIDDK works closely with the

Indian Health Service to improve the health and quality of life of

American Indians. The NIDDK’s extramural Division of Diabetes,

Endocrinology, and Metabolic Diseases, which Dr. Fradkin heads,

has worked closely with IHS’s Division of Diabetes Treatment and

Prevention in the development of the Special Diabetes Program for

Indians competitive grant program, which has developed a DPPlike lifestyle intervention program for American Indians with prediabetes, for implementation at 36 tribal grantee sites, among

which the Gila River Indian Community is included.

In addition, the NIDDK, IHS, CDC, tribal colleges and universities, and the Tribal Leaders’ Diabetes Committee jointly developed an educational program that aims to increase knowledge of

the biomedical sciences in tribal schools. The Director of IHS’s Division of Diabetes Treatment and Prevention and its National Diabetes Program, Dr. Kelly Acton, serves as a member of the statutory Diabetes Mellitus Interagency Coordinating Committee, which

coordinates activities of all Federal diabetes programs.

Mr. Chairman and members of the committee, I hope these examples convey the firm commitment of the NIH and NIDDK, in

partnership with our sister agencies, to combating diabetes in

American Indians.

In conclusion, I thank the members of the U.S. Senate on behalf

of the scientists who work in diabetes and the millions of Americans affected by it. Thank you for continuing support of biomedical

research through which we are improving the health of all Americans.

I appreciate the opportunity to address you on behalf of the NIH

and NIDDK, and would be pleased to answer your questions.

[Prepared statement of Dr. Knowler appears in appendix.]

The CHAIRMAN. Dr. Knowler, thank you very much.

It goes without saying that diabetes is a serious problem for our

entire country. We focus today with respect to the Indian community because the incidence and rate of diabetes is so much higher.

So that is the purpose of our having this hearing to try to evaluate

how the Special Diabetes Program for Indians is working and what

is happening out in the country.

Mr. Knowler, on page 5, after describing the Gila River Indian

Community experience, you say:

Unfortunately, the frequency of kidney failures is increasing among younger Gila

River Indian Community members because of the increasing rate at which diabetes

develops in youth.

You indicated in your testimony that tracking here has gone on

since 1965, and we have intervened with a diabetes program, detecting the onset of diabetes, the treatment and a range of things.
9

I am encouraged by Dr. Grim’s assessment of what has been

done, but especially with the attention that has been paid to this

particular tribe as a model to try to understand what is happening,

tell me why do we find that there is an increasing rate at which

diabetes develops in youth? What is going on there?

Mr. KNOWLER. As you point out, this is one of the disappointments of our progress in diabetes. We have not improved the situation in terms of incidence of diabetes in youth. There are a number

of reasons for this. A major one is that the increasing amount of

obesity seen throughout the country and most of the world is clearly affecting American Indians. Obesity is a very strong predictor of

diabetes at all ages. So that is one of the serious problems.

The CHAIRMAN. On that point, I am sorry to interrupt you, but

can you give me the connection between obesity and the onset of

diabetes?

Mr. KNOWLER. Yes; the heavier a person is, the greater is the

risk of diabetes. This is true in children and adults. I can’t say that

if you exceed so many pounds, all of a sudden you will get diabetes.

But the greater a person’s weight is relative to height, the greater

is the risk of getting type 2 diabetes.

An encouraging thing about this, as we showed in the DPP, is

that much of that risk is reversible. People who are overweight can

lose weight, and that lowers their risk of diabetes. But the heavier

a person is, the greater the risk that they develop type 2 diabetes.

There are a number of reasons for that. We don’t understand them

fully, but too much fat in the body interferes with the action of insulin in the body to control blood sugar. Fat also produces hormones which have metabolic effects.

So there are a number of reasons that fatness increases risk of

diabetes. This is now an important area of research these days, understanding why that is. But the fact is very clear that the heavier

a person is, the greater the risk of diabetes.

The CHAIRMAN. I am going to ask a really fundamental question

here. I probably should know the answer to this. But if you have

a younger person, a juvenile with the onset of juvenile diabetes,

and that person is obese, you are saying there probably is a connection there, and that person then loses a great deal of weight, does

the diabetes stay with that person? Do you simply treat it? Or once

you have on onset of type 2, I think I understand the answer, but

why don’t you tell me?

Mr. KNOWLER. First of all, I want to clarify one thing in case not

everyone understands about juvenile diabetes. When we talk about

American Indians, almost all diabetes in youth is type 2 diabetes,

the kind that in most populations occurs in adulthood.

We are not talking about type 1 diabetes, the disease of islet cell

destruction and lack of insulin production. That disease is not

strongly related to obesity, if at all. But for type 2 diabetes, whether it occurs in youth or adults, weight loss is very important in the

treatment, although it usually does not restore a person to normal

once diabetes has developed.

The CHAIRMAN. It does not reverse the disease.

Mr. KNOWLER. Not completely, but partially. It certainly greatly

improves the situation.
10

The CHAIRMAN. Dr. Grim, you describe what we have learned in

9 years. It seems to me that there is some reason for encouragement, although I mentioned the onset of diabetes as exists in Dr.

Knowler’s testimony, is increasing among young people in this tribe

that is under great inspection to try to understand this.

What can we expect with substantial intervention and programs

and so on, what can we expect in the next 5 to 10 years? You describe the progress we have had, but you know anecdotally that

when we go to our Indian reservations and talk to people, to find

a crowd, go to the dialysis center. You know, just talk to people.

Diabetes is still a major, major problem, despite the fact that we

are out there doing some things, you are out there doing some

things. What can we expect in 5 to 10 years if we would continue

these programs and be even more aggressive? What kind of

progress do you think we can make?

Mr. GRIM. I am going to let Dr. Moore get prepared to say something about that, too, since she works intimately in that program.

The CHAIRMAN. All right.

Mr. GRIM. One of the things I will say is that because this is a

disease that has still been on the rise in our population, and the

fact that the moneys that Congress made available have allowed us

to find people either at earlier and earlier ages, or people that

never knew they had diabetes. About one-third of the people out

there that have diabetes were not even aware that they did have

it. So early on, our numbers, as we improved our data systems,

spiked.

In my written testimony and in some of the oral, I talked about

a lot of the clinical indicators. We have our entire diabetic active

users being tracked for clinical indicators, their blood pressure,

their cholesterol, their hemoglobin. We see a number of things, and

we have seen population-wide improvements in all of those.

You heard me mention some of the statistical things that have

occurred over time and the number of programs that are now there

for nutrition and weight management and exercise, all the things

that the trials that Dr. Knowler mentioned have shown were now

proven to reduce either the incidence or prevalence of diabetes.

So we are hopeful that after a decade, we have seen some improvements and better control. We think that it will take another

decade or perhaps longer before we really get a strong handle on

it. We hope it is not an entire generation, a totally generational

thing, but it is not a quick fight to end a chronic disease like this.

The CHAIRMAN. Dr. Moore, what can we expect in 5 to 10 years

if we keep investing in these programs and work hard to do it?

Mr. MOORE. Thank you, Senator.

In 2008, we anticipate that we will have results available from

our targeted demonstration projects, which actually are implementing the diabetes prevention program education curriculum, and

some of the other activities such as lifestyle coaching in adults who

have diabetes. This is a very cost effective strategy.

In 2008, we will be able to disseminate this information to other

American Indian and Alaska Native communities who have not

participated directly in this intervention.

The CHAIRMAN. Is there a particularly exciting demonstration

project out there that you see? I know you don’t have all the re-
11

sults, but give me an example of something that is really exciting

with respect to these demonstration projects.

Mr. MOORE. Well, one of the examples is a program in Alaska

that has managed to already have patients complete the intensive

curriculum from DPP. All of the participants are enthusiastic, have

learned much about diabetes prevention, and have been able to

successfully manage their weight, which is the key ingredient here

in terms of preventing diabetes.

I think what we can also expect to happen in another 5 to 10

years is that we will have results available on clinical trials that

are currently taking place in youth related to the treatment of diabetes, as well as some prevention activities that are being studied

that are school-based. Once those results are available, I think the

Special Diabetes Program for Indians will have American Indian

and Alaska Native communities poised to translate-those findings

quickly, and to try and implement the findings from those studies

in our communities.

The CHAIRMAN. Dr. Fradkin, can you describe just briefly, I understand that obesity is a predictor attendant to this issue of diabetes. I assume that there is a predisposition for diabetes among this

population. Is that a genetic predisposition? And then second, tell

me about the relationship of blood pressure to treatment, prevention, et cetera.

Mr. FRADKIN. Sir, there is a very strong genetic predisposition to

diabetes. We know this from twin studies in which in type 2 diabetes there is an even stronger concordance of diabetes among twins

than in type 1, the so-called juvenile diabetes. Dr. Knowler’s group

is pursuing genetic investigations to try to identify some of the

genes involved in type 2 diabetes. We did, through the Diabetes

Prevention Program, confirm that a gene that was recently discovered to be an important risk factor for type 2 diabetes occurs in

American minority populations. This gene was initially discovered

through an industry-supported effort in a European Caucasian population. It is also present in American minorities.

Most importantly, we showed that the people who carry that genetic variant were able to benefit from the Diabetes Prevention

Program lifestyle.

I wonder if I could followup on what Dr. Moore said about what

might happen in future years with regard to the Special Funding

Program. I just want to make the point that the Diabetes Prevention Program that Dr. Knowler described, which showed that losing

on average 15 pounds can reduce your risk of diabetes by 58 percent, now is being translated across Indian country through the

IHS.

We at NIH have two major clinical trials now ongoing looking at

childhood type 2 diabetes in minority populations, including American Indians. When the results of those trials become available, we

anticipate that there will be additional findings that will need to

be translated so that the American people can get the benefit of

those.

One of those is a study of middle school children where we are

actually randomizing the schools to test a school-delivered intervention. We think this could be more cost effective than trying individually to identify and treat people at high risk. We are changing
12

physical activity. We are changing the food service. We have a behavioral intervention. We are trying to involve the families.

If we show that this program decreases the risk factors for type

2 diabetes in middle school children, then that is something that

the IHS will want to translate in Indian country. Likewise, because

this problem of type 2 in children is really a new and emerging

problem, we don’t know how to treat type 2 diabetes in children,

so we are doing a trial to figure out the best way of treating it.

When we have that information, again, the IHS will want to translate that into their programs.

The CHAIRMAN. Thank you very much.

Mr. GRIM. Could I say something, Senator Dorgan?

The CHAIRMAN. Yes, Dr. Grim.

Mr. GRIM. Just very briefly, I think that is one of the strongest

things about our program, the network that has been developed of

IHS, tribal and urban programs all over the country and the passionate people that are out there. They say from research to clinical

practice sometimes takes 10 to 13 years to put it in place. Once

something has been proven in research, we have been able to get

it spread all over the country almost immediately. I think that is

one of the strengths that this program has brought to our system.

The CHAIRMAN. Thank you very much.

Senator Thomas.

Senator THOMAS. Thank you for your testimony. You go into

great detail on the causes of diabetes, but we need to deal a little

more with what we can do about it. The reports show that up until

the early 2000’s, there was an 80-percent increase, sometimes a

100-percent increase in diabetes among young people.

How effective have we been? You haven’t really indicated the impact we have had over the last 4 years of this program.

Mr. MOORE. What we have been able to do in terms of prevention

is that we have an enormous amount of programs that are addressing nutrition and physical activities.

Senator THOMAS. What has been the impact? What has been the

result?

Mr. MOORE. The impact has been that now our youth are more

aware of their risk for diabetes. Dr. Knowler mentioned in his testimony that I am the chair of the American Indian Alaska Native

Work Group for the National Diabetes Education Program. From

focus groups that we have conducted with teenagers, when we

started a campaign to increase physical activity among youth, to

reduce their risk for diabetes, many youth knew about diabetes,

but they didn’t know that they were at risk for the development of

the disease themselves.

So certainly, awareness about diabetes has increased a great deal

in American Indian and Alaska Native communities as a result of

the Special Diabetes Program for Indians.

Second, this has been an incredible priority among our tribal

leaders and among our SDPI communities. The majority of the programs are directing activities toward youth, and I think you will

hear about a wonderful program in the Dakotas and Nebraska in

the Aberdeen area that has really done some remarkable things

with making kids feel better about themselves, maybe being less
13

likely to have depression, which is an associated risk factor for the

development of diabetes.

Senator THOMAS. Do you have any idea of what impact the program has had on problem? The process and the education is fine,

but what has been the impact overall?

