Statement of the Problem

Youth-onset type 2 diabetes seriously threatens the future well-being of American Indian and Alaska Native communities. Studies point to the continued dramatic rise of both childhood obesity and type 2 diabetes in American Indian and Alaska Native youth.1-8 In a 2002-2003 study on the prevalence of overweight and obesity among 11 538 Northern Plains American Indian children, aged 5-17 years, more than 40% of the children at 5 years of age were overweight and almost one-quarter of them were obese. Compared with data collected in 1995-1996 on children on these same reservations, the prevalence of overweight and obesity had increased by 4.5% and 4.3%, respectively.3 In 2005, obesity prevalence was 18.4% at 4 years of age among a nationally representative sample of US children. The highest obesity prevalence among different racial and ethnic groups-31.2%-was found in American Indian and Alaska Native children in whom obesity was twice as common as in non-Hispanic white or Asian children.4

In parallel with these obesity trends, the prevalence of diagnosed type 2 diabetes increased by 68% among American Indian and Alaska Native adolescents aged 15 to 19 years who used Indian Health Service (IHS) health care services from 1990 to 2004.9 Only 2 tribal-specific prevalence studies on youth-onset diabetes are available. Navajo youth aged 15 to 19 years had the greatest risk of type 2 diabetes of all racial/ethnic groups in the SEARCH for Diabetes in Youth Study-a multiethnic population-based study designed to describe incident childhood diabetes among non-Hispanic whites, Hispanics, Asian/Pacific Islanders, African Americans, and American Indians.10,11 Among Pima Indian youth of southern Arizona, diabetes increased 2 to 3 times during the 30 years prior to 1996.5 Moreover, the rising incidence of diabetes among the Pima over the past 40 years has been confined to the youth population.8

Besides the paucity of data on national and tribal-specific trends on childhood obesity and type 2 diabetes, there are other limitations in the current literature describing the burden of diabetes in American Indian and Alaska Native youth. A limitation of the IHS study on diabetes prevalence among youth is that data on diabetes prevalence was not collected on 40% of American Indians and Alaska Natives who do not reside in the IHS service area or those residing in counties on or near Indian reservations who do not utilize IHS or tribally operated health care facilities.9,12 Furthermore, little is known about diabetes prevalence among the urban Indian youth population. In addition, more longitudinal studies of the prevalence of obesity and other chronic diseases, including type 2 diabetes, would be helpful in the accurate determination of the extent of these conditions in youth across American Indian and Alaska Native communities in the United States. Such studies might also elucidate previously unrecognized modifiable risk factors for more effective and culturally specific interventions.

Youth-onset type 2 diabetes is not only increasing but also a serious health problem. American Indians and Alaska Natives who develop type 2 diabetes during childhood and adolescence will experience more years of disease burden and a higher probability of developing serious type 2 diabetes-related complications.5,7,13,14 The increased frequency of diabetes among young American Indian and Alaska Native women of childbearing age poses an additional risk to future generations as intrauterine exposure to maternal diabetes places the fetus at increased risk of not only congenital defects and perinatal death but also future onset of diabetes.7,14-16 This has led some researchers to describe a vicious cycle of early onset of diabetes, diabetes during pregnancy, followed by early onset of diabetes in the next generation.7,15,16

Several key differences between type 1 and type 2 diabetes also contribute to the dire public health consequences of this growing epidemic among children and adolescents. Type 2 diabetes confers additional cardiovascular risk due to its association with insulin resistance.17,18 There is a possibility of greater microvascular disease from youth-onset type 2 diabetes than type 1, particularly for diabetic nephropathy.17,19,20 In addition, type 2 diabetes in children and adolescents may be associated with fewer symptoms than type 1, and its treatment is often more focused on lifestyle modification and behavior change, which results in decreased patient and family adherence. Increasingly, children with type 2 diabetes are being seen with uncontrolled hyperglycemia and their diabetes in an advanced stage.11,21 Children, more so than adults, are largely dependent on a well-functioning family unit to ensure health care access and a supportive environment to live well with a chronic disease such as diabetes. Poverty and unemployment; low educational levels; limited access to adequate health services, especially in remote and rural locations; less availability of healthier food choices and fewer options for safe and regular physical activity; and specific tribal or culturally held beliefs about diabetes represent significant challenges to American Indian and Alaska Native families, as well as their health care providers, in meeting the needs of children and adolescents with diabetes.14 To address these issues, strong evidence-based approaches to both prevention and treatment of youth-onset type 2 diabetes are an urgent priority for American Indian and Alaska Native communities.

