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Objectives: To examine trends in diabetes prevalence, incidence, complications and mortality between 1985 and 2006 among Alaska Native people., Study Design: We used data from the population-based Alaska Native Diabetes Registry, which includes all people who receive care in the Alaska Tribal Health System., Methods: We compared the periods of 1986-1990 and 2002-2006 for diabetes-related amputations, renal replacement and mortality using Poisson regression. Complications and mortality data were examined for trends using Poisson regression. Survival analyses for those diagnosed since 31 December 1985 were performed using the Cox proportional hazard model., Results: Age-adjusted diabetes prevalence increased from 17.3 in 1985 to 47.6/1,000 in 2006. The number of Alaska Native people living in Alaska with diabetes increased from 610 in 1985 to 3,386 in 2006. Diabetes incidence rates have also increased. Comparing age-adjusted rates for the 5-year periods 1986-1990 and 2002-2006, amputations decreased from 5.3 to 2.6/1,000, renal replacement decreased from 3.3 to 1.2/1,000 and mortality decreased from 41.7 to 33.2/1,000. Yearly analyses showed a downward trend for amputations, renal replacement and mortality rates. Survival analyses showed a significantly higher hazard ratio for any amputations, major amputations and renal replacement for the earlier time period compared to the most recent time period., Conclusions: An increase in risk factors, awareness, funding and case-finding may be contributing to the increase in prevalence and incidence of diagnosed diabetes. While diabetes prevalence and incidence are increasing among Alaska Native people, our results suggest that even in remote, rural areas, complications and mortality can be reduced.

Objective: The prevalence of diabetes is increasing rapidly among Alaska's Indian, Eskimo and Aleut populations. Approximately half the Native people with diabetes have no road access to hospitals or physicians, presenting a challenge in the attempt to prevent lower extremity amputation as a complication. In late 1998 funding became available for diabetes prevention and treatment among Native Americans. The tribal health corporations in Alaska decided to use a portion of this funding to implement a high-risk foot program to decrease the amputation rate., Program Design: The program initially involved a surgical podiatrist who provided training to local staff and performed preventive and reconstructive surgery on several patients with impending amputations. The program then provided training for a physical therapist to become a certified pedorthist. This individual established the long-term maintenance phase of the program by conducting diabetic foot clinics routinely at the Alaska Native Medical Center, a referral center in Anchorage. He also travels to other regions of the state to provide training for village and hospital-based health care providers and to conduct field clinics. A system was established in a common database management program to track the patients' foot conditions. Patient education is emphasized., Results: The overall amputation incidence among all Alaska Native patients with diabetes decreased from 7.6/1,000 in the pre-program period (1996 to 1998) to 2.7/1,000 in the post-program period (1999-2001) (p<.001). The rate among Aleuts, who previously had the highest amputation incidence, decreased from 17.4/1,000 to 3.1/1,000 over the same time periods (p<.001). Among people who had had diabetes at least 10 years, the overall amputation incidence decreased from 16.4/1,000 to 6.8/1,000 (p=.021); among Aleuts the rate fell from 24.5/1,000 to 2.6/1,000 (p=.01)., Conclusions: Though longer follow-up is needed, these data suggest that even in populations living in isolated regions, diabetic amputations can be prevented by a coordinated system to identify high-risk feet and provide preventive treatment and education in the context of a comprehensive diabetes management program in an integrated health system.

Objectives: To provide optimum health care to indigenous people with diabetes, to prevent diabetes, and to monitor the epidemiology of diabetes and selected complications. The purposes of this paper are to describe the program and to present data that highlights the major problems and successes., Study Design: Descriptive epidemiology report of diabetes and population service program based on yearly chart review data., Methods: Almost half of Alaska Natives with diabetes have no direct access to physicians or hospitals. Health care delivery is now managed by the tribes themselves. Program emphases include maintenance of a population-based registry, formal training for village health aides, physical activity programs, patient education, primary prevention activities and adherence to standards of care to prevent complications. A centralized registry is maintained to assure that epidemiological data is available and patients are not lost to follow-up. Each year a random sample of charts at each major facility is audited against nationally standardized care guidelines., Results: The prevalence of diabetes among Alaska Natives increased 80% over the 13 years from 1985 to 1998 (15.7/1000 to 28.3/1000, age adjusted to U.S. 1980 population). For the years 1986-1998 the incidence rates of lower extremity amputation and end stage renal disease were 6.1/1000 and 2.0/1000 respectively. The level of care provided to Alaska Native patients is comparable to that provided to the general diabetic patient population seen in Alaskan urban clinics., Conclusions: In spite of logistic challenges, care provided to Alaska Native people with diabetes compares favorably to that provided in other settings. Incidence rates of lower extremity amputation and end stage renal disease also remain comparable to or lower than those in other U.S. populations. Many aspects of our system could be extended to other chronic disease programs serving isolated indigenous populations. Primary prevention of diabetes remains a major challenge as life styles change.