Mr. MOORE. Well, one impact has been more partnerships in

making a healthier environment.

Senator THOMAS. Well, what has it done? What have they accomplished?

Mr. MOORE. They have accomplished changes in vending machines in our school systems.

Senator THOMAS. I really would like to talk about the percentage

of growth of the diabetes problem and the number of people who

are involved. Has the diabetes rate been reduced? Are we making

any progress other than building programs?

Mr. MOORE. Yes; I believe we are making progress, but as has

been stated from NIH, it is still unknown in terms of what are all

the factors that are related to the prevention of diabetes. Weight

certainly is a factor, and we have been addressing that in our programs and have developed best practices. We have also developed

a best practice on diabetes in youth, and have shared that with our

American Indian and Alaska Native communities.

Senator THOMAS. Okay, please. You go on about the programs.

I want to know the program results. Are there fewer people getting

diabetes? Is the growth in the rate of diabetes less than it was? Are

we making progress on the ground? Or is it just programs?

Mr. MOORE. I believe we are making a lot of grassroots progress.

Senator THOMAS. Do you have any figures? Do you have any real

facts?

Mr. MOORE. Well, the facts that we have is that a number of programs are addressing it. We have our clinical diabetes audit outcome measures that we have been following related to our population who have diabetes.

Senator THOMAS. Okay. That is what I would like to hear.

Mr. MOORE. We have had improvement in control of blood pressure. We have had improvement in control of blood sugar among

our patients with diabetes. We have seen a decline during the time

period of SDPI for the A1C levels from 8.9 percent to 7.9 percent.

Seven percent is considered ideal blood glucose control for people

with diabetes.

Senator THOMAS. Do you have a smaller percentage of young Indians being involved than we did 5 years ago?

Mr. MOORE. The latest data from 2004 shows that the rate is increasing among our young patients.

Senator THOMAS. Increasing.

Mr. MOORE. It is increasing. However, as Dr. Grim pointed out

earlier, because of the Special Diabetes Program for Indians, we

have had more efforts directed towards screening for diabetes,

which would also increase our rates, and, it will take decades to

reverse the epidemic of type 2 Diabetes that we are seeing in our

population.

Senator THOMAS. So would you comment, Doctor, on any progress

being made?
14

Mr. GRIM. We are making progress on the clinical indicators, and

programmatically on the number of programs that are out there

that have been proven in science to help reduce or eliminate the

risk of diabetes. What I would say is that the numbers that we see

going up, we don’t know what the rate of increase would have been

if we didn’t have this program. That is something that is hard to

predict. The fact that we have increased our data systems and the

amount of screening going on just normally would make one think

that you are going to start finding more of it out there than you

had found before because of the more intensive effort.

We cannot tell you would that rate of growth have been higher

had we not had these programs.

Senator THOMAS. Is it lower because you have the programs?

Mr. GRIM. We believe that the rate would have been higher.

Senator THOMAS. You mean lower?

Mr. GRIM. No; the rates have increased actually. The rate in our

youth have continued to increase, we would like to think at a slower rate than——

Senator THOMAS. Does that make you look at the programs to

see if in fact it is effective? Are there other things we could do?

What are the best practices that you mentioned?

Mr. GRIM. We are continuously evaluating the program. One

thing I failed to mention, we have another report that is going to

be coming to Congress we hope in 2007. We have the two other reports that we have turned in, but we do have 18 best practices that

our experts, along with others around the country, have developed.

There is not a single grant program out there that is not using one

or more of those best practices. We have studied the literature——

Senator THOMAS. What is it would you say, are there some general reasons why it is more dominant in the Indian population than

in the general population?

Mr. GRIM. I probably would leave that either to Dr. Moore or the

scientists here about the scientific background of why it is more

dominant.

Senator THOMAS. Is it behavioral, lifestyle? What causes it? Are

there causes for it?

Mr. GRIM. Behavioral, lifestyle, plus probably genetic component

as well, all of those things.

Senator THOMAS. Sixty years ago, we didn’t know that there was

any diabetes in the Indian tribes.

Mr. GRIM. And there was next to none 60 years ago, we believe.

Some people say it has been the rapid change in lifestyle that the

Indian population has seen in the last 100 years to 200 years, and

that genetically they have not been able to keep up with the diet

and lifestyle that is more predominant these days. I think that is

an issue with the Nation as a whole. We are seeing diabetes rise

in the Nation because of a more sedentary lifestyle, for the behavioral choices, as well as a number of perhaps public policy issues,

too, in the country.

Senator THOMAS. I guess I am just saying, and I understand you

are working very hard at it, but we need to try and determine what

it is that is the cause for diabetes and then determine if we are

making any progress. We can get into research until it is neverending, but we have to study causes and results.
15

Mr. GRIM. I would have to say we have probably one of the most

evaluated programs in the country for diabetes. We would love to

share more information with you at your convenience, sir.

Senator THOMAS. Thank you.

Mr. MOORE. And please stay tuned for our next report. This is

the cover. It has been submitted to DHHS for review. Once the review is completed, it will be available.

The CHAIRMAN. Dr. Fradkin, you wanted to make another comment?

Mr. FRADKIN. I do. I just want to emphasize that there are two

aspects to this program. One is trying to prevent diabetes, but the

other is trying to prevent complications in people who have diabetes. Now, preventing diabetes is hard because involves lifestyle,

and that is a hard thing to change. But the things that can be

changed in the clinics are the ways the diabetes is being taken care

of.

Here, the numbers that Dr. Grim gave you are incredibly impressive. The IHS got the hemoglobin A1C down from 8.9 percent to

7.9 percent. Clinical research has shown that 1 percent difference

would be expected, if sustained, to decrease diabetes complications

by 40 percent. So it is a huge accomplishment that the IHS got the

A1C down from what is close to poor control of blood sugar to what

is near good control.

Senator THOMAS. How has that impacted the folks?

Mr. KNOWLER. Could I address that?

Senator THOMAS. Yes.

Mr. KNOWLER. I would like to give one example again in the area

of management of diabetes that I mentioned briefly. According to

the U.S. Renal Data System’s, national data on new patients starting dialysis, the rates per person since 1999 have actually been

going down in American Indians, while they continue going up in

all the other ethnic groups in the country.

It is hard to attribute improvements like that to any single factor. The increased knowledge of the importance of treating blood

pressure, the use of many new very powerful drugs that improve

blood pressure and kidney function, and the resources that have

gone into treating diabetes in American Indians are probably responsible for this improvement.

So there is a very hard outcome that has turned the corner. It

is still a huge problem, as you know, but it is starting to get better.

Mr. GRIM. And just briefly, it has improved the quality of life of

those patients because their diabetes is under better control so the

progression and all the complications of diabetes has either been

slowed or halted. It has also saved our system money. You saw in

multiple people’s testimony that the average cost to treat a patient

with diabetes is about $13,000 a year, which is huge in our system,

a huge prevalence of diabetes.

And so, bringing that population blood sugar under control just

by that 1 percentage point has saved our system a lot of money in

treatment costs, less pharmaceuticals that the patients have to be

on, less complications or amputations. So it has led to both quality

of life and savings to our system.
16

The CHAIRMAN. Let me thank all of you for your testimony. We

would ask that you be available to answer written questions that

we will continue to send your direction.

Thank you very much. We will have other hearings on this subject, but we appreciate your being here today.

I am sorry, Senator Smith. I apologize. I did not see you come

back in.

Again, thank you very much, Dr. Grim.

Next, the panel will include Buford Rolin, chairman, Poarch

Band of Creek Indians, cochair of the Tribal Leaders Diabetes

Committee, and cochair of the National Steering Committee for the

Reauthorization of the Indian Health Care Improvement Act; Dr.

James Brosseau, director of the Altru Diabetes Center in Grand

Forks, ND, a member of the American Diabetes Association Native

American Committee; Dr. Biron Baker, Primary Care Physician,

Med Center One, Bismarck; Sam McCracken, director, Nike Native

American Business Program, Beaverton, OR; and Donna Vandall,

director of the Whirling Thunder Wellness Center.

We thank all of you for being here this morning, and being a part

of this hearing. I am going to begin with Chairman Rolin. Let me

indicate that we are asking to have you summarize your testimony

and your entire statement will be made a part of the permanent

record.

Chairman Rolin, thank you for being with us. Why don’t you proceed.

STATEMENT OF BUFORD ROLIN, CHAIRMAN, POARCH BAND

OF CREEK INDIANS, COCHAIR OF THE TRIBAL LEADERS DIABETES COMMITTEE, AND COCHAIR OF THE NATIONAL

STEERING COMMITTEE FOR THE REAUTHORIZATION OF

THE INDIAN HEALTH CARE IMPROVEMENT ACT

Mr. ROLIN. Thank you, Senator Dorgan.

It is a pleasure to be here today to discuss with you the Special

Diabetes Program. This important program is making a critical difference in the prevention and treatment of diabetes and cardiovascular disease for American Indians and Alaska Natives.

As I am sure you are aware, and as you have heard already, the

rates of diabetes for American Indians and Alaska Natives are the

highest in the United States, with rates of diagnosed diabetes in

adults as high as 60 percent in some of our communities. Earlier

you mentioned the fact that Congress had appropriated in 1997 the

special diabetes funding because of the alarming rate of diabetes

in the American Indian and Alaska Native communities.

The Special Diabetes Program emerged in the wake of increasing

public concern about the human and economic costs of diabetes in

the United States and its growing prevalence among the American

Indian and Alaska Native population. In 2002, Congress reauthorized the Special Diabetes Program for $150 million per year for fiscal years 2004 and 2008. The IHS was directed to expand this program to implement competitive grants. The competitive grants are

awarded to reduce cardiovascular disease and data improvement.

Earlier, it was noted that there are 333 programs within the

IHS, bringing the total number of grants to Indian country to 399

programs. The Special Diabetes Fund is set to expire in October
17

2008. The American Diabetes Association [ADA] and the Juvenile

Diabetes Research Foundation [JDRF] and the National Indian

Health Board [NIHB] hosted a meeting on June 13 and 14, 2006

to bring tribal leaders and key stakeholders together to discuss

how to approach the reauthorization of the Special Diabetes funding. In October 2006, the TLDC, with the consensus of the NIHB,

mailed a letter to all tribal leaders seeking input as to the future

funding of the Special Diabetes Program. This letter specifically

asked the tribal leaders whether they would support an increase of

the amount of $200 million a year for 5 years, and I am happy to

report that the tribes responded unanimously in that.

The ADA and JDRF have been great partners with the NIHB in

an effort to secure appropriate funding for diabetes research and

the Special Diabetes funding.

The NIHB was recently informed that two young members of the

Choctaw and Chickasaw Tribes will join 150 other children from

across the United States to participate in the JDRF’s Children’s

Congress to be held June 17–20 in Washington, DC. These young

people will be walking the halls of Congress and meeting their lawmakers in discussing type 1 diabetes. Desiree Cameron of the

Choctaw Nation and Erica Rosebush of the Choctaw and Chickasaw Nations were elected from over 1,000 applicants. In a letter to

Members of Congress, Erica writes:

I wish there were a cure for type 1 diabetes so I could live a more normal life

like my friends and family. A cure would allow me to eat and drink without checking my blood sugars and counting carbs for insulin. Finding a cure would mean my

parents wouldn’t have to pay for my supplies that cost a lot. Me, my parents and

my brother would not have to worry about sleeping all night because my blood sugars would be too low or go high and make me sick.

As chairman of my own tribe, the Poarch Band of Creek Indians,

I wish that more people had an opportunity to come to Washington,

DC to express those same concerns. Some of the samples of the prevention screening and treatment services that are provided by IHS

tribal and urban diabetes programs are clinical annual examinations of eyes, teeth, and feet, newer and more effective medications

and therapies, laboratory tests to assist diabetes control and consultation, screening of elders and children for risk factors associated with diabetes, nutrition education and counseling services by

registered dieticians, culturally appropriate diabetes education and

awareness activities, diabetes from our provincial programs for

children and families, community-based health eating programs,

and area schools and nursing homes and community physical fitness activities.

As chairman of the Tribal Leaders Diabetes Committee, I have

had the unique opportunity to work very closely with Dr. Charles

Grim, director of IHS, and Dr. Kelly Moore, director of the IHS Division of Diabetes Treatment and Prevention Program, to oversee

the development of the culturally sensitive and appropriate diabetes programs throughout Indian country.

