Diabetes and Obesity in Indian Country: An Epidemic Rising and What Can Be Done

Childhood obesity in the United States has reached epidemic levels. Nowhere is this
more evident than with American Indian and Alaskan Native (AI/AN) children and youth, who suffer from overweight and obesity issues at a significantly higher rate than any other group. Obesity is costing around 147 billion (2008), primarily due to medical spending, which 37 percent of that was spent on the AI/AN population by the Indian Health Service. Obesity is a primary cause of Type II diabetes. According to the American Diabetes Association, the cost of diabetes in 2007 was $174 billion nationally, compared to the $245 billion in 2012. These numbers reflect a 41 percent increase in just five years. AI/AN people suffer from obesity-related Type II diabetes at the highest rate of any other US ethnic group. The alarming rise of childhood obesity in the AI/AN population has many resultant economic, personal and cultural costs. Thus, efforts to ameliorate childhood obesity have the potential to have a broad impact across Native communities and their constituents.
Obesity: Prevalence and Consequences in Indian Country
Obesity can lead to diabetes, hypertension, and cardio-vascular disease, sleep apnea,
asthma and a variety of other medical, psychological and economic issues. Alarmingly, AI/AN children suffer from obesity at much higher rates than children in the general US population. For example, 45% of AI/AN children between the ages of 2-5 years old are overweight or obese compared to 12.1% in the general population. A similar disparity is found up to 18 years of age (AI/AN obesity rate = 31% compared to 18% for the general population age 6-18). A recent study that was conducted on American Indian 2nd graders in South Dakota, New Mexico, and Arizona, concluded that 20.3% of the children are overweight, while 28.6% are obese. According the United States Department of Agriculture, AI/AN children are nearly twice as likely to suffer from food insecurity, obesity, and Type II diabetes, than the average non- AI/AN child in the US. In fact, AI/AN people have the highest age-adjusted prevalence of diabetes among all U.S. racial and ethnic groups. There seems to be a precipitous rise in the prevalence of diabetes among AI/AN youth: There was a 68% increase in diabetes diagnoses in 15 to 19 year old AI/AN youth in the 10-year period between 1994-2004. These are troubling numbers, especially given the propensity for obese children to become obese adults and the subsequent cost to personal achievement, self-esteem and social welfare.
Food Insecurity
Food insecurity as defined by the USDA is “constraints leading to serious problems such
as the family suffering hunger or being unable to purchase a balanced diet or enough food for their children or the parents skipping meals so the children can eat”. For children ages 6-12, food insecurity is related to a weakening immune system, school absences, grade repetition, tardiness, aggression, anxiety, poor mathematical skills, psychosocial dysfunction and poor social interaction skills. It is also associated obesity. Food insecurities occur in Indian Country for a variety of reasons including not having access to grocery stores, often resulting in a diet featuring foods commonly found in convenience stores. Convenience store food prices range between 30- 50 percent higher than similar products in grocery stores, which often leads to lower access to affordable and healthy food options that lead to a diet high in processed food, high in calories but generally possesses poor nutritional content. The USDA provides programs such as the Food Distribution Program on Indian Reservations (FDPIR) and Commodity Supplemental Food Program (CSFP) to cater to those who need it. These programs serve about 85 percent of some Tribal communities and are targeted to relieve food insecurity. While such programs target hunger, however, they may not provide the constituents of a healthy diet. The list of healthier alternatives provided by the USDA has greatly improved over time, but the provided foods are generally high in salt, sugar and fat, encouraging a diet that is high in complex carbohydrates and other ingredients associated with obesity. Regardless of the source, the availability of the constituents of a healthy diet is often beyond the reach of many AI/AN families.
