[Senate Hearing 115-48]
[From the U.S. Government Publishing Office]
S. Hrg. 115-48
NATIVE YOUTH: PROMOTING DIABETES PREVENTION THROUGH HEALTHY LIVING
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HEARING
before the
COMMITTEE ON INDIAN AFFAIRS
UNITED STATES SENATE
ONE HUNDRED FIFTEENTH CONGRESS
FIRST SESSION
__________
MARCH 29, 2017
__________
Printed for the use of the Committee on Indian Affairs
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COMMITTEE ON INDIAN AFFAIRS
JOHN HOEVEN, North Dakota, Chairman
TOM UDALL, New Mexico, Vice Chairman
JOHN BARRASSO, Wyoming MARIA CANTWELL, Washington
JOHN McCAIN, Arizona JON TESTER, Montana,
LISA MURKOWSKI, Alaska AL FRANKEN, Minnesota
JAMES LANKFORD, Oklahoma BRIAN SCHATZ, Hawaii
STEVE DAINES, Montana HEIDI HEITKAMP, North Dakota
MIKE CRAPO, Idaho CATHERINE CORTEZ MASTO, Nevada
JERRY MORAN, Kansas
T. Michael Andrews, Majority Staff Director and Chief Counsel
Jennifer Romero, Minority Staff Director and Chief Counsel
C O N T E N T S
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Page
Hearing held on March 29, 2017................................... 1
Statement of Senator Cortez Masto................................ 4
Statement of Senator Daines...................................... 3
Statement of Senator Franken..................................... 4
Statement of Senator Heitkamp.................................... 28
Statement of Senator Hoeven...................................... 1
Statement of Senator Murkowski................................... 4
Statement of Senator Udall....................................... 2
Witnesses
Buchanan, Rear Admiral Chris, Acting Director, Indian Health
Service, U.S. Department of Health and Human Services.......... 6
Prepared statement........................................... 7
Eagle, Jared, Director, Fort Berthold Diabetes Program, Three
Affiliated Tribes.............................................. 14
Prepared statement........................................... 15
Hawley, Hon. Vinton, Chairperson, National Indian Health Board
(NIHB)......................................................... 9
Prepared statement........................................... 11
Sensmeier, Martin, Actor and Ambassador, Boys & Girls Clubs of
America........................................................ 16
Prepared statement........................................... 18
Villegas, Alton, Tribal Youth, Salt River Pima-Maricopa Indian
Community; Accompanied by Rachel Seepie, Senior Fitness
Specialist, Diabetes Service Program--Health Service........... 20
Prepared statement........................................... 21
Appendix
Allen, Hon. W. Ron, Tribal Chairman, Jamestown S'Klallam Tribe;
Board Chairman, Self-Governance Communication &
Education Tribal Consortium, prepared statement................ 39
Barlow, Allison, Ph.D, MA, MPH, Director, Center for American
Indian Health, Johns Hopkins Bloomberg School of Public Health,
prepared statement............................................. 41
Crabbe, Kamana'opono M., Ph.D. (Ka Pouhana)/CEO, Office of
Hawaiian Affairs (OHA), prepared statement..................... 45
Rock, Patrick M. MD,, CEO, Indian Health Board of Minneapolis,
Inc., prepared statement....................................... 46
Tuomi, Ashley, President, National Council of Urban Indian
Health, prepared statement..................................... 47
United South and Eastern Tribes Sovereignty Protection Fund (USET
SPF), prepared statement....................................... 41
NATIVE YOUTH: PROMOTING DIABETES PREVENTION THROUGH HEALTHY LIVING
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WEDNESDAY, MARCH 29, 2017
U.S. Senate,
Committee on Indian Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 2:45 p.m. in room
628, Dirksen Senate Office Building, Hon. John Hoeven,
Chairman of the Committee, presiding.
OPENING STATEMENT OF HON. JOHN HOEVEN,
U.S. SENATOR FROM NORTH DAKOTA
The Chairman. Good afternoon. We will call this hearing to
order.
Up front, I want to thank all our panelists for being here.
Today the Committee will hold an oversight hearing on
Native Youth: Promoting Diabetes Prevention through Healthy
Living.
In 1997, Congress authorized the Special Diabetes Program
for Indians to address the extraordinary prevalence of diabetes
among Indians. It is now in its twentieth year and up for
reauthorization this year.
This program has demonstrated significant inroads in
reducing diabetes and its complications, such as limb
amputations, heart disease and kidney failure. However, there
is still more work to be done.
Indian people have a greater chance of being diagnosed with
diabetes than any other racial or ethnic group in the Country.
It is the fifth leading cause of death for Native people. This
disease is now afflicting the youth.
Native youth are reportedly nine times higher than non-
Hispanic whites to be diagnosed with Type 2 diabetes and the
related complications of heart disease, kidney failure, and
other diseases.
I look forward to hearing from our witnesses regarding why,
according to Indian Health Service information, and during the
existence of this special program, the rates of diabetes among
the youth have increased and obesity rates have pretty much
stayed the same.
As we know, obesity is one indicator for the future risk of
becoming diabetic. If it is not decreasing, then before we
reauthorize this program and talk about a funding authorization
level, we need to examine how well this special program is
serving the Native American youth.
We know, on the bright side, Type 2 diabetes is both
preventable and manageable, particularly through healthy
living. Healthier lifestyles can help improve blood glucose
levels, decrease obesity rates, lower blood pressure, and
decrease bad cholesterol levels for our youth.
Today we look forward to hearing from our witnesses on how
they are making a difference in the lives of Native youth and
any improvements needed for this special program. We must work
together to prevent further diabetes prevalence in Indian
Country and continue the good work that is currently being
done.
With that, I want to start with a special welcome to one of
our witnesses today. Again, I welcome all of you but a special
welcome to a witness from my home State of North Dakota, Mr.
Jared Eagle. Thank you for being here from the Three Affiliated
Tribes in New Town, North Dakota.
I want to thank all of you for being here and welcome you.
I also want to turn to Vice Chairman Udall for any opening
statement he would like to make.
STATEMENT OF HON. TOM UDALL,
U.S. SENATOR FROM NEW MEXICO
Senator Udall. Thank you very much, Chairman Hoeven, for
calling this oversight hearing on Native Youth and Diabetes
Prevention.
Too often in this Committee, we hear about the challenges
facing Indian Country but I hope today's hearing will give us
an opportunity to focus on the success stories. Throughout my
time in public service, I have been fortunate to get to know
some truly inspiring Native youth. Whether it is meeting with
students from the Santa Fe Indian School on a trip to D.C. or
joining kids from Santa Clara Pueblo's Youth Running Club for a
run back in New Mexico, the one thing I always hear when I talk
with Native youth is how important community, culture and
mentorship are to their success.
As a committee, we should look for more ways to support the
efforts of tribes and Native communities to engage Native youth
in healthy lifestyles. I am glad we are here to learn more
about the positive impact that culturally informed community
health promotion programs can have in Indian Country.
One of the main ways Congress has supported tribally-driven
diabetes prevention initiatives over the last 20 years has been
through authorizing the Special Diabetes Program for Indians,
otherwise known by the acronym SDPI. SDPI funds diabetes
prevention and treatment programs in more than 300 Native
communities across the Country, resulting in a 61 percent
increase in culturally-based diabetes education programs.
The SDPI impact can be measured by more than statistics and
health care cost savings. This program has helped to improve
the quality of life for thousands of diabetic and pre-diabetic
American Indians and Alaska Natives. I am sure many of the
witnesses here today can attest to the positive impacts SDPI
has had on their communities.
Despite the outstanding impact this program has had over
the last two decades, it has suffered under the strain of one
to two year reauthorizations. These short-term extensions have
made it difficult for tribal diabetes programs to plan for the
long term.
That is why I introduced a bill to reauthorize SDPI for
another seven years. This long-term extension will provide
Native grantees with peace of mind during the annual
appropriations process and it makes a commonsense investment in
preventive health care programs that will curb ever increasing
medical costs.
I will conclude by inviting other members of this Committee
in support of reauthorization of SDPI. I look forward to
hearing from our witnesses about the innovative work SDPI has
helped fund in their communities.
Thank you again, Mr. Chairman, for focusing on diabetes and
prevention in this Committee.
The Chairman. Thank you, Senator Udall.
Are there other members who would like to make an opening
statement?
STATEMENT OF HON. STEVE DAINES,
U.S. SENATOR FROM MONTANA
Senator Daines. Thank you, Chairman Hoeven and Vice
Chairman Udall.
Let me tell you a story. It is the story of Dustin
Mitchell.
Dustin is 14 years old. He is a member of the Confederated
Salish and Kootenai Tribes of the Flathead Reservation in
Northwest Montana. He is a regular, fun loving kid. He plays
football, goes to school, and drives race car competition in
the summer.
In 2012, he was diagnosed with diabetes. The diagnosis came
as a shock to him and his family. The Mitchells did not have
other family members who had struggled with diabetes before and
needed to learn how to cope with Dustin's new challenge.
Soon thereafter, Dustin attended the American Diabetes
Association's Camp Montana in Fishtail, Montana. There is a
name for you, Fishtail, Montana, a beautiful place in our
State. That is where he went to camp. He learned about healthy
eating, exercise and how to manage his diabetes.
Now, Dustin still plays football in the summer and he is
still racing racecars but this year, his Bandolero race car
will feature a large sticker that will read ``Hope,'' along
with the signature diabetes awareness blood drop that calls
attention of others to this epidemic.
Native children ages 10 to 19 years old are nine times more
likely than their young Caucasian counterparts to be diagnosed
with Type 2 diabetes. Through lifestyle adaptations like the
ones Dustin made and by supporting the Special Diabetes for
Indians Program, which every Montana tribe benefits from, we
can prevent more Indian children and adults alike from becoming
diabetic.
Thank you, Mr. Chairman.
The Chairman. Thank you, Senator Daines.
Senator Franken.
STATEMENT OF HON. AL FRANKEN,
U.S. SENATOR FROM MINNESOTA
Senator Franken. Thank you, Chairman Hoeven and Vice
Chairman Udall, for calling this oversight hearing.
Thank you to all of our witnesses for your testimony today.
I look forward to hearing your testimony. I will keep my
remarks very brief.
Many of us in this room have spent years working on this
issue. For me, diabetes was the topic of the second Floor
speech I gave when I became a U.S. Senator. It has been an
issue I have worked on ever since. We are all aware of the toll
of diabetes on families across the Nation, specifically of
course in Indian Country which is why this hearing is an
important opportunity for this Committee to take up this
important issue, one that is so prevalent among our Indian
youth.
Thank you again, Mr. Chairman and Ranking Member, and all
of our witnesses. I look forward to your testimony.
The Chairman. Senator Cortez Masto.
STATEMENT OF HON. CATHERINE CORTEZ MASTO,
U.S. SENATOR FROM NEVADA
Senator Cortez Masto. Chairman Hoeven, thank you so much
and Ranking Member Udall.
This is a fantastic panel. I just wanted the opportunity,
however, to introduce all of you to one of the panelists from
the great State of Nevada. That is Chairman Vinton Hawley from
the Lake Paiute Tribe located in Nevada. I am so pleased you
were able to join us today.
Chairman Hawley is here today in his capacity as the Chair
of the National Indian Health Board which represents tribal
governments that both operate their own health care systems and
those that rely on care provided through the Indian Health
Service.
He also serves as President of the Nevada Intertribal
Council, a network of 27 tribes and community organizations
serving Indian people living in Nevada and the Great Basin
region. He is a proud member of both the Pyramid Lake Paiute
Tribe and the Hopi-Tewa. I am so happy he is here to join us
today. Welcome to all of you and thank you.
The Chairman. Senator Murkowski.
STATEMENT OF HON. LISA MURKOWSKI,
U.S. SENATOR FROM ALASKA
Senator Murkowski. Thank you, Mr. Chairman.
I too will be brief but I thank you for having this very
important hearing today. I think we have recognized here in
Congress that we are dealing with something that is epidemic in
proportion and to know that we have dedicated funding through
the SDPI program in hopes of obtaining better data, lowering
the rates and making a real impact in the lives of not only
children but all of Native Americans.
We have seen some encouraging signs in Alaska through the
SDPI program as we deal with the diabetes epidemic today. We
have 19 Native organizations or tribes participating in
programs across the State.
We still have a pretty big problem. According to CDC, in
2014, approximately 41,181 in Alaska, 7.6 percent of the
population had been diagnosed with diabetes. We understand what
this leads to in terms of other serious conditions.
It is not only the individual that has diabetes, it is the
toll on the families as well as they care for their loved ones,
but also the fact that it is passed down through generations,
sometimes through factors such as poor eating habits, and a
lack of a healthy lifestyle. Those too are passed down.
In Alaska, we have some additional challenges. In remote
areas, when you have an inability to get good, healthy foods in
a grocery store, your fruits and vegetables, they just do not
exist or if they do, they are too expensive, so many of our
Alaska Natives rely on good subsistence food whether it is
moose, caribou or fish.
Sometimes these foods are not available, so you have to
rely on less healthy alternatives which are costly and
contribute to further challenges. Also, you have long winters
that make healthy outside activities somewhat limited.
We are making some good progress. I think that is
important, particularly the progress with our young people.
I would like to recognize one of our panelists this
afternoon and thank him for joining us today. Martin Sensmeier
was raised in Yakutat, Alaska, a small community, less than
1,000 people, a beautiful community. Martin is Tlingit and
Koyukon-Athabascan.
I want to thank you for traveling here today, Martin. It is
a long haul. We know that. The last time I saw you in D.C., you
had once again traveled all the way across the Country to spend
just one day, just one day, with Native youth. That truly was
your personal statement and commitment to the mission and the
cause that you lead so ably and competently. You are a role
model for so many.
I thank you for that and I thank you for being here and
providing us with your comments today.
With that, Mr. Chairman, I thank you.
The Chairman. Thank you, Senator Murkowski.
We are very pleased to have our witnesses today. They are:
Rear Admiral Chris Buchanan, Acting Director, Indian Health
Service, U.S. Department of Health and Human Services,
Rockville, Maryland; The Honorable Vinton Hawley, Chair,
National Indian Health Board, Washington, D.C.; Mr. Jared
Eagle, Program Director, Fort Berthold Diabetes Program--Three
Affiliated Tribes, New Town, North Dakota; Mr. Martin
Sensmeier, Actor and Ambassador, Boys & Girls Clubs of America,
Atlanta, Georgia, most recently in the movie The Magnificent
Seven. We will get a few more details on his acting as well as
diabetes. I know I am not the only one interested to hear a
little bit more about that.
Mr. Alton Villegas is also here. He represents Tribal Youth
from the Salt River Pima-Maricopa Indian Community, Scottsdale,
Arizona. I understand they tried to take you out for a
hamburger last night and you ordered a salad. Way to go. You
are setting a good example right there. Ms. Rachel Seepie,
Senior Fitness Specialist, Diabetes Service Program - Health
Service, Salt River Pima-Maricopa Indian Community, Scottsdale,
Arizona, is with him also.
Thanks again to all of you. If you will hold your comments
to five minutes if you could, your full written statement will
be made a part of the permanent record.
Admiral Buchanan.
STATEMENT OF REAR ADMIRAL CHRIS BUCHANAN, ACTING DIRECTOR,
INDIAN HEALTH SERVICE, U.S. DEPARTMENT OF HEALTH AND HUMAN
SERVICES
Mr. Buchanan. Good afternoon everyone. Good afternoon,
Chairman Hoeven, Vice Chairman Udall, and members of the
Committee.
My name is Chris Buchanan. I am an enrolled tribal member
of the Seminole Nation of Oklahoma. I am a Commissioned Corps
officer with the Public Health Service and the Acting IHS
Director. I have been with the Indian Health Service for about
24 years and have held various levels of assignments within the
Indian Health Service.
I am truly honored to be here to testify before the Senate
Committee on Indian Affairs concerning Native youth and
promoting diabetes prevention and healthy living.
Mr. Chairman, I want to thank you and Vice Chairman Udall
for your leadership on the Committee and for elevating the
importance of delivering quality health through the Indian
Health Service.
Diabetes is a chronic disease, is complex and costly and
requires tremendous long-term efforts to prevent and treat.
American Indians and Alaska Native people are affected more by
diabetes. Diabetes rates in these populations are more than
twice that of non-Hispanic Whites in the United States.
I am happy to report after several decades of intensive
efforts by the Indian Health programs and partners we are
seeing clear evidence that this epidemic has leveled off.
Within our communities, the years of increasing rates of
diabetes stopped in 2011 and it has not risen since that time.
As shown by the graph to the left, new cases of kidney
failure due to diabetes declined by 54 percent among American
Indians and Alaska Native adults from 1996 to 2013. This is a
much larger decline than in any other racial group in the
United States.
As the future of Indian Country depends on the health of
its youth, recent data shows there is good news here as well.
The rate of Type 2 diabetes in American Indian youth ages 10 to
19 did not increase from 2001 to 2009.
Although the rate is still higher than other ethnic and
racial groups, the rate of obesity in American Indian and
Alaska Native youth has also leveled off. The obesity rate in
American Indian and Alaska Native children ages 2 to 19 years
remained nearly constant from 2006 to 2015. However, it is
still higher than U.S. youth overall.
Several key factors contributed to this significant and
ongoing progress including the Special Diabetes Program for
Indians, also known as SDPI. Twenty years ago, in 1997,
Congress created the SDPI in response to the diabetes epidemic
that was escalating at an alarming rate in the Native
population.
The SDPI Program provides grants to tribal IHS urban Indian
Health organizations for diabetes prevention and treatment
services. Grantees collectively serve over 782,000 American
Indians and Alaska Native people per year. Two-thirds of the
grantees use at least some of their SDPI funds to work with
children and youth.
Examples of the services that grantees implement to reduce
risk factors of obesity and diabetes in youth include school
and community-based physical activity, nutrition and education,
community gardens, American Indian and Alaska Native
traditional sports and dancing and obesity management clinics.
In addition to the SDPI, the IHS has established
partnerships to advance the health of Native youth and
families. The Indian Health Service provides $1 million per
year to support obesity prevention at Boys and Girls Clubs in
Indian Country.
We do this through a cooperative agreement with the
National Congress of American Indians. The NCAI awards funds to
these clubs so that they can implement the program known as
TRAIL. Over 14,000 Native youth have participated in the TRAIL
program since 2003.
Although it takes many years to turn around an epidemic
like diabetes, American Indians and Alaska Native communities
are making a significant improvement in childhood obesity,
diabetes prevalence and diabetes and kidney-related failure.
Thank you for your commitment to Native youth as well as
your vision and leadership for diabetes prevention and
treatment among American Indians and Alaska Native people.
I would be happy to answer any questions the Committee may
have. Thank you.
[The prepared statement of Mr. Buchanan follows:]
Prepared Statement of Rear Admiral Chris Buchanan, Acting Director,
Indian Health Service, U.S. Department of Health and Human Services
Chairman and Members of the Committee:
Good afternoon, Chairman Hoeven, Vice-Chairman Udall, and Members
of the Committee. I am Chris Buchanan, an enrolled member of the
Seminole Nation of Oklahoma and currently the Acting Director of the
Indian Health Service (IHS). Prior to that I was the IHS Deputy
Director, leading and overseeing IHS operations to ensure delivery of
quality comprehensive health services. I am pleased to have the
opportunity to testify before the Senate Committee on Indian Affairs on
our accomplishments in preventing diabetes for Native youth through our
work in partnership with American Indian and Alaska Native (AI/AN)
communities. I would like to thank you and Vice-Chairman Udall for your
leadership on the Committee and for elevating the importance of
delivering quality care through the Indian Health Service.
The IHS plays a unique role in the Department of Health and Human
Services (HHS) because it is a health care system that was established
to meet Federal trust responsibilities to American Indians and Alaska
Natives. The mission of the IHS, in partnership with American Indian
and Alaska Native people, is to raise the physical, mental, social, and
spiritual health of AI/ANs to the highest level. The IHS provides
comprehensive health service delivery to approximately 2.2 million AI/
ANs through 26 hospitals, 59 health centers, 32 health stations, and
nine school health centers. Tribes also provide healthcare access
through an additional 19 hospitals, 284 health centers, 163 Alaska
Village Clinics, 79 health stations, and eight school health centers.
Diabetes is a complex and costly chronic disease that requires
tremendous long-term efforts to prevent and treat. Although diabetes is
a nationwide public health problem, AI/AN people have been and remain
disproportionately affected, with diabetes prevalence more than twice
that for non-Hispanic whites in the United States. However, after
several decades of intensive efforts by the IHS, Tribes, Urban Indian
health organizations, and other partners, we are seeing clear evidence
that this epidemic has leveled off.
In AI/AN people, the years of increasing diabetes prevalence
stopped in 2011 and it has not risen since that time. \1\ In addition,
data show that focusing on quality, team-based clinical care has
reduced devastating complications from diabetes. According to the
January 2017 Centers for Disease Control and Prevention (CDC) Vital
Signs report, new cases of diabetes-related kidney failure decreased
dramatically (54 percent) among AI/AN adults from 1996 to 2013, a much
larger decline than in any other racial group in the United States. \2\
This decrease is especially important given that Medicare spent over
$82,000 per person for beneficiaries of all races with diabetes-
related, end-stage kidney disease in 2013. \3\
---------------------------------------------------------------------------
\1\ IHS National Data Warehouse. 2016.