The Fort Berthold model diabetes program, located in New Town,

ND is an example of teaching and cooking classes and menu planners for local schools. The Fort Totten model diabetes program located in Fort Totten, ND, organizes several community activities

such as diabetes walk and run, and various other programs. The

Whirling Thunder Wellness Program operated by the Winnebago
18

Tribe of Nebraska is a multi-disciplinary program. The IHS service

unit program in Zuni, NM has identified 25 percent of those ages

29 and older, and 50 percent of those ages 49 and older as having

diabetes.

While these are just some of the examples of the model diabetes

programs located throughout Indian country, all of the programs

continue to face many challenges. There is a lack of staff and staff

turnover, lack of data, case management systems, and a lack of

adequate facility space to provide basic service to the community

and educational and fitness activities.

An overall concern, Senator, of these programs is that if this

funding is not kept in place, a lot of this will not continue to be

achieved. The vision of the TLDC is to empower our American Indian and Alaska Native people to live free of diabetes through

healthy lifestyles, while preserving cultural traditions and values

through tribal leadership, direction, communication, and education.

I appreciate the Senate Committee on Indian Affairs scheduling

this oversight hearing on diabetes in Indian country, and especially

the Special Diabetes Program. I invite the committee to schedule

field hearings in Indian country for diabetes.

Thank you for inviting me to testify.

[Prepared statement of Mr. Rolin appears in appendix.]

The CHAIRMAN. Chairman Rolin, thank you very much. Thanks

for being with us today and presenting your testimony.

Next, we will hear from Dr. James Brosseau, the director of the

Altru Diabetes Center in Grand Forks, ND, a member of the American Diabetes Association Native American Committee.

Mr. Brosseau, thank you for joining us.

STATEMENT OF JAMES BROSSEAU, DIRECTOR, ALTRU DIABETES CENTER, MEMBER OF THE AMERICAN DIABETES ASSOCIATION NATIVE AMERICAN COMMUNITY

Mr. BROSSEAU. Thanks, Senator Dorgan and other members of

the committee. It is an honor to be here.

I have been connected with the IHS since back in the early

1970’s, and for that entire time I have worked as a practitioner

dealing with diabetes in the clinic on a day to day basis, so that

is the perspective I bring to this.

In addition, I have been involved with the Awakening the Spirit

Committee of the American Diabetes Association, with Dr. Kelly

Moore, who is in the room, too.

I would just like to say that I think the IHS and the Special Diabetes Program for Indians have just done wonderful things, and I

certainly hope that they can be continued on. I won’t go any further into a description of those programs.

I brought me today about 1 dozen testimonials from people living

on reservations in North Dakota. I wanted to share some of their

feelings about what it is like to be diabetic and living in Indian

country right now.

First of all, many of them are frustrated with things such as lack

of services in the evenings or on the weekends, and are frustrated

by having long waits in the clinic, a short visit with the doctor, and

then leaving with a prescription.
19

The CHAIRMAN. Dr. Brosseau, could you move the microphone

just a bit closer to you and speak up just a bit. Thank you.

Mr. BROSSEAU. Okay. Is that better?

The CHAIRMAN. That is better.

Mr. BROSSEAU. Okay. I was just listing some of the frustrations

of people who are served by the IHS, including lack of services in

the evenings and on weekends, long waits to see the doctor, and

then the sense that you were just given a prescription and sent out

the door.

There are manpower shortages and patients complain about having to see different providers each time, availability of new treatments in the sense that rationing is going on, such as you alluded

to at the beginning of the hearings. And then many people also feel

that they are less valued as people because they are Indian people

living in rural reservations in places like North Dakota.

We also see frustration with contract care, where people come to

a larger center for treatment and then are given prescriptions for

newer medications which are not yet available in the IHS facilities.

And then there is also frustration on the part of providers, too, who

want to do a much better job, but are handcuffed by shortages.

So these complaints sound a lot like what I hear from patients

in my clinic in the non-Indian communities, too. When I started

working in the IHS back in the 1970’s, things weren’t so complex

and the magnitude of the problem was not nearly as great. So I

think that we have to think about new ways of doing things.

First of all, I think all of us agree our medical care system, our

health care system needs and overhaul right from the top down.

But for rural clinics and for Indian country in particular we can

make some changes now which I think make some sense. For example, medical schools, I think they need to be more selective in

taking admissions not just on the basis of what the grade point average is, but they should be looking at people who have ties to their

communities. The INMED program at the University of North Dakota started out this way, and probably still does that, but we need

to be doing this for people from all backgrounds who have ties to

communities and are more likely to stay there.

Perhaps there could be some accelerated programs, since primary

care is a problem all across the country, maybe accelerated programs for people who already have a pretty good education. I think

access problems needs to be remedied, and chronic disease, we

have to change the way we deal with a chronic disease. A 10-

minute visit is not going to work for a person with diabetes. There

are too many aspects of diabetes to cover in a short clinic visit.

So we have to look at more of a team approach, and I think

something like group medical visits, which have been developed in

managed care programs, would be very ideal for many IHS settings, worksite wellness programs where we actually go to the

places where people are working to do preventive care.

There definitely has to be better collaboration between tribal

health programs and the IHS. I know others might want to speak

to that also. We should be having programs for pre-diabetics, people that have not yet developed diabetes, because we know that

over a 10-year period, we could probably prevent about 50 percent
20

of those people from progressing to diabetes just by implementing

lifestyle change.

School programs, which address primary prevention, are very important and many of these have been developed under the Special

Diabetes Program for Indians and need to be continued. And then

also alluding to something the first panel talked about, research in

diabetes has been fantastic, and the developments over the past 10

years or so have been just unbelievable, but now we have to find

a way to translate those developments to the clinic setting, and

that is where I would like to see the attention placed.

So in summary, I would say that the Special Diabetes Program

has been great, and I hope it can be continued. We do need some

fresh thinking to solve manpower problems. Medical schools really

have to find new ways to get people out into the rural communities

and then new approaches to access and treatment of chronic disease in the clinics would be a great help in dealing with the problems of diabetes, where we have the whole team present and all

members of the health care team present also.

Thank you very much.

[Prepared statement of Dr. Brosseau appears in appendix.]

The CHAIRMAN. Dr. Brosseau, thank you very much.

Senator Smith, the next witness, I believe, is from Oregon.

Would you like to introduce the next witness?

Senator SMITH. Thank you, Mr. Chairman.

I did remark earlier that Sam McCracken is with the Nike Corporation. They are doing some great things, as you will soon hear,

on this issue. I applaud them. I thank Sam for being here representing the great efforts they are making.

The CHAIRMAN. Mr. McCracken, thank you for being here. You

may proceed.

STATEMENT OF SAM MCCRACKEN, DIRECTOR, NIKE NATIVE

AMERICAN BUSINESS PROGRAM

Mr. MCCRACKEN. Hello. My name is Sam McCracken. I am a

member of the Fort Peck Tribes and I am manager of Nike’s Native

American Programs.

[Phrase in native tongue.] Loosely translated, I am named after

my grandfather, Thomas Duck, a provider for the Assiniboine people. My clan is the Red Bottom clan, after my grandmother.

Chairman Dorgan, Senator Smith, Vice Chairman Thomas, and

other committee members, thank you for the opportunity to testify

today on this vital topic facing the Native American community.

Nike applauds this committee for holding this hearing, and we look

forward to continuing our public-private partnership under your

leadership.

Senator Smith, thank you for the kind words and overall support. Native American tribes in Oregon and across the country

have benefitted from your stern leadership and are grateful for

your role on this powerful committee.

The impact of diabetes in my community is a topic very close to

my heart. Raised on the Fort Peck Indian Reservation in Montana,

I have seen first-hand the needs and opportunities facing my community. I personally experienced the tragedy of diabetes. In 2001,

I lost my mother to type 2 diabetes. Her passing has renewed my
21

passion to speak directly and find ways to combat this deadly disease.

I happen to work for a company that lends its powerful voice to

get my community active. As the manager of Nike’s Native American Program, I have had the opportunity to work with government

officials and community leaders in the creation of Nike’s Native

American Community Program, which is a multi-tiered initiative to

support and encourage physical activity on Native lands to combat

diabetes.

The program has served several key components, and I would

like to take this opportunity to highlight some of our achievements

today. First, Indian Health Service’s memorandum of understanding. Under the leadership of Indian Health Service’s Director, Dr.

Charles Grim, Leo Nolan, Senior Policy Analyst, the Nike Native

American Community Program helped forge the unique partnership with the Indian Health Service’s with the signing of the historic memorandum of understanding in 2003.

The goals of the memorandum of understanding helped those

communities gain a better understanding of the importance of exercise at any age, particularly those individuals with diabetes. With

these goals, and with our research with the Indian Health Service,

Nike has developed an innovative shoe that offers increased comfort and a new design fit that helped fit the needs of the Native

American foot. With this hope of a new design, we will encourage

and motivate Natives to be more physically active. The shoe is still

in development and it will be offered through a limited distribution

to qualified Native American community partners.

Second, the Native American Incentive Program. It was created

in 2000 while working closely with diabetes program coordinators

with some 100 tribal agencies. In this program, Nike provides product, mentoring and recreation for tribal populations. Nike is also

partner with several national stakeholders and government officials, and some of those agencies were included in testifying today.

Working with the Boys and Girls Clubs, we have introduced

NikeGO on Native lands. Today, there are 67 sites across the country. NikeGO provides a culturally relevant physical activity curriculum and equipment all designed to help Native youth between

the ages of 8 and 15 discover the joy of movement and physical activity. Nike has also donated more than $1 million in product to

support this program.

Third, Nike always listens to the voice of the athlete to inspire

and motivate. One such athlete is Notah Begay, III, a four time

PGA Tour winner and Native American golfer. Notah has played

a central role in helping Nike educate Native Americans about the

benefits of exercise in combating the spread of diabetes. In 2004,

Mr. Begay joined Dr. Grim and myself at the annual session of the

National Congress of American Indians. Mr. Begay was instrumental in kicking off the first-ever National Native American Health

and Fitness Day.

In May 2006, Nike announced the 5 year partnership with the

Iroquois National Lacrosse Organization, providing the Iroquois

Nationals with footwear and apparel. The partnership was developed out of Nike’s commitment to working with Native commu-
22

nities, and another means to inspire physical activity among Native youth.

In closing, Mr. Chairman, the mission of the Nike brand is to

bring inspiration and innovation to each and every athlete in the

world. We believe our program is true to its mission. I am fortunate to have the opportunity to work for a company that strives to

make a difference, but more can be done. Expanding innovative

public and private partnerships, and this committee support, is

crucial.

I want to thank you for this opportunity to share the Nike story.

[Prepared statement of Mr. McCracken appears in appendix.]

The CHAIRMAN. Mr. McCracken, it is quite an interesting story,

and an admirable one as well. We appreciate very much your being

here today. Thank you.

Mr. MCCRACKEN. Thank you.

The CHAIRMAN. Next, we will hear from Dr. Biron Baker, who is

a primary care physician at Med Center One in Bismarck, North

Dakota. Dr. Baker, thank you for joining us. You may proceed.

STATEMENT OF DR. BIRON BAKER, PRIMARY CARE

PHYSICIAN, MED CENTER ONE

Mr. BAKER. Thank you, Mr. Chairman, members of the Committee.

My name is Biron Baker. I am a board-certified family practice

physician currently working in Bismarck, ND. My tribal affiliation

is I am a member of the Mandan and Hidatsa Tribes. My Hidatsa

name is Ah Gu Ga Naha Naish. The literal translation, or the loose

translation, would be ‘‘Stands Above.’’ It is based on the educational things that I have achieved.

I care passionately about what happens to the health care of

American Indian people, because I was groomed from early on to

work for the Indian Health Service. My mother, her two sisters,

and her two brothers combined had over 150 years between them

of working for the Indian Health Service. Now, that being said, I

will go into some other issues here that explain why I am not an

Indian Health Service employee.

In my statement, I have the usual statistics and so forth, but I

think those have been gone over to a great degree this morning,

and I don’t think I will belabor that. When we think about the effectiveness of the Special Diabetes Program, I think if we want to

investigate the rates of increase and whether or not the rates of increase have slowed, we might compare the rates of increase between Canadian Indians and American Indians, since the Canadian Indians would not be beneficiaries of this program.

Our diets are high in processed foods and fatty foods, and I think

rapid modernization of diet has led to some of the problems that

we have had. Some researchers have postulated that, and research

has been bearing it out.

