[Senate Hearing 110-19]
[From the U.S. Government Publishing Office]



                                                         S. Hrg. 110-19
 
                       DIABETES IN INDIAN COUNTRY

=======================================================================

                                HEARING

                               BEFORE THE

                      COMMITTEE ON INDIAN AFFAIRS
                          UNITED STATES SENATE

                       ONE HUNDRED TENTH CONGRESS

                             FIRST SESSION

                                   ON

   DIABETES IN INDIAN COUNTRY, WITH PARTICULAR FOCUS ON THE SPECIAL 
                            DIABETES PROGRAM

                               __________

                            FEBRUARY 8, 2007
                             WASHINGTON, DC

                    U.S. GOVERNMENT PRINTING OFFICE
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                      COMMITTEE ON INDIAN AFFAIRS

                BYRON L. DORGAN, North Dakota, Chairman

                  CRAIG THOMAS, Wyoming Vice Chairman

DANIEL K. INOUYE, Hawaii             JOHN McCAIN, Arizona
KENT CONRAD, North Dakota            PETE V. DOMENICI, New Mexico
DANIEL K. AKAKA, Hawaii              GORDON SMITH, Oregon
TIM JOHNSON, South Dakota            LISA MURKOWSKI, Alaska
MARIA CANTWELL, Washington           RICHARD BURR, North Carolina
CLAIRE McCASKILL, Missouri           TOM COBURN, M.D., Oklahoma
JON TESTER, Montana

                Sara G. Garland, Majority Staff Director

              David A. Mullon Jr. Minority Staff Director

                                  (ii)

  
                            C O N T E N T S

                              ----------                              
                                                                   Page
Statements:
    Baker, Biron, Primary Care Physician, MED, Center One........    22
    Brosseau, James, director, Altru Diabetes Center, member of 
      the American Diabetes Association Native American Community    18
    Dorgan, Hon. Byron L., U.S. Senator from North Dakota, 
      chairman, Committee on Indian Affairs......................     1
    Fradkin, Judith, director, Division of Endocrinology, and 
      Metabolic Diseases, National Institute of Diabetes and 
      Digestive and Kidney Disease, National Institutes of 
      Health, Department of Health and Human Services............     6
    Grim, Charles W., director, Indian Health Service, Department 
      of Health and Human Services...............................     3
    Knowler, William, chief, Diabetes Epidemiology and Clinical 
      Research Section, Division of Intramural Research, National 
      Institute of Diabetes and Digestive and Kidney Disease, 
      National Institutes of Health, Department of Health and 
      Human Services.............................................     6
    McCracken, Sam, director, Nike Native American Business 
      Program....................................................    20
    Moore, Kelly, clinical specialty consultant, Division of 
      Diabetes Treatment and Prevention, Department of Health and 
      Human Services.............................................     3
    Rolin, Buford, chairman, Poarch Band of Creek Indians, 
      cochair, Tribal Leaders Diabetes Committee, and cochair, 
      National Steering Committee for the Reauthorization of the 
      Indian Health Care Improvement Act.........................    16
    Thomas, Hon. Craig, U.S. Senator from Wyoming, vice chairman, 
      Committee on Indian Affairs................................     2
    Vandall, Donna, director, Whirling Thunder Wellness Center...    26

                                Appendix

Prepared statements:
    Baker, Biron.................................................    33
    Barnard, MD, Neal D., president, Physicians Committee for 
      Responsible Medicine (with attachment).....................    43
    Brosseau, James (with attachment)............................    69
    Bursell, Sven-Erik, Joslin Diabetes Center...................    90
    Grim, Charles W..............................................    93
    Inouye, Hon. Daniel K., U.S. Senator from Hawaii.............    35
    Johnson, Jacqueline, executive director, National Congress of 
      American Indians (with attachment).........................   102
    Knowler, William (with attachment)...........................    36
    McCracken, Sam...............................................    40
    Rolin, Buford................................................   107
    Vandall, Donna (with attachment).............................   113


                       DIABETES IN INDIAN COUNTRY

                              ----------                              


                       THURSDAY, FEBRUARY 8, 2007


                                       U.S. Senate,
                               Committee on Indian Affairs,
                                                    Washington, DC.
    The committee met, pursuant to notice, at 9:39 a.m. in room 
485 Senate Russell Office Building, Hon. Byron Dorgan (chairman 
of the committee) presiding.
    Present: Senators Dorgan, Cantwell, Conrad, Smith, Tester, 
and Thomas.

  STATEMENT OF HON. BYRON L. DORGAN, U.S. SENATOR FROM NORTH 
         DAKOTA, CHAIRMAN, COMMITTEE ON INDIAN AFFAIRS

    The Chairman. Next, we will turn to the purpose of the 
hearing this morning. Let me thank my colleagues for allowing 
us to pass these four pieces of legislation early on. As I 
indicated, three of them had previously gotten through the 
entire Senate, but did not get through the House. We want very 
much for there to be an opportunity to move all legislation 
through the full Congress and get them signed. That is why we 
wanted to start early on this occasion.
    Let me talk about the oversight hearing today, diabetes in 
Indian country. In 1997, as part of the Balanced Budget Act, 
Congress established what is called a designated fund to 
address diabetes in Indian country. It created the Special 
Diabetes Program for Indians, along with a separate 
authorization for Special Diabetes Programs for children with 
type 1 diabetes; $30 million was authorized for the Special 
Diabetes Program for Indians in each of 1998 through fiscal 
year 2002.
    The program has grown to $150 million per year. The Special 
Diabetes Program for Indians is administered by the IHS 
Division of Diabetes Treatment and Prevention. It is recognized 
as the most comprehensive rural system of care for diabetes in 
the United States. Grants under this program have been awarded 
by the Indian Health Service to 400 Indian Health Service, 
tribal and urban Indian programs within the 12 IHS areas and 35 
States. The program now serves about 116,000 Native American 
people with various prevention and treatment services.
    The committee has not held an oversight hearing on diabetes 
since the Special Diabetes Program for Indians was established 
in 1997. The program will need to be reauthorized after fiscal 
year 2008, so today's hearing is timely.
    I wanted to just make a point that we are going to talk a 
lot about health care on Indian reservations in this Congress. 
I believe that there is health care rationing going on on 
reservations. Nobody talks much about it. We have a bona fide 
crisis in health care. One part of that crisis has to do with 
diabetes, a very significant problem, a scourge that we need to 
deal with. There are programs underway, as I have just 
described, that provide some hope. We want to find out how they 
work, what more we can do. But this is an illness that afflicts 
Native Americans more than any other group in our country.
    I have been to the dialysis centers. I have been to the 
diagnostic centers on reservations all across this country. The 
stories you hear are just heartbreaking, of people who 
struggle, whose families struggle with this.
    Yesterday, I had a group of I believe 30 American Indians 
in my office, some of them young college students. I asked how 
many of them have in their family someone who is affected by 
diabetes. I think 80 percent of them raised their hands.
    We are going to have substantial testimony today from 
people from around the country to talk about these issues. I 
want to thank the witnesses who have decided to come at our 
invitation. I am going to ask that when witnesses testify, they 
would summarize their testimony. We have in almost all cases 
the testimony that has been submitted, and all of the written 
testimony will be included in full in the record. Our record 
will remain open for 2 weeks to allow others who might wish to 
submit additional testimony for this hearing.
    I now want to recognize my colleague, Senator Thomas, the 
vice chairman, for an opening statement.
    Senator Thomas. Thank you very much, Mr. Chairman. I 
appreciate your holding this hearing today.

STATEMENT OF HON. CRAIG THOMAS, U.S. SENATOR FROM WYOMING, VICE 
             CHAIRMAN, COMMITTEE ON INDIAN AFFAIRS

    Senator Thomas. I share the concerns about the high rate of 
diabetes in the Indian communities. Indians have the highest 
known rate of type 2 diabetes in the world, according to the 
NIH. Type 2 diabetes is a major cause of blindness, kidney 
failure, cause of death and lower limb amputations. And it is 
largely preventable, according to IHS. So I think it is good 
that we move forward and seek to take advantage of those 
potential possibilities for prevention.
    I do encourage the Indian tribes to take the lead in 
fighting and preventing this disease. I am pleased that 
partners such as those we will hear from today have joined in 
the effort, particularly those directed at Indian Youth, before 
diabetes has a stronghold in their lives.
    So welcome to the witnesses, and I look forward to the 
testimony.
    The Chairman. Senator Thomas, thank you very much.
    As I prepare to call the first panel, I want to just 
mention to you the first story I think I told on the floor of 
the U.S. Senate, as I talked about Indian health care and 
diabetes, was a story about a man named Laidman Fox. He was a 
traditional Mandan, Hidatsa, Arikara man who, like many other 
members of his family, had diabetes. He had his feet amputated, 
then he had his knees gone, and then he had his legs gone. When 
the doctors finally told him that he was going to lose his 
hands, he decided that he would go home and prepare to die. He 
wanted to discontinue the dialysis machine and go home, and he 
did. He had been on the pow-wow trail for many years, so he had 
a lot of friends around the country, and they came to see him 
as he stayed at home and his health deteriorated. He sang 
Indian songs and prepared to die. And he died 2\1/2\ years ago.
    But it is not a unique or unusual story. It is happening 
all the time all over this country, and it is a devastating 
illness that we need to continue to battle.
    So let me, with that, ask Dr. Charles Grim, director of 
Indian Health Service, to come forward, accompanied by Dr. 
Kelly Moore. Is Dr. Grim here? Dr. Grim. Dr. Kelly Moore is a 
clinical specialty consultant from Albuquerque, NM.
    Mr. William Knowler is the chief, Diabetes Epidemiology and 
Clinical Research Section, at the NIH, accompanied by Dr. 
Judith Fradkin, director of the Division of Diabetes, also at 
the NIH.
    Let me thank the four of you for being here.
    Let me mention that the second panel today will be Buford 
Rolin, chairman of the Poarch Band of Creek Indians; Dr. James 
Brosseau, Altru Diabetes Center; Sam McCracken, director, Nike 
Native American Business Program; and Donna Vandall, director, 
Whirling Thunder Wellness Center.
    Let me thank all of you for being here.
    With our first panel, Dr. Grim, let me ask you to proceed.

STATEMENT OF CHARLES W. GRIM, DIRECTOR, INDIAN HEALTH SERVICE, 
 DEPARTMENT OF HEALTH AND HUMAN SERVICES, ACCOMPANIED BY KELLY 
    MOORE, CLINICAL SPECIALTY CONSULTANT TO THE DIVISION OF 
               DIABETES TREATMENT AND PREVENTION

    Mr. Grim. Good morning, Mr. Chairman and Mr. Vice Chairman. 
My name is Dr. Charles Grim, director of the Indian Health 
Service. As you mentioned, I am accompanied today by Dr. Kelly 
Moore, who is our Clinical Consultant at our National Diabetes 
Program in Albuquerque.
    We are pleased to be here to testify on behalf of Secretary 
Leavitt on the Special Diabetes Program for Indians. We are 
very appreciative of the committee taking time to have an 
oversight hearing on this important issue.
    Diabetes has quickly emerged as one of the most serious and 
devastating health problems of our time. American Indians and 
Alaska Natives, as you noted in your opening statement, carry 
the heaviest burden and suffer from among the highest rates of 
diabetes in the world. In some of our communities, more than 
one-half of adults have diabetes, with prevalence rates 
reaching as high as 60 percent.
    American Indians and Alaska Natives have the highest age-
adjusted rates of diabetes, at 16.3 percent, among all U.S. 
racial and ethnic groups. On average, American Indians and 
Alaska Natives are 2.3 times as likely to have diabetes as non-
Hispanic whites of similar age.
    The rates of diabetes in our communities vary across the 
country. The lowest rates are found among the Alaska Natives, 
while the highest are found among our Nashville and Tucson area 
tribes. Yet, while Alaska has the lowest prevalence, the data 
from our systems show that the increases in adults in Alaska 
from 1997 to 2002 show that they have had the greatest increase 
in that time period.
    Alarmingly, the disease is increasingly affecting our 
American Indian and Alaska Native youth. I know you have seen 
over the years that our statistics show in a 14-year period 
from 1990 to 2004, we have seen an increase of 128 percent 
among 15 to 19 year olds and a 77-percent increase was seen 
among American Indian and Alaska Native children and youth less 
than 15 years of age.
    As you noted in your opening statement, Senator, in 1997 
Congress passed the Special Diabetes Program for Indians in 
recognition of the enormity of the problem in Indian country. 
You all recognized that should be a grant program that would 
provide funding for diabetes prevention and treatment at IHS, 
tribal and urban Indian health programs across the Nation. That 
program has now been in operation for almost 10 years, and 
recognized as one of the most comprehensive health programs 
ever developed for American Indian and Alaska Natives, reaching 
nearly all federally recognized tribes around the Country.
    The Indian Health Service, as directed by Congress, 
established three major components of that program. I just want 
to briefly point them out for you. There is a community-
directed program that provides grants to 333 IHS tribal and 
urban programs in 35 States to begin or enhance diabetes 
prevention and treatment programs. These grant programs make up 
the community-directed diabetes program, and those grant 
programs are designed to carryout interventions that will best 
address the problems of diabetes in their individual 
communities.
    The second area is the targeted demonstration projects. In 
2004, Congress directed the Indian Health Service to develop 
and implement a comprehensive grant program which was to 
prevent diabetes in high-risk individuals, and then to prevent 
cardiovascular disease, one of the most compelling 
complications of diabetes. We have now established competitive 
grants in those two areas and have 66 of those that are awarded 
across the country.
    A third area was strengthening our diabetes data 
infrastructure. We have used the administrative funding from 
the Special Diabetes Program for Indians to strengthen our 
diabetes data and to use on the expansion and implementation of 
our electronic health record.
    The Indian Health Service has been evaluating the program 
ever since Congress gave us the money. In two interim reports 
in both 2000 and 2004, we presented extensive data to Congress 
that evaluated those programs. In fact, I have given to your 
staff today about a half dozen copies of that 2004 report, if 
any of you would like additional copies of that.
    We have used well established public health evaluation 
methods to document the accomplishments of that program. I 
think you will find some of the results in there remarkable and 
outstanding. Just to mention a few, we have increased the 
number of people with diabetes that are screened for kidney 
disease. We have increased the number of people who are 
screened for diabetic eye and foot disease. We have improved 
blood sugar control at the population level with mean A1C 
levels decreasing from 8.9 percent to 7.9 percent. We have 
decreased population mean blood levels. We have decreased 
population mean cholesterol levels, as well as triglyceride 
levels.
    Just a few of the programmatic accomplishments, we have 
striking results in almost every area that you can look at. As 
an example, we have seen improvements in physical activity 
programs, now with 92 percent of the grant programs having 
community walking or running, as opposed to 20 percent before 
the program started. About 80 percent now offer some sort of 
exercise class, compared with 16 percent before. There are huge 
numbers of percentage improvements like that, both before and 
after the program.
    We have tracked how we have spent the money and shown that 
$48 million has been spent going toward primary prevention of 
diabetes, one of the most cost effective methods known. We have 
invested approximately $57 million of that toward screening and 
treatment activities for complications of diabetes. We are 
consistently using best practices around the country in our 
programs, utilizing some of the most cost effective 
interventions that are known in the country.
    In closing, the Special Diabetes Program for Indians has 
brought tribes together over these past nine years to work 
toward a common purpose and sharing information and lessons 
learned along the way. We have shown in public health 
evaluation activities that these programs have been very 
successful in improving diabetes care and outcomes, as well as 
launching primary prevention efforts on reservations and in 
urban areas where none existed.
    Our evaluation of the program and its clinical measures 
suggest that population levels of diabetes health is better 
than ever among our American Indian and Alaska Native patients 
since the implementation of the program. In its 9 years, we 
have demonstrated positive public health impact is possible 
when the tribes and congressional initiatives are focused on a 
common outcome, which is building a diabetes-free future for 
our American Indians and Alaska Natives.
    Mr. Chairman, that concludes my comments. I would be 
pleased to answer any questions that you or members of the 
committee have.
    [Prepared statement of Dr. Grim appears in appendix.]
    The Chairman. Dr. Grim, thank you very much.
    Next, we will hear from Dr. William Knowler, chief, 
Diabetes Epidemiology and Clinical Research Section at the 
National Institutes of Health.
    Mr. Knowler, thank you for being with us.

