Funded Pilot Projects

Gestational diabetes and breastfeeding among American Indian and Alaska Native women

Luciana E. Hebert, PhD

Gestational diabetes, defined as diabetes that develops during pregnancy, is a serious, common, and pressing maternal and child health issue that disproportionately affects American Indian and Alaska Native (AI/AN) women. Gestational diabetes can have lifelong impacts for both mothers and children. During pregnancy, gestational diabetes increases the risk for pre-eclampsia, pre-term birth, and cesarean delivery. Following delivery, gestational diabetes places both mothers and children at higher risk of type 2 diabetes. Although breastfeeding is protective against development of diabetes following gestational diabetes, AI/AN women are less likely to initiate breastfeeding than other groups of women. However, no previous study has rigorously evaluated gestational diabetes, breastfeeding, and risk and protective factors in AI/AN women. This study involves a multistate analysis using data from the Pregnancy Risk Assessment Monitoring System (PRAMS) to explore gestational diabetes and breastfeeding patterns (initiation and duration) among AI/AN women compared to other racial and ethnic groups. First, we will examine risk factors related to gestational diabetes and how they differ for AI/AN women compared to other racial and ethnic groups. Second, we will examine the association of gestational diabetes with breastfeeding patterns among AI/AN women in PRAMS. This study will use secondary data from multiple states (Alaska, Washington, Oklahoma, New Mexico, and South Dakota) and years (2016-2018). Findings will provide valuable information about gestational diabetes and breastfeeding among Native women and inform development of culturally appropriate interventions.

Publications from this work:

Hebert LH, Nikolaus CJ, Zamora-Kapoor A, Sinclair K. (2022). Gestational diabetes and breastfeeding among women of different races/ethnicities: Evidence from the Pregnancy Risk Assessment Monitoring Surveys. Journal of Racial and Ethnic Disparities, e-pub 2022. doi:10.1007/s40615-022-01356-w

Food insecurity as a longitudinal predictor of diet sensitive cardiometabolic risk factors among American Indian and Alaska Native adults

Cassandra Nikolaus, PhD 

American Indians and Alaska Natives (AI/ANs) are at elevated risk for diet sensitive chronic diseases, including diabetes. This may, in part, be explained by food insecurity, defined as insufficient access to nutritious foods, and reported by 25% of AI/AN households. In the general population, food insecurity is associated with chronic diseases, healthcare costs, and premature mortality. However, these associations have not been established in data where AI/AN are identified, weakening the ability to develop culturally relevant interventions. Further, most prior research relies on cross-sectional data. To address these gaps, Add Health data will be analyzed to assess the relationship between food insecurity and diet sensitive cardiometabolic risk factors among AI/AN respondents. This pilot will use data from the two most recent assessment waves: wave 4, collected in 2008, and wave 5, collected in 2016-2018. Food security was measured in wave 4. Diet sensitive cardiometabolic risk factors (weight, fasting glucose, A1c, blood lipids, and blood pressure) were assessed at both waves. Using these data, the aims for this pilot are to: 1) assess the cross-sectional association of food insecurity and diet sensitive cardiometabolic risk factors among AI/AN adults during young adulthood in comparison with non-Hispanic white, non-Hispanic Black, and Hispanic respondents; and 2) assess the longitudinal relationship between food insecurity in young adulthood and changes in diet sensitive cardiometabolic risk factors across ten years among AI/AN, non-Hispanic white, non-Hispanic Black, and Hispanic adults.

Publications from this work:

Nikolaus CJ, Hebert LE, Zamora-Kapoor A, Sinclair KI. Risk of food insecurity in young adulthood and longitudinal changes in cardiometabolic health: Evidence from the National Longitudinal Study of Adolescent to Adult Health. Journal of Nutrition, 2022. doi:10.1093/jn/nxac055

Nikolaus CJ, Zamora-Kapoor A, Hebert LE, Sinclair K. Association of food security with cardiometabolic health during young adulthood: Cross-sectional comparison of American Indian adults with other racial/ethnic groups. BMJ Open, 2022 doi:10.1136/bmjopen-2021-054162

Food insecurity and healthful eating for American Indian and Alaska Native adults with type 2 diabetes: Perspectives from key stakeholders

Sarah Stotz, PhD, MS, RD, CDE, LD

Food insecurity is well documented as a barrier to healthful eating and diabetes self-management. American Indians and Alaska Natives (AI/AN) are twice as likely to experience food insecurity and type 2 diabetes (T2D) than non-AI/ANs. For this proposed project, we will conduct secondary analyses on the qualitative data collected as part of a needs assessment aimed to inform the cultural adaptation of an existing diabetes nutrition education program for AI/AN adults with T2D. This project will explore themes regarding food insecurity and healthful eating for diabetes management in AI/AN communities, as described by AI/ANs with T2D and key stakeholders. Findings from the project will serve as preliminary study to support a future large-scale grant proposal to develop AI/AN-specific nutrition education interventions that address food insecurity as it pertains to diabetes self-management.

