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Objective: To examine stakeholder perspectives on food insecurity and associated challenges to healthy eating among American Indian and Alaska Native (AI/AN) adults with type 2 diabetes (T2D). Methods: Focus groups and interviews were conducted with purposively selected stakeholders: AI/ANs with T2D, their family members, healthcare administrators, nutrition and diabetes educators, and national content experts on AI/AN health. Two coders analyzed transcripts using the constant-comparison method. Results: Key themes included (1) rural- and urban-dwelling AI/ANs experience different primary food security and associated challenges; (2) factors contributing to food insecurity extend beyond cost of healthy food; and (3) barriers to consuming fresh, healthy food include cost, preparation time, limited cooking knowledge, and challenges with gardening. Discussion: Resources for AI/ANs with T2D who experience food insecurity and associated challenges to healthy eating should be tailored based on urban versus rural location and should address cost and other barriers to consumption of fresh fruits and vegetables.

Background American Indian and Alaska Native (AI/AN) adults have a higher prevalence of type 2 diabetes (T2D) and related complications than non-AI/AN adults. As healthy eating is a cornerstone of diabetes self-management, nutrition education plays an important role in diabetes self-management education. Objective To understand stakeholder perspectives on facilitators and barriers to healthy eating for AI/AN adults with T2D in order to inform the cultural adaptation of an existing diabetes nutrition education curriculum. Methods Individual interviews were conducted with 9 national content experts in diabetes nutrition education (e.g. registered dietitians, diabetes educators, experts on AI/AN food insecurity) and 10 community-based key informants, including tribal health administrators, nutrition/diabetes educators, Native elders, and tribal leaders. Four focus groups were conducted with AI/AN adults with T2D (n = 29) and 4 focus groups were conducted with their family members (n = 22). Focus groups and community-based key informant interviews were conducted at 4 urban and reservation sites in the USA. Focus groups and interviews were recorded and transcribed verbatim. We employed the constant comparison method for data analysis and used Atlas.ti (Mac version 8.0) to digitalize the analytic process. Results Three key themes emerged. First, a diabetes nutrition education program for AI/ANs should accommodate diversity across AI/AN communities. Second, it is important to build on AI/AN strengths and facilitators to healthy eating (e.g. strong community and family support systems, traditional foods, and food acquisition and preparation practices). Third, it is important to address barriers to healthy eating (e.g. food insecurity, challenges to preparation of home-cooked meals, excessive access to processed and fast food, competing priorities and stressors, loss of access to traditional foods, and traditional food-acquisition practices and preparation) and provide resources and strategies for mitigating these barriers. Conclusions Findings were used to inform the cultural adaptation of a nutrition education program for AI/AN adults with T2D., To understand key stakeholder perspectives regarding facilitators and barriers to healthy eating for American Indians with type 2 diabetes to inform the cultural adaptation of a diabetes nutrition education program.

Indigenous peoples experience a disparate burden of chronic diseases and lower access to health education resources compared with other populations. Technology can increase access to health education resources, potentially reducing health inequities in these vulnerable populations. Although many Indigenous communities have limited access to the Internet, this barrier is decreasing as tribes and Indigenous-serving organizations work to improve TechQuity. Using Arksey and O’Malley’s framework, we conducted a scoping literature review to identify technology-based health education interventions designed for Indigenous adults. We searched multiple databases, limiting papers to those written in English, describing interventions for participants 18 years of age or older, and published between 1999–2020. The review yielded 229 articles, nine of which met eligibility criteria. Findings suggest a paucity of technology-based health education interventions designed for Indigenous peoples and limited testing of the existing resources. Future health disparity research should focus on development and rigorous testing of such interventions.

Background Individuals often report concurrent social risk factors such as food insecurity, unstable housing, and transportation barriers. Comparing relative changes between pairs of social risk factors may identify those that are more resistant to change. Objective The objective of this study was to develop a method to describe relative changes in pairs of social risk factors. Research design This was a prospective cohort study. Subjects Participants in a randomized controlled trial of hypertension care in an Urban Indian Health Organization. Measures We measured 7 social risk factors (housing, transportation, food, clothing, health care, utilities, and debts) at enrollment, 6, and 12 months among 295 participants in the trial. We hypothesized that pairwise comparisons could identify social risk factors that were less likely to change over time. We used conditional odds ratios (ORs) with 95% confidence intervals (CIs) to rank each pair. Results Food, clothing, health care, utilities, and debts had more changes between 0 and 6 months relative to housing (OR=2.3, 3.4, 4.7, 3.5, and 3.4, respectively; all 95% CI excluded 1.0). These same social risk factors also had more changes between baseline and 6 months relative to transportation (OR=2.8, 3.4, 4.9, 4.7, and 4.1, respectively; all 95% CI excluded 1.0). Changes in housing and transportation risk factors were comparable (OR=0.7, 95% CI: 0.4-1.4). Relative changes between 6 and 12 months were similar. Conclusions Housing and transportation exhibited fewer relative changes than other social risk factors and might be more resistant to change. Awareness of the relationships between social risk factors can help define priorities for intervention.

Objective:To explore stakeholder perspectives regarding online diabetes nutrition education for American Indians and Alaska Natives (AI/AN) with type 2 diabetes (T2D).Design:Qualitative data were collected through focus groups and interviews. Focus group participants completed a brief demographic and internet use survey.Setting:Focus groups and community participant interviews were conducted in diverse AI/AN communities. Interviews with nationally recognised content experts were held via teleconference.Participants:Eight focus groups were conducted with AI/AN adults with T2D (n 29) and their family members (n 22). Community participant interviews were conducted with eleven clinicians and healthcare administrators working in Native communities. Interviews with nine content experts included clinicians and researchers serving AI/AN.Results:Qualitative content analysis used constant comparative method for coding and generating themes across transcripts. Descriptive statistics were computed from surveys. AI/AN adults access the internet primarily through smartphones, use the internet for many purposes and identify opportunities for online diabetes nutrition education.Conclusions:Online diabetes nutrition education may be feasible in Indian Country. These findings will inform the development of an eLearning diabetes nutrition education programme for AI/AN adults with T2D.

Interactive voice response and text message (IVR‐T) technology may improve hypertension control in under‐resourced settings. We conducted a randomized clinical trial to determine whether an IVR‐T intervention would improve blood pressure (BP), medication adherence and visit keeping among adults with hypertension from multiple racial and ethnic groups in primary care at an Urban Indian Health Organization in Albuquerque, New Mexico. Two hundred and ninety‐five participants were randomly assigned to IVR‐T (N = 148) or to usual care (N = 147). The IVR‐T arm received reminders for clinic visits, messages to reschedule missed clinic visits, monthly medication refill reminders, weekly motivational messages, and a blood pressure cuff. The usual care arm received no messages. The primary outcome was change in systolic BP (SBP) between baseline and 12 months. Secondary outcomes included change in SBP between baseline and 6 months, change in diastolic BP (DBP) at 6 and 12 months, self‐reported adherence at 6 months, and the proportion of missed primary care clinic appointments. The intervention did not affect SBP or DBP at 6 or 12 months. The 12‐month change in SBP/DBP was 1.66/1.10 mm Hg in usual care and 0.23/1.34 mm Hg in the intervention group (P values = .57 and .88, respectively). Self‐reported medication adherence improved comparably in both groups, and there was no difference in percentage of kept visits. Several features of study design, clinic operations, and data transfer were barriers to demonstrating effectiveness.