STATEMENT OF WILLIAM KNOWLER, CHIEF, DIABETES EPIDEMIOLOGY AND 
  CLINICAL RESEARCH SECTION, DIVISION OF INTRAMURAL RESEARCH, 
    NATIONAL INSTITUTE OF DIABETES AND DIGESTIVE AND KIDNEY 
 DISEASES, NATIONAL INSTITUTES OF HEALTH, DEPARTMENT OF HEALTH 
 AND HUMAN SERVICES, ACCOMPANIED BY JUDITH FRADKIN, DIRECTOR, 
 DIVISION OF DIABETES, ENDOCRINOLOGY, AND METABOLIC DISEASES, 
    NATIONAL INSTITUTE OF DIABETES AND DIGESTIVE AND KIDNEY 
                            DISEASES

    Mr. Knowler. Thank you.
    Mr. Chairman, members of the committee, I am Bill Knowler, 
as you heard, from the NIDDK. Our institute has the primary 
responsibility for diabetes research at the National Institutes 
of Health. I am accompanied by Dr. Judith Fradkin, director of 
NIDDK's extramural Division of Diabetes, Endocrinology and 
Metabolic Diseases.
    I am pleased to testify today regarding NIDDK's efforts to 
combat diabetes in American Indians, the population with the 
highest known rates of type 2 diabetes in the world.
    For the past 31 years, I have conducted diabetes research 
with the Gila River Indian Community at the NIDDK's Phoenix 
branch in Arizona, a part of NIDDK's intramural research 
program. Our goals are to gain greater knowledge of the 
genetic, environmental and behavioral factors that lead to type 
2 diabetes, obesity and their complications, and develop more 
effective treatments and ways to prevent these diseases.
    Most of our research is conducted in collaboration with the 
Pima Indians of the Gila River Indian Community near Phoenix. 
Some of our programs also include other American Indians in 
Arizona and New Mexico. In our longitudinal population study in 
the Gila River Community, begun in 1965, we conduct periodic 
examinations focused on diabetes and its risk factors and 
complications.
    This study has contributed much to the world's current 
understanding of the causes and consequences of type 2 diabetes 
and its complications, including the serious long-term 
consequences of childhood obesity and type 2 diabetes, the 
importance of obesity in the development of type 2 diabetes, 
and the concept that type 2 diabetes and its complications can 
be prevented or delayed by modifying or treating factors that 
put people at high risk. We are all indebted to this community 
for these advances in medical knowledge.
    Our research has also facilitated improved treatment and 
prevention services in this community, leading to improved 
hemoglobin A1C, the main measure of glucose control in patients 
with diabetes, and lower blood pressure.
    In fact, attainment of American Diabetes Association 
treatment goals for diabetes is better in this community than 
in the Nation as a whole, thanks to the diligent efforts of the 
tribal health program in implementing research-based standards 
of care.
    Another example of a successful intervention is the 
Diabetes Prevention Program, or DPP, that was stimulated by the 
results of research suggesting that type 2 diabetes is 
preventable. The findings of the DPP are among the most 
encouraging to come from diabetes research in the past decade. 
I would like to tell you briefly about this clinical trial.
    Our branch, along with 22 university sites, conducted the 
DPP to examine the effects of a lifestyle-based weight loss 
intervention and drug treatment on the development of type 2 
diabetes in adults at high risk. The weight loss intervention 
resulted in a 58 percent reduction in the rate of developing 
type 2 diabetes. The drug metformin reduced diabetes risk by 31 
percent.
    These interventions worked equally well in men and women 
and in all ethnic groups studied, including American Indians. 
These results convey an important message to American Indians 
and others at high risk for type 2 diabetes: You can prevent or 
delay diabetes.
    The DPP participants continue to be followed in the DPP 
outcome study to assess the long-term effects of the 
interventions on preventing type 2 diabetes and diabetes 
complications. The DPP was primarily funded by NIDDK, but also 
had substantial personnel and financial support from the IHS. 
It is an outstanding example of collaboration between NIDDK and 
the IHS in a research study, the results of which greatly 
influence clinical practice in Indian country and throughout 
the world.
    The complications of diabetes affect the eyes, kidneys, 
heart, feet, gums and blood vessels. Poor control of blood 
glucose and blood pressure, long duration of diabetes, and 
genetic factors increase the risk of diabetes complications, 
such as those affecting the kidneys, a major problem for 
Southwestern American Indians and a focus of our research.
    I am pleased to report that the rate of progression to 
kidney failure among diabetic Gila River Indian Community 
members at least 45 years of age has declined since 1990, 
suggesting that newer treatments for diabetic kidney disease 
are slowing its progression. Since 1999, a similar decline in 
the rate of diabetic kidney failure has been seen nationally in 
American Indians, but not in other racial or ethnic groups.
    Unfortunately, the frequency of kidney failure is 
increasing among younger Gila River Indian Community members 
because of the increasing rate at which diabetes develops in 
youth.
    Most of the research I have described has had a large and 
immediate impact on prevention and treatment of type 2 
diabetes. To achieve even greater progress or to eliminate the 
disease altogether, we believe that a more fundamental 
understanding of its causes and biological mechanisms is 
needed. To this end, we have also pursued research in the 
genetic susceptibility factors for obesity, type 2 diabetes, 
and its complications.
    Our research to date suggests that some genetic factors 
important for obesity and diabetes in Pima Indians are the same 
as in other racial or ethnic groups, but some are different. 
Understanding the genetic factors contributing to type 2 
diabetes in different populations will help us understand the 
biologic mechanisms causing diabetes, which will lead to better 
ways of predicting those at highest risk and preventing onset 
of the disease or its progression.
    A minute ago, I described the successful Diabetes 
Prevention Program, or DPP. To disseminate its important 
findings to people at risk for diabetes, the National Diabetes 
Education Program, or NDEP, developed the ``Small Steps, Big 
Rewards, Prevent Type 2 Diabetes'' education campaign. The NDEP 
is sponsored by the NIDDK, CDC, IHS, and over 200 partners. Dr. 
Kelly Moore, who is here today, chairs the NDEP's American 
Indian/Alaska Native Work Group.
    In addition to the diabetes prevention campaign, the NDEP 
has developed culture-specific material for American Indians 
with diabetes. The NIDDK is committed to continuing these 
educational efforts to disseminate the positive results of its 
clinical trials to benefit public health.
    I am pleased to report that the NIDDK works closely with 
the Indian Health Service to improve the health and quality of 
life of American Indians. The NIDDK's extramural Division of 
Diabetes, Endocrinology, and Metabolic Diseases, which Dr. 
Fradkin heads, has worked closely with IHS's Division of 
Diabetes Treatment and Prevention in the development of the 
Special Diabetes Program for Indians competitive grant program, 
which has developed a DPP-like lifestyle intervention program 
for American Indians with pre-diabetes, for implementation at 
36 tribal grantee sites, among which the Gila River Indian 
Community is included.
    In addition, the NIDDK, IHS, CDC, tribal colleges and 
universities, and the Tribal Leaders' Diabetes Committee 
jointly developed an educational program that aims to increase 
knowledge of the biomedical sciences in tribal schools. The 
Director of IHS's Division of Diabetes Treatment and Prevention 
and its National Diabetes Program, Dr. Kelly Acton, serves as a 
member of the statutory Diabetes Mellitus Interagency 
Coordinating Committee, which coordinates activities of all 
Federal diabetes programs.
    Mr. Chairman and members of the committee, I hope these 
examples convey the firm commitment of the NIH and NIDDK, in 
partnership with our sister agencies, to combating diabetes in 
American Indians.
    In conclusion, I thank the members of the U.S. Senate on 
behalf of the scientists who work in diabetes and the millions 
of Americans affected by it. Thank you for continuing support 
of biomedical research through which we are improving the 
health of all Americans.
    I appreciate the opportunity to address you on behalf of 
the NIH and NIDDK, and would be pleased to answer your 
questions.
    [Prepared statement of Dr. Knowler appears in appendix.]
    The Chairman. Dr. Knowler, thank you very much.
    It goes without saying that diabetes is a serious problem 
for our entire country. We focus today with respect to the 
Indian community because the incidence and rate of diabetes is 
so much higher. So that is the purpose of our having this 
hearing to try to evaluate how the Special Diabetes Program for 
Indians is working and what is happening out in the country.
    Mr. Knowler, on page 5, after describing the Gila River 
Indian Community experience, you say:

    Unfortunately, the frequency of kidney failures is 
increasing among younger Gila River Indian Community members 
because of the increasing rate at which diabetes develops in 
youth.

