Lifestyle changes related to obesity, eating behavior, and physical activity R E V I E W A R T I C L ELifestyle factors related to obesity, eating behavior, and physical activity play a major role in the prevention and treatment of type 2 diabetes. In recent years, there has been progress in the development of behavioral strategies to modify these lifestyle behaviors. Further research, however, is clearly needed, because the rates of obesity in our country are escalating, and changing behavior for the long term has proven to be very difficult. This review article, which grew out of a National Institute of Diabetes and Digestive and Kidney Diseases conference on behavioral science research in diabetes, identifies four key topics related to obesity and physical activity that should be given high priority in future research efforts: 1) environmental factors related to obesity, eating, and physical activity; 2) adoption and maintenance of healthful eating, physical activity, and weight; 3) etiology of eating and physical activity; and 4) multiple behavior changes. This review article discusses the significance of each of these four topics, briefly reviews prior research in each area, identifies barriers to progress, and makes specific research recommendations. Diabetes Care R e v i e w s / C o m m e n t a r i e s / P o s i t i o n S t a t e m e n t s 118DIABETES CARE, VOLUME 24, NUMBER 1, JANUARY 2001Lifestyle changes and diabetes help in the treatment of diabetes. Weight loss and exercise have both been shown to decrease insulin resistance, a major physiological defect related to the development of diabetes, and to improve glycemic control (11,12). These interventions also ameliorate hypertension and lipid abnormalities and thus may contribute to reduction in risk of coronary heart disease (CHD) in individuals with type 2 diabetes (12). Given that behaviors (namely diet and physical activity) are among the strongest risk factors for type 2 diabetes (1) and a key aspect of its treatment, it is important that behavioral research focus on how best to change these behaviors. Four key areas have been identified for future research related to lifestyle modification. ENVIRONMENTAL FACTORS RELATED TO OBESITY, OVEREATING, AND PHYSICAL INACTIVITYWhy is this topic significant? As noted above, differences in lifestyle appear to be related to the differential rates of diabetes and obesity across cultures and within our own culture over time (13). These differences in behavior may, in turn, reflect differences in the macroenvironment. Evidence indicating the importance of the environment is seen, for example, in studies comparing Pima Indians, who live in rural Mexico and follow a traditional Pima lifestyle, with Pima Indians living in Arizona, who consume a Westernized diet and are more sedentary (14). Despite the apparent similarity in genetic background of these two Pima communities, the Mexican Pimas have markedly lower rates of obesity and diabetes than the Arizona Pimas. Many other examples of the negative effects of West...

OBJECTIVEThe landmark Diabetes Prevention Program (DPP) showed that lifestyle intervention can prevent or delay the onset of diabetes for those at risk. We evaluated a translational implementation of this intervention in a diverse set of American Indian and Alaska Native (AI/AN) communities.RESEARCH DESIGN AND METHODSThe Special Diabetes Program for Indians Diabetes Prevention (SDPI-DP) demonstration project implemented the DPP lifestyle intervention among 36 health care programs serving 80 tribes. A total of 2,553 participants with prediabetes were recruited and started intervention by 31 July 2008. They were offered the 16-session Lifestyle Balance Curriculum and underwent a thorough clinical assessment for evaluation of their diabetes status and risk at baseline, soon after completing the curriculum (postcurriculum), and annually for up to 3 years. Diabetes incidence was estimated. Weight loss, changes in blood pressure and lipid levels, and lifestyle changes after intervention were also evaluated.RESULTSThe completion rates of SDPI-DP were 74, 59, 42, and 33% for the postcurriculum and year 1, 2, and 3 assessments, respectively. The crude incidence of diabetes among SDPI-DP participants was 4.0% per year. Significant improvements in weight, blood pressure, and lipid levels were observed immediately after the intervention and annually thereafter for 3 years. Class attendance strongly correlated with diabetes incidence rate, weight loss, and change in systolic blood pressure.CONCLUSIONSOur findings demonstrate the feasibility and potential of translating the lifestyle intervention in diverse AI/AN communities. They have important implications for future dissemination and institutionalization of the intervention throughout the Native American health system.

Diabetes should be considered a major public health problem among young American Indians and Alaska Natives.