\2\ Bullock A, Burrows NR, Narva AS, et al. Vital Signs: Decrease
in Incidence of Diabetes-Related End-Stage Renal Disease among American
Indians/Alaska Natives--United States, 1996-2013. MMWR Morb Mortal Wkly
Rep 2017;66:26-32. DOI: http://dx.doi.org/10.15585/mmwr.mm6601e1.
\3\ Id.
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As the future of Indian Country depends on the health of its youth,
recent data show that there is good news here as well. Although the
prevalence of type 2 diabetes in American Indian (AI) youth ages 10-19
is higher than in other racial/ethnic groups, the prevalence for AI
youth in this age group did not increase from 2001-2009. However,
during that same period, it increased significantly for white, black,
and Hispanic youth. \4\ Even better, as it predicts future diabetes
risk, the prevalence of obesity in AI/AN youth has also leveled off.
Although higher than in US youth overall, obesity prevalence in AI/AN
children and youth ages 2-19 years remained nearly constant from 2006-
2015. \5\ Several key factors contributed to this significant and
ongoing progress, including the Special Diabetes Program for Indians
(SDPI).
---------------------------------------------------------------------------
\4\ Dabelea D, Mayer-Davis EJ, Saydah S, et al. Prevalence of Type
1 and Type 2 Diabetes Among Children and Adolescents From 2001 to 2009.
JAMA 2014 May 7;311(17): 1778-1786.
\5\ Ogden CL, Carroll MD, Lawman HG, et al. Trends in Obesity
Prevalence Among Children and Adolescents in the United States, 1988-
1994 Through 2013-2014. JAMA 2016:315 (21):2292-2299; IHS National Data
Warehouse. 2016.
---------------------------------------------------------------------------
The SDPI was established by Congress in 1997 in response to the
diabetes epidemic that was escalating at an alarming rate in AI/AN
people. The SDPI provides grants to Tribal, IHS, and Urban Indian
health organizations for diabetes prevention and treatment services.
The IHS administers the SDPI grant program to promote evidence-based
best practices as well as to ensure accountability for the funds and
compliance with grants regulations. The SDPI 2014 Report to Congress
documented the continued improvements in key clinical outcome measures
since the inception of the SDPI. The SDPI is currently authorized at
$150 million per year through the end of FY 2017.
Since the inception of SDPI, grantees have successfully implemented
evidence-based and community-driven strategies to prevent and treat
diabetes. There are currently 301 SDPI grant programs in 35 States, 252
Tribal, 20 IHS, and 29 Urban. Grantees collectively served over 782,000
AI/AN people per year, with two-thirds of grantees using at least some
of their SDPI funding to work with children and youth. Examples of
services that grantees implement to reduce risk factors for obesity and
diabetes in youth include school and community-based physical activity
and nutrition education, community gardens, AI/AN traditional sports
and dancing, cooking classes, sports leagues, and obesity-management
clinics. The innovative programs they have developed honor and
incorporate their unique and diverse tribal cultures.
In addition to the SDPI, the IHS has established many partnerships
to advance the health of Native youth and families. The IHS provides $1
million per year to support obesity prevention at Boys & Girls Clubs
(Clubs) in Indian Country through a cooperative agreement with the
National Congress of American Indians (NCAI). NCAI conducts an annual
grant process to awards funds to Native Clubs so they can implement the
Together Raising Awareness for Indian Life (TRAIL) program. TRAIL uses
a comprehensive curriculum that includes educational, nutritional, and
physical activities to promote healthy lifestyles, obesity prevention,
and self-esteem for AI/AN youth. Over 14,000 AI/AN youth, ages seven
through 11 years, have participated in the TRAIL program since 2003.
As important as it is to work with school-aged children, recent
science has shown that risk factors for obesity and diabetes start in
the earliest days and years of life. IHS has a Memorandum of
Understanding with Johns Hopkins University's Center for American
Indian Health to promote implementation of their evidence-based Family
Spirit home visiting intervention. Working with pregnant women and
young families, Family Spirit has been proven to reduce risk factors in
American Indian children that are associated with later development of
obesity and substance abuse. \6\
---------------------------------------------------------------------------
\6\ Barlow A, Mullany B, Neault N, et al. Paraprofessional-
delivered, home-visiting intervention for American Indian teen mothers
and children: 3-year outcomes from a randomized controlled trial. Am J
Psychiatry 2015;172:154-162
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Although it takes many years to turn around an epidemic like
diabetes, this is happening in AI/AN communities, with significant
improvements in childhood obesity, diabetes prevalence, and diabetes-
related kidney failure. Thank you for your commitment to Native youth
as well as your vision and leadership for diabetes prevention and
treatment among AI/AN people. I look forward to continuing to work with
you, our communities, and other partners to ensure the health of our
Native youth and families. I will be happy to answer any questions the
Committee may have.
The Chairman. Thank you, Admiral.
Mr. Hawley.
STATEMENT OF HON. VINTON HAWLEY, CHAIRPERSON, NATIONAL INDIAN
HEALTH BOARD
Mr. Hawley. Chairman Hoeven, Vice Chairman Udall and
members of the Committee, thank you for holding this important
hearing on improving the lives and health of American Indian
and Alaska Native youth through preventing diabetes.
My name is Vinton Hawley, Chairman of the Pyramid Lake
Paiute Tribe, President of the Intertribal Council of Nevada
and Chairperson of the National Indian Health Board. I
appreciate the opportunity to provide this testimony today on
behalf of the National Indian Health Board and the 567 Native
Nations we serve.
One of the most prominent health disparities in tribal
communities is the high rate of Type 2 diabetes. Our people of
all ages are impacted by Type 2 diabetes and its many chronic
complications whether through our own individual diagnosis or
the diagnosis of a loved one.
Because of stories like this and the many tribal families
who endure suffering because of Type 2 diabetes, tribal
communities must have the resources and support they need to
access fresh and nutritious foods, safe places for physical
activity and quality diabetes treatment and intervention
programs. Because traditional subsistence lifestyles have been
replaced with Federal programs such as the Food Distribution
Program on Indian reservations, many tribal communities have a
new reliance on store-bought foods, poor access to fresh
produce, and have increased consumption of fast foods.
These compounding issues have resulted in our children
suffering from higher rates of obesity and related
complications, such as Type 2 diabetes. Our Native youth ages
10-19 are nine times more likely to have Type 2 diabetes
compared to non-Natives. This is unacceptable.
People with diabetes diagnosed before they turn 20 years
old have a life expectancy that is up to 27 years shorter than
people without diabetes.
One program in particular, the Special Diabetes Program for
Indians, has been a major success for diabetes treatment and
prevention programs throughout Indian Country. SDPI, as stated,
was enacted by Congress in 1997. Along with its sister program
for Type 1 diabetes research, it has become the Nation's most
strategic, comprehensive and effective effort to combat
diabetes and its complications.
This success is largely because communities design and
implement their own diabetes interventions that are culturally
appropriate. SDPI currently provides grants for over 300
programs in 35 States.
The success is shown in national data. Because of SDPI, our
communities are reducing individual cholesterol levels, A1C
levels and losing weight. Since SDPI started, end stage renal
disease due to diabetes in our people has gone down by 54
percent.
Treatment for this is the biggest driver of Medicare costs,
about $87,000 per patient per year just by reducing ESRD-D, we
are saving the Federal Government millions of dollars a year
and more importantly, saving the lives of our people.
SDPI is also improving entire tribal communities. For
example, the Pyramid Lake Paiute Tribe focuses on diabetes
education. Over the years, my tribe's diabetes education has
evolved to be conveyed to our tribal youth that diabetes does
not have to be a death sentence as it is often perceived.
Youth are also now more engaged with their aunts, uncles,
grandmas and grandpas. They can help those family members know
diabetes is manageable. We are living longer lives and SDPI is
uniting communities, preserving cultures and filling
generational gaps.
SDPI authorization is set to expire this September. We urge
Congress to act swiftly to reauthorize SDPI and ensure
continuity and the successful prevention and intervention
efforts being conducted all across Indian Country. In addition
to SDPI reauthorization, the National Indian Health Board has
developed other recommendations for tribes and policymakers to
pursue and strengthen diabetes prevention efforts for Native
youth. In the interest of time, I would direct you to our
written testimony for further detailed recommendations.
While tribes have made important gains in recent years in
terms of Type 2 diabetes funding, improved health outcomes and
the leveling off of diabetes incidence rates through
initiatives like SDPI, there is still a long way to go before
Native youth, children and families will no longer be
devastated by the impacts of diabetes and its complications.
Thank you again for the opportunity to offer this
statement. We appreciate being able to work together with you
on this important issue. We look forward to working together on
issues such as confirming an IHS director.
The National Indian Health Board and the 567 federally-
recognized tribes we serve endorsed Dr. Charles Green as IHS
director and will work with the Committee to achieve his
confirmation.
Thank you. If you have any questions, I am more than happy
to answer those.
[The prepared statement of Mr. Hawley follows:]
Prepared Statement of Vinton Hawley, Chairperson, National Indian
Health Board (NIHB)
Introduction
Chairman Hoeven, Vice Chairman Udall and Members of the Committee,
thank you for holding this important hearing on improving the lives and
health of American Indian and Alaska Native youth through preventing
diabetes. Thank you for the opportunity to provide this testimony on
behalf of the National Indian Health Board (NIHB).
The federal promise to provide for the health of Indian people was
made long ago. Since the earliest days of the Republic, all branches of
the federal government have acknowledged the nation's obligations to
the Tribes and the special trust relationship between the United States
and Tribes. The United States assumed this responsibility through a
series of treaties with Tribes, exchanging compensation and benefits
for Tribal land and peace. The Snyder Act of 1921 (25 USC 13)
legislatively affirmed this trust responsibility. To facilitate
upholding its responsibility, the federal government created the Indian
Health Service (IHS) and tasked the agency with providing health
services to AI/ANs. Since its creation in 1955, IHS has worked to
fulfill the federal promise to provide health care to Native people.
To provide context for this discussion, I would first like to
provide you with some health statistics for American Indians and Alaska
Natives (AI/ANs). The AI/AN life expectancy is 4.5 years less than the
rate for the U.S. all races population. AI/ANs suffer disproportionally
from a variety of diseases. According to IHS data from 2005-2007, AI/AN
people die at higher rates than other Americans from alcoholism (552
percent higher), unintentional injuries (138 percent higher), homicide
(83 percent higher) and suicide (74 percent higher). Indian Country
also suffers disproportionately from diabetes at a rate 182 percent
higher than the general U.S. population.
Chronic poverty, historical trauma, remote locations, and a
devastatingly under-funded Indian health delivery system all contribute
to these statistics. The United States is too great a nation to stand
idly by while AI/ANs, the first Americans, live with these realities.
Diabetes in Indian Country
American Indian and Alaska Native (AI/AN) youth, children, and
families face many disparate adverse experiences and health outcomes
compared to the general U.S. population. One of the most prominent
health disparities in Tribal communities is the high rate of type 2
diabetes. AI/ANs of all ages are disproportionately impacted by type 2
diabetes and its many chronic complications- whether through their own
individual diagnosis or the diagnosis of a loved one. The Gila River
Indian Community has reported a 4 year old presenting with type 2
diabetes--and they are not alone. As such, Tribal communities must have
the resources and support they need to access fresh and nutritious
foods, safe places for physical activity, and quality diabetes
treatment and intervention programs.
Because AI/AN traditional subsistence lifestyles have been replaced
with federal programs such as the Food Distribution Program on Indian
Reservations, the Food Stamp Program, and the Commodity Supplemental
Food Program, many Tribal communities have a new reliance on store-
bought foods, poor access to fresh produce, and have increased
consumption of fast foods. These compounding issues have resulted in
American Indian and Alaska Native children suffering from higher rates
of obesity and related complications, such as type 2 diabetes. \1\
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\1\ Story, M. et al. (2003). Obesity in American-Indian Children:
Prevalence, Consequences, and Prevention. Preventative Medicine, 37(1),
S3-S12, S5.
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Even in the general U.S. population, type 2 diabetes is
increasingly diagnosed in youth and now accounts for 20-50 percent of
new-onset diabetes case patients. However, type 2 diabetes
disproportionately affects minority race and ethnic groups--with the
highest rates being among American Indian and Alaska Native youth.
While few longitudinal studies have been conducted, it has been
suggested that the increase in type 2 diabetes in youth is a result of
an increase in obesity in the overall population. \2\ The majority of
studies that have been done have been conducted on American and
Canadian Indigenous populations because of the high rates of diabetes
experienced in Tribal communities. Therefore, we know American Indian
and Alaska Native youth age 10-19 are nine times more likely to have
diagnosed type 2 diabetes compared to young non-Hispanic whites in the
same age group. \3\ Furthermore, from 1990-2009 AI/AN youth age 15-19
experienced an increase in diagnosed diabetes of 110 percent. \4\ While
these statistics are staggering, there are personal stories and real
life implications behind each of the Native youth and families that
have been diagnosed with type 2 diabetes. People with diabetes
diagnosed before the age of 20 years have a life expectancy that is 15-
27 years shorter than people without diabetes. \5\ Given this, it is
more important than ever that Tribal communities work to prevent
diabetes and its complications in young American Indians and Alaska
Natives. One program in particular, the Special Diabetes Program for
Indians (SDPI), has been especially successful in establishing and
sustaining effective diabetes treatment and prevention programs in
Indian Country.
---------------------------------------------------------------------------
\2\ (Dabelea, et al., 2014) (2)
\3\ SEARCH for Diabetes in Youth Study http://www.ncbi.nlm.nih.gov/
pubmed/17015542
\4\ IHS Division of Diabetes Statistics https://www.ihs.gov/sdpi/
includes/themes/newihstheme/display_objects/documents/factsheets/
Fact_sheet_AIAN_508c.pdf
\5\ (Mayer-Davis, et al., 2009)
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Special Diabetes Program for Indians
Because of the rising rates of type 2 diabetes in American Indian
and Alaska Native youth and the U.S. population in general, Congress
established the Special Diabetes Program for Indians in 1997. The SDPI
was first funded through the Balanced Budget Act in conjunction with
the Special Diabetes Program for Type 1 Diabetes (SDP)--a program that
addresses the opportunities in type 1 diabetes research. Together,
these two programs have become the nation's most strategic,
comprehensive and effective effort to combat diabetes and its
complications.
The SDPI is changing the troubling statistics for American Indians
and Alaska Natives of all ages with marked and measurable improvements
in average blood sugar levels, reductions in the incidence of
cardiovascular disease, prevention and weight management programs for
our youth, and a significant increase in the promotion of healthy
lifestyle behaviors. This success is due to the nature of this grant
program that allows communities to design and implement diabetes
interventions that address specific cultural approaches identified
community priorities. The SDPI currently provides grants for over 300
programs in 35 states.
As a result of intensive data collection and analysis over the past
two decades of the SDPI, we are able to demonstrate remarkable outcomes
from SDPI programs, including a reduction in A1C levels, reduced
cholesterol levels, and weight loss of program participants around
Indian Country. Recently, the Centers for Disease Control and
Prevention (CDC) published data in its Morbidity and Mortality Weekly
Report about the remarkable decline in End-Stage Renal Disease (ESRD)
due to diabetes seen in American Indians and Alaska Natives in 1996-
2013. During this time period, similar to that of the SDPI, AI/ANs have
experienced a 54 percent decline in incidence rates of ESRD due to
diabetes--the steepest decline of any other ethnic group. The CDC
report also states, ``because of SDPI, the partnership of IHS and I/T/U
programs is stronger, and together they provide a comprehensive public
health-oriented national program that has demonstrated success in
addressing the diabetes epidemic and reducing complications such as
ESRD-D.'' \6\ ESRD treatment costs Medicare roughly $87,000 per
patient, per year, so SDPI is also resulting in significant cost
savings for federal health programs. \7\
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\6\ (Bullock, et al., 2017)
\7\ U.S. Renal Data System: https://www.usrds.org/2013/view/
v2_11.aspx, Accessed on March 27, 2017.
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As the data shows, the diabetes treatment and prevention programs
funded by SDPI are clearly improving, as well as saving lives, in
Tribal communities and transforming the way diabetes is addressed. For
example, the Alaska Native Tribal Health Consortium's (ANTHC) ``Store
Outside Your Door'' program highlights traditional foods of the Native
peoples living within the region and teaches families how to harvest
and prepare nutritious traditional foods that do not include many of
the preservatives and sugars of the processed foods often available at
local grocery stores. This model makes nutritious foods accessible to
the community and infuses the local Indigenous culture back into
mealtime. Another example of the effective, innovative community health
programming being conducted in Tribal communities around Indian Country
is the ``Cherokee Choices'' program at the Eastern Band of Cherokee
Indians (EBCI). Like many Tribal communities, the EBCI has higher rates
of obesity and type 2 diabetes than the U.S. general population. To
combat these high rates, the Cherokee Choices program includes three
main components: elementary school mentoring, worksite wellness for
adults, and church-based health promotion. \8\ As a holistic approach
to preventing diabetes and obesity in the local AI/AN population,
Cherokee Choices also seeks to address racism, historic grief and
trauma, mental health, and creates a supportive environment for
developing positive policy changes.
---------------------------------------------------------------------------
\8\ Bachar JJ, Lefler LJ, Reed L, McCoy T, Bailey R, Bell R.
Cherokee Choices: a diabetes prevention program for American Indians.
Prev Chronic Dis [serial online] 2006 Jul [date cited]. Available from:
URL: http://www.cdc.gov/pcd/issues/2006/jul/05_0221.htm
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These are just two examples of the over 300 Tribal programs
nationwide taking an innovative, holistic and community- and evidenced-
based approach to preventing diabetes in Native youth, children and
families. As one young American Indian from the Klamath Diabetes
Program stated after participating in the diabetes prevention program
at the Cow Creek Consortium in Oregon, ``I truly believe [SDPI] can
dramatically improve the health of the Klamath Tribes and bring us mo
ben dic hosintambiek (``good health'' in Klamath). I would have never
had the courage or been in the shape necessary to accomplish my goals
had it not been for the Diabetes Prevention Program. It is imperative
that these types of programs are firmly in place to lead us to the next
level of good health''.
Most recently in the long history of the SDPI, in April 14, 2015,
the U.S. Senate passed a two year reauthorization of the Special
Diabetes Program for Indians (SDPI) as part of The Medicare Access and
Children's Health Insurance Program (CHIP) Reauthorization Act of 2015
(P.L. 114-10). The measure passed the Senate by a bipartisan vote of
92-8. This followed action by the U.S. House of Representatives on
March 26, 2015, which also passed the legislation by a bipartisan vote.
SDPI is one of many programs in this legislation. However, the
reauthorization is set to expire on September 30, 2017. Meaning, over
300 diabetes treatment and prevention programs around the country would
no longer be available to the most vulnerable population for this
devastating disease. Congress must act swiftly to reauthorize the SDPI
and ensure continuity in the successful prevention and intervention
efforts being conducted all across Indian Country.
NIHB and Tribes are encouraged by the strong support enjoyed by
SDPI in Congress. In September 2016, a letter addressed to
Congressional leadership in support of SDPI and SDP garnered signatures
from 356 House Members and 75 Senators. We hope that Congressional
leaders make the renewal of these programs a legislative priority in
the coming months. Failure to enact SDPI swiftly will result in the
loss of staff for many SDPI programs living in rural areas and will
cause disruptions to patient care.
Putting First Kids 1st
The National Indian Health Board, in partnership with the National
Congress of American Indians, the National Indian Education
Association, and the National Indian Child Welfare Association have
created a joint policy agenda for American Indian and Alaska Native
children. This agenda, updated in 2015, is intended to be a tool to
develop integrated policy approaches and specific recommendations for
Tribal governments, policymakers, and local leaders to use when
creating and implementing a vision for thriving, vibrant Native
communities. The agenda includes a ``Healthy Lifestyles'' component
that outlines policy recommendations that would specifically help
policymakers and Tribal communities prevent diabetes in Native youth,
children, and families through increasing physical activity, improving
access to nutritious foods, and increasing access to health care and
public health services. \9\ In addition to the swift reauthorization of
the Special Diabetes Program for Indians outlined earlier, the NIHB
puts forth the following recommendations for Tribes and policymakers to
pursue to strengthen diabetes prevention efforts and to make healthy
lifestyles more accessible to Native youth and families:
---------------------------------------------------------------------------
\9\ Native Children's Policy Agenda: Putting First Kids 1st http://
nihb.org/docs/10122015/Aug_2015_Native_Childrens_Policy_Agenda.pdf
Ensure that community food programs, especially youth
breakfast and lunch programs, incorporate healthy food choices
---------------------------------------------------------------------------
and locally produced or traditional food options.
Co-locate food assistance programs to serve meals to elders
along with Head Start, child care, or school programs to reduce
administrative costs and resources.
Work to improve the Food Distribution Program on Indian
Reservations by incorporating more traditional, locally-
produced foods as healthier options.
Provide direct funding to Tribes who want to administer the
Supplemental Nutrition Assistance Program (formerly the Food
Stamp Program).
Work to create similar options for the Women, Infants and
Children (WIC) program and increase Tribal flexibility in
administering this program.
Advocate for Tribal provisions within the National School
Lunch Program and the School Breakfast Program for Tribal
schools.