    You indicated in your testimony that tracking here has gone 
on since 1965, and we have intervened with a diabetes program, 
detecting the onset of diabetes, the treatment and a range of 
things.
    I am encouraged by Dr. Grim's assessment of what has been 
done, but especially with the attention that has been paid to 
this particular tribe as a model to try to understand what is 
happening, tell me why do we find that there is an increasing 
rate at which diabetes develops in youth? What is going on 
there?
    Mr. Knowler. As you point out, this is one of the 
disappointments of our progress in diabetes. We have not 
improved the situation in terms of incidence of diabetes in 
youth. There are a number of reasons for this. A major one is 
that the increasing amount of obesity seen throughout the 
country and most of the world is clearly affecting American 
Indians. Obesity is a very strong predictor of diabetes at all 
ages. So that is one of the serious problems.
    The Chairman. On that point, I am sorry to interrupt you, 
but can you give me the connection between obesity and the 
onset of diabetes?
    Mr. Knowler. Yes; the heavier a person is, the greater is 
the risk of diabetes. This is true in children and adults. I 
can't say that if you exceed so many pounds, all of a sudden 
you will get diabetes. But the greater a person's weight is 
relative to height, the greater is the risk of getting type 2 
diabetes.
    An encouraging thing about this, as we showed in the DPP, 
is that much of that risk is reversible. People who are 
overweight can lose weight, and that lowers their risk of 
diabetes. But the heavier a person is, the greater the risk 
that they develop type 2 diabetes. There are a number of 
reasons for that. We don't understand them fully, but too much 
fat in the body interferes with the action of insulin in the 
body to control blood sugar. Fat also produces hormones which 
have metabolic effects.
    So there are a number of reasons that fatness increases 
risk of diabetes. This is now an important area of research 
these days, understanding why that is. But the fact is very 
clear that the heavier a person is, the greater the risk of 
diabetes.
    The Chairman. I am going to ask a really fundamental 
question here. I probably should know the answer to this. But 
if you have a younger person, a juvenile with the onset of 
juvenile diabetes, and that person is obese, you are saying 
there probably is a connection there, and that person then 
loses a great deal of weight, does the diabetes stay with that 
person? Do you simply treat it? Or once you have on onset of 
type 2, I think I understand the answer, but why don't you tell 
me?
    Mr. Knowler. First of all, I want to clarify one thing in 
case not everyone understands about juvenile diabetes. When we 
talk about American Indians, almost all diabetes in youth is 
type 2 diabetes, the kind that in most populations occurs in 
adulthood.
    We are not talking about type 1 diabetes, the disease of 
islet cell destruction and lack of insulin production. That 
disease is not strongly related to obesity, if at all. But for 
type 2 diabetes, whether it occurs in youth or adults, weight 
loss is very important in the treatment, although it usually 
does not restore a person to normal once diabetes has 
developed.
    The Chairman. It does not reverse the disease.
    Mr. Knowler. Not completely, but partially. It certainly 
greatly improves the situation.
    The Chairman. Dr. Grim, you describe what we have learned 
in 9 years. It seems to me that there is some reason for 
encouragement, although I mentioned the onset of diabetes as 
exists in Dr. Knowler's testimony, is increasing among young 
people in this tribe that is under great inspection to try to 
understand this.
    What can we expect with substantial intervention and 
programs and so on, what can we expect in the next 5 to 10 
years? You describe the progress we have had, but you know 
anecdotally that when we go to our Indian reservations and talk 
to people, to find a crowd, go to the dialysis center. You 
know, just talk to people. Diabetes is still a major, major 
problem, despite the fact that we are out there doing some 
things, you are out there doing some things. What can we expect 
in 5 to 10 years if we would continue these programs and be 
even more aggressive? What kind of progress do you think we can 
make?
    Mr. Grim. I am going to let Dr. Moore get prepared to say 
something about that, too, since she works intimately in that 
program.
    The Chairman. All right.
    Mr. Grim. One of the things I will say is that because this 
is a disease that has still been on the rise in our population, 
and the fact that the moneys that Congress made available have 
allowed us to find people either at earlier and earlier ages, 
or people that never knew they had diabetes. About one-third of 
the people out there that have diabetes were not even aware 
that they did have it. So early on, our numbers, as we improved 
our data systems, spiked.
    In my written testimony and in some of the oral, I talked 
about a lot of the clinical indicators. We have our entire 
diabetic active users being tracked for clinical indicators, 
their blood pressure, their cholesterol, their hemoglobin. We 
see a number of things, and we have seen population-wide 
improvements in all of those.
    You heard me mention some of the statistical things that 
have occurred over time and the number of programs that are now 
there for nutrition and weight management and exercise, all the 
things that the trials that Dr. Knowler mentioned have shown 
were now proven to reduce either the incidence or prevalence of 
diabetes.
    So we are hopeful that after a decade, we have seen some 
improvements and better control. We think that it will take 
another decade or perhaps longer before we really get a strong 
handle on it. We hope it is not an entire generation, a totally 
generational thing, but it is not a quick fight to end a 
chronic disease like this.
    The Chairman. Dr. Moore, what can we expect in 5 to 10 
years if we keep investing in these programs and work hard to 
do it?
    Mr. Moore. Thank you, Senator.
    In 2008, we anticipate that we will have results available 
from our targeted demonstration projects, which actually are 
implementing the diabetes prevention program education 
curriculum, and some of the other activities such as lifestyle 
coaching in adults who have diabetes. This is a very cost 
effective strategy.
    In 2008, we will be able to disseminate this information to 
other American Indian and Alaska Native communities who have 
not participated directly in this intervention.
    The Chairman. Is there a particularly exciting 
demonstration project out there that you see? I know you don't 
have all the results, but give me an example of something that 
is really exciting with respect to these demonstration 
projects.
    Mr. Moore. Well, one of the examples is a program in Alaska 
that has managed to already have patients complete the 
intensive curriculum from DPP. All of the participants are 
enthusiastic, have learned much about diabetes prevention, and 
have been able to successfully manage their weight, which is 
the key ingredient here in terms of preventing diabetes.
    I think what we can also expect to happen in another 5 to 
10 years is that we will have results available on clinical 
trials that are currently taking place in youth related to the 
treatment of diabetes, as well as some prevention activities 
that are being studied that are school-based. Once those 
results are available, I think the Special Diabetes Program for 
Indians will have American Indian and Alaska Native communities 
poised to translate-those findings quickly, and to try and 
implement the findings from those studies in our communities.
    The Chairman. Dr. Fradkin, can you describe just briefly, I 
understand that obesity is a predictor attendant to this issue 
of diabetes. I assume that there is a predisposition for 
diabetes among this population. Is that a genetic 
predisposition? And then second, tell me about the relationship 
of blood pressure to treatment, prevention, et cetera.
    Mr. Fradkin. Sir, there is a very strong genetic 
predisposition to diabetes. We know this from twin studies in 
which in type 2 diabetes there is an even stronger concordance 
of diabetes among twins than in type 1, the so-called juvenile 
diabetes. Dr. Knowler's group is pursuing genetic 
investigations to try to identify some of the genes involved in 
type 2 diabetes. We did, through the Diabetes Prevention 
Program, confirm that a gene that was recently discovered to be 
an important risk factor for type 2 diabetes occurs in American 
minority populations. This gene was initially discovered 
through an industry-supported effort in a European Caucasian 
population. It is also present in American minorities.
    Most importantly, we showed that the people who carry that 
genetic variant were able to benefit from the Diabetes 
Prevention Program lifestyle.
    I wonder if I could followup on what Dr. Moore said about 
what might happen in future years with regard to the Special 
Funding Program. I just want to make the point that the 
Diabetes Prevention Program that Dr. Knowler described, which 
showed that losing on average 15 pounds can reduce your risk of 
diabetes by 58 percent, now is being translated across Indian 
country through the IHS.
    We at NIH have two major clinical trials now ongoing 
looking at childhood type 2 diabetes in minority populations, 
including American Indians. When the results of those trials 
become available, we anticipate that there will be additional 
findings that will need to be translated so that the American 
people can get the benefit of those.
    One of those is a study of middle school children where we 
are actually randomizing the schools to test a school-delivered 
intervention. We think this could be more cost effective than 
trying individually to identify and treat people at high risk. 
We are changing physical activity. We are changing the food 
service. We have a behavioral intervention. We are trying to 
involve the families.
    If we show that this program decreases the risk factors for 
type 2 diabetes in middle school children, then that is 
something that the IHS will want to translate in Indian 
country. Likewise, because this problem of type 2 in children 
is really a new and emerging problem, we don't know how to 
treat type 2 diabetes in children, so we are doing a trial to 
figure out the best way of treating it. When we have that 
information, again, the IHS will want to translate that into 
their programs.
    The Chairman. Thank you very much.
    Mr. Grim. Could I say something, Senator Dorgan?
    The Chairman. Yes, Dr. Grim.
    Mr. Grim. Just very briefly, I think that is one of the 
strongest things about our program, the network that has been 
developed of IHS, tribal and urban programs all over the 
country and the passionate people that are out there. They say 
from research to clinical practice sometimes takes 10 to 13 
years to put it in place. Once something has been proven in 
research, we have been able to get it spread all over the 
country almost immediately. I think that is one of the 
strengths that this program has brought to our system.
    The Chairman. Thank you very much.
    Senator Thomas.
    Senator Thomas. Thank you for your testimony. You go into 
great detail on the causes of diabetes, but we need to deal a 
little more with what we can do about it. The reports show that 
up until the early 2000's, there was an 80-percent increase, 
sometimes a 100-percent increase in diabetes among young 
people.
    How effective have we been? You haven't really indicated 
the impact we have had over the last 4 years of this program.
    Mr. Moore. What we have been able to do in terms of 
prevention is that we have an enormous amount of programs that 
are addressing nutrition and physical activities.
    Senator Thomas. What has been the impact? What has been the 
result?
    Mr. Moore. The impact has been that now our youth are more 
aware of their risk for diabetes. Dr. Knowler mentioned in his 
testimony that I am the chair of the American Indian Alaska 
Native Work Group for the National Diabetes Education Program. 
From focus groups that we have conducted with teenagers, when 
we started a campaign to increase physical activity among 
youth, to reduce their risk for diabetes, many youth knew about 
diabetes, but they didn't know that they were at risk for the 
development of the disease themselves.
    So certainly, awareness about diabetes has increased a 
great deal in American Indian and Alaska Native communities as 
a result of the Special Diabetes Program for Indians.
    Second, this has been an incredible priority among our 
tribal leaders and among our SDPI communities. The majority of 
the programs are directing activities toward youth, and I think 
you will hear about a wonderful program in the Dakotas and 
Nebraska in the Aberdeen area that has really done some 
remarkable things with making kids feel better about 
themselves, maybe being less likely to have depression, which 
is an associated risk factor for the development of diabetes.
    Senator Thomas. Do you have any idea of what impact the 
program has had on problem? The process and the education is 
fine, but what has been the impact overall?
    Mr. Moore. Well, one impact has been more partnerships in 
making a healthier environment.
    Senator Thomas. Well, what has it done? What have they 
accomplished?
    Mr. Moore. They have accomplished changes in vending 
machines in our school systems.
    Senator Thomas. I really would like to talk about the 
percentage of growth of the diabetes problem and the number of 
people who are involved. Has the diabetes rate been reduced? 
Are we making any progress other than building programs?
    Mr. Moore. Yes; I believe we are making progress, but as 
has been stated from NIH, it is still unknown in terms of what 
are all the factors that are related to the prevention of 
diabetes. Weight certainly is a factor, and we have been 
addressing that in our programs and have developed best 
practices. We have also developed a best practice on diabetes 
in youth, and have shared that with our American Indian and 
Alaska Native communities.
    Senator Thomas. Okay, please. You go on about the programs. 
I want to know the program results. Are there fewer people 
getting diabetes? Is the growth in the rate of diabetes less 
than it was? Are we making progress on the ground? Or is it 
just programs?
    Mr. Moore. I believe we are making a lot of grassroots 
progress.
    Senator Thomas. Do you have any figures? Do you have any 
real facts?
    Mr. Moore. Well, the facts that we have is that a number of 
programs are addressing it. We have our clinical diabetes audit 
outcome measures that we have been following related to our 
population who have diabetes.
    Senator Thomas. Okay. That is what I would like to hear.
    Mr. Moore. We have had improvement in control of blood 
pressure. We have had improvement in control of blood sugar 
among our patients with diabetes. We have seen a decline during 
the time period of SDPI for the A1C levels from 8.9 percent to 
7.9 percent. Seven percent is considered ideal blood glucose 
control for people with diabetes.
    Senator Thomas. Do you have a smaller percentage of young 
Indians being involved than we did 5 years ago?
    Mr. Moore. The latest data from 2004 shows that the rate is 
increasing among our young patients.
    Senator Thomas. Increasing.
    Mr. Moore. It is increasing. However, as Dr. Grim pointed 
out earlier, because of the Special Diabetes Program for 
Indians, we have had more efforts directed towards screening 
for diabetes, which would also increase our rates, and, it will 
take decades to reverse the epidemic of type 2 Diabetes that we 
are seeing in our population.
    Senator Thomas. So would you comment, Doctor, on any 
progress being made?
    Mr. Grim. We are making progress on the clinical 
indicators, and programmatically on the number of programs that 
are out there that have been proven in science to help reduce 
or eliminate the risk of diabetes. What I would say is that the 
numbers that we see going up, we don't know what the rate of 
increase would have been if we didn't have this program. That 
is something that is hard to predict. The fact that we have 
increased our data systems and the amount of screening going on 
just normally would make one think that you are going to start 
finding more of it out there than you had found before because 
of the more intensive effort.
    We cannot tell you would that rate of growth have been 
higher had we not had these programs.
    Senator Thomas. Is it lower because you have the programs?
    Mr. Grim. We believe that the rate would have been higher.
    Senator Thomas. You mean lower?
    Mr. Grim. No; the rates have increased actually. The rate 
in our youth have continued to increase, we would like to think 
at a slower rate than----
    Senator Thomas. Does that make you look at the programs to 
see if in fact it is effective? Are there other things we could 
do? What are the best practices that you mentioned?
    Mr. Grim. We are continuously evaluating the program. One 
thing I failed to mention, we have another report that is going 
to be coming to Congress we hope in 2007. We have the two other 
reports that we have turned in, but we do have 18 best 
practices that our experts, along with others around the 
country, have developed. There is not a single grant program 
out there that is not using one or more of those best 
practices. We have studied the literature----
    Senator Thomas. What is it would you say, are there some 
general reasons why it is more dominant in the Indian 
population than in the general population?
    Mr. Grim. I probably would leave that either to Dr. Moore 
or the scientists here about the scientific background of why 
it is more dominant.
    Senator Thomas. Is it behavioral, lifestyle? What causes 
it? Are there causes for it?
    Mr. Grim. Behavioral, lifestyle, plus probably genetic 
component as well, all of those things.
    Senator Thomas. Sixty years ago, we didn't know that there 
was any diabetes in the Indian tribes.
    Mr. Grim. And there was next to none 60 years ago, we 
believe. Some people say it has been the rapid change in 
lifestyle that the Indian population has seen in the last 100 
years to 200 years, and that genetically they have not been 
able to keep up with the diet and lifestyle that is more 
predominant these days. I think that is an issue with the 
Nation as a whole. We are seeing diabetes rise in the Nation 
because of a more sedentary lifestyle, for the behavioral 
choices, as well as a number of perhaps public policy issues, 
too, in the country.
    Senator Thomas. I guess I am just saying, and I understand 
you are working very hard at it, but we need to try and 
determine what it is that is the cause for diabetes and then 
determine if we are making any progress. We can get into 
research until it is never-ending, but we have to study causes 
and results.
    Mr. Grim. I would have to say we have probably one of the 
most evaluated programs in the country for diabetes. We would 
love to share more information with you at your convenience, 
sir.
    Senator Thomas. Thank you.
    Mr. Moore. And please stay tuned for our next report. This 
is the cover. It has been submitted to DHHS for review. Once 
the review is completed, it will be available.
    The Chairman. Dr. Fradkin, you wanted to make another 
comment?
    Mr. Fradkin. I do. I just want to emphasize that there are 
two aspects to this program. One is trying to prevent diabetes, 
but the other is trying to prevent complications in people who 
have diabetes. Now, preventing diabetes is hard because 
involves lifestyle, and that is a hard thing to change. But the 
things that can be changed in the clinics are the ways the 
diabetes is being taken care of.
    Here, the numbers that Dr. Grim gave you are incredibly 
impressive. The IHS got the hemoglobin A1C down from 8.9 
percent to 7.9 percent. Clinical research has shown that 1 
percent difference would be expected, if sustained, to decrease 
diabetes complications by 40 percent. So it is a huge 
accomplishment that the IHS got the A1C down from what is close 
to poor control of blood sugar to what is near good control.
    Senator Thomas. How has that impacted the folks?
    Mr. Knowler. Could I address that?
    Senator Thomas. Yes.
    Mr. Knowler. I would like to give one example again in the 
area of management of diabetes that I mentioned briefly. 
According to the U.S. Renal Data System's, national data on new 
patients starting dialysis, the rates per person since 1999 
have actually been going down in American Indians, while they 
continue going up in all the other ethnic groups in the 
country.
    It is hard to attribute improvements like that to any 
single factor. The increased knowledge of the importance of 
treating blood pressure, the use of many new very powerful 
drugs that improve blood pressure and kidney function, and the 
resources that have gone into treating diabetes in American 
Indians are probably responsible for this improvement.
    So there is a very hard outcome that has turned the corner. 
It is still a huge problem, as you know, but it is starting to 
get better.
    Mr. Grim. And just briefly, it has improved the quality of 
life of those patients because their diabetes is under better 
control so the progression and all the complications of 
diabetes has either been slowed or halted. It has also saved 
our system money. You saw in multiple people's testimony that 
the average cost to treat a patient with diabetes is about 
$13,000 a year, which is huge in our system, a huge prevalence 
of diabetes.
    And so, bringing that population blood sugar under control 
just by that 1 percentage point has saved our system a lot of 
money in treatment costs, less pharmaceuticals that the 
patients have to be on, less complications or amputations. So 
it has led to both quality of life and savings to our system.
    The Chairman. Let me thank all of you for your testimony. 
We would ask that you be available to answer written questions 
that we will continue to send your direction.
    Thank you very much. We will have other hearings on this 
subject, but we appreciate your being here today.
    I am sorry, Senator Smith. I apologize. I did not see you 
come back in.
    Again, thank you very much, Dr. Grim.
    Next, the panel will include Buford Rolin, chairman, Poarch 
Band of Creek Indians, cochair of the Tribal Leaders Diabetes 
Committee, and cochair of the National Steering Committee for 
the Reauthorization of the Indian Health Care Improvement Act; 
Dr. James Brosseau, director of the Altru Diabetes Center in 
Grand Forks, ND, a member of the American Diabetes Association 
Native American Committee; Dr. Biron Baker, Primary Care 
Physician, Med Center One, Bismarck; Sam McCracken, director, 
Nike Native American Business Program, Beaverton, OR; and Donna 
Vandall, director of the Whirling Thunder Wellness Center.
    We thank all of you for being here this morning, and being 
a part of this hearing. I am going to begin with Chairman 
Rolin. Let me indicate that we are asking to have you summarize 
your testimony and your entire statement will be made a part of 
the permanent record.
    Chairman Rolin, thank you for being with us. Why don't you 
proceed.

   STATEMENT OF BUFORD ROLIN, CHAIRMAN, POARCH BAND OF CREEK 
INDIANS, COCHAIR OF THE TRIBAL LEADERS DIABETES COMMITTEE, AND 
      COCHAIR OF THE NATIONAL STEERING COMMITTEE FOR THE 
   REAUTHORIZATION OF THE INDIAN HEALTH CARE IMPROVEMENT ACT

    Mr. Rolin. Thank you, Senator Dorgan.
    It is a pleasure to be here today to discuss with you the 
Special Diabetes Program. This important program is making a 
critical difference in the prevention and treatment of diabetes 
and cardiovascular disease for American Indians and Alaska 
Natives.
    As I am sure you are aware, and as you have heard already, 
the rates of diabetes for American Indians and Alaska Natives 
are the highest in the United States, with rates of diagnosed 
diabetes in adults as high as 60 percent in some of our 
communities. Earlier you mentioned the fact that Congress had 
appropriated in 1997 the special diabetes funding because of 
the alarming rate of diabetes in the American Indian and Alaska 
Native communities.
    The Special Diabetes Program emerged in the wake of 
increasing public concern about the human and economic costs of 
diabetes in the United States and its growing prevalence among 
the American Indian and Alaska Native population. In 2002, 
Congress reauthorized the Special Diabetes Program for $150 
million per year for fiscal years 2004 and 2008. The IHS was 
directed to expand this program to implement competitive 
grants. The competitive grants are awarded to reduce 
cardiovascular disease and data improvement.
    Earlier, it was noted that there are 333 programs within 
the IHS, bringing the total number of grants to Indian country 
to 399 programs. The Special Diabetes Fund is set to expire in 
October 2008. The American Diabetes Association [ADA] and the 
Juvenile Diabetes Research Foundation [JDRF] and the National 
Indian Health Board [NIHB] hosted a meeting on June 13 and 14, 
2006 to bring tribal leaders and key stakeholders together to 
discuss how to approach the reauthorization of the Special 
Diabetes funding. In October 2006, the TLDC, with the consensus 
of the NIHB, mailed a letter to all tribal leaders seeking 
input as to the future funding of the Special Diabetes Program. 
This letter specifically asked the tribal leaders whether they 
would support an increase of the amount of $200 million a year 
for 5 years, and I am happy to report that the tribes responded 
unanimously in that.
    The ADA and JDRF have been great partners with the NIHB in 
an effort to secure appropriate funding for diabetes research 
and the Special Diabetes funding.
    The NIHB was recently informed that two young members of 
the Choctaw and Chickasaw Tribes will join 150 other children 
from across the United States to participate in the JDRF's 
Children's Congress to be held June 17-20 in Washington, DC. 
These young people will be walking the halls of Congress and 
meeting their lawmakers in discussing type 1 diabetes. Desiree 
Cameron of the Choctaw Nation and Erica Rosebush of the Choctaw 
and Chickasaw Nations were elected from over 1,000 applicants. 
In a letter to Members of Congress, Erica writes:

    I wish there were a cure for type 1 diabetes so I could 
live a more normal life like my friends and family. A cure 
would allow me to eat and drink without checking my blood 
sugars and counting carbs for insulin. Finding a cure would 
mean my parents wouldn't have to pay for my supplies that cost 
a lot. Me, my parents and my brother would not have to worry 
about sleeping all night because my blood sugars would be too 
low or go high and make me sick.