AIAN women have higher risk for GDM. Early preconception counseling (PC) about healthy lifestyle/weight and mothers’ support could reduce these risks. We describe and compare parallel measures of SS with RH/GDM risk: daughters’ perceived SS from mothers, and mothers’ perceived SS for daughters. Methods: Secondary analysis used baseline data from 113 mother-daughter (M-D) dyads from four sites participating in Stopping GDM, an online randomized trial to reduce risks of GDM. Perceived maternal SS was amounts (0=no support, to 5=a lot of support) and types of SS re: RH, healthy lifestyle behaviors, and seeking PC to prevent GDM (instrumental SS, e.g., help get birth control; informational SS, e.g., on pregnancy/GDM) . M-D independently completed online measures of perceived available maternal SS. We performed descriptive, within-dyad comparative/correlational analyses. Results: AIAN AYA (n=113; mean age 17±3yrs; BMI 29±8.3 kg/m2) and their mothers (n=113; age 44.7±9yrs; 45% had > 2-4 college; 44% married) . AYA reported moderately high levels of maternal SS: total (16±5; range:0-20) ; instrumental (12±4; 0-15) ; informational (4±2; 0-5) . Mothers reported high levels of SS to give their daughters: total (20±1; range:15-20) ; instrumental (15±1; 10-15) ; informational (5±0; 0-5) . Mothers reported significantly higher levels of SS to give their daughters compared to their daughters’ perception of available maternal SS (p Disclosure D. Charron-Prochownik: None. S.M. Sereika: None. A.F. Fischl: None. N. O'Banion: None. K.L. Gonzales: None. L. Chalmers: None. K.R. Moore: Consultant; Novo Nordisk. Funding RNR014831 grant

Background American Indian/Alaska Native (AI/AN) adolescents are at higher risk for gestational diabetes (GDM), type 2 diabetes, and pregnancy complications than the general population. Objective To inform cultural adaptation of a validated evidence-based intervention (VEBI) originally designed to deliver preconception counseling and diabetes education to non-AI/AN teens with diabetes. Design Qualitative data were collected using focus group and individual interview methods with health care professionals and experts (n = 16) in AI/AN health, GDM, adolescent health, and/or mother-daughter communication. A semistructured discussion guide elicited responses about provision of care for AI/AN girls at risk for GDM, experience with successful programs for AI/AN teens, comfort of mother/daughter dyads in talking about diabetes and reproductive health and reactions to video clips and booklet selections from the VEBI. All interviews were recorded and transcribed verbatim, and data analysis included inductive coding and identification of emergent themes. Results Providers felt teens and their moms would be comfortable talking about the VEBI topics and that teens who did not feel comfortable talking to their mom would likely rely on another adult female. Participants suggested including: AI/AN images/motifs, education with a community focus, and avoiding directive language. Concerns included: socioeconomic issues that affect AI/AN people such as: food and housing insecurity, abuse, and historical trauma. Conclusions Perspectives from these participants have been used to guide the development of a culturally tailored GDM risk reduction program for AI/AN girls. This program will be available to health care providers who serve the AI/AN population.

Youth homelessness is a serious national challenge affecting millions of young people every year. However, due to their relatively small population size, together with limitations related to data and research efforts on homelessness to date, prevalence estimates and evidence of homelessness experiences among American Indian and Alaska Native (AIAN) youth have been scarce. This is particularly the case at the national level. We report findings on the prevalence, characteristics, and correlates of AIAN youth experiencing homelessness that are based on a nationally representative survey on homelessness among adolescents and young adults, age 13 to 25. The overall national survey sample included 25,492 respondents. During a 12-month period, approximately 10.2% of AIAN households with 13-17 year olds reported youth homelessness or runaway experiences that lasted at least one night. For AIAN 18-25 year olds, the 12-month population prevalence of homelessness experiences was 12.2%. AIAN young adults had three times the prevalence rate of homelessness as their White non-Hispanic peers. Furthermore, most AIAN youth experiencing homelessness, like most AIAN people overall, reside in predominantly urban counties. Controlling for other variables, lower educational attainment, and parenting (especially if unmarried) were associated with higher likelihood of homelessness. There is a clear and urgent need for tailored, culturally-responsive homelessness prevention and intervention strategies, along with focused housing and support investments, for AIAN young people and the communities in which they live. The federal government and local jurisdictions need to take policy actions to address high rates of AIAN youth homelessness in urban and suburban communities, in addition to policies centered on AIAN reservations and rural communities.

OBJECTIVE: To elicit feedback from tribal leaders and American Indian/Alaska Native (AI/AN) health system administrators as a national stakeholder perspective to inform the development of a gestational diabetes mellitus (GDM) risk reduction and preconception counseling intervention for AI/AN teenagers at high risk for GDM. METHODS: A semi-structured focus group interview guide was developed by both principal investigators and qualitative methods experts. Using open-ended questions about the Reproductive-health Education and Awareness of Diabetes in Youth for Girls (READY-Girls) booklet and video clips, AI/AN health care system administrators and elected tribal leaders attending the 2015 National Indian Health Board Conference in Washington, DC, made recommendations on adaptation for an AI/AN audience. The focus group was recorded, transcribed verbatim, and analyzed by two researchers using an inductive coding technique with constant comparison method as supported by the grounded theory approach. RESULTS: Recommendations from the 12 participants included: (1) the best ways to communicate with AI/AN teenagers, (2) the importance of parental, family, and community education and engagement to support AI/AN teenagers in GDM risk reduction, and (3) building on traditional AI/AN cultural values and practices, while accommodating differences between tribes and regions. CONCLUSION: Findings from this focus group were used to inform the iterative development of a GDM risk reduction and preconception counseling intervention for AI/AN teenagers.

Purpose of Review This scoping literature review seeks to answer the question “What is known in the existing literature about multi-level diabetes prevention and treatment interventions for Native people living in the United States and Canada?” Recent Findings Multi-level interventions to prevent and/or treat chronic diseases, such as diabetes, promise to help individuals who experience health disparities related to social determinants of health. As described by the socio-ecological model, such interventions mobilize support through a combination of individual, interpersonal, organizational, community, and policy levels of activity. Summary This review revealed little literature about multi-level diabetes prevention and/or treatment programs for US and Canada-based Native peoples. Ten interventions were identified; all focused on diabetes prevention; eight were specific to youth. Multi-level intervention design elements were largely individual-, school-, and community-based. Only three interventions included environmental or policy-level components.