Causes of the Epidemic

The rise of diabetes in American Indian and Alaska Native communities has a complex and multifaceted background. Obesity is the predominant risk factor for the development of type 2 diabetes among youth.22 Given this well-recognized association between type 2 diabetes among youth and childhood obesity17,23 and the relationship of obesity to diabetes specifically among American Indian and Alaska Natives,24,25 one can anticipate that the epidemic of type 2 diabetes among American Indian and Alaska Native children will continue to escalate unless the burgeoning childhood obesity epidemic in their communities is abated.

Lifestyle behaviors, such as an unhealthy diet and physical inactivity, are among other major contributors to the diabetes epidemic. National dietary and entertainment trends, such as larger portion sizes; increased consumption of sweetened beverages; increased time spent in sedentary activities such as watching television, playing video and computer games, and online "web-surfing"; and reductions in compulsory physical education in schools, have all impacted the homes, schools, and communities of American Indians and Alaska Natives. For example, American Indian and Alaska Native urban youth self-reported levels of physical activity that fall short of the Healthy People 2010 target goals and were more likely than white youth to watch 3 or more hours of television on an average school day (45.1% and 31.7%, respectively) in the national Youth Risk Behavior Survey.26 Other factors, however, such as poverty and lower socioeconomic status,27-31 social injustice, trauma, and forced cultural change and displacement leading to cultural disintegration, also play a significant role.32

The consequences of social disadvantage for American Indians and Alaska Native families are often unemployment, poverty, and associated poor quality diet, physical inactivity, overcrowded or poor living conditions, psychosocial stress, and chronic illness. Many American Indians and Alaska Natives live in environments-both social and physical-that place them at higher risk than many other Americans for exposure to traumatic events.33 Recent research findings indicate that these traumatic events, including abusive and neglectful experiences in early childhood, are strongly linked with health status and affect adult health decades later. Diabetes, heart disease, obesity, and alcoholism have all been shown to have roots in adverse conditions and events.31,34-38 Unhealthy coping skills, such as overeating, smoking, and the consumption of excessive amounts of alcohol, are likely learned at an early age by American Indian and Alaska Native children as well as other children with lower socioeconomic status who grow up in such adverse conditions.39

Risk Factors for Youth-Onset Type 2 Diabetes

Obesity, family history of type 2 diabetes, both high and low birth weight, bottle feeding, and intrauterine exposure to diabetes have been associated with developing type 2 diabetes among the Pima of the Gila River Indian Community of southern Arizona.40,41 Intrauterine exposure to diabetes has been found to have the strongest association for the later development of diabetes among the Pima.16,41 Thus, interventions that address the modifiable risk factors in infants and children, such as bottle feeding, obesity, and intrauterine exposure to diabetes, are warranted. Disruption of the vicious cycle created by intrauterine exposure to diabetes requires effective interventions to reduce the risk of diabetes among women of childbearing age, such as effective obesity prevention.14

Depression has also been found to be much more common in Pima individuals 18 years or older with diabetes42 and is several times more common among American Indians and Alaska Natives than in the general US population.43 Pima Indians with depression have been shown to have poorer control of their diabetes.42 Paying special attention to the mental, emotional, and spiritual health of American Indian and Alaska Native children and adolescents is particularly important in preventing depression associated with being overweight and/or having diabetes.

Promising Interventions Provide a Message of Hope

While much remains to be done to reduce the burden of childhood type 2 diabetes in American Indian and Alaska Native communities, many tribal and urban Indian community programs, such as the Special Diabetes Program for Indians grant programs, have recognized this concern and continue to support comprehensive interventions for childhood obesity and diabetes prevention in their communities. In addition to incorporating a broad-based public health approach to promote healthy behaviors such as regular, vigorous physical activity and a healthy diet for American Indian and Alaska Native children, families, and communities, these programs are instilling self-esteem, confidence, and a resurgence of cultural identity and pride among Native youth.

