<DOC>
[110 Senate Hearings]
[From the U.S. Government Printing Office via GPO Access]
[DOCID: f:33311.wais]
S. Hrg. 110-19
DIABETES IN INDIAN COUNTRY
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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
U.S. GOVERNMENT PRINTING OFFICE
33-311 WASHINGTON : 2007
_____________________________________________________________________________
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COMMITTEE ON INDIAN AFFAIRS
BYRON L. DORGAN, North Dakota, Chairman
CRAIG THOMAS, Wyoming Vice Chairman
DANIEL K. INOUYE, Hawaii JOHN McCAIN, Arizona
KENT CONRAD, North Dakota PETE V. DOMENICI, New Mexico
DANIEL K. AKAKA, Hawaii GORDON SMITH, Oregon
TIM JOHNSON, South Dakota LISA MURKOWSKI, Alaska
MARIA CANTWELL, Washington RICHARD BURR, North Carolina
CLAIRE McCASKILL, Missouri TOM COBURN, M.D., Oklahoma
JON TESTER, Montana
Sara G. Garland, Majority Staff Director
David A. Mullon Jr. Minority Staff Director
(ii)
C O N T E N T S
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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
DIABETES IN INDIAN COUNTRY
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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 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 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 2\1/2\ 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 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 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.
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 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 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 DPP-like lifestyle intervention program
for American Indians with pre-diabetes, 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.
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.
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 results, 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 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 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?
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 never-ending, but we have to study causes
and results.
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.
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 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 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.
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 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 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
communities, 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 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
practitioner 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 one-half 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.
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 ex-clinician. 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 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 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 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 11\1/2\.
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 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 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
Coca-Cola 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 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,
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.]
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A P P E N D I X
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Additional Material Submitted for the Record
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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 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
two-armed 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 announced 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 one-half 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 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 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 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; 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 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.
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.
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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.
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 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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