Gestational diabetes mellitus (GDM) is the most common complication of pregnancy and contributes to increased risk for T2D in both the mother and offspring. American Indians are at higher risk of GDM and subsequent diagnosis of T2D than non-Hispanic white women. This project examined the experiences of American Indian mother-daughter (M-D) dyads as participants and the site coordinators who facilitated a GDM risk reduction and preconception counseling randomized controlled trial (RCT) to evaluate Stopping GDM (SGDM). The SGDM RCT included 4 visits over 9 months which dyads attended together but completed SGDM intervention (video and eBook) and questionnaires separately. SGDM content included GDM risk reduction (e.g., healthy nutrition), GDM risk awareness/health beliefs, preconception counseling, reproductive health communication, and family planning. For this study, dyads (n=22 dyads) were recruited from three of the five study sites and site coordinators from all sites participated (n=6). Mothers, daughters, and site coordinators were in separate focus groups. Focus groups were facilitated by trained qualitative researchers, conducted/recorded remotely using Zoom, transcribed verbatim, and analyzed using qualitative content analysis and Atlas.ti. Themes include: 1) SGDM provided valuable quality time and conversation about GDM and reproductive health among dyads; 2) GDM risk factors and risk reduction was largely new information for most dyads; 3) all sites experienced challenges to study engagement and recruitment; 4) recommendations for study improvement: personalized recruitment that is clinic-based and mother-focused; remote/asynchronous study visits; and significantly shorter content. These findings will be used to inform revisions of SGDM to improve the program and for a broader, more inclusive version of the program for other at-risk females. Disclosure S. A. Stotz: None. A. F. Fischl: None. M. A. Terry: None. H. Garrow: None. N. O’banion: None. L. Chalmers: None. K. R. Moore: None. D. Charron-prochownik: None. Funding National Institutes of Health (UL1TR001857 to D.C-P.); National Institute of Nursing Research (1R01NR014831-01A1 to D.C-P., K.R.M.)

Gestational Diabetes Mellitus (GDM) is the most common complication of pregnancy and potentially causes problemsfor both mother and baby, including risks of developing type 2 diabetes (T2D). Compared to other Americans, Indigenous youth have more risk factors and higher rates of GDM. We developed Stopping GDM a GDM risk reduction and reproductive health program for American Indian adolescent females. To further deepen the cultural strengths of the program we draw on constructs from Indigenous ways of knowing, such as Ancestral Knowledge System (AKS). We conducted a secondary analysis on an existing qualitative dataset collected during the Stopping GDM study using AKS as a secondary framework. Key constructs from AKS include: relationships, place-based knowledge, generational networks, holistic approaches, language, cultural heritage, and critical reflection. This dataset includes focus groups with AI adolescent girls (age 12-20) (n=13); their adult female caregivers (n=9); and AI women with a history of GDM or T2D (n=5) from two urban sites. All focus groups were moderated by a trained qualitative researcher with a notetaker and semi-structured moderator guide and analyzed using Atlas.ti. Four primary themes supported by the AKS framework constructs emerged: 1) the important and unique role of women in Native communities; 2) traditional ways as they relate to women, reproductive health, and wellness; 3) support for women’s wellness and reproduction; 4) social determinants as challenges for Indigenous communities in promoting healthy behaviors. These findings will be used to support expansion of Stopping GDM to increase its cultural relevance for a broader Indigenous priority audience which includes Native Hawaiian and Alaska Native communities. Disclosure D. Charron-prochownik: None. R. Soon: None. S. A. Stotz: None. A. F. Fischl: None. K. L. Gonzales: None. M. Mau: None. K. R. Moore: None. Funding National Institutes of Health (UL1TR001857 to D.C-P.); National Institute of Nursing Research (1R01NR014831-01A1 to D.C-P., K.R.M.)

Family engagement may improve disease management, yet little is known about this topic as it relates to underrepresented minorities who receive care in low-resource primary care settings. This study aimed to explore family engagement in diabetes and hypertension management at an Urban Indian Health Organization to identify opportunities and challenges, and inform care strategies. We employed semi-structured interviews, genograms, eco-maps, and timelines, among 23 English- and Spanish-speaking American Indian and Latino adults with a dual diagnosis of type 2 diabetes and hypertension and 13 family members. Using thematic analysis, we found that family support is not always available, patients have difficulty sharing medical information, and family often live far away. Conversely, opportunities to leverage included a desire for increased engagement, motivation from the younger generation, prevention within the family, outreach to family members with the same conditions, and learning from elders and ancestors. Implications for programs, clinical care, and research are discussed.

Food insecurity is well documented as a social determinant of health and as a barrier to healthful eating and diabetes management. American Indians and Alaska Natives (AI/ANs) are twice as likely to experience food insecurity and type 2 diabetes (T2D) as non-Hispanic Whites. The purpose of this project was to identify themes regarding food insecurity and healthful eating in relation to diabetes management among AI/AN adults with T2D. The reported analysis used qualitative data originally collected to inform adaptation of an existing American Diabetes Association diabetes nutrition education program for AI/AN adults with T2D. Qualitative data were collected through focus groups and interviews with AI/ANs with T2D, their family members, and key stakeholders such as healthcare administrators, registered dietitians, and diabetes educators. Two coders analyzed transcripts in their entirety using the constant-comparison method for qualitative content analysis. Key themes included the following: (1) Rural and urban AI/ANs have different primary food security challenges. AI/ANs who live in rural reservation locations discussed loss of traditional foods and loss of access to land where these foods were once found. Urban-dwelling AI/ANs, on the other hand, highlighted the cost of healthful food as their primary food security challenge. (2) AI/ANs discussed logistical problems with accessing healthy food (i.e., lack of time, need for convenience, easy access to fast and processed food, high cost of healthful food, loss of traditional food) whereas nutrition educators focused on solutions, such as cooking and nutrition education. (3) When discussing the high cost of healthful foods, focus group participants concentrated almost exclusively on the high cost of fresh produce as opposed to other healthful food products. Findings from this analysis will help inform the development of food security resources for AI/ANs with T2D. Disclosure S.A. Stotz: None. S. Lockhart: None. A.G. Brega: None. K.R. Moore: None. Funding American Diabetes Association (4-18-SMSC-01 to K.R.M.); National Institutes of Health (P30DK092923); Center for American Indian and Alaska Native Diabetes Translational Research

Introduction: Little research has focused on enhancing knowledge and health beliefs in female AYA at risk for GDM and their mothers, particularly in the AI/AN population. We examined the change in knowledge and health beliefs about GDM at the baseline visit between the intervention (n=60) and control (n=53) arms of the Stopping GDM Trial among AI/AN female AYA at risk for GDM (i.e., daughters) and their mothers. Methods: Grounded in the Expanded Health Belief Model and using a randomized controlled trial design, this investigation focused on the efficacy of a video viewed at the baseline visit of a culturally tailored online program to enhance knowledge and health beliefs to decrease GDM risk in 113 AI/AN female AYA (74% AI; on average 16.9±3.0 years old; 45% in grades 9-12) and their mother or an adult female (e.g., grandmother) (80% mother; 82% AI; on average 44.7±9.4 years old; 44% college educated). All completed established measures of knowledge and health beliefs (benefits, barriers, severity, susceptibility) before and after viewing the video. Data were analyzed using descriptive statistics and linear mixed modeling. Results: At the baseline visit daughters in the intervention group had greater mean increase in overall reproductive health and GDM knowledge (p=.010), and more specifically family planning knowledge (p=.003), compared to the control group. Daughters on average increased both diabetes prevention comprehensive (p=.048) and GDM (p Conclusions: These initial results support the use of culturally tailored behavioral interventions to improve knowledge and health beliefs to reduce GDM risk in AI/AN female AYA. Disclosure S.M. Sereika: None. K.R. Moore: None. S.A. Stotz: None. A.F. Fischl: None. L. Chalmers: None. H. Garrow: None. K.L. Gonzales: None. N. O’Banion: None. D. Charron-Prochownik: None. Funding National Institutes of Health (R01NR114831)

“Plant blindness” is defined as the failure to appreciate the fundamental importance of plants. To address this phenomenon, we created the Pet Plant Project (P3) where students grow an unknown plant from seed, monitor development, and relate lecture concepts to their plant on a daily basis. A qualitative survey was administered and analyzed to evaluate student responses to the experience. Themes in the analysis, identified across 209 student-participants at Tennessee Tech University, included positive reinforcement of lecture material, a new-found appreciation for plants, responsibility and pride related to plant care, a continued desire to grow plants, and more. Statistical results included: 73% of students noticed plants more after the project; 76% planned to grow plants in the future; and 68% made a connection with their own plant that bolstered engagement in course materials.