    As chairman of my own tribe, the Poarch Band of Creek 
Indians, I wish that more people had an opportunity to come to 
Washington, DC to express those same concerns. Some of the 
samples of the prevention screening and treatment services that 
are provided by IHS tribal and urban diabetes programs are 
clinical annual examinations of eyes, teeth, and feet, newer 
and more effective medications and therapies, laboratory tests 
to assist diabetes control and consultation, screening of 
elders and children for risk factors associated with diabetes, 
nutrition education and counseling services by registered 
dieticians, culturally appropriate diabetes education and 
awareness activities, diabetes from our provincial programs for 
children and families, community-based health eating programs, 
and area schools and nursing homes and community physical 
fitness activities.
    As chairman of the Tribal Leaders Diabetes Committee, I 
have had the unique opportunity to work very closely with Dr. 
Charles Grim, director of IHS, and Dr. Kelly Moore, director of 
the IHS Division of Diabetes Treatment and Prevention Program, 
to oversee the development of the culturally sensitive and 
appropriate diabetes programs throughout Indian country.
    The Fort Berthold model diabetes program, located in New 
Town, ND is an example of teaching and cooking classes and menu 
planners for local schools. The Fort Totten model diabetes 
program located in Fort Totten, ND, organizes several community 
activities such as diabetes walk and run, and various other 
programs. The Whirling Thunder Wellness Program operated by the 
Winnebago Tribe of Nebraska is a multi-disciplinary program. 
The IHS service unit program in Zuni, NM has identified 25 
percent of those ages 29 and older, and 50 percent of those 
ages 49 and older as having diabetes.
    While these are just some of the examples of the model 
diabetes programs located throughout Indian country, all of the 
programs continue to face many challenges. There is a lack of 
staff and staff turnover, lack of data, case management 
systems, and a lack of adequate facility space to provide basic 
service to the community and educational and fitness 
activities.
    An overall concern, Senator, of these programs is that if 
this funding is not kept in place, a lot of this will not 
continue to be achieved. The vision of the TLDC is to empower 
our American Indian and Alaska Native people to live free of 
diabetes through healthy lifestyles, while preserving cultural 
traditions and values through tribal leadership, direction, 
communication, and education.
    I appreciate the Senate Committee on Indian Affairs 
scheduling this oversight hearing on diabetes in Indian 
country, and especially the Special Diabetes Program. I invite 
the committee to schedule field hearings in Indian country for 
diabetes.
    Thank you for inviting me to testify.
    [Prepared statement of Mr. Rolin appears in appendix.]
    The Chairman. Chairman Rolin, thank you very much. Thanks 
for being with us today and presenting your testimony.
    Next, we will hear from Dr. James Brosseau, the director of 
the Altru Diabetes Center in Grand Forks, ND, a member of the 
American Diabetes Association Native American Committee.
    Mr. Brosseau, thank you for joining us.

 STATEMENT OF JAMES BROSSEAU, DIRECTOR, ALTRU DIABETES CENTER, 
  MEMBER OF THE AMERICAN DIABETES ASSOCIATION NATIVE AMERICAN 
                           COMMUNITY

    Mr. Brosseau. Thanks, Senator Dorgan and other members of 
the committee. It is an honor to be here.
    I have been connected with the IHS since back in the early 
1970's, and for that entire time I have worked as a 
practitioner dealing with diabetes in the clinic on a day to 
day basis, so that is the perspective I bring to this.
    In addition, I have been involved with the Awakening the 
Spirit Committee of the American Diabetes Association, with Dr. 
Kelly Moore, who is in the room, too.
    I would just like to say that I think the IHS and the 
Special Diabetes Program for Indians have just done wonderful 
things, and I certainly hope that they can be continued on. I 
won't go any further into a description of those programs.
    I brought me today about 1 dozen testimonials from people 
living on reservations in North Dakota. I wanted to share some 
of their feelings about what it is like to be diabetic and 
living in Indian country right now.
    First of all, many of them are frustrated with things such 
as lack of services in the evenings or on the weekends, and are 
frustrated by having long waits in the clinic, a short visit 
with the doctor, and then leaving with a prescription.
    The Chairman. Dr. Brosseau, could you move the microphone 
just a bit closer to you and speak up just a bit. Thank you.
    Mr. Brosseau. Okay. Is that better?
    The Chairman. That is better.
    Mr. Brosseau. Okay. I was just listing some of the 
frustrations of people who are served by the IHS, including 
lack of services in the evenings and on weekends, long waits to 
see the doctor, and then the sense that you were just given a 
prescription and sent out the door.
    There are manpower shortages and patients complain about 
having to see different providers each time, availability of 
new treatments in the sense that rationing is going on, such as 
you alluded to at the beginning of the hearings. And then many 
people also feel that they are less valued as people because 
they are Indian people living in rural reservations in places 
like North Dakota.
    We also see frustration with contract care, where people 
come to a larger center for treatment and then are given 
prescriptions for newer medications which are not yet available 
in the IHS facilities. And then there is also frustration on 
the part of providers, too, who want to do a much better job, 
but are handcuffed by shortages.
    So these complaints sound a lot like what I hear from 
patients in my clinic in the non-Indian communities, too. When 
I started working in the IHS back in the 1970's, things weren't 
so complex and the magnitude of the problem was not nearly as 
great. So I think that we have to think about new ways of doing 
things.
    First of all, I think all of us agree our medical care 
system, our health care system needs and overhaul right from 
the top down. But for rural clinics and for Indian country in 
particular we can make some changes now which I think make some 
sense. For example, medical schools, I think they need to be 
more selective in taking admissions not just on the basis of 
what the grade point average is, but they should be looking at 
people who have ties to their communities. The INMED program at 
the University of North Dakota started out this way, and 
probably still does that, but we need to be doing this for 
people from all backgrounds who have ties to communities and 
are more likely to stay there.
    Perhaps there could be some accelerated programs, since 
primary care is a problem all across the country, maybe 
accelerated programs for people who already have a pretty good 
education. I think access problems needs to be remedied, and 
chronic disease, we have to change the way we deal with a 
chronic disease. A 10-minute visit is not going to work for a 
person with diabetes. There are too many aspects of diabetes to 
cover in a short clinic visit.
    So we have to look at more of a team approach, and I think 
something like group medical visits, which have been developed 
in managed care programs, would be very ideal for many IHS 
settings, worksite wellness programs where we actually go to 
the places where people are working to do preventive care.
    There definitely has to be better collaboration between 
tribal health programs and the IHS. I know others might want to 
speak to that also. We should be having programs for pre-
diabetics, people that have not yet developed diabetes, because 
we know that over a 10-year period, we could probably prevent 
about 50 percent of those people from progressing to diabetes 
just by implementing lifestyle change.
    School programs, which address primary prevention, are very 
important and many of these have been developed under the 
Special Diabetes Program for Indians and need to be continued. 
And then also alluding to something the first panel talked 
about, research in diabetes has been fantastic, and the 
developments over the past 10 years or so have been just 
unbelievable, but now we have to find a way to translate those 
developments to the clinic setting, and that is where I would 
like to see the attention placed.
    So in summary, I would say that the Special Diabetes 
Program has been great, and I hope it can be continued. We do 
need some fresh thinking to solve manpower problems. Medical 
schools really have to find new ways to get people out into the 
rural communities and then new approaches to access and 
treatment of chronic disease in the clinics would be a great 
help in dealing with the problems of diabetes, where we have 
the whole team present and all members of the health care team 
present also.
    Thank you very much.
    [Prepared statement of Dr. Brosseau appears in appendix.]
    The Chairman. Dr. Brosseau, thank you very much.
    Senator Smith, the next witness, I believe, is from Oregon. 
Would you like to introduce the next witness?
    Senator Smith. Thank you, Mr. Chairman.
    I did remark earlier that Sam McCracken is with the Nike 
Corporation. They are doing some great things, as you will soon 
hear, on this issue. I applaud them. I thank Sam for being here 
representing the great efforts they are making.
    The Chairman. Mr. McCracken, thank you for being here. You 
may proceed.

  STATEMENT OF SAM McCRACKEN, DIRECTOR, NIKE NATIVE AMERICAN 
                        BUSINESS PROGRAM

    Mr. McCracken. Hello. My name is Sam McCracken. I am a 
member of the Fort Peck Tribes and I am manager of Nike's 
Native American Programs.
    [Phrase in native tongue.] Loosely translated, I am named 
after my grandfather, Thomas Duck, a provider for the 
Assiniboine people. My clan is the Red Bottom clan, after my 
grandmother.
    Chairman Dorgan, Senator Smith, Vice Chairman Thomas, and 
other committee members, thank you for the opportunity to 
testify today on this vital topic facing the Native American 
community. Nike applauds this committee for holding this 
hearing, and we look forward to continuing our public-private 
partnership under your leadership.
    Senator Smith, thank you for the kind words and overall 
support. Native American tribes in Oregon and across the 
country have benefitted from your stern leadership and are 
grateful for your role on this powerful committee.
    The impact of diabetes in my community is a topic very 
close to my heart. Raised on the Fort Peck Indian Reservation 
in Montana, I have seen first-hand the needs and opportunities 
facing my community. I personally experienced the tragedy of 
diabetes. In 2001, I lost my mother to type 2 diabetes. Her 
passing has renewed my passion to speak directly and find ways 
to combat this deadly disease.
    I happen to work for a company that lends its powerful 
voice to get my community active. As the manager of Nike's 
Native American Program, I have had the opportunity to work 
with government officials and community leaders in the creation 
of Nike's Native American Community Program, which is a multi-
tiered initiative to support and encourage physical activity on 
Native lands to combat diabetes.
    The program has served several key components, and I would 
like to take this opportunity to highlight some of our 
achievements today. First, Indian Health Service's memorandum 
of understanding. Under the leadership of Indian Health 
Service's Director, Dr. Charles Grim, Leo Nolan, Senior Policy 
Analyst, the Nike Native American Community Program helped 
forge the unique partnership with the Indian Health Service's 
with the signing of the historic memorandum of understanding in 
2003.
    The goals of the memorandum of understanding helped those 
communities gain a better understanding of the importance of 
exercise at any age, particularly those individuals with 
diabetes. With these goals, and with our research with the 
Indian Health Service, Nike has developed an innovative shoe 
that offers increased comfort and a new design fit that helped 
fit the needs of the Native American foot. With this hope of a 
new design, we will encourage and motivate Natives to be more 
physically active. The shoe is still in development and it will 
be offered through a limited distribution to qualified Native 
American community partners.
    Second, the Native American Incentive Program. It was 
created in 2000 while working closely with diabetes program 
coordinators with some 100 tribal agencies. In this program, 
Nike provides product, mentoring and recreation for tribal 
populations. Nike is also partner with several national 
stakeholders and government officials, and some of those 
agencies were included in testifying today. Working with the 
Boys and Girls Clubs, we have introduced NikeGO on Native 
lands. Today, there are 67 sites across the country. NikeGO 
provides a culturally relevant physical activity curriculum and 
equipment all designed to help Native youth between the ages of 
8 and 15 discover the joy of movement and physical activity. 
Nike has also donated more than $1 million in product to 
support this program.
    Third, Nike always listens to the voice of the athlete to 
inspire and motivate. One such athlete is Notah Begay, III, a 
four time PGA Tour winner and Native American golfer. Notah has 
played a central role in helping Nike educate Native Americans 
about the benefits of exercise in combating the spread of 
diabetes. In 2004, Mr. Begay joined Dr. Grim and myself at the 
annual session of the National Congress of American Indians. 
Mr. Begay was instrumental in kicking off the first-ever 
National Native American Health and Fitness Day.
    In May 2006, Nike announced the 5 year partnership with the 
Iroquois National Lacrosse Organization, providing the Iroquois 
Nationals with footwear and apparel. The partnership was 
developed out of Nike's commitment to working with Native 
communities, and another means to inspire physical activity 
among Native youth.
    In closing, Mr. Chairman, the mission of the Nike brand is 
to bring inspiration and innovation to each and every athlete 
in the world. We believe our program is true to its mission. I 
am fortunate to have the opportunity to work for a company that 
strives to make a difference, but more can be done. Expanding 
innovative public and private partnerships, and this committee 
support, is crucial.
    I want to thank you for this opportunity to share the Nike 
story.
    [Prepared statement of Mr. McCracken appears in appendix.]
    The Chairman. Mr. McCracken, it is quite an interesting 
story, and an admirable one as well. We appreciate very much 
your being here today. Thank you.
    Mr. McCracken. Thank you.
    The Chairman. Next, we will hear from Dr. Biron Baker, who 
is a primary care physician at Med Center One in Bismarck, 
North Dakota. Dr. Baker, thank you for joining us. You may 
proceed.

