DIANE BERRY, P H D , A N P - B C , MARKOS SAMOS, MA, LPC, SUSAN STORTI, P H D AND MARGARET GREY, D R P H , F A A N , C P N P , C D E Abstract: The researchers engaged in two in-depth focus groups with ten Native American elders and six Native American parents examining the experience of diabetes in their community and what they feel would help improve current management of diabetes and prevent diabetes. Major themes emerged for both the elders and parents around issues of family history, medical care, education, prevention, and community. However, sub themes for the elders and parents sometimes differed. Both groups agreed that diabetes was a problem and that management and prevention were important within the context of their community and culture. Findings from this study suggest strategies for developing a culture specific diabetes management and prevention program. Key Words: Management, Native American Community, Prevention, Type 2 Diabetes

LISTENING TO CONCERNS ABOUT TYPE 2 DIABETES IN AN NATIVE AMERICAN COMMUNITY he epidemic of type 2 diabetes in Native American communities has occurred primarily during the second half of this century (American Diabetes Association [ADA], 2009; Dabelea et al., 1998; Denny, Holtzman, & Cobb, 2003; Gohdes, 1995; Gohdes et al., 2004; Lee, Howard, Savage & Cohen et al., 1995; Macaulay et al., 1997; Marlow, Melkus, & Bosma, 1998). The incidence and prevalence of the disease has increased dramatically as traditional lifestyles have been minimized due to acculturation into western norms with an increased intake of high fat calorie dense food and decreased physical activity (Denny et al., 2003; Hood, Kelly, Martinez, Shuman, & Seeker-Walker, 1997).

T

Diane Berry, PhD, CANP, is Assistant Professor in the School of Nursing at the University of North Carolina at Chapel Hill in Chapel Hill, NC 27599-7460. Markos Samos, MA, LPC, is Special Assistant to Secretary Jones, Mashantucket Pequot Tribal Nation, Tribal Council, Mashantucket, CT 06338. Susan Storti, PhD, is Director, the Addiction Technology Transfer Center Network at Brown University in Providence, RI 02912. Margaret Grey, DrPH, FAAN, CPNP, CDE, is Dean and Annie Goodrich Professor at the Yale School of Nursing in New Haven, CT 06536-0740. The Corresponding author is: Dr. Berry who may be reached at: 919-843-8561 (Phone); 919-933-0848 (Fax); or [email protected].

Diabetes is currently the sixth leading cause of death among Native Americans and Alaska Natives in the United States (ADA, 2009; Gohdes, 1995). Native American adults and children in the United States are at an increased risk for developing overweight, obesity, and type 2 diabetes (Rosenbloom, 2003).The risk factors include a positive family history, genetic predisposition, maternal diabetes, low birtri weiglit, puberty, overweight, obesity, pre-diabetes, and environmental factors related to nutritional intake and physical activity (ADA). ' Approximately 15% of Native Americans (approximately 107,775) who receive care from the Indian Health Service have type 2 diabetes (Centers for Disease Control and Prevention [CDC], 2004). However, 15% is felt to be an underestimation of the true prevalence of type 2 diabetes in this population. Native Americans were 2.6 times more likely to develop diabetes compared to non-Hispanic whites of a similar age (Gohdes, 1995). In the Atlantic geograpliic area, the prevalence of type 2 diabetes in 20-65 year old Native Americans has been estimated to be ajpproximately 21% (Rios-Burrows, 1999). ¡ There is a recent increase in type 2 diabetes in Native American children and adolescents (ADA, 2009; Rosenbloom & Silverstein, 2003). Approximately 70|% of cases of diabetes diagnosed in youth less than 20 years of age on the reservations in Montana have the clinical characteristics of type 2 diabetes (Gohdes ¡et al., 2004). Type 1 diabetes is rare in the Native American population (ADA). | I I

