Division of Diabetes Treatment and Prevention - Leading the effort to treat and prevent diabetes in American Indians and Alaska Natives

The White Earth Reservation is the largest in the state of Minnesota, encompassing over 1,000 square miles and serving about 11,000 people through its IHS health clinic. When its diabetes program first received SDPI Community Directed Program funding in 1999, staff could not envision where they would be in 13 years. At the time there was only one small fitness center serving the entire tribe and no podiatrist. Today the program has implemented numerous activities to support its Physical Activity and Foot Care Best Practices. "We have an excellent diabetes prevention and management program. We are on track," said LaRaye Anderson, Diabetes Program Coordinator.
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The White Earth Reservation is the largest in the state of Minnesota, encompassing over 1,000 square miles and serving about 11,000 people through its IHS health clinic. When its diabetes program first received SDPI Community Directed Program funding in 1999, staff could not envision where they would be in 13 years. At the time there was only one small fitness center serving the entire tribe and no podiatrist. Today the program has implemented numerous activities to support its Physical Activity and Foot Care Best Practices. "We have an excellent diabetes prevention and management program. We are on track," said LaRaye Anderson, Diabetes Program Coordinator.

There are diabetes fitness centers offering free personal training at four of the tribe's villages. Clients can work out with trainers or participate in group classes of Zumba® fitness, kick boxing, kettlebell, pole walking, step aerobics and boot camp fitness. Several 5K run/walks and regular blood sugar, A1C, blood pressure and kidney screenings are offered each year. Diabetes program staff collaborate with other programs to offer healthy snacks and schedule the 5K run/walks at the same time as community gatherings like powwows.

Healthy Living Bingo is held monthly in each village. About 40 adults and children attend each month and learn how to prevent diabetes – how to attain healthy blood pressure, cholesterol and blood sugar numbers, how to eat healthy using My Plate and the importance of regular physical activity. Diabetes Bingo, which focuses on preventing diabetes complications, is also held monthly in each village. About 25 people attend and learn how to prevent diabetes complications by managing their blood sugars, taking medications as prescribed and keeping medical appointments.

In fitness centers and community gathering rooms, brightly colored posters of Aimee Smith, a young White Earth fancy shawl dancer, decorate the walls. Diabetes program staff developed the poster with the words "White Earth Dancing to Defeat Diabetes." Staff also developed a logo featuring a cyclist, a runner and a traditional dancer accompanying the phrase "Exercise is medicine."

A podiatry surgeon travels to villages in a mobile clinic giving foot checks and handing out breathable socks, orthotics and special shoes, a direct result of the tribe's diabetes program implementing the Foot Care Best Practice. "We were concerned with the lack of a podiatrist and the high number of amputations, so we chose the Foot Care Best Practice to address this," said LaRaye. "In the ten years since the tribe has contracted with the podiatry surgeon, amputations have decreased and awareness has increased on the importance of preventing ulcers and maintaining good foot care."

Diabetes staff evaluates activities by gathering assessments and evaluations. GPRA (Government Performance Results Act) numbers and diabetes audit information allow staff to assess the program's impact. On one fitness program evaluation form, a client wrote what she accomplished after only two months: "I can put on my own socks and shoes. I can fasten my seat belt. I have been able to stop taking two medications, saving me $170 each month!"

Another client reported: "In one year, I lost 150 pounds! I am walking without my walker and started gardening again. I feel responsible for my health and have faith in myself."

Many clients have commented that the professional, helpful staff is key to learning about diabetes prevention and management. "They are kind to all who walk through the fitness center doors," said a client.

Although many community members have lost weight, obesity and overweight continue to be a challenge at White Earth. "We are building on what we have learned," says LaRaye. "It takes empathetic, professional and energetic staff, which we have. And it takes time, so we are working now with our sights on future goals. The obesity and overweight numbers are challenges that face everyone in the United States. I feel we are on the right path in educating our people and offering opportunities to participate in fitness no matter what a person's fitness level or interests are."

