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Diabetes In Indian Country

News from Indian Country / New America Media, News Report, Karen Hollish

 ASHLAND and ODANAH, Wis. — Helen “Frannie” Shinaway carefully spritzes hair gel into her tidy black mullet. She'd already squeezed on her jeans, tucked in a salmon pink T-shirt and put on a gold necklace and earrings specially reserved for this event: Thursday night darts. But tonight she’ll be going alone.

It's been more than a decade since Shinaway and her husband Archie started playing in the bar darts league, a local tradition bringing together people around Ashland, Wis. The area includes nearby Odanah, the town center of the Bad River Indian Reservation, a sprawling wilderness along Lake Superior that is home to about 1,500 members of the Bad River Band of Lake Superior Chippewa, the Shinaway’s tribe.

Archie, who has had type 2 diabetes for 25 years, has been unable to participate in the darts league since three years ago, when he began energy-draining kidney dialysis three times a week.

Over Triple the Prevalence

Overall, the statistics for surviving diabetes in Indian Country are bleak. American Indian and Alaska Native diabetics like Archie are three-and-a-half times more likely to experience diabetic-related kidney failure than the general population.

Bad River is among the top third areas in Indian country with the highest prevalence of diabetes. More than half of the reservation’s population either has the disease or is showing early signs of it. As nurse practitioner Mike Murphy put it, “Everybody out here knows somebody with diabetes.”

Adding to the Shinaways' ongoing anxiety is waiting for “the call” announcing an appropriate kidney donor has arrived for Archie. Once it comes, they'll hurry down to University of Minnesota Fairview Hospital in Minneapolis, almost a four-hour drive from Ashland.

Diabetes: The Obesity Factor

Diabetes is characterized by excessive glucose, or sugar, in the blood. In people diagnosed with type 2 diabetes, either their pancreas is making too little insulin, a hormone that breaks down carbohydrates into energy, or their body can't use the insulin it makes. 

With type 1 diabetes, often called juvenile diabetes, the pancreas cannot make insulin at all. Type 1 diabetics must always rely on daily injections of synthetic insulin or use an insulin pump to stay alive. Only 5 to 10 percent of U.S. diabetics have type 1. 

Pinpointing the exact causes of type 2 diabetes is difficult, said Stephen Rith-Najarian, a medical consultant with the Indian Health Service. Although experts generally agree that a variety of factors lead to the disease, he said, two that stand out are genetics and obesity. 

Scientists are yet to quantify the impact of genetics on the disease, Rith-Najarian said. But they believe genes that trigger diabetes must be fairly common, because the disease is increasingly prevalent among Americans of many backgrounds. 

In recent years, Rith-Najarian explained, the public health community has focused more on obesity. Although being overweight increases one's chances of contracting type 2 diabetes, having a certain kind of fat — the “intra-abdominal fat” that harbors under and around the stomach — really puts someone at risk, he said. 

Other lifestyle choices, such as tobacco use or the quality of care a pregnant mother provides her growing baby, also can contribute to the onset of diabetes. But genetics and obesity are still considered the key culprits, Rith-Najarian said. 

Also disturbing is that the average age of diagnosis for diabetes, long considered an older person's disease, is trending downward, with more and more younger people getting it every year.

In their ongoing struggles with type 2 diabetes, the Shinaways are hardly alone. Archie is one of about 24 million people in the United States who have the disease, according to the Centers for Disease Control and Prevention, and the country's overall prevalence keeps shooting up every year.

Compared to the prevalence of diabetes for all Americans, 12 percent, Native Americans and Alaska Natives lead the way at 16.5 percent, according to the most recent figures from Indian Health Services.

Even more sobering is that Native Americans and Alaska Natives are three times as likely to die from the disease as other Americans. Death from uncontrolled diabetes often comes with cardiovascular disease, kidney failure, blindness, nerve disease or lower-limb amputations.

Stephen Rith-Najarian, a medical consultant who works with the Indian Health Service (IHS), said that means Bad River and other tribes located in the Upper Midwest are in the top third of American Indian communities in terms of diabetes prevalence.

Also troubling is another large segment of the population that's teetering toward a diagnosis, the people with “metabolic syndrome,” a condition also called pre-diabetes. These individuals show early warning signs of the condition, such as elevated blood-sugar levels, high blood pressure or a budding pudginess around their middle.

Changing Attitudes Across Generations

On a recent afternoon, the Bad River Elderly Center buzzed with the sound of several dozen elders chatting and eating lunches of roast beef, buttered carrots and mashed potatoes with gravy. Dessert was pineapple chunks, and there was plenty of regular but watery coffee on hand, with the optional additions of Splenda and powered creamer.

Every weekday, the center offers a free meal to tribal members ages 55 or older. Knowing that elders have an increased risk of developing diabetes, the management tries to offset it by having a nutritionist critique the center’s menu and suggest options.

The sunlit, spacious building is a frequent destination for elders, such as Amoose, 70, a retired photojournalist, who worked with the tribe when it had a newspaper. Amoose usually has plenty to say about tribal politics, which have been particularly tumultuous in recent years. But he is less talkative about the state of his diabetes, which he's had for 15 years.

“I don't know,” he said, pausing between bites of gravy and potatoes. “I haven't tested.”

When asked why not, Amoose quips, “Bad news -- it never goes away.”

His is a common refrain. With Bad River's widespread diabetic prevalence comes a collective resignation to the disease that makes many health workers cringe.

Back at Bad River’s health department, nurse practitioner Mike Murphy is working to change this. He's the case manager for Bad River Heart Watch, a program that provides intensive case management to people with diabetes and pre-diabetes.

The program started six years ago, as one of 30 Healthy Heart pilot projects funded nationwide by the IHS Special Diabetes Program for Indians (SDPI). These projects, as well as a host of other diabetes treatment and prevention efforts funded through SDPI, will end after 2011 unless Congress reauthorizes the program.

Heart Watch

Heart Watch has also provided the guidance and encouragement to sustain people like Archie Shinaway. Murphy helped Shinaway lose weight, get his blood sugars under control and discovered his kidney failure.

But despite Heart Watch and Archie's hard work, the family has been through several big scares in recent years. What started as a small foot infection quickly turned Archie's toes black, making their skin peel off and creating a horrid stench. He lost two toes from one infection, but the damage could have been worse. He also had a staph infection that, had it made its way to his heart, could have killed him, Frannie said.

Whenever Archie has a cut or scrape now, Frannie is right there to clean and disinfect it. She makes it her job to know every injury afflicting his legs and feet.

Frannie talked about how Archie's infections, his amputated toes, and his increasingly dire need for a new kidney have changed how she thinks about them as a couple. Previously, she never hesitated to imagine their future together. Now, though, she stops herself when she starts imagining too many years ahead. Her eyes misting over with tears, she said she just doesn't know if he'll be around.

Having a successful kidney transplant would make it much more likely that Archie will be able to continue on, at a higher quality of life, for years to come. So every Shinaway family member always has their cell phone, or sometimes two, on them, so they can mobilize the moment the hospital call comes.

Frannie looks out the window. Her ride is there. Archie, who used to be one of the meanest dart-slingers in town, will stay home to rest.

Frannie heads out alone for darts, hoping, as she always does, that soon the call will come.

This article was conceived and produced as a project for New America Media’s Ethnic Elders News Fellowship, supported by The Atlantic Philanthropies.

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