Background Food insecurity can negatively impact chronic disease management. Older adults often have more nutrition-related chronic disease and barriers to healthful eating such as unreliable transportation and living on a fixed-income. Urban American Indian (AI) serving clinics provide a trusted source of care for American Indian elders and services to mitigate food insecurity among American Indian elders are warranted. Objective The objective of this study was to explore the perspectives of AI elders living in 1 large city regarding locally available food insecurity resources and opportunities for the urban clinic to expand food insecurity support. Study Design, Setting, Participants Qualitative individual interviews with AI elderly (≥60 years old) patients from an urban AI clinic. Participants (n = 24) engaged in 1 30–90-minute telephone interview. Participants were recruited by clinic staff. Measurable Outcome/Analysis One researcher conducted all interviews using a semi-structured moderator guide with probes. “Scenario-based” questions were included to obtain interviewee responses to each scenario. This approach was intended to de-stigmatize food insecurity for participants who may have felt shame in sharing their own experiences with food insecurity. Interviews were audio recorded, transcribed verbatim, and analyzed using the constant comparison method and Atlas.ti. Results Four key themes emerged: 1) hunger-mitigating resources exist but don't necessarily lessen food insecurity; 2) multiple layers of challenges present barriers to healthy nutrition for AI elders; 3) unique facilitators rooted in AI culture can help decrease food insecurity; and 4) there are many clinic-based opportunities for programs to improve food insecurity. Conclusion These findings provide a foundation for urban-serving AI clinics to develop and implement food insecurity resources for their elders. Resources should build on cultural strengths and be specific to the challenges faced by elders. Some challenges are not unique to AIs and similar resources could be developed for other urban organizations serving elders.

Introduction American Indian and Alaska Native (AIAN) girls have double the risk of obesity, pregnancy, and gestational diabetes mellitus (GDM) than the general U.S. population. The purpose of this study was to beta test Stopping GDM (SGDM), a GDM risk reduction intervention for at-risk AIAN teens, before beginning a randomized controlled trial. Method A sample of 11 AIAN mothers and daughters were recruited through an urban Indian health program. Daughters were at risk of GDM as assessed by a BMI ≥ 85th percentile. Pre- and posttest online questionnaires evaluated the online intervention (e-book and video). Results Mean pre- to posttest knowledge increased for mothers and daughters on diabetes prevention, reproductive health, and GDM knowledge. Daughters demonstrated an increased self-efficacy for healthy living and pregnancy planning. Satisfaction for the e-book, video, and online survey was moderately high to very high. Discussion The SGDM intervention is feasible and acceptable in AIAN mother–daughter dyads. These findings informed the SGDM intervention and the randomized controlled trial evaluation protocol.

Background American Indian and Alaska Native (AI/AN) women have a higher risk of gestational diabetes mellitus (GDM) and subsequent diagnosis of diabetes than do non-Hispanic White women. Healthy eating is key to weight management both prior to pregnancy and between pregnancies and can reduce the risk of developing GDM. Our research team developed an innovative preconception counseling and diabetes risk-reduction program, which includes nutrition and weight-management principles and is culturally tailored for adolescent AI/AN women. The program is entitled Stopping Gestational Diabetes Mellitus (SGDM). Objective The purpose of this article is to examine nutrition-related information collected as a part of the formative qualitative research conducted for the development of a preconception counseling and gestational diabetes risk-reduction program, SGDM. Methods This in-depth secondary analysis explored the original qualitative data from the needs assessment for SGDM program development. Participants included AI/AN women with a history of GDM (n = 5); AI/AN girls at risk of GDM (n = 14), and their mothers (n = 11), health care providers, and health administrators who care for AI/AN girls (n = 16); AI/AN elected leaders; and Indian health system administrators (n = 12). All focus groups and interviews were reanalyzed utilizing the following research question: “How do key stakeholders discuss food and/or nutrition in terms of gestational diabetes risk reduction for AI/AN adolescent girls?” Results Three primary nutrition themes emerged: 1) AI/AN women were aware of healthy nutrition, healthy weight gain during pregnancy, and healthy nutrition for people with type 2 diabetes, but these principles were not linked to reducing the risk of GDM; 2) participants expressed the need for education on the role of nutrition and weight management in GDM risk reduction; 3) participants shared challenges of healthful eating during and before pregnancy for AI/AN women. Conclusions These stakeholders’ comments informed the development of the nutrition components of SGDM., We examined qualitative data to understand perspectives of key stakeholders regarding the role of nutrition in gestational diabetes mellitus (GDM) risk reduction for at-risk American Indian and Alaska Native women.

To provide an updated synopsis of the research and clinical practice findings on pregnancy and gestational diabetes mellitus (GDM) in American Indian and Alaska Native (AIAN) adolescents and to describe the newly developed “Stopping GDM,” an early intervention, culturally tailored risk reduction program for AIAN girls and their mothers. Five research articles met our inclusion criteria. Three retrospective quantitative studies published in the past 10 years corroborated a 1.5 to 2 times higher prevalence for GDM for all age groups in the AIAN population as compared to other ethnic groups, and that the percentage of GDM cases attributable to overweight and obesity was highest for AIs (52.8%). Moreover, First Nations women across all age groups had more adverse pregnancy risk factors than non-First Nations women. Out of the five selected articles, two were qualitative research articles: one examined AIAN women’s experiences of having GDM or type 2 diabetes (T2D) during pregnancy and the other appraised the understanding of GDM and reproductive health of at-risk AIAN girls. There is a paucity of research published on this topic. AIAN females are at high risk for developing GDM. Early, culturally responsive interventions and cohort follow-up studies are needed among adolescents and young adults, using technology that appeals to this age group.