Spatial clustering and associated determinants of diabetes in Navajo youth

Christine Wey Hockett, PhD

(with Dana Dabelea, MD, PhD, Sonya S. Shin, MD, MPH, Michael C. Wimberly, PhD, Phoutdavone Phimphasone-Brady, PhD, and Anna Bellatorre, PhD)

American Indian youth (aged 0-19 years) have the highest incidence of pediatric type 2 diabetes (T2D) in the United States; however, there is limited research on the geographic variation of T2D in youth, and none in high-risk populations, such as American Indians. In response to this gap in the literature, this project will build upon our long-standing collaborations between academic researchers and Native stakeholders to identify areas within Navajo Nation that have a higher than expected burden of T2D (hotspots) and explore what ecological characteristics explain these hotspots. The specific aims of our project are 1) to identify spatial clusters of T2D incident cases in Native youth on Navajo Nation from 2002 through 2016, 2) determine what social and environmental determinants are associated with high-risk clusters of T2D on Navajo Nation; and 3) host a half-day mini-summit, involving key community stakeholders, to disseminate the results of the project. Key community stakeholders may be able to use these results to prioritize resources and target efforts for pediatric diabetes prevention.​

Clinical and social determinants of health for obesity: A Lifespan investigation of overweight/obesity among American Indians and Alaska Natives

Cheryl Conway, PhD,  Amber Fyfe-Johnson, PhD, Vanessa Hiratsuka, PhD, Kimberly Huyser, PhD, and Michelle Johnson-Jennings, PhD

American Indians and Alaska Natives (AI/ANs) have a prevalence of diabetes that is 2 to 3 times that of the general U.S. population. Obesity, a key risk factor for type 2 diabetes, is common in AI/AN populations and often begins in early childhood. 
 The prevalence of obesity is significantly higher among Native preschoolers, school-aged children, youth, and adults than in the comparable subgroups of the general U.S. population. Social determinants of health (SDOH), or the conditions in which
 people are born, grow, live, and work (e.g., socioeconomic conditions, access to health care, and food access and security), are known to influence racial disparities in health outcomes. Although some research suggests that SDOH may play an important
 role in the high rates of obesity, diabetes, and cardiovascular disease among Native people, the literature does not provide clear conclusions regarding the association of SDOH with diabetes-related outcomes in Native populations.

The objective of this pilot project is to investigate the relationship between SDOH and diabetes outcomes in AI/ANs, using a life course perspective. Analyzing longitudinal data available from the Indian Health Service’s (IHS) Improving Health Care
 Delivery Data Project (IHCDDP), five Early-Stage Investigators from our collaborating Satellite Centers are addressing three specific aims: 1) the association of SDOH with diabetes-related outcomes among AI/AN mothers (obesity, gestational diabetes)
 and birthweight of Native newborns; 2) the association of SDOH with diabetes-related outcomes among Native children,  adolescents, and young adults (Body Mass Index, pre-diabetes, diabetes); and 3) the association of food access and security
 with diabetes-related outcomes among Native elders.

Publications from this work

Fyfe-Johnson, A. L., Reid, M. M., Jiang, L., Chang, J. J., Huyser, K. R., Hiratsuka, V. Y., Johnson-Jennings, M. D., Conway, C. M., Goins, T. R., Sinclair, K. A., Steiner, J. F., Brega, A. G., Manson, S. M., & O'Connell, J. Social determinants of health and body mass index in American Indian/Alaska Native children. Child Obesity, 2022. doi:10.1089/chi.2022.0012 

Goins, R. T., Conway, C., Reid, M., Jiang, L., Chang, J., Huyser, K. R., Brega, A. G., Steiner, J. F., Fyfe-Johnson, A. L., Johnson-Jennings, M., Hiratsuka, V., Manson, S. M., & O'Connell, J. Social determinants of obesity in American Indian
 and Alaska Native peoples aged ≥ 50 years. Public Health Nutrition, 2022. doi:10.1017/s1368980022000945 