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It's a typical morning for Allene Stanley (Cheyenne River Sioux). By ten AM she has walked over 1400 steps -- some of them up a hill to get more of an aerobic workout. She has eaten a small orange instead of drinking a glass of orange juice. She has not even thought of having a "Diet Dew" because all soda is gone from her house. Just seven weeks ago, Allene started her days differently. Her eating habits weren't as good and daily exercise was not a habit. But she has been attending the Denver Indian Health and Family Services (DIHFS) program Fork n' Road once a week for almost two months and has changed many of her eating and exercise habits.

Diabetes Program Manager Kathy Canclini, MN, RN, CDE, and other staff of this urban clinic started the program, funded by the Special Diabetes Program for Indians (SDPI) Community Directed Grant Program, in January 2010. The clever name, Fork n' Road, reflects the program's focus of making better lifestyle choices by improving eating habits (fork) and increasing exercise (road) to lose weight and prevent or manage diabetes.

"We had a 91 percent obesity rate," explains Kathy. "The Best Practice we chose was Weight Management. We were inspired by the Best Practice and we used the Division of Diabetes Treatment and Prevention's Balancing Your Life and Diabetes curriculum."

Like most urban Indian clinics DIHFS has a client population with characteristics common to Natives living in big cities, diversity being the most prominent. "I would guess that 80 to 90 percent of tribes are represented among our clients, from Native Hawaiians, to Alaska Natives, to members of tribes in Maine" says Kathy. Many of the center's clients do not have health insurance. Some are travelling and some live in Denver for a while, then move.

DIHFS staff view these challenges as positives. "Our clients appreciate meeting other Native people. They appreciate how we sincerely care for them, how we slow things down, taking time to provide many hours of diabetes education classes, as compared to two hours at non-Indian hospitals or clinics. They appreciate how we honor and respect their values."

The foremost value among their clients is family. Diabetes Prevention Specialist Kristen Curcija, MPH, says, as a non-Indian, she has learned a lot about the values of her Native clients. "I have learned how much they value their families and how our teaching has a ripple effect throughout their families. Everyone is so open and sharing. We hear their heartbreaking stories of how diabetes has impacted their cousins, their aunties. After listening, I started to understand the enormity of the love and care our clients have for each other."

In addition to learning about values, staff have learned what works to put on a successful weight loss program at their urban Indian clinic. Here are some of their tips:

1. Use a team approach involving all staff from the clinic and the diabetes program. "The clinic refers patients to us, and we refer clients to the clinic" says Kathy. "We establish a relationship with the clinic patients and they are more likely to come to our classes."
2. Develop a program name, logo. Think creatively to name your program and develop your logo – have fun with it! Use the logo on materials to foster an identity for your program. You are welcome to borrow the name and logo Fork n' Road if it will help you market your program.
3. Consider creating a contract for staff and clients to sign at start of classes. The DIHFS Fork n' Road Program Behavior Contract includes the statement: I promise to enjoy myself during class.
4. Include interactive activities. While waiting for other clients to arrive participants play catch with an inflated "Weight Loss Toss-Up Ball", which has nutrition and exercise questions printed on it. Participants are encouraged to provide the answers.
5. Repetition helps. Staff never assume clients know information about nutrition, like how to read labels. They teach, then teach again as needed -- repetition works!
6. Expect and celebrate the small changes clients make, like switching from whole milk to skim milk, being able to decrease medications (as ordered by the provider) due to weight loss, wearing smaller-sized clothing, walking around a park and eating more fruits and vegetables. "We are delighted when our clients make eating habit changes and even more excited when we see them smiling, laughing, and feeling better about themselves" says Lorraine Gill, RD, MA, CDE.
7. Be delighted by your clients' huge successes, like dramatic drops in A1C, LDLs and lower BMIs. Some DIHFS clients' A1Cs have dropped from 14 percent to under 7 percent!
8. Evaluate to show clients' successes. During the first and last classes, clients complete a form developed by the DIHFS Diabetes Program called "Assessment and Evaluation of Healthy Behaviors". Participants give themselves a rating from "rarely" to "regularly" (1-5 Likert scale) regarding nutrition and exercise habits. For Best Practice outcome grant reporting, staff compare before and after class scores. In the last class staff use the SDPI In Review, which asks participants to assess their current habits to show them how much progress they have made and what changes they need to focus on in the future.
9. Conduct follow-up assessments. At six and 12 months after the program, clients are re-evaluated for weight, BMI, body measurements and Healthy Behavior Ratings. Again, the team celebrates and/or re-motivates the participant with ongoing support.