The prevalence of diabetes is relatively low among Eskimo people in contrast to that in other Native American populations. The reasons for this may be partially explained by differences in the occurrence of insulin resistance. In this report we compare fasting insulin levels, which correlate with insulin resistance, in Alaskan Eskimo subjects to those among American Indians. After adjusting for age, gender, and body mass index, and using identical laboratory methods, we found significantly lower insulin levels among Eskimo compared with Indian participants with normal glucose tolerance. Among Eskimos insulin levels increased with increasing body mass index, were higher for women than men, and did not appreciably change with age. Our data suggest that among Eskimo people insulin resistance may be less prevalent or severe than among American Indians, but that obesity is associated with increased insulin resistance. Future analyses will examine the association between insulin levels and other correlates of the insulin resistance syndrome. We hope that by further characterizing insulin resistance or sensitivity among Eskimo people, specific recommendations can be made that will lead to cardiovascular risk factor reduction.

Objective: Determine the prevalence of hypertension in Alaska Natives and evaluate risk factors., Design: Population-based univariate and multivariate analysis of blood pressure in 1124 Alaska Natives over 20 years of age., Results: The sample had mean: age 45 years, body mass index 27, systolic pressure 123 mmHg and diastolic pressure 73 mmHg. The age-adjusted rate of hypertension > or = 160/95 mmHg was 9.1% and 6.8% among Athabascan Indians and Yup'ik Eskimos, respectively. After controlling for age and sex there was significantly more hypertension among Athabascan Indians (OR = 1.53, CI = 1.07-2.2, p = 0.019) compared to Yup'ik Eskimos. Race was significantly associated with blood pressure > or = 140/90 when controlled for age and overweight (p = 0.01, OR = 0.78, CI = 0.69-0.95). The presence of hypertension was significantly associated with the following: intake of non-indigenous food (p = 0.01); mechanized activities (p = 0.01); and glucose intolerance in both women (p = 0.043) and men (p = 0.001). Multiple regression analysis revealed age (OR = 1.06, CI = 1.05-1.08) and overweight in both men (OR = 3.02, CI = 1.85-4.93) and women (OR = 2.76, CI = 1.81-4.19) to be significantly associated with BP > or = 140/90., Conclusion: Hypertension is no longer rare in Alaska Natives and is associated with overweight, non-indigenous diet, mechanized activities, and glucose intolerance.

Objective: To determine the prevalence and incidence of diabetes in Alaska Natives and the incidence of cerebrovascular accidents (stroke), myocardial infarction (MI), end-stage renal disease (ESRD), lower-extremity amputations (LEA), and mortality over a 6- to 8-year period., Research Design and Methods: The data derive from a registry of diagnosed diabetes (World Health Organization [WHO] criteria) of the Alaska Area Native Health Service (AANHS), from medical records, and from the Alaska Bureau of Vital Statistics., Results: From 1986 to 1993, the prevalence of diabetes in Alaska Natives increased by 22% from 15.7 to 19.2 per 1,000 people. Of these cases, nearly all were diagnosed with type II diabetes. During the same period, 614 new cases were diagnosed. The incidence was 1.5 per 1,000 Alaska Natives per year. The incidence of confirmed MI was 8.0 per 1,000 person-years of diabetes. Aleuts had the highest rate, followed by Indians and Eskimos. The incidence of confirmed stroke was 10.6 per 1,000 person-years of diabetes. Eskimos had a significantly higher rate than Indians (P = 0.002), and women had a higher rate than men. The incidence of LEA was 5.0 per 1,000 person-years of diabetes. The incidence rate dropped significantly after instituting a foot care program. The incidence for ESRD was 3.3 per 1,000 and also showed a decline with time. The all-cause mortality rate of 43.2 per 1,000 person-years of diabetes was nearly equal between men and women. Among Alaska Natives with diabetes, cardiovascular disease (CVD) was the most common cause of death, followed by cancer and diabetes, per se., Conclusions: We conclude that diabetes is increasing in Alaska Natives, who are experiencing both the microvascular and macrovascular complications of diabetes. The incidence of LEA and ESRD show some evidence of a decrease after intervention efforts.