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I i

Type 2 diabetes is a disease of insulin resistance. Insulin resistance is defined as the inability of the body to use its own insulin to properly control blood glucose and may be present for years before diabetes is diagnosed (ADA, 2009). Type 2 diabetes develops when metabolic defects such as peripheral insulin resistance in muscle tissues, decreased pancreatic insulin secretion, and increased hepatic glucose output emerge (Rosenbloom & Silverstein, 2003). When the acute insulin response fails to compensate for insulin resistance, postprandial hyperglycemia develops, which is followed by fasting hyperglycemia (fasting serum blood glucose >126 mg/ dL). Pre-diabetes includes impaired glucose tolerance (2-houT glucose level between 140-199 mg/dl during a oral glucose tolerance test) and impaired fasting glucose (glucose level between 110-125 mg/dl) (ADA). Pima Indians have been shown to exhibit both increased insulin secretion and insulin resistance with impaired glucose tolerance (Gohdes, 1995). Native Americans with impaired glucose tolerance have a higher incidence of diabetes when compared to those whose glucose levels are within normal range (Knowler, Saad, Pettitt, Nelson, & Bennett, 1993). The incidence of overweight and obesity has increased among Native American communities with 95% of Pima Indians with diabetes being overweight (National Institute of Diabetes Digestive and Kidney Diseases [NIDDK], 1995). The thrifty gene is thought to predispose certain cultural groups to the development of obesity (Carter, Pugh, & Monterrosa, 1996). Central adiposity or upper body adiposity is a stronger risk factor for the development of type 2 diabetes compared to excess weight that is carried in the hips and thighs (Snijder et al., 2004). The waist to hip ratio measurement with increased central adiposity was found to be more strongly associated with type 2 diabetes than body mass index in young Pima Indians (Gohdes, 1995). Nutrition and physical activity patterns have changed for many members of Native American communities over the last several decades. Nutritional patterns have moved away from traditional diets to a diet higher in fat and calories (Gohdes, 1995). In addition, physical activity has decreased and sedentary activity has increased with the use of television and video games (Gohdes, 1995). Increased intake of fat and calories, decreased physical activity, and increased sedentary behavior has diet has been linked to the increased prevalence of type 2 diabetes in adults and children across all cultures (ADA, 2009). Pima Indians in Mexico consuming a traditional diet and physical activity patterns had a lower prevalence of type 2 diabetes than Pima Indians living in Arizona (Carter et al., 1996). Diabetes is associated with the co-morbidities of hyperlipidemia, hypertension, and cardiovascular disease (ADA, 2009). Studies of Native Américains in Arizona and Oklahoma demonstrated that hyperlipidemia and hypertension were more prevalent in Native Americans compared to non-Hispanic whites (Welty et al., 1995). Diabetes is a major risk factor for the development of cardiovascular aisease and cardiovascular cfisease is currently the leading cause of death in Native Americans (Oser et al., 2005). From 1975 to 1984, the majority of