When clients finish the Fork n' Road Program they are presented with a certificate of graduation and are then eligible to join the Crossroads Program, which focuses on the rest of the Diabetes Self-Management Education. Crossroads is a program primarily offered to clients with diabetes, although all are welcome to attend. Staff chose not to do separate classes for those with diabetes and those without diabetes because nutrition, exercise and behavior change education is applicable to all.

To find out more about the Fork n' Road or Crossroads Programs, contact Kathy Canclini, 303-953-6604 or kcanclini@dihfs.org.

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During the first moments of the Fork n' Road diabetes education class at the Denver Indian Health and Family Services (DIHFS) clinic, Charlene Irani appeared to not be a happy camper. Her arms were crossed as if she was prepared for a preaching. "I was afraid and emotional. I did not want to be there. I thought, 'If you're going to tell me what to do, then I'm not listening.' "

Fast forward seven weeks to the last day of the once-a-week classes and Charlene is laughing and telling stories. She says the classes were not what she expected. "Talking to staff was like talking to a friend," she recalls. "We would tell a story and then Kathy (Canclini, Diabetes Program Manager) would tell a story and we could all relate. The staff didn't talk down to us. That's why we were able to share."

After the first several minutes of class, arms are uncrossed, smiles start appearing, more voices contribute. There are people from the Navajo, Seminole, Sioux and other tribes. It quickly becomes obvious that this diabetes nutrition and exercise class is not like the 2-hour program of a nearby hospital. It caters to the values and needs of Native Americans from diverse tribes, those who have insurance and those who don't; and it provides information in a way Native clients appreciate – not rushed but applicable to body, mind, spirit, emotion and family.

Meet three people who participated in the DIHFS Fork n' Road Program:

Robin Colombe (Rosebud Sioux)

"I grew up in Nebraska and came to Denver 40 years ago when I was 22. I found out I had pre-diabetes about five or six years ago. I had insurance at the time and was told that my blood sugar was high. But I was given no education. Soon after that I was diagnosed with diabetes.

"I lost my insurance and came to DIHFS. They are the ones who educated me about how to manage diabetes. After the first few classes I learned what I had to do to get my blood sugar under control. I learned how to read labels and the correct portion sizes. When I go out to eat I learned that I should eat half of what I order. I do that now.

"My habits have changed. I don't drink pop. I drink water, milk, or low-calorie drinks. I am trying to eat more vegetables. I eat more low-salt foods to help my blood pressure and my A1C level has dropped."

Geraldine Thomas (Navajo)

"I grew up in Gallup, New Mexico, and came to Denver in 1989. I don't have diabetes, but it's in my family. My A1C level was high and I had pre-diabetes. I was overweight and wanted to lose weight; I didn't want to get diabetes. I thought, "I refuse to accept diabetes. I am going to do something about it.' I was in the Fork n' Road Program two years ago.

"At first, I was embarrassed that I was a person who might get diabetes and lose limbs. I didn't want to talk about diabetes. But the staff helped me. Kathy had compassion in her heart for Native people. She never put anyone down. And Kristen taught us exercises we could do at home, without special equipment or extra expense. They both showed us that diabetes could be avoided or managed and we could live long, healthy lives.

"I learned about nutrition and avoiding diabetes – how to read food labels, the correct portion sizes, how to add more fruits and vegetables to your diet. Pound by pound, weight started coming off. I've lost 16 pounds in two years! I used to wear size 16 and now I wear size 12! My A1C went from 6.5 to 5.9.