   STATEMENT OF Dr. BIRON BAKER, PRIMARY CARE PHYSICIAN, MED 
                           CENTER ONE

    Mr. Baker. Thank you, Mr. Chairman, members of the 
Committee.
    My name is Biron Baker. I am a board-certified family 
practice physician currently working in Bismarck, ND. My tribal 
affiliation is I am a member of the Mandan and Hidatsa Tribes. 
My Hidatsa name is Ah Gu Ga Naha Naish. The literal 
translation, or the loose translation, would be ``Stands 
Above.'' It is based on the educational things that I have 
achieved.
    I care passionately about what happens to the health care 
of American Indian people, because I was groomed from early on 
to work for the Indian Health Service. My mother, her two 
sisters, and her two brothers combined had over 150 years 
between them of working for the Indian Health Service. Now, 
that being said, I will go into some other issues here that 
explain why I am not an Indian Health Service employee.
    In my statement, I have the usual statistics and so forth, 
but I think those have been gone over to a great degree this 
morning, and I don't think I will belabor that. When we think 
about the effectiveness of the Special Diabetes Program, I 
think if we want to investigate the rates of increase and 
whether or not the rates of increase have slowed, we might 
compare the rates of increase between Canadian Indians and 
American Indians, since the Canadian Indians would not be 
beneficiaries of this program.
    Our diets are high in processed foods and fatty foods, and 
I think rapid modernization of diet has led to some of the 
problems that we have had. Some researchers have postulated 
that, and research has been bearing it out.
    I wanted to talk about the severity of complications of 
diabetes in Indian people. It is something that is readily 
apparent. It is something that we can see almost just at a 
glance. My former boss, before I became a physician, I was a 
jailer for the BIA. My boss, this vital man 15 years older than 
myself, through the years we became great friends. He has 
congestive heart failure. He is blind. He has lost parts of his 
feet. He has had bypass surgery. He is essentially living on 
borrowed time. He retired early from the BIA. I helped him do 
this. It saddens me to think of my friend this way.
    My youngest patient that had problems with complications 
from diabetes was a 22-year old man from Standing Rock who came 
to see me in the clinic one day. His creatinine, a measure of 
kidney function that we take through the blood, was already 
1.6. When I told him he had lost essentially half of his kidney 
function, he continued joking with me and continued trying to 
pass everything off. He didn't necessarily want to hear what 
was going on.
    Finally, in 1 moment of inspiration, I guess, I suggested 
that he and I go visit the kidney dialysis unit and together we 
can pick out a chair for him. That finally seemed to get my 
point across, but this is just evidence of some of the 
resistance we can face as clinicians, particularly in Indian 
country.
    One of the things that I have used that maybe other people 
don't necessarily use, is a sense of humor, which at times can 
be morbid. The thing with that is, a lot of elder people have 
explained to me, well, we have two choices. We can laugh or we 
can cry. I choose to laugh. And if I laugh with my patients, 
sometimes I get the point across a little bit better.
    One of the other things that has always concerned me, 
continues to concern me, is the quality of care available at 
Indian Health Service facilities. Now, nationwide, I am not 
necessarily aware of how that goes, but I do understand how it 
works in the Aberdeen area. The Aberdeen area in particular has 
had more than its share, I think, of substandard providers. I 
mention this because I think standardization of care of 
diabetes is important. The Special Diabetes Program is 
important. However, the implementation of anything that is 
recommended in standardized care practices has to be understood 
by the clinicians who are delivering the care, or it is not 
effective.
    One of the things that just happened to me recently was I 
had a diabetic patient from Standing Rock who fell down the 
steps at her home, had three days worth of knee pain. He right 
knee was swollen. She went to the Indian Health Service clinic 
and saw a locum physician there, a temporary physician at the 
Indian Health Service facility. He instructed her to wrap her 
knee in cabbage leaves. It sounded made up, but from my past 
experience, unfortunately, I know it wasn't.
    I obtained an MRI of her knee and she had a torn anterior 
cruciate ligament, something that clearly wasn't going to be 
fixed by cabbage leaves.
    I think that the Special Diabetes Program for Indians has 
done a lot of good, but I think that the quality of the 
administrators and the clinicians in the Indian Health Service 
has not followed suit. It saddens me to think that the Aberdeen 
area Indian Health Service seems to attract the worst of the 
lot. I am not sure how that happened. I am not sure why that 
is, but I think it leads to frustration in the ranks of 
otherwise qualified clinicians, which then leads to an exodus 
of the skilled clinicians and retention of the substandard 
clinicians.
    I observed during my time with the Indian Health Service 
what I termed an ``any warm body'' philosophy. We had a nurse 
practitioner in McLaughlin, SD who was somewhat less than 
effective, to put it diplomatically. In my attempts to get her 
either reassigned or terminated, I was reminded several times 
that if that were to happen, who would see the patients in 
McLaughlin?
    It never seemed to quite sink in to my administrator that 
we are doing some harm here, more than we are doing good. I 
thought about that for awhile, and I tried to reconcile that 
within myself, why is this the way that this is? It occurred to 
me then that it was because my administrator wasn't necessarily 
a health care administrator. Rather, this was somebody who had 
just been with the system for so long that it was assumed by 
people higher up that truly this person must have learned 
something about health care in all the years that they worked 
for the Indian Health Service; let's try him as an 
administrator.
    Pharmaceutical options remain a problem for American 
Indians. What I see is a disparity because I am in a private 
setting, so I get American Indian patients who have insurance, 
who have Medicaid, who have options other than Indian Health 
Service. So my patients that come to see me off the reservation 
actually get the standard of care that that anyone else would 
receive with their insurance, because what I see is that in the 
Indian Health Service, we see older insulin preparations. We 
see older oral medication preparations. And we see things being 
done that typically we don't think work anymore.
    In my clinical practice, there isn't any reason to treat a 
known diabetic with diet and exercise alone. The research 
indicates that with early intervention, with a combination of 
TZD and biguanide medications, you can actually recover some of 
the pancreatic function that has been lost. At the time of 
diagnosis, we estimate one-half the pancreatic function is gone 
at diagnosis.
    So if we can do something that is going to recover some of 
that function, we are going to. Unfortunately, in some 
providers, we are still seeing diet and exercise alone as 
monotherapy. Sometimes we are seeing some of the older 
medications used first line as monotherapy.
    Even with the standardization of care, then, we have to 
have clinicians who understand the standard of care to be able 
to implement it. These disparities that I am talking about also 
exist in the frustrations that Dr. Brosseau talked about with 
contract health services are something that is readily apparent 
as well. People might ask, what does all this have to do with 
diabetes on an Indian reservation? It is all so interconnected 
that you cannot separate one from the other.
    I had the dubious honor of being the chief of Medical Staff 
and having to meet as the chairman of the contract health 
services meeting every morning where we got together and 
decided, basically, who was going to get treatment and who was 
not. My patient who really stands out is a 60-year old rancher 
who had been waiting 4 years to have a simple rotator cuff 
replacement and take care of some of the chronic bursitis in 
one of his arms. He had been waiting 4 years, and I asked the 
committee, why are we still sitting on this? The answer I got 
was that it wasn't life or limb threatening.
    I was able to successfully argue that a one-armed rancher 
isn't going to be able to earn enough income to feed himself 
for very long, which then eventually would threaten his life. 
Through this process of reasoning, we were able to get a two-
armed rancher out of the deal, and he was happy and sent a card 
of thanks. But he had to wait 4 years and he had to have 
somebody go to bat for him. A lot of other people with 
insurance, he got what people with insurance take for granted: 
Good health care within a reasonable timeframe. He really 
stands out for me.
    The administrators, in particular, within Indian Health 
Service, has been a source of frustration for myself and for 
other colleagues for a long period of time now. I worked with 
an administrator who was an ex-physician's assistant. Any 
clinician, I think, will tell you that we love what we do so 
much, we can't imagine doing anything else. So whenever we see 
someone who is an ex any kind of clinician, the radar goes up 
and we want to know why they are an ex-clinician. Pretty soon, 
I was able to find out. This man made no decisions that I am 
aware of, with the exception of the one he made to retire. The 
other administrator I dealt with had been with the Indian 
Health Service for 20 years and had trouble reading his budget. 
He couldn't understand that the numbers in parentheses were 
negative items in his line item budget.
    I can't tell you how much frustration this causes when we 
are trying to get things done and we have a guy in the room who 
can't read the budget. At an annual meeting of chief medical 
officers and service unit directors, we had someone stand up 
and introduce his new service unit director: Here she is; she 
is a GS-11. The rest of us in the room are GS-15's, and people 
who understand Government pay scales will see that there is 
quite a disparity.
    Why was she a GS-11? She had 1 year of residency and quit, 
and she was hired full-time having not completed a full 
residency. Someone thought that this was perfectly acceptable 
for care in Indian country. I don't think it is. I think it 
represents lowering the bar, diminishing the standard. We can't 
settle for that. But this man didn't see it. He was proud that 
he had a chief of staff who was a GS-11, and look how much 
money I saved. That was his impetus.
    Eventually, I did have to leave the Indian Health Service. 
I tried then to work for a tribal health program and I can see 
that there has to be some better oversight of self-
determination efforts of tribes. Tribal chairmen might disagree 
with me on this, but what I am finding is that political 
cronyism and nepotism are in force, and every problem that we 
see becomes magnified.
    We had one situation where the tribal chairman's sister was 
placed in charge of the dialysis unit. She was an RN with no 
personnel background and no dialysis background. Instantly, she 
drove a wedge between herself and the staff because she had 
never worked in a kidney dialysis unit. The staff at the KDU 
thought she was incompetent. They clearly thought this was a 
political appointment. They all resigned in protest. For 8 
months, our patients were bused between 70 miles and 160 miles 
away to get their dialysis three times a week, in vans.
    This upset me considerably, and other people were upset as 
well, but I think if we had some sort of an oversight situation 
there, that I don't have enough government knowledge about how 
that would work, but the chairman's response to this, then, was 
to put his sister in charge of health care and recruitment of 
physicians. Obviously, that didn't work either.
    The Chairman. Dr. Baker, I need to ask you to summarize, if 
you would. We are running out of time.
    Mr. Baker. I will finish here. I do have some solutions. I 
don't want everybody to go away thinking that all I did was 
come here to complain. I think that the Indian Health Service 
is funded at roughly 40 percent level of need, and I don't 
advocate throwing money at a problem, but this is where I make 
an exception. The area offices seem to provide a layer of 
administrative capability without real function. I think if the 
area offices were eliminated, those FTE's could better service 
Indian people through enhanced contract health service fund 
availability.
    Thank you for the opportunity to present this morning. I 
will entertain any questions anyone has.
    [Prepared statement of Dr. Baker appendix.]
    The Chairman. Dr. Baker, thank you very much for coming.
    And finally, Donna Vandall, director of the Whirling 
Thunder Wellness Center, Winnebago, NE.
    Ms. Vandall, thank you very much for being here. You may 
proceed.