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cardiovascular related deaths in Pima Indians occurred in those individuals with diabetes (Gohdes, 1995). In the U.S. mortality from cardiovascular disease was higher in Native Americans compared to non-Hispanic whites (Lee et al., 1998). Complications from diabetes include diabetic retinopathy, diabetic nephropathy, and lower extremity amputations (ADA, 2009). Diabetic retinopathy is caused by chronically high blood glucose levels, which causes deterioration of the blood vessels in the eye and leads to decreased vision and blindness (ADA). The proportion of Native Americans with diabetes who reside on reservations receiving yearly retinal examinations for diabetic retinopathy was found to be only 33% in British Columbia's First Nations Communities (Kaur, Maberly, Chang, & Hay, 2004). Oklahoma Indians have a 49% prevalence of diabetic neuropathy (Gohdes, 1995). Pima Indians have also been found to have an increased prevalence of diabetic neuropathy (Carter et al., 1996). Asians were more likely to have toe amputations compared with non-Hispanic whites or otrier ethnicities, while Native Americans were more likely to have below-the-knee amputations (Young, Maynard, Reiber, & Boyko, 2003). In the U.S., Native Americans had the highest risk of amputation (RR 1.74, 95% CI 1.39-2.18), followed by African Americans (RR 1.41,95% CI 1.34-1.48) and Hispanics (RR 1.28, 95% CI 1.20-1.38) compared with non-Hispanic whites (Young et al., 2003). Native Americans with diabetes are diagnosed with end-stage renal disease six times more frequently than non-Hispanic whites (Gohdes, 1995). Between 1990 and 2001, the annual number of new Southwestern Native Americans (SWAI) starting treatment for diabetes-related end stage renal disease (ESRD) increased from 154 to 320, and the age-adjusted diabetes-related ESRD incidence per 10,000 population increased 34% (6.2-8.3 per 10,000 people) (Burrows, Narva, Geiss, Engelgau, & Acton, 2005). However, after adjusting for the increasing number of people with diabetes in the SWAI population between 1993 and 2001, the age-adjusted incidence of diabetes-related ESRD among SWAIs with diabetes decreased 31 %, from 80.4 to 55.8 per 10,000 people with diabetes (Burrows et al., 2005). The Diabetes Prevention Program (DPP) demonstrated that people at high risk for developing type 2 diabetes could decrease their risk by 58% through a lifestyle intervention of proper diet and exercise (DPP Research Group, 2002). Of the 3,234 participants enrolled in the DPP, 45% were African Americans, Hispanic Americans, Asian Americans, Pacific Islanders, and Native Americans, who suffered disproportionately from type 2 diabetes (DPP Research Group). Lifestyle intervention successfully reduced the risk of developing type 2 diabetes across both genders and all ethnic groups by 45% (DPP Research Group). Despite type 2 diabetes reaching epidemic proportions in the U.S. with minority groups including Native Americans at an increased risk, there is little documented research regarding whether Native Americans feel there is a problem with diabetes and overweight in their communities, their attitudes toward current treatment programs, and what programs they felt would help

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their communities prevent the development of type 2 diabetes. Research demonstrates perceptions of Native Americans concerning diabetes include: a realistic fear of change; active social support mechanism; interventions must be culturally and historically consistent with Native American values and traditions; and children in particular, need to be taught what healthy lifestyles are in a manner that is fun and interactive (Satterfield, et al, 2003.). Ghallenges in addressing diabetes as reported by tribal members include: time restraints and demands of daily living; fast food and sedentary entertainment; the added expense of eating nutritionally balanced healthy meals; general lack of awareness and/or understanding about diabetes; and changing behaviors whiles maintaining the integrity of the family structure (Liburd and Vinicor, 2003; Satterfield et al., 2003). The purpose of this study was to explore the attitudes and concerns of Native American elders and parents felt there was a problem with diabetes in their community and potential approaches for prevention. We conducted two focus groups with members of a northeast Native American community to better understand their needs and provide a foundation to develop a program to prevent type 2 diabetes. METHODS Following human subjects approval, participants were recruited for two focus groups through a brochure that was mailed out with a monthly newsletter to all families on the reservation. Community members were asked to contact one of the co-investigators by telephone if they wished to join one of the four focus groups. The co-investigator described the research process in detail including all data collection procedures and questions were encouraged. Sample and Setting The two groups provided an opportunity for the elders and parents to talk and discuss their concerns regarding type 2 diabetes and overweight. Inclusion criteria included either gender, no major diagnosis that would affect their participation in the study, read and speak in English, and consented to participate in the study. Principles of cultural sensitivity w^ere used in recruitment strategies and screening. Focus groups in this study were utilized to provide time for elders and parents to be heard on issues related to diabetes and overweight. The data were collected in a private room in the community center of a northeast Native American tribe through two in-depth focus groups on one day in the winter of 2005. Procedures As a part of the focus group protocol, each focus group session began with introductions and a description of the purpose of the study. The consent form and HIPAA form were reviewed with each focus group member by the principal investigator or a co-investigator. Informed consent was obtained before the focus groups began by one of the co-investigators after providing a full description of the study, the requirements

