TYPE 2 DIABETES 

I CAN LOWER MY RISK FOR 

A Guide for American Indians 

U.S. Department 

of Health and 

Human Services 

NATIONAL INSTITUTES OF HEALTH National Diabetes Information Clearinghouse 

Research Gives Hope Diabetes Can Be Prevented 

Although people with diabetes can prevent or delay complications by 

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

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

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

Prevention Program (DPP), prove that we can prevent or delay the disease. 

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

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

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

participated in the DPP. 

The DPP tested three approaches to preventing diabetes: making lifestyle 

changes, taking a diabetes pill, or following the standard diabetes education 

approach. People in the lifestyle change group exercised about 30 minutes a 

day, 5 days a week, usually by walking, and they lowered their intake of fat 

and calories. Those who took the diabetes pill metformin received standard 

information on exercise and diet, as is done in an Indian Health Service 

clinic or tribal physician’s office. These approaches were compared with the 

third group who only received the standard information on exercise and diet 

and took a placebo—a pill without medicine in it. 

The DPP results showed that people in the 

lifestyle change group reduced their risk 

of getting type 2 diabetes by 58 percent. 

Average weight loss in the first year of the 

study was 15 pounds. Lifestyle change 

was even more effective in those 60 years 

and older. They reduced their risk by 

71 percent. People who took metformin 

and received standard information on 

exercise and diet reduced their risk by 

31 percent. “After I started 

exercising and watching what 

I eat, my blood glucose levels 

returned to normal.” 
The Diabetes Prevention Program Outcomes Study (DPPOS) has continued 

to follow most DPP participants since the DPP ended in 2001. The 

DPPOS has shown that the benefits of weight loss and metformin last for 

at least 10 years. Ten years after they enrolled in the DPP, people in the 

lifestyle change group had reduced their risk for developing diabetes by 

34 percent. Those in the lifestyle change group age 60 or older had reduced 

their risk of developing diabetes by 49 percent. 

Participants in the lifestyle change group also had fewer heart and blood 

vessel disease risk factors, including lower blood pressure and triglyceride 

levels, even though they took fewer drugs to control their heart disease risk. 

The metformin group had reduced their risk of developing diabetes by 

18 percent. Even though controlling your weight with lifestyle changes is 

challenging, it produces long-term health rewards by lowering your risk for 

type 2 diabetes, lowering your blood glucose levels, and reducing other risk 

factors for heart disease. 
Contents
�

	 1	 What is diabetes? 

	 

2	 What are the signs and 

symptoms of type 2 diabetes? 


 

2	 What does pre-diabetes mean?

	 	 

	 3	 What factors increase my risk 

for type 2 diabetes? 

	 

4	 Should I be tested for diabetes? 

	 

4	 	How can I lower my risk for 

diabetes? 

	 

13	 Hope through Research

	 

	14	 Daily Food and Drink Tracker

	 

	14	 Daily Physical Activity Tracker

	 

17	 Acknowledgments

What is diabetes? 

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

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

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

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

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

diabetes, however, either no longer make enough insulin, or their insulin 

doesn’t work properly, or both. 

Type 2 diabetes 

Type 2 diabetes is the most common type in American Indians. This type of 

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

diabetes because the cells in the muscles, liver, and fat do not use insulin 

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

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

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

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

amputation. 

Other kinds of diabetes 

Type 1 diabetes 

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

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

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

Gestational diabetes 

Gestational diabetes is first diagnosed during pregnancy. It occurs when 

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

background raises the risk of developing gestational diabetes. Although this 

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

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

1 
What are the signs and symptoms 

of type 2 diabetes? 

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

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

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

Look for 

➜ increased thirst 

➜ increased hunger 

➜ fatigue 

➜ increased urination, 

especially at night 

➜ unexplained weight loss 

➜ blurred vision 

➜ sores that do not heal 

What does pre-diabetes mean? 

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

enough for a diagnosis of diabetes. Having pre-diabetes also means you’re 

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

symptoms of pre-diabetes. However, you can reduce the risk of getting 

diabetes and even return blood glucose levels to normal with modest weight 

loss through healthy eating and moderate physical activity. 

2 
What factors increase my risk 

for type 2 diabetes? 

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

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

item that is true for you. Then show this list to your health care provider. 

My mother had diabetes when I was born. 

I am overweight. 

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

My family background is American Indian. 