One important diabetes-prevention strategy is breast-feeding promotion. Breast-feeding plays a particularly important role in preventing both obesity and type 2 diabetes. Exclusive breast-feeding for the first 2 months of life has been associated with a 40% reduction in type 2 diabetes among Pima Indians.44 The Phoenix Indian Medical Center found that American Indian and Alaska Native children who were breast-fed exclusively for the first 6 months of life experienced an overweight and obesity rate of 23% at the ages of 3 and 4 years, as compared with an overweight and obesity rate of 64% in children who were formula-fed exclusively.45

The Special Diabetes Program for Indians grant programs have also worked closely with school and community partners to establish policy and environmental changes that support physical activity and healthy eating strategies. For example, grant programs have successfully changed school vending machine and wellness policies, increased the availability of school and community physical activity opportunities, increased access to fitness facilities for children and youth, and built or improved local playgrounds. These programs have created a supportive environment for children and youth to exercise more and eat healthier foods, helping to lower their risk for developing diabetes.46,47

An example of progress in addressing youth physical activity and diabetes prevention is the Summercise Program in Nome, Alaska, sponsored by the Norton Sound Health Corporation's Special Diabetes Program for Indians grant.46 The goals of Summercise are to increase children's physical activity, help them lose weight, and encourage them to eat healthy foods. The program uses community health care professionals and teen role models to lead activities drawn from the local Inuit culture such as traditional games and dances, including kayaking, hiking, and berry picking, to teach kids about physical activity and nutrition. Even during the winter, Summercise continues to reach and empower youth through health fairs, school presentations, community events, and winter sports. More than 400 Nome kids older than 5 years have participated in Summercise.

The National Diabetes Education Program (NDEP) Move It!! And Reduce Your Risk of Diabetes Campaign was developed to help create awareness about the growing problem of diabetes in American Indian and Alaska Native youth and the importance of physical activity in reducing risk factors for diabetes.48 The campaign has been widely disseminated in American Indian and Alaska Native health programs and schools, and case studies of 3 tribal Move It!! programs in Minnesota, Michigan, and Oklahoma are described in more detail elsewhere.49 The Move It!! school kit was designed to empower Native youth to create their own physical activity and diabetes awareness strategies and program plan, with facilitation by a teacher, school counselor, or coach. The kit contains a cover letter for the school principal with instructions, tips on getting started, a fact sheet about type 2 diabetes in youth for students and another diabetes fact sheet for teachers, three Move It!! campaign posters, a resource list, a newsletter, a template news release/newsletter article, a flyer with instructions for ordering pedometers, information on other NDEP materials, and a CD-ROM of all the materials for customization. Schools are encouraged to implement activities with their students to create awareness about diabetes and to encourage physical activity. Schools are also encouraged to customize the posters with pictures of teens from their schools and their school logos. The Move It!! school kit has been a successful NDEP product that helps local schools and communities implement diabetes prevention activities for youth. With its focus on directly encouraging youth to develop activities, the school kit has resulted in a diverse set of culturally and community-relevant diabetes prevention activities that promote physical activity.

Conclusions

Despite the implementation of promising strategies to encourage physical activity and reduce diabetes risk in many American Indian and Alaska Native communities, strong evidence-based approaches to both prevention and treatment of youth-onset type 2 diabetes are still needed. To ensure success in turning the tide of this public health crisis, the rapid translation and dissemination of the latest scientific research on weight management and diabetes prevention and treatment for children and youth are essential. A multicenter, population-based prevention study, called the STOPP T2DM (Study to Treat Or Prevent Pediatric Type 2 Diabetes Mellitus), is currently under way and may provide useful information on the prevention of type 2 diabetes.50 HEALTHY, a middle school-based primary prevention trial conducted between 2006 and 2009 in 42 schools, 6 at each of 7 centers located across the country, is also starting to publish preliminary findings.51 It is also imperative that existing community-based diabetes prevention and physical activity programs for youth be more rigorously evaluated with measurable outcomes.

Further research is also needed to define and address the psychosocial risk factors, such as hostility, depression, and social isolation, which are associated with diabetes, obesity, cardiovascular disease, and other chronic conditions. Interventions to address maternal depression may hold exceptional promise for this population, but more studies are needed. More research on the appropriate promotion of healthy body images and their association with desired outcomes, such as effective weight loss, lower rates of depression and other mood disorders, healthier eating habits, and lower rates of eating disorders, among American Indian and Alaska Native youth should be another priority. Culturally effective and sensitive models to teach healthy coping skills are also needed. Finally, policy makers and clinicians must recognize that childhood diabetes, overweight, and obesity are chronic conditions that require long-term management and that investment in prevention is worthwhile. By employing a multifaceted approach that includes families, schools, the health care system, tribal spiritual and political leaders, and other important stakeholders outside the health arena, American Indian and Alaska Native communities can offer a pathway to health and wellness for their children and youth, their families, and their future generations.

REFERENCES