AIAN women have a higher risk for GDM and subsequently type 2 diabetes (T2D) than non-AIAN white females. We adapted a validated diabetes preconception counseling (PC) program for AIAN girls at high risk for GDM and their mothers. This paper presents preliminary baseline data, prior to the intervention, of both the girls and their mothers enrolled in an RCT to evaluate changes in GDM risk-reduction awareness, knowledge, health beliefs and behaviors after the Stopping GDM intervention. Data were collected using a dyadic model; both AIAN girls and their AIAN mothers (adult female caregiver) participated. These findings are on 27 mother (M) - daughter (D) dyads (n=54) from 2 of 4 sites (Southwestern U.S.). D (ages 12-24 years) were at risk for GDM as defined by BMI ≥85thpercentile or family history of T2D, and did not have diabetes (HbA1c < 6.5%). M’s mean (±SD) age was 41.3±14.1 years and 56% (n=15) had at least some college education; D’s mean age was 16.3±2.9 years and 89% were students. M and D completed online questionnaires separately on awareness, knowledge and health beliefs regarding GDM and reproductive health and healthy lifestyle. One open-ended question on awareness of GDM revealed that participants were unaware of GDM or the daughters’ risks. Mean pre-intervention knowledge scores were low for both M and D on diabetes prevention (M: 76.4+14.3, range=54-100%; D: 58.2+12.4, range=27-82%) and reproductive health and GDM knowledge (M: 67.2+11.2, range=46-85%; D: 35.0+18.3, range=0-62%). D had moderate levels of self-efficacy for healthy living (53.2±14.6) and pregnancy planning (86.4±22.6). Most Ds reported no communication with healthcare professionals (HCP) or their Ms regarding GDM or PC [(with HCP=15%; 8%, respectively), (with M= 15%; 4%,)]. Both AIAN mothers and daughters lacked awareness and knowledge of the girl’s risk for developing GDM. Developing culturally relevant PC programs could help decrease these risks. Disclosure D. Charron-Prochownik: None. S.M. Sereika: None. S.A. Stotz: None. A.F. Fischl: None. N. O'Banion: None. J. Powell: None. M.L. Aspaas: None. S. Goudeau: None. S.J. Thorkelson: None. S. Beirne: None. K.R. Moore: None. Funding National Institute of Nursing Research (1R01NR014831-01A1)

Nutrition education is known to promote healthful dietary behaviors and reduce diet-related complications among people with diabetes. American Indians and Alaska Natives (AIAN) have more than double the risk for type 2 diabetes (T2D) and diabetes-related complications than non-Hispanic whites. Despite the high prevalence of T2D in AIAN communities, AIANs often lack access to diabetes-related nutrition education, particularly resources targeted to AIAN audiences. Literature suggests that online nutrition education may effectively serve low-income audiences, but research specific to AIANs is scarce. We employed qualitative focus group and individual interview methods to understand stakeholder perspectives on the feasibility of an online eLearning diabetes nutrition education program for AIAN adults with T2D. We interviewed four types of stakeholders, including: experts in AIAN diabetes nutrition education (n=9); AIAN educators, Native elders, and tribal leaders (n=11); and AIAN adults with T2D (n=29) and their family members (n=22) at 4 geographically distinct urban and reservation sites. Focus groups and interviews were recorded and transcribed verbatim. The constant comparison method guided data coding and thematic analysis and Atlas.ti (Mac Version 8.0) was used to digitalize the analysis. Participants shared that smartphone-based Internet access is common among AIAN adults, except for the very old. Sixty percent of focus group participants indicated that they use the Internet at least daily. Participants reported interest in online education opportunities that are reputable, culturally adapted for AIAN people, and smartphone friendly. Educators and leaders indicated that access to a registered dietitian and food resource management education via online learning would provide Native people with the additional support needed to eat healthfully in communities with high rates of food insecurity and limited access to healthy food. Disclosure S.A. Stotz: None. A.G. Brega: None. K.R. Moore: None. Funding American Diabetes Association (4-18-SMSC-01 to K.R.M.)

American Indian and Alaska Native (AIAN) adults have a higher rate of type 2 diabetes (T2D) and related complications than non-AIAN adults. Nutrition is the cornerstone of diabetes self-management and nutrition education is a key component of diabetes self-management education. The purpose of this research was to understand stakeholder perspectives on how to adapt the American Diabetes Association (ADA) newly developed nutrition education program entitled “What Can I Eat? Choices for People with T2D and their Families” (WCIE) for AIAN adults. Using focus group and individual interview methods, we interviewed experts in AIAN diabetes nutrition education (n=9); AIAN educators, Native elders, and tribal leaders (n=11); and AIAN adults with T2D (n=29) and their family members (n=22) at 4 geographically distinct urban and reservation sites nationwide. Focus groups and interviews were recorded and transcribed verbatim. We employed the constant comparison method for data analysis and used Atlas.ti (Mac version 8.0) to digitalize the analytical process. Qualitative analysis identified specific facilitators and barriers to healthy eating in Native communities. Facilitators included: strong community and family support systems, traditional values of balance and gratitude, Native pride, and community-based wellness goals. Barriers included: food insecurity, challenges to preparation of home-cooked meals, high consumption of fast food and sugar-sweetened beverages, and loss of access to traditional foods and food-acquisition practices. Findings will be used to culturally adapt the existing ADA WCIE diabetes nutrition education program for AIAN adults with T2D. Disclosure K.R. Moore: None. S.A. Stotz: None. A.G. Brega: None. K.L. Gonzales: None. Funding American Diabetes Association (4-18-SMSC-01 to K.R.M.)

Purpose American Indian and Alaska Native (AIAN) women are disproportionately affected by gestational diabetes mellitus (GDM). GDM is a risk factor for subsequent diagnosis of type 2 diabetes (T2D) in both mother and offspring, yet there is minimal research being conducted in this population. The purpose of this portion of a larger 5-year study is to examine AIAN women’s experiences of having GDM or T2D during pregnancy, inform the development of a GDM risk reduction and preconception counseling (PC) program tailored to AIAN girls, and enhance mother-daughter communication and support within the program. Methods AIAN women with TD2 or a history of GDM (N = 5) were interviewed to understand their unique perspectives on diabetes and pregnancy, behaviors to reduce risk, and content for a PC education program for AIAN girls. Interviews were digitally recorded, transcribed verbatim, and analyzed using the constant comparison method to construct themes across the interviews. Results Four primary themes were constructed: lack of knowledge on GDM and GDM risk factors, importance of AIAN culture for health and wellness, suggestions for communication with AIAN girls to reduce risk of GDM, and the emotional impact of GDM diagnosis. Conclusions Participants wished they had known about risk factors for GDM and how to reduce their own risk of developing GDM. Findings from this study have been used to adapt an existing PC program, originally developed for non-AIAN girls with diabetes, for AIAN girls who do not have diabetes but have risk factors for developing GDM in future pregnancies.

AIAN women have twice the risk compared to the general U.S. population of adolescent obesity, pregnancy, and GDM. Stopping GDM (SGDM), a GDM risk reduction intervention tailored for at-risk AIAN teens, is based on a validated preconception-counseling program, READY-Girls. Prior to starting a multi-tribal randomized controlled trial (RCT) to test SGDM’s effectiveness, a feasibility study was conducted in Denver, CO with AIAN participants (4 mothers, 5 daughters). Mother-daughter (M-D) dyads were recruited through an Urban Indian Health program. Daughters were at risk for GDM as assessed by BMI >85th percentile and did not have diabetes based on finger-stick HbA1c < 6.5%. Mother’s (M) mean age was 44.4±8.8 years and 100% had some college education; daughter’s (D) mean age was 15.9±2.7 years and 80% were In conclusion, we determined that the SGDM intervention is feasible and acceptable in AIAN M-D dyads. These findings will be used to finalize the SGDM education materials and data collection protocol for the upcoming full-scale RCT. Disclosure K.R. Moore: Advisory Panel; Self; Merck Foundation. S.A. Stotz: None. K.J. Nadeau: None. S.M. Sereika: None. Y. Garcia Reyes: None. H.R. Stein: None. D. Charron-Prochownik: None.