"Now I share with my children and grandchildren. I talk about the importance of knowing your A1C level, about how to avoid diabetes and what symptoms to watch for. I estimate I have talked to 15 friends and family members about how to stay healthy. God has helped me get on this healthy, positive path and I hope I am passing it on."

Charlene Irani (Seminole/Kiowa)

"I grew up in Oklahoma and moved here in 1985. My mother and brother died from diabetes complications and my sister has diabetes. When I found out I had it, I cried. I didn't want my life to be like other family members who had diabetes. But I didn't know what to expect or what to do. I wanted to learn everything I could so I could help myself be healthy with diabetes.

"In the classes, I learned to eat regular-sized portions. I learned how much sugar is in pop and fruit juice, so I stopped drinking them. I stopped eating fried foods. Now I bake and boil meat and chicken. I eat less peas and rice, and more broccoli and spinach.

"I have lost 35 pounds! I walk three times a week for about one and a half miles, and I can breathe easily! And, I'm getting better sleep. I feel more rested.

"I'm trying to share what I've learned. I've told my friends' grandchildren, 'Look! My lunch is colorful. It has an apple in it and no pop.' I'm happy that the grandchildren stopped drinking pop.

"When I was 43, I was diagnosed with an aneurism and was told I didn't have long to live. Now I'm 54 and I feel great. God gave me this extra time, time that I wasn't expecting I would have. I want to give back. I am a volunteer for Native cancer research. I also volunteer to help get water filters to homes on the Pine Ridge Reservation. I want to live a long time so I can continue to help others."

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The Mississippi Band of Choctaw Indians (MBCI) was awarded its first SDPI grant in 1998. The Community Directed Diabetes Prevention Program initially began with three staff members. In the beginning, staff conducted many community events such as walks, blood sugar screenings and health fairs. In 2004, the Demonstration Project (now the SDPI Diabetes Prevention Initiative) was added to the Mississippi Choctaw Diabetes Prevention Program.

Fourteen years after being awarded its first SDPI grant, MBCI/SDPI Program Manager Darlene Willis looks back at what she and her staff have learned. "We have matured professionally," she says. "We were always focusing solely on prevention of diabetes. It was like I had tunnel vision. I paid very little attention to the management aspect of diabetes."

About three years ago, Darlene took a closer look at the program, assessing its structure and personnel. She read every word of the grant application. "I had an epiphany," recalls Darlene. "I realized I was listed as the person responsible for the grant operations of the program. I thought, 'This is mine.' I realized I had complete autonomy over the program and, at that moment, the tunnel vision of doing just diabetes prevention activities lifted."

She decided to call a meeting of "the minds," everyone who was providing diabetes care within the SDPI grant programs. This included physicians, podiatrists, dietitians, and the CDE. She says it was a pivotal point in the program's structure. Darlene said to the group, "We are here today because we have one thing in common, DIABETES. We receive grant funding for diabetes prevention and management. We all need to begin to work together for better results. NOW is the time to begin to work in unison for our people's sake."

Darlene carefully reviewed the Diabetes Audit and realized improvements and adjustments were needed. With the help of the hospital's Clinical Applications Coordinator (CAC), she began to understand what needed to be done. The CAC was initiating the "Improved Patient Care Committee" through IHS Improving Patient Care Model. The IPC model led to establishing the "I Care Team" within the hospital which led to the birth of "Diabetes Wellness Day" in coordination with the Retinopathy Clinic.

During Diabetes Wellness Day, a patient is provided a foot exam, eye exam, exercise instruction, diabetes education, nutrition assessment, depression screening, height/weight/blood pressure measurements, labs, dental exam, and immunizations. "Diabetes Wellness Day is all-inclusive. It is like one-stop shopping for our patients. It takes only a couple of hours for patients to receive services that, if scheduled one at a time, could take an entire year to complete. Patients love it and the Diabetes Audit Report improved tremendously," says Darlene.

The MBCI SDPI Program has grown to eleven staff members. Diabetes prevention activities are still a big part of it. For example, the SDPI DP Initiative recruits, assesses, and diagnoses patients for pre-diabetes, then enrolls them in a 16-week intensive diabetes prevention class.