Hiratsuka, V. Y., Reid, M., Chang, J., Jiang, L., Brega, A. G., Fyfe-Johnson, A. L., Huyser, K. R., Johnson-Jennings, M., Conway, C., Steiner, J. F., Rockell, J., Dillard, D. A., Moore, K., Manson, S. M., & O'Connell, J. Associations between
 rurality, pre-pregnancy health status, and macrosomia in American Indian/Alaska Native populations. Maternal and Child Health Journal, 2022. doi:10.1007/s10995-022-03536-w 

Johnson-Jennings, M. D., Reid, M., Jiang, L., Huyser, K. R., Brega, A. G., Steine, J. F., Manson, S. M., Chang, J., Fyfe-Johnson, A. L., Hiratsuka, V., Conway, C., & O'Connell, J. American Indian Alaska Native (AIAN) adolescents and obesity:
 the influence of social determinants of health, mental health, and substance use. International Journal of Obesity, 2023. doi:10.1038/s41366-022-01236-7 

Engaging families to improve diabetes management at an Urban Indian Health Organization

Meredith Fort, PhD

Pediatric obesity and type 2 diabetes in American Indian youth

Pediatric obesity and type 2 diabetes (T2D) are global public health problems worldwide, and American Indian (AI) youth have the highest incidence and prevalence of T2D in the United States. We recently completed an 8-month pilot and feasibility trial
 of a behavioral intervention designed to reduce these risks in 62 overweight/obese AI youth aged 7-10 years. To maintain the momentum of this research and to guide dissemination and implementation plans across AI communities, we conducted a 1-year
 community-based participatory research process with Navajo Nation in conjunction with the Special Diabetes Program for Indians (SDPI). Our specific aims are: 1) to share the findings of the pilot study with study participants, TTPP research team,
 local community leaders, and relevant stakeholders; 2) to explore opportunities for the sustainable implementation of the program within the larger Navajo Nation community; 3) to plan for a larger dissemination and implementation research study that
 will expand the program to additional AI communities. By continuing our collaboration with Navajo Nation and using lessons learned from SDPI, we can prepare to expand the TTPP for youth in AI communities in a sustainable, effective manner.

American Indian and TOPS Collaboration for Health (AITCH)

Nia Mitchell, MD

American Indians are at increased risk for Type 2 diabetes compared to other Americans. A primary risk factor for diabetes is being overweight or obese, and American Indians are more likely to be overweight or obese than other Americans.  Therefore, effective interventions focused on weight management hold promise for diminishing the diabetes-related disparities American Indians face.  Take Off Pounds Sensibly (TOPS) is a nonprofit, low-cost, peer-led, nationally available weight loss program, and a recent study showed that TOPS helped people lose 5% of their initial weight and maintain the weight loss for up to 3 years.  Each TOPS chapter decides the types of programs it would like to include; therefore each chapter can be tailored to fit the needs of its members. The objective of this project is to explore and address barriers to the diffusion of TOPS in the American Indian community in the Denver metropolitan area by offering the program to 50 American Indian participants through a local community organization that serves the American Indian community.  Both qualitative and quantitative assessments will be utilized. Surveys will be used to evaluate the eating and physical activity patterns, self efficacy, and stages of change pre- and post-intervention.  Focus groups will be used to determine the feasibility and acceptability of the program and to get feedback on ways to tailor the program to the American Indian community.  We will also assess the weight change of participants over a 12 week intervention.

Numeracy Intervention to Improve Diabetes Self-care (NIIDS) 

Angela Brega, PhD

Growing evidence suggests that the ability to understand and use numbers (“numeracy”) may have important implications for diabetes self-care.  Compared to patients with stronger numerical skills, those with limited numeracy check their blood sugar levels less frequently, are less likely to adjust their insulin doses based on carbohydrate intake and blood sugar levels, have less confidence that they can manage their diabetes (i.e., self-efficacy), and have worse glycemic control. The objective of this project is to develop a computerized intervention to teach American Indian patients a subset of the numeracy skills needed to manage diabetes.  The intervention will focus on three sets of self-care skills (understanding blood glucose values, monitoring carbohydrate intake, managing cardiovascular risk) and will be culturally tailored for the American Indian tribe that is participating in the project.  The computerized intervention will incorporate audio- and video-based education and will comply with recommendations for clear communication of health information.  Pilot testing of the intervention will be conducted with 50 American Indian patients with diabetes from a large Indian Health Service clinic serving our partner tribe.  Using a pre-post design, we will examine change over time in diabetes numeracy, self-efficacy, stage of change, and self-care behavior.