[Senate Hearing 115-48]
[From the U.S. Government Publishing Office]




                                                         S. Hrg. 115-48
 
   NATIVE YOUTH: PROMOTING DIABETES PREVENTION THROUGH HEALTHY LIVING

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

                                HEARING

                               before the

                      COMMITTEE ON INDIAN AFFAIRS
                          UNITED STATES SENATE

                     ONE HUNDRED FIFTEENTH CONGRESS

                             FIRST SESSION

                               __________

                             MARCH 29, 2017

                               __________

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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

                              ----------                              
                                                                   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

                              ----------                              


                       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.
---------------------------------------------------------------------------
    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
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \1\ Story, M. et al. (2003). Obesity in American-Indian Children: 
Prevalence, Consequences, and Prevention. Preventative Medicine, 37(1), 
S3-S12, S5.
---------------------------------------------------------------------------
    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)
---------------------------------------------------------------------------
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\
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \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
---------------------------------------------------------------------------
    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.''