of subjects, and the risks/benefits of the study. T|he co-investigator described the research process in detail including all data collection procedures and questions were encouraged. Confidentiality issues were discussed and participants were reminded that their participation was voluntary. ' Data Collection The focus group protocol included personnel, room set-up, supplies, and questions to be asKed during each of the focus groups. A flip chart was positioned and was visible to all participants. At each focus group, the following individuals were present. The facilitator had primary responsibility for conducting the focus groups. She was responsible for explaining the stu'dy to the participants and obtaining informed consent. She facilitated^the focus group discussions and ensured that all participants had an opportunity to speak. The note-taker took notes and provided a summary at the end of each focus group. The timekeeper had the primary responsibility of running the tape recorder and monitoring time. The co-investigators also assisted in collecting the demographic data sheet and the consent forms. The room was set up for 10 participants in a circle and healthy snacks and beverages were served. Participants were asked questions by the focus gro^up leader according to the interview guide developed for the focus groups by the researchers (Table 1). ¡ The first focus group enrolled 8 Native American elders to examine community readiness for change, effective ways to address the issues, how they might support the process, and their experience with diabetes and obesity in their families. The second focus group

Table 1. Focus Group Questions Focus Group Questions for Elders 1. Do you feel that the community is ready to start making changes to treat overweight and prevent diabetes? 2. How do you feel would be the most effective way to address changes in your community? , 3. How do you feel you as a group you could help support changes in your community? 4. Please share your experiences with obesity and diabetes in your families? Focus Group Questions for Parents 1. Please share your experience with overweight and diabetes in your families? ' 2. What do you think causes overweight and diabetes? ' 3. What do you think would be helpful to deal with overweight and diabetes? 4. What are the nutrition and exercise patterns in your families? 5. What do you think can be done to help? 6. What would you as parents like to do? 7. Please share with us any barriers that you think might prevent the development a program to treat overweight and that may help to prevent type 2 diabetes in your community?

I

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enrolled 6 overweight or obese Native American parents of at risk for overweight or overweight children who are at risk for developing type 2 diabetes. The parent focus group examined whetrier there was a problem with overweight and/or diabetes in their family, what causes overweight and diabetes, what would be helpful for them to deal with diabetes and overweight in their community, what their families current health behaviors were, what could be done to help, what would they like to do, and if they knew of any barriers that might prevent the development a program to prevent type 2 diabetes in their community. Each focus group was considered complete when the participants felt there was nothing more to share. The focus groups lasted between 60 to 75 minutes. Data Analysis All focus groups were audio taped and transcribed verbatim. Data were analyzed through coding and categorization by three of the authors. Themes were developed and data examined across groups. Summary statements that captured the main ideas were developed and will be used to develop an intervention to prevent type 2 diabetes in this community (Table 2).

in the study. Fifty-seven percent were male, 71% married, and 85% worked full-time. The participants were well educated with 79% (n = 11) attending college and obtaining a degree. Seventy-nine (n = 11) percent did not wish to respond or left blank the question regarding income. Overall, 29% (n = 4) felt their health was excellent, whereas 50% (n = 7) felt their health was good and 21% (n = 3) felt their health was fair. Sixty-five (n = 9) percent felt they had a health problem and listed overweight, obesity, diabetes, high blood pressure, asthma, arthritis, stomach or heart problems as the cause. Themes Results are presented with emerging themes and subthemes (Table 2). Five major themes emerged across the groups and included family history, medical care, education, prevention, and community (Table 2). However, there were some differences between elders and parents in the sub themes. Family History. When discussing the theme of family history, the elders felt there was a reluctance to share family history with other family members while they would support developing a confidential family history system that their children could access to get medical information.

RESULTS Participant Characteristics

"lam an elder in my family, buti don't know what my grandfather and great grandfather had because it was never told to me, so who do I go to when they are all gone? Everyone was so private back then. They didn't tell you unless you went to their funeral, and then you

The study sample of both focus groups included fourteen participants ranging in age from 34 to 71 years (M = 49.6; SD + 10.6) who were willing to participate

Table 2. Themes of Focus Groups Themes

Sub themes Tribal Leaders and Elders

Parents

Family History

Reluctance to Share Family History Confidential Family History System

Inability to Gather Family History Lack of Family History

Medical Care

Knowledgeable Diabetes Health Care Providers Diabetes Clinic on Reservation Health and Wellness Program on Reservation Expense of Medical Supplies and Prescriptions

Knowledgeable Health Care Providers Inaccurate Weight Charts Disorders with Overweight Consequences of Behavior

Education

Time Management Education Stress Management Education Nutrition Education Programs Economical Healthy Eating Fun Community Exercise Programs

Stress Management Training Nutrition Education Programs Family Exercise Program

Prevention

Holistic Program that Fits the Communities Needs Developing Problem-Solving Skills Developing Self-Esteem in Community Members Developing a Support System for Community Members

Family Training in Lifestyle Change Family Support

Community

Model of Change that is Culturally Competent and Personal

Change the School Lunch Program

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found out that he had this or that. Maybe they can start a sheet for each family with family history information only they (children) can see."