Preventing and Managing Childhood Obesity and Diabetes at the Tribal Level
American Indian and Alaskan Native children and youth are some of the country’s most
vulnerable, but most promising, individuals. In addition to the development of a strong research base to guide interventions, culturally relevant efforts to promote healthy eating and increase physical activity are essential. With targeted efforts to develop and implement evidence-base strategies in Indian Country, obesity and diabetes can be prevented.
Honey We Shrunk The Kids
Prevention and managing childhood obesity and diabetes can be accomplished through
healthier eating and exercising. Access to better food may be a problem for most tribes, but there are ways to help such as Tribal gardens. In realization of the consequences to their people, many Tribes and Tribal members endeavor to return to a more traditional diet. The number of Tribal gardens has been increasing as a cost effective alternative for a healthier diet and a way to bring people together for the common good, connecting families, the youth and elders. For example, the Coharie Indian Tribe has two tribal centers, each with two community gardens. In addition to the healthy food they provide, the gardens have brought the youth and the elders together resulting in an increase in participation in Tribal activities. In collaboration with the USDA, the Tyonek Tribe in Anchorage, Alaska, has had marked success with the implementation of a community garden. Planting events in the school have encouraged the participation of children and the promotion of healthy eating habits children. The U.S. Department of Commerce Economic Development Authority’s Public Works and Economic Adjustment Assistance Programs provide investment assistance for communities who develop a sustainable Comprehensive Economic Development Strategy (CEDS). The
CEDS is the outcome of a regional planning process designed to guide the responsible economic growth of an area by leveraging community strengths and participation toward definable goals. In a unique and promising strategy to impact the health and economic well-being of their community, the Standing Rock Sioux Tribe recently included ways to improve access to healthy food, including farmer’s markets, community gardens, fitness/recreational programs and youth programs in their CEDS. The Standing Rock Sioux Tribe is paving the way for a new path to address many of these critical issues by targeting a critical issue within their community.
Move It and Lose It
Increasing physical activity in schools and safely within communities is also an effective
strategy to combat childhood obesity and diabetes. Increases in recess time, physical education opportunities and access to extracurricular after school programs that highlight physical activity have been proven to positively affect obesity as well as build a community. Over 45 percent of children in grade 9 through 12 watch more than 3 hours of television on a daily basis. Given the association between obesity and sedentary activities, alternatives to television watching are important to consider. Physical activity for children youth is key to establishing life-long healthy habits, the earlier the better. Accessibility to proper educational materials to encourage physical activity is problematic in Tribal communities. However, even when the appreciation and motivation for physical activity is evident, access to facilities, from gyms to safe neighborhoods in which to play, are often not readily available or accessible. To be successful, access to fitness facilities needs to be provided within every Tribal Community ad these communities are creatively prioritizing these priorities. In January of 2014, the Dine Community Advocacy Alliance (DCAA) initiated a 2 percent tax on junk food and elimination a pre-existing 5 percent tax on fresh produce, water and healthier foods. The revenue will be used to start wellness/fitness centers and provide programs on decreasing the obesity rate
that has plagued this Tribe. In a community where many children are considered obese, this new legislation opens the door for essential revenue to combat this issue. This is just one of the ways that Tribal communities are seeking to address this important health crisis. Some concerns about the definition of junk food and how to process/monitor the tax, led to a veto.

