Funded Pilot Projects

Current projects

Liz Anderson
Liz Anderson, DSW, LCSW, Associate Research Scientist, Pacific Institute for Research and Evaluation

End-of-life care among American Indian and Alaska Native Medicare enrollees with diabetes

Pilot Investigator: Liz Anderson, DSW, LCSW

Despite high chronic disease and mortality rates, little is known about end-of-life care among American Indian and Alaska Native peoples (AIANs). AIANs have the highest diabetes rate of any racial or ethnic group. They are more likely to experience preventable hospitalizations and die from diabetes complications overall and at younger ages than non-Hispanic White adults. AIANs also have the highest premature mortality rate of any other race and are less likely to use hospice than Whites. Advance care planning (ACP) is a preventive intervention that allows people to express their medical wishes if they are unable to communicate and is associated with improved end-of-life care. Yet, research has found that 93% AIANs had never heard of a living will, a type of ACP. No study to date has examined hospitalization and hospice use at the end-of-life for a large nationally represented sample of AIANs. Thus, there is an urgent need to understand AIANs’ use of end-of-life health services. To address this gap, we will conduct secondary data analysis using Centers for Medicare and Medicaid Services 2019 Medicare data to understand end-of-life care with the following aims: 1) compare hospitalization and hospice use between AIAN and White beneficiaries by diabetes status; 2) examine associations between hospitalization and hospice use and personal characteristics between AIAN and White beneficiaries by diabetes status; and 3) conduct an exploratory analysis of ACP use in AIAN by patient characteristics to assess our ability to conduct a comprehensive multivariable analysis of ACP use in the future.

Ginny Lane
Ginny Lane, PhD, Assistant Professor, University of Idaho

Diabetic Ketoacidosis in Children: Risk Factors & Racial Disparities

Pilot Investigator: Ginny Lane, PhD

Diabetic ketoacidosis (DKA) is an acute hyperglycemic emergency in people with diabetes. Noted risk factors for recurrent DKA include low socioeconomic status, adolescence, female sex, high glycated hemoglobin (HbA1c), previous episodes of DKA, and a history of mental health problems. Among children, risk factors for DKA include poor diabetes control, previous episodes of DKA, unstable or challenging family or social circumstances, adolescent age, being a peripubertal girl, and having limited access to medical services. It is unknown whether Native American children with diabetes experience the same risk factors for DKA. Using secondary data from the SEARCH for Diabetes in Youth project, the study team will address the following specific aims: (1) Evaluate the association of socioeconomic status, sex, HbA1c, treatment cost burden, diabetic instruction, episodes of missed medication, frequency of blood testing, disordered eating, quality of life, and dietary glycemic load with episodes of DKA among children; and (2) Evaluate whether there are differences in these relationships between various racial and ethnic groups.
Chao Li
Chao Li, PhD, Clinical Assistant Professor, Oklahoma State University Center for Health Sciences

Longitudinal association among smoking, alcohol consumption and key diabetes and cardiovascular biomarkers among American Indians with diabetes

Pilot Investigator: Chao Li, PhD

The adverse effects of smoking on diabetes have been widely studied in the general population.  Numerous studies have reported that smoking can cause inflammation and dysfunction of endothelial, lipid and glucose metabolism and Beta-cell toxicity, damage tissue and vascular, increase insulin resistance and reduce insulin secretion. The direct effect of alcohol consumption on diabetes is complex and controversial. Some evidence indicates that moderate alcohol consumption may have a beneficial long-term effect on diabetes through improving glucose control and insulin sensitivity. On the contrary, low-level and binge alcohol consumption have been related with hypoglycemia and other adverse health outcomes, including increased risk of diabetic neuropathy and retinopathy, atherosclerosis, hepatocellular carcinoma, and problems of neuroendocrine, gastrointestinal, and sexual functioning. However, there is limited research that has been focused on the longitudinal and quantitative relationship between smoking and alcohol consumption and diabetes among American Indians (AIs). To evaluate the longitudinal relationship among smoking, alcohol consumption and key cardiovascular and diabetes biomarkers among AIs with diabetes. The hypothesis is that smoking has a negative, and alcohol consumption has a curvilinear, longitudinal dose-response effect on all or part of these key diabetes and cardiovascular biomarkers. This is a longitudinal cohort study, and the results will quantify the extent to which smoking and alcohol consumption, potentially modifiable factors, impact the evolution of HbA1c, fasting glucose, 2-h glucose and serum lipids among AIs with diabetes. 

Project supported in part by American Diabetes Association.

Susie Lopez
Susanna Lopez, PhD, Postdoctoral Fellow, Oklahoma State University Center for Health Sciences

Understanding substance use and mental health symptoms in the relationship between food insecurity and diabetes in American Indian adults

Pilot Investigator: Susanna Lopez, PhD

American Indians (AIs) face significant disparities in obesity and diabetes due to colonization and their forced removal from their traditional homelands and foods. AIs are 3 times more likely to experience food insecurity, defined as limited or uncertain access to nutritious foods, compared to the general population. Food insecurity is significantly associated with poor diet, which, in turn, is the greatest risk factor for the development of obesity and diabetes. Depression, heavy alcohol use, and tobacco use are also associated with diabetes and poor diabetes management. Though less research has examined associations between depression, heavy alcohol use, tobacco use, and food insecurity, preliminary results suggest food insecurity is a risk factor for depression and risky substance use. More research is needed to further explore these relationships among AI communities. The present study is a secondary analysis seeking to investigate these associations using data from a larger study in partnership with the Chickasaw Nation. It is hypothesized that 1) AI adults with diabetes who are food insecure will report greater levels of depression, alcohol use, and smoking than those who are not food insecure, and 2) improvements in food insecurity over time will be associated with improvements in depression, alcohol use, and smoking; furthermore, these improvements will be stronger among those without diabetes than those with diabetes. The results of this study will advance knowledge in the relationships of both systemic and psychosocial factors on diabetes development, prevention, and management in a rural AI community.