Work with school nutrition programs to replace junk foods
with healthier options in vending machines and school
cafeterias. These programs should permit Tribal administration
and should ensure that state-administered programs are
sufficiently responsive to the needs of Native youth.
Promote the expansion of retail grocery markets in Native
communities.
Support federal programs that encourage at-home food
production, such as backyard gardens and training on planting
and maintenance.
Work to ensure that Bureau of Indian Education (BIE)
schools receive funding to build and upgrade sports-related
facilities, such as gymnasiums, fields, and tracks to increase
safe places for Native children and youth to be physically
active.
Incorporate wellness programs in health clinics and
facilities. While health care addresses disease prevention and
treatment, wellness encompasses daily lifestyle choices,
environment, emotional and spiritual well-being, and health
education. Through wellness promotion, the incidence of health
problems can be reduced, along with long term health care
costs.
Improve outreach services and health education. For
example, a Tribal diabetes patient education program, which
focuses on teaching people how to manage their disease on a
daily basis, is an important tool for reducing diabetes-related
complications. These programs can also be directed to helping
children manage their diabetes from an early age. Similarly,
community outreach services can help educate people about the
availability of health benefits and teach children to make
healthy choices early in life.
Develop school-based health clinics. Students perform
better in class when they are healthy and ready to learn.
School-based health centers bring the doctor's office to the
school so students avoid health-related absences and get
support to succeed in the classroom.
Conclusion
Thank you again for the opportunity to offer this written
statement. While Tribes have made important gains in recent years in
terms of type 2 diabetes funding, improved health outcomes, and the
leveling off of diabetes incidence rates, there is still a long way to
go before Native youth, children, and families will no longer be
devastated by the impacts of diabetes and its complications.
The Chairman. Thank you, Mr. Hawley.
Mr. Eagle.
STATEMENT OF JARED EAGLE, DIRECTOR, FORT BERTHOLD DIABETES
PROGRAM, THREE AFFILIATED TRIBES
Mr. Eagle. Good afternoon, Committee, and Chairman Hoeven.
Thank you for the opportunity to speak.
My name is Jared Eagle. I am a member of the Three
Affiliated Tribes, the Mandan, Hidatsa, and Arikara Nation.
We serve the people of the Three Affiliated Tribes. We have
benefitted SDPI funding for the last 18 years, 15 of those
mainly in the clinical format with the last three being in the
preventative aspects of it, specifically on youth.
I cannot express enough the importance of the SDPI
initiative and the resources that it provides to our community.
Through SDPI funding, we have been able to provide essential
treatment and prevention initiatives to our over 750 diagnosed
patients and provide prevention services to over 1,200 youth
based through five schools and about 250 square miles.
The focus of our program is to provide access to effective
nutrition and physical activity opportunities that are not
accessible to the people on our reservation in most aspects.
These initiatives include group fitness classes, cooking
classes, grocery store tours, one-on-one dietitian
consultation, and prevention resources through screening and
education.
We live in a food desert. Of the six communities, we only
have two grocery stores in those two communities so access to
fresh produce and healthy foods is very minimal sometimes. The
overweight and obesity rates on Fort Berthold are 55 percent
among youth grades K-12. The adult population is about 86
percent overweight and obese.
The direct link between overweight, obesity and diabetes
prevalence, specifically in Native Americans, and the
importance of SDPI programming could not be more evident for
us.
One major aspect that we incorporate to combat this
epidemic which affects about 15 percent the MHA Nation is our
Healthy Futures Program. Through Healthy Futures, we screen
1,200 youth in grades K-12 to identify if they are in an
overweight or obese status. We identify what their Body Mass
Index is. We screen them; for diabetes, and if they show signs
of being pre-diabetic, they are referred to a more intense
follow-up service with a pediatrician and our clinical staff.
Through this process ,we are able to connect directly with
the parents to make the necessary changes to develop and
instill healthy behaviors and to avoid a lifestyle of chronic
disease.
The work we do at the Fort Berthold Diabetes Program allows
us to connect with the communities, and provides us the
opportunity to reach a broad demographic of people that our IHS
clinic or another hospital simply cannot reach outside of a
traditional medical practice.
Culturally, we are able to create deep and lasting
connections as well as providing services such as traditional
food education, gardening, language and educating at powwows.
Other community gatherings reach into and across the
communities and make a much stronger individual connection to
help save lives. Through SDPI funding we are able to provide
these types of services to reduce the incidence of diabetes,
preserve the health of our people and reduce the long-term
health care costs that they could face.
Thank you for allowing me to witness in front of you today.
I will answer any questions or provide any additional
information you might need.
[The prepared statement of Mr. Eagle follows:]
Prepared Statement of Jared Eagle, Director, Fort Berthold Diabetes
Program, Three Affiliated Tribes
Good afternoon Committee, my name is Jared Eagle, I am the Director
of the Fort Berthold Diabetes Program in New Town, ND. We serve the
people of the Three Affiliated Tribes, the Mandan, Hidatsa, and Arikara
Nation. Our program has benefitted from 18 years of SDPI funding
providing essential diabetes related services to our people ranging
from clinical care and prevention for the first 15 years and
specifically targeted towards prevention initiatives the past three
years.
I cannot express enough the importance of the SDPI initiative and
the resources that it provides to our community. Through SDPI funding
we are able to provide essential treatment and prevention initiatives
to our 750 diagnosed patients and over 1,200 youth spread out among our
six communities and five schools in a 250 mile radius.
The focus of our program is to provide access to effective
nutrition and physical activity opportunities not accessible to the
people on our reservation. These initiatives include group fitness
classes, cooking classes, grocery store tours, one-on-one dietitian
consultation and prevention resources through screening and education.
We live in a food desert, and of the six communities on Fort
Berthold only two have grocery stores and access to fresh produce and
healthy food options. The overweight and obesity rates on Fort Berthold
are 55 percent among youth grades K-12 and 86 percent among the adult
population. The direct link between overweight/obesity and diabetes
prevalence, specifically in Native Americans, the importance of SDPI
programming could not be more evident.
One major aspect that we incorporate to combat this epidemic which
effects about 15 percent of the MHA Nation is our Healthy Futures
Program. We screen 1,200 youth in grades K-12 to identify if they are
overweight or obese. Those with a high Body Mass Index (BMI), are then
screened for diabetes, and if they show signs of being pre-diabetic
they are referred for more intense follow-up services with a
pediatrician and our clinical team. Through this process we are able to
connect directly with the parents to start making the necessary changes
to develop and instill healthy behaviors to avoid a lifestyle of
chronic disease.
The work we do at the Fort Berthold Diabetes Program allows us to
connect with the communities, and provides us the opportunity to reach
a broad demographic of people that our IHS clinic or another hospital
simply cannot reach outside of a traditional medical practice.
Culturally, we are able to create deep and lasting connections as well
in providing services such as traditional food education, gardening,
language and educating at powwows and other community gatherings that
reach into and across the communities and make a much stronger
individual connection and save lives.
Through SDPI funding we are able to provide these types of services
to reduce the incidence of diabetes, preserving the health of our
people and reducing the long-term health care costs that they could
face. Thank you for allowing me to testify and I would be happy to
answer any questions or provide any additional information.
The Chairman. Thank you, Mr. Eagle. We appreciate it.
Mr. Sensmeier, I understand you are in the Magnificent
Seven, is that correct, and you have a new movie coming out
entitled Wind River.
Mr. Sensmeier. That is right.
The Chairman. Give us a quick once-over about your
character in the last movie and what you are going to do in the
next movie.
Mr. Sensmeier. In the Magnificent Seven, I played one of
the Seven starring alongside our national spokesperson and club
alumni, Mr. Denzel Washington. In Wind River, I star alongside
Jeremy Renner, Elizabeth Olsen and Graham Greene. It takes
place on the Wind River, Wyoming Reservation. It is a murder
mystery. I am not going to tell you too much about that. I will
let you go see it.
STATEMENT OF MARTIN SENSMEIER, ACTOR AND AMBASSADOR, BOYS &
GIRLS CLUBS OF AMERICA
Mr. Sensmeier. Chairman Hoeven, Ranking Member Udall, and
distinguished members of the Committee, I want to thank you for
the opportunity to testify at today's hearing.
[Greeting in Native Language.]
My original name is [phrase in Native Language]. I am from
the Eagle Bear Clan of the Tlingit Tribe of Alaska.
As a Native American actor and Native ambassador of Boys &
Girls Clubs of America, it is an honor to be here today to
advocate for wellness among Native people of all Nations,
focusing largely on our youth.
Growing up, I attended the Boys & Girls Club of Alaska and
learned early the benefits of a healthy and active lifestyle.
Health is not just about physical and medical, it also impacts
how young people cope with emotional and mental health.
I am privileged to be an Ambassador for the Boys & Girls
Clubs of America and I am a member of the Native Wellness
Institute as well as an Ambassador for the Nike N7 Fund. These
platforms have provided an opportunity to reach out to more
youth and play a role as a mentor and advocate promoting
healthy life styles for our Native youth.
As a former Club kid, I can testify to how Boys & Girls
Clubs on Native Lands are working to decrease the high rates of
diabetes and obesity in Indian communities though physical
activities, nutrition, and education.
For 25 years, Boys & Girls Clubs of America has established
an enduring presence on Native lands. Currently, there are
nearly 200 Boys & Girls Clubs serving over 86,000 Native youth,
from over 100 different American Indian, Alaska Native and
Hawaiian communities in 27 States.
As the Nation's largest service provider to Native youth,
Boys & Girls Clubs in Indian Country are committed to
addressing unique to Native lands through increasing culturally
relevant and meaningful opportunities.
Healthy eating and being active has always been a major
part of my life. I have been so excited to see the partnership
between the Boys & Girls Clubs of America, the National
Congress of American Indians and the Indian Health Service on
programs such as TRAIL to diabetes prevention that is making
healthy living an essential part of the club members'
experience.
Even more exciting, however, is the IHS funded program that
looks to include traditional food in activities so that youth
are connecting with their culture as well as keeping their
bodies healthy. I have heard directly that some of the clubs'
kids are getting introduced to dried moose meat. It is
personally one of my favorites.
The TRAIL Program has reached over 14,000 Native youth in
communities across our Country, including my home State of
Alaska. I would personally like to thank IHS, NCAI, BGCA and
Congress for their continued support of this impactful program
that encourages healthy habits and resiliency in Native youth.
It has made a profound difference in Indian Country. I have
no doubt it will continue to do so as this Committee lends its
direct support. Additionally, through BGCA's Healthy Habits
program that serves K-12, youth learn to adopt healthy eating
habits. The lessons cover dietary guidelines, understanding
food labels, strategies to increase food and vegetable
consumption and interactive healthy cooking demonstrations.
Roughly 91 percent of participants reported maintaining or
improving their nutrition and healthy habits. Successes were
achieved through increasing knowledge about healthy nutritional
choices, teaching how to identify healthy options in the
grocery store and demonstrating healthy meal preparation. This
also includes sharing lessons learned with families and
community elders.
Additionally, Triple Play, BGCA's comprehensive health and
wellness program, strives to improve the health of Club members
ages 6 to 18 by increasing their daily physical activity and
teaching them good nutrition. This program utilizes three
components: mind, body and soul.
The mind component teaches youth to eat smart through the
power of choice, calories, vitamins and minerals, the food
pyramid and appropriate portion size. The body component boosts
Clubs' traditional physical activities to a higher level by
providing sports and fitness activities for all youth. The Soul
component helps build positive relationships and cooperation
among youth and young people.
In addition, Clubs provide programming that incorporates
tribal-focused, non-traditional sports, such as cultural dance,
canoeing and archery; while nutrition programs incorporate
local, cultural foods and culinary customs to ensure kids are
moving and eating a balanced, healthy diet. Generations of
children currently benefit from investments in programs at
Clubs which help them grow into healthy, responsible adults.
I would like to say that the Boys & Girls Clubs of America
has been a very integral part of my success. I am directly
affected by diabetes. My dad has diabetes. I am proud to use my
platform to be a part of this movement to stop diabetes in
Indian Country.
Again, I thank the Committee. We appreciate your interest
in this critical issue. I am happy to respond to any questions
you may have regarding the movies or the movement.
[The prepared statement of Mr. Sensmeier follows:]
Prepared Statement of Martin Sensmeier, Actor and Ambassador, Boys &
Girls Clubs of America
Chairman Hoeven, Ranking Member Udall, and distinguished members of
the Committee, thank you for the opportunity to testify at today's
hearing. My name is Martin Sensmeier of Tlingit, Koyukon-Athabascan,
and Irish descent. I was raised in a Tlingit Coastal Community in
Southeast Alaska and grew up learning and participating in the
traditions of my Tribe. As a Native American actor and Native
ambassador of Boys & Girls Clubs of America, it is honor to be here
today to advocate for wellness among Native people of all Nations,
focusing largely on youth.
Growing up, I attended the Boys & Girls Club of Alaska and learned
early the benefits of a healthy and active lifestyle. Health is not
just about physical and medical, it also impacts how young people cope
with emotional and mental health. Throughout my life and career as an
actor it has been important to maintain these habits. I am privileged
to be an Ambassador for the Boys & Girls Clubs of America and I am a
member of the Native Wellness Institute. These platforms have provided
an opportunity to reach out to more youth and play a role as a mentor
and advocate promoting healthy life styles for our Native youth.
As a former Club kid, I can testify to how Boys & Girls Clubs on
Native Lands are working to decrease the high rates of diabetes and
obesity in Indian communities though physical activities, nutrition,
and education. For 25 years, Boys & Girls Clubs of America has
established an enduring presence on Native lands and has committed to
improving the capacity of Boys & Girls Clubs to serve these youth.
Currently, there are nearly 200 Boys & Girls Clubs serving over 86,000
Native youth, from over 100 different American Indian, Alaska Native
and Hawaiian communities in 27 states.
Boys & Girls Clubs of America continues its pledge to assist
communities and expand youth development in Indian Country. Such
efforts have been demonstrated by the establishment of the Boys & Girls
Clubs of America's Native Services in 2013, and growth in national
staff, many who are Native themselves, that work across the country to
support our Club professionals. As the Nation's largest service
provider to Native youth, Boys & Girls Clubs in Indian Country are
committed to addressing the challenges and issues unique to Native
lands through an increase in opportunities that are culturally relevant
and meaningful.
While many Native youth thrive and succeed in life, as a whole they
are one of our country's most vulnerable populations. Persistent issues
of unemployment, poverty, physical and sexual abuse and a host of other
risk factors existing in Indian Country, have created a climate where
suicide, alcoholism and drug abuse amongst tribal youth is perpetuated.
There are many statistics that paint an alarming portrait of the well-
being of Native youth in America today. Because time is limited, I will
offer just two that we are here today to discuss.
1. Native American youth have disproportionally high rates of
obesity and diabetes relative to the American populations.
2. The rate of type-2 diabetes among AI/AN youth is nearly 3
times the national average.
Research found that 12-19 year-old AI/AN youth participating in a
survey consumed fruits, vegetables and dairy products less than once
per day, which is below the recommended dietary allowance.
There are multiple factors that have led to the decline in physical
activity and poor nutrition habits across our Native lands. On many
Native lands, families are likely to purchase foods that are locally
accessible, familiar and convenient to prepare, but may be lacking in
nutritional value. Youth many not learn the skills and tools to prepare
healthy, balanced meals at home. This contributes to obesity,
malnutrition related diseases, and a pattern of poor eating habits.
Because of the relationship between diet and obesity, Clubs are
promoting healthy eating behaviors that can help decrease the
prevalence of obesity. Boys & Girls Clubs on Native Lands provide the
greatest opportunity for impact. Boys & Girls Clubs of America's vision
is to turn these Clubs into models of wellness, improving the nutrition
and health of youth and families in some of our nation's most
impoverished communities.
Through programs like the Boys & Girls Clubs of America's Healthy
Habits program that serves K-12, our Clubs empower Native youth with
the knowledge and resources to adopt healthy eating habits. Healthy
Habits provides outcome-driven nutrition education opportunities for
Club members, which is critical to improving their health and wellness.
In 2016, 16 Boys & Girls Clubs in Indian Country from across the
country representing various tribal communities provided healthy meals
and nutrition education utilizing BGCA's Healthy Habits program in a
culturally sensitive and age appropriate way. Lessons covered dietary
guidelines, understanding food labels, identifying food groups,
strategies to increase fruit and vegetable consumption, and interactive
healthy meal and snack cooking demonstrations. Clubs reported that,
with consistent participation in the program, youth have begun to share
new information and healthy eating strategies with their families.
Native Clubs that implemented the Healthy Habits program reported
progress made to promote health and wellness among youth and the
greater community. Roughly 91 percent of participants reported
maintaining or improving their nutrition and healthy habits,
specifically 74 percent improved and 17 percent maintained. Successes
were achieved through increasing knowledge about healthy nutritional
choices, teaching how to identify healthy options in the grocery store
and demonstrating healthy meal preparation. This also includes sharing
lessons learned with families and community elders.
Other programs like, Triple Play, BGCA's comprehensive health and
wellness program, developed in collaboration with the U.S. Department
of Health and Human Services, strives to improve the overall health of
Club members ages 6-18 by increasing their daily physical activity,
teaching them good nutrition and helping them develop healthy
relationships. This program utilizes three components, Mind, Body and
Soul. The Mind component encourages young people to eat smart through
the Healthy Habits program, which covers the power of choice, calories,
vitamins and minerals, the food pyramid and appropriate portion size.
The Body component boosts Clubs' traditional physical activities to a
higher level by providing sports and fitness activities for all youth.
Body programs include six daily fitness challenges; teen Sports Clubs
focused on leadership development, service and careers in athletics;
and Triple Play Games Tournaments, inter-Club sectional tournaments
that involve multiple team sports. The Soul component helps build
positive relationships and cooperation among young people.
In addition, Clubs provide programming that incorporates tribal-
focused, non-traditional sports, such as cultural dance, canoeing and
archery; while nutrition programs incorporate local, cultural foods and
culinary customs to ensure kids are moving and eating a balanced,
healthy diet.
According to the 2013 United States Census, American Indians/Alaska
Natives had a higher rate of poverty than any other racial group, which
was 29 percent as compared to the national poverty rate of 15 percent.
Due to high poverty rates, access to healthy food options may be
limited. As such, meals and snacks provided during Club hours may be
the only or last meal a child eats during the day.
Over a lifetime, the medical costs associated with childhood
obesity are about $19,000 more per child than those for a child of
normal weight. \1\
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\1\ Finkelstein, E.A., Graham, W.C.K. and Molhotra, R. (2014).
``Lifetime Direct Medical Costs of Childhood Obesity,'' Pediatrics,
Vol. 133, No. 5, 854-862, http://pediatrics.aapublications.org/content/
133/5/854.short.
Every 100 youth Boys & Girls Clubs help develop habits that
enable them to maintain a healthy weight, could save as much as
---------------------------------------------------------------------------
$1.9 million in lifetime medical costs.
According to the Centers for Disease Control and
Prevention, 31 percent of Native Youth are obese, a rate 177
percent higher than that of the general population. Whereas
only 30 percent of all U.S. youth get physical exercise every
day, Boys & Girls Clubs' outcome data reports 60 percent of
Native Club youth exercise 5 or more days per week.
For 25 years, Boys & Girls Clubs in Indian Country have proven to
be a game-changer for Native youth, by helping them overcome the many
societal issues and personal obstacles they face in their communities
and home environments. We would not have been nearly as successful
without partners like the Indian Health Services and the National
Council of American Indians.
Boys & Girls Clubs will continue to play a critical role in
breaking a perpetual cycle of extreme poverty, low academic
performance, and significant health problems. We envision Native youth
on their path to great futures, succeeding in school, becoming
community leaders, assuming roles as contributing members of the
workforce, and engaging in regular physical activity and good
nutrition.
Boys & Girls Clubs in Indian Country have an unprecedented
opportunity to help more Native youth to lead sustainable change, while
embracing their culture and traditions. We believe generations of
children to come will benefit from investments in programs and
services, such as Boys & Girls Clubs, that help them grow into
responsible adults--and that America stands to gain from the increased
productivity and contributions of these future citizens and Native
leaders.
Again, thank you to the Committee, we appreciate your interest in
this critical issue. We are happy to respond to any questions.
The Chairman. Thank you, Mr. Sensmeier.
Mr. Sensmeier. Thank you.
Mr. Villegas and Ms. Seepie.
STATEMENT OF ALTON VILLEGAS, TRIBAL YOUTH, SALT RIVER PIMA-
MARICOPA INDIAN COMMUNITY;
ACCOMPANIED BY RACHEL SEEPIE, SENIOR FITNESS
SPECIALIST, DIABETES SERVICE PROGRAM--HEALTH
SERVICE
Mr. Villegas. Good day, everybody. My name is Alton
Villegas.
I am 11 years old and going to be turning 12 in December. I
am the oldest brother in my family. I have two really good
friends Lorenzo Klein Romero and James Upshaw.
I am a member of the Salt River Pima-Maricopa Indian
Community. I am a member of the fifth grade at Salt River
Elementary School. I like my school very much and my favorite
subject is reading. I also like sports like cross country and
wrestling.
When I am home, I like to go jumping on my trampoline with
my siblings. Soon, because it is almost summer, I get to go
swimming.
Last summer I went to a diabetes prevention camp which is
funded by the SDPI grant. My mom and my grandma have diabetes.