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

weighing more than 9 pounds. 

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

that I have high blood pressure. 

My cholesterol levels are higher than normal. My HDL cholesterol— 

“good” cholesterol—is below 35 mg/dL, or my triglyceride level is 

above 250 mg/dL. 

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

“I didn’t know I had 

diabetes until I had a 

blood test at the clinic.” 

3 
Should I be tested for diabetes? 

Anyone 45 years of age or older should consider getting tested for diabetes. If you are 45 or older and overweight, getting tested is strongly 

recommended. Ask your health care provider for an A1C test, a fasting 

blood glucose test, or an oral glucose tolerance test. Your health care 

provider will tell you if you have normal blood glucose, pre-diabetes, or 

diabetes. If you are told you have pre-diabetes, have your blood glucose 

checked again in 1 year. 

How can I lower my risk for 

diabetes? 

You can do a lot to lower your risk. The 

small steps you take can lead to big rewards. 

➜ Reach and maintain a reasonable 

body weight.
�

➜ Make wise food choices most 

of the time.
�

➜ Be physically active every day. 

➜ Take your prescribed medicines. 

Doing these things can reduce your risk of 

developing type 2 diabetes. Keeping your 

blood pressure and cholesterol on target also 

helps you stay healthy. 

If you are pregnant, plan to breastfeed your baby. Ask your health care 

provider for the names of people to call for help learning to breastfeed. Besides being good for your baby, breastfeeding is good for you. 

Studies done with the help of Pima Indian volunteers have shown that 

breastfeeding may lower the baby’s risk of becoming overweight and 

getting diabetes. 

“My great grandmother told 

me to breastfeed my child so 

the baby would be healthy.” 

4 
 

 

Getting Started 

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

the changes easier by taking these steps: 

➜ Make a plan to change something that you do. 

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

➜ Plan what you need to get ready. 

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

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

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

activity—when you do what you have planned. 

Your health care provider, a registered dietitian, or a counselor can help you 

make a plan. 

Reach and Maintain a Reasonable Body Weight 

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

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

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

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

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

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

7 percent of their body weight lowered their risk of developing type 2 

diabetes. They had less than half the risk of developing diabetes as people 

who didn’t make lifestyle changes. A 5- to 7-percent weight loss for a 

150-pound person, for example, would be about 7 to 10 pounds. If you’re 

overweight, choose sensible ways to lose weight. 

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

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

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

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

biking or walking with a friend. 

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

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

that’s right for you. 

5 
 

 

 

 

 

 

 

 

 

Choosing My Weight Loss Goal 

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

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

➜ you’re physically active 

➜ you cut down on fat and calories 

Use these steps to choose a goal. Talk with your health care provider 

and your dietitian about your goal and how to reach it. 

To find your weight loss goal for losing about 5 to 7 percent of your 

weight, find the weight closest to yours on the chart below. Follow the 

row across to see how many pounds you need to lose. 

	 

	 

Your	weight	 

in	pounds	 

5	percent	loss	 

in	pounds*	 

7	percent	loss	 

in	pounds** 

150 8 11 

175 9 12 

200 10 14 

225 11 16 

250 13 18 

275 14 19 

300 15 21 

325 16 23 

350 18 25 

*To find your exact weight loss goal in pounds for a 5 percent loss, 

multiply your weight by .05. 

**To find your exact weight loss goal in pounds for a 7 percent loss, 

multiply your weight by .07. 

continued 

6 
Write your weight loss goal here: 

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

about ___________ pounds.

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

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

Start date: ___________________

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

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

for meeting your goal here: 

End date: ___________________ 

7 
 

 

 

 

 

 

 

 

 

Make Wise Food Choices Most of The Time 

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

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

cholesterol. 

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

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

Tracker form on page 15 to write down what you eat and drink. 

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

sizes of main courses, meat, desserts, and other foods high in fat. 

Increase the amount of fruits and vegetables at every meal. Page 9 

provides a chart for choosing sensible serving sizes using your hand as 

a measuring guide. Because your hand is proportioned to the rest of 

your body, it can be used to measure a healthy serving size for your 

body. Remember, the chart is only a guide. Choose your serving sizes 

and foods wisely. 

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

health care provider or dietitian can help you figure out how many 

grams of fat to have every day. You can check food labels for fat content. For example, if your food choices add up to about 2,000 calories 

a day, try to eat no more than 56 grams of fat. See page 10 for ways to 

lower the fat in your meals and snacks. 