The MBCI SDPI-funded Community Directed Diabetes Prevention Program also is lessening the impact of diabetes by implementing two Best Practices (Foot Care and Eye Care). "For so long, we focused on prevention activities. We are now putting extra effort into implementing the Best Practices. It's new for us, but someday it will be as automatic as doing diabetes prevention activities," says Darlene.

"We are always looking for better ways of doing things because our goal is to improve the health care of our patients. We love to share our ideas with others and we will always welcome others' ideas. One thing I do is always reflect back to the mission and vision of the Choctaw Health Department which is to 'raise the status of the Choctaw people to the highest level possible'. This mission keeps me focused."

For more information, contact Darlene Willis: dbwillis@choctaw.org, 601-389-6312.

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The SDPI Healthy Heart Program at the Whiteriver Indian Health Service started at the onset of the Healthy Heart Demonstration Projects, in 2005. From the beginning, the Healthy Heart Program had its own place, across the parking lot from the hospital. Over the years, the staff has prioritized the development of positive, trusting relationships between case managers and participants.

Kristy Klinger, Healthy Heart Project Coordinator, explains, "We have a dedicated place where people can go, and be asked, 'How is your life going? What is working for you? What are you willing to work on? How can we help you?"

She says extra effort is made to see participants at their scheduled time, to avoid making them wait to see their case managers. Appointments are usually 30-60 minutes long.

"By seeing participants right away, and not being rushed when we meet with them, we are showing them that they are respected. This fosters trust, and creates an opportunity for ongoing, open communication."

The relationship of trust goes beyond the exam room and the Healthy Heart office. Participants have passed on diabetes and heart health information to family members and friends.

"I have heard stories of participants telling their support people about us, our program, and what they've learned."

As a result, there have been increased numbers of people making and keeping their appointments, and attending Healthy Heart activities held in the community, such as nature walks, traditional weaving, and community gardening.

"Their participation and enthusiastic attitudes show they believe in the Healthy Heart Program. It shows they trust us, and because they trust us, they have ownership in the program. They see the Healthy Heart Program as their program."

For more information, contact Kristy Klinger, PharmD, CDE, 928-338-3612.

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The Shoshone-Paiute Diabetes Program, located in Owyhee, Nevada, was first awarded funding from the Special Diabetes Program for Indians (SDPI) in 1997, and has been conducting diabetes prevention and management activities for 15 years. At the end of 2011, staff looked back on what they had recently accomplished:

• Tribal community members harvested organic food from the tribe's "Hoop House" a hot house built from large hoops and plastic. Youth through elders helped build the Hoop House, moving soil, tilling, planting, caring for and harvesting produce. The Hoop House is located next to a community church, which hosted a December pot roast dinner featuring organic new potatoes and onions from the garden.
• Depression screening and eye care best practices were implemented. Statistics from the optometry program showed that 747 patients were seen in the tribe's optometry clinic from September 2011 to October 2011. (There are approximately 2,000 people living in the Owyhee and surrounding areas.)
• Rez Yoga reported that as many as 17 people attended the twice-weekly classes. Attendees say that it helps them be more flexible, build muscle and reduce stress.
• The December Diabetes Health Fair held on December 15 had 95 participants. To show that health benefits can be obtained by walking for only 10 minutes twice a day, the walk/run part of the day was divided into two parts: a morning 10-minute and an afternoon 10-minute walk/run. Between the walk/runs, a lunch featuring a pita-pocket taco named "Ya ah Be Sha Pi-ta-co" was served. It contained rinsed lean ground beef seasoned with spices, home-made pinto beans, lettuce, tomatoes and low-fat cheese. A reservation restaurant, Taste of Heaven Kountry Kitchen, has added the "Ya ah Be Sha Pi-ta-co" to its menu that includes other items listed under a new category: Healthy Heart Options.

For more information, contact Marlene Thomas: thomas.agnes@shopai.org, 775-757-2415.

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