A lot of people in Salt River have diabetes, sadly. I think a
lot of people have diabetes because they do not eat healthy and
they do not exercise.
I want to be healthy so I went to camp. I wanted to be able
to help my mom and my grandma be healthier. I also wanted to
show my brothers and sisters how they could be healthier. When
I was there, I lost nearly 16 pounds. I am not done.
Camp also helped me make better choices in what I eat and
they taught me that playing outside was fun and not boring.
When I came home from camp, my family thought I would like to
have a hamburger, fries or a pizza but I did not want that or
the salt. At the time, I did not eat the salt, I did not eat
all of it.
Like Mr. Hoeven said, that is my idea, order a salad.
Chicken Caesar is really good. You should go there.
They were very surprised. I remembered eating junk was not
okay, but if I did that, the program taught me eating good and
exercising, I would lower my sugar and feel better and I did. I
cannot wait to go back to camp again this year. I know I will
learn more and will have a lot of fun.
I think more kids would learn from the diabetes camp and
they can help other people in Salt River to be healthier so
they will not be sick.
I would like to invite you to come to Arizona in the
summer. We go to camp where it is not so hot. I want you to see
our camp.
Thanks for helping me and helping my mom and my grandma.
[The prepared statement of Mr. Villegas follows:]
Prepared Statement of Alton Villegas, Tribal Youth, Salt River Pima-
Maricopa Indian Community; Accompanied by Rachel Seepie, Senior Fitness
Specialist, Diabetes Service Program--Health Service
Background
The Salt River Pima-Maricopa Indian Community appreciates the
opportunity to provide oral and written testimony to the Senate Select
Committee on Indian Affairs on the Special Diabetes Prevention
Initiative, particularly relating to prevention of diabetes among
Native Youth through Healthy Living.
The Salt River Pima-Maricopa Indian Community (Community) is a
federally recognized tribe created by federal Executive Order on June
14, 1879 and is the homeland of two distinct tribes; the Pima--``Onk
Akimel O'odham'' (River People), and the Maricopa--``Xalychidom
Piipaash'' (People who live toward the Water). The Community is
comprised of 52,600 acres, with 19,000 held as a natural preserve,
which are divided into Community-owned land and individual allotments.
SRPMIC consists of two geographical areas; the Salt River and Lehi
Communities that are separated by the Salt River, with the Lehi
Community located south of the river. The Community lands are adjacent
to the Phoenix metropolitan area in central Arizona and located within
Maricopa County. SRPMIC shares a common boundary with the cities of
Mesa, Tempe, and Scottsdale, town of Fountain Hills and Ft. McDowell
Yavapai Nation. Current total enrolled membership is 10,378 of which
approximately 6,000 members reside within the Community's boundaries.
Unlike many remotely located Indian reservations, SRPMIC lies
within a county determined to be one of the most rapidly growing
metropolitan populations, which has brought two major commuter freeways
to the Community. However, the Community still lags far behind the
United States and nearby adjacent cities in both social and economic
development and experiences social and health problems similar to those
found on more remotely located reservations.
Medical services are provided by a combination of Indian Health
Service (Phoenix Indian Medical Center and the Salt River Health
Clinic), regional healthcare corporations (Scottsdale Osborn Hospital
and Mayo Clinic), and private practice providers located throughout the
metropolitan area.
In addition, the Community supports a Department of Health and
Human Services (HHS) which provides clinical staff working in
coordination with federal providers at the Salt River Health Clinic.
Within HHS, there are Public Health workers, Behavioral Health
therapists, Prevention and Intervention services, psychiatrists, WIC
and other administrative staff. These programs are supported not only
with tribal funds but other grant funding.
The Community has over 10,000 enrolled members and approximately
6000 of our members live in Salt River. 39 percent of our members are
under age 18. 53 percent of our members are female and 47 percent are
male. The five year rolling average age of death for 2016 and the four
preceding years is 48.19 years of age for males and 58.09 years of age
for females. The highest number of deaths occur in the age group 20-45.
Many of the deaths are related to diabetes and its' complications.
Special Diabetes Prevention Initiative in SRPMIC
The Community Council has identified reducing the prevalence of
diabetes in the Community as a needed priority. The Council views the
prevalence of diabetes and resulting complications as one of the
related causes to the early death rates in the Community. The
consequence of these early deaths are devastating for the children,
families and the Community.
Health issues in the Community have been identified by the elected
Community Council, Diabetes Advisory Team (DAT), and obesity screening
by the elementary and high school nurses.
Since many of our tribal members and their families receive health
care through the Indian Health Service, we are able to pull the
following data from the electronic health record system for the time
period January 1, 2016--December 31, 2016.
There are 1062 patients from the Salt River Community who are in
the Diabetes Registry. We know from the data that there are more
females than males who are diabetic and seeking medical care. We also
know that the prevalence is highest in the age grouping 45-64 years of
age. The diabetics in our Community are almost all Type 2 diabetics who
are obese or severely obese with a majority being diagnosed 10+ years
ago. There is a high number of these patients who have been diagnosed
with hypertension (829) and also some patients diagnosed with
cardiovascular disease (277). Almost half of those diagnosed with Type
2, have chronic kidney disease.
Gender: Female = 652; Male = 410
Age: <20 yr = 12; 20-44 = 278; 45-64 = 547; 65>= 225
Type Type 1 = 1; Type 2 = 1061
Duration of Diabetes: Less than 1 year = 33; Less than 10 years
= 401; More than 10 years = 467
For those participating in Diabetes treatment, 26 percent use diet
and exercise to help control their diabetes. They may also use the diet
and exercise in combination with insulin 43 percent or metformin 31
percent.
The SRPMIC Diabetes Services Program, is community based and
operates within the Department of Health and Human Services (DHHS)
Division of Health Services. The Salt River Health Clinic is a unique
partnership between the Indian Health Service Phoenix Indian Medical
Center (PIMC) and the DHHS. The Diabetes Services Program collaborates
with the SRPMIC Clinic providers to ensure coordination of services,
and to address the Community members' need for prevention and treatment
at every stage
SDPI--Youth Focus
Approximately 3 years ago we had a 6 year old child diagnosed with
Type 2 diabetes and we identified the youngest person being dialyzed
was age 25. This situation led to greater partnering with the schools
and families to have a greater impact on diabetes diagnoses and
prevention.
Screening in the schools revealed that 52 percent of the students
are above the 95th percentile for weight demonstrating a critical need
for more intervention with children, youth, and their families focusing
on increased fitness to reduce the risk for diabetes. The screening
data suggests that children's weight begins to dramatically increase by
the age of 9.
The following diabetes related health issues also impact the youth:
The Community experience challenges and barriers for
diabetes prevention, including the Community culture.
Accessing nutritious food is difficult for Community
residents.
Existing diabetes intervention services need to be
expanded.
Programs do not always reach the people that need the
services.
People need the intervention to fit their needs.
Why the SDPI is Important to the Salt River Pima-Maricopa Indian
Community
Innovative Programming
The SDPI grant has afforded several opportunities to the Community
to explore innovative approaches to diabetes prevention and
intervention that go beyond the traditional nutrition and exercise
curricula. The SRPMIC Diabetes Services Program has hosted two
instances of Yoga Teacher Training (YTT) in partnership with the non-
profit Conscious Community Yoga to create certified yoga instructors.
Yoga is a great low-impact introduction to exercise that takes a
holistic approach to health and wellness. To date, approximately 12
individuals have completed the YTT and conduct yoga classes within the
Department of Corrections (DOC), Journey to Recovery (residential
treatment), and at the Fitness Center. Participants at the DOC have
seen encouraging outcomes related to blood pressure and an increased
general sense of calmness. Interestingly, the DOC program has a higher
attendance from the male population than the female population.
More recently, the SRPMIC Diabetes Services Program is sponsoring a
traditional Chinese medicine (TCM) approach to health and wellness
called the 5 Elements Wellness Program. The Community has partnered
with a local TCM practitioner, Dr. Qingsong Xiao, to conduct a 12-week
program that includes exercise, wellness education, herbal supplements
and acupuncture. Participants report incredible outcomes that include
several point decreases in A1c readings, an increase in energy and
activity level, better and more consistent sleep, and weight loss. This
has become a very popular program within the Community, and HHS has
included a children's component to the program that started at the end
of February, 2017.
Collaborations with Women, Infants and Children (WIC) and the School
The Diabetes Program partners with other programs to reach all ages
of the Community. The WIC supervisor has a team of four that works with
families to educate on the importance of breastfeeding, preparing and
eating nutritious meals and managing gestational diabetes. The fitness
center staff also assist with offering child friendly exercises during
FIT WIC sessions so parents learn about the importance of starting
physical activity at a young age.
There are two schools on the reservation serving children from pre-
school through 12th grade. The Diabetes program has been able to
collaborate with the schools in teaching students about eating healthy
and staying active. One initiative known as #GetFit, aims to teach
student athletes in becoming role models, wellness champions, to fellow
students. The program this year was expanded to reach the parents of
student athletes and Physical Education students. Through this program
families have the opportunity to learn healthy lifestyle behaviors as
well as setting healthy goals as a family.
The Diabetes Camp
The American Indian Youth Wellness (Diabetes Prevention) Camp was
established in 1991. Through a collaborative partnership with the
University of Arizona and other tribes these one week camps are
continuing to be offered. Salt River Pima-Maricopa Indian Community has
been participating in camp since the mid 1900's. Every summer in June,
the Diabetes Program has been able to pay for and send 20 students and
8 volunteers to camp. The camp involves American Indian youth from
tribes across the Southwest, primarily Arizona, to a one week intensive
residential camp. At camp, kids learn healthy eating habits and ways to
make exercise fun, consistent, and habitual. The best part of camp is
that activities take place in an American Indian context, deeply rooted
in culture. This integration increases our effectiveness and makes
health fun.
Community Wellness Activities
Every year the SRPMIC Diabetes Services Program is able to organize
and host several walks within the Community to encourage physical
fitness and as outreach for the program itself. Families are encouraged
to walk together, often you will see not only the parent, but also the
grandparent participating. Additionally, the fitness staff are often
called upon by other departments to lead warm-up exercises for
activities, i.e. the annual Fall Overhaul which is an Administration
hosted event as a community service project for employees; collaborate
on certain awareness campaigns such as walks for domestic violence, and
suicide prevention.
Summary
The Community appreciates the opportunity to provide testimony on
the Special Diabetes Prevention Initiative and the impact that it has
had on youth wellness. We appreciate the support of Congress in
ensuring that the program continues to be available so that our goal of
Community wellness can be achieved.
The Chairman. Thank you, Mr. Villegas, that was very good.
Ms. Seepie.
Ms. Seepie. Good afternoon, Chairman Hoeven, Vice Chairman
Udall and members of the Committee.
My name is Rachel Seepie and I am a member of the Salt
River Pima-Maricopa Indian Community in Arizona.
It is an honor to appear before you to share my personal
journey and let you know how important SDPI has been for me and
many members of the community. My community, the Salt River
Pima-Maricopa Indian Community, has over 10,000 enrolled
members; approximately 6,000 members live within the borders of
the community.
Demographically in our community, nearly 40 percent of our
members are under the age of 18. By gender, 53 percent of our
members are female, 47 percent are male. As you may be aware,
the Pima have been the subject of national surveys, news pieces
and other studies documenting the high rate of diabetes that
exists.
For example, the five-year rolling average age of death of
our community for 2016 was 48 years old for male and 58 years
old for female. Many of these deaths are directly related to
diabetes and its complications.
For many years, the SDPI grant has approved a program for
the Committee to give nutritional education and physical
activity to prevent diabetes and help those with Type 2
diabetes to lead a healthier lifestyle. I believe with
continuation of the grant, more community members of the Salt
River Pima-Maricopa Indian Community will learn what is needed
to have a healthier lifestyle.
In my own experience, the program has helped me strive to
have a healthier life. I am the mother of three children. I
learned through the years that physical activity is the key to
staying healthy with Type 2 diabetes. Yes, I do have Type 2
diabetes. I have been controlling my Type 2 diabetes with
eating well and exercising.
When I was first diagnosed with Type 2 diabetes, I did take
medication to control my diabetes. At one time, I decided that
I did not want to take medication anymore. I used what I
learned from our program in our community to control my
diabetes, healthy eating and physical activity. Some of the
physical activities I am involved in are aerobic exercise
classes, hiking, and running long distance triathlons. For the
past ten years, I have run six marathons, 10 half marathons and
many triathlons.
The personal achievement I am most proud of is finishing
two Iron Man triathlons. I will always remember when I crossed
the finish line after swimming 2.4 miles, biking 112 miles and
running a marathon which is 26.2 miles, the announcer saying,
you are an Iron Man. I heard that twice.
I am also involved in teaching group exercise classes for
both youth and seniors in my community. As a result, I have
felt healthier and hopefully the people who come to my classes
feel healthier also.
I see my doctor and I have positive results. My blood sugar
levels have gone down to near normal. My heart rate is low,
which means my heart is healthy and strong and I have lost
weight myself.
I believe because of the SDPI grant I have more information
I need to take care of myself and my family and to live a
healthier life so my children can live their lives without Type
2 diabetes.
My vision is that the Salt River Pima-Maricopa Indian
Community and our members will learn how to become healthier
and that they will have long, full lives without Type 2
diabetes.
Thank you for allowing me to share these few words. I am
happy to answer any questions.
The Chairman. Ms. Seepie, your record running marathons and
the Iron Man contest is remarkable.
Ms. Seepie. Thank you.
The Chairman. An amazing achievement and very impressive.
Again, we appreciate all of our witnesses very much. At
this time, I will turn to Senator Murkowski.
Senator Murkowski. Thank you, Chairman Hoeven. I appreciate
it.
Thank you to all of our panelists. I think in so many
different ways, you each are such significant role models for
others. Some may be doing it in a more high-profile way, like
you, Martin, or perhaps Alton, it is what you can do as you go
back to your classroom and talk to other kids about why it is
important to each healthy.
The lessons that have shared with us today are all very
real takeaways that can make a difference. I think we recognize
that so much of this is education. We have talked about the
significance of the SDPI program and all that is.
Education only goes so far. You have to act on it and take
that step to do the exercise. You have to take that step to
order the salad. You have to be proactive with it.
Martin, I noted that it was not too long ago that you flew
back up to Juneau to attend the Gold Medal Basketball
Tournament that is going on there. Again, it is one of these
things where you are flying incredible distances to go to be
somewhere where I guess you probably did really love basketball
growing up in Yakutat but the fact of the matter is this gives
you an opportunity to role model for these other kids so that
they see that exercise can be fun.
Can you speak a little bit to this whole aspect of being
the role model to get others to be motivated and change
behavior because I think this is such an important part of what
we are trying to do here.
Mr. Sensmeier. Yes, we got a gold medal. I think it is one
of the oldest, if not the oldest, tournament in the United
States, the 71st annual tournament this year. I grew up going.
My dad took me. My dad was a Golden Gloves boxer and he started
taking me to Gold Medal when I was eight years old.
Basketball has actually become a part of our culture.
Physical fitness has always been a big part of my life.
Growing up and attending the Boys & Girls Club, I always
had access to that. I had good role models there I looked up to
and also mentors who encouraged me to dream big. I was always
taught that physical fitness and applying myself, learning
nutritional education and all those things that were provided
through the clubs would help me get to the level where I am
today. I believe that.
There is a quote by Kevin Spacey that says if you should be
so lucky to make it to the top, it is your duty to send the
elevator back down. I think given the platform I have been
blessed to have, I feel it is important, it is a responsibility
to promote healthy and active lifestyles in our communities to
prevent diabetes and other issues we are dealing with.
Senator Murkowski. We appreciate your leadership and that
role modeling that goes on.
I was struck, Mr. Eagle, with your testimony coming from
Fort Berthold. You talked about lack of access to healthy
foods, the fact that in your reservation stores, available
fresh produce is limited.
It strikes me that you are in very much the same situation
we have up north in Alaska where 80 percent of our communities
are not connected by road, so you have food that is flown in
and it is expensive, if you can get it.
Quite honestly, oftentimes it has been sitting somewhere
for a long period of time. By the time it gets to the main hub
and gets out to the village, if it is lettuce, it is brown,
wilted, or dead and nothing that anyone would want to eat.
Kids do not know what color a banana should really look
like because by the time it gets to a village, it is really not
fit for consumption. So many of our kids have grown up not only
not tasting these good, healthy foods, but if they are able to
taste it, they are bad by then so they do not like it.
When we think about the education we are building, that is
great but we also have to be able to have the access. I know
that through USDA and FDA, we have allowed our schools in
Alaska, several of our village schools, to accept donated
traditional foods that can be served as part of the school
lunch menu.
You are having good fish. They are making fish soup instead
of opening a can of chili made somewhere else and loaded with
preservatives and whatever they load it with. Making sure we
have access to the good, healthy traditional foods I think is
so important.
We also need to make sure that again we have a way to help
get the good food available at an affordable price. We do have
our programs out there through SNAP and some of the others, but
I look at the connection between the debilitating disease that
can be arrested if we are able to focus on diet and exercise.
If we cannot make that good food available, we are still
very, very challenged. Know this is something I want to
continue to work on with the Committee. We have things like
essential air service that help us lower our prices for food.
That is on the budget floor right now. It is something we have
to address. That is a subject for another time.
Thank you, Mr. Chairman.
The Chairman. Senator Murkowski, you are right. I agree.
Senator Franken.
Senator Franken. Thank you, Mr. Chairman, again.
As I said in my opening, I have been working on the fight
against diabetes since I got here. I, along with Senator Lugar
of Indiana, got the National Diabetes Prevention Program into
the ACA. It is a program that works with people who are pre-
diabetic and their glucose levels are elevated. It gives them
16 weeks of training in both exercise and physical training and
16 weeks in nutritional training. It works.
It has been demonstrated to work. It especially works in
older people who are pre-diabetic. They are 70 percent less
likely to become diabetic in the next five years if they take
the 16-week program. That is why CMS covers it under Medicare
if you are on Medicare.
Can you tell me, Admiral, about the programs in IHS and how
the Indian direct program may differ? Are you familiar with the
National Diabetes Prevention Program?
Mr. Buchanan. I am not familiar.
Senator Franken. It is something that WISE did with the
CDC. It is 16 weeks of nutritional training accompanied with 16
weeks of physical training. What is the program in Indian
Country?
Mr. Buchanan. The program in Indian Country takes a
holistic approach as was mentioned earlier in some of our
discussions. Some of the ideas that were mentioned related to
education, physical activity, those sorts of things. We cannot
forget social economics that play a big part in this.
Senator Franken. Is there a protocol? Is there a specific
protocol?
Mr. Buchanan. Could you ask the question again?
Senator Franken. Is there a specific protocol to the
program? In other words, the National Diabetes Prevention
Program has 16 weeks of physical training and then nutritional
training. I know it encompasses those elements of nutrition and
exercise.
I was wondering is there a period of time in which it is
taught?
Mr. Buchanan. With the special diabetes program, we accept
applications and it is based on the submissions from the
applicants. We have tool kits that are developed and utilized.
We utilize best practices we learned as described in some of
the testimony provided earlier. It is really a community-based
program.
Senator Franken. It is different for each area?
Mr. Buchanan. Correct.
Senator Franken. I understand.
A few years ago, I was not in Salt River, but I was in Gila
River and they have a resort there that at the time had the
best golf course in the Starwood system and the only five-star
restaurant in Arizona.
They showed me around their hospital, which was a great
state-of-the-art hospital. But they pointed me to three out
buildings, I think it was three, and they said those are our
dialysis buildings.
They have a five-star restaurant at the resort which is
like 15 miles from where everyone lives, but where everyone
lives is a food desert. I just think that is an enormous issue.
It is hard to eat well when that food is not available. Every
time I see them, the Gila River folks, I ask them what is going
on with that.
It just seems if you have a five-star restaurant 15 miles
away, wherever you are getting that produce at the five-star
restaurant, you can get some of it to where you live. I was
wondering if anyone had any comments on that. Mr. Eagle?
Mr. Eagle. Maybe I am answering your question wrong as well
but as far as SDPI goes and best practices. Those best
practices allow us to do a multidimensional array of things
from grocery store tours to having DPP. We run DPP in our
program.
Senator Franken. You do?
Mr. Eagle. It is through collaboration with the North
Dakota Health Department, with our local IHS and we utilize the
TRAIL Program with the Boys & Girls Clubs. We use that program
in our schools and have been doing that for over ten years and
we are not a Boys & Girls Club.
SDPI allows us to be very multidimensional and to reach all
those different aspects that meet the needs of our people. As
you said, nothing is the same in Utah or Montana. Nothing is
the same in Fort Berthold as it is in Spirit Lake or Belcort.
We are all a bit different. You meet the needs of your people
through the services they want to see.
Senator Franken. Right. Thank you, Mr. Eagle.
Thank you.
The Chairman. Senator Heitkamp.
STATEMENT OF HON. HEIDI HEITKAMP,
U.S. SENATOR FROM NORTH DAKOTA
Senator Heitkamp. Thank you, Mr. Chairman and Vice Chairman
Udall for having this hearing.
One thing I want to examine is the intersection of diabetes
prevention with behavior and mental health and the
complications that having other challenges in communities
presents beyond food deserts.