The once low prevalence of non-insulin-dependent (Type 2) diabetes (NIDDM) in Eskimos and Indians has risen approximately fourfold over the past 30 years, suggesting the presence of a non-genetic factor affecting NIDDM prevalence. At the same time, traditional physical activities required of a subsistence (self-sufficiency) lifestyle have diminished. Since physical activity has been shown to prevent NIDDM in other populations, we performed a case-control study of physical activity and glucose intolerance in 666 Yup'ik Eskimos and Athabaskan Indians > or = 40 years old in 15 villages in the Yukon Kuskokwim Delta in Alaska. Self-administered questionnaires were used to determine whether subjects participated in a number of traditional activities and/or their modern counterpart (for example, dog sledding and riding motorized vehicles). Intensity values and a score were defined for the activities. Cases included known or newly discovered impaired glucose tolerance or NIDDM. Newly discovered cases were defined by oral glucose tolerance testing of those individuals were screening blood glucose values > or = 6.7 mmol l-1 by random capillary blood glucose testing. Cases included 11 newly discovered (1 with a history of IGT) and 26 known cases of NIDDM, and 17 newly discovered and 1 known cases of IGT. The results showed that, compared to a reference group with low-level physical activity, moderate level physical activity (odds ratio, OR, 0.7, 95% confidence interval [CI] 0.4-1.3) and high level activity (OR 0.2, CI 0.1-0.6) were associated with a lower prevalence of glucose intolerance, adjusted for age, ethnicity, body mass index, and sex.

Objective: To investigate frequency of food intake, body weight, and glucose intolerance in Alaska Natives., Design: Height, weight, and random blood glucose levels were measured and a frequency-of-food-intake questionnaire was obtained. This questionnaire classified persons as consumers of indigenous foods or nonindigenous foods within three food groups. Those with a random blood glucose measurement > or = 6.72 mmol/L received an oral glucose tolerance test., Setting: Community screening in 15 villages in Alaska., Subjects: Nutrition screenings were done for 1,124 Alaska Native residents aged 20 years or older. An oral glucose tolerance test was done for 202 subjects., Outcomes Measured: Subjects were classified as consumers of indigenous or nonindigenous foods within three food groups. A diagnosis of non-insulin-dependent diabetes mellitus (NIDDM) was made on the basis of World Health Organization criteria. A determination of overweight was made on the basis of National Center for Health Statistics criteria., Statistical Analysis: A chi 2 test with Yates correction, t test, and linear regression, with two-sided P values., Results: Athabascan Indians had twice the rate of NIDDM as Yup'ik Eskimos with significantly higher frequency of nonindigenous food intake, plus lower frequency of indigenous carbohydrate and fat intake. Subjects < or = 30 years old consumed significantly more nonindigenous protein and fat and low-nutrient-density carbohydrates than those > or = 60 years old. Persons who had glucose intolerance reported significantly greater consumption of nonindigenous protein and less seal oil. Incidence of overweight was significantly higher than was found 25 years ago. Participants with glucose intolerance were significantly more overweight than others., Conclusion: A pattern of increased frequency of nonindigenous protein, low-nutrient-density carbohydrate, and fat intake with less indigenous carbohydrate and fat consumption was found in subjects < or = 30 years old and in association with the higher rate of NIDDM found in the Athabascan Indians. Persons with glucose intolerance were significantly more overweight than others., Applications: Although the nutritional value of indigenous foods for reducing disease risk should be promoted, nutrition education, especially among young adults, should also include building skills to select and prepare nonindigenous foods to attain a healthful diet. Although snacking is a concern, dietary fat was the most significant factor in obesity and NIDDM.