On the bright side, the Healthy Dine Nation Act of 2014 was passed and signed into law on November 24, 2014! “This administration has advocated for healthy living since we took office. Vice President Jim has run across this great Nation all four years of our administration,” President Shelly said. My time at the National Indian Health Board, I really saw first hand the dedication VP Rex Lee Jim and President Shelly had on fighting diabetes and obesity in their community.  It’ll be interesting to see how this unfolds as time goes on and if it something other Tribal communities can implement.
Policy Proposals and Partnerships
Clearly, much needs to be done to combat childhood obesity in Indian Country. One of
the greatest challenges to moving forward, however, has been collecting adequate data for this population. Good data is essential to developing targeted strategies and investing in the most effective interventions. The most important task ahead is providing the strategy and resources to do this right. Much more research is needed to guide responsible interventions and cultivate the research base to determine the best practices.

On October 23rd 2013, Rep. Diana DeGette introduced HR 3322, “Eliminating Disparities
in Diabetes Prevention, Access and Care Act of 2013.” This legislation is an effort to “to
prevent and treat diabetes, to promote and improve the care of individuals with diabetes, and to reduce health disparities, relating to diabetes within racial and ethnic minority groups; African Americans, Hispanic Americans, Asian Americans, Native Hawaiian, Pacific Islander, and American Indian/Alaska Native communities to the Committee on Energy and Commerce”. This bill will address key concerns with regard to obtaining the information needed to address important issues surrounding the childhood obesity epidemic. Another key strategy is the development of synergistic partnerships between groups already committed to these efforts. There are is diverse array of established networks that show promise with respect to working with AI/AN communities on initiatives focused on reducing childhood obesity in Indian Country. Below is a partial list of some of the some of the promising programs that seek to target childhood obesity and diabetes in Indian Country at the nutritional, educational, and physical activity levels.

• Michelle Obama’s, “Let’s Move in Indian Country” is one of several promising
  programs for combating childhood obesity in AI/AN children and youth. Let’s
  Move in Indian Country” is supporting the Tribal leaders as they create food
  policy councils and other initiatives within Tribal communities.
• The Strategies to Overcome and Prevent (STOP) Obesity Alliance is an
  organization that targets cultural barriers and uses a systemic approach to promote
  efforts to combat issues like childhood obesity and diabetes.
• The National Institute of Diabetes and Digestive and Kidney Diseases’ (NIDDK)
  Diabetes Education in Tribal Schools (DETS) program has developed a K-12
  curriculum specifically targets at AI/AN children and youth in an effort to
  translate research about Type 2 Diabetes in a culturally appropriate and effective
  manner.
• Together Raising Awareness for Indian Life (TRAIL) is a partnership between
  the Indian Health Service (IHS), the National Council of American Indians
  (NCAI), Boys & Girls Clubs of America (BGCA), Nike, and FirstPic, Inc. This
  grant funds 50 Native American Boys and Girls Clubs and has, to date, served
  over 12,000 Native American children and youth in over 80 tribal communities.
  Many tribes lack the funding or motivation for invest in and maintain a Boys and
  Girls Club. The Penobscot Indian Nation Boys and Girls Club, for example, faces
  many challenges as a result of inconsistent funding and the subsequent employee
  fluctuation. Consequently, tribal youth cannot count on a safe and consistent
  venue for physical activity and extra-curricular experiences. This group has
  partnered with TRAIL to improve access to quality programming and improved
  health education.
• The Notah Begay III Foundation (NB3F) was created to prevent Type 2 diabetes
  and its leading cause, obesity by promoting research and prevention efforts
  focused on physical activity. NB3F has re-introduced the native sport, lacrosse to
  Native communities to offer both a connection to culture as well as much needed
  exercise. NB3F is partnered with IHS and Nike N7, where more prevention
  efforts are being taken seriously, recently resulting in signing the Memorandum of
  Understanding at the White House in November 2013 between the NB3F and the
  Acting Director of IHS, Yvette Roubideaux.
• Partnership for a Healthier America was founded in 2010. It partners with the
  private sector to promote the health of our nation’s youth, targeting childhood
  specifically. These efforts are focused on making healthier nutritional choices
  affordable and accessible as well as promoting physical activity, such as Play
  Streets Program. Play Streets Program is created to provide safe places for
  children to play. While no such program is targeted toward AI/AN communities
  at present, this organization’s efforts hold great promise for Tribal interventions.

Native Voices: What You Can Do
There are concrete actions that can be taken by individuals, families, institutions, and
policy makers to ameliorate the potential for obesity and the issues associated with it. The easy availability of affordable nutritional choices and an active lifestyle, for example, play important roles in preventing obesity and can be greatly influenced by appropriate healthy policy and habits. Advocating for improvement in the availability of affordable and healthier foods is just the one step in developing a healthier lifestyle. Collaborating with organizations to provide better quality commodity foods to Tribes, raising funds for Tribes to build community gardens, addressing and investigating food insecurity issues are all part of a broad-based plan to combat childhood obesity. It is essential that we advocate for state and local policies that promote good nutrition and increased physical
activity, such as providing safe sidewalks and running/bike trails. Local and national efforts to increase the nutritional content of available food choices, education for communities on the effects of poor diet and inactivity on the long-term health of children, and increased resources for early medical intervention are essential to curbing this epidemic. Working together at every level, allows for this epidemic to be reversed and paving a healthier, more vibrant path for the American Indian and Alaska Native youth and communities.