When someone is suffering from chronic depression, it is
not likely they are going to be compliant or even capable maybe
at that point in their life of doing the great work that our
witnesses talked about today, running a triathlon or educating
a whole family about the value of nutrition.
I would like to talk a bit about how we can do a better job
holistically because I think when we just focus on one piece,
we miss the rest. For instance, some of the highest rates of
tobacco usage in my State are in Indian Country. You know this,
Jared.
How do we incorporate broadly additional programs to meet
all the challenges that I think would maybe achieve better
results? We will start with you, Admiral.
Mr. Buchanan. In 1997, when the program first started, IHS
awarded $30 million. Thirty percent of our facilities had
diabetes clinical program teams. Since that time, in 2004, we
were currently funded at $115 million, that number went up well
above 97 percent.
The diabetes clinical program team can vary depending on
the resources available and those sorts of things with
physicians, nurses and behavioral health specialists being a
part of that team and taking that holistic approach.
We have come a long way from 1997 to now. Continuing that
with some of the best practices is an approach forward.
Senator Heitkamp. Vinton?
Mr. Hawley. Building public health systems within tribes
would definitely help assist tribes with behavioral health
issues. I think with SDPI, it also gives the tribes, as Mr.
Eagle stated, the ability to create that infrastructure for
your own tribe cultural competency.
If you are encompassing your needs of your tribe and the
needs of your people based on your cultural relevancy because
we are all different, we are not all the same, we are not all
in the same areas and we do our own issues within our own
regions, I think with SDPI, it gives tribes the ability to look
at your culture and incorporate it.
When you are incorporating those areas within diabetes, all
of those cultural components are also covered in behavioral
health issues. It gives you a sense of identity, a sense of
well being, a sense of this is who I am, this is where I am
from. This is historically what our people did that allowed us
to live within ourselves, within our communities and also to
live healthy.
I think it encompasses a lot when you talk about behavioral
health and the ability to be well, live well, and live healthy
and incorporate it. That is a unique thing with SDPI and
behavioral health because that is another component that all
tribes across the Nation have serious issues with. That
encompasses a lot. Thank you for the question.
Senator Heitkamp. Jared?
Mr. Eagle. I know I can specifically speak for the work
that we do in Fort Berthold but as Senator Murkowski and you
just said, we need to work on getting those food deserts
access.
I think there is another piece though with behavioral
health in the work that we do with SDPI. That is teaching
people how to manage when you do not have it. From the example
in my testimony, two of the six communities on Fort Berthold
have grocery stores. The other four do not. They have access to
a convenience store where you can buy chips and pop.
One of our local convenience stores is actually the leader
in the State of North Dakota per capita for chip sales. It is a
community of less than 700. That says something.
Through SDPI, we try to focus on that behavior because it
is a decision to buy what you are buying. If it is not there,
yes, that is a major obstacle I agree but there are ways to
change that behavior into what is a better option.
All those things are looked at through the different
curricula that we utilize such as TRAIL and DPP. In all the
activities we do, it is addressed in some form, but not
specifically with a mental health provider.
Senator Heitkamp. I think my point was that siloing just
has not worked.
Mr. Eagle. Yes.
Senator Heitkamp. It is like saying we are going to fix
problems with youth challenges simply with the housing program
and ignoring education and health care. This needs to be a
collaborative effort.
It is good to hear that this program actually encourages
the integration and expansion into behavioral health but we
need to do a better job.
The Chairman. Thank you, Senator Heitkamp.
Admiral, my question for you is we are seeing a decrease in
adults but not in youth in terms of both the diabetes and
obesity rates. Why is that and what do we need to do?
Mr. Buchanan. We are seeing an increase in youth?
The Chairman. My understanding is we are seeing a decline
in the rates for adults but not so with youth. Why is that and
what can we do?
Mr. Buchanan. The youth rate is leveling off for sure. The
Special Diabetes Program has had a tremendous impact over the
last 20 years. We are utilizing those lessons learned and best
practices going forward to address the youth. Of 301 grantees,
252 are tribal programs. We are utilizing some of those best
practices to address the youth.
The Chairman. Are there changes, improvements or
recommendations that you would make to the program? Are there
performance measures that should be employed?
Mr. Buchanan. With the Special Diabetes Program enacted by
Congress, we are reporting on an annual basis on the outcomes
related to the diabetes program. We are happy to work with the
Committee going forward.
The Chairman. Are there recommendations you would make for
changes or improvements to the program?
Mr. Buchanan. Changes or improvements, we a have a Tribal
Leaders Diabetes Committee that is an advisory committee to the
director. Any significant changes that happen through the
program, we work through the Tribal Leaders Diabetes Committee
to provide recommendations to the director. The activities up
to this point have been recommendations from that committee.
The Chairman. Mr. Hawley, how could the SDPI program be
improved to help further reduce youth obesity and diabetes
rates in tribal communities?
Mr. Hawley. I think overall is the education and public
health. I think the public health is an important tool that can
be utilized to educate. In the testimony, I talked a bit about
how much more tribal youth are aware than I was when I was in
high school of anything that goes on, and the things they are
exposed nowadays is beyond anything I remember. I just cannot
believe they are aware of some of the things they are aware of
and their ability to be engaged, to overcome and get involved,
and get active.
That also is our responsibility to show them and encourage,
educate and promote. I think that is the key. We have some
activities outside of the regular work but then you also have
the individuals who are managing these programs even at the
national level who are advocating.
However, you also have the individuals who are doing things
outside on their own time throughout the week to be engaged,
educate and convey the message that we are advocating at this
level.
I think it goes a long way when you talk about what we can
do to change. As a tribal leader, I know reductions say a lot
and raises flags for tribal leaders because we think about
tribes doing more with less. We have always done that, I think.
When we talk about those things, the first thing that comes
to my mind is how are we going to do more with less because we
have done it before and that is what we are going to have to do
again but also educating our youth to be active, engaged and
the voice of change.
We heard the testimony from the young man down the table
and what they are able to accomplish. This is one 11-year old.
When that changes throughout Indian Country, it says a lot for
the activities. I think it starts with education.
The Chairman. Mr. Eagle, I am very impressed with the
variety of things you are doing. It speaks to the flexibility
of the program which is encouraging. Are there other things
that you think would be helpful as we work to reauthorize this
program, things we should be looking to try to do?
Mr. Eagle. One thing I guess comes to my mind immediately
when it comes to change would be what Vice Chairman Udall said
in his opening remarks about continuation funding. The previous
example from the kidney report they did and the correlation
between SDPI starting and how those rates have declined in
conjunction with SDPI funding. That has been done, like you
said in a one to two-year reapplication process.
The Chairman. Right.
Mr. Eagle. What would happen if this was funded for several
years, we had this funding and were able to make plans and do
that kind of work on a long-term basis?
The Chairman. The idea of reauthorizing for a longer period
of time and then even maybe carry over funds or something like
that would help you, create continuity in your programs and
strengthen them?
Mr. Eagle. Absolutely.
The Chairman. I will pause here and turn to the Vice
Chairman.
Senator Udall. Thank you, Mr. Chairman.
SDPI is an excellent example of the difference investing in
preventative care can make for whole communities. All of you,
in a way, have demonstrated that. Unfortunately, this Committee
hears from Native constituents that access to preventative and
specialty care remains limited in Indian Country.
Admiral, this is for you. In fiscal year 2017, how many
Indian Health Service areas can fund, purchase and refer care
above medical priority Level 1?
Mr. Buchanan. That is a great question. All of our
facilities should at least fund between Level 1 in all PRC
programs.
Senator Udall. All of the facilities are doing that now?
Mr. Buchanan. That is correct.
Senator Udall. Where does the money for these preventative
services come from, direct appropriations or third party
billing from Medicaid and insurance?
Mr. Buchanan. I need to back up a little bit.
Senator Udall. Go ahead.
Mr. Buchanan. You were asking for preventative services
related to PRC?
Senator Udall. Yes.
Mr. Buchanan. PRC is specifically for the different
categories and it goes into different sections from Level 1,
Level 2, down to Levels 3 and 4. The preventative piece is
farther down. When I was responding, Level 1 is for life and
limb types of activity.
Senator Udall. Right.
Mr. Buchanan. I do not have the answer for the preventative
piece of it. I can definitely get back to you on that.
Senator Udall. The point of the question I think was how
widespread is the preventative service in all the facilities
with SDPI? I think that is what we were trying to get at. You
can answer for the record but is it widespread? Is it not in
that many areas?
Mr. Buchanan. Currently, we have 252 tribal programs. We
have about 29 urban programs that are funded and about 15-20
Federal programs funded through SDPI. All those programs, SDPI
is all about prevention. Correlating that, we have 782,000
people impacted by the SDPI Program. I hope that answers your
question.
Senator Udall. Is it in every Indian Health Service area?
Mr. Buchanan. Thirty-five States. I am hearing my staff say
yes, we have SDPI in all of our facilities across the area.
Senator Udall. The point was made here and several of the
witnesses have asked and been asked, we know it is a key to
have healthy food but can they access healthy food. To any of
you this is kind of a yes or no question.
Those of you living in Indian Country, can you access
healthy food in Indian Country or are you living in food
deserts? Give me just a yes or no on that. Can you access
healthy food? Jared?
Mr. Eagle. At Forth Berthold, we can. Like said, in limited
areas, there are two grocery stores based on a 250-mile radius.
Senator Udall. It is a lot like the Navajo Reservation
where we have 175,000 people over 27,000 square miles and we
have ten grocery stores. Is that true in the rest of your
communities?
Mr. Sensmeier. In Alaska, in a lot of the communities
there, we have limited access to fresh produce.
Senator Udall. In your community, Martin, limited access?
Mr. Sensmeier. It is getting better. You see it is
improving but up north, well, my mom comes from the Yukon, it
is very limited.
Senator Udall. Very limited.
Mr. Hawley.
Mr. Hawley. Very rural, limited access.
Senator Udall. Mr. Villegas, do you get that good salad you
were talking about earlier there?
Mr. Villegas. Yes.
Senator Udall. Okay, good. You two are from the same
community. Would you agree with that?
Ms. Seepie. Yes, we live in an area where we are surrounded
by the city, major cities like Scottsdale, Mesa and Phoenix, so
we do have access to fresh vegetables and produce.
Senator Udall. How about on the reservation?
Ms. Seepie. On the reservation, we do also have a food bank
that does give out fresh fruits and vegetables that community
members can also access.
Senator Udall. Please.
Mr. Sensmeier. I think on some of the reservations you see
failing health but they do have access to fresh produce and
stuff like that. It is really helpful when you have programs
like Triple Play through the Boys & Girls Clubs of America that
educate these young kids about nutrition because one of the
biggest problems we have in Indian Country is the lack of
nutritional education.
Fried bread, for example, a lot of Native people think
fried bread is a Native traditional food. It is not. That was a
ration that was given. Now there is a vicious cycle that
greatly contributes to diabetes.
When you educate these kids, and break that cycle, then
they have a better understanding of how to eat better. Triple
Play is one of the great programs. It improves the health of
club members ages 6 through 18. The mind component is the
biggest one, teaching them to eat smart through the power of
choice, calories, vitamins and minerals and appropriate portion
size.
I think when we have programs like this our chance of
breaking these cycles is a lot greater. My Club rep actually
has some really great announcements about that if she can have
a chance to speak at some point.
Senator Udall. Mr. Chairman, I have run over. Thank you.
The Chairman. Martin, my question kind of goes to a role
model in general, not only in terms of healthy eating but in
general, good habits, a good lifestyle, how you succeed as a
young person and so forth.
For a minute, tell us how you got into acting. It sounds
like you had sports and so forth in your background and the
Boys & Girls Club but how do you get from that and get into
acting particularly at such a high level?
Then talk about it in terms of how you can be a role model
or how you get other young people to achieve their dreams? It
might be acting or sports or something else for them. Just talk
about your own experience for a minute. We are interested to
hear, at least I am, how you transitioned to acting and what it
took to be successful and what you would advise other young
people like maybe Mr. Villegas, to do to achieve their dreams.
Mr. Sensmeier. It has always been a dream of mine ever
since I was a kid. Billy Mills, who was the only American to
ever win the 10,000-meter race in the Olympics won in 1964. He
was from Pine Ridge Indian Reservation.
I heard him speak one time. He said our children and kids
live in a poverty of dreams. They are not allowed to dream;
they do not know how to dream. When you encourage them to dream
and make them believe in themselves, great things can happen.
I always had that support system through the Club, my
parent and role models I saw growing up. That dream was always
there. Getting access to be able to make that happen was kind
of an unrealistic idea.
I did what a lot of young people do in Alaska. I got into
fishing, construction and ended up working on an oil rig. While
I was working on the oil rig, I had a lot of time off, two
weeks on and two weeks off, so I started traveling to
California.
I was like, I am going to check out an acting class. I
started getting around other people that were dreaming big. I
started seeing people succeed. I was like, okay, I can do this.
I stuck with it and stayed persistent and believed in my own
ability and started becoming successful.
One of the ways I would like to encourage youth, I try to
do my best, is I maintain my connection with the community and
make myself accessible to the community. I get a lot of
requests to travel around and visit different Native
communities all over the Country. I cannot name how many
reservations I have been to. I have been in Florida,
Connecticut, New York, Washington, Nevada, California, all over
the place.
Whether they pay me or not, I try to make myself as
accessible as I can. When I am there, I try to promote healthy
lifestyles. Senator Murkowski mentioned the Gold Medal
tournament in Alaska and I made it a point to go home to that,
because everybody at home, all the kids look up to me.
When they see me actively living a healthy lifestyle and
also participating in a sporting event, they want to do that
too. I wore a Mohawk in the movie and I had ten kids
surrounding me and half of them had Mohawks.
I have never set out to be a leader. I do not think of
myself as a leader. I think of myself as an example and I
strive to be that.
The Chairman. There is no question you are a leader and
that you are having a very powerful, positive impact on your
peers and young people. I just want to encourage you to keep it
up. Your coming here today shows you care and you are willing
to give back. Given where you, that is a remarkable and
wonderful thing.
Mr. Sensmeier. Thank you. I appreciate that.
The Chairman. Thank you so much.
Mr. Villegas, I am going to turn to you and ask how do you
get kids your age tuned in to just what you are doing and
talking about? How do you do it? How do you get other people
your age to start thinking about health, diet and the right
kind of lifestyle as you are doing at a pretty darned young
age? Any ideas how you get them interested in it?
Mr. Villegas. I do not know. It is kind of hard.
The Chairman. It is hard.
Mr. Villegas. Yes.
The Chairman. Do you talk to them about it?
Mr. Villegas. Yes, I talk to many people about it saying
they should really go to the camp and why they should start
eating healthy and all that stuff. I tell them all the time but
not a lot of people care because they have to give up hot
Cheetos.
The Chairman. Can't they have hot Cheetos once in a while
if the rest of the time they are following a really good diet?
Mr. Villegas. No, it is up to them, hot Cheetos, they are
addicted to it. I see kids buy at least four bags a day from
the ice cream man.
The Chairman. I think the fact that you are a good example
and talking to them about it really does help so I encourage
you to keep doing it just as you are today.
Mr. Villegas. There is one thing they have to do to get to
that.
The Chairman. Okay?
Mr. Villegas. We must destroy the ice cream man.
The Chairman. Okay. We will make sure we get that in the
record.
Mr. Villegas. I also think we should have more flyers
everywhere saying a good start is to go the camp. Put up a
whole bunch of flyers. The reason I found out about the camp
was because of a lady named Ms. Mary Lynn. She gave me a flyer
and I thought, this sounds like fun and when I was there, I was
like, yay, I know how to exercise.
I think that people should know about it and at least
consider it and go to the camp. I want to encourage people to
go and tell them all the fun stuff that we have.
The Chairman. That sounds like very good advice. Thank you.
Thanks for being here today.
Ms. Seepie, I would ask you the same question that I asked
some of the other witnesses. Your record with the training and
discipline it takes to run marathons and participate in the
Iron Man is just unbelievable. Clearly, if you can get other
people to think in terms of that kind discipline and
perseverance, it is going to make a huge difference to them not
only in their health but in everything they do.
Are there other things we can do with this program that you
think would help, that would strengthen the program or
encourage people to do some of the things you have done?
Ms. Seepie. I can only talk about my community, what they
have given me, the knowledge and education about diabetes,
physical fitness and eating healthy. With the SDPI, we do have
a few programs like Lifestyle Balance which is a 12-week based
program. It is based on nutrition, exercise and behavioral
health. It gets pretty much all the components.
As an individual who was diagnosed with diabetes, I know,
from feeling depression and knowing that you have diabetes at a
young age, it can affect your life.
Also, I am a physical fitness specialist in my community. I
teach different group exercise classes, pre-school and
elementary students and seniors also. I teach a group of age
groups. All I can say is, I think I am pretty much encouraging
them as a regular. I think of myself as just a regular
community member in my community.
When they see me, some of the kids will say, oh, you are
the lady that teaches Zumba. I say, yeah, I am the lady that
teaches Zumba. When can you come to Zumba class or when are you
going to come to the Boys & Girls Club and teach Zumba?
I think just being a role model and encouraging people to
come to our program, the Diabetes Prevention Program in Salt
River is important. One good program that we have been doing is
with one of our nutritionist, Maggie Fisher, is Young Wellness
Warriors. I am a part of it too, as a physical fitness-exercise
person. I am also in the program with my daughter.
We are educated on nutrition and also make healthy food
goals in that program. They see other families in that program
learning about healthy eating. We do hands-on activities. They
get the chance to also help out in the kitchen cooking healthy
meals. Whatever they have in the home, we provide that
education and learning together as a family. I think that has
helped me and some of the participants.
The Chairman. Good. I am encouraged both as I hear about
your program and certainly, Mr. Eagle, about your program in
terms of SDPI helping make a difference because of what you are
out there doing. I appreciate it.
Senator Cortez Masto, we would turn to you at this point if
you have questions.
Senator Cortez Masto. Thank you, Mr. Chair, so much.
I have competing hearings going on so I have had to step in
and out. But that does not mean that this topic is not
important for me, particularly in the State of Nevada where we
have tribal communities. I have worked with as Attorney General
looking at issues affecting the health of Native communities,
particularly our youth.
I have a quick question for Chairman Hawley. This whole
concept of food deserts concerns me. I say that because most
people do not realize in Nevada, the distance between Las Vegas
and Reno is over 400 miles. That is an eight-hour drive. There
is nothing but desert in between.
Just to get to an urban area, many of our tribal
communities have to drive four hours with desert everywhere. I
completely understand.
Can you elaborate, you may have talked about this, the food
deserts and what we have done in Nevada to address this to
bring healthy lifestyles but more importantly, fresh produce
and fresh food to some of our communities?
Mr. Hawley. The concept of food deserts even in Arizona, a
lot of communities, Native communities nationwide are in food
deserts. A lot of our Native communities are anywhere from half
a hour to four hours away from a town or what have you.
Some reservations have grocery stores on them; others do
not. Some of them have local C stores. They have the local junk
food and that type of thing where you go in and get your basic
needs and that is about it. It is interesting that the concept
exists for Natives nationwide and the access you have or do not
have.
We talked about traditional resources, traditional
gathering, you have hunting and fishing, all those sources but
then we also will tap into the food banks where you do have the
commodities. But commodities have changed over the years. The
quality of the food that is provided has gotten better. Food
banks have been there.
A lot of communities will refer to a town day. You have
your families who will have one day out of a month designated
to making those trips to town to buy everything in bulk, bring
it back and store it, preserve it or freeze it. You do what you
have to do. That is how you survive for the month off a town
day.
You think about those things and also you consider the fact
that you utilize the traditional methods of hunting and
gathering. It is a real situation and it is concerning. Sitting
on the panel is the first time that I have heard the term.
I started thinking about all the different things, the town
days and all the planning Natives do just to go get the food
you need to survive or have the nutritious meals that you count
on every day, the seasonal gathering and the day-to-day
activities if you are hunting or fishing, that type of thing.
I really believe that is an issue but tribes are being
creative, communities are being creative. As I said, we do tap
into the resources, Meals on Wheels for elders, those types of
social programs that we tap into the same as any State or city
taps into social service resources and human services. They are
all very much a huge component of how tribes operate daily.
Senator Cortez Masto. Thank you very much.
Thanks to all the panelists for being here and discussing
this important topic. I do think it is an area that needs to be
addressed. I think when we are talking just in general about
healthy living, healthy choices, having access is the key to
prevention and addressing so many of the health care issues we
see in some of our tribal communities.
I appreciate all the comments today and look forward to
working with all of you. Thank you again for being here.
The Chairman. Thank you, Senator.
I would turn to Vice Chairman Udall for any other
questions.
Senator Udall. Thank you.
SDPI has been flat funded for over a decade now despite the
high return on investment. Admiral Buchanan and Chairman
Hawley, how has the flat funding limited the impact of SDPI
over the years?
Mr. Buchanan. The results speak for themselves. As far as
the 20 years of progress we have made, the chart that was
shown, activities going down to continue that process, again,
it is a high priority for the agency moving forward.
Senator Udall. When you talked about the progress going
down, was that for adults and children?
Mr. Buchanan. That was for adults.
Senator Udall. Adults. Is there the same number for
children? Since this was authorized as a pilot program in 1997,
have the numbers gone down for children?
Mr. Buchanan. There has not been a study that specifically
focuses on children related to that for more data, but with the
graph, the funding was implemented. In 1997, you can see a
sharp spike coming down from that point forward.