STATEMENT OF DONNA VANDALL, DIRECTOR, WHIRLING THUNDER WELLNESS 
                             CENTER

    Ms. Vandall. Good morning, members of the committee and the 
people who are here in this room. I am known by the people who 
know me in Winnebago, my Indian name is We-huh-changaga, which 
means Water Spirit Woman. It is from the Water Spirit clan.
    Our program began in 1995, contracted from Indian Health 
Service. We spent many years doing screenings, which produced a 
lot of diabetics. Screenings do that. And then we found some 
startling things. By screening school-age children, we realized 
that in 10 years if those children grew up, we would have 
double the diabetics that we had at that time. This was 
frightening and traumatic to the providers, and to our program.
    About that time, SDPI became available. We developed strong 
activities, strong programs and services. But the most 
important thing we learned was that we needed to collaborate 
and network with everybody in the community who would work with 
us. That translate-s into almost 70 hours of time in the 
Whirling Thunder Wellness Center that is occupied by community 
members of all ages, from preschool to senior citizens.
    Taking education and nutrition and activities, attempting 
to change lifestyles, setting up programs that the people 
themselves want, not the programs that Indian Health Service 
through the research thought was good, not the programs that 
providers thought were good, but the programs that the people 
felt that they could live with and adapt.
    We worked for another 5 or 6 years; 18 months ago, we 
started Ho Chunk Hope, which is dealing exclusively with pre-
diabetic people. We have a full plate all the time, with a 
total of 15 staff people working nonstop to try and achieve the 
results that we know we can achieve by changing lifestyles and 
reducing the diabetic population in our community.
    We believe that the efforts we have made are at a critical 
point right now, and that they need to continue. If other 
tribes are functioning in the same way, they need to continue, 
and things get worse before they get better.
    Our prevalence in 2000 for diabetics was at 10.8 percent 
according to the IHS statistics. In 2006, it is at 17 percent. 
But at the same time, Ho Chunk Hope has shown to us in 18 
months of intensive work that you can take people who are ready 
to convert into full diabetes and back them away from it, so 
they do not become diabetics. It is very heartening, very 
exciting work that is being done by the dedicated staff at the 
Whirling Thunder Wellness Center, and in Ho Chunk Hope.
    Many people have come and served and worked through our 
program and with our program. Many leaders have looked and 
said, this program works. Whirling Thunder, incidentally, is 
named for a leader of a band of Winnebago who signed a treaty 
in 1832 and asked for a doctor. Culture and spirituality have 
become a major part of our work with Indian Health Service, 
with our local hospital. That is one of the major partners that 
we need to have. We are not clinicians. I am not a medical 
person. We have served as a buffer with our programs between 
Indian Health Service and the tribal population. Indian Health 
Service has a need to be able to reach the people that they 
serve.
    We serve as a buffer by bringing them in, treating them 
very well, getting them to the providers, introducing them, 
being a pillow that helps them to achieve their health status. 
We have seen many improvements in our diabetic community. We 
have had almost no, well no amputations that I am aware of in 
the past 6 or 7 years, and very few people on dialysis.
    The intensive work that is being conducted is being 
conducted at the tribal level with the funds that come from 
SDPI and from Indian Health Service Diabetes Program that we 
have contracted. Indian Health Service still has a vital role 
in the community, because they have the medical providers and 
they have the hospitals.
    So with that in mind, I want to say that Indian country is 
very much aware of this committee and its membership. We know 
your burdens and we appreciate your work. A few months ago, I 
attended a gathering in the Northern Plains, and a veteran was 
asked to pray for the evening meal. We prayed for the people. 
We prayed for the men and women fighting in a war far, far 
away. We prayed for our tribal leaders. We prayed for the 
leaders of this Nation. And we prayed for Senator Tim Johnson 
and his family.
    At these kinds of gatherings, and in our ceremonies when 
the smoke rises, it carries our prayers, and you are there. We 
hold you close.
    Thank you.
    [Prepared statement of Ms. Vandall appars in appendix.]
    The Chairman. Ms. Vandall, thank you very much. As you 
indicate, Senator Tim Johnson is a member of this committee, 
and cares very deeply about all of these issues. We expect that 
Senator Johnson will rejoin us here in the U.S. Senate. On his 
behalf and the behalf of other members of this committee, let 
me thank all of you for testifying.
    I do want to mention that we have many, many hearings going 
on this morning here in the U.S. Senate. In fact, I serve on 
three committees that are now holding hearings even as I am 
here. It is one of the difficulties of trying to do all that 
one is required, especially in as many committees and 
subcommittees on which we serve. So our members are at other 
hearings, but there is a great deal of interest in this issue 
in the Congress.
    Let me ask a couple of questions. Mr. McCracken, your 
company, of course, is a for-profit commercial enterprise, but 
we also recognize that it has been a very public-spirited 
company in many ways. You described the new shoe design for 
Native American diabetics. Would you tell us just a moment 
about that again?
    Mr. McCracken. Sure. I would be happy to. Through our 
partnership with the Indian Health Service, the memorandum of 
understanding, we were looking for a tangible outcome of that 
document. What Nike does best is we innovate. So we took our 
sports and research lab, we call them ``lab rats,'' out to the 
field to scan Native American feet across the country, knowing 
the issues that complicate people with diabetes.
    Though the shoe will hopefully motivate and create 
opportunities for physical activity and promote physical 
activity, the thought of the shoe was built from the inside 
out, knowing the complications that come with a person who is 
pre-diabetic or diabetic in their foot. Those folks took that 
into consideration as they built it from the inside out, with a 
seamless inside.
    From those scannings, we built a special last that was 
designed and developed for the Native American foot. If I could 
give you a brief example, a normal Nike shoe if you were to buy 
an in-line Nike shoe, in a men's size, it is a D width. From 
our scientific research we did by scanning 500 plus feet across 
Indian country, we found that the average Native American male 
foot was an EE. So when they would try to stick their foot into 
a normal, which we call an in-line Nike Shoe, we can understand 
why the discomfort was there.
    So we are hopefully going to develop some comfort, which 
will then encourage physical activity. And with the efforts of 
physical activity, we are not on the medical side so we don't 
can't speak on behalf of those, but hopefully we can encourage 
physical activity with this product because there is going to 
be a sense of comfort around the product.
    The Chairman. And the size of your shoes?
    Mr. McCracken. What is that?
    The Chairman. The size of your shoes?
    Mr. McCracken. My shoes? I am 11\1/2\.
    The Chairman. Double E?
    Mr. McCracken. Double E. I squeeze into those.
    The Chairman. All right. You squeeze into them.
    Mr. McCracken. I squeeze into them. [Laughter.]
    The Chairman. Mr. McCracken, thank you very much for being 
with us, as I indicated.
    Mr. Brosseau, in your experience, are the new medicines 
that have been available and treating diabetes, are those 
medicines available on Indian reservations, or widely 
available? I think you touched on that just briefly.
    Mr. Brosseau. Some of them are, and some of them aren't. In 
the past 10 years, there has just been an explosion of new 
medications, insulin sensitizers and drugs which don't lower 
the blood sugar below normal. Metformin was the first of those, 
and that is available in Indian Health Service facilities, but 
the newer ones such as the thiazolidinedione and then these new 
incretin drugs, I am not sure if they are available yet or not. 
Maybe someone else could answer that question for me.
    Then there are these new forms of analog insulins which 
also have been slow to come to Indian country. They have really 
also improved our ability to treat people appropriately.
    The Chairman. Dr. Baker, your assessment? Are most of these 
new medicines available?
    Mr. Baker. Some are not, some of the newer things that have 
been happening recently. We have used GLP1 analogs and DPP4 
inhibitors. These things are probably several years away from 
being available at the Indian Health Service. Those medications 
are very exciting in terms of the potential side effect that 
one of them has for weight loss, and the favorable side effect 
profile that drug interactions just aren't there. It doesn't 
drop the blood sugar below normal, and on average you get a 1 
or more percent greater reduction in hemoglobin A1C with these 
drugs. So in my estimation, then, these are very valuable drugs 
in the arsenal not to have.
    The Chairman. We will do some work to try to evaluate how 
frequently they are available or not available to those that 
need them. I think that is an important thing for us to try to 
understand. Understanding a better treatment regime, 
understanding the efficacy of new medicines is one thing, but 
having them available is the most important part of that 
understanding.
    I want to ask about the issue of Indian health generally, 
and the delivery of health services with respect to clinics and 
the number of hours clinics are open. Because those with 
diabetes have lots of complications, and are often showing up 
for treatment at different hours of the days or nights or 
weekends. My experience on a number of Indian reservations with 
the Indian Health Service is they have a clinic, it opens at 8 
or 8:30 in the morning, and closes at 4:30 or 5 in the 
afternoon; not open Saturday; not open Sunday.
    So there really is a substantial limited opportunity. I 
have been talking about trying to develop a new medical model 
on reservations, very much like some of the commercial sector 
are trying to do across this country. On the commercial side, 
they are doing low cost, no appointment, walk-in clinics, in 
some cases staffed by nurse practitioners or physician 
assistants and so on, for routine diagnosis, but available 7 
days a week at rather extensive hours.
    I would ask any of you who wish to answer, is it your 
experience that on most reservations, there are limited clinic 
hours available for those who wish to show up at clinics? Does 
anybody have any experience? Chairman Rolin?
    Mr. Rolin. Yes, sir; that is true. Normal hours are from 8 
a.m. to 5 p.m.. In my own clinic, what we have done is 
certainly we have designated 1 day a week to deal specifically 
with diabetes. We begin at 7:30 in the morning with breakfast, 
and then we monitor the patient's activities during the day. 
But one of the things that we have taken into consideration is 
extending the hours and setting up various times, including the 
weekend, for these very special clinics and all, that we can 
accomplish and provide the services to our people, Senator.
    The Chairman. Ms. Vandall, do you have a BIA school on your 
reservation?
    Ms. Vandall. We do not.
    The Chairman. You do not.
    Ms. Vandall. No.
    The Chairman. Does anyone have any knowledge of whether the 
BIA-run schools have pop, soda, and candy machines on their 
school premises? I will ask the BIA about that at some point. 
There is a discussion generally across the country about having 
machines distributing soda or pop as it is called in my part of 
the country, and chips and so on, snack foods.
    Ms. Vandall, someone else described diabetes bingo. You 
described a poker walk. Was it you? Okay. Diabetes bingo, I 
don't know who described that.
    Mr. Rolin. I mentioned that, sir.
    The Chairman. You did. That is instructional? Something 
people are doing in order to produce information to them that 
is useful? Can you describe it?
    Mr. Rolin. It is an educational program and I am working 
with them on it. It is working. Also, what I didn't mention is 
we have a kids program as well, teaching them about utilizing 
what the various foods are and all, and how it can affect them. 
This is also part of that program. It is called ``Kids Cafe.''
    The Chairman. The reason I asked about what kids are able 
to access in their schools, in this case the BIA schools 
because those are the schools over which we have some funding 
responsibilities, is I wanted to try to understand whether we 
are trying to educate about fruits and vegetables and diet on 
the one hand, and then offer advertising as you walk out of a 
classroom into the lobby of a school for some liquid sugar and 
some high-fat snacks. I will get information from the BIA about 
that.
    I make that point despite the fact that I was drinking a 
Coca-Cola this morning. [Laughter.]
    Recognizing that I have had other healthy food and drink 
this morning.
    Let me say this, this is I think one of the most important 
health issues facing Native Americans, the first Americans. We 
have a lot of health issues facing them. I did not today, but I 
certainly will the next time I have Dr. Grim here to talk about 
the Indian Health Service budget, and we will do that soon, I 
will again inquire to try to find out what part of Indian 
health is unmet. My guess is it is about 40 percent, 45 
percent, based on what I have been able to extract, but getting 
that information is like pulling teeth.
    In fact, there is full scale, I think because of that, full 
scale rationing of health care. Rationing of health care would 
be very controversial if people understand what it is going on. 
It goes on all the time on Indian reservations. I have spoken 
on the floor of the Senate about the stories that describe it, 
a woman hauled in, I mentioned this before at a hearing, a 
woman hauled into a hospital on a gurney from one of our Indian 
reservations in our State, hauled into a hospital on a gurney, 
having a heart attack, with a piece of paper taped to her 
thigh. And the piece of paper said to the hospital 
administrator: ``Understand now, if you admit this patient, the 
Indian Health Service will not be paying any of the costs.'' 
Understand that, we are out of contract health care money.
    She had a heart attack. It is unbelievable that these 
things go on, and yet they go on.
    Mr. Baker, you described the prospect of a one-armed 
rancher trying to make a living, someone who waits 4 years. You 
know, when you talk about health care in this country and the 
system, people say, ``Well, we don't want a system like these 
other countries have because you wait too long.'' Well, waiting 
is something a lot of Native Americans understand, 
unfortunately, and suffering during that wait is something they 
understand as well.
    Contract health, dealing with life or limb, is a 
circumstance where there is a lot of suffering because someone 
doesn't meet that test. I had just two Saturdays ago a 
listening session in Minneapolis and we had 150 Indian leaders 
and Indian tribal members come. One of the tribal chairmen 
said, ``My tribe runs out of contract health care funding in 
January,'' that is the fourth month of the year. That means for 
eight months of the year, there is no contract health funding 
left. That is pretty unbelievable.
    Another tribal chair testified before this committee and 
said, ``We understand. The refrain on our reservation is, don't 
get sick after June.'' If you get sick after June, there is no 
contract health care money left. That is rationing of health 
care to a population that is a population at risk. It is 
unacceptable in this country. We need to find a way using this 
committee and others to put a magnifying glass up there and 
tell the American people this is happening, and it is wrong; 
tell the rest of the Congress it is happening, and it is wrong; 
and that we have a responsibility to do something about it.
    Let me make one final point, because I know, Dr. Baker, 
your testimony will I am sure raise questions by some people 
who will say, you know what? The Indian Health Service has some 
unbelievably wonderful, dedicated people who work across this 
country in tough situations. They could be making a lot of 
money elsewhere, but they choose to serve. And God bless them 
for doing it.
    Yes; that is the case. I am sure that is the case, and I 
have met many of them, and I walk away from them thinking, what 
a blessing it is they have chosen this career.
    It is also the case, I am sure, that there are people 
unqualified; that there are people who do not have the same 
motives. We need to work on all of that, and I will in other 
venues work with Dr. Grim at hearings talking about a range of 
those issues.
    Let me thank all five of you for being present today. This 
is the first of a series of hearings we will hold on health 
care. I will be holding a listening session. We are doing a 
number of listening sessions across the country with Indian 
tribal members and leaders to talk about a range of issues, 
especially health care. I mentioned one that we held just 
recently in Minneapolis for a five-State region. I will be 
holding one in Phoenix in the next 2 weeks. We are trying to 
see if we can hold it on the Gila River Indian Reservation, 
which is just I believe south of Phoenix. I expect we will 
probably be doing it on that reservation, which was interesting 
to me that there was a lot of discussion about the study that 
ranges from 1965 forward on that reservation. So I will be able 
to have some information as I hold a regional listening session 
there with my colleague, Senator Thomas.
    At any rate, I appreciate all of you being here. Chairman 
Rolin, you had a last comment?
    Mr. Rolin. Yes; I would just like to say, Senator, we 
appreciate this hearing and what is being done, but just a 
reminder that it took many, many years to achieve the progress 
that was made to reduce cancer in this country. We have only 
been working at this now a little over 8 years. We are seeing 
progress, and the progress is coming through the empowerment 
that the communities have taken to make sure that we address 
this deadly disease.
    The Chairman. And I think, what Senator Thomas was asking 
represents the most important questions for those in Congress 
who are asked to contribute $150 million toward this priority, 
and hopefully perhaps even more toward this priority in the 
future, because it saves lives. What he is asking is not just 
the empirical evidence, but what is the empirical evidence, and 
then what are the stories that describe to us that there is 
real progress? Because you don't know how often agencies come 
to us, to Senator Thomas and myself and others, and say, well, 
we have a program. Well, good for them for having a program.
    The question we ask is, what is being accomplished with 
this funding? I think that from my knowledge, there is a very 
substantial amount of good investment being made that is going 
to produce substantial results. That is what Vice Chairman 
Thomas is asking, and it is the question every member of 
Congress will ask. We have competing needs for limited 
resources.
    But I can't think of a priority that is much more 
significant than this. If you go to reservations, go to the 
dialysis centers, go visit with the families who are suffering 
through these difficulties with diabetes at the root of the 
difficulties, I can't think of a much higher priority. I think 
that is the point that Senator Thomas was making as well.
    In order for us to do this and continue doing it, we need 
to be able to tell our colleagues in Congress, here is the 
achievement; here is the body of achievement. It is 
substantial. It is impressive, and will continue. And that is 
what we need from you, and we appreciate your being here today 
to give us a part of that.
    This hearing is adjourned.
    [Whereupon, at 11:25 a.m., the committee was adjourned.]


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                            A P P E N D I X

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              Additional Material Submitted for the Record

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   Prepared Statement of Biron Baker, M.D., Primary Care Physician, 
                             Medcenter One

    Greetings Mr. Chairman and members of the committee:
    It is an honor to be asked to testify before this distinguished 
body on an issue of vital importance to Native Americans at risk and 
diagnosed with diabetes. My name is Biron Baker and I am a Board 
Certified Family Practice physician. I worked for the Indian Health 
Service on the Fort Berthold and Standing Rock Service Units in central 
North Dakota for over 3 years. I am currently employed by Medcenter One 
in Bismarck, ND. I am an enrolled member of the Three Affiliated Tribes 
of western North Dakota. My Hidatsa name is Ali Gu Ga Naha Naish. A 
loose translation of this would be ``Stands Above.'' I've been asked to 
provide information on diabetes in Indian country.
    According to the Center for Disease Control, American Indian and 
Alaska Natives are 2.6 times more likely to develop type 2 diabetes as 
non-Hispanic whites of similar age.
    Type 2 diabetes is the type of diabetes that the overwhelming 
majority of American Indians are afflicted with. The problem, in 
simplest terms, is the inability of the body to utilize its own insulin 
to regulate blood glucose levels. Data that I've read indicates that 
the prevalence of type 2 diabetes in American Indians has increased by 
over 100 percent in the past 15 years, and the complications are worse 
in American Indians. Greater than 17 percent of all adult American 
Indians have diabetes and the problem is growing. The total number of 
diabetics in the United States is at 21 million and another 41 million 
are ``pre-diabetic.''
    Comorbid conditions in Indians with diabetes outpace that of all 
other minority groups. When I think of health problems of our country 
as a whole, I can magnify those problems in Indian country without much 
effort. Our use of tobacco (not in the religious sense) is near 50 
percent. We know that diabetics face the same risk of heart attack as 
someone who has already experienced a first heart attack. This is 
compounded by tobacco use disorder. Our rates of alcoholism and alcohol 
related disorders far outpace the rest of the country and this can 
prevent standard of care practices for diabetics. Our diets are high in 
processed and fatty foods and the obesity rate is staggering. Rapid 
modernization of diet is implicated by several researchers as part of 
the problem. Primary prevention is relatively new in Indian country and 
it's had some success. This is area that holds great potential.
    The severity of complications associated with diabetes in Indian 
people is readily apparent. I once worked for a man 15 years older than 
me and now because of complications related to diabetes he is a very 
ill man. He is blind, his kidneys are shutting down and he is 
approaching dialysis, he has lost parts of his feet, he had cardiac 
bypass surgery and now has congestive heart failure. At 56 years of 
age, this once vital retired police officer is living on borrowed time. 
My youngest patient with complications was a 22-year-old man from 
Standing Rock who had lost half his kidney function before he was 
diagnosed with diabetes. I was having trouble impressing upon him the 
need to change his lifestyle. I finally asked him to accompany me to 
the kidney dialysis unit so we could pick out a chair for him to 
dialyze in three times a week for 4 hours each session. That seemed to 
get my point across, but this is evidence of the type of resistance 
clinicians can face.
    Quality of care at Indian Health Service facilities has been a 
documented problem. I have seen this problem from the time that I 
worked with the Indian Health Service in 1997 until today. I had a 
diabetic patient from the Standing Rock Reservation see me in the 
clinic in Bismarck with fluid in her knee joint. She had gone to the 
Indian Health Service facility for evaluation and was told by the 
physician to wrap her knee in cabbage leaves for several days. I 
obtained an MRI of her knee and found a torn anterior cruciate 
ligament. While enhancing funding for the Special Diabetes Program for 
Indians and standardization of care has shown some benefit, the quality 
of clinicians and administrators in the Indian Health Service has not 
followed suit. The Indian Health Service has become a haven for 
administrators and clinicians who would otherwise never be able to 
maintain employment. Sadly, the Aberdeen Area Indian Health Service 
seems to attract the worst of the lot. This leads to frustration in the 
ranks of otherwise qualified clinicians, and an exodus of skilled 
clinicians inevitably occurs. It is the principal reason that I no 
longer work for the Indian Health Service. During my time with Indian 
Health Service, I observed what I termed an ``any warm body'' 
philosophy. Even if clinicians were inadequate, they were kept on staff 
because to remove them would overwork the rest of the medical staff. hi 
the long run, this created more problems than it solved, but 
administration never seemed to recognize this. Perhaps it's because the 
administrators I dealt with were not healthcare administrators, but 
rather they were people who were promoted simply because they were 
still with the system after many years, and surely must have learned 
something.
    Pharmaceutical options remain a problem for Indians accessing care 
at Indian Health Service facilities. Many of these patients are using 
older insulin preparations and older oral medications because that is 
what the pharmacy budgets allow. Typically, Indian Health Service 
pharmacies run significantly over budget, and disparities still exist. 
Diabetes programs can purchase glucometers, but not medications. 
Prevention and early intervention related to diet and exercise is not 
used as a standard of care on the reservation. Sulfonylurea medications 
are now third line oral agents, but we see patients on them as 
monotherapy, first line agents. Part of this is limited pharmacy 
budgets, but part of it also lies with medical staff ability. Even with 
standardized ``cook book'' approaches to the treatment of diabetes, the 
clinician must be aware of standard of care practices. Otherwise, we 
see an example of ``the eye cannot see what the mind does not know.''
    Significant care disparities exist between insured and uninsured 
American Indians. The insured population will often seek medical 
services at an off reservation private practice type of environment, 
and care follows what typically happens for every other insured 
American. Medical, diagnostic and therapeutic interventions are more 
readily available. The uninsured population will seek care at an Indian 
Health Service facility and will have that care rationed. Any 
procedure, test, consultation or intervention that is not deemed ``life 
or limb threatening'' will not happen. Direct care or care available at 
the Indian Health Service facility, is provided. Contract Health, or 
offsite care, is doled out by the Contract Health Service committee 
that meets Monday through Friday mornings. Most requests for referral 
are impossible after May or June of each fiscal year because of 
depleted funds. Patients are not unintelligent, and recognize this 
disparity at once. One patient stands out for me. While at Fort 
Berthold, I was informed during a Contracted Health Service meeting 
that a particular patient had been waiting for a shoulder repair for 4 
years, but that we couldn't approve it because it wasn't ``life 
threatening.'' I asked what he did for a living, and was informed he 
was a rancher. I successfully argued to the committee that a one-armed 
60-year-old rancher was unlikely to be able to earn enough to eat, thus 
eventually threatening his life. His surgery was approved, and the now 
two-armed rancher sent me a note of thanks. He waited 4 years for 
something that insured Americans take for granted: Good care within a 
reasonable timeframe. Serving as the chair of the Contracted Health 
Service committee was one of my most distasteful duties as a clinical 
director with the Indian Health Service.
    Administrative ineptitude within the Indian Health Service is a 
glaring problem. During a budget meeting, I met an administrator who 
did not understand his line items. It was explained to him that the 
numbers in parentheses were negative, and represented a deficit in that 
particular line item. He had been with the Indian Health Service for 20 
years at that point. I worked with another administrator who was a 
``washed up'' physician's assistant. To my knowledge, the only decision 
he ever made was the one he made to retire. I knew administrators from 
other service units within the Aberdeen Area Indian Health Service as 
well. At an annual meeting of chief medical officers and service unit 
directors [CEO's], one of the clinic CEO's announced that he had just 
hired a physician with only 1 year of residency as his chief medical 
officer. He was very proud of this, and announced her salary as a GS-
11. The rest of us chief medical officers in the room had completed 3 
year residencies, and we were GS-15's. People familiar with government 
pay scales will recognize this as a significant disparity. That the 
Indian Health Service will even hire physicians who haven't completed 
residency training boggles the mind. It represents setting the bar 
lower for the future, and encourages misfits and miscreants to apply 
for work with the Indian Health Service. His statement also opened a 
rift between medical staff present and administrators in the room, and 
a lively discussion ensued. Never tell an Indian Health Service 
physician he's overpaid; he makes one-half to two-thirds of what his 
peers in private practice make. That's just for primary care. That gap 
is wider with specialties. The fact that the administrator was so out 
of touch with reality was what saddened me. All he could see was that 
he saved money in his medical staff budget.
    There must be better oversight of self-determination efforts of 
tribes. Political cronyism and nepotism were in force where I worked. 
We once were forced to work with a dialysis unit with an unqualified 
nurse placed in charge. She was the tribal chairman's sister, so we 
tried to make do. All the staff nurses resigned in protest, and for 8 
months our 18 dialysis patients were bussed to dialysis units 70 to 160 
miles away, several different locations, so the chairman's sister could 
ran the dialysis unit. The chairman's solution to all this was to place 
his sister in charge of tribal healthcare. The dialysis unit eventually 
reopened, but our dialysis patients paid for it for 8 months. All too 
often, unqualified personnel are placed in charge of self determination 
efforts, to the detriment of the populace. With better oversight, self 
determination could work. It could be mandated that such a venture not 
take place until qualified personnel with a plan are in place.
    As bad as things seem, there are solutions. The Indian Health 
Service must make it a priority to hire and retain competent 
administrators and medical staff. The scholarship program currently in 
place could be expanded to include healthcare administration as well. 
It would seem that strong leaders in these positions would be able to 
eventually recruit and retain competent physicians. If those two areas 
were addressed seriously, quality of care would improve immeasurably. 
This would impact diabetes and other health issues in Indian country. 
While I don't usually advocate throwing money at a problem, this is a 
case where I make an exception. The Indian Health Service is funded at 
roughly 40 percent of the level needed. In some areas, the Indian 
Health Service has done well. With administrators and medical staff, 
they have not. Increased funding for enhanced and expanded training 
programs would make a world of difference.
    The Area Offices seem to provide another layer of administration 
without real function. All area offices should be eliminated, and 
service units should have the autonomy and authority to tailor their 
needs to fit the needs of the population they serve. During my time 
with Indian Health Service, at no time was the Area Office any help; in 
fact, they were a constant hindrance. Any real problems I had as a 
clinical director or chief of staff were sent to headquarters, and I 
worked with them to resolve issues. Many times I found myself wondering 
how much more Contracted Health Service funds we would have at the 
service unit level if all those FTE's at the Area Office simply didn't 
exist. I wondered how many more patients would have ``optional'' joint 
replacement surgery, ``optional'' CT scans, ``optional'' consultations 
with a specialist, and so on. With completely qualified leaders of the 
reservation clinics, the Indian Health Service wouldn't need Area 
Offices for anything.
    Tribal governments and Indian Health Service administrators must 
work together. Poorly planned tribal ventures are based directly on 
poorly ran Indian Health Service clinics. With qualified administrators 
who are real leaders, the tribal governments will learn to trust their 
counterparts in the Indian Health Service. I don't believe this is 
actually anyone's job presently. No liaison currently exists, simply 
mutual dislike and distrust. Cooperation would enhance patient care by 
preventing duplication of services, and coordination of resources.
    Thank you again for allowing me to participate this morning. I 
would welcome the opportunity to work with any of you on these issues, 
and I invite your questions.
                                 ______
                                 

