Best-Practice Programs Reduce Diabetes Rate Among Native Americans, Alaskans

by U.S. Medicine

November 1, 2011

Following encouraging results from a demonstration project that involved 36 Indian Health Service (IHS), tribal and urban Indian health programs, the IHS has added “Youth and Type 2 Diabetes Prevention and Treatment” to its list of best practices.

diabetes treatment algorithms.jpgThat program involves a variety of interventions — everything from exercise programs to nutrition counseling to increased medical monitoring — customized for American Indian and Alaska Native cultures.

These best practices are more than mere “window-dressing;” they have been given “teeth” through IHS policy, according to agency officials. (The complete list of 20 best practices can be found below; the other 19 were updated this year.)

“A couple of years ago when we looked at SDPI (Special Diabetes Program for Indians) grant programs, we decided each of the community-directed grant programs was required to do at least one best practice, so we get consistency in over 300 grant programs,” explained Lorraine Valdez, MPA, BSN, RN, Acting Director / Nurse Consultant for the IHS OCPS (Office of Clinical and Preventive Services) Division of Diabetes Treatment and Prevention in Albuquerque.

These best practices, she adds:

  • Are based on findings from the latest scientific research, outcomes studies and successful experiences of diabetes programs.
  • Provide IHS, Tribal and Urban Indian healthcare programs with relevant, evidence-based information on caring for American Indians and Alaska Natives with diabetes or at risk of developing diabetes.
  • Can help diabetes care teams assess what works and what does not work.

Project provides incentive

The decision to add the new best practice follows years of research, not only by the IHS, but by the National Institutes of Health (NIH). In fact, it was the results of the NIH-funded Diabetes Prevention Program research study that both inspired and formed the foundation (with its 16-session lifestyle curriculum) for the demonstration project, according to Valdez.

Best-Practice Programs Reduce Diabetes Rate Among Native Americans, Alaskans Cont.

Indian Health Service Best Practices


  1. Adult Weight Management and Cardiometabolic Risk Management and Diabetes Guidelines
  2. Breastfeeding Support
  3. Cardiovascular Health and Diabetes
  4. Diabetes/Pre-Diabetes Case Management
  5. Community Advocacy
  6. Community Diabetes Screening
  7. Depression Care
  8. Diabetes Prevention
  9. Diabetes and Pregnancy
  10. Diabetes Self-Management Education (DSME) and Support
  11. Diabetes Eye Care
  12. Foot Care
  13. Nutrition for Diabetes Prevention and Care
  14. Oral Health Care
  15. Pharmaceutical Care
  16. Physical Activity for Diabetes Prevention and Care
  17. School Health: Promoting Healthy Eating and Physical Activity and Managing Diabetes in the School Setting
  18. Screening for Chronic Kidney Disease
  19. Systems of Care
  20. Youth and Type 2 Diabetes Prevention and Treatment

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Best-Practice Programs Reduce Diabetes Rate Among Native Americans, Alaskans Cont.

These successes were formally recognized recently with a Special Recognition Award from Dr. Yvette Roubideaux, director of the IHS, “for innovative and outstanding teamwork that successfully demonstrated cardiovascular disease risk reduction in American Indian and Alaska Native communities.”

“It is true that we face significant challenges in dealing with the diabetes epidemic, but the belief is strong among American Indian and Alaska Native communities that they are on the path to a diabetes-free future,” Valdez said.

Work is Ongoing

Even with successes such as the demonstration projects, IHS is not resting on its laurels, said Valdez. Best practices are updated every two years, with the 2011 list not only adding the prevention and treatment best practice, but also incorporating updates to the others. “We try to update the best practices approximately every two years to ensure that they are up to date and provide the latest science and benchmarks for grant programs to use as they work to improve their programs and the health of their communities,” she explained.

The most obvious type of change, Valdez continued, has to do with updates in clinical standards of care from other organizations. So, for example, if the American Heart Association changes the definition of “good” blood pressure, the IHS standards need to reflect that.