Senator Udall. Chairman Hawley.
Mr. Hawley. I can definitely say that with the flat source
of funding for x amount of years, our tribal communities are
growing and with the flat source of funding, I can definitely
also say that. I made the statement earlier that we sometimes
expect more for less. When our communities continue to grow and
we have growing populations of elders and youth coming up and
then you have the unborn coming up, you think about how over a
year a tribe or even a community population can increase.
There is definitely an impact but the percentage, as the
Admiral said, we do not know the direct impact or the
percentage because we have not looked at those studies yet.
Just thinking about the previous comments about doing a little
bit more with a little bit less, figuratively in my mind that
is what I am thinking.
We are doing a little bit more every time our populations
get bigger but with the same amount of funding. How big an
impact does that really have except for we are doing a little
bit more work because we are addressing a larger population.
Do we have the same outputs? Possibly. We do not know. Are
we doing the same thing over and over? Not likely because of
the flexibility that the SDPI programs have nationwide. A lot
of ideas are being implemented in different areas that are
working for some areas.
Ideas are being passed back and forth. Tribes are being
very creative within their programs to provide the service.
Senator Udall. Admiral, did you have something to add on
that?
Mr. Buchanan. I would agree that the tribes are truly the
partners that are driving the innovations and changes going
forward making those programs specific to their needs moving
forward. That is the success behind the SDPI programs.
Senator Udall. On the success, the numbers I have, tell me
if any of you disagree with these. SDPI has supported a 61
percent growth in the use of culturally-tailored diabetes
education programs which we have heard today make a real
impact, if it is culturally-tailored, it is in the community
and addressing the community's needs.
The CDC has linked SDPI to a 54 percent decrease in
diabetes-related kidney failure in the population. Is that what
was on the chart you showed us?
Mr. Buchanan. Yes, sir.
Senator Udall. Thank you, Mr. Chairman.
The Chairman. I have just one follow-up question. Are you
doing studies of the effect of SDPI on Native youth? You have
adults and youth. Are you actually looking at the impact SDPI
is having on Native youth and are you measuring that?
Mr. Buchanan. We are working with adults, that is what the
SDPI program is designed to do, to work with the adults to
reduce diabetes, since 1997. We are utilizing our programs, as
mentioned earlier, related to the National Congress of American
Indians. Doing specific studies right now, we are not doing
that as I understand it.
The Chairman. Why?
Mr. Buchanan. That is a great question. We are utilizing
the information we are getting from our adults. I can mention
the holistic approach, going forward and utilizing those best
practices as mentioned on the panel today to address our youth.
The Chairman. At this point, I would ask are there other
questions from the Senators?
[No audible response.]
The Chairman. I want to turn to the panel and say to all of
you, thank you very much for being here.
Members may also submit follow-up questions for the record
if they so desire. The hearing record will be open for two
weeks.
To all of our witnesses, thank you for the good work you
are doing out there. We appreciate you being here so much.
With that, we are adjourned.
[Whereupon, at 4:20 p.m., the Committee was adjourned.]
A P P E N D I X
Prepared Statement of Hon. W. Ron Allen, Tribal Chairman, Jamestown
S'Klallam Tribe; Board Chairman, Self-Governance Communication &
Education Tribal Consortium
The Self-Governance Communication & Education Tribal Consortium1
(SGCETC), representing more than 360 Self-Governance Tribes, writes to
enthusiastically endorse the success of the Special Diabetes Program
for Indians (SDPI) and to support the National Indian Health Board's
(NIHB) written testimony. SGCETC appreciates that the Senate Committee
on Indian Affairs (SCIA) convened a hearing to highlight the success
and challenges of SDPI and we submit this testimony to be included in
the hearing record.
Though many issues were discussed during the hearing, SGCETC would
like to provide comments and recommendations based on the proposals and
priorities Self- Governance Tribes outline in the 2017-2019 Self-
Governance Strategic Plan. In particular, Self-Governance Tribes would
like to highlight the SDPI Diabetes Prevention Initiative's (SDPI DPI)
success record and the flexibility SDPI allows for community driven
solutions. We have also provided a few recommendations about how to
improve the program in anticipated legislative reauthorization efforts.
Recent data illustrates SDPI is curbing the rate of Type 2 diabetes
and related diseases through a lifestyle intervention program adapted
from the National Institutes of Health Diabetes Prevention Program and
implemented in many Tribal communities. By 2014 the structured
lifestyle program showed significant improvements among participants in
key behaviors and diabetes risk factors, including weight loss, BMI,
healthy eating, and regular physical activity. See Table 1 below.
Overall, SDPI is producing a significant return on the federal
investment and has become an effective federal initiative to combat
diabetes and its complications. In Fiscal Year (FY) 2016, more than
one-third of the SDPI grants and nearly forty-five percent of the total
grant funds were administered by Self-Governance Tribes. SDPI has
become a crucial preventative and clinical program Self-Governance
Tribes use to prevent longterm illness. In fact, many Self-Governance
Tribes have integrated SDPI so fully into their clinical day-to-day
responsibilities it is hard to determine where one begins and the other
ends. It is precisely this flexibility that has made SDPI a successful
program across more than 300 unique Tribal communities.
1 The SGCETC consists of Tribal Leadership whose mission is to
ensure that implementation of Tribal Self-Governance legislation and
authorities in the Bureau of Indian Affairs (BIA) and Indian Health
Service (IHS) are in compliance with the Tribal Self-Governance Program
policies, regulations, and guidelines.
Table 1. SDPI DPI Changes in Diabetes Risk Factors
------------------------------------------------------------------------
MEASURE RESULTS RESULTS
------------------------------------------------------------------------
Baseline 1 Follow-up 2
(n=7,097) (n=4,549)
Weight Loss
Mean Weight (lbs) 218 208
Mean BMI (kg/m2) 35.9 34.4
Lifestyle Behaviors
Ate healthy foods once or more per week 77% 87%
Ate unhealthy foods less than once per week 53% 81%
Regular physical activity 30% 53%
------------------------------------------------------------------------
SPDI allows Tribes to implement diabetes related programs within
their clinic or as part of other health outreach programs that are
separate from the physical facilities--providing access to the services
no matter where the patient is located. While programs vary in their
operation, each Tribe is required to identify at least one of eighteen
best practices and report on the key measurements of that best practice
semi-annually and annually. Additionally, SDPI grantees are required to
submit to an annual Diabetes Care and Outcome audit, review the
results, and adjust programs as necessary. Grantees are also required
to participate in training and IHS offers free Continuing Medical
Education opportunities virtually and in-person as a resource to meet
that requirement. The IHS Division of Diabetes Treatment and Prevention
also provides Standards of Care and Clinical Practice recommendations
for clinicians to use in the treatment of patients with or at risk of
developing Type 2 Diabetes--all of which are available, for anyone to
access, on their website.
Self-Governance Tribes assert that the difference between
maintaining the current status and decreasing rates of Type 2 Diabetes
in Tribal communities largely depends on implementation of the program
in the future. As such, we have a number of recommendations for
Congress to consider as they plan to reauthorize the legislation prior
to its expiration in September of 2017.
Permanently reauthorize SDPI. Congress established the SDPI in 1997
as part of the Balanced Budget Act to address the growing epidemic of
diabetes in American Indian and Alaska Native communities. SDPI
programs have become the nation's most strategic and comprehensive
effort to combat diabetes. Self-Governance Tribes believe the success
of these programs requires the permanent reauthorization of SDPI. We
also assert that a permanent reauthorization would decrease burdensome
administrative constraints SDPI grantees currently experience, such as
the ability to recruit highly qualified staff on a permanent basis.
Provide a $50 million increase for SDPI. Funding for SDPI has not
increased since 2001, when Congress increased support from $100 million
to $150 million. An increase in funding is necessary to maintain SDPI
and make a difference in the rates of Type 2 Diabetes among American
Indian and Alaska Native Youth. As such, Self-Governance Tribes request
that the Committee consider increasing the authorization for SDPI to
$200 million. A $50 million increase will essentially level the field
for SDPI grantees, as that increase only reflects inflation to 2017. As
a few panelists stated, Tribes are used to doing more with less, but
the time has come to provide a substantive increase that would give
Tribes the room to sufficiently administer the program.
Limit oversight and administrative burden. Although improved
delivery of care and increased primary prevention of Type 2 Diabetes
over the past 20 years is readily documented, the annual grant
application process remains cumbersome and time consuming. Tribes and
Tribal Organizations are required to submit lengthy applications
describing the activities and best practices on which they will report,
even when the activities and funding do not significantly change. The
short-term authorizations for SDPI detracts IHS and grantees from
creating a long-term strategy. Self-Governance Tribes assert that, in
combination with a longer or permanent authorization, longer grant
periods would create more substantive change in Tribal communities,
because it would encourage Tribes to track their performance over a
longer period of time and set attainable goals that are based on
health-related outcomes. Self-Governance Tribes also ask that a limited
amount of reporting be required. Though currently data is only
collected a few times a year, data collection and entry are burdensome
and time consuming. The grant application process and required
reporting merely result in a diversion of federal funds from their
intended purpose--serving patients who have or at risk of developing
Type 2 Diabetes.
Allow grantees to collect contract support costs. IHS has
maintained that Tribes can only collect indirect costs related to the
performance and delivery of services from within the grant award. This
ultimately results in fewer services being delivered in Tribal
communities. As we described above, the administrative requirements to
properly implement a SDPI grant is quite burdensome. Allowing Tribes to
properly account for indirect and direct costs related to the program
would effectively provide grantees with an increase in funding.
SDPI continues to illustrate that healthier and stronger Tribal
communities are possible with community driven, culturally applicable
action plans and national best practices. As the Committee looks
forward to reauthorization, we hope that you account for the
flexibility needed to properly implement a prevention and treatment
program in Tribal communities across the country and consider the
positive effects a long-term reauthorization, funding increase, and
simplification of oversight could have in the success of SDPI.
In closing, SGCETC would like to thank the Committee for the
opportunity to submit testimony. We look forward to working with you on
the successful SDPI reauthorization.
______
Prepared Statement of Allison Barlow, Ph.D, MA, MPH, Director, Center
for American Indian Health, Johns Hopkins Bloomberg School of Public
Health
Dear Senators Hoeven and Udall,
I am writing as Director of the Center for American Indian Health
at the Johns Hopkins Bloomberg School of Public Health, to request that
my written testimony be included in the record for the hearing on March
29, 2017 entitled ``Native Youth: Promoting Diabetes Prevention through
Healthy Living.'' In my expert opinion, the Special Diabetes Prevention
Initiative (SPDI) has produced very positive results and I urge you to
encourage your colleagues to consider level funding at $150 million in
the FY17 and FY18 budgets.
Congress's continued support for SPDI will yield tremendous return
on investment by hastening the discovery of cost-effective solutions
for preventing diabetes for all Americans through a proven program that
has demonstrated sound evidence and accountability.
The Johns Hopkins Center for American Indian Health has held a
Memorandum of Understanding with Indian Health Service (IHS) since its
founding in 1991. Johns Hopkins and IHS leverage research findings and
disseminate best practices to overcome tribal health disparities. The
Center also works to scale up solutions found effective with American
Indian communities to other vulnerable American communities.
In terms of of public health impact, my colleagues and I at the
Johns Hopkins Center for American Indian Health cannot overstate the
importance of the 1997-enacted SPDI to American Indian and Alaska
Native health and well-being. The achievements that have occurred over
the past 20 years are of tremendous public health significance: these
achievements include a decrease in type 2 diabetes in American Indian
and Alaska Native youth, a 54 percent reduction in end-stage renal
disease between 1997-2013, and the levelling off of obesity levels in
American Indian children.
This progress has occurred through congressionally-appropriated
resources ($150 million/year) that Indian Health Service has been able
to extend to 301 tribal communities across 35 states. Through the
leadership of the IHS Diabetes Program director, Ann Bullock, MD, these
dollars have materialized into comprehensive, creative, and effective
prevention strategies that are now being recognized as a model for the
nation and the world. For example, a leading international journal just
published a reference to SPDI impact:
A promising new report demonstrates a substantial decline in
the incidence of diabetic end-stage renal disease among
American Indians and Alaska Natives, coinciding with a public
health intervention targeting diabetes management in this
population. This success may offer a model for interventions to
improve kidney disease outcomes in other high-risk
populations.--C. Wyatt, Kidney International (2017) 91, 766-768
However, the work of SPDI is not done. American Indian and Alaska
Native children and families still shoulder the greatest disparities in
obesity, diabetes, and related health and workforce consequences of any
racial or ethnic group in the nation. This constellation of disease is
the result of forced lifestyle changes brought about through
colonization. The degradation of American Indian health due to
commercialized diets and sedentary lifestyles forecasts what will be
the fate of the majority of Americans if we don't continue to discover
effective public health intervention to curb obesity and diabetes.
Further, building interventions with the highest risk, lowest-income
population makes the most scientific and economic sense.
Sustained investment in SPDI will continue to produce fruitful
innovations for high-risk populations and ultimately save our nation
inestimable costs in human suffering, lost productivity, and health
care and workforce dollars. Indeed, Dr. Bullock's latest work through
SPDI to support intervention with expectant parents through children's
early life (0 to 3 years) is designed to prevent diabetes starting in
the womb. Early life intervention could revolutionize how we will
protect children's health and our nation's prosperity.
Thank you for including these comments in the record.
______
Prepared Statement of United South and Eastern Tribes Sovereignty
Protection Fund (USET SPF)
United South and Eastern Tribes Sovereignty Protection Fund (USET
SPF) is pleased to provide the Senate Committee on Indian Affairs
(SCIA) with testimony for the record of its March 29th oversight
hearing, ``Native Youth: Promoting Diabetes Prevention Through Healthy
Living.'' USET SPF appreciates the SCIA for making the reauthorization
of the Special Diabetes Program for Indians (SDPI) a priority for this
Congress. The SDPI program has made inroads in diabetes care and
prevention in Indian Country, including in the development of youth
education and prevention initiatives. The program must be reauthorized
this Fiscal Year.
USET SPF is a non-profit, inter-tribal organization representing 26
federally recognized Tribal Nations from Texas across to Florida and up
to Maine. \1\ USET SPF is dedicated to enhancing the development of
federally recognized Indian Tribal Nations, to improving the
capabilities of Tribal governments, and assisting USET SPF Member
Tribal Nations in dealing effectively with public policy issues and in
serving the broad needs of Indian people. This includes advocating for
the full exercise of inherent Tribal sovereignty.
---------------------------------------------------------------------------
\1\ USET SPF member Tribal Nations include: Alabama-Coushatta Tribe
of Texas (TX), Aroostook Band of Micmac Indians (ME), Catawba Indian
Nation (SC), Cayuga Nation (NY), Chitimacha Tribe of Louisiana (LA),
Coushatta Tribe of Louisiana (LA), Eastern Band of Cherokee Indians
(NC), Houlton Band of Maliseet Indians (ME), Jena Band of Choctaw
Indians (LA), Mashantucket Pequot Indian Tribe (CT), Mashpee Wampanoag
Tribe (MA), Miccosukee Tribe of Indians of Florida (FL), Mississippi
Band of Choctaw Indians (MS), Mohegan Tribe of Indians of Connecticut
(CT), Narragansett Indian Tribe (RI), Oneida Indian Nation (NY),
Passamaquoddy Tribe at Indian Township (ME), Passamaquoddy Tribe at
Pleasant Point (ME), Penobscot Indian Nation (ME), Poarch Band of Creek
Indians (AL), Saint Regis Mohawk Tribe (NY), Seminole Tribe of Florida
(FL), Seneca Nation of Indians (NY), Shinnecock Indian Nation (NY),
Tunica-Biloxi Tribe of Louisiana (LA), and the Wampanoag Tribe of Gay
Head (Aquinnah) (MA).
---------------------------------------------------------------------------
Special Diabetes Program for Indians (SDPI) and Diabetes Prevention
Programs
In response to the disproportionately high rate of type 2 diabetes
in American Indians and Alaska Native (AI/AN) communities, Congress
passed the Balanced Budget Act in 1997 establishing the SDPI as a grant
program for the prevention and treatment of diabetes at a funding level
of $30 million per year for five years. After extensive Tribal
consultation, the Indian Health Service (IHS) distributed the funding
to over 300 IHS, Tribal and Urban AI/AN health programs. In 2001,
Congress increased the amount of SDPI funding to $100 million per year,
and then again increased it to $150 million per year from 2004-2010,
which was then extended for an additional 3 years through Fiscal Year
(FY) 2013. Since FY 2013, SDPI had been extended in one year
increments, however, the most recent extension as a part of the `Doc
Fix' legislation in June of 2015, authorized two additional years at
$150 million/year through September 30, 2017. With SDPI set to expire
this year, it is critical that this Congress prioritize its
reauthorization.
In the Indian Health Service (IHS) Nashville Area, the prevalence
rate of diabetes is 23 percent, which is 3.6 times higher than the U.S.
all races age-adjusted rate of 6.4 percent. Rates can be even higher in
individual USET SPF states, like Louisiana and Mississippi, where
prevalence rates for our member Tribal Nations are at 29.5 percent and
36.7 percent, respectively. Despite the severity of the epidemic,
Tribal Nations have implemented successful and culturally relevant
diabetes prevention and treatment activities through the SDPI grant
program.
USET \2\ has been an SDPI grantee since its inception, and is
unique in that it applies for the SDPI grant on behalf of 20 of its
member Tribal Nations as the primary grantee. USET then enters into
subcontract agreements with participating Tribal Nations for local
program implementation. Our member Tribal Nations continue to feel this
is the easiest and best grant option for them, as many are small
communities with limited staffing and resources to write a grant of
this magnitude. USET's administration of grant dollars allows local
level staff to focus on the prevention, care, and treatment of diabetes
within their communities.
---------------------------------------------------------------------------
\2\ USET, or United South and Eastern Tribes, is the 501(c)3 sister
organization to USET SPF, which is a 501(c)4. USET provides
programmatic and technical support to our 26 member Tribal Nations.
---------------------------------------------------------------------------
Through SDPI and its Diabetes Prevention Program (DP, a program
piloted as part of the larger SDPI), Tribal Nations have built
significant infrastructure to address the health needs of their pre-
diabetic and diabetic citizens. This includes diabetes specific health
providers, regular testing and monitoring, nutritionists, fitness
programs, and patient education. In addition to avoiding the more
costly consequences of diabetes, like End Stage Renal Disease and limb
amputations, among the diabetic population, Tribal SDPI programs have
successfully prevented the disease among at-risk groups. In fact, after
steadily increasing over the preceding two decades, between 2000 and
2011, incidence rates of ESRD in AI/AN people with diabetes decreased
43 percent--more than for any other racial group in the U.S. \3\
---------------------------------------------------------------------------
\3\ IHS SDPI 2014 Report to Congress.
---------------------------------------------------------------------------
In 2004, through the SDPI program, IHS piloted the DP program to
implement lifestyle interventions, which were found effective through
clinical trials in the National Institutes of Health-led clinical trial
on diabetes prevention throughout the federal system. By May 2014,
approximately 4,549 high-risk AI/AN participants completed program
courses on healthy lifestyle interventions. Among those that completed
the program, 87 percent of participants ate healthy foods once or more
per week versus the pre-intervention baseline of 77 percent and 53
percent engaged regularly in physical activity compared to 30 percent
pre-intervention. IHS estimates that the incidence rate of diabetes for
participants in the SDPI DP was 6.5 percent compared to the 11 percent
for the NIH Placebo group. The lower rates of diabetes incidence show
the efficacy of SDPI DP interventions and the success of diabetes
prevention infrastructure in Indian Country.
Challenges with Diabetes Prevention Program Certifications
Although we acknowledge the importance of evidence-based Diabetes
Prevention Programs (DPP) through the Centers for Disease Control and
Prevention (CDC), we do not believe this is the only approach for
Indian Country in administering quality prevention programs. This is
because many USET SPF member Tribal Nations do not have the capacity to
meet the strict eligibility criteria and program requirements. USET SPF
is currently aware of at least one Tribal Nation health program with
CDC DPP certification at risk of losing its certification due to on-
going challenges with recruitment of patients meeting the eligibility
criteria, as well as overly narrow quality and reimbursement
indicators. These indicators have unrealistic target thresholds and
should be subject to individual targets that better meet the health
objectives of a particular program. Additionally, the current criteria
omits indicators on behavioral change, which are important for
measuring the success of these lifestyle interventions. Indicators
should include behavioral change measures related to diet and exercise,
which are major factors in diabetes prevention and were proven
effective through the SDPI DP pilot. In order for our Tribal Nations to
continue programming with CDC DPP certification, these flexibilities
are necessary to account for the unique circumstances and challenges of
diabetes prevention work in Indian Country.
Similar challenges exist for our smaller member Tribal Nations
which operate SDPI programs and may wish to seek CDC DPP certification
in the future. Under the current criteria, many USET SPF member Tribal
Nations would be precluded from participation due to a lack of
capacity, staffing shortages, and small populations of patients meeting
patient eligibility criteria. Many of these Nations do not have the
staffing bandwidth to undertake the administrative burdens of applying
for CDC DPP or American Diabetes Association recognition.
SDPI Advancements
Like other Tribal Nations across the country, USET SPF Tribal
Nations suffer disproportionately from a variety of health issues,
leading oftentimes to a severely reduced quality of life and life span.