➜	 Cut down on calories by eating smaller 

servings and by cutting back on fat. 

People in the DPP lifestyle change 

group lowered their daily calorie total 

by an average of about 450 calories. 

Your health care provider or dietitian 

can work with you to develop a meal 

plan that helps you lose weight.
�

➜	 Choose healthy commodity foods 

(items provided by the government to 

help people consume a nutritious diet), 

including those lower in fat.
�

➜	 When you meet your goal, reward yourself with something special, like a new 

outfit or a movie. 

8 

“Having fruit for dessert 

instead of sweets has helped 

me lose weight.” 
Choose Sensible Serving Sizes 

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

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

or a deck of 

cards 

1 cup cooked vegetables 

salads 

casseroles or stews, such as 

chili with beans 

milk 

an averagesized fist 

1/2 cup fruit or fruit juice 

starchy vegetables, such as 

potatoes or corn 

pinto beans and other dried beans 

rice or noodles 

cereal 

half of an averagesized fist 

1 ounce snack food one handful 

1 Tablespoon salad dressing the tip of a thumb 

1 teaspoon margarine a fingertip 

9 
Ways to Lower The Amount of Fat in Your Meals 

and Snacks 

1 Choose lower-fat foods.
�

Example:
�

Instead of sunflower seeds (20 grams of fat), choose 

pretzels (1 gram). 

Savings: 19 grams. 

2 Use low-fat versions of foods.
�

Example:
�

Instead of regular margarine (5 grams of fat), use 

low-fat margarine (2 grams).
�

Savings: 3 grams. 

3 Use low-fat seasonings.
�

Example:
�

Instead of putting butter and sour cream on your baked potato 

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

Savings: 20 grams. 

4 Cook with less fat.
�

Example:
�

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

or grill the chicken (9 grams).
�

Savings: 22 grams.
�

10 

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

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

products are high in calories. Check the food label.
Be Physically Active Every Day 

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

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

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

an exercise program slowly. Talk with your health care provider first about 

what kinds of exercise would be safe for you. Then make a plan to increase 

your regular physical activity. 

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

the Daily Physical Activity Tracker form on page 16 to keep track of 

your physical activity. 

➜ Aim for at least 30 minutes of 

physical activity a day most 

days of the week.
�

➜ Incorporate physical activity 

into plans with family and 

friends. Set a good example 

for your children. Play softball on weekends. Go on a 

family hike.
�

➜ Be active every day. For 

example, walk to the store, clean 

the house, or work in the garden, 

rather than watch TV.
� “Walking makes 

me feel good.” 

11 

Getting Started on a Walking Routine 

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

with your health care provider about whether it’s OK for you to walk for 

exercise. Then get comfortable shoes that provide good support. You can 

use the chart on page 16 to start your routine gradually. Try to walk at least 

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

 

 

 

 

 

 

 

 

My Walking Program 

Week	 

number	 

	 

Warm-up	time	 

(minutes)	 

Walk	slowly	 

Fast	walk	time	 

(minutes)	 

Walk	briskly	 

Cool-down	time	 

(minutes)	 

Walk	slowly 

Total	 

(minutes) 

1 5 5 5 15 

2 5 8 5 18 

3 5 11 5 21 

4 5 14 5 24 

5 5 17 5 27 

6 5 20 5 30 

7 5 23 5 33 

8 5 26 5 36 

9+ 5 30 5 40 

Source: Small Steps. Big Rewards. Your Game Plan for Preventing Type 2 

Diabetes. A publication of the National Diabetes Education Program. 

Take Your Prescribed Medicines 

Some people need medicines to help control their blood pressure or 

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

doctor if you should take metformin to prevent type 2 diabetes. Metformin 

is a medicine that makes insulin work better and can reduce the risk of 

type 2 diabetes. 

12 
Hope through Research 

With the help and participation of many Pima Indian volunteers over 

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

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

diabetes. We know keeping blood glucose, blood pressure, and blood cholesterol under control is very important. We know pregnant women with 

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

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

even for a few weeks, helps protect babies from becoming overweight and 

developing diabetes. 

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

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

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

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

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

to develop more ways to prevent diabetes and take care of those who already 

have diabetes. 

