Brown-skinned people on crutches and in wheelchairs, not tomahawks and feathered headdresses, are what children on Indian reservations draw when they depict their tribes.
The bodies are not sleek and muscular, but obese, sometimes with legs missing.
The reason is diabetes.
Although in the United States no more than one person in 25 has this disease (half without knowing it), in some American Indian tribes the rate is as high as one in two adults over age 35.
Only since World War II has diabetes become a major health problem of American Indians. First it was seen in older people, but now it is common in people under 30. Overall, about 150,000 Indians may be affected.
Tough Burden to Bear
A new condition, tribes have few traditional medicines or approaches to treat it. The Indian Health Service only recently mobilized to battle the disease and the conditions that make this group of people so susceptible. Yet because diabetes requires drastic life style changes and lifelong diligence to control, often those afflicted find their condition a tough burden to bear.
“There’s a fatalism about diabetes among Indians,” said Dr. N. Burton Attico, a maternal health consultant at the Phoenix Indian Medical Center. “It’s not a matter of if they are going to develop diabetes; it’s a matter of when. That’s a horrible thing to have hanging over their heads.”
Diabetes refers to disorders related to abnormal levels of sugar in the blood. In healthy individuals, chemical messengers such as insulin help steady blood sugar. Insulin causes the body to store or burn sugar in the body’s cells so that it does not build up to dangerously high levels in the blood after meals.
The two major forms are called Type I or insulin-dependent, and Type II, adult-onset or non-insulin dependent diabetes. Type I diabetics do not have enough insulin; Type II diabetics often have insulin but their bodies do not respond properly to this messenger.
Most diabetic Indians have Type II diabetes, known as adult-onset because it usually strikes after age 35, but that is not the case on Indian reservations.
“This used to be a disease of old people,” said Robert Young, a scientist at the Native American Research and Training Center in Tucson. “We even have people who get it in their teens.”
A few have symptoms even before age 10.
In Phoenix, a 5-year-old child and more recently a 3-year-old child were diagnosed as having this “adult” disease.
The consequences of this high, uncontrolled sweetness in the blood can be deadly--and expensive. As more diabetics develop complications, the cost increases.
“It’s going to be far beyond the Indian Health Service budget to pay for it,” said Dr. Clifton Bogardus, who directs a National Institute of Diabetes and Digestive and Kidney Diseases research program in Phoenix.
Indians receive free medical care. But the burden of diabetes could change that.
Diabetes is the second most common reason that American Indians go to the hospital. Within 15 years of diagnosis, one in five diabetics has kidney problems that often require dialysis.
Half will develop high blood pressure, and almost as many will have heart disease or circulation problems that can lead to leg amputations.
In October, researchers from the University of Pittsburgh reported that the rate of heart attacks in Navajo men had doubled in the past 10 years, possibly due to complications from diabetes.
Diabetics are two to six times as likely to have strokes. One in five develop cataracts or glaucoma. About 5% go blind.
The problems are relatively new ones to American Americans, and the nature-nurture debate rages as scientists and clinicians struggle to understand the causes and come up with ways to stem this epidemic.
Health practitioners blame modern diet and sedentary reservation life while scientists like Bogardus fault the body’s biochemistry.
“I think that the major reason people get diabetes has got to do with the genetic background,” Bogardus said in a telephone interview.
At the research program in Phoenix, investigators track the number of diabetics and study the causes of obesity in Pima Indians. Obesity is a major risk factor for diabetes in American Indians and seems to have a genetic basis.
Some experts suggest that through the millennia, people who lived in harsh environments like deserts survived only if they had the ability to store lots of calories when food was plentiful so as to make it through periods without food.
That group of people tended to burn calories slower and to be fat. That reasoning may also explain why Polynesians are so heavy, Bogardus said. Those are the only people who could survive the long boat trips.
Not all Indian tribes are equally afflicted.
The rate among southern Arizona’s Pima Indians over age 35 is 50%. In the same state, seven in 10 adults from the Tohono O’Odham tribe have the disease.
About one in three Cherokees, Zunis and Senecas and one in four Apaches, Pawnees, and Paiutes develop the diabetes by age 35. Many other tribes have incidences greater than 10%, more than five times the incidence in the Unired States overall.
The problem of diabetes was recognized only 25 years ago after a National Institutes of Health research team sent to study arthritis in Indians along the Gila River in Arizona found almost half of those Indians had diabetes.
The researchers have since been screening everyone above age 14 and tracking high blood pressure, kidney problems and changes in the retina that could lead to blindness.
“We went in 80 years from essentially zero diabetes to the highest diabetes rate in the world,” said Dr. Kermit Smith, Phoenix area diabetes control officer for the Indian Health Service. “We first started seeing it in 60-year-olds. Then it jumped down to 40-year-olds. Now, we’re seeing it in our young children.”
Much has changed since the turn of the century. The Tohono O’Odham no longer till four or five fields in hopes of harvesting one or two crops. Nor do they migrate between the desert and the mountains each year.
The forefathers of today’s diabetic tribe relied on native desert plants, primarily beans rich in protein and starches, for food.
“Before World War II, they were basically starving,” Bogardus said. “I think the genes were there.”