Objectives. To estimate obesity and overweight prevalence in American Indian and Alaska Native (AI/AN) children across genders, ages, and geographic regions in the Indian Health Service active clinical population. Methods. We obtained data from the Indian Health Service National Data Warehouse. At least 184 000 AI/AN children aged 2 to 19 years had body mass index data for each year studied, 2006 to 2015. We calculated body mass index percentiles with the 2000 Centers for Disease Control and Prevention growth charts. Results. In 2015, the prevalence of overweight and obesity in AI/AN children aged 2 to 19 years was 18.5% and 29.7%, respectively. Boys had higher obesity prevalence than girls (31.5% vs 27.9%). Children aged 12 to 19 years had a higher prevalence of overweight and obesity than younger children. The AI/AN children in our study had a higher prevalence of obesity than US children overall in the National Health and Nutrition Examination Survey. Results for 2006 through 2014 were similar. Conclusions. The prevalence of overweight and obesity among AI/AN children in this population may have stabilized, while remaining higher than prevalence for US children overall.

Background: Efficient and effective strategies for treating chronic health conditions such as hypertension are particularly needed for under-resourced clinics such as Urban Indian Health Organizations (UIHOs). Objective: The objective of the Controlling Blood Pressure Trial is to assess the impact of an interactive voice response and text message (IVR-T) intervention compared with usual care among individuals with hypertension receiving care at a UIHO in Albuquerque, New Mexico. This manuscript presents the baseline characteristics of individuals enrolled in the trial and compares their characteristics with those in the hypertension registry who did not enroll in the trial. Methods: A hypertension registry developed from the clinic’s electronic health record was used for recruitment. Potentially eligible participants were contacted by letter and then by phone. Those who expressed interest completed an in-person baseline visit that included a baseline survey and blood pressure measurement using standardized procedures. Individuals randomized to the intervention group could opt to receive either automated text messages or automated phone calls in either English or Spanish. The messages include reminders of upcoming appointments at First Nations Community HealthSource, requests to reschedule recently missed appointments, monthly reminders to refill medications, and weekly motivational messages to encourage self-care, appointment keeping, and medication taking for hypertension. Individuals in the IVR-T arm could opt to nominate a care partner to also receive notices of upcoming and missed appointments. Individuals in the IVR-T arm were also offered a home blood pressure monitor. Follow-up visits will be conducted at 6 months and 12 months. Results: Over a 9.5-month period from April 2017 to January 2018, 295 participants were enrolled from a recruitment list of 1497 individuals. The enrolled cohort had a mean age of 53 years, was 25.1% (74/295) American Indian or Alaska Native and 51.9% (153/295) Hispanic, and 39.0% (115/295) had a baseline blood pressure greater than or equal to 140/90 mmHg. Overall, the differences between those enrolled in the trial and patients with hypertension who were ineligible, those who could not be reached, or those who chose not to enroll were minimal. Enrolled individuals had a slightly lower blood pressure (129/77 mmHg vs 132/79 mmHg; P=.04 for systolic blood pressure and P=.01 for diastolic blood pressure), were more likely to self-pay for their care (26% vs 10%; P

The National Heart, Lung, and Blood Institute developed the Honoring the Gift of Heart Health (HGHH) curriculum to promote cardiovascular knowledge and heart-healthy lifestyles among American Indians and Alaska Natives (AI/ANs). Using data from a small randomized trial designed to reduce diabetes and cardiovascular disease (CVD) risk among overweight/obese AI/ANs, we evaluated the impact of an adapted HGHH curriculum on cardiovascular knowledge. We also assessed whether the curriculum was effective across levels of health literacy (defined as the 'capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions'). We examined change in knowledge from baseline to 3 months for two groups: HGHH (N = 89) and control (N = 50). Compared with controls, HGHH participants showed significant improvement in heart attack knowledge and marginally significant improvement in stroke and general CVD knowledge. HGHH participants attending ≥1 class showed significantly greater improvement than controls on all three measures. Although HGHH participants with inadequate health literacy had worse heart attack and stroke knowledge at baseline and 3 months than did participants with adequate skills, the degree of improvement in knowledge did not differ by health literacy level. HGHH appears to improve cardiovascular knowledge among AI/ANs across health literacy levels.

OBJECTIVE:Over the last 3 decades, the prevalence of childhood obesity has increased dramatically in North America, ushering in a variety of health problems, including type 2 diabetes mellitus (T2DM), which previously was not typically seen until much later in life. This technical report describes, in detail, the procedures undertaken to develop the recommendations given in the accompanying clinical practice guideline, “Management of Type 2 Diabetes Mellitus in Children and Adolescents,” and provides in-depth information about the rationale for the recommendations and the studies used to make the clinical practice guideline’s recommendations.METHODS:A primary literature search was conducted relating to the treatment of T2DM in children and adolescents, and a secondary literature search was conducted relating to the screening and treatment of T2DM’s comorbidities in children and adolescents. Inclusion criteria were prospectively and unanimously agreed on by members of the committee. An article was eligible for inclusion if it addressed treatment (primary search) or 1 of 4 comorbidities (secondary search) of T2DM, was published in 1990 or later, was written in English, and included an abstract. Only primary research inquiries were considered; review articles were considered if they included primary data or opinion. The research population had to constitute children and/or adolescents with an existing diagnosis of T2DM; studies of adult patients were considered if at least 10% of the study population was younger than 35 years. All retrieved titles, abstracts, and articles were reviewed by the consulting epidemiologist.RESULTS:Thousands of articles were retrieved and considered in both searches on the basis of the aforementioned criteria. From those, in the primary search, 199 abstracts were identified for possible inclusion, 58 of which were retained for systematic review. Five of these studies were classified as grade A studies, 1 as grade B, 20 as grade C, and 32 as grade D. Articles regarding treatment of T2DM selected for inclusion were divided into 4 major subcategories on the basis of type of treatment being discussed: (1) medical treatments (32 studies); (2) nonmedical treatments (9 studies); (3) provider behaviors (8 studies); and (4) social issues (9 studies). From the secondary search, an additional 336 abstracts relating to comorbidities were identified for possible inclusion, of which 26 were retained for systematic review. These articles included the following: 1 systematic review of literature regarding comorbidities of T2DM in adolescents; 5 expert opinions presenting global recommendations not based on evidence; 5 cohort studies reporting natural history of disease and comorbidities; 3 with specific attention to comorbidity patterns in specific ethnic groups (case-control, cohort, and clinical report using adult literature); 3 reporting an association between microalbuminuria and retinopathy (2 case-control, 1 cohort); 3 reporting the prevalence of nephropathy (cohort); 1 reporting peripheral vascular disease (case series); 2 discussing retinopathy (1 case-control, 1 position statement); and 3 addressing hyperlipidemia (American Heart Association position statement on cardiovascular risks; American Diabetes Association consensus statement; case series). A breakdown of grade of recommendation shows no grade A studies, 10 grade B studies, 6 grade C studies, and 10 grade D studies. With regard to screening and treatment recommendations for comorbidities, data in children are scarce, and the available literature is conflicting. Therapeutic recommendations for hypertension, dyslipidemia, retinopathy, microalbuminuria, and depression were summarized from expert guideline documents and are presented in detail in the guideline. The references are provided, but the committee did not independently assess the supporting evidence. Screening tools are provided in the Supplemental Information.