 Prepared Statement of Hon. Daniel K. Inouye, U.S. Senator from Hawaii

    Thank you, Mr. Chairman. I commend the committee for holding this 
oversight hearing on diabetes in Indian country with an emphasis on the 
Special Diabetes Program for Indians.
    The statistics are alarming. We are here today because American 
Indians and Alaska Natives have a higher incidence of type 2 diabetes 
than any other racial or ethnic group in the United States. I am told, 
among Indian children and young adults, there has been an increase of 
80 percent in type 2 diabetes. These data underscore the importance of 
the Special Diabetes Program for Indians, which provides grants to 
nearly 400 Indian Health Service, tribal, and urban Indian programs in 
35 States. In 2005, approximately 116,000 individuals received services 
from these programs. One thing is clear. This program is addressing the 
critical health needs in Indian country.
    In Hawaii, Native Hawaiians also experience similar disparities in 
diabetes incidence and mortality. In 2004, Native Hawaiians had the 
highest mortality rate associated with diabetes in the State--a rate 
which is roughly 119 percent higher than the statewide rate for all 
racial groups.
    Our examination of the Special Diabetes Program for Indians is a 
crucial step toward our larger goal of assuring that American Indians 
and Alaska Natives attain some parity of good health comparable to that 
of the larger U.S. population.
    Thank you, again, Mr. Chairman for holding this much needed hearing 
today.
                                 ______
                                 

    Prepared Statement of William C. Knowler, M.D., Dr.P.H., Chief, 
    Diabetes Epidemiology and Clinical Research Section Division of 
 Intramural Research National Institute of Diabetes and Digestive and 
Kidney Diseases National Institutes of Health Department of Health and 
                             Human Services

    Mr. Chairman and members of the committee: I am William Knowler, 
chief of the Diabetes Epidemiology and Clinical Research Section of the 
National Institute of Diabetes and Digestive and Kidney Diseases 
[NIDDK]. Our Institute has primary responsibility for diabetes research 
at the National Institutes of Health [NIH] of the Department of Health 
and Human Services [HHS]. I am accompanied by Dr. Judith Fradkin, who 
is the director of the NIDDK's extramural Division of Diabetes, 
Endocrinology, and Metabolic Diseases.
    I am pleased to testify today regarding NIDDK's efforts to combat 
diabetes in American Indians, the population with the highest known 
rates of type 2 diabetes in the world. In addition to hitting American 
Indians the hardest, type 2 diabetes has become a very significant and 
increasing health problem nationwide. Both type 1 diabetes and type 2 
diabetes are major causes of blindness, kidney failure, and 
cardiovascular death, and the combined economic cost of type 1 diabetes 
and type 2 diabetes in the United States is over $130 billion annually. 
Reducing the incidence of diabetes would clearly reduce suffering and 
benefit our society.
    For the past 31 years, I have conducted research on diabetes with 
the Gila River Indian Community at the NIDDK's Phoenix Epidemiology and 
Clinical Research Branch in Arizona. This Branch is a major component 
of NIDDK's intramural research program, and is located in Phoenix 
because of its emphasis on research in American Indian populations. The 
Branch develops and applies epidemiologic, clinical, and genetic 
methods in the investigation of diabetes and its complications, which 
are particularly common among southwestern American Indians.
    Through basic and clinical research, we can gain greater insights 
into the genetic and environmental factors that lead to the development 
of type 2 diabetes, develop effective treatments, and perhaps most 
importantly develop strategies and programs to prevent or delay the 
onset of the disease. My particular research focuses on the risk 
factors for type 2 diabetes and its complications [especially diabetic 
kidney, eye, and heart disease], obesity and its relationship to 
diabetes, and diagnostic criteria for diabetes.

             GILA RIVER INDIAN COMMUNITY LONGITUDINAL STUDY

    Most of the research of our Branch is conducted in collaboration 
with the members of the Gila River Indian Community [most of whom are 
Pima Indians] near Phoenix. Some of our programs also include other 
American Indians in Arizona and New Mexico. In our longitudinal 
population study in the Gila River Indian Community, begun in 1965, we 
examine community residents at regular intervals. The examinations 
focus on diabetes and its risk factors and complications. This study 
has contributed much to the world's current understanding of the causes 
and consequences of type 2 diabetes and its complications, for which we 
are all indebted to this community. The study has led to other research 
on obesity and physiologic problems such as insulin resistance and 
defects in insulin secretion that play a major role in type 2 diabetes. 
By carefully evaluating the relationships between plasma glucose 
concentrations and the specific signs of diabetes, we established 
criteria for diagnosing diabetes and identifying non-diabetic persons 
at high risk of developing diabetes. These criteria have been adopted 
for worldwide use. The study also led to recognizing the importance of 
control of high blood glucose and high blood pressure in diabetes. 
These are now standard components of diabetes care throughout Indian 
country and the entire world.
    I am happy to report that these improvements in standards of care 
have directly benefited members of the Gila River Indian Community. 
Over the last 30 years there has been a rise in the percentage of 
people with diabetes receiving medical treatment to control blood 2 
glucose, coinciding with a fall in average blood glucose. There has 
also been a marked increase in the use of blood pressure medicines 
accompanied by a fall in average blood pressure. The sharp increase in 
the use of both aspirin and cholesterol lowering agents in recent years 
may reduce the risk for heart disease in people with diabetes. The 
rates of attainment of American Diabetes Association treatment goals 
for diabetes are better in this community than in the Nation as a 
whole, thanks to the diligent efforts of the tribal health program in 
implementing research-based standards of care.
    Finally, the research has contributed to understanding the serious 
long-term consequences of childhood obesity and type 2 diabetes, the 
importance of obesity on the development of type 2 diabetes, and the 
concept that type 2 diabetes and its complications can be prevented or 
delayed by modifying or treating factors that put people at high risk. 
These results stimulated the development of the Diabetes Prevention 
Program [DPP].

                 THE DIABETES PREVENTION PROGRAM [DPP]

    The findings of the DPP are among the most encouraging and valuable 
to come from diabetes research in the past decade. I would like to tell 
you briefly about this clinical trial. Our Branch, along with 22 
university sites, participated in the DPP to examine the effects of a 
lifestyle-based weight-loss intervention and pharmacologic 
interventions on the development of type 2 diabetes in adults with pre-
diabetes. These interventions were tested because our previous research 
findings suggested that reducing weight or improving insulin resistance 
might prevent type 2 diabetes. About half of the nearly 4,000 DPP 
participants were from minority groups. The lifestyle intervention, 
that included modest weight loss and increased physical activity, 
resulted in a dramatically reduced risk--by 58 percent--of developing 
type 2 diabetes. The intervention with the drug metformin reduced 
diabetes risk by 31 percent. The lifestyle and metformin interventions 
worked well in both men and women and in all ethnic groups studied, 
including the American Indians. This significant finding conveys an 
important message to American Indians and other people at high risk for 
type 2 diabetes: By adopting a moderate, consistent diet and exercise 
weight-loss program, diabetes can be prevented or delayed. The 
importance of translating these results into practice is paramount. The 
American Indian and other DPP participants continue to be followed in 
the DPP Outcomes Study to assess the durability of the effects of the 
DPP interventions on preventing type 2 diabetes and determine their 
impact on development of diabetes complications.
    The DPP, primarily funded by the NIDDK but also with substantial 
support from the Indian Health Service [IHS], has had a large impact on 
many IHS and tribal health programs to prevent diabetes, as I will 
describe later. The DPP is an outstanding collaboration between NIDDK 
and the IHS in a research study testing ideas that came from population 
research and, in turn, greatly influencing and benefiting clinical 
practice in Indian country and throughout the world.

                       COMPLICATIONS OF DIABETES

    Diabetes is associated with many complications that affect the 
eyes, kidneys, heart, feet, gums, and blood vessels. The kidney 
complications of diabetes often lead to heart attacks or to the need 
for dialysis or kidney transplantation. Poor control of blood glucose 
and blood pressure, long duration of diabetes, and genetic factors 
increase the risk of diabetes complications such as those affecting the 
kidneys. We recently discovered an additional treatable factor: 
Periodontal disease, an infection of the gums that is very common in 
American Indians with diabetes. It is the major cause of tooth loss, 
but the risks of periodontal disease extend well beyond the mouth. 
Periodontal disease also increases the risk of kidney disease and is 
associated with higher death rates from kidney disease and heart 
attacks in those with diabetes.
    The rate of progression to kidney failure among diabetic Gila River 
Indian Community members who are at least 45 years old has declined 
since 1990, suggesting that newer treatments for diabetic kidney 
disease are slowing its progression. Since 1999, a similar decline in 
the rate of diabetic kidney failure has been seen nationally in 
American Indians but not in other racial or ethnic groups. 
Unfortunately, the frequency of kidney failure is increasing among 
younger Gila River Indian Community members because of the increasing 
rate at which diabetes develops in youth; 5 percent of Community 
members 15 to 19 years of age now have diabetes, and many of them will 
develop kidney failure or die of diabetes complications by their 
forties or fifties.
    Death rates from heart disease have doubled among Gila River Indian 
Community members with diabetes in recent years, while deaths 
attributed to diabetic kidney disease have declined. These changes are 
due primarily to improvements in dialysis care that have reduced deaths 
from kidney disease, while the risk of death from heart disease remains 
high. On the other hand, death rates from heart disease remained very 
low in non-diabetic Community members and have not changed over the 
past 40 years. This finding points to the importance of preventing 
diabetes and its kidney complications as a means of reducing the risk 
of heart disease.

               LOOK AHEAD [ACTION FOR HEALTH IN DIABETES]

    American Indians are part of a major NIDDK diabetes treatment 
clinical trial, called Look AHEAD [Action for Health in Diabetes], 
which is a multicenter randomized clinical trial examining the long-
term effects of a lifestyle weight-loss intervention on the development 
of cardiovascular disease and other complications of diabetes. A 
Southwest American Indian Look AHEAD clinical center at our Branch 
includes participants from American Indian communities in Arizona and 
New Mexico.

                         OVERWEIGHT AND OBESITY

    Because obesity is an important and modifiable risk factor for the 
development of type 2 diabetes, we seek to understand in more detail 
why some people become overweight or obese. We also conduct research on 
better ways of preventing or reversing these conditions. Much of this 
research is conducted in our inpatient clinical research unit in the 
Phoenix Indian Medical Center. Specifically, we are studying genetic 
and other causes of why some people overeat and exercise too little, 
because these are the major factors causing obesity, not ``slow 
metabolism'' or abnormalities of resting energy expenditure. We are 
also studying factors that predict which people respond best to weight-
loss interventions by achieving and, more importantly, maintaining 
weight loss.

                           GENETICS RESEARCH

    Most of the research I have described has had large and immediate 
impacts on the prevention and treatment of type 2 diabetes. To achieve 
even greater progress or to eliminate the disease altogether, we 
believe that a more fundamental understanding of its causes and 
biological mechanisms is needed. To this end, we have also pursued 
research in the genetic susceptibility factors for obesity, type 2 
diabetes, and its complications, including diabetic kidney disease.
    There is a large body of scientific evidence that obesity and type 
2 diabetes have major genetic determinants, and there have been 
considerable advances in technologies to identify genes for such 
complex health conditions. These new methods need to be applied across 
various populations and individual American Indian communities, because 
different genes, or different variants within the same gene, may 
increase the risk of these conditions in different groups.
    In the past year a major type 2 diabetes susceptibility gene was 
identified in Iceland, and it appears to be a major gene for diabetes 
in Whites around the world, but not, for example, in the Pimas of the 
Gila River Indian Community. We are testing the possibility that 
polymorphisms [that is, common variations in the sequence of DNA among 
individuals] in other genes in the same metabolic pathway increase the 
risk of diabetes among the Pimas. Conversely, a genetic polymorphism, 
that is unique to the Ojee Cree Tribe in Canada was found to greatly 
increase their risk of diabetes. By contrast, our previous discovery of 
a region on chromosome I that contains a gene or genes involved in 
diabetes susceptibility in the Pima Indians has been widely replicated 
around the world. We work with an international consortium of 
scientists to precisely identify this gene.

