..Felicia Schanche Hodge, DrPH

Professor, School of Nursing Professor, School of Public Health

Director, Center for American Indian/ Indigenous Research & Education

CAIIRE

University of California,Los Angeles (UCLA)

Report on Diabetes Wellness Study in So. Dakota &

Nebraska• Requested to write the proposal

• To coordinate the study

• To conduct the data analysis

• Hired local RNs and others to assist

• Held focus groups to better understand

• Held series of Talking Circles to educate, empower, and to change attitude

Diabetes Wellness StudyDiabetes Wellness Study

• Funders: National Institute of Health National Institute of Nursing

Research (NINR)

• Dates: 1998 – 2003

• Principal Investigator: Felicia Hodge, DrPH

• Project Director: Lorelei DeCora

Improving Prevention Practices & Improving Prevention Practices & Diabetic Treatment Compliance Diabetic Treatment Compliance

• Improve Knowledge

• Teach Skills

• Change Attitudes

• Screening

Diabetes is Epidemic in Diabetes is Epidemic in Indian CountryIndian Country

• Type 2 diabetes, once uncommon among indigenous peoples of the North American continent, is now at epidemic levels among all tribes.

• Type 2 diabetes first diagnosed in 1945 among American Indians.

• Type 2 diabetes is now 3-6 times the national average among some tribes.

A recent newsprint reports:A recent newsprint reports:• Diabetes is principally a disorder of

metabolism. It is impossible to store fat or become obese unless we consume considerable amounts of dietary carbohydrate: this is basic biochemistry.

• Diet, physical activity, and maintaining healthy weight advised.

• Early screening is essential to reduce threats of complications.

• The lack of early detection and culturally-bound illness beliefs and attitudes may add to diabetes-related complications, such as depression, heart disease, blindness and amputations.

• Combination of depression and fatalistic beliefs impacts diabetes self-management and lifestyles behaviors.

• The importance of early diabetes

detection through screenings and the use of culturally appropriate tools (Talking Circles) to aid in the education, intervention and screenings of diabetes increases knowledge about the disease and improves healthy lifestyle choices.

A Triple ProblemA Triple Problem• The Triple Problem = Type 2 diabetes,

obesity, and cardiovascular disease.

• Very high carbohydrate, low-fat diet that has been imposed upon our population since the 1980s.

• Thus making it difficult to control blood sugar, even with industrial doses of insulin and certainly not with oral hypoglycemic agents.

Co-morbid ConditionsCo-morbid Conditions• Cardiovascular Disease (CVD) is the

# 1 cause of death among AI/ANs.

• Obesity found to be among 82% in a study of rural California Indians.

• Loss of limbs, eyesight and functionality due to damaged blood vessels.

• Kidney failure, blindness, loss of toes, limbs.

CHANGING LIFESTYLESCHANGING LIFESTYLES

Sedentary lifestyles

Changed from high activity and labor to low daily activity & unemployment

Poor nutrition

Changed from subsistence living

to high carb high processed foods

Diabetes Wellness ProjectDiabetes Wellness Project• Felicia Hodge, Principal Investigator

Lorelei DeCora, Project Director• Screening, increasing knowledge, skills• Intervention study (Talking Circles)• Experimental Design N = 324• Reservation Sites:

- Pine Ridge (Oglala Sioux)- Rose Bud Sioux- Yankton Sioux- Winnebago

• •

Project Phases• Focus Groups• Randomized

Intervention - Winnebago - Pine Ridge, - Yankton- Rosebud Sioux

• Data Analysis

Focus Groups Examined the Focus Groups Examined the Cultural Constructs of DiabetesCultural Constructs of Diabetes

- Etiology unknown- A disease brought in from outside- Belief that all Indians will get diabetes- Cannot prevent onset of diabetes - Once you get diabetes, there is nothing to

prevent it from getting worse Fatalistic Beliefs

Talking Circle InterventionsTalking Circle Interventions

• Based on Community Participatory Research that conceptualizes social capital as:- Social Life Networks- Norms (including reciprocity) - Trust- Respect