I wanted to talk about the severity of complications of diabetes

in Indian people. It is something that is readily apparent. It is

something that we can see almost just at a glance. My former boss,

before I became a physician, I was a jailer for the BIA. My boss,

this vital man 15 years older than myself, through the years we became great friends. He has congestive heart failure. He is blind. He
23

has lost parts of his feet. He has had bypass surgery. He is essentially living on borrowed time. He retired early from the BIA. I

helped him do this. It saddens me to think of my friend this way.

My youngest patient that had problems with complications from

diabetes was a 22-year old man from Standing Rock who came to

see me in the clinic one day. His creatinine, a measure of kidney

function that we take through the blood, was already 1.6. When I

told him he had lost essentially half of his kidney function, he continued joking with me and continued trying to pass everything off.

He didn’t necessarily want to hear what was going on.

Finally, in 1 moment of inspiration, I guess, I suggested that he

and I go visit the kidney dialysis unit and together we can pick out

a chair for him. That finally seemed to get my point across, but

this is just evidence of some of the resistance we can face as clinicians, particularly in Indian country.

One of the things that I have used that maybe other people don’t

necessarily use, is a sense of humor, which at times can be morbid.

The thing with that is, a lot of elder people have explained to me,

well, we have two choices. We can laugh or we can cry. I choose

to laugh. And if I laugh with my patients, sometimes I get the

point across a little bit better.

One of the other things that has always concerned me, continues

to concern me, is the quality of care available at Indian Health

Service facilities. Now, nationwide, I am not necessarily aware of

how that goes, but I do understand how it works in the Aberdeen

area. The Aberdeen area in particular has had more than its share,

I think, of substandard providers. I mention this because I think

standardization of care of diabetes is important. The Special Diabetes Program is important. However, the implementation of anything that is recommended in standardized care practices has to be

understood by the clinicians who are delivering the care, or it is not

effective.

One of the things that just happened to me recently was I had

a diabetic patient from Standing Rock who fell down the steps at

her home, had three days worth of knee pain. He right knee was

swollen. She went to the Indian Health Service clinic and saw a

locum physician there, a temporary physician at the Indian Health

Service facility. He instructed her to wrap her knee in cabbage

leaves. It sounded made up, but from my past experience, unfortunately, I know it wasn’t.

I obtained an MRI of her knee and she had a torn anterior

cruciate ligament, something that clearly wasn’t going to be fixed

by cabbage leaves.

I think that the Special Diabetes Program for Indians has done

a lot of good, but I think that the quality of the administrators and

the clinicians in the Indian Health Service has not followed suit.

It saddens me to think that the Aberdeen area Indian Health Service seems to attract the worst of the lot. I am not sure how that

happened. I am not sure why that is, but I think it leads to frustration in the ranks of otherwise qualified clinicians, which then leads

to an exodus of the skilled clinicians and retention of the substandard clinicians.

I observed during my time with the Indian Health Service what

I termed an ‘‘any warm body’’ philosophy. We had a nurse practi-
24

tioner in McLaughlin, SD who was somewhat less than effective,

to put it diplomatically. In my attempts to get her either reassigned or terminated, I was reminded several times that if that

were to happen, who would see the patients in McLaughlin?

It never seemed to quite sink in to my administrator that we are

doing some harm here, more than we are doing good. I thought

about that for awhile, and I tried to reconcile that within myself,

why is this the way that this is? It occurred to me then that it was

because my administrator wasn’t necessarily a health care administrator. Rather, this was somebody who had just been with the

system for so long that it was assumed by people higher up that

truly this person must have learned something about health care

in all the years that they worked for the Indian Health Service;

let’s try him as an administrator.

Pharmaceutical options remain a problem for American Indians.

What I see is a disparity because I am in a private setting, so I

get American Indian patients who have insurance, who have Medicaid, who have options other than Indian Health Service. So my

patients that come to see me off the reservation actually get the

standard of care that that anyone else would receive with their insurance, because what I see is that in the Indian Health Service,

we see older insulin preparations. We see older oral medication

preparations. And we see things being done that typically we don’t

think work anymore.

In my clinical practice, there isn’t any reason to treat a known

diabetic with diet and exercise alone. The research indicates that

with early intervention, with a combination of TZD and biguanide

medications, you can actually recover some of the pancreatic function that has been lost. At the time of diagnosis, we estimate onehalf the pancreatic function is gone at diagnosis.

So if we can do something that is going to recover some of that

function, we are going to. Unfortunately, in some providers, we are

still seeing diet and exercise alone as monotherapy. Sometimes we

are seeing some of the older medications used first line as

monotherapy.

Even with the standardization of care, then, we have to have clinicians who understand the standard of care to be able to implement it. These disparities that I am talking about also exist in the

frustrations that Dr. Brosseau talked about with contract health

services are something that is readily apparent as well. People

might ask, what does all this have to do with diabetes on an Indian

reservation? It is all so interconnected that you cannot separate

one from the other.

I had the dubious honor of being the chief of Medical Staff and

having to meet as the chairman of the contract health services

meeting every morning where we got together and decided, basically, who was going to get treatment and who was not. My patient

who really stands out is a 60-year old rancher who had been waiting 4 years to have a simple rotator cuff replacement and take care

of some of the chronic bursitis in one of his arms. He had been

waiting 4 years, and I asked the committee, why are we still sitting

on this? The answer I got was that it wasn’t life or limb threatening.
25

I was able to successfully argue that a one-armed rancher isn’t

going to be able to earn enough income to feed himself for very

long, which then eventually would threaten his life. Through this

process of reasoning, we were able to get a two-armed rancher out

of the deal, and he was happy and sent a card of thanks. But he

had to wait 4 years and he had to have somebody go to bat for him.

A lot of other people with insurance, he got what people with insurance take for granted: Good health care within a reasonable timeframe. He really stands out for me.

The administrators, in particular, within Indian Health Service,

has been a source of frustration for myself and for other colleagues

for a long period of time now. I worked with an administrator who

was an ex-physician’s assistant. Any clinician, I think, will tell you

that we love what we do so much, we can’t imagine doing anything

else. So whenever we see someone who is an ex any kind of clinician, the radar goes up and we want to know why they are an exclinician. Pretty soon, I was able to find out. This man made no decisions that I am aware of, with the exception of the one he made

to retire. The other administrator I dealt with had been with the

Indian Health Service for 20 years and had trouble reading his

budget. He couldn’t understand that the numbers in parentheses

were negative items in his line item budget.

I can’t tell you how much frustration this causes when we are

trying to get things done and we have a guy in the room who can’t

read the budget. At an annual meeting of chief medical officers and

service unit directors, we had someone stand up and introduce his

new service unit director: Here she is; she is a GS–11. The rest of

us in the room are GS–15’s, and people who understand Government pay scales will see that there is quite a disparity.

Why was she a GS–11? She had 1 year of residency and quit, and

she was hired full-time having not completed a full residency.

Someone thought that this was perfectly acceptable for care in Indian country. I don’t think it is. I think it represents lowering the

bar, diminishing the standard. We can’t settle for that. But this

man didn’t see it. He was proud that he had a chief of staff who

was a GS–11, and look how much money I saved. That was his impetus.

Eventually, I did have to leave the Indian Health Service. I tried

then to work for a tribal health program and I can see that there

has to be some better oversight of self-determination efforts of

tribes. Tribal chairmen might disagree with me on this, but what

I am finding is that political cronyism and nepotism are in force,

and every problem that we see becomes magnified.

We had one situation where the tribal chairman’s sister was

placed in charge of the dialysis unit. She was an RN with no personnel background and no dialysis background. Instantly, she

drove a wedge between herself and the staff because she had never

worked in a kidney dialysis unit. The staff at the KDU thought she

was incompetent. They clearly thought this was a political appointment. They all resigned in protest. For 8 months, our patients were

bused between 70 miles and 160 miles away to get their dialysis

three times a week, in vans.

This upset me considerably, and other people were upset as well,

but I think if we had some sort of an oversight situation there, that
26

I don’t have enough government knowledge about how that would

work, but the chairman’s response to this, then, was to put his sister in charge of health care and recruitment of physicians. Obviously, that didn’t work either.

The CHAIRMAN. Dr. Baker, I need to ask you to summarize, if

you would. We are running out of time.

Mr. BAKER. I will finish here. I do have some solutions. I don’t

want everybody to go away thinking that all I did was come here

to complain. I think that the Indian Health Service is funded at

roughly 40 percent level of need, and I don’t advocate throwing

money at a problem, but this is where I make an exception. The

area offices seem to provide a layer of administrative capability

without real function. I think if the area offices were eliminated,

those FTE’s could better service Indian people through enhanced

contract health service fund availability.

Thank you for the opportunity to present this morning. I will entertain any questions anyone has.

[Prepared statement of Dr. Baker appendix.]

The CHAIRMAN. Dr. Baker, thank you very much for coming.

And finally, Donna Vandall, director of the Whirling Thunder

Wellness Center, Winnebago, NE.

Ms. Vandall, thank you very much for being here. You may proceed.

STATEMENT OF DONNA VANDALL, DIRECTOR, WHIRLING

THUNDER WELLNESS CENTER

Ms. VANDALL. Good morning, members of the committee and the

people who are here in this room. I am known by the people who

know me in Winnebago, my Indian name is We-huh-changaga,

which means Water Spirit Woman. It is from the Water Spirit clan.

Our program began in 1995, contracted from Indian Health Service. We spent many years doing screenings, which produced a lot

of diabetics. Screenings do that. And then we found some startling

things. By screening school-age children, we realized that in 10

years if those children grew up, we would have double the diabetics

that we had at that time. This was frightening and traumatic to

the providers, and to our program.

About that time, SDPI became available. We developed strong

activities, strong programs and services. But the most important

thing we learned was that we needed to collaborate and network

with everybody in the community who would work with us. That

translate-s into almost 70 hours of time in the Whirling Thunder

Wellness Center that is occupied by community members of all

ages, from preschool to senior citizens.

Taking education and nutrition and activities, attempting to

change lifestyles, setting up programs that the people themselves

want, not the programs that Indian Health Service through the research thought was good, not the programs that providers thought

were good, but the programs that the people felt that they could

live with and adapt.

We worked for another 5 or 6 years; 18 months ago, we started

Ho Chunk Hope, which is dealing exclusively with pre-diabetic people. We have a full plate all the time, with a total of 15 staff people

working nonstop to try and achieve the results that we know we
27

can achieve by changing lifestyles and reducing the diabetic population in our community.

We believe that the efforts we have made are at a critical point

right now, and that they need to continue. If other tribes are functioning in the same way, they need to continue, and things get

worse before they get better.

Our prevalence in 2000 for diabetics was at 10.8 percent according to the IHS statistics. In 2006, it is at 17 percent. But at the

same time, Ho Chunk Hope has shown to us in 18 months of intensive work that you can take people who are ready to convert into

full diabetes and back them away from it, so they do not become

diabetics. It is very heartening, very exciting work that is being

done by the dedicated staff at the Whirling Thunder Wellness Center, and in Ho Chunk Hope.

Many people have come and served and worked through our program and with our program. Many leaders have looked and said,

this program works. Whirling Thunder, incidentally, is named for

a leader of a band of Winnebago who signed a treaty in 1832 and

asked for a doctor. Culture and spirituality have become a major

part of our work with Indian Health Service, with our local hospital. That is one of the major partners that we need to have. We

are not clinicians. I am not a medical person. We have served as

a buffer with our programs between Indian Health Service and the

tribal population. Indian Health Service has a need to be able to

reach the people that they serve.

We serve as a buffer by bringing them in, treating them very

well, getting them to the providers, introducing them, being a pillow that helps them to achieve their health status. We have seen

many improvements in our diabetic community. We have had almost no, well no amputations that I am aware of in the past 6 or

7 years, and very few people on dialysis.

The intensive work that is being conducted is being conducted at

the tribal level with the funds that come from SDPI and from Indian Health Service Diabetes Program that we have contracted. Indian Health Service still has a vital role in the community, because

they have the medical providers and they have the hospitals.

So with that in mind, I want to say that Indian country is very

much aware of this committee and its membership. We know your

burdens and we appreciate your work. A few months ago, I attended a gathering in the Northern Plains, and a veteran was

asked to pray for the evening meal. We prayed for the people. We

prayed for the men and women fighting in a war far, far away. We

prayed for our tribal leaders. We prayed for the leaders of this Nation. And we prayed for Senator Tim Johnson and his family.