In contrast, the parents felt that it was difficult to learn and gather family history and felt there was a lack of family history available to them from the elders. " I am sure there would be a lot of resistance to a sheet of paper for family history, but maybe if someone met with the elders individually and asked them what their family history was or asked them to formulate a sheet and we could give it to them to fill out and then they could share it with their family members. That might work" Medical Care. Both elders and parents acknowledged that they needed knowledgeable diabetes health care providers available to their community. The elders felt that they needed a diabetes clinic and a health and wellness program available on-site and assistance to cover the expense of medical supplies and prescriptions since many lived on a fixed income. "I come from a family of diabetics and live on a limited income and can't afford the supplies and medicines. We need a program to prevent diabetes and a clinic here that is convenient for people who have diabetes." In contrast, the parents were concerned with weight charts that were inaccurate, disorders with overweight, and consequences of behavior such as eating too much and exercising to little in themselves and their children. One parent shared his thoughts on what his family was trying to do to make change for their overweight son:

! ; ; ; ,

"My oldest son is ten, he's starting to put on weight. Factor in our lifestyle such as ordering pizza and then he sits in front of the TV or the computer and he doesn't get a lot of activity. None of us do. He is starting to get overweight on the doctor's charts. The doctor has not really said a lot even with our family history of diabetes. We are trying to make some changes such as eating better ana exercising more since my brother now has diabetes."

Education. Both elders and parents felt there were many educational needs on the reservation. The need for nutrition and stress management was a common theme for both groups. One of the elders shared that his mother |was 81 years old and recently had a heart attack and that she was in the hospital and the dietician was saying: "You have got to change the way you eat and you have to go on an exchange diet. And I am watching my mom while this lady is talking nutrition and it is going in one ear and out the other. She is really not saying anything to help. My mom goes to the grocery store, she buys what she buys anil when the nutritionist is \ saying you have got to exchange carbs, you only got \ this many in a day, read it on me can, she is talking a i foreign language. Talk about stress"

However, the elders also felt they needed time management education, information on how to eat healthier and cook more economically. " We need a program that deals with time management and how to do this. It is

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cheaper to eat out than to cook at home. How can we compensate for that?" Both elders and parents felt they needed to have exercise programs that were fun and community a|nd family orientated available on the reservation to encourage more physical activity. One parent shared that he felt it was all about: "Creative marketing, if you sell the most appealing part of the product and sell that in a creative, imaginative, and consistent manner. Another areas is if they want to do it, if they don't want to do it, then they are not going to do it. You have to make it ¡un, like a competi- j tion like the Walk Across America Challenges, or when | you help someone, or challenge somebody. That is cool i and fun!" I Prevention. In prevention of type 2 diabetes, the elders and parents differed. The elders felt that a holistic program that fits the needs of the community was important, and that the community needed help devleloping problem-solving skills, improving self-esteem, and developing a support system for all community members. One elder shared his vision for a diabetes prevention program: " We need to develop a holistic program for both adults and children that you can do comfortably within the I confines of your daily work schedule or after school j that includes some components of nutrition education, j learning about time management, learning about how ' to cook differently, learning about making lifestyle pattern changes on a daily basis, as well as exercise that is incorporated into your daily life."

Another elder felt that as a part of the program that learning problem-solving skills was important. "We need to learn problem-solving skills that help us with our diet and exercise everyday. Like making a baked chicken on Sunday and having that to eat two or three days of the week." In addition, to a holistic program and problem-solving, improving self-esteem " in community members is very important so that they feel comfortable making changes in what they eat and when and how they exercise." Elders felt that community members needed a support system. "You need to have support, because once you learn all of this information, it is good, and you try it for a couple of days, but then you need the support to keep it going long-term." In contrast parents were concerned with the need for their families receiving training in making lifestyle change and that the family needed a lot of supporti to make changes in nutrition and exercise. ; "Working with parents in terms of helping them understand where their children should be in their projected growth patterns for younger children as well as teenagers. I think if you can peak people's curiosity to want to know more and make nutrition and exercise information readily accessible that would help. We need to include the community to make change."