             THE NATIONAL DIABETES EDUCATION PROGRAM [NDEP]

    To disseminate the important findings of the DPP to people at risk 
for diabetes, the NDEP developed the ``Small Steps, Big Rewards, 
Prevent Type 2 Diabetes'' education campaign. The NDEP is sponsored by 
the NIDDK, the Centers for Disease Control and Prevention [CDC], and 
over 200 partners. The campaign, which includes material tailored to 
American Indians, emphasizes the practical application of the DPP 
findings and includes lifestyle-change tools for those at risk, patient 
education materials for healthcare providers, web-based resources for 
healthcare providers and consumers, and public service announcements. 
In addition to educational material on diabetes prevention, the NDEP 
has developed culturally specific messages on the importance of 
controlling blood glucose levels to prevent life-threatening diabetes 
complications for American Indians already diagnosed with diabetes. The 
NIDDK is committed to continuing these types of educational efforts to 
disseminate the positive results of its clinical trials to benefit 
public health.

                         NIDDK-IHS PARTNERSHIPS

    Mr. Chairman, I'm pleased to tell you that the NIDDK works closely 
with the Indian Health Service to improve the health and quality of 
life of American Indians. The NIDDK's extramural Division of Diabetes, 
Endocrinology, and Metabolic Diseases, which Dr. Fradkin heads, has 
worked closely with the IHS' Division of Diabetes Treatment and 
Prevention in the development of the ``Special Diabetes Program for 
Indians Competitive Grant Program,'' which has developed a DPP-like 
lifestyle intervention program for American Indians diagnosed with pre-
diabetes, for implementation testing at 36 tribal grantee sites. Since 
the awarding of the 36 grants, including one to the Gila River Indian 
Community, NIDDK has participated in the Steering Committee for this 
program. In addition, the director of the IHS' Division of Diabetes 
Treatment and Prevention and its National Diabetes Program, Dr. Kelly 
Acton, serves as a member of the statutory Diabetes Mellitus 
Interagency Coordinating Committee, which is chaired by the NIDDK. This 
committee serves an important function by coordinating activities of 
all Federal programs related to diabetes and its complications.
    In addition, the NIDDK, IHS, CDC, Tribal Colleges and Universities, 
and the Tribal Leaders Diabetes Committee Joined together to develop 
``Diabetes-Based Science Education in Tribal Schools,'' which is an 
educational curriculum development program to enhance understanding and 
appreciation of diabetes, and within this framework, to increase 
knowledge of the biomedical sciences in Tribal elementary, middle, and 
high schools. One goal of the program is to enhance awareness and 
understanding of diabetes among students, families, community members, 
and teachers to prevent the disease and to help affected Tribal members 
better manage their diabetes. Another objective of the program is to 
increase the numbers of American Indians who enter the health research 
professions. The IHS continues to make critical personnel and financial 
contributions to the successful and influential prevention research 
program, the DPP and the DPP Outcomes Study.

                               CONCLUSION

    Mr. Chairman and members of the committee, I hope that these few 
examples convey the firm commitment of the NIH and NIDDK, in 
partnership with our sister agencies, to combating diabetes in American 
Indians. The central mission of the NIH is to conduct and support 
biomedical research aimed at decreasing the burden of disease in the 
United States. In diabetes, I believe that the NIH's mission is being 
well served and that the future is encouraging for the ultimate control 
and prevention of diabetes in American Indians and all Americans. Let 
me conclude with a note of special thanks to the members of the U.S. 
Senate on behalf of the community of scientists who work in diabetes. 
Thank you for the continuing encouragement of biomedical research 
through which we hope to improve the health of all Americans.
    I appreciate the opportunity to address the committee on behalf of 
the NIH and NIDDK and would be pleased to respond to any questions you 
may have.

                               BIOGRAPHY

    Dr. William C. Knowler has worked with American Indians in the 
Southwestern United States for the last 31 years as a research 
physician with the National Institute of Diabetes and Digestive and 
Kidney Diseases [NIDDK]. He is chief of the Diabetes Epidemiology and 
Clinical Research Section of NlDDK in Phoenix, AZ, where he conducts 
research in type 2 diabetes, complications of diabetes, obesity, and 
other health concerns of American Indians. He also serves with two 
national diabetes clinical trials evaluating the best ways to prevent 
the development of type 2 diabetes and the occurrence of cardiovascular 
complications of the disease and in a national study of the hereditary 
factors in the development of diabetic kidney disease.
    Dr. Knowler was born and educated in Iowa City, receiving his BA in 
mathematics from the University of Iowa. He then received doctoral 
degrees in medicine and public health from Harvard University and 
further clinical training in Boston before moving to the NIDDK in 
Arizona in 1975. He is widely recognized for his research in the causes 
and prevention of type 2 diabetes and its complications. His research 
findings have been widely implemented in clinical practice, in 
particular in Indian Health Service and tribal programs serving 
American Indians.
    Dr. Knowler is widely sought as a lecturer and teacher, has 
published over 400 medical research articles and book chapters, and 
serves as a reviewer or editor for several medical journals. He is 
recognized as one of the world's 250 most highly cited researchers in 
clinical medicine and in biology and biochemistry. He has been honored 
for his research and its clinical applications with many awards, most 
notably the Kelly West Award for Epidemiology from the American 
Diabetes Association, the Tribal Leaders Diabetes Committee award for 
research in treatment and prevention of diabetes in American Indians, 
and the NIDDK Director's Award for national leadership in diabetes 
prevention.
                                 ______
                                 

 Prepared Statement of Sam McCracken Native American Business Manager, 
                          Nike, Beaverton, OR

    Committee Chairman Dorgan, Vice Chairman Thomas and other members 
of the committee on Indian Affairs, thank you for the opportunity to 
speak to you today in support of diabetes prevention and the overall 
health of Native American communities and the important role that 
corporate commitment can play in addressing these issues.
    At Nike, diversity is celebrated. In that spirit, Nike actively 
supports the Native American community through a variety of 
initiatives, programs and grants that seek to increase physical 
activity of young people on Native lands to help improve their lives 
and aid in the prevention of prevalent health issues such as diabetes.
    Like of all of you, we at Nike are very aware and concerned about 
the mounting diabetes epidemic among Native Americans and the high 
percentage of cases among Native American youth.
    I am named after my great grandfather Thomas Duck a provider for 
the Assiniboine and my clan is the red bottom clan. Today I am the 
Director of Nike's Native American Business Program and a proud member 
of the Ft. Peck Tribes [Sioux and Assiniboine Tribes] in northeastern 
Montana. In 2001 the tragedy of diabetes struck my family when I lost 
my mother to type 2 diabetes. I am committed to forging a healthier 
future for all Native Americans, a future where diabetes is a thing of 
the past and physical fitness among youth is at an all-time high. 
Together, as public and private partners, I believe we can overcome 
anything.

The Problem

    Diabetes strikes 13 percent of the Native American population. Even 
more concerning is the 80 percent increase of diabetes among Native 
American children and young adults. Complications from diabetes lead to 
major causes of death and health problems in Native American 
communities including an amputation rate that is three-to-four times 
higher.

Nike's Approach

    Through my passion and Nike's commitment to the community we have 
worked with government officials and community elders in the creation 
of Nike's Native American community program which is a multi-tiered 
initiative to support and encourage physical activity on Native 
American lands to combat diabetes. The program has several key 
components that are detailed as follows.

Indian Health Service [IHS] and Nike Memorandum of Understanding

    Under the leadership of Indian Health Services director, Dr. 
Charles Grim and Leo Nolan, Senior Policy Analyst for External Affairs 
for IHS, the Nike Native American community program helped forge a 
unique partnership with IHS, with the signing of an important 
Memorandum of Understanding [MOU] in November 2003. Nike and IHS signed 
the MOU to collaborate on a promotion of healthy lifestyles and healthy 
choices for all American Indian and Alaska Natives. The MOU is a 
voluntary collaboration between business and government that aims to 
dramatically increase the amount of health information available in 
American Indian and Alaska Native communities. The goal of the MOU is 
to help those communities gain a better understanding of the importance 
of exercise at any age, particularly for those individuals with 
diabetes.
    The MOU supports the President of the United States' ``Healthier 
U.S. Initiative,'' the Secretary of Health & Human Services' 
Preventative Initiative ``Steps to a Healthier U.S.'' and the Indian 
Health Services' ``Health Promotion/Disease Prevention Initiative.''
    In 2003, Dr. Grim offered this perspective on the new Indian Health 
Service partnership: ``The mission statement of Nike shares a common 
basis for collaborative activities with the IHS and other Federal 
agencies. That basis is the improvement of the health and fitness of 
every American.''
    Continued Grim, ``Overweight and obesity are the fastest-growing 
causes of preventable disease and death in America and are contributing 
factors in diabetes, heart disease, high blood pressure, stroke and 
poor cholesterol levels. Nearly 13 percent of the Indian population is 
affected by diabetes, and this campaign can help promote positive 
changes in the health issues associated with these and many other 
illnesses and diseases in American Indian communities.''
    ``Regular physical activity contributes to better health by 
reducing obesity and the many chronic conditions associated with it, 
including increased diabetes and heart disease,'' said Health and Human 
Services Secretary Tommy G. Thompson at the time of the MOU signing in 
2003. ``This new partnership will serve American Indian and Alaska 
Native communities by expanding the information available on the 
importance of physical activity.''
    Nike stands by the words of co-founder Bill Bowerman who said that 
if you have a body, you are an athlete. Applying this thinking in 
conjunction with the goal of the MOU and through deeper understanding 
in working with the IHS, Nike is developing an innovative new shoe that 
offers increased comfort through a uniquely designed fit for the Native 
American foot. Nike's goal with this new design is to increase comfort 
among Native Americans in the hopes that it will encourage and motivate 
these citizens to exercise and maintain their physical fitness. The 
shoe is still in development and will be offered through limited 
distribution to qualified Native American Business partners.

Native American Incentive Program

    In 2000, Nike began the Native American Incentive Program. Working 
closely with the diabetes program coordinators of some 116 tribal 
agencies, Nike provides product for their fitness promotion programs 
and partners with these tribes to provide mentoring and recreational 
events for the tribal population.
    The White Earth Reservation Tribal Council, in White Earth, Minn., 
for example, began its Diabetes Project with one center and a total of 
45 participants. With help from Nike, the program has grown to five 
Fitness/Wellness centers, 1130 participants, 350 participants in a 100-
Mile Walk program, 275 diabetes camp participants, and 40 attendees a 
month in its water-aerobics classes. Ages of the participants range 
from 10 to 92.
    Nike's U.S. Community Affairs program has also partnered with 
several national stakeholders and government officials. These key 
partners include the Indian Health Services, the Department of U.S. 
Health and Human Services, FirstPic, and the Boys & Girls Clubs which 
introduced the NikeGO on Native Lands program at six Boys & Girls Clubs 
sites on Indian reservations. Through this pilot program, NikeGO 
provides a culturally relevant physical activity curriculum, training, 
equipment and incentives, all designed to help Native American youth 
ages 8-15 discover the joy of movement and the fun of physical 
activity. Since 2004, NikeGO on Native Lands has expanded to include 
grants to 67 Boys and Girls Clubs on Indian Reservation across 20 
states. Fifteen of those grants were awarded this year. Last year, Nike 
donated more than $1 million in product to support this program.

Listen to the Voice of the Athlete

    Nike has always listened to the voice of the athlete to inspire and 
motivate both within its organization and within the community. Nike 
has applied this philosophy to the Native American community, as well.
    Native American golfer Notah Begay III, a 4-time winner on the PGA 
Tour, has played a central role in helping Nike educate Native 
Americans about the benefits of exercise. In fact, Mr. Begay's efforts 
off the golf course specifically focus on preventing the continued 
spread of diabetes in the Native American community. In 2004, Mr. Begay 
joined Dr. Grim and me at the annual session of the National Congress 
of American Indians. Mr. Begay was instrumental in kicking off the 
first ever National Native American Health and Fitness day.
    In May 2006, Nike announced a 5-year partnership with the Iroquois 
National Lacrosse organization, providing the Iroquois Nationals with 
footwear and apparel, including team uniforms, warm-ups and casual 
sports apparel. Nike designed the new uniforms to pay homage to the 
Iroquois Nation's rich history in the sport. They debuted last summer 
at the 2006 World Lacrosse Championships in London, Ontario, Canada.
    The Iroquois Nationals today are the only indigenous nation 
worldwide participating in international sports competition, meaning 
that the Iroquois Nationals compete for the world title alongside the 
United States, Canada and other qualifying countries at each World 
Lacrosse Championship.
    The partnership developed out of Nike's commitment to working with 
the Native American community and as another means of inspiring 
physical activity among Native American youth.
    ``We are proud to have Nike support us at this exciting time in our 
history,'' said Chief Oren Lyons of the Iroquois Nationals at the time 
of the partnership announcement. ``The Iroquois Nationals Program has 
had a significant impact on the youth of our confederacy providing an 
international showcase for our players and our culture. With Nike's 
support, we will be able to continue to send our best athletes to 
compete and promote lacrosse to the world, sharing the game and our 
history.''
    Historically, the game of lacrosse may be one of the oldest team 
sports in the world, and the roots of modern day lacrosse can be traced 
back to the Iroquois. For over 500 years, lacrosse has played an 
integral part of the Iroquois Confederacy well being. As lacrosse 
continues to grow in popularity around the world, Iroquois Nation 
leaders are committed to promote its heritage and drive broader 
participation in healthy physical activity among its people.
    Late in 2006, the Native American Basketball Invitational [NABI], 
the largest all Native American basketball tournament in North America, 
announced Diana Taurasi as its first Honorary Commissioner through its 
partnership with Nike.
    ``Nike has been a sponsor of NABI since the tournament's inception 
in 2003. Our national tournament, organized for the sole purpose of 
creating college scholarship opportunities for Native American high 
school athletes, will feature 80 tribal teams from the United States 
and Canada. Nike's willingness to stand beside our efforts to make NAB[ 
successful has been instrumental in our rapid growth'' said GinaMarie 
Scarpa-Mabry, co-founder of NABI, at the time of the announcement.
    Since its inception, NABI has created numerous opportunities for 
Native American students to receive college athletic scholarships by 
showcasing high school athletes from Native American communities from 
throughout North America in one location. NABI's goal for the July 2007 
tournament is to become a NCAA certified summer event, which will make 
NABI the first all Native American tournament certified by the NCAA.

Conclusion

    The mission of the Nike brand is to bring inspiration and 
innovation to every athlete in the world. Also, one of the company's 
celebrated maxims is to ``Do the Right Thing.'' On behalf of Nike, I 
believe that our program designed to provide diabetes prevention and 
overall improved health to Native American communities is true to both 
its mission and key maxim.
    A future rid of diabetes within the Native American community can 
only be realized if we inspire and instill healthy lifestyles in our 
youth today. Nike and its partners in the corporate, nonprofit and 
government arenas have an opportunity to shape these kids' lives now, 
and help them form positive habits and attitudes that last a lifetime.
    I am very fortunate to have the opportunity to work for a company 
that is thriving to make a difference, but we will only be as 
successful as the partnerships we forge along the way. Your leadership 
on this issue is critical, and we look forward working with you.

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