Objective: Investigate the Accu-Chek II and visual Chemstrip bG methods for non-insulin dependent diabetes mellitus (NIDDM) screening under field conditions with the aid of local providers., Methods: Compare simultaneous random Chemstrip bG, Accu-Chek II and plasma glucose levels using a 6.7 mM cut-off, followed by a 75 gram 2 hour oral glucose tolerance test while screening 1124 people in 15 Alaskan villages with the aid of local personnel during winter field conditions., Results: The Accu-Chek II and visual Chemstrip bG methods detected 92% and 96%, respectively, of those newly diagnosed with NIDDM whose plasma screen was > or = 6.7 mM. The Accu-Chek II provided correlations of 0.774, 0.850, 0.923, and 0.946 with random, fasting, 1 and 2 hour plasma glucose. The mean Accu-Chek II, Chemstrip bG and plasma levels at which NIDDM was diagnosed were not statistically different. Receiver operator characteristic (ROC) curve analysis revealed optimum screening cut-off values for subsequent new diagnosis of NIDDM to be 8.3, 7.7, and 8.0 mM for visual, Accu-Chek II and hexokinase methods (p = NS)., Conclusion: The Accu-Chek II and Chemstrip bG provided accurate glucose data in random NIDDM screening under field conditions with multiple local providers.

Objective: To provide descriptive epidemiological data on diabetes mellitus among Alaska Natives, including incidence, updated prevalence, and incidence rates of ESRD, LEA, MI, and stroke in the diabetic population., Research Design and Methods: In IHS and tribal contract hospitals and clinics throughout Alaska, Alaskan Indians, Eskimos, and Aleuts living in Alaska with documented diabetes mellitus were studied from 1986 to 1987., Results: The number of diabetic patients increased from 610 to 708, and the prevalence changed from 15.7 to 17.4/1000 (not a statistically significant increase). Incidence rates per 10,000 diabetic person-yr for complications were 38 for ESRD, 69 for LEA, 92 for MI, and 92 for stroke., Conclusions: The prevalence of diabetes mellitus increased during the period of observation, but not to a statistically significant degree. Incidence rates for diabetes are lower than for the U.S. general population, but complications rates are as high as those in other diabetic populations.

Objective: To estimate the prevalence of diabetes mellitus and overweight in two populations of Alaska Natives and to compare the results with previous data., Research Design and Methods: Participants' heights, weights, and random plasma glucose levels were determined. Those with a glucose of greater than or equal to 6.72 mM received a follow-up glucose-tolerance test, interpreted by WHO criteria. Overweight was defined by National Center for Health Statistics criteria and also by criteria used in previous studies. The subjects were Eskimo and Athabascan residents greater than or equal to 40 yr of age in 15 villages in southwestern Alaska., Results: Diabetes prevalence was 4.7% for Eskimos and 10.0% for Indians. Among Eskimo men and women, the prevalence of overweight was 34 and 56%, respectively, among Indian men and women, it was 29 and 55%, respectively. Comparisons with past data indicate that the prevalence of diabetes has increased from 1.7% in 1962 for Eskimos and 1.8% in 1969 for Indians., Conclusions: The prevalence of diabetes appears to have increased among Eskimos and Indians in Alaska. Overweight appears to be a significant problem in both groups.

The prevalence of diabetes mellitus in Alaska Natives has been thought to be low, but no survey of this condition in all natives has been conducted. Medical records from 1979 to 1985 were reviewed to determine the prevalence of diagnosed diabetes mellitus in Alaska Natives. Computerized outpatient and inpatient medical record data and clinician reports were used to identify cases. As of December 1985, 610 living Alaska Natives fulfilled diagnostic criteria for diabetes. Type II diabetes mellitus was found in 564 subjects, type I diabetes was found in 15 subjects, and unspecified type of diabetes was found in 31 subjects. The overall age-adjusted prevalence of diabetes mellitus, 15.7/1000, was lower than the overall United States rate of 24.7/1000. However, age-adjusted prevalence varied considerably by ethnic group; the prevalence was 27.2/1000 among Aleuts, 22.0/1000 among Alaskan Indians, and 8.8/1000 among Alaskan Eskimos. Rates within the Eskimo subgroups varied by a factor of four. Compared with previous reports, the prevalence of diabetes mellitus in Alaskan Eskimos appears to have increased. Diabetes mellitus is no longer a rare condition among Alaska Natives.