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Community. The theme of community for elders and parents were quite different. The elders felt that they needed a model of change that was culturally competent and personal and the parents felt they needed help with changing the school lunch program to help prevent the development of overweight in their children. One elder shared: " We have had tribal members here that have gone to a place, learned the proper things to do, but when they get back, the environment is not conducive to keeping up with the changes that they have learned and it is more than just eating, there is a lot of different aspects, which I think people really have to learn in the community where they live.

In contrast, a parent felt the school hot lunch program had to change. "French fries and mozzarella sticks are not healthy roods. You know an 8 year old is not going to choose a salad." The findings suggest that the elders and parents of the community are knowledgeable about what they feel would go into developing a good program to prevent type 2 diabetes in their community. The elders have an overarching view of the communities needs and the parents were insightful at what would be instrumental to be included on the family and individual level. In closing one elder shared: " The community is ready to start something to prevent diabetes or become more active. I think the problem isn't are we ready. I think the problem is what steps do we need to take to make sure we do this in the most effective way. We need programs for children and adults alreaadiagnosed with diabetes and a prevention program that we can work with younger children and a younger age so that they do not gain weight and develop type 2 diabetes."

DISCUSSION Results of this study revealed that Native American elders and parents shared the same overall concerns regarding type 2 diabetes in their communities and families. However, the nuances revealed in the sub themes clearly differentiated the differing levels of the community, family, and individual concern regarding type 2 diabetes and overweight. The results suggest the importance of developing a culturally sensitive multilevel program that targets the individual, family, and community to manage and prevent type 2 diabetes in this high-risk group. Documenting family history poses a particular problem for Native Americans who have a family history of a type 2 diabetes. Historically, members of this population have been medically underserved resulting in incomplete health histories, and there is a general reluctance of tribal members to share medical history due to concerns of confidentiality based on negative past experiences with the medical practice and research community at large. The tribal elders and parents plan to meet and discuss this important issue further and develop a plan that will respect each member of the community while

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making medical histories more available to each tribal member. Elders and parents felt that their medical care lacked experienced and convenient health care providers who understood their unique family history and risk of developing type 2 diabetes. This was congruent with recent studies that continue to support that Native Americans are and remain at greater risk of having increased rates of physical inactivity, overweight, an(l type 2 diabetes (Denny et al., 2003; Denny, Holtzman, Coins, & Croft, 2005). In some Native American communities approximately 50% of adults have type 2 diabetes (Lee, Howard, & Savage, 1995). Native Americans have suffered from significant disparities in health and quality of care for over 50 years. The federal government has failed to fund the Indian Health Service (IHS) adequately for the care of over 1.8 million patients it is charged with serving (Roubideaux, 2005). The IHS per capita health care expenditures are lower than many other health care systems in the U.S, which leaves many Native Americans with a lack of access to high quality medical care to manage and prevent chronic health problems like diabetes (IHS, 2000; Roubideaux, 2002, 2005; Roubideaux et al., 2000). Therefore, working toward health care that is culturally sensitive and more easily accessible will be a priority for this community who are at high-risk for developing type 2 diabetes. According to both elders and parents there are many educational needs on the reservation. Nutrition and stress management were a common theme for both groups. However, the elders felt they also needed education on time management and how to cook and eat healthy food that was economical. However, a majority of the elders and parents felt that there is a resistance to change in the community. Interventions that are marketed as fun, age appropriate, and culturally sensitive may decrease community resistance. In another study that met with resistance, the inclusion of Native American peer facilitators in education on the management and prevention of type 2 diabetes was viewed as positive by the community, because the peer communicators were knowledgeable about Native American culture and were trained in community facilitation and type 2 diabetes (Struthers, Hodge, & De Cora, 2003). Ed^ucational programs must be (developed that address the needs of the community and are d^elivered in a manner that takes into account cultural relevance and families living on a fixed income and teaches nutrition, exercise, and stress management. Prevention was discussed in the context of developing a holistic program that fits the needs of the community and includes the development of problem-solving skills, improving self-esteem, and developing a support system for all community members to prevent type 2 diabetes. The importance of not just delivering a program to prevent diabetes, but imbedding the program into the community so that healthy nutrition and exercise became a part of everyday life was felt to be important. The development of a program that is participatory and community based and delivers nutrition, exercise, and behavioral interventions on an individual, family, and community level will be planned with continued input and feedback from the community. Summer 2009