OBJECTIVE: To determine trends in diabetes prevalence among Native Americans and Alaska Natives. RESEARCH DESIGN AND METHODS: From 1990 to 1997, Native Americans and Alaska Natives with diabetes were identified from the Indian Health Service (IHS) national outpatient database, and prevalence was calculated using these cases and estimates of the Native American and Alaskan population served by IHS and tribal health facilities. Prevalence was age-adjusted by the direct method based on the 1980 U.S. population. RESULTS: Between 1990 and 1997, the number of Native Americans and Alaska Natives of all ages with diagnosed diabetes increased from 43,262 to 64,474 individuals. Prevalence of diagnosed diabetes increased by 29%. By 1997, prevalence among Native Americans and Alaska Natives was 5.4%, and the age-adjusted prevalence was 8.0%. During the entire 1990-1997 period, prevalence among women was higher than that among men, but the rate of increase was higher among men than women (37 vs. 25%). In 1997, age-adjusted prevalence of diabetes varied by region and ranged from 3% in the Alaska region to 17% in the Atlantic region. The increase in prevalence between 1990 and 1997 ranged from 16% in the Northern Plains region to 76% in the Alaska region. CONCLUSIONS: Diabetes is common among Native Americans and Alaska Natives, and it increased substantially during the 8-year period examined. Effective interventions for primary, secondary, and tertiary, prevention are needed to address the substantial and rapidly growing burden of diabetes among Native Americans and Alaska Natives.

The Indian Health Service (IHS), a federal health system, cares for 2 million of the country's 5.2 million American Indian and Alaska Native people. This system has increasingly focused on innovative uses of health information technology and telemedicine, as well as comprehensive, locally tailored prevention and disease management programs, to promote health equity in a population facing multiple health disparities. Important recent achievements include a reduction in the life-expectancy gap between American Indian and Alaska Native people and whites (from eight years to five years) and improved measures of diabetes control (including 20 percent and 10 percent reductions in the levels of low-density lipoprotein cholesterol and hemoglobin A1c, respectively). However, disparities persist between American Indian and Alaska Native people and the overall US population. Continued innovation and increased funding are required to further improve health and achieve equity.

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OBJECTIVEAmerican Indians and Alaska Natives are 2.3 times more likely to have diabetes than are individuals in the U.S. general population. The objective of this study was to compare morbidity among American Indian and U.S. adults with diabetes.RESEARCH DESIGN AND METHODSWe extracted demographic and health service utilization data for an adult American Indian population aged 18–64 years (n = 30,121) served by the Phoenix Service Unit from the Indian Health Service clinical reporting system. Similar data for a U.S. population (n = 1,500,002) with commercial health insurance, matched by age and sex to the American Indian population, were drawn from the MartketScan Research Database. We used Diagnostic Cost Groups to identify medical conditions for which each individual was treated and to assign a risk score to quantify his or her morbidity burden. We compared the prevalence of comorbidities and morbidity burden of American Indian and U.S. adults with diabetes.RESULTSAmerican Indians with diabetes had significantly higher rates of hypertension, cerebrovascular disease, renal failure, lower-extremity amputations, and liver disease than commercially insured U.S. adults with diabetes (P < 0.05). The American Indian prevalence rates were 61.2, 6.9, 3.9, 1.8, and 7.1%, respectively. The morbidity burden among the American Indian with diabetes exceeded that of the insured U.S. adults with diabetes by 50%.CONCLUSIONSThe morbidity burden associated with diabetes among American Indians seen at the Phoenix Service Unit far exceeded that of commercially insured U.S. adults. These findings point to the urgency of enhancing diabetes prevention and treatment services for American Indians/Alaska Natives to reduce diabetes-related disparities.

The Everyday Discrimination Scale (EDS) has been used widely as a measure of subjective experiences of discrimination. The usefulness of this measure for assessments of perceived experiences of discrimination by American Indian and Alaska Native (AI/AN) peoples has not been explored. Data derived from the Special Diabetes Program for Indians – Healthy Heart Demonstration Project (SDPI-HH), a large-scale initiative to reduce cardiovascular risk among AI/ANs with Type 2 diabetes. Participants (N=3,039) completed a self-report survey that included the EDS and measures of convergent and divergent validity. Missing data were estimated by multiple imputation techniques. Reliability estimates for the EDS were calculated, yielding a single factor with high internal consistency (α=0.92). Younger, more educated respondents reported greater perceived discrimination; retired or widowed respondents reported less. Convergent validity was evidenced by levels of distress, anger, and hostility, which increased as the level of perceived discrimination increased (all p<0.001). Divergent validity was evidenced by the absence of an association between EDS and resilient coping. Resilient coping and insulin-specific diabetes knowledge were not significantly associated with perceived discrimination (p=0.61 and 0.16, respectively). However, general diabetes-related health knowledge was significantly associated with perceived discrimination (p=0.02). The EDS is a promising measure for assessing perceived experiences of discrimination among those AI/ANs who participated in the SDPI-HH.