Objective Research suggests that health literacy (HL) is associated with clinical outcomes. Few studies, however, have examined the mechanisms accounting for this relationship. To understand why HL is related to outcomes, we tested a theoretical framework proposing that diabetes-related knowledge and behavior mediate (explain) the relationship between HL and glycemic control (i.e., A1c). Methods Analyses used baseline data from the Special Diabetes Program for Indians Healthy Heart Project ( N =2594), an intervention to reduce cardiovascular risk among American Indians/Alaska Natives (AI/ANs) with diabetes. Three nested structural equation models tested the theoretical framework. Results Model 1 demonstrated that participants with stronger HL skills had better glycemic control. Model 2 tested whether diabetes-related behaviors accounted for this relationship. Self-monitoring of blood glucose significantly mediated the HL-A1c relationship. Model 3 examined the role of diabetes knowledge, showing that it mediated the relationship between HL and dietary behavior. When knowledge was included, behavior was no longer a significant mediator, suggesting that knowledge was the main driver of the relationship between HL with A1c. Conclusion Interventions to improve knowledge may be particularly important in enhancing outcomes among AI/ANs with diabetes. Practice implications Strategies known to enhance patient comprehension may enable low-literate patients to develop needed diabetes knowledge.

Background: American Indian/Alaska Native (AIAN) women have twice the risk compared to the general US population of adolescent obesity, pregnancy, and gestational diabetes. The purpose of this study was to

Tobacco use and secondhand tobacco-smoke (SHS) exposure are major national and international health concerns. Pediatricians and other clinicians who care for children are uniquely positioned to assist patients and families with tobacco-use prevention and treatment. Understanding the nature and extent of tobacco use and SHS exposure is an essential first step toward the goal of eliminating tobacco use and its consequences in the pediatric population. The next steps include counseling patients and family members to avoid SHS exposures or cease tobacco use; advocacy for policies that protect children from SHS exposure; and elimination of tobacco use in the media, public places, and homes. Three overarching principles of this policy can be identified: (1) there is no safe way to use tobacco; (2) there is no safe level or duration of exposure to SHS; and (3) the financial and political power of individuals, organizations, and government should be used to support tobacco control. Pediatricians are advised not to smoke or use tobacco; to make their homes, cars, and workplaces tobacco free; to consider tobacco control when making personal and professional decisions; to support and advocate for comprehensive tobacco control; and to advise parents and patients not to start using tobacco or to quit if they are already using tobacco. Prohibiting both tobacco advertising and the use of tobacco products in the media is recommended. Recommendations for eliminating SHS exposure and reducing tobacco use include attaining universal (1) smoke-free home, car, school, work, and play environments, both inside and outside, (2) treatment of tobacco use and dependence through employer, insurance, state, and federal supports, (3) implementation and enforcement of evidence-based tobacco-control measures in local, state, national, and international jurisdictions, and (4) financial and systems support for training in and research of effective ways to prevent and treat tobacco use and SHS exposure. Pediatricians, their staff and colleagues, and the American Academy of Pediatrics have key responsibilities in tobacco control to promote the health of children, adolescents, and young adults.

Childhood obesity is a national public health crisis. The National Diabetes Education Program (NDEP), the National Institutes of Health and Kaiser Permanente have developed community tools and resources for children and families to lower their risk for obesity through healthier, active lifestyles. The authors describe innovative practices and community mobilization case studies from the NDEP “Move It! and Reduce Your Risk for Diabetes” program and the NIH We Can!TM - Ways to Enhance Children’s Activity and Nutrition, and programs from Kaiser Permanente for the promotion of healthier lifestyles for children and families. Replication of these creative programs can be modified to be implemented in communities throughout the United States.

OBJECTIVE To assess trends in diabetes screening among American Indian adults and identify opportunities to extend blood glucose screening to those at risk for undiagnosed diabetes and prediabetes. METHODS In 1999, 2001, and 2003, approximately 1,000 American Indian adults aged 18 years and older living on or near the seven reservations in Montana were interviewed through telephone surveys. RESULTS Of respondents without diagnosed diabetes, the proportion who recalled blood glucose screening for diabetes within the past 3 years increased from 68 percent in 1999 to 78 percent in 2003. Between 1999 and 2003, screening increased among men (64%-75%), women (71%-80%), those aged 18-44 years (64%-72%), and those aged 45 years and older (76%-84%). Factors independently associated with screening included age more than 45 years, family history of diabetes, and a history of high cholesterol. Current smokers were less likely to report screening compared to nonsmokers. Gender, obesity, and a history of high blood pressure were not associated with screening. CONCLUSIONS Although self-reported diabetes screening increased over a 5-year period among Indians in Montana, additional groups who could benefit from screening include younger and obese individuals, and those with hypertension.

Objectives. We reviewed changes in blood glucose, blood pressure, and cholesterol levels among American Indians and Alaska Natives between 1995 and 2001 to estimate the quality of diabetes care in the Indian Health Service (IHS) health care delivery system. Methods. We conducted a cross-sectional analysis of data from the Indian Health Service Diabetes Care and Outcomes Audit. Results. Adjusted mean Hemoglobin A1c (HbA1c) levels (7.9% vs 8.9%) and mean diastolic blood pressure levels (76 vs 79 mm Hg) were lower in 2001 than in 1995, respectively. A similar pattern was observed for mean total cholesterol (193 vs 208 mg/dL) and triglyceride (235 vs 257 mg/dL) levels in 2001 and 1995, respectively. Conclusions. We identified changes in intermediate clinical outcomes over the period from 1995 to 2001 that may reflect the global impact of increased resource allocation and improvements in processes on the quality of diabetes care, and we describe the results that may be achieved when community, health program, and congressional initiatives focus on common goals.

The prevalence of diabetes is two- to threefold higher in American Indians in Montana compared with the non-Indian population. High rates of diabetes have also been described in Canadian aboriginal populations closely related to the tribes in Montana. Diabetes in pregnancy has increased among Indian mothers and high-birth-weight babies are increasingly likely to be born to Indian mothers with diabetes in pregnancy. Over 70% of the incident cases of diabetes in youth less than 20 years of age on the reservations have the clinical characteristics of type 2 diabetes. Cardiovascular disease mortality rates are high among Indians in Montana, and the prevalence of smoking in the Indian populations of Montana and the neighboring tribes in Canada is remarkably high. Indians in Montana are more likely than non-Indians of similar age to believe that diabetes is preventable and to recall advice about diabetes risk.

Objectives. We evaluated cardiovascular disease (CVD) risk factors in American Indians/Alaska Natives (AI/ANs) with diabetes in the Special Diabetes Program for Indians Healthy Heart (SDPI-HH) Demonstration Project. Methods. Multidisciplinary teams implemented an intensive case management intervention among 30 health care programs serving 138 tribes. The project recruited 3373 participants, with and without current CVD, between 2006 and 2009. We examined data collected at baseline and 1 year later to determine whether improvements occurred in CVD risk factors and in Framingham coronary heart disease (CHD) risk scores, aspirin use, and smoking status. Results. A1c levels decreased an average of 0.2% (P Conclusions. SDPI-HH successfully translated an intensive case management intervention. Creative retention strategies and an improved understanding of organizational challenges are needed for future Indian health translational efforts.