Changes in Life Styles
Now the Tohono O’Odham have settled into ranches and reservations. High unemployment, mechanization of farming and processed foods available from the government have led to poor eating habits and a sedentary life style. Fats often make up 40 to 50% of the daily diet, which may exceed 4,000 calories.
All this extra food plays havoc with the body’s sugar regulatory mechanisms. The problem is made worse by obesity: Overweight people who are not diabetic store sugar less efficiently and suffer chemical imbalances in the blood that impair the body’s responses to insulin.
As a result, since 1938, the average weight has climbed 50 pounds or more, according to Dr. James Justice at the Arizona Health Sciences Center in Tucson. A man in his 20s then weighed about 156 pounds but now would weigh 213, with much of that weight concentrated in the upper body.
In 1979, the Indian Health Service set up five centers to work to control the diabetes epidemic. Each of the 12 Indian Health Service districts has a diabetes control officer. Some progress has been made, especially with respect to treating pregnant women to ensure their babies are born healthy.
There is increased evidence that certain native foods can be very helpful and that exercise makes a big difference. But even the most optimistic experts agree that fighting the diabetes epidemic is an uphill battle made more complex by Indian culture, misconceptions and economic constraints.
“We’re funded at about half of what we should be funded at,” said Attico about the Indian Health Service diabetes programs.
Doctors first prescribe better meal planning and increased exercise. If those efforts fail to keep the diabetes under control, then the patients take pills to prod the pancreas into producing more insulin. The last resort is insulin injections.
About three-quarters of the diabetics on Indian reservations need pills, while another 14% require shots.
“But the insulin doesn’t always help,” Smith said.
Unlike people with Type I diabetes, American Indians with this diabetes often have higher than normal levels of insulin in their blood. But their bodies do not respond to this chemical messenger. This “insulin resistance” makes them more susceptible to diabetes.
Some experts are concerned that diabetics may beget more diabetics, not just because of the genetic predisposition.
Babies born to diabetic mothers often start off life larger than normal and never slim down.
“They are much more likely to become obese and therefore much more likely to be diabetic,” Bogardus said.
At ages 15 to 19, more than half of those born to diabetic mothers weigh 40% more than they should. But these teen-agers do not seem to worry about the weight.
“A big problem is coming up with something that motivates people to change their behavior,” said Smith, an Indian who has watched his entire family succumb to diabetes and its complications. “There’s no peer pressure to not be fat. It seems to be an acceptable thing.”
Many aspects of Indian culture make diabetes difficult to accept and difficult to work to make constructive changes.
“From the perspective of the health belief system of some Indians, this is a sentence of death. The patient feels not only that the disease is beyond his or her control, but also that all efforts to follow a strict medical regimen to control this disease are useless,” Young said.
Individuals cannot lobby for changes in the family diet in their own behalf.
“You must consider that they will not demand for themselves the things that would keep them healthy,” Raymond Kane, a White River Apache and nursing home supervisor told health educators at a spring conference.
A brother or sister must step in as an advocate and insist, for example, that more of the family budget be spent on fresh fruit.
Food has great religious and social value, according to Yvonne Jackson, chief of the nutrition and dietetics section of the Indian Health Service in Rockville, Md.
Food is an important symbol of health, well-being and prosperity, and often it is culturally unacceptable to refuse a meal.
Indians place different values on what they eat. For the Seminole Indians of Florida, meat gives strength, whereas vegetables are so insignificant that the closest native word for vegetable translates to weeds.
Despite a doctor’s advice, such foods do not fit into the Seminole concept of a healthy diet, and some fruits and vegetables are taboo according to traditional medical lore.
But recent work indicates that a return to native foods can help battle blood sugar. An important part of the traditional diet, tepary beans provide six to eight grams of fiber per serving, almost as much as bran flakes, and seem to protect the body against steep rises in blood sugar levels that occur after meals.
The gum of mesquite seeds, the pads of prickly pear cactus and plantago seeds also help reduce the need for insulin.
“This isn’t magic,” said Gary Nabhan, director of the Desert Botanical Gardens in Phoenix and author of “Gathering the Desert.” “It’s not a romantic notion to say native foods are better for you.”
Desert foods help slow digestion of starches, according to Australian nutritionists who in 1987 reported results from studies involving six foods--corn, lima beans, white teparies, yellow teparies, mesquite beans and acorns--from the American Southwest.
Other research in Australia has shown that traditional foods also help control diabetes in Aborigines, who also suffer from high rates of diabetes.
Procedures at Arizona’s diabetic clinics for Indians stress “self-care,” and Smith hopes that approach helps the patients develop stronger motivation to make the changes needed to keep their blood sugar levels under control.
Other treatment programs make use of support groups and of a family advocate to help patients deal with the stress. Relaxation and meditation techniques are included in the treatment, as is instruction in food preparation.
Elsewhere, programs stress education and seek to incorporate native culture to make treatment more effective. In the University of Toronto native diabetes program for local Objibway and Cree Indians, concepts about diabetes are presented in the context of mythology.
In Florida, folk tales based on Seminole mythology describe appropriate ways to deal with diabetes.
“We’ve made inroads in certain things,” Smith said. “Before our philosophy was, ‘Come in, and we’ll take care of you.’ Our emphasis now is, ‘We’re here to assist you.’ We hope this philosophy will help us make a more rapid mind-set change for these patients.”