AI/ANs suffer from obesity, hypertension, heart disease, and diabetes
at rates much higher than the general U.S. population. Data shows that
AI/ANs have the highest rates of diabetes in the U.S. and are more than
twice as likely as white adults to have diabetes. IHS' SDPI grant
program is beginning to turn these statistics around. Recent data shows
that through SDPI, USET Tribal Nations have made significant progress.
Between 2013 and 2015, USET Tribal Nations increased the percentage of:
Healthy blood sugar in our diabetes patients from 45
percent to 49 percent;
Normal blood pressure from 60 percent to 62 percent; and
The rate of annual eye exams from 45 percent to 55 percent.
Through collaborations, best practices, and prevention initiatives
resulting from SDPI, our Tribal Nations are making strides. Nashville
Area AI/ANs are living longer with diabetes, with increased access to
specialty care and better control of the disease, all due to this
essential program.
For example, the Passamaquoddy Tribe of Maine (USET SDPI sub
contractor) is working in partnership with the University of Maine's
Cooperative Extension Program and the Pleasant Point Health Center SDPI
Program collaborated on two community programs, the first being a 4-
week program called Dining with Diabetes Down East. The program was
adapted to include information specific to the Passamaquoddy community,
culturally specific foods, and some use of the Passamaquoddy language.
Each session included a presentation, cooking demonstrations, and
facilitated discussion. An overview of the Diabetes ``ABCs'' (A1C,
Blood Pleasure and Cholesterol) was presented during the first session
and the other sessions covered other aspects of diabetes prevention.
The program gave many participants a new outlook on traditional foods
and culture within their communities, while developing healthy habits
for long-term prevention.
The second program was teaching the Diabetes Education in Tribal
Schools (DETS) curriculum to pre-school, kindergarten, first, and
second grade students from October 2015--March 2016. The children and
teachers learned about more and less healthy foods and activities; and
about diabetes. One of the last classes involved bringing in a
community member with diabetes so that the students could ask them
questions about the disease. The success of the program is due to the
collaborative effort between the teachers, students, Pleasant Point
Health Center SDPI program and the University of Maine Cooperative
Extension. These collaborations are only some of the impacts that SDPI
has had on Tribal communities, including youth.
Native Youth: Obesity and Diabetes Rates
The impacts of obesity and diabetes on Native youth are troubling.
In the IHS Nashville Area, Tribal Nations have been able to maintain
the low rates of diabetes for youth under 20 years of age (accounting
for less than 1 percent of the total diabetes population) within our
communities. However, many USET SPF Tribal Nation battle high youth
obesity rates, with over half of the youth between the ages of 2 and 5
years falling into the obese body mass index ranges. Some initiatives
that USET SPF Tribal Nations are utilizing through SDPI to decrease
these rates are:
Teaching the DETS curriculum in schools or after school
programs;
Making healthy food choices available and fun/interesting
to Native youth;
Learning about traditional Tribal Nation foods and
incorporating them into diets;
Providing healthier foods in vending machines;
Providing healthy cooking and/or snack preparation classes
for kids; and
Limiting fast food meals for kids and providing quick,
easy, healthy options for families on the go.
SDPI plays an important role in ensuring USET SPF Tribal Nations
are able to reduce high rates of obesity among our youth. These types
of interventions reduce the incidence of risk factors for diabetes,
such as obesity, providing long-term health benefits.
Access to Healthy Food and Fresh Vegetables
Tribal Nations are located in some of the most rural and
impoverished communities, lacking overall access to health care and
healthy food options. Limited access to healthier foods, such as fresh
vegetables, is often times a barrier to maintaining a healthy diet.
USET SPF member Tribal Nations vary in their ability access to
healthier food options, but through SDPI, all are utilizing methods to
increase traditional foods and healthier options available to Tribal
communities. SDPI has allowed for community and school gardens,
providing access to healthier and fresh foods, while encouraging
physical activity. Tribal Nations are incorporating traditional foods
and language into these gardens as a means to maintaining community and
youth cultural knowledge and the foods our ancestors consumed.
Reauthorize SDPI
Despite its documented success, funding for SDPI has been flat
since 2004, even as inflation and medical costs rise. Tribal Nations
and Congress have made significant investments in preventing and
managing diabetes. In order to continue making progress in the fight
against the disease in Indian Country, SDPI must be reauthorized this
Fiscal Year to avoid the loss of Tribal programs, prevention, and
progress. Any lapse in reauthorization will cause the costs of diabetes
and its complications to increase again for Tribal communities, and
precious jobs created by this program will cease. USET SPF is urging
Congress to reauthorize the SDPI for multiple years at no less $150
million/year, with incremental increases each year based on medical
inflation rates. Congress must not allow this successful investment to
lapse, just as its effects arebeing realized in the form of strong data
and widespread lifestyle changes. Timely reauthorization will ensure
that Tribal Nations can continue the fight against this epidemic
without interruption.
Conclusion
USET SPF appreciates the opportunity to provide comments following
the SCIA hearing on Native Youth: Promoting Diabetes Prevention through
Healthy Living. Over the past 19 years, Indian Country has been leading
the fight against the diabetes epidemic, and assisting patients and
communities affected by the disease. Congress and IHS, along with
Tribal Nations, recognize the importance and effectiveness of SDPI
interventions in improving and maintaining the health of Tribal
communities. USET SPF urges this Congress to reauthorize SDPI before it
expires on September 30, 2017, and looks forward to working with the
Committee on advancing this vital legislation.
______
Prepared Statement of Kamana'opono M. Crabbe, Ph.D. (Ka Pouhana)/CEO,
Office of Hawaiian Affairs (OHA)
Aloha e Honorable Chairman John Hoeven, Vice Chairman Tom UdaIl,
and members of the Senate Committee on Indian Affairs,
Mahalo (thank you) for the opportunity to submit testimony
regarding the Committee's March 29, 201 7 Oversight Hearing on ``Native
Youth: Promoting Diabetes Prevention Through Healthy Living.'' The
Office of Hawaiian Affairs (OHA) is a public trust and independent
state agency established through the Hawai'i State Constitution to
improve the lives of Hawai'i's indigenous people (Native Hawaiians).
OHA's enabling statute charges it to advocate on behalf of Native
Hawaiians, and to assess policies and practices as they may affect
Native Hawaiians. OHA is also named in various federal statutes as a
recognized Native Hawaiian organization with standing to be consulted
with on matters pertaining to Native Hawaiian rights and cultural
resources. With that kuleana (responsibility) in mind, our agency is
pleased to submit testimony for the record.
OHA operates under a strategy plan which includes Mauli OIa
(health) as a strategic priority of the agency. Our agency collaborates
with various organizations to strengthen our community's resources in
six strategic priorities, including health. We employ the Native
Hawaiian framework of Mauli Ola in our work to advance the health and
well-being of Native Hawaiians. In this framework, individual health is
connected to a number of environmental and social factors, also known
as social determinants of health. We focus on physical, emotional,
mental, and spiritual health, as well as social, economic, and
environmental factors influencing health and wellbeing at each stage of
our beneficiaries' lives. Ancestral wisdom as well as mainstream
historical record and scientific research reflects that prior to
regular Western contact, Native Hawaiians were a thriving, abundantly
healthy people living in what Congress, through Public Law 103-1 50
described as ``a highly organized, self-sufficient, subsistent social
system based on communal land tenure with a sophisticated language,
culture, and religion.''
Unfortunately, Western contact and the erosion of Native Hawaiian
control over our resources greatly disrupted the land-based social
determinants of health that Native Hawaiians had established. Since
then, the health challenges laced by the Native Hawaiian community have
greatly evolved. While communicable diseases were once the greatest
threat facing the Native Hawaiian community in the late eighteenth
through early twentieth century, noncommunicable diseases pose a
serious threat today. In this respect and others, we share many of the
needs and concerns of our American Indian and Alaska Native brothers
and sisters. Many chronic diseases, especially asthma, hypertension,
and diabetes, have a higher prevalence within the Native Hawaiian
community in comparison with the general population of the State of
Hawai'i. \1\ It has been estimated that one in three Native Hawaiian
adults have or are at-risk for diabetes or pre-diabetes. \2\ In 2010,
the age-adjusted prevalence rate of Native Hawaiians living with
diabetes was 84.4 per 1,000 people, while the State of Hawai'i's
overall prevalence was 59.9 per 1,000 people. \3\
---------------------------------------------------------------------------
\1\ See OFFICE OF HAWAIIAN AFFAIRS, NATIVE HAWAIIAN HEALTH FACT
SHEET 2015, VOL.1, CHRONIC DISEASE, available at http://
i19of32x2y133s8o4xzaOgf14.wpengine.netdna-cdn.com/wp-content/uploads/
Volume-1-Chronic-Diseases-FINAL.pdf.
\2\ 2See UNIVERSITY OF HAWAI'I AT MANOA JOHN A. BURNS SCHOOL OF
MEDICINE CENTER FOR NATIVE AND PACIFIC HEALTH DISPARITIES RESEARCH
DEPARTMENT OF NATIVE HAWAIIAN HEALTH, ASSESSMENT AND PRIORITIES FOR
HEALTH & WELL-BEING IN NATIVE HAWAIIANS & OTHER PACIFIC PEOPLES,
available at http://www.hicore.org/media/assets/
JABSOMStudyreNHHealth_20131.pdf
\3\ 3See OFFICE OF HAWAIIAN AFFAIRS, NATIVE HAWAIIAN HEALTH FACT
SHEET 2015, VOL.1, CHRONIC DISEASE, available at http://
19of32x2y133s8o4xzaOgIl4.wpengine.netdna-cdn.com/wp-content/uploads/
Volume-1-Chronic-Diseases-FINAL.pdf
---------------------------------------------------------------------------
According to the Centers for Disease Control and Prevention (CDC),
there are a number of risk factors that increase the likelihood of
developing diabetes. Obesity is one such factor strongly linked with
the development of Type 2 Diabetes. \4\ Patients who are obese and
diagnosed with Type 2 Diabetes often have poor control of their blood
sugar, blood pressure, and cholesterol, which can all lead to severe
health complications. \5\ Obesity is a problem facing the Native
Hawaiian community. In 201 2, the Native Hawaiian obesity rate in
Hawai'i was 44 4% \6\ This rate is in stark contrast to the State of
HawaVi's relatively low obesity rate of 23.6 percent, which is much
lower than most of the nation. \7\ Native Hawaiian youth are also
affected by obesity, and Native Hawaiian public school students have a
rate that is much higher than their peers in the State. \8\
---------------------------------------------------------------------------
\4\ See CENTERS FOR DISEASE CONTROL AND PREVENTION, NATIONAL CENTER
FOR CHRONIC DISEASE PREVENTION AND HEALTH PROMOTION, DIABETES REPORT
CARD 2014, available at https://www.cdc.gov/diabetes/pdfs/library/
diabetesreportcard2014.pdf
\5\ Ibid.
\6\ See OFFICE OF HAWAIIAN AFFAIRS, NATIVE HAWAIIAN HEALTH FACT
SHEET 2015, VOL.1, CHRONIC DISEASE, available at http://
19of32x2yl33s8o4xzaOgf14.wpengine.netdna-cdn.com/wp-content/uploads/
Volume-l-Chronic-Diseases-FINAL.pdf
\7\ Ibid.
\8\ Ibid.
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OHA currently funds a number of programs in Hawai'i that use the
Mauli Ola framework for diabetes treatment and prevention for Native
Hawaiians. One such program, the Hua Ola Project, is managed by the
Boys & Girls Club of the Big Island, and instills lifelong fitness and
dietary habits in youth through culturally responsive experiential
education. Another program currently funded by OHA is I Ola Lahui's
KUlana Hawai'i project, which provides comprehensive, culturally-minded
weight and chronic disease management services to Native Hawaiian
adults and their families. The continued delivery of innovative
programs that focus on Native Hawaiian adults and emphasize youth
education is critical to addressing the health disparities of Native
Hawaiians. Beyond these critical initiatives, Papa OIa Lokahi and the
five Native Hawaiian Health Care Systems located within the State
provide research, education, and other services, as well as foster and
encourage collaborations for a holistic approach to health care in the
Native Hawaiian community broadly.
Significant health improvements have been achieved in programs
integrating cultural practices into health interventions. \9\ To create
a lasting effect on the health of Native Hawaiians and decrease
diabetes prevalence in the Native Hawaiian community, Native Hawaiian
adults, youth, and families must be provided the opportunity to engage
in these types of healthy living programs, diabetes management
education, and other diabetes prevention programs and culturally-
grounded services in the Mauli Ola framework.
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\9\ 9See UNIVERSITY OF HAWAI'I AT MANOA JOHN A. BURNS SCHOOL OF
MEDICINE CENTER FOR NATIVE AND PACIFIC HEALTH DISPARITIES RESEARCH
DEPARTMENT OF NATIVE HAWAIIAN HEALTH, ASSESSMENT AND PRIORITIES FOR
HEALTH & WELL-BEING IN NATIVE HAWAIIANS & OTHER PACIFIC PEOPLES,
available at http://www.hicore.org/media/assets/
JABSOMStudyreNH_Health_20131.pdf
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OHA once again thanks the Committee for holding this oversight
hearing on Native youth and the promotion of healthy lifestyles. This
important topic needs to continue to be addressed in Native American,
Alaska Native, and Native Hawaiian communities. We humbly ask that
Hawai'i's indigenous people also be considered in whatever legislative
and oversight initiatives Congress engages in to address these
important issues. I look forward to continuing to work with you on
these issues and others affecting our Native people.
______
Prepared Statement of Patrick M. Rock, MD, CEO, Indian Health Board of
Minneapolis, Inc.
Dear Senator:
On behalf of the Indian Health Board of Minneapolis, I thank you
for your interest in the issues that are important to American Indian/
Alaska Native (AI/AN) people. My clinic is also a proud member of the
National Council of Urban Indian Health, which represents the interests
of the more than 40 urban Indian health providers (UIHPs) the Congress
has established in far-flung locations across the nation to serve urban
Indians, who constitute more than 70 percent of all AI/AN people.
AI/AN adults are 2.3 times more likely to have diabetes compared
with non-Hispanic whites and the death rate due to diabetes for AI/AN
is 1.6 times higher than the general U.S. population. SDPI, which is an
indispensable part of the solution to this scourge, supports over 330
diabetes treatment and prevention programs in 35 states, which have led
to significant advances in diabetes education, prevention, and
treatment.
The good news is SDPI works and it saves money in the long run. In
2000-2011, the incidence rate of End-Stage Renal Disease (ESRD) in AI/
AN people with diabetes declined by 43 percent--a greater decline than
any other racial or ethnic group. ESRD is the largest cost-driver of
Medicare costs.
Reduction in the incidence rate translates into significant cost
savings for Medicare, the IHS, and third party payers.
S. 747 would reauthorize SDPI for seven years--from fiscal year
2018 through fiscal year 2024--at no increase in cost other than taking
into account health care inflation. I urge you to cosponsor The Special
Diabetes Program for Indians Reauthorization Act of 2017 (S. 747),
which was recently introduced by Senator Tom Udall (D-NM). SDPI will be
shut down on September 30 if the program is not reauthorized in time.
If SDPI's reauthorization is not to fall through the cracks, it is
imperative that Senator Udall's bill be supported through co-
sponsorships.
SDPI has become the most comprehensive treatment and prevention
programing available to NA/AI in the Minneapolis-St Paul Metro area. We
are one of the longest funded programs in the United States. We have
also been recognized nationally and locally in providing innovative
diabetes programing.
Thanks for your consideration of my views. Please let me know if
you will cosponsor S. 747, so I can share the news with our clinic's
patients and providers. I will check in with your staff in two weeks on
this matter because so much is at stake for Indian Country. Please let
me know if you have any questions.
______
Prepared Statement of Ashley Tuomi, President, National Council of
Urban Indian Health
On behalf of the National Council of Urban Indian Health (NCUIH),
which represents urban Indian health care programs (UIHPs) across the
nation that provide high-quality, culturally-competent care to urban
Indians, who constitute more than 70 percent of all American Indians/
Alaska Natives (AI/AN), I, Ashley Tuomi, NCUIH's President, submit this
testimony for the record in relation to the March 29, 2017, oversight
hearing held by the Senate Committee on Indian Affairs on the Special
Diabetes Program for Indians (SDPI).
I thank Chairman Hoeven for holding this hearing as well as his
interest in SDPI and Ranking Member Udall for his recent introduction
of the Special Diabetes Program for Indians Reauthorization Act of 2017
(S. 747), which NCUIH strongly supports. S. 747 would reauthorize SDPI
for seven years-from fiscal year 2018 through fiscal year 2024--at no
increase in cost other than taking into account health care inflation.
NCUIH urges Senators to cosponsor this important legislation in order
to show the support necessary to secure SDPI's timely reauthorization.
It is imperative that SDPI be reauthorized before its expiration on
September 30. Grants to health care providers in Indian Country made
pursuant to SDPI have been instrumental in the marked reduction in the
incidence rate of diabetes-and the related savings to Medicare, the
Indian Health Service (IHS), and third party providers.
At NCUIH's recent Washington Summit, timely reauthorization of SDPI
was one of our organization's top legislative priorities, even with a
broad and comprehensive legislative agenda. The failure to reauthorize
this program would severely undermine the promising progress UIHPs and
Indian Country have made against diabetes. UIHPs are proud of their
role in the fight against diabetes,--Out of the 301 SDPI grants, 30
grants (out of 43 urban programs) went to UIHPs, or 6.65 percent of the
$136,074,763 SDPI funds awarded nationally.
The Committee is very familiar with the grim statistics of the toll
that diabetes inflicts on Indian Country. AI/AN adults are 2.3 times
more likely to have diabetes compared with non-Hispanic whites and the
death rate due to diabetes for AI/AN is 1.6 times higher than the
general U.S. population. And the costs in dollars are also
extraordinary--in 2012 alone 11 percent of AI/AN with diabetes
accounted for 37 percent of all IHS adult treatment costs.
However, the Committee also knows that SDPI achieves outstanding
results and that the program saves significant money in the long run.
SDPI supports over 330 diabetes treatment and prevention programs in 35
states, which have led to significant advances in diabetes education,
prevention, and treatment. In 2000-2011, the incidence rate of End-
Stage Renal Disease (ESRD) in AI/AN people with diabetes declined by
43%--a greater decline than any other racial or ethnic group. ESRD is
the largest cost-driver of Medicare costs. Reduction in the incidence
rate translates into significant cost savings for Medicare, third party
payers, as well as IHS.
Let me tell the Committee how seven UIHPs have used SDPI funds to
provide valuable services which have transformed and saved their
patients' lives.
First, we can start in the northeast to Detroit, Michigan where my
own program, American Indian Health and Family Services, resides. Last
year we attempted to refer clients for services outside of the agency
that we sponsored with SDPI funds for diabetic testing, but we found
that program unsuccessful, as patients were unlikely to follow-up with
the referral. During this fiscal year we changed course and decided
with SDPI funds we would purchase a retinal camera that now allows us
to do undialated eye exams in the clinic. Now that we have our own
equipment in house, we are able to catch the patients right when they
enter our facility and there has been an immediately increase in
retinal eye exams. We are catching diabetes as soon as it enters the
door, thanks to SDPI funding.
Then we can travel to the Great Plains, at the South Dakota Urban
Indian Health (SDUIH), which serves both Pierre and Sioux Falls with
full-time primary and behavioral health clinics.
SDUIH has participated in the SDPI program for fifteen years.
Throughout this time, SDUIH, with its accreditation from the American
Diabetes Association, has provided direct diabetes patient education,
prevention and treatment services that benefits those who have diabetes
as well as those who are at high-risk of getting diabetes.
SDPI funds have made it possible for SDUIH to add physical fitness
centers located on-site within the clinic facility that offer new and
state-of-the-art equipment. SDUIH has also added a fully operational
teaching kitchen that allows patients to participate in cooking classes
and learn how to improve their diets.
SDPI funds support the program's grocery store tours during which
patients are accompanied by a care manager who teaches them how to shop
for healthier and more nutritious food. Funds have also been used to
purchase the lab equipment necessary for operating a high-level
diabetes program, including Piccolo machines, DCA Vantage Analyzers,
and HemoCue testing devices.
SDPI funds allow SDUIH to employ highly-qualified staff to prevent
and treat diabetes, including certified educators, registered
dieticians, licensed nutritionists, fitness/yoga class instructors, and
child care providers.
Ms. Donna LC Keeler, the SDUIH Executive Director, reports that
SDPI funds have allowed her program to provide a wide array of services
to the diabetic patients serviced by SDUIH. According to the most
recent Indian Health Service Annual Diabetes Audit, 59 percent of the
program's patients have had diabetes less than 20 years and 79 percent
are diagnosed with comorbidity of hypertension which demonstrates the
need of continued funding and services. Positive results from SDPI for
the SDUIH program include 55 percent of their patients having blood
sugar (A1c) control of 7.9 or less and 77 percent having blood pressure
of 140/90 or less, so progress is being made but there still is so much
left to do.
Thanks to SDUIH's use of SDPI funds, 100 percent of all diabetic
patients are screened for tobacco use; 97 percent have comprehensive
foot exams; 77 percent have retinal imaging eye exams; 71 percent have
annual dental exams; 99 percent have diabetes education; 97 percent
have physical activity education; 85 percent have flu/pneumococcal
vaccines; 73 percent have hepatitis B immunizations; and 100 percent of
diabetic patients are screened for depression.