Background: Cardiovascular disease (CVD) is the leading cause of death for both American Indian and non-Indian adults. Few published studies have compared the prevalence of CVD and related risk factors in Indians to that in non-Indians in the same geographic area. Objective: To compare CVD and risk factors in American Indian and non-Indian populations in Montana. Methods: Adult American Indians ( n =1000) living on or near Montana’s seven reservations and non-Indian ( n =905) Montanans statewide were interviewed through the 1999 Behavioral Risk Factor Surveillance Survey (BRFSS). Results: Indians aged ≥45 years reported a significantly higher prevalence of CVD compared to non-Indians (18% vs 10%). In persons aged 18–44 years, Indians were more likely to report hypertension (15% vs 10%), obesity (29% vs 12%), and smoking (42% vs 24%) compared to non-Indians. For persons aged ≥45 years, Indians reported higher rates of diabetes (24% vs 9%), obesity (38% vs 16%), and smoking (32% vs 13%) compared to non-Indians. Non-Indians aged ≥45 years reported having been diagnosed with high cholesterol more frequently than did Indians (32% vs 24%). Conclusions: Both Indians and non-Indians in Montana reported a substantial burden of CVD. The CVD risk patterns differ in the two populations. Prevention programs should be tailored to the risk burdens in these communities with particular emphasis on smoking cessation and the prevention of obesity.

The objective of this study was to compare self-reported measures of diabetes care with measures derived from medical records in a well-defined population. Diabetes measures were collected through a 1997 Behavioral Risk Factor Surveillance System telephone survey of American Indians living on or near 7 Montana reservations (N = 398) and were compared with data collected from charts of a systematic sample of American Indians with diabetes seen in 1997 at Indian Health Service (IHS) facilities. Survey respondents were more likely to report a duration of diabetes > or = 10 years (44 vs 31%), annual dilated retinal exam (75 vs 59%), and an influenza immunization in the past year (73 vs 57%) compared with estimates from the chart audit. Estimates of pneumococcal immunization (88 vs 42%), annual cholesterol screening (86 vs 69%), and overweight, based on body mass index (67 vs 50%), were significantly higher from the chart audit. No significant differences were found between the survey respondents and the chart audit data for annual foot exams (65 vs 61%), annual blood pressure checks (98 vs 93%), high cholesterol (35 vs 41%), and high blood pressure (54 vs 64%). These findings suggest that self-reported data may over and underestimate specific measures of diabetes care.

Over the past 3 decades, the prevalence of childhood obesity has increased dramatically in North America, ushering in a variety of health problems, including type 2 diabetes mellitus (T2DM), which previously was not typically seen until much later in life. The rapid emergence of childhood T2DM poses challenges to many physicians who find themselves generally ill-equipped to treat adult diseases encountered in children. This clinical practice guideline was developed to provide evidence-based recommendations on managing 10- to 18-year-old patients in whom T2DM has been diagnosed. The American Academy of Pediatrics (AAP) convened a Subcommittee on Management of T2DM in Children and Adolescents with the support of the American Diabetes Association, the Pediatric Endocrine Society, the American Academy of Family Physicians, and the Academy of Nutrition and Dietetics (formerly the American Dietetic Association). These groups collaborated to develop an evidence report that served as a major source of information for these practice guideline recommendations. The guideline emphasizes the use of management modalities that have been shown to affect clinical outcomes in this pediatric population. Recommendations are made for situations in which either insulin or metformin is the preferred first-line treatment of children and adolescents with T2DM. The recommendations suggest integrating lifestyle modifications (ie, diet and exercise) in concert with medication rather than as an isolated initial treatment approach. Guidelines for frequency of monitoring hemoglobin A1c (HbA1c) and finger-stick blood glucose (BG) concentrations are presented. Decisions were made on the basis of a systematic grading of the quality of evidence and strength of recommendation. The clinical practice guideline underwent peer review before it was approved by the AAP. This clinical practice guideline is not intended to replace clinical judgment or establish a protocol for the care of all children with T2DM, and its recommendations may not provide the only appropriate approach to the management of children with T2DM. Providers should consult experts trained in the care of children and adolescents with T2DM when treatment goals are not met or when therapy with insulin is initiated. The AAP acknowledges that some primary care clinicians may not be confident of their ability to successfully treat T2DM in a child because of the child’s age, coexisting conditions, and/or other concerns. At any point at which a clinician feels he or she is not adequately trained or is uncertain about treatment, a referral to a pediatric medical subspecialist should be made. If a diagnosis of T2DM is made by a pediatric medical subspecialist, the primary care clinician should develop a comanagement strategy with the subspecialist to ensure that the child continues to receive appropriate care consistent with a medical home model in which the pediatrician partners with parents to ensure that all health needs are met.

Background: Cardiovascular disease (CVD) is common among American Indians/Alaska Natives (AI/ANs). Given limited access to health care, urban AI/ANs may be at particular risk. Lack of available data, however, limits our understanding of cardiovascular health in this population. Objectives: We conducted a survey to characterize CVD-related knowledge, behavior, and risk of urban AI/ANs. Results related to knowledge are reported. Methods: In collaboration with the Indian clinics in two urban communities, we surveyed 298 AI/ANs. Results: Respondents recognized approximately half of the symptoms of heart attack and stroke, and were significantly less likely to recognize each symptom than reported in national studies using the same items. General CVD knowledge (e.g., risks of high blood pressure) was stronger, although areas for improvement were noted. Conclusions: Urban AI/ANs would benefit from efforts to enhance CVD knowledge. These preliminary data are providing the foundation for community-based efforts to address CVD risk among urban AI/ANs.

Youth-onset type 2 diabetes has emerged as a significant public health concern for American Indians and Alaska Natives. Data from the National Institutes of Health longitudinal epidemiological study among the Pima Indians of southern Arizona and the Indian Health Service continue to document a rising incidence and prevalence of type 2 diabetes among American Indian and Alaska Native youth. Although national trends related to lack of physical activity and to unhealthy nutrition behaviors have contributed to the epidemic, the adverse conditions created by poverty, social injustice, trauma, and cultural disruption are also important in understanding the underlying causes for this public health crisis. This adverse environment is likely to provide little support for healthy nutrition and physical activity behaviors as well as other diabetes self-care behaviors. Known risk factors from the Pima Indian studies, such as intrauterine exposure to diabetes, bottle-feeding, and obesity, provide a basis for worthwhile intervention strategies. In this article, the author will review the current literature on the epidemiology of youth-onset type 2 diabetes among American Indians and Alaska Natives, discuss causes for the diabetes epidemic among American Indians and Alaska Natives, review risk factors for youth-onset type 2 diabetes in this population, and share promising youth physical activity promotion programs created and implemented specifically for American Indian and Alaska Native youth. However, more research on interventions to address the Native communities' psychosocial issues and concerns around youth-onset type 2 diabetes is urgently needed.