Changing Numbers, Changing Needs American Indian Demography and Public Health (1996) / Chapter Skim
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12 Diabetes Mellitus in Native Americans: The Problem and Its Implications
12 Diabetes Mellitus in Native Americans: The Problem and Its Implications
Pages 262-288
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From page 262... ...
However, since World War II, it has become one of the most common serious diseases among many Native American tribes (Sievers and Fisher, 1985~; in 1987, there were at least 72,000 Native Americans in the United States with diagnosed diabetes (Newman et al., 1990~. Diabetes occurring in Native Americans is almost exclusively the type referred to as NIDDM or non-insulin-dependent diabetes mellitus (Sievers and Fisher, 1985~.
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From page 263... ...
With a view to informing and influencing health policy, this paper: · reviews the magnitude of the problem of NIDDM among Native American populations; · summarizes current knowledge about the determinants of NIDDM; · describes the major complications of NIDDM; · assesses the potential for preventing or delaying NIDDM and its main complications; and · suggests research directions that can facilitate the prevention of NIDDM and its complications in Native Americans. PIMA INDIAN STUDY Pima Indians, living in a geographically defined part of the Gila River Indian Community of Arizona, have participated in a longitudinal study of diabetes and its complications since 1965 (Bennett et al., 1971)
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From page 264... ...
The prevalence rates of diagnosed diabetes among Native Americans vary across tribes and are generally higher than in the U.S. population as a whole (Carter et al., 1989; Freeman et al., 1989; Acton et al., 1993b; Valway et al., 1993~.
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From page 265... ...
Evidence for a higher prevalence of diabetes among Native Americans is also available from an epidemiological study that compared the Pima Indians with a predominantly white population of Rochester, Minnesota (Knowler et al., 1978~. This study found that the Pimas had an age-sex standardized diabetes prevalence rate 12.7 times that of Caucasians and that, in contrast to the picture among the Pimas, diabetes prevalence in Rochester was higher for men than for women.
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From page 266... ...
Incidence The Pimas have the highest reported incidence of diabetes in the world 19 times the rate of diagnosed diabetes among the predominantly white population of Rochester, Minnesota (Knowler et al., 1978) , and a high incidence of the disease has also been reported among other Native American tribes (Rith-Najarian et al., 1993~.
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From page 267... ...
~ ~ \ x_ · ·\ ~ ~ `\~ i 25- 35- 45- 55- ~ 65 40 20 O Age We, 0 5- tS /) / /-' 25- 35- 45- 55- >65 FIGURE 12-2 Age-sex specific incidence rates of diabetes among Pima Indians during three decades.
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From page 268... ...
As shown in Figure 12-3, the agesex adjusted incidence of diabetes among Pima Indians increases with body mass index (BMI) , a measure of obesity.
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From page 269... ...
However, evidence suggests that a high-fat diet may be related to the development of the disease (Eriksson and Lingarde, 1991; Marshall et al., 1994~. Few data are available for Native Americans linking dietary factors with the development of NIDDM, except for one study of the Pima Indians that found a possible association with a high-calorie diet (Bennett et al., 1984~.
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From page 270... ...
Physical Activity There is evidence that increased physical activity may have a protective effect on the development of NIDDM (Frisch et al., 1986; Schranz et al., 1991; Manson et al., 1991, 1992; Helmrich et al., 1991~. As shown in Figure 12-5, the age-adjusted prevalence of NIDDM among Pima Indians aged 15-36 was lower with higher amounts of leisure physical activity in the preceding year.
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From page 271... ...
(1993~. levels of physical activity may be protective against NIDDM is consistent with the observation that diabetes was apparently rare among Native Americans in the past, when they were a physically active agricultural and hunter-gatherer society.
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From page 272... ...
As seen in Figure 12-6, compared with the New York State population, a greater-than-expected number of both male and female members of the Seneca Nation died from all causes, from infectious diseases, from diabetes, from liver cirrhosis, from accidents and injuries, and from suicides, while a lowerthan-expected number died from cancers and cardiovascular diseases. A similar pattern of deaths was found among the Pima Indians (Sievers et al., 1990)
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From page 273... ...