Ms. Keeler sums up the fight being waged by SDUIH against diabetes:
``While, clearly, SDPI has been a success--lives of patients have been
saved and their health status has been improved--much work remains to
be done. Without SDPI funds, SDUIH would not be able to retain the
dedicated diabetes staff that have accomplished so much for so many
patients. It is critical to continue funding in order to fight against
diabetes in Indian County.''
Let's shift our focus to Tulsa, Oklahoma, where the Indian
community is served by the Indian Health Care Resource Center of Tulsa
(IHCRC), a comprehensive clinic which cares for almost 12,000 patients
annually. Accredited by the American Association of Diabetes Educators,
IHCRC has used SDPI funds for almost 20 years to offer a variety of
programming, including diabetes case management, fitness and exercise,
nutrition counseling, and diabetes education.
Ms. Carmelita Skeeter, the program's chief executive officer,
reports that during FY2016 alone, IHCRC's diabetes program served 1,410
duplicated patients in the clinic for diabetes case management (63),
diabetes education (649), diet management (604), and exercise/fitness
education (94). Specific program goals include glycemic control,
nutrition education, and physical activity education. IHCRC's public
health nurse, originally funded through the Healthy Heart program and
now through SDPI, coordinates community efforts and the integration of
diabetes case management into primary care, especially for repeatedly
non-compliant patients.
A chart audit of 881 patients with diabetes revealed that 77
percent had known hypertension and 72 percent had a Body Mass Index
(BMI) of 30.00 or above (obesity). Based on BMI, one-third of IHCRC's
3,700 patients under the age of 18 are overweight or obese. With this
information in mind, IHCRC knows that helping patients to develop a
healthy lifestyle can also help to end the vicious cycle of this
disease.
IHCRC's diabetes programs have been enhanced in recent years to
include prevention, especially for youth and families. Collaboration
with the N7 Fund, Southern Plains Tribal Health Board, and an area
funder have helped to further expand the programs.
Programs range from summer wellness camps to training teachers and
youth workers to use physical activity in teaching. This teaching style
has proven to activate the brain, improve on-task behavior during
academic instruction time, and increase daily physical activity levels
among children. The Sit Less, Move More, Learn Better program, attended
by approximately 60 teachers and youth workers each year, has helped
more than 70,000 youth across Oklahoma.
The youth fitness and diabetes prevention program includes Summer
Wellness Camp, a youth run club (initially funded by the N7 Fund),
youth fitness programs, and two annual Family, Fun and Fitness Days.
Each year, more than 300 youth attend the camp which focuses on
diabetes prevention, healthy lifestyles, leadership, team-building,
cultural experiences, and problem-solving.
The annual family fun and fitness festival, attended by more than
450 people since inception, brings families together in an active
environment. The day's highlight is the One Mile Fun Run and Walk.
The program's fight against diabetes has been further enhanced by
engaging youth and families in a running club in which 25 youth and
their family members participate. The club meets every Saturday morning
to run together and participates in approximately six community runs
during the year. During the winter group members work out at the YMCA
and participate as a club in social activities and community service.
``No one could have ever anticipated the changes that occurred in
the running club participants,'' reports Ms. Skeeter. ``Youth have
become stronger and healthier. They have become socially connected with
one another and with others they have met through community races.
Families have begun running and working out together. Youth self-esteem
has improved. Youth have learned to provide encouragement to others
including their own family members. Community volunteers including
members of American Electric Power's Native American employee group
have become extremely involved with the club. Overall, the diabetes
education program has made significant strides in diabetes prevention
for youth and families.''
Like Ms. Keeler, her counterpart in South Dakota, Ms. Skeeter is a
passionate supporter of SDPI, having seen modest amounts of money turn
around the lives of so many Tulsans in such meaningful ways, and she is
also determined to see the program reauthorized.
Let's take the I-44 west and learn how the Oklahoma City Indian
Clinic (OKCIC) has used SDPI funds for 18 years to provide essential
services to its 2,948 patients with diabetes, 2,994 patients with
prediabetes, and 4,672 youth patients, out of an active patient clinic
population of 18,077.
Beginning in 2001, reports Ms. Robyn Sunday-Allen, OKCIC's chief
executive officer, SDPI funds began paying for the program's first
Teaching Urbans Roads To Lifestyle & Exercise (TURTLE) Camp for
children. This initial day camp for OKCIC youth was focused on diabetes
prevention for children 12 to 16 years of age. Sessions on nutrition,
exercise, diabetes education, drug and alcohol abuse, tobacco abuse
have been held by OKCIC for the past 16 years.
SDPI funding has also allowed OKCIC to add a wellness center to the
clinic's campus. Patients are able to work out individually,
participate in group activities or meet with a personal trainer/life
coach. In fact, the wellness center has become the social community for
OKCIC patients as they participate in group fitness classes, diabetes
prevention/education meetings, cooking classes, and cultural
activities.
Recognizing the importance of good nutrition, OKCIC began holding
cooking demonstration classes in 2013, and SDPI funding helped to equip
a kitchen. All patients and their families are welcome to learn from
the registered dietitian/chef to see how to prepare healthy foods
within a reasonable budget. Participation in the cooking classes has
increased from 560 visits in 2013 to 1670 in 2016.
In addition, OKCIC provides annual back-to-school physicals,
immunizations and screening at the program's Children's Health Fair.
Through these screenings, youth at risk are referred to follow-up
services where parents and their children receive education to make the
necessary changes to develop healthy lifestyle habits. ``SDPI
funding,'' reports Ms. Sunday-Allen, ``allows OKCIC to go beyond being
simply an ambulatory health care facility, which helps to endow our
patients with the courage to move towards healthier lifestyles.''
OKCIC, thanks in large part to SDPI funds, provides disease
prevention programming to AI/AN children in an effort to prevent Type 2
diabetes and related co-morbidities. These programs include weekly
afterschool programs, school break programs and 1:1 nutrition and
physical activity counseling. Afterschool programming includes boxing,
adventure sports, running, golf, and tennis. School break programs
include, in addition to TURTLE Camp: Kids in the Kitchen, swimming
lessons, NYPD Camp (Native Youth Preventing Diabetes), jump rope camp,
basketball camp, dance clinic, culture camp and NKOG Camp (Native Kids
on the Go!).
All interventions assess children for weight status, acanthosis
nigricans, blood pressure and obesity-causing behaviors such as sugar-
sweetened beverage intake, fruit and vegetable intake, physical
activity engagement and screen time. The OKCIC staff uses this
information to create fun and effective nutrition-and physical
activity-based activities that re-enforce the lifestyle modifications
necessary to maintain a healthy weight and reduce the risk for Type 2
diabetes. Each disease prevention experience includes a nutrition and
physical activity component.
Ms. Sunday-Allen reports that outcomes after post-programming
demonstrate that the ``patient population experienced a substantial
decrease in BMI percentile, the pediatric gauge for weight. In fact,
the average BMI percentile dipped less than the level used for
overweight classification (80th percentile), which is an encouraging
sign of positive disease prevention progress. The change in BMI
percentile may be a result of the significant decrease in sugar-
sweetened beverage consumption and a decrease in sedentary screen time
usage. While time in physical activity did decrease, the average
remains above the Center for Disease Control's recommendation. These
programs are made possible by SDPI funds for health educators, which
include registered dietitians, physical activity specialists and
support personnel as well as for venue rental, program supplies, and
food.''
Ms. Sunday-Allen recognizes that OKCIC's significant anti-diabetes
effort would not have been possible without SDPI funds, and she
strongly urges the Congress to reauthorize the program before the end
of the fiscal year.
Let's finish our survey of how specific UIHPs are using SDPI funds
by heading to the west coast. First, let's hear from the Native
American Rehabilitation Association of the Northwest (NARA), which
serves eight locations in the Greater Portland Area. NARA focuses its
diabetes efforts on screening, prevention, early diagnosis, and
mitigating against complications caused by diabetes. Using SDPI funds
since 1999, NARA has established a stable, cohesive, multi-disciplinary
clinical group with more than 65 years of combined experience that
serves over 500 people with diabetes and 1,000 patients with
prediabetes.
NARA celebrated the success of its diabetes prevention program in
2016, receiving plaudits from lawmakers and public health experts
alike. Since NARA first offered prevention classes in June 2006, the
133 graduates who completed the 20-week lifestyle balance curriculum--
which includes weekly group meetings, tracking food intake, and
increasing physical activity--collectively lost 1,350 pounds and 213
inches from their waist. NARA reports that prevention program graduates
eat less unhealthy food, and more fruits, vegetables, and whole grains.
NARA staff continue to meet with graduates monthly and support them as
they strive to change their lifestyles.
NARA sees cultural competency and community partnerships as keys to
its success in its fight against diabetes, striving to achieve a
visible presence at community gatherings, cultural activities and
powwows, in order to provide diabetes education and outreach.
NARA partners with the Casey Eye Institute's Outreach Team at
Oregon Health Sciences University, which uses the team's mobile eye van
to provide free dilated eye exams and prescriptions for glasses twice a
year to the program's patients with diabetes. NARA also partners with
the Mount Tabor podiatry office, which often treats the program's
uninsured patients free of charge.
NARA shares best practices with the Northwest Portland Area Indian
Health Board and local tribal organizations as well as the American
Diabetes Association.
And through a partnership with mental and behavioral consultants,
almost forty patients with poorly controlled diabetes (i.e., A1C
greater than 9.0 percent) have been screened using a culturally-
specific trauma examination process. The results indicate a strong
correlation between a history of personal, past and/or
intergenerational trauma and poorly-controlled diabetes. When patients
screen positive for trauma, the behavioral health consultant
coordinates referrals to a mental health consultant.
NARA successfully uses Saturday diabetes clinics, which are the
program's convenient ``one-stop-shop'' clinic for people with diabetes
to receive their annual diabetes ``tune-up.'' Services provided at
these clinics are podiatry, nutrition and exercise counseling, foot and
nail care education, immunizations, laboratory testing, medication
adjustments, diabetes education, and digital retinal screening. In
fact, the percentages of patients completing a foot exam (97 percent vs
80 percent), eye exam (78 percent vs 51 percent) and diabetes education
(96 percent vs 84 percent) were higher for Saturday diabetes clinic
participants than the general NARA diabetes patient population.
If the Congress fails to reauthorize SDPI, NARA would no longer be
able to provide the Portland Indian community with the following
services: diabetes screening; diabetes prevention; diabetes self-
management education classes; nutrition and exercise counseling,
podiatry services, retinal imaging services, and dilated eye exams for
diabetics; and case-management for patients with prediabetes and
diabetes.
Now, let's head south to California, where the Indian Health Center
of Santa Clara Valley (IHCSCV) has established a holistic anti-diabetes
program for education, prevention, and treatment that is an example for
the general population of northern California.
IHCSCV's education effort is led by a registered nurse and it is
further staffed with health educators, who provide one-on-one and group
education about diabetes, teaching patients how to prevent the onset of
the disease and mitigate against its complications--whether at the
patient's home, at the program's wellness center, or at other health
care facilities. Almost one-third of the budget for the wellness center
has been paid for by SDPI funds.
IHCSCV's diabetes program, which was originally funded by SDPI,
works to prevent or delay the onset of diabetes through manageable
lifestyle changes. Although the SDPI grant expired last year, IHCSCV
continues its fight against diabetes because of its continued harshly
disproportionate impact on the Indian community in Northern California.
IHCSCV's primary care staff at the main facility as well as at
three family practice clinics, and one pediatric clinic used SDPI funds
to provide patients with the tools they need to manage their condition,
including glucometers, test strips, lancets, blood sugar logs, pill
cutters, diabetes socks, feet mirrors, and oral health supplies.
Patients whose condition is more problematic benefit from intensive
case-management.
IHCSCV's anti-diabetes effort is impressive in its
comprehensiveness. IHCSCV has a fitness center that is free for all
patients and available to patients at all skill levels. Many fitness
classes are designed for patients who are elderly or have limited
mobility, including Zumba and chair exercise classes. IHCSCV's fitness
coordinator is also a personal trainer, who is able to offer one-on-one
personal training to patients of all ages and skill levels.
IHCSCV helps its diabetes patients overcome transportation barriers
imposed by limited mobility and social isolation. The program provides
transportation for medical, dental, counseling, and specialty
appointments, as well as to the wellness center and community events
that are hosted for the Indian community by IHCSCV and its partners.
IHCSCV's diabetes patients often have many health complications and
are facing other obstacles to their health--including homelessness,
mental disabilities, limited income, and lack of health insurance.
IHCSCV's case management team works closely with the patients and their
primary care providers to coordinate the care within and outside of the
program. The case management team arranges appointments with dentists,
licensed clinical social workers, and psychiatrists at the program as
well as with outside specialists like cardiologists, endocrinologists,
nephrologists, and oncologists. In fact, some IHCSCV managers speak
with their patients almost daily.
Like other UIHPs, IHCSCV believes it is imperative to reauthorize
SDPI. Despite its accomplishments in the fight against diabetes, the
program continues to treat new Indian patients with diabetes. Loss of
SDPI funds would result in a significant decrease in access to
transportation, which could mean that many patients would be less
likely to receive the regular care necessary to control their diabetes.
Loss of SDPI funds would also prevent IHCSCV from engaging in its
aggressive, comprehensive case management or providing diabetes
refreshers, which are two hour education classes specifically tailored
for Indian patients with diabetes.
Finally, let's head north, to the Seattle Indian Health Board
(SIHB). Thanks to the SDPI funds, they have a diabetic team that
provides a comprehensive case management team consisting of a
nutritionist, RN, MA, case manager, and PharmD. This team has been able
to provide robust case management services that supplement the care our
patients receive from their primary care provider.
The services they provide because of the SDPI program include
diabetes and lifestyle education, assistance developing and reaching
self-care goals, support for well-being, referral assistance, etc. The
program has also provided group education classes on topics including
exercise, diet, and general diabetes education. SDPI funding has also
provided onsite optometry and podiatry specialty services for our
diabetic patients.
Without SDPI, SIHB would anticipate at least a 75 percent reduction
in the diabetic case management services that they currently provide.
They would also lose the ability to track and follow up with diabetic
patients who were lost from care or have poor follow-up. This would
inevitably lead to poorer outcomes for the patients and increased
medical costs for the entire health system.
NCUIH appreciates the opportunity to testify about the challenging
but promising work of UIHPs in educating against, preventing, and
treating diabetes which have, literally, saved and transformed lives in
Indian Country. So much of that work would not have been possible
without SDPI, which is why NCUIH strongly urges the Committee to ensure
that the program continues without any interruption. Quite simply, SDPI
must be reauthorized if Indian Country is to educate against, treat,
and prevent the terrible scourge that is diabetes. Thank you for your
consideration. Please contact NCUIH if you have any questions about our
testimony.
*Here is an appreciative note Ms. Keeler received from one SDUIH
patient about the program's SDPI-funded diabetes treatment:
``I just wanted to touch base with you and thank you for
getting me involved in the program. If you ever had any doubts
about the importance of it, I want to let you know I did go to
my eye exam and they did find I had cataracts due to my
diabetes. So this program, in the long run will have saved my
life. I just wanted to let you know what they found. This has
certainly, with no pun intended, opened my eyes to my
responsibility in regards to my diabetes. Again-just a call to
say thank you. Also, my children both have pre-diabetes and
would like them to start coming to your facility. But anyway,
this work is so important and thank you again!''
*Sally is a 12-year-old participant in IHCRC's Running Strong youth
run club. A wonderful but unexpected outcome of the club is that many
parents are inspired to participate with their children, and Sally's
mother registered to run alongside her daughter in a 5K.
``I did my first 5K!!! I was not in the front of the pack but I
wasn't the last one either so I will take that as a win!!! I
did it for my amazing daughter Sally who of course kicked my
butt. She did great in her first 5K also. I am so proud. Wished
I could have seen her come over the finish line. I did meet
some very sweet ladies that helped me along the way. And a huge
thanks to Sally's run club!!! You all are rock stars.''
One week later, there was another 5K--this one in brutally cold
weather. Sally's mom commented:
``Today I finished another 5K with the help of my amazing
daughter. She ran back and got me and helped me finish strong.
She is such an amazing kid. Although the running is hard I love
that we are doing it together. Even if she kicks my butt (lol).
It is something we can enjoy and push each other with. All of
it wouldn't be possible without her amazing run group and coach
Jennie Howard. We could never thank you enough.''
*Here is the success story of one family in which every member
weighed in excess of 250 pounds when they began IHCRC's program:
``I wanted to let you know what a positive move this has been
for our whole family. The first positive is our weight loss.
Our oldest son lost 109 pounds during the past year. His
younger brother only lost 17 pounds but his grades increased as
his weight has decreased. I can't thank you enough for the
changes that you have brought to my family! I just can't
believe the positive outcome of exercise!
``We have stopped drinking sweet tea and we haven't eliminated
sweets but we only have them on special occasions. We have also
tried to limit our bread/other sugar intake. A big deal for us
was portion size, we seen nothing wrong with eating 2 or 3
plates. Now we try to only have 1. We work out at least 5 times
a week. We try to go 7 days a week but sometimes other
activities interfere (work/school). We also play volleyball and
basketball.
``We are a healthy family and working towards improving that
even more and we enjoy it!!! I began using my Facebook page as
an exercise log to help keep me accountable. This in turn has
encouraged many of my friends to begin walking or working out.
I am motivating others and it feels awesome! I have people
private message me about what they are trying to do because
they don't want to go public in case they fail, and I encourage
them that a little exercise is better than none and there is no
failing when you are doing something to move your body around.
``My husband was diagnosed borderline diabetic. Diabetes runs
on his side of the family and he has seen all the struggles his
dad has before he passed away from it. We are hoping that all
of the things we have done will defeat that disease and break
the cycle.''
*Here are five testimonials from patients who have been treated for
diabetes by OKCIC.
1. GS, a proud ``great great grandpa'' and an OKCIC patient for
more than 30 years, states:
``Different foot doctors all wanted to cut off my foot. I would
take off my shoes and show them my foot and they all said if
they didn't take off my foot, they'd have to take off my leg up
my knee''. I came to Oklahoma City Indian Clinic and saw the
Wound Care Team. They said, `We can save that!' Everyone was so
positive here. OKCIC gave me support care, the podiatrist and
other doctors have been a great help.''
2. ``Six years ago I was approached by a member of the Steps to
Achieve Results (STAR) program in the Oklahoma City Indian
Clinic wellness center. I was told about an upcoming Diabetes
Alert Day.I was given an appointment with my provider and I
found out I was pre-diabetic. I have seen diabetes at its
worst. So, of course when I learned I was pre-diabetic, I
wanted to learn as much as I could in order to keep from
becoming diabetic. I did not want my children to see me like I
saw my dad. I knew they would take care of me, but I did not
want them to have to. I enrolled in the STAR program where I
learned how to count my daily fat grams and calories. I also
learned how to prepare my food differently. I learned how to
lose 7 percent of my starting weight and how to keep it off by
adding activity with my food choices. I learned a lot and after
16 weeks finished the program. After being in the program, I
thought it would be interesting to work in the medical field
helping my Native people. In time, an opportunity arose and a
life coach position became available. I applied and now am a
proud member of the STAR team for a little over 4 and half
years. In the process, I have also obtained a certified
personal trainer certificate. I get to help my Native brothers
and sisters in a rewarding capacity by using my experience and
the strength of the curriculum. Through the many acquaintances,
I have made some lifelong friendships.''
3. ``I have lost a total of 15 pounds with the Star program. I
have increased my activity and I feel amazing as the result. I
feel I'm not out of breathe anymore when doing cardio. I am an
active runner and with all the pounds being taken away my legs
don't hurt like they use to when running last spring. I have
also seen results as my pull ups are looking a lot better than
they ever have because I am down 15 pounds from what I had
started with. The benefits are incredible. I get compliments
from so many people wondering what I am doing. This program
does not make me feel like it is a diet but a true lifestyle
change. This class has truly helped me with my diet completely.
This class has helped me learn about proteins and I don't have
to get it from chicken. My recipes and lunches have been so
much more creative because of this class and I am so thankful
it has brought me to this place of being healthy and happy. I
love how the program is setup because it's in baby steps and
the staff has been amazing because when I would slip, they got
me back on track so now it's just a habit to stay on the
healthy lifestyle.''
4. ``STAR cooking and Get SET has helped me out a lot. It has
motivated me to come into the clinic and exercise. STAR cooking
has taught me how to cook properly for my health and to stay on
the right diet plan to continue my health management. The
reason I come to STAR cooking is because I have high blood
pressure, which caused my kidneys to fail. The diet plan for
diabetics is similar for what I need to do on my diet plan with
my health issues. I'm a 74-year-old woman and this helps me to
keep healthy.''
5. BL has managed to lose 20 pounds since she began the STAR
program. By the end of the initial 8 weeks, she managed to lose
12 pounds:
``Prior to my participation in the STAR Program I felt that I
would be unable to make significant changes to my weight and to
my overall health. I have tried other methods and programs that
were not effective. The life coaches celebrated even the
smallest improvements and gave me different options to overcome
obstacles as well. The STAR program has equipped me with tools
and resources so that I can make informed changes that will
result in a healthier future.''