IHS also has pioneered in standard development, said Valdez, noting, “In 1986 the IHS Division of Diabetes developed the IHS Standards of Care for Patients with Type 2 Diabetes, the first set of national clinical guidelines for diabetes care published by any U.S. organization. Over the past 25 years these guidelines have helped healthcare professionals provide excellent care to AI/AN people with diabetes using evidenced-based strategies.” Research has shown that using these strategies for controlling glucose, blood pressure and lipids reduces the risk of diabetes complications and improves patients’ quality of life.

In order to track the care provided using the Standard of Care, the IHS Division of Diabetes developed the Diabetes Care and Outcomes Audit — a process for assessing diabetes care and health outcomes for AI/ANs with diagnosed diabetes — also in 1986. “This allows local communities to identify areas for improvement and implement strategies to work towards the goal of providing the highest quality of care, as outlined in the Standards of Care,” Valdez said.

The bottom line, she added, is that interest in diabetes prevention is “very high,” and, now that the new best practice has been implemented, IHS is working on developing information on how to start a basic prevention program, which will include educational resources and tools.

Best-Practice Programs Reduce Diabetes Rate Among Native Americans, Alaskans Cont.

The need for such a program targeting the Native population is clear, she said.

“Type 2 diabetes has quickly emerged as one of the most serious and devastating health problems of our time; although the growing diabetes epidemic threatens populations around the world, American Indians and Alaska Natives suffer disproportionately from the highest rates of diabetes in the United States,” she pointed out. In some communities, Valdez noted, more than half of adults age 18 and older have diagnosed diabetes, with prevalence rates reaching as high as 60% and greater.  

IHS Director meets with Tribal Leaders Diabetes Committee
The Tribal Leaders Diabetes Committee (TLDC) met recently with Yvette Roubideaux – Indian Health Service Director to develop a new strategic plan for the Special Diabetes Program for Indians. Photo from IHS website.

With such a high prevalence, it’s tempting to say that the increased risk is due to being American Indian, but Valdez said it’s not as simple as that. “There is some science that points to some genetic component, but it’s not as simple as saying, ‘I have a family history, so I’m going to get it,’” she explained. “Obesity (the greatest risk factor for Type 2 diabetes) is more prevalent in some tribal communities than in others.”

There was a time, she added, when the prevalence of Type 2 diabetes was very low in the Alaska area, as was obesity. “But since they became ‘civilized,’ you could blame fast-food for the increase,” she said.

With the growing challenge of obesity among children, they are now being targeted as well.

“With the programs we have in place, there are quite a few of them that have activities targeted at kids, like physical activity or weight management for obese kids and their families,” said Valdez, adding that the IHS is working under an initiative that is part of First Lady Michele Obama’s “Let’s Move” program.

Significant results achieved

The results of the demonstration project give Valdez and others hope that progress is being made. Using a method adapted for Native patients, people at risk for diabetes were encouraged to lose weight through increased physical activity, healthy eating habits and individual and group coaching. On average, those who completed the follow-up assessment had a significantly reduced eight-year risk of developing diabetes, she reported.

“The diabetes incidence rate of participants (4.3% per year), when compared to the NIH Diabetes Prevention Program study, was similar to the NIH study’s lifestyle intervention group and lower than the placebo group (11% per year) in that study,” she observed. Enrollees also achieved significant weight loss, increased physical activity, improved consumption of healthy foods, lower blood pressures, lower glucose levels and improved health-related quality of life at the follow-up and annual assessments compared with baseline.

A concurrent SDPI Healthy Heart Demonstration Project was funded in 30 IHS, tribal and urban Indian health programs to implement an intensive, clinic-based case management intervention to reduce cardiovascular disease risk factors in individuals with diabetes. Enrollees who completed the follow-up assessment had a significantly reduced 10-year risk of developing coronary heart disease. They also had significant improvements in meeting goals for control of blood pressure and blood glucose and achieved improved lipid profiles. For example, the percent of enrollees with blood pressures < 130/80 mmHg increased from 42% at baseline to 49% at the first annual assessment. Enrollees also achieved increased physical activity, increased use of aspirin, and more became non-smokers from baseline to annual assessments.

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