Participants in clinical trials can play a more active role in their own health 

care, gain access to new research treatments before they are widely available, 

and help others by contributing to medical research. For information about 

current studies, visit www.ClinicalTrials.gov. 

13 
 

 

Keeping Track 

Daily Food and Drink Tracker 

Use the form on page 15 to keep track of everything you eat and drink. 

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

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

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

1–888–693–NDEP (1–888–693–6337) and request a copy of the Game 

Plan Fat and Calorie Counter. Or view it online at www.ndep.nih.gov/ 

diabetes/pubs/GP_FatCal.pdf. 

SaMPLE 

DaTE	 December 1, 2011 DaILY	FOOD	aND	DRINK	TRaCKER 

Time	 Name	 amount	 Fat	Grams	 Calories 

8:00 am oatmeal 1/2 cup 1 80 

fat-free milk 1 cup 0 90 

Daily Physical Activity Tracker 

Use the form on page 16 to keep track of your physical activity. Make a 

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

SaMPLE 

DaTE	 December 1, 2011 DaILY	PHYSICaL	aCTIVITY	TRaCKER 

Type	of	activity	 Minutes 

Walking 20 

Gardening 10 

14 
Daily Food and Drink Tracker 

DaTE 

	 Time	 Name	 amount	 Fat	Grams	 Calories 

TOTALS

15 
Daily Physical Activity Tracker 

DaTE 

Type	of	activity	 Minutes 

TOTAL

16 
 

Acknowledgments 

The authors and reviewers of this prevention information wish to 

thank the tribal leaders, American Indian Communities, health care 

facilities that supported the DPP, and the many American Indians 

who participated in the DPP. Their generous gifts of time and 

energy are bringing the message that small steps result in big health 

rewards for all American Indians. 

Publications produced by the Clearinghouse are carefully reviewed by both 

NIDDK scientists and outside experts. This publication was originally 

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

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

also reviewed by American Indian health care providers who work with 

the National Diabetes Education Program. Comments from members of 

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

American Indian communities have also been included. Tammy L. Brown, 

M.P.H., R.D., B.C.-A.D.M., C.D.E., Captain, U.S.P.H.S.; Lorraine 

Valdez, R.N., M.P.A., C.D.E.; Wendy Sandoval, Ph.D., R.D., C.D.E.; 

Gordon Quam, B.S.N., R.N., C.D.R., U.S.P.H.S.; and Cecelia Shorty of 

the Indian Health Service reviewed the updated version of the publication. 

This publication may contain information about medications. When prepared, 

this publication included the most current information available. For updates or 

for questions about any medications, contact the U.S. Food and Drug Administration toll-free at 1–888–INFO–FDA (1–888–463–6332) or visit www.fda.gov. 

Consult your health care provider for more information. 

17 
Notes 

18 
Notes 

19 
Notes 

20 
National Diabetes Education Program 

1 Diabetes Way 

Bethesda, MD 20814–9692 

Phone: 1–888–693–NDEP (1–888–693–6337) 

TTY: 1–866–569–1162 

Fax: 703–738–4929 

Email: ndep@mail.nih.gov 

Internet: www.ndep.nih.gov 

www.yourdiabetesinfo.org 

The National Diabetes Education Program is a federally funded program 

sponsored by the U.S. Department of Health and Human Services’ National 

Institutes of Health and the Centers for Disease Control and Prevention and 

includes over 200 partners at the federal, state, and local levels, working together 

to reduce the morbidity and mortality associated with diabetes. 

National Diabetes Information Clearinghouse 

1 Information Way 

Bethesda, MD 20892–3560 

Phone: 1–800–860–8747 

TTY: 1–866–569–1162 

Fax: 703–738–4929 

Email: ndic@info.niddk.nih.gov 

Internet: www.diabetes.niddk.nih.gov 

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

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

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

of Health and Human Services. Established in 1978, the Clearinghouse provides information about diabetes to people with diabetes and to their families, 

health care professionals, and the public. The NDIC answers inquiries, develops 

and distributes publications, and works closely with professional and patient 

organizations and Government agencies to coordinate resources about diabetes. 

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

publication to duplicate and distribute as many copies as desired. 

This publication is available at www.diabetes.niddk.nih.gov. 
 - 

U.S. DEPARTMENT OF HEALTH 

AND HUMAN SERVICES 

National Institutes of Health 

NIH Publication No. 11–5337 

August 2011 

The NIDDK prints on recycled paper with bio based ink.