Talking Circle SessionsTalking Circle Sessions• Meet once a week for 1-2 hours

• Meets for 8-12 weeks

• Led by peer facilitator

• Traditional foods (buffalo) served• Curriculum: empowerment-self efficacy

Study FindingsStudy Findings• INCREASE IN KNOWLEDGE• Especially the “at-risk” group• Younger groups• In diabetes knowledge, food fat,

fiber, nutrition and exercise.

• CHANGE IN ATTITUDE• Reduction of fatalism (at-risk)• Improvement in empowerment

Increased Knowledge ScoresIncreased Knowledge Scores• Knowledge scores increased

significantly at posttest (pre-post test) as compared to control sites.

+ Diabetes knowledge

+ Fiber food knowledge

+ Fatty food knowledge

+ Exercise knowledge

Multiple regression data analysis Multiple regression data analysis for knowledge vs. interventionfor knowledge vs. intervention

• Response Adjusted for age and gender

(SE) p-value

Total Knowledge 0.329 (0.076) p<0.0001

Diabetes Knowledge 0.191 (0.064) p=0.003

Fat food Knowledge 0.041 (0.017) p=0.02

Fiber food Knowledge 0.045 (0.019) p=0.018

Exercise Knowledge 0.045 (0.022) p=0.04

Increase in Increase in KKnowledge Scoresnowledge ScoresCompared to Control GroupsCompared to Control Groups

• Increase in male K score (p=0.002)

• Increase in female K score (p=0.001)

• Increase in diabetic’s K score (p=0.02)

• Increase in at-risk K score (p=0.0003)

• Further, multiple regression analysis showed in overall K scores increased for the Intervention group was significantly higher (p=0.0002)

Predictors of Predictors of KK Change Change

• Younger age

• Obesity status

• Employment status

Were predictors for change in total Knowledge Scores

• •

Depression and Diabetes

• Depression rates are high

• Smoking rates are high

• Depression, smoking, low empowerment and low knowledge levels were found in the population.

• Improved in the study group

Percent Depression and Percent Depression and Substance Abuse ReportedSubstance Abuse Reported

#1 #2 #3 #4

• Depression 21.4 14.3 8.8 28.6

• Smoking cigs 62.3 37.5 73.2 52.9

• Tx for alcohol 22.5 20.9 22.3 27.0and drugs

• •

Diabetes Wellness –Fatalistic Attitude

• “I will probably get diabetes at some time in my life.”

• “There is nothing I can do to prevent getting diabetes.”

• “There is nothing that can be done to prevent diabetes from getting worse.”

• •

Diabetes Wellness –Fatalistic Attitude

• “I will probably get diabetes at some time in my life.”

• “There is nothing I can do to prevent getting diabetes.”

• “There is nothing that can be done to prevent diabetes from getting worse.”

Fatalistic Attitudes

0%10%20%30%40%50%60%70%

I will getdiabetes

Can donothingabout it

Can'tpreventdiabetes

TRT - pre

TRT - post

Control - pre

Control - post

I will get diabetesFemale/Male “at risk” Participants

0%

10%

20%

30%

40%

50%

60%

70%

FEMALES p<.001

MALES

TRT - preTRT - postControl - preControl - post

Can do nothing to prevent diabetes Female/Male“at risk” Participants

0%

5%10%

15%20%

25%30%35%

FEMALES P=.02

MALES

TRT - preTRT - postControl - preControl - post

Once you get diabetes, there is nothing to prevent getting worse

0%

5%

10%

15%

20%

25%

30%

FEMALES MALES

TRT - preTRT - postControl - preControl - post

FindingsFindings• Statistically significant increase in levels

of knowledge

• Statistically significant increase in screening

• Statistically significant reduction of fatalistic beliefs

• Reduction of watching TV

• Increased attention to diet, physical activity.