At these kinds of gatherings, and in our ceremonies when the

smoke rises, it carries our prayers, and you are there. We hold you

close.

Thank you.

[Prepared statement of Ms. Vandall appars in appendix.]

The CHAIRMAN. Ms. Vandall, thank you very much. As you indicate, Senator Tim Johnson is a member of this committee, and

cares very deeply about all of these issues. We expect that Senator

Johnson will rejoin us here in the U.S. Senate. On his behalf and
28

the behalf of other members of this committee, let me thank all of

you for testifying.

I do want to mention that we have many, many hearings going

on this morning here in the U.S. Senate. In fact, I serve on three

committees that are now holding hearings even as I am here. It is

one of the difficulties of trying to do all that one is required, especially in as many committees and subcommittees on which we

serve. So our members are at other hearings, but there is a great

deal of interest in this issue in the Congress.

Let me ask a couple of questions. Mr. McCracken, your company,

of course, is a for-profit commercial enterprise, but we also recognize that it has been a very public-spirited company in many ways.

You described the new shoe design for Native American diabetics.

Would you tell us just a moment about that again?

Mr. MCCRACKEN. Sure. I would be happy to. Through our partnership with the Indian Health Service, the memorandum of understanding, we were looking for a tangible outcome of that document. What Nike does best is we innovate. So we took our sports

and research lab, we call them ‘‘lab rats,’’ out to the field to scan

Native American feet across the country, knowing the issues that

complicate people with diabetes.

Though the shoe will hopefully motivate and create opportunities

for physical activity and promote physical activity, the thought of

the shoe was built from the inside out, knowing the complications

that come with a person who is pre-diabetic or diabetic in their

foot. Those folks took that into consideration as they built it from

the inside out, with a seamless inside.

From those scannings, we built a special last that was designed

and developed for the Native American foot. If I could give you a

brief example, a normal Nike shoe if you were to buy an in-line

Nike shoe, in a men’s size, it is a D width. From our scientific research we did by scanning 500 plus feet across Indian country, we

found that the average Native American male foot was an EE. So

when they would try to stick their foot into a normal, which we call

an in-line Nike Shoe, we can understand why the discomfort was

there.

So we are hopefully going to develop some comfort, which will

then encourage physical activity. And with the efforts of physical

activity, we are not on the medical side so we don’t can’t speak on

behalf of those, but hopefully we can encourage physical activity

with this product because there is going to be a sense of comfort

around the product.

The CHAIRMAN. And the size of your shoes?

Mr. MCCRACKEN. What is that?

The CHAIRMAN. The size of your shoes?

Mr. MCCRACKEN. My shoes? I am 111⁄2.

The CHAIRMAN. Double E?

Mr. MCCRACKEN. Double E. I squeeze into those.

The CHAIRMAN. All right. You squeeze into them.

Mr. MCCRACKEN. I squeeze into them. [Laughter.]

The CHAIRMAN. Mr. McCracken, thank you very much for being

with us, as I indicated.

Mr. Brosseau, in your experience, are the new medicines that

have been available and treating diabetes, are those medicines
29

available on Indian reservations, or widely available? I think you

touched on that just briefly.

Mr. BROSSEAU. Some of them are, and some of them aren’t. In

the past 10 years, there has just been an explosion of new medications, insulin sensitizers and drugs which don’t lower the blood

sugar below normal. Metformin was the first of those, and that is

available in Indian Health Service facilities, but the newer ones

such as the thiazolidinedione and then these new incretin drugs,

I am not sure if they are available yet or not. Maybe someone else

could answer that question for me.

Then there are these new forms of analog insulins which also

have been slow to come to Indian country. They have really also

improved our ability to treat people appropriately.

The CHAIRMAN. Dr. Baker, your assessment? Are most of these

new medicines available?

Mr. BAKER. Some are not, some of the newer things that have

been happening recently. We have used GLP1 analogs and DPP4

inhibitors. These things are probably several years away from

being available at the Indian Health Service. Those medications

are very exciting in terms of the potential side effect that one of

them has for weight loss, and the favorable side effect profile that

drug interactions just aren’t there. It doesn’t drop the blood sugar

below normal, and on average you get a 1 or more percent greater

reduction in hemoglobin A1C with these drugs. So in my estimation, then, these are very valuable drugs in the arsenal not to

have.

The CHAIRMAN. We will do some work to try to evaluate how frequently they are available or not available to those that need them.

I think that is an important thing for us to try to understand. Understanding a better treatment regime, understanding the efficacy

of new medicines is one thing, but having them available is the

most important part of that understanding.

I want to ask about the issue of Indian health generally, and the

delivery of health services with respect to clinics and the number

of hours clinics are open. Because those with diabetes have lots of

complications, and are often showing up for treatment at different

hours of the days or nights or weekends. My experience on a number of Indian reservations with the Indian Health Service is they

have a clinic, it opens at 8 or 8:30 in the morning, and closes at

4:30 or 5 in the afternoon; not open Saturday; not open Sunday.

So there really is a substantial limited opportunity. I have been

talking about trying to develop a new medical model on reservations, very much like some of the commercial sector are trying to

do across this country. On the commercial side, they are doing low

cost, no appointment, walk-in clinics, in some cases staffed by

nurse practitioners or physician assistants and so on, for routine

diagnosis, but available 7 days a week at rather extensive hours.

I would ask any of you who wish to answer, is it your experience

that on most reservations, there are limited clinic hours available

for those who wish to show up at clinics? Does anybody have any

experience? Chairman Rolin?

Mr. ROLIN. Yes, sir; that is true. Normal hours are from 8 a.m.

to 5 p.m.. In my own clinic, what we have done is certainly we have

designated 1 day a week to deal specifically with diabetes. We
30

begin at 7:30 in the morning with breakfast, and then we monitor

the patient’s activities during the day. But one of the things that

we have taken into consideration is extending the hours and setting up various times, including the weekend, for these very special

clinics and all, that we can accomplish and provide the services to

our people, Senator.

The CHAIRMAN. Ms. Vandall, do you have a BIA school on your

reservation?

Ms. VANDALL. We do not.

The CHAIRMAN. You do not.

Ms. VANDALL. No.

The CHAIRMAN. Does anyone have any knowledge of whether the

BIA-run schools have pop, soda, and candy machines on their

school premises? I will ask the BIA about that at some point. There

is a discussion generally across the country about having machines

distributing soda or pop as it is called in my part of the country,

and chips and so on, snack foods.

Ms. Vandall, someone else described diabetes bingo. You described a poker walk. Was it you? Okay. Diabetes bingo, I don’t

know who described that.

Mr. ROLIN. I mentioned that, sir.

The CHAIRMAN. You did. That is instructional? Something people

are doing in order to produce information to them that is useful?

Can you describe it?

Mr. ROLIN. It is an educational program and I am working with

them on it. It is working. Also, what I didn’t mention is we have

a kids program as well, teaching them about utilizing what the

various foods are and all, and how it can affect them. This is also

part of that program. It is called ‘‘Kids Cafe.’’

The CHAIRMAN. The reason I asked about what kids are able to

access in their schools, in this case the BIA schools because those

are the schools over which we have some funding responsibilities,

is I wanted to try to understand whether we are trying to educate

about fruits and vegetables and diet on the one hand, and then

offer advertising as you walk out of a classroom into the lobby of

a school for some liquid sugar and some high-fat snacks. I will get

information from the BIA about that.

I make that point despite the fact that I was drinking a CocaCola this morning. [Laughter.]

Recognizing that I have had other healthy food and drink this

morning.

Let me say this, this is I think one of the most important health

issues facing Native Americans, the first Americans. We have a lot

of health issues facing them. I did not today, but I certainly will

the next time I have Dr. Grim here to talk about the Indian Health

Service budget, and we will do that soon, I will again inquire to try

to find out what part of Indian health is unmet. My guess is it is

about 40 percent, 45 percent, based on what I have been able to

extract, but getting that information is like pulling teeth.

In fact, there is full scale, I think because of that, full scale rationing of health care. Rationing of health care would be very controversial if people understand what it is going on. It goes on all

the time on Indian reservations. I have spoken on the floor of the

Senate about the stories that describe it, a woman hauled in, I
31

mentioned this before at a hearing, a woman hauled into a hospital

on a gurney from one of our Indian reservations in our State,

hauled into a hospital on a gurney, having a heart attack, with a

piece of paper taped to her thigh. And the piece of paper said to

the hospital administrator: ‘‘Understand now, if you admit this patient, the Indian Health Service will not be paying any of the

costs.’’ Understand that, we are out of contract health care money.

She had a heart attack. It is unbelievable that these things go

on, and yet they go on.

Mr. Baker, you described the prospect of a one-armed rancher

trying to make a living, someone who waits 4 years. You know,

when you talk about health care in this country and the system,

people say, ‘‘Well, we don’t want a system like these other countries have because you wait too long.’’ Well, waiting is something

a lot of Native Americans understand, unfortunately, and suffering

during that wait is something they understand as well.

Contract health, dealing with life or limb, is a circumstance

where there is a lot of suffering because someone doesn’t meet that

test. I had just two Saturdays ago a listening session in Minneapolis and we had 150 Indian leaders and Indian tribal members

come. One of the tribal chairmen said, ‘‘My tribe runs out of contract health care funding in January,’’ that is the fourth month of

the year. That means for eight months of the year, there is no contract health funding left. That is pretty unbelievable.

Another tribal chair testified before this committee and said, ‘‘We

understand. The refrain on our reservation is, don’t get sick after

June.’’ If you get sick after June, there is no contract health care

money left. That is rationing of health care to a population that is

a population at risk. It is unacceptable in this country. We need to

find a way using this committee and others to put a magnifying

glass up there and tell the American people this is happening, and

it is wrong; tell the rest of the Congress it is happening, and it is

wrong; and that we have a responsibility to do something about it.

Let me make one final point, because I know, Dr. Baker, your

testimony will I am sure raise questions by some people who will

say, you know what? The Indian Health Service has some unbelievably wonderful, dedicated people who work across this country in

tough situations. They could be making a lot of money elsewhere,

but they choose to serve. And God bless them for doing it.

Yes; that is the case. I am sure that is the case, and I have met

many of them, and I walk away from them thinking, what a blessing it is they have chosen this career.

It is also the case, I am sure, that there are people unqualified;

that there are people who do not have the same motives. We need

to work on all of that, and I will in other venues work with Dr.

Grim at hearings talking about a range of those issues.

Let me thank all five of you for being present today. This is the

first of a series of hearings we will hold on health care. I will be

holding a listening session. We are doing a number of listening sessions across the country with Indian tribal members and leaders to

talk about a range of issues, especially health care. I mentioned

one that we held just recently in Minneapolis for a five-State region. I will be holding one in Phoenix in the next 2 weeks. We are

trying to see if we can hold it on the Gila River Indian Reservation,
32

which is just I believe south of Phoenix. I expect we will probably

be doing it on that reservation, which was interesting to me that

there was a lot of discussion about the study that ranges from 1965

forward on that reservation. So I will be able to have some information as I hold a regional listening session there with my colleague, Senator Thomas.

At any rate, I appreciate all of you being here. Chairman Rolin,

you had a last comment?

Mr. ROLIN. Yes; I would just like to say, Senator, we appreciate

this hearing and what is being done, but just a reminder that it

took many, many years to achieve the progress that was made to

reduce cancer in this country. We have only been working at this

now a little over 8 years. We are seeing progress, and the progress

is coming through the empowerment that the communities have

taken to make sure that we address this deadly disease.

The CHAIRMAN. And I think, what Senator Thomas was asking

represents the most important questions for those in Congress who

are asked to contribute $150 million toward this priority, and hopefully perhaps even more toward this priority in the future, because

it saves lives. What he is asking is not just the empirical evidence,

but what is the empirical evidence, and then what are the stories

that describe to us that there is real progress? Because you don’t

know how often agencies come to us, to Senator Thomas and myself and others, and say, well, we have a program. Well, good for

them for having a program.

The question we ask is, what is being accomplished with this

funding? I think that from my knowledge, there is a very substantial amount of good investment being made that is going to produce

substantial results. That is what Vice Chairman Thomas is asking,

and it is the question every member of Congress will ask. We have

competing needs for limited resources.

But I can’t think of a priority that is much more significant than

this. If you go to reservations, go to the dialysis centers, go visit

with the families who are suffering through these difficulties with

diabetes at the root of the difficulties, I can’t think of a much higher priority. I think that is the point that Senator Thomas was making as well.