The importance of community was similar to other studies with other Native American tribes (Belza et al., 2004; Devlin, Roberts, Okaya, & Xiong, 2006; Grams et al., 1996; Roubideaux et al., 2000) in the desire to develop a culturally sensitive health care intervention to manage and prevent type 2 diabetes. What differed in our study was that both elders and parents felt that the intervention must include individuals, families, and the community taking into consideration tribal values while addressing the importance of healthy nutrition and exercise in an economic manner. As a result of this study initial changes have begun with efforts undertaken by the tribal nation to incorporate dietary changes into tribal activities and meetings. This has included full disclosure of the nutritional value of prepared foods, instruction on portion control, and the provision of healthy alternatives. For example, free soft drinks have been replaced in the community center with the healthy option of free sugar-freeflavoredwater. Additionally, the tribal operated child development center has instituted change to its meal program by replacing low nutritional value foods and snacks such as chips and regular soda with nutritious lower calorie options such as fresh fruit, pretzels, and water. The tribal community sees diabetes as a major health threat to its very existence. This community nas experienced repeated loss of its members due to diabetes and its complications. This concern has raised a level of awareness and urgency to address this life-threatening disease. Efforts to work with all members of the tribal community are underway, but will require additional interventions. The extent of diabetes in this Native American community demands public health programs that incorporate specific culturally sensitive nutrition, exercise, and behavioral interventions designed to sustain long-term management and prevention. IMPLICATIONS

The study has implications for the design of a multilevel diabetes management and prevention program for this Native American communities, families, and individuals. This study can contribute new knowledge to address concerns regarding family history, medical care, education, and prevention programs within the Native American community. Every effort should be made to provide American Indians with accessible and affordable health promoting programs to reduce type 2 diabetes in both children and adults. Demographic trends suggest that type 2 diabetes will continue to rise in the future with minority groups most affected. A diabetes program would have to address both management and prevention of type 2 diabetes on a community, family, and individual level. Both diabetes programs would have to be embedded in culture and developed in a participatory manner with the communities input. Study limitations include studying Native American elders and parents only from two tribes and the small sample size, which limit its generalizability, as these may not be representative of all Native American tribes. Therefore, future focus group research should include more diverse Native American tribes to support content validity. Despite the limitations, the significant strength

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of this study is that this is the first attempt to understand the impact of type 2 diabetes in this group of Native Americans and! provides a foundation to work with the community to develop a program to manage and prevent type 2 diabetes in their community. ' I

REFERENCES

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American Diabetes Association. (2009). Clinical Practice Recommendations 2009. Diabetes Care, 32(1), Sl-97. ! Belza, B., Walwick, J., Shiu-Thornton, S., Schwartz, S., Taylor, M., & LoGerfo, J. (2004). Older adult perspectives on physical activity and exercise: voices from multiple cultures. Prevention of Chronic Disease, 1 (4), A09. I Burrows, N. R., Narva, A. S., Geiss, L. S., Engelgau, M. M.j & Acton, K. J. (2005). End-stage renal disease due to diabetes among southwestern Native Americans, 1990-2001. Diabetes Care, 28(5), 1041-1044. ' Carter, J. S., Pugh, J. A., & Monterrosa, A. (1996). Non-insulin-dependent diabetes mellitus in minorities in the United States. Annals of Internal Medicine, Ï25(3), 221-232. Centers for Disease Control and Prevention. (2004). National diabetes fact sheet: general information and national estimates o diabetes in the United States. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control

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