There is considerable variation among Native American tribes in diabetes mortality rates. The IHS area-specific diabetes mortality rates for 1984-1986, without accounting for underreporting of diabetes and Native American heritage in vital statistics, ranged from 10 to 93/100,000, compared with 15/100,000 for the U.S.
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From page 274... ...
Among both men and women, Native Americans had the highest diabetes mortality rates in New Mexico starting around the beginning of the 1980s. Furthermore, age-adjusted mortality rates for Native American women, which were the lowest for any group in 1958, increased by 5.5 times over the 30-year period; during the same period, rates for Native American men increased by 2.5 times.
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From page 275... ...
High rates of ESRD have also been reported among several other Native American tribes. It was found that 88 percent of ESRD among the Cherokee Indians was attributable to diabetes, and the incidence of ESRD caused by diabetes was 2.5 times the rate reported among the U.S.
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From page 276... ...
Diabetic subjects with amputation had an age-adjusted death rate 1.6 times higher than the rate among nonamputees; on average, 61 percent of diabetic subjects survived 5 years after their first LEA. Furthermore, the age-sex adjusted rate of LEA among diabetic Pima Indians was 3.7 times that found in a study by the Centers for Disease Control in six U.S.
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From page 277... ...
However, given the magnitude of NIDDM among Native American populations and the nature of the major risk factors involved, it would be well worthwhile to test carefully planned population-based life-style interventions in selected communities along
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From page 278... ...
(Miettinen, 1974~. Suitable data for the Pima Indians were used to assess the potential impact of diabetes prevention on mortality, ESRD, and LEA, with the results shown in Table 12-2.
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From page 279... ...
25% 20% 15% 10% 5% All-causes mortality 14.3 1.5 4.0 6.5 9.1 11.7 Natural-causes mortality 16.2 1.5 4.5 7.4 10.4 13.3 IHD mortality 92.1 8.1 24.8 41.9 58.6 75.4 Stroke mortality 7.7 0.8 2.1 3.6 4.9 6.3 Infectious disease mortality 7.7 0.8 2.1 3.6 4.9 6.3 End-stage renal disease 94.4 9.7 26.3 43.4 60.3 77.3 Lower-extremity amputation 96.6 8.1 27.7 44.3 61.4 79.1 aPARF1 = Population attributable risk fraction under the current diabetes prevalence of 27.6 percent. bExpected (%)
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From page 280... ...
Blood Glucose Control Complications of NIDDM in Native Americans are related to the concentration of blood glucose (Dorf et al., 1976; Pettitt et al., 1980; Nelson et al., 1989; Lee et al., 1992~. It has been shown that tight control of blood glucose can prevent or delay the onset of complications, but this evidence is based on subjects with insulin-dependent diabetes mellitus (IDDM)
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From page 281... ...
Such approaches are likely to complement clinical trials among high-risk individuals. Blood Glucose Control Multicenter studies in Native American communities aimed at understanding optimal ways of achieving blood glucose control in NIDDM subjects would facilitate the prevention of diabetic complications.
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From page 282... ...
Bennett, and M Miller 1976 Retinopathy in Pima Indians: Relationship to glucose level, duration of diabetes, and age at examination in a population with a high prevalence of diabetes mellitus.
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From page 283... ...
Miller 1978 Diabetes incidence and prevalence in Pima Indians: a 19-fold greater incidence than in Rochester, Minn. American Journal of Epidemiology 108:497-504.
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From page 284... ...
Saad, and P.H. Bennett 1990 Diabetes mellitus in the Pima Indians: Incidence, risk factors and pathogenesis.
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From page 285... ...
diabetes mellitus in the Pima Indians. Diabetologia 31:730-736.
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From page 286... ...
Nelson, and P.H. Bennett 1990 Adverse mortality experience of a Southwestern American Indian Community: Overall death rates and underlying causes of death in Pima Indians.
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From page 287... ...
Terasaki 1981 HLA-A2 and type 2 diabetes mellitus in Pima Indians: An association of allele frequency with age. Diabetologia 21:460463.
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From page 288... ...
King. 1990 The epidemiology and natural history of NIDDM: Lessons from the South Pacific.
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