In order for us to do this and continue doing it, we need to be

able to tell our colleagues in Congress, here is the achievement;

here is the body of achievement. It is substantial. It is impressive,

and will continue. And that is what we need from you, and we appreciate your being here today to give us a part of that.

This hearing is adjourned.

[Whereupon, at 11:25 a.m., the committee was adjourned.]
(33)

APPENDIX

ADDITIONAL MATERIAL SUBMITTED FOR THE RECORD

PREPARED STATEMENT OF BIRON BAKER, M.D., PRIMARY CARE PHYSICIAN, MEDCENTER ONE

Greetings Mr. Chairman and members of the committee:

It is an honor to be asked to testify before this distinguished body on an issue

of vital importance to Native Americans at risk and diagnosed with diabetes. My

name is Biron Baker and I am a Board Certified Family Practice physician. I

worked for the Indian Health Service on the Fort Berthold and Standing Rock Service Units in central North Dakota for over 3 years. I am currently employed by

Medcenter One in Bismarck, ND. I am an enrolled member of the Three Affiliated

Tribes of western North Dakota. My Hidatsa name is Ali Gu Ga Naha Naish. A

loose translation of this would be ‘‘Stands Above.’’ I’ve been asked to provide information on diabetes in Indian country.

According to the Center for Disease Control, American Indian and Alaska Natives

are 2.6 times more likely to develop type 2 diabetes as non-Hispanic whites of similar age.

Type 2 diabetes is the type of diabetes that the overwhelming majority of American Indians are afflicted with. The problem, in simplest terms, is the inability of

the body to utilize its own insulin to regulate blood glucose levels. Data that I’ve

read indicates that the prevalence of type 2 diabetes in American Indians has increased by over 100 percent in the past 15 years, and the complications are worse

in American Indians. Greater than 17 percent of all adult American Indians have

diabetes and the problem is growing. The total number of diabetics in the United

States is at 21 million and another 41 million are ‘‘pre-diabetic.’’

Comorbid conditions in Indians with diabetes outpace that of all other minority

groups. When I think of health problems of our country as a whole, I can magnify

those problems in Indian country without much effort. Our use of tobacco (not in

the religious sense) is near 50 percent. We know that diabetics face the same risk

of heart attack as someone who has already experienced a first heart attack. This

is compounded by tobacco use disorder. Our rates of alcoholism and alcohol related

disorders far outpace the rest of the country and this can prevent standard of care

practices for diabetics. Our diets are high in processed and fatty foods and the obesity rate is staggering. Rapid modernization of diet is implicated by several researchers as part of the problem. Primary prevention is relatively new in Indian

country and it’s had some success. This is area that holds great potential.

The severity of complications associated with diabetes in Indian people is readily

apparent. I once worked for a man 15 years older than me and now because of complications related to diabetes he is a very ill man. He is blind, his kidneys are shutting down and he is approaching dialysis, he has lost parts of his feet, he had cardiac bypass surgery and now has congestive heart failure. At 56 years of age, this

once vital retired police officer is living on borrowed time. My youngest patient with

complications was a 22-year-old man from Standing Rock who had lost half his kidney function before he was diagnosed with diabetes. I was having trouble impressing upon him the need to change his lifestyle. I finally asked him to accompany me
34

to the kidney dialysis unit so we could pick out a chair for him to dialyze in three

times a week for 4 hours each session. That seemed to get my point across, but this

is evidence of the type of resistance clinicians can face.

Quality of care at Indian Health Service facilities has been a documented problem. I have seen this problem from the time that I worked with the Indian Health

Service in 1997 until today. I had a diabetic patient from the Standing Rock Reservation see me in the clinic in Bismarck with fluid in her knee joint. She had gone

to the Indian Health Service facility for evaluation and was told by the physician

to wrap her knee in cabbage leaves for several days. I obtained an MRI of her knee

and found a torn anterior cruciate ligament. While enhancing funding for the Special Diabetes Program for Indians and standardization of care has shown some benefit, the quality of clinicians and administrators in the Indian Health Service has

not followed suit. The Indian Health Service has become a haven for administrators

and clinicians who would otherwise never be able to maintain employment. Sadly,

the Aberdeen Area Indian Health Service seems to attract the worst of the lot. This

leads to frustration in the ranks of otherwise qualified clinicians, and an exodus of

skilled clinicians inevitably occurs. It is the principal reason that I no longer work

for the Indian Health Service. During my time with Indian Health Service, I observed what I termed an ‘‘any warm body’’ philosophy. Even if clinicians were inadequate, they were kept on staff because to remove them would overwork the rest

of the medical staff. hi the long run, this created more problems than it solved, but

administration never seemed to recognize this. Perhaps it’s because the administrators I dealt with were not healthcare administrators, but rather they were people

who were promoted simply because they were still with the system after many

years, and surely must have learned something.

Pharmaceutical options remain a problem for Indians accessing care at Indian

Health Service facilities. Many of these patients are using older insulin preparations

and older oral medications because that is what the pharmacy budgets allow. Typically, Indian Health Service pharmacies run significantly over budget, and disparities still exist. Diabetes programs can purchase glucometers, but not medications.

Prevention and early intervention related to diet and exercise is not used as a

standard of care on the reservation. Sulfonylurea medications are now third line

oral agents, but we see patients on them as monotherapy, first line agents. Part of

this is limited pharmacy budgets, but part of it also lies with medical staff ability.

Even with standardized ‘‘cook book’’ approaches to the treatment of diabetes, the clinician must be aware of standard of care practices. Otherwise, we see an example

of ‘‘the eye cannot see what the mind does not know.’’

Significant care disparities exist between insured and uninsured American Indians. The insured population will often seek medical services at an off reservation

private practice type of environment, and care follows what typically happens for

every other insured American. Medical, diagnostic and therapeutic interventions are

more readily available. The uninsured population will seek care at an Indian Health

Service facility and will have that care rationed. Any procedure, test, consultation

or intervention that is not deemed ‘‘life or limb threatening’’ will not happen. Direct

care or care available at the Indian Health Service facility, is provided. Contract

Health, or offsite care, is doled out by the Contract Health Service committee that

meets Monday through Friday mornings. Most requests for referral are impossible

after May or June of each fiscal year because of depleted funds. Patients are not

unintelligent, and recognize this disparity at once. One patient stands out for me.

While at Fort Berthold, I was informed during a Contracted Health Service meeting

that a particular patient had been waiting for a shoulder repair for 4 years, but that

we couldn’t approve it because it wasn’t ‘‘life threatening.’’ I asked what he did for

a living, and was informed he was a rancher. I successfully argued to the committee

that a one-armed 60-year-old rancher was unlikely to be able to earn enough to eat,

thus eventually threatening his life. His surgery was approved, and the now twoarmed rancher sent me a note of thanks. He waited 4 years for something that insured Americans take for granted: Good care within a reasonable timeframe. Serving as the chair of the Contracted Health Service committee was one of my most

distasteful duties as a clinical director with the Indian Health Service.

Administrative ineptitude within the Indian Health Service is a glaring problem.

During a budget meeting, I met an administrator who did not understand his line

items. It was explained to him that the numbers in parentheses were negative, and

represented a deficit in that particular line item. He had been with the Indian

Health Service for 20 years at that point. I worked with another administrator who

was a ‘‘washed up’’ physician’s assistant. To my knowledge, the only decision he ever

made was the one he made to retire. I knew administrators from other service units

within the Aberdeen Area Indian Health Service as well. At an annual meeting of

chief medical officers and service unit directors [CEO’s], one of the clinic CEO’s an-
35

nounced that he had just hired a physician with only 1 year of residency as his chief

medical officer. He was very proud of this, and announced her salary as a GS–11.

The rest of us chief medical officers in the room had completed 3 year residencies,

and we were GS–15’s. People familiar with government pay scales will recognize

this as a significant disparity. That the Indian Health Service will even hire physicians who haven’t completed residency training boggles the mind. It represents setting the bar lower for the future, and encourages misfits and miscreants to apply

for work with the Indian Health Service. His statement also opened a rift between

medical staff present and administrators in the room, and a lively discussion ensued. Never tell an Indian Health Service physician he’s overpaid; he makes onehalf to two-thirds of what his peers in private practice make. That’s just for primary

care. That gap is wider with specialties. The fact that the administrator was so out

of touch with reality was what saddened me. All he could see was that he saved

money in his medical staff budget.

There must be better oversight of self-determination efforts of tribes. Political cronyism and nepotism were in force where I worked. We once were forced to work

with a dialysis unit with an unqualified nurse placed in charge. She was the tribal

chairman’s sister, so we tried to make do. All the staff nurses resigned in protest,

and for 8 months our 18 dialysis patients were bussed to dialysis units 70 to 160

miles away, several different locations, so the chairman’s sister could ran the dialysis unit. The chairman’s solution to all this was to place his sister in charge of tribal

healthcare. The dialysis unit eventually reopened, but our dialysis patients paid for

it for 8 months. All too often, unqualified personnel are placed in charge of self determination efforts, to the detriment of the populace. With better oversight, self determination could work. It could be mandated that such a venture not take place

until qualified personnel with a plan are in place.

As bad as things seem, there are solutions. The Indian Health Service must make

it a priority to hire and retain competent administrators and medical staff. The

scholarship program currently in place could be expanded to include healthcare administration as well. It would seem that strong leaders in these positions would be

able to eventually recruit and retain competent physicians. If those two areas were

addressed seriously, quality of care would improve immeasurably. This would impact diabetes and other health issues in Indian country. While I don’t usually advocate throwing money at a problem, this is a case where I make an exception. The

Indian Health Service is funded at roughly 40 percent of the level needed. In some

areas, the Indian Health Service has done well. With administrators and medical

staff, they have not. Increased funding for enhanced and expanded training programs would make a world of difference.

The Area Offices seem to provide another layer of administration without real

function. All area offices should be eliminated, and service units should have the

autonomy and authority to tailor their needs to fit the needs of the population they

serve. During my time with Indian Health Service, at no time was the Area Office

any help; in fact, they were a constant hindrance. Any real problems I had as a clinical director or chief of staff were sent to headquarters, and I worked with them

to resolve issues. Many times I found myself wondering how much more Contracted

Health Service funds we would have at the service unit level if all those FTE’s at

the Area Office simply didn’t exist. I wondered how many more patients would have

‘‘optional’’ joint replacement surgery, ‘‘optional’’ CT scans, ‘‘optional’’ consultations

with a specialist, and so on. With completely qualified leaders of the reservation

clinics, the Indian Health Service wouldn’t need Area Offices for anything.

Tribal governments and Indian Health Service administrators must work together. Poorly planned tribal ventures are based directly on poorly ran Indian

Health Service clinics. With qualified administrators who are real leaders, the tribal

governments will learn to trust their counterparts in the Indian Health Service. I

don’t believe this is actually anyone’s job presently. No liaison currently exists, simply mutual dislike and distrust. Cooperation would enhance patient care by preventing duplication of services, and coordination of resources.

Thank you again for allowing me to participate this morning. I would welcome

the opportunity to work with any of you on these issues, and I invite your questions.

PREPARED STATEMENT OF HON. DANIEL K. INOUYE, U.S. SENATOR FROM HAWAII

Thank you, Mr. Chairman. I commend the committee for holding this oversight

hearing on diabetes in Indian country with an emphasis on the Special Diabetes

Program for Indians.

The statistics are alarming. We are here today because American Indians and

Alaska Natives have a higher incidence of type 2 diabetes than any other racial or
36

ethnic group in the United States. I am told, among Indian children and young

adults, there has been an increase of 80 percent in type 2 diabetes. These data underscore the importance of the Special Diabetes Program for Indians, which provides

grants to nearly 400 Indian Health Service, tribal, and urban Indian programs in

35 States. In 2005, approximately 116,000 individuals received services from these

programs. One thing is clear. This program is addressing the critical health needs

in Indian country.

In Hawaii, Native Hawaiians also experience similar disparities in diabetes incidence and mortality. In 2004, Native Hawaiians had the highest mortality rate associated with diabetes in the State—a rate which is roughly 119 percent higher than

the statewide rate for all racial groups.

Our examination of the Special Diabetes Program for Indians is a crucial step toward our larger goal of assuring that American Indians and Alaska Natives attain

some parity of good health comparable to that of the larger U.S. population.

Thank you, again, Mr. Chairman for holding this much needed hearing today.