Talking Circles

• Talking Circles Intervention had significant results in reducing fatalistic attitudes toward diabetes.

• Significant difference between pre-posttest scores seen in females.

• Reduction in other chronic health conditions were not as significant – need more time?

RECOMMENDATIONS:RECOMMENDATIONS:

• Reduce Obesity:- by reducing carb- increasing exercise

- screening for diabetes- screening for co-morbid conditions* sores that heal slowly* vision problems*

numbness*depression

- improve screening in depression

34

• Collect the Dietary Recall Log

• Watch the Diabetes Wellness video

• Look at people’s perceptions of diabetes

• Learn diabetes myths from fact

OBJECTIVES: Session 2

35

MYTHS OF DIABETES• Diabetes has always been with us, is in all of our families, and is inevitable in our lives.

• Nothing that we can do can influence our chances of getting diabetes or help control our disease once we get diabetes.

36

• If one must take insulin for diabetes, they will have a poorer outcome than those that don’t.

• Once a person develops a complication from diabetes, there is nothing that can be done.

• Diabetes only affects the body, and not the mind.

MYTHS OF DIABETES

SECTION II: DIABETESSESSION 2: DIABETES – PerceptionsMAIN POINTS•Know myths from facts on diabetes.•Begin the process of challenging a fatalistic perspective on diabetes.•Begin the process of promoting empowerment and having the ability to overcome diabetes.MATERIALS:•Sign-in sheet•Traditional story•Paper•Pens•Diabetes Wellness Video•Curriculum Flip Chart•Myths of Diabetes Handouts•Refreshments

ACTIVITIES:•Welcome circle members as they arrive. Have them sign in.•You or ask circle member to say traditional prayer for circle and food.•Read traditional story.•Inclusion exercise:Star exercise: Hand out a piece of paper and pen to each person. Ask them to draw a five-pointed star on the paper. Tell them that they will be asked to write something on the point of each star that they will be asked to share.

Point 1. Favorite FoodPoint 2. A famous person with whom they would like to visit.Point 3. Something they like to do in their free time.Point 4. Something they hope to learn in the Talking Circles.Point 5. Why they decided to participate in the Talking Circles.

Describe Objectives for Session 2 from flip chart.OBJECTIVES: FLIP CHART•Collect the dietary recall log.•Watch the Diabetes Wellness Video.•Look at people’s perceptions of diabetes.•Learn diabetes myths from fact.

Collect Food Diaries.Show Diabetes Wellness Video.Ask members for comments on the video and their beliefs about diabetes.Distribute Dr. Lehmann’s Myths of Diabetes handout. Review myths and facts using the flip chart. Promote group discussion on myths and facts.

Diabetes has always been with us, is in all of our families, and is inevitable in our lives. (FALSE)Nothing that we can do can influence our changes of getting diabetes or help control our disease once we get diabetes. (FALSE)Diabetes usually shows symptoms when it first starts in the body. (FALSE)If I must take insulin for diabetes, I will have a poorer outcome than someone who doesn’t. (FALSE)Giving myself a shot of insulin is extremely painful. (FALSE)Once a person develops a complication from diabetes, there is nothing that can be done. (FALSE)Diabetes only affects the body, not the mind. (FALSE)•Review Objectives for Session 2 from flip chart to be sure they were all completed.•Thank circle members for their participation, attendance and commitment.Refreshments

To download the Diabetes To download the Diabetes Talking Circle MaterialsTalking Circle Materials

http://www.seva.org/dtc http://www.seva.org/dtc

To receive a FREE copy of the To receive a FREE copy of the video, curriculum, cookbook, video, curriculum, cookbook,

measurement and publicationsmeasurement and publications

Contact:Contact:

www.fhodge@sonnet.ucla.eduwww.fhodge@sonnet.ucla.edu