Project supported in part by American Diabetes Association.

Erin Morgan
Erin Morgan, PhD, Research Assistant Professor, Institute for Research and Education to Advance Community Health 

Perceptions of masculinity and health behaviors among Native men

Pilot Investigator: Erin Morgan, PhD

American Indian (AI) men have the highest age-adjusted prevalence of type 2 diabetes (~18%) among U.S. men, while non-Hispanic White men have the lowest (~7%). Participation in clinical trials and diabetes intervention programs is quite low among AI men, which is perhaps due, in part, to the influence of perceived gender roles and social norms around health behavior. This project leverages the Strong Men, Strong Community (SMSC) study to understand the role of masculinity in diabetes prevention. The SMSC study was a clinical trial of a culturally appropriate adaptation of the Diabetes Prevention Program that aims to improve diet and increase exercise among AI men at high risk for diabetes. Data collection assessed self-reported engagement in diabetes prevention strategies (diet, exercise, healthcare engagement), perceived importance of various skills and behaviors in relation to masculinity, and influences on participants’ ideas of what it means to “be a man.”  Using cross-sectional data from the baseline study visit (n = 270), we will evaluate relationships between perceptions of masculinity and current diabetes prevention strategies (diet, exercise, healthcare engagement) at baseline. Furthermore, we will conduct longitudinal analyses with data collected at follow-up visits over 12 months to assess how these relationships and views of masculinity change over time with continued participation in the intervention. Findings from these analyses will inform future diabetes interventions on the importance of incorporating cultural perspectives of masculinity into curriculum, and on whether influencing views on manhood may be one effective strategy to improve diabetes-related outcomes for AI men.

Maja Pedersen
Maja Pedersen, PhD, Faculty Affiliate at University of Montana & Postdoctoral Fellow at Stanford University

Using CBPR and a life course perspective to examine physical activity among rural American Indian mid-life and older adults

Pilot Investigator: Maja Pederson, PhD

American Indian (AI) adults are more likely to develop heart disease and die from it than non-Hispanic white (NHW) adults. Likewise, diabetes mellitus (diabetes) has a three-fold higher rate in AI adults than in NHWs and is the most important clinical risk factor for heart disease among AI populations. Physical activity (PA) is a powerful protective behavior known to reduce risk for heart disease and diabetes. Yet, PA rates are low among AI adults, and understanding of PA influences among this population is limited. This study responds to recent calls for advanced knowledge on PA among historically marginalized populations by attending to contextual factors (e.g., social, and environmental influences), and life course factors (e.g., life events and life transitions), that may impact PA engagement and participation. This study is part of an ongoing community-based participatory research (CBPR) partnership, including AI and non-AI study team members representing academic and tribal community-based entities. The team will use a CBPR approach and qualitative description to analyze data from semi-structured interviews (N=21) conducted among rural AI adults on topics of PA and wellbeing. The study is theoretically grounded in the NIMHD Health Disparities framework and the life course perspective. A collaborative, iterative content analysis process will be applied, guided by the theoretical framework. Findings will provide insight into contextual and life course factors influencing PA engagement and participation among AI adults, informing optimized timing and settings for customized interventions to increase PA, reduce diabetes and heart disease, and promote long-term wellbeing among AI populations.
Brandon Varilek
Brandon Varilek, PhD, Assistant Professor, University of Nebraska Medical Center

Palliative care use among American Indians with end-stage renal disease caused by diabetes

Pilot Investigator: Brandon Varilek, PhD

American Indians and Alaska Natives (AI/ANs) are twice as likely to be diagnosed with diabetes than non-Hispanic Whites (NHWs). Persons with diabetes are at greater risk of end-stage renal disease (ESRD) and nearly two-thirds of all ESRD in AI/AN populations was caused by diabetes in 2013. Implementation of health promotion practices, such as nutrition and exercise programs, are essential to preserve renal function. Palliative care is also a health promotion practice that can improve quality of life for those with ESRD. Additionally, kidney transplantation is a desirable option to treat ESRD. Inclusion of palliative care in ESRD settings can help balance patient goals of care with transplant requirements to promote transplant readiness. No studies exist to date that examine the use of palliative care prior to kidney transplant among AI/ANs with ERSD r/t diabetes or viewed this problem using ETR’s Health Equity Framework by correlating aims to the Area Deprivation Index (ADI). To address this gap, we will conduct a secondary data analysis using United States Renal Data System data to understand the following aims: 1) Between AI/ANs and NHWs, compare the prevalence of ESRD r/t diabetes and ADI ratings nationally and by IHS region, 2) Among AI/ANs and NHWs with ESRD r/t diabetes who received a kidney transplant, contrast the rate of hospice referrals nationally, by IHS region, and correlate to the ADI rating, and 3) Between AI/ANs and NHWs, evaluate survival time after diagnosis with ESRD r/t diabetes nationally, by IHS region, and correlate to the ADI rating.

Previously funded projects

Centers for American Indian & Alaska Native Health

Colorado School of Public Health

CU Anschutz

Nighthorse Campbell Native Health Building

13055 East 17th Avenue

Mail Stop F800

Aurora, CO 80045

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