PREPARED STATEMENT OF WILLIAM C. KNOWLER, M.D., DR.P.H., CHIEF, DIABETES

EPIDEMIOLOGY AND CLINICAL RESEARCH SECTION DIVISION OF INTRAMURAL RESEARCH NATIONAL INSTITUTE OF DIABETES AND DIGESTIVE AND KIDNEY DISEASES

NATIONAL INSTITUTES OF HEALTH DEPARTMENT OF HEALTH AND HUMAN SERVICES

Mr. Chairman and members of the committee: I am William Knowler, chief of the

Diabetes Epidemiology and Clinical Research Section of the National Institute of Diabetes and Digestive and Kidney Diseases [NIDDK]. Our Institute has primary responsibility for diabetes research at the National Institutes of Health [NIH] of the

Department of Health and Human Services [HHS]. I am accompanied by Dr. Judith

Fradkin, who is the director of the NIDDK’s extramural Division of Diabetes, Endocrinology, and Metabolic Diseases.

I am pleased to testify today regarding NIDDK’s efforts to combat diabetes in

American Indians, the population with the highest known rates of type 2 diabetes

in the world. In addition to hitting American Indians the hardest, type 2 diabetes

has become a very significant and increasing health problem nationwide. Both type

1 diabetes and type 2 diabetes are major causes of blindness, kidney failure, and

cardiovascular death, and the combined economic cost of type 1 diabetes and type

2 diabetes in the United States is over $130 billion annually. Reducing the incidence

of diabetes would clearly reduce suffering and benefit our society.

For the past 31 years, I have conducted research on diabetes with the Gila River

Indian Community at the NIDDK’s Phoenix Epidemiology and Clinical Research

Branch in Arizona. This Branch is a major component of NIDDK’s intramural research program, and is located in Phoenix because of its emphasis on research in

American Indian populations. The Branch develops and applies epidemiologic, clinical, and genetic methods in the investigation of diabetes and its complications,

which are particularly common among southwestern American Indians.

Through basic and clinical research, we can gain greater insights into the genetic

and environmental factors that lead to the development of type 2 diabetes, develop

effective treatments, and perhaps most importantly develop strategies and programs

to prevent or delay the onset of the disease. My particular research focuses on the

risk factors for type 2 diabetes and its complications [especially diabetic kidney, eye,

and heart disease], obesity and its relationship to diabetes, and diagnostic criteria

for diabetes.

GILA RIVER INDIAN COMMUNITY LONGITUDINAL STUDY

Most of the research of our Branch is conducted in collaboration with the members of the Gila River Indian Community [most of whom are Pima Indians] near

Phoenix. Some of our programs also include other American Indians in Arizona and

New Mexico. In our longitudinal population study in the Gila River Indian Community, begun in 1965, we examine community residents at regular intervals. The examinations focus on diabetes and its risk factors and complications. This study has

contributed much to the world’s current understanding of the causes and consequences of type 2 diabetes and its complications, for which we are all indebted

to this community. The study has led to other research on obesity and physiologic

problems such as insulin resistance and defects in insulin secretion that play a

major role in type 2 diabetes. By carefully evaluating the relationships between

plasma glucose concentrations and the specific signs of diabetes, we established criteria for diagnosing diabetes and identifying non-diabetic persons at high risk of developing diabetes. These criteria have been adopted for worldwide use. The study
37

also led to recognizing the importance of control of high blood glucose and high

blood pressure in diabetes. These are now standard components of diabetes care

throughout Indian country and the entire world.

I am happy to report that these improvements in standards of care have directly

benefited members of the Gila River Indian Community. Over the last 30 years

there has been a rise in the percentage of people with diabetes receiving medical

treatment to control blood 2 glucose, coinciding with a fall in average blood glucose.

There has also been a marked increase in the use of blood pressure medicines accompanied by a fall in average blood pressure. The sharp increase in the use of both

aspirin and cholesterol lowering agents in recent years may reduce the risk for

heart disease in people with diabetes. The rates of attainment of American Diabetes

Association treatment goals for diabetes are better in this community than in the

Nation as a whole, thanks to the diligent efforts of the tribal health program in implementing research-based standards of care.

Finally, the research has contributed to understanding the serious long-term consequences of childhood obesity and type 2 diabetes, the importance of obesity on the

development of type 2 diabetes, and the concept that type 2 diabetes and its complications can be prevented or delayed by modifying or treating factors that put people at high risk. These results stimulated the development of the Diabetes Prevention Program [DPP].

THE DIABETES PREVENTION PROGRAM [DPP]

The findings of the DPP are among the most encouraging and valuable to come

from diabetes research in the past decade. I would like to tell you briefly about this

clinical trial. Our Branch, along with 22 university sites, participated in the DPP

to examine the effects of a lifestyle-based weight-loss intervention and pharmacologic interventions on the development of type 2 diabetes in adults with pre-diabetes. These interventions were tested because our previous research findings suggested that reducing weight or improving insulin resistance might prevent type 2

diabetes. About half of the nearly 4,000 DPP participants were from minority

groups. The lifestyle intervention, that included modest weight loss and increased

physical activity, resulted in a dramatically reduced risk—by 58 percent—of developing type 2 diabetes. The intervention with the drug metformin reduced diabetes

risk by 31 percent. The lifestyle and metformin interventions worked well in both

men and women and in all ethnic groups studied, including the American Indians.

This significant finding conveys an important message to American Indians and

other people at high risk for type 2 diabetes: By adopting a moderate, consistent

diet and exercise weight-loss program, diabetes can be prevented or delayed. The

importance of translating these results into practice is paramount. The American

Indian and other DPP participants continue to be followed in the DPP Outcomes

Study to assess the durability of the effects of the DPP interventions on preventing

type 2 diabetes and determine their impact on development of diabetes complications.

The DPP, primarily funded by the NIDDK but also with substantial support from

the Indian Health Service [IHS], has had a large impact on many IHS and tribal

health programs to prevent diabetes, as I will describe later. The DPP is an outstanding collaboration between NIDDK and the IHS in a research study testing

ideas that came from population research and, in turn, greatly influencing and benefiting clinical practice in Indian country and throughout the world.

COMPLICATIONS OF DIABETES

Diabetes is associated with many complications that affect the eyes, kidneys,

heart, feet, gums, and blood vessels. The kidney complications of diabetes often lead

to heart attacks or to the need for dialysis or kidney transplantation. Poor control

of blood glucose and blood pressure, long duration of diabetes, and genetic factors

increase the risk of diabetes complications such as those affecting the kidneys. We

recently discovered an additional treatable factor: Periodontal disease, an infection

of the gums that is very common in American Indians with diabetes. It is the major

cause of tooth loss, but the risks of periodontal disease extend well beyond the

mouth. Periodontal disease also increases the risk of kidney disease and is associated with higher death rates from kidney disease and heart attacks in those with

diabetes.

The rate of progression to kidney failure among diabetic Gila River Indian Community members who are at least 45 years old has declined since 1990, suggesting

that newer treatments for diabetic kidney disease are slowing its progression. Since

1999, a similar decline in the rate of diabetic kidney failure has been seen nation-
38

ally in American Indians but not in other racial or ethnic groups. Unfortunately,

the frequency of kidney failure is increasing among younger Gila River Indian Community members because of the increasing rate at which diabetes develops in youth;

5 percent of Community members 15 to 19 years of age now have diabetes, and

many of them will develop kidney failure or die of diabetes complications by their

forties or fifties.

Death rates from heart disease have doubled among Gila River Indian Community members with diabetes in recent years, while deaths attributed to diabetic kidney disease have declined. These changes are due primarily to improvements in dialysis care that have reduced deaths from kidney disease, while the risk of death

from heart disease remains high. On the other hand, death rates from heart disease

remained very low in non-diabetic Community members and have not changed over

the past 40 years. This finding points to the importance of preventing diabetes and

its kidney complications as a means of reducing the risk of heart disease.

LOOK AHEAD [ACTION FOR HEALTH IN DIABETES]

American Indians are part of a major NIDDK diabetes treatment clinical trial,

called Look AHEAD [Action for Health in Diabetes], which is a multicenter randomized clinical trial examining the long-term effects of a lifestyle weight-loss intervention on the development of cardiovascular disease and other complications of diabetes. A Southwest American Indian Look AHEAD clinical center at our Branch includes participants from American Indian communities in Arizona and New Mexico.

OVERWEIGHT AND OBESITY

Because obesity is an important and modifiable risk factor for the development

of type 2 diabetes, we seek to understand in more detail why some people become

overweight or obese. We also conduct research on better ways of preventing or reversing these conditions. Much of this research is conducted in our inpatient clinical

research unit in the Phoenix Indian Medical Center. Specifically, we are studying

genetic and other causes of why some people overeat and exercise too little, because

these are the major factors causing obesity, not ‘‘slow metabolism’’ or abnormalities

of resting energy expenditure. We are also studying factors that predict which people respond best to weight-loss interventions by achieving and, more importantly,

maintaining weight loss.

GENETICS RESEARCH

Most of the research I have described has had large and immediate impacts on

the prevention and treatment of type 2 diabetes. To achieve even greater progress

or to eliminate the disease altogether, we believe that a more fundamental understanding of its causes and biological mechanisms is needed. To this end, we have

also pursued research in the genetic susceptibility factors for obesity, type 2 diabetes, and its complications, including diabetic kidney disease.

There is a large body of scientific evidence that obesity and type 2 diabetes have

major genetic determinants, and there have been considerable advances in technologies to identify genes for such complex health conditions. These new methods

need to be applied across various populations and individual American Indian communities, because different genes, or different variants within the same gene, may

increase the risk of these conditions in different groups.

In the past year a major type 2 diabetes susceptibility gene was identified in Iceland, and it appears to be a major gene for diabetes in Whites around the world,

but not, for example, in the Pimas of the Gila River Indian Community. We are testing the possibility that polymorphisms [that is, common variations in the sequence

of DNA among individuals] in other genes in the same metabolic pathway increase

the risk of diabetes among the Pimas. Conversely, a genetic polymorphism, that is

unique to the Ojee Cree Tribe in Canada was found to greatly increase their risk

of diabetes. By contrast, our previous discovery of a region on chromosome I that

contains a gene or genes involved in diabetes susceptibility in the Pima Indians has

been widely replicated around the world. We work with an international consortium

of scientists to precisely identify this gene.

THE NATIONAL DIABETES EDUCATION PROGRAM [NDEP]

To disseminate the important findings of the DPP to people at risk for diabetes,

the NDEP developed the ‘‘Small Steps, Big Rewards, Prevent Type 2 Diabetes’’ education campaign. The NDEP is sponsored by the NIDDK, the Centers for Disease
39

Control and Prevention [CDC], and over 200 partners. The campaign, which includes material tailored to American Indians, emphasizes the practical application

of the DPP findings and includes lifestyle-change tools for those at risk, patient education materials for healthcare providers, web-based resources for healthcare providers and consumers, and public service announcements. In addition to educational

material on diabetes prevention, the NDEP has developed culturally specific messages on the importance of controlling blood glucose levels to prevent life-threatening diabetes complications for American Indians already diagnosed with diabetes.

The NIDDK is committed to continuing these types of educational efforts to disseminate the positive results of its clinical trials to benefit public health.

NIDDK–IHS PARTNERSHIPS

Mr. Chairman, I’m pleased to tell you that the NIDDK works closely with the Indian Health Service to improve the health and quality of life of American Indians.

The NIDDK’s extramural Division of Diabetes, Endocrinology, and Metabolic Diseases, which Dr. Fradkin heads, has worked closely with the IHS’ Division of Diabetes Treatment and Prevention in the development of the ‘‘Special Diabetes Program

for Indians Competitive Grant Program,’’ which has developed a DPP-like lifestyle

intervention program for American Indians diagnosed with pre-diabetes, for implementation testing at 36 tribal grantee sites. Since the awarding of the 36 grants,

including one to the Gila River Indian Community, NIDDK has participated in the

Steering Committee for this program. In addition, the director of the IHS’ Division

of Diabetes Treatment and Prevention and its National Diabetes Program, Dr. Kelly

Acton, serves as a member of the statutory Diabetes Mellitus Interagency Coordinating Committee, which is chaired by the NIDDK. This committee serves an important function by coordinating activities of all Federal programs related to diabetes

and its complications.

In addition, the NIDDK, IHS, CDC, Tribal Colleges and Universities, and the

Tribal Leaders Diabetes Committee Joined together to develop ‘‘Diabetes-Based

Science Education in Tribal Schools,’’ which is an educational curriculum development program to enhance understanding and appreciation of diabetes, and within

this framework, to increase knowledge of the biomedical sciences in Tribal elementary, middle, and high schools. One goal of the program is to enhance awareness

and understanding of diabetes among students, families, community members, and

teachers to prevent the disease and to help affected Tribal members better manage

their diabetes. Another objective of the program is to increase the numbers of American Indians who enter the health research professions. The IHS continues to make

critical personnel and financial contributions to the successful and influential prevention research program, the DPP and the DPP Outcomes Study.

CONCLUSION

Mr. Chairman and members of the committee, I hope that these few examples

convey the firm commitment of the NIH and NIDDK, in partnership with our sister

agencies, to combating diabetes in American Indians. The central mission of the

NIH is to conduct and support biomedical research aimed at decreasing the burden

of disease in the United States. In diabetes, I believe that the NIH’s mission is

being well served and that the future is encouraging for the ultimate control and

prevention of diabetes in American Indians and all Americans. Let me conclude with

a note of special thanks to the members of the U.S. Senate on behalf of the community of scientists who work in diabetes. Thank you for the continuing encouragement

of biomedical research through which we hope to improve the health of all Americans.

I appreciate the opportunity to address the committee on behalf of the NIH and

NIDDK and would be pleased to respond to any questions you may have.

BIOGRAPHY

Dr. William C. Knowler has worked with American Indians in the Southwestern

United States for the last 31 years as a research physician with the National Institute of Diabetes and Digestive and Kidney Diseases [NIDDK]. He is chief of the Diabetes Epidemiology and Clinical Research Section of NlDDK in Phoenix, AZ, where

he conducts research in type 2 diabetes, complications of diabetes, obesity, and other

health concerns of American Indians. He also serves with two national diabetes clinical trials evaluating the best ways to prevent the development of type 2 diabetes

and the occurrence of cardiovascular complications of the disease and in a national

study of the hereditary factors in the development of diabetic kidney disease.
40

Dr. Knowler was born and educated in Iowa City, receiving his BA in mathematics from the University of Iowa. He then received doctoral degrees in medicine

and public health from Harvard University and further clinical training in Boston

before moving to the NIDDK in Arizona in 1975. He is widely recognized for his

research in the causes and prevention of type 2 diabetes and its complications. His

research findings have been widely implemented in clinical practice, in particular

in Indian Health Service and tribal programs serving American Indians.

Dr. Knowler is widely sought as a lecturer and teacher, has published over 400

medical research articles and book chapters, and serves as a reviewer or editor for

several medical journals. He is recognized as one of the world’s 250 most highly

cited researchers in clinical medicine and in biology and biochemistry. He has been

honored for his research and its clinical applications with many awards, most notably the Kelly West Award for Epidemiology from the American Diabetes Association,

the Tribal Leaders Diabetes Committee award for research in treatment and prevention of diabetes in American Indians, and the NIDDK Director’s Award for national leadership in diabetes prevention.

PREPARED STATEMENT OF SAM MCCRACKEN NATIVE AMERICAN BUSINESS MANAGER,

NIKE, BEAVERTON, OR

Committee Chairman Dorgan, Vice Chairman Thomas and other members of the

committee on Indian Affairs, thank you for the opportunity to speak to you today

in support of diabetes prevention and the overall health of Native American communities and the important role that corporate commitment can play in addressing

these issues.

At Nike, diversity is celebrated. In that spirit, Nike actively supports the Native

American community through a variety of initiatives, programs and grants that

seek to increase physical activity of young people on Native lands to help improve

their lives and aid in the prevention of prevalent health issues such as diabetes.

Like of all of you, we at Nike are very aware and concerned about the mounting

diabetes epidemic among Native Americans and the high percentage of cases among

Native American youth.

I am named after my great grandfather Thomas Duck a provider for the Assiniboine and my clan is the red bottom clan. Today I am the Director of Nike’s Native

American Business Program and a proud member of the Ft. Peck Tribes [Sioux and

Assiniboine Tribes] in northeastern Montana. In 2001 the tragedy of diabetes struck

my family when I lost my mother to type 2 diabetes. I am committed to forging a

healthier future for all Native Americans, a future where diabetes is a thing of the

past and physical fitness among youth is at an all-time high. Together, as public

and private partners, I believe we can overcome anything.

The Problem

Diabetes strikes 13 percent of the Native American population. Even more concerning is the 80 percent increase of diabetes among Native American children and

young adults. Complications from diabetes lead to major causes of death and health

problems in Native American communities including an amputation rate that is

three-to-four times higher.

Nike’s Approach

Through my passion and Nike’s commitment to the community we have worked

with government officials and community elders in the creation of Nike’s Native

American community program which is a multi-tiered initiative to support and encourage physical activity on Native American lands to combat diabetes. The program has several key components that are detailed as follows.

Indian Health Service [IHS] and Nike Memorandum of Understanding

Under the leadership of Indian Health Services director, Dr. Charles Grim and

Leo Nolan, Senior Policy Analyst for External Affairs for IHS, the Nike Native

American community program helped forge a unique partnership with IHS, with the

signing of an important Memorandum of Understanding [MOU] in November 2003.

Nike and IHS signed the MOU to collaborate on a promotion of healthy lifestyles

and healthy choices for all American Indian and Alaska Natives. The MOU is a voluntary collaboration between business and government that aims to dramatically increase the amount of health information available in American Indian and Alaska

Native communities. The goal of the MOU is to help those communities gain a better understanding of the importance of exercise at any age, particularly for those

individuals with diabetes.
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The MOU supports the President of the United States’ ‘‘Healthier U.S. Initiative,’’

the Secretary of Health & Human Services’ Preventative Initiative ‘‘Steps to a

Healthier U.S.’’ and the Indian Health Services’ ‘‘Health Promotion/Disease Prevention Initiative.’’

In 2003, Dr. Grim offered this perspective on the new Indian Health Service partnership: ‘‘The mission statement of Nike shares a common basis for collaborative activities with the IHS and other Federal agencies. That basis is the improvement of

the health and fitness of every American.’’

Continued Grim, ‘‘Overweight and obesity are the fastest-growing causes of preventable disease and death in America and are contributing factors in diabetes,

heart disease, high blood pressure, stroke and poor cholesterol levels. Nearly 13 percent of the Indian population is affected by diabetes, and this campaign can help

promote positive changes in the health issues associated with these and many other

illnesses and diseases in American Indian communities.’’

‘‘Regular physical activity contributes to better health by reducing obesity and the

many chronic conditions associated with it, including increased diabetes and heart

disease,’’ said Health and Human Services Secretary Tommy G. Thompson at the

time of the MOU signing in 2003. ‘‘This new partnership will serve American Indian

and Alaska Native communities by expanding the information available on the importance of physical activity.’’

Nike stands by the words of co-founder Bill Bowerman who said that if you have

a body, you are an athlete. Applying this thinking in conjunction with the goal of

the MOU and through deeper understanding in working with the IHS, Nike is developing an innovative new shoe that offers increased comfort through a uniquely

designed fit for the Native American foot. Nike’s goal with this new design is to increase comfort among Native Americans in the hopes that it will encourage and motivate these citizens to exercise and maintain their physical fitness. The shoe is still

in development and will be offered through limited distribution to qualified Native

American Business partners.

Native American Incentive Program

In 2000, Nike began the Native American Incentive Program. Working closely

with the diabetes program coordinators of some 116 tribal agencies, Nike provides

product for their fitness promotion programs and partners with these tribes to provide mentoring and recreational events for the tribal population.

The White Earth Reservation Tribal Council, in White Earth, Minn., for example,

began its Diabetes Project with one center and a total of 45 participants. With help

from Nike, the program has grown to five Fitness/Wellness centers, 1130 participants, 350 participants in a 100-Mile Walk program, 275 diabetes camp participants, and 40 attendees a month in its water-aerobics classes. Ages of the participants range from 10 to 92.

Nike’s U.S. Community Affairs program has also partnered with several national

stakeholders and government officials. These key partners include the Indian

Health Services, the Department of U.S. Health and Human Services, FirstPic, and

the Boys & Girls Clubs which introduced the NikeGO on Native Lands program at

six Boys & Girls Clubs sites on Indian reservations. Through this pilot program,

NikeGO provides a culturally relevant physical activity curriculum, training, equipment and incentives, all designed to help Native American youth ages 8–15 discover

the joy of movement and the fun of physical activity. Since 2004, NikeGO on Native

Lands has expanded to include grants to 67 Boys and Girls Clubs on Indian Reservation across 20 states. Fifteen of those grants were awarded this year. Last year,

Nike donated more than $1 million in product to support this program.

Listen to the Voice of the Athlete

Nike has always listened to the voice of the athlete to inspire and motivate both

within its organization and within the community. Nike has applied this philosophy

to the Native American community, as well.

Native American golfer Notah Begay III, a 4-time winner on the PGA Tour, has

played a central role in helping Nike educate Native Americans about the benefits

of exercise. In fact, Mr. Begay’s efforts off the golf course specifically focus on preventing the continued spread of diabetes in the Native American community. In

2004, Mr. Begay joined Dr. Grim and me at the annual session of the National Congress of American Indians. Mr. Begay was instrumental in kicking off the first ever

National Native American Health and Fitness day.

In May 2006, Nike announced a 5-year partnership with the Iroquois National Lacrosse organization, providing the Iroquois Nationals with footwear and apparel, including team uniforms, warm-ups and casual sports apparel. Nike designed the new

uniforms to pay homage to the Iroquois Nation’s rich history in the sport. They
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debuted last summer at the 2006 World Lacrosse Championships in London, Ontario, Canada.

The Iroquois Nationals today are the only indigenous nation worldwide participating in international sports competition, meaning that the Iroquois Nationals compete for the world title alongside the United States, Canada and other qualifying

countries at each World Lacrosse Championship.

The partnership developed out of Nike’s commitment to working with the Native

American community and as another means of inspiring physical activity among

Native American youth.

‘‘We are proud to have Nike support us at this exciting time in our history,’’ said

Chief Oren Lyons of the Iroquois Nationals at the time of the partnership announcement. ‘‘The Iroquois Nationals Program has had a significant impact on the youth

of our confederacy providing an international showcase for our players and our culture. With Nike’s support, we will be able to continue to send our best athletes to

compete and promote lacrosse to the world, sharing the game and our history.’’

Historically, the game of lacrosse may be one of the oldest team sports in the

world, and the roots of modern day lacrosse can be traced back to the Iroquois. For

over 500 years, lacrosse has played an integral part of the Iroquois Confederacy well

being. As lacrosse continues to grow in popularity around the world, Iroquois Nation

leaders are committed to promote its heritage and drive broader participation in

healthy physical activity among its people.

Late in 2006, the Native American Basketball Invitational [NABI], the largest all

Native American basketball tournament in North America, announced Diana

Taurasi as its first Honorary Commissioner through its partnership with Nike.

‘‘Nike has been a sponsor of NABI since the tournament’s inception in 2003. Our

national tournament, organized for the sole purpose of creating college scholarship

opportunities for Native American high school athletes, will feature 80 tribal teams

from the United States and Canada. Nike’s willingness to stand beside our efforts

to make NAB[ successful has been instrumental in our rapid growth’’ said

GinaMarie Scarpa-Mabry, co-founder of NABI, at the time of the announcement.

Since its inception, NABI has created numerous opportunities for Native American students to receive college athletic scholarships by showcasing high school athletes from Native American communities from throughout North America in one location. NABI’s goal for the July 2007 tournament is to become a NCAA certified

summer event, which will make NABI the first all Native American tournament certified by the NCAA.

Conclusion

The mission of the Nike brand is to bring inspiration and innovation to every athlete in the world. Also, one of the company’s celebrated maxims is to ‘‘Do the Right

Thing.’’ On behalf of Nike, I believe that our program designed to provide diabetes

prevention and overall improved health to Native American communities is true to

both its mission and key maxim.

A future rid of diabetes within the Native American community can only be realized if we inspire and instill healthy lifestyles in our youth today. Nike and its partners in the corporate, nonprofit and government arenas have an opportunity to

shape these kids’ lives now, and help them form positive habits and attitudes that

last a lifetime.

I am very fortunate to have the opportunity to work for a company that is thriving to make a difference, but we will only be as successful as the partnerships we

forge along the way. Your leadership on this issue is critical, and we look forward

working with you.
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