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Marisa Pigeon showing an unhealthy artery during Diabetes Bingo.
The Community-Directed SDPI Program of the Lower Sioux Tribe in south central Minnesota offers many diabetes management and prevention activities. These include monthly education classes about diabetes and heart disease, women and men's health nights, exercise classes for all ages, and diabetes bingo.
The term "diabetes bingo" may sound like an oxymoron. Can diabetes, a serious word, and bingo, a fun word, be combined? "Yes," says Marisa Pigeon, RN, SDPI Program Manager.
During a typical diabetes bingo class, Marisa hands out laminated boards to each player. Across the top are the letters B.I.N.G.O. which stand for diabetes-related categories: body parts, insulin, nutrition, glucose and other. Under each letter are columns of five illustrations that match cards Marisa may select. Everyone is studying their boards of 25 illustrations such as a pill container with a clock in the background, a glucometer with a test strip about to be inserted, and a naked (skinless) chicken.
Marisa holds up a card with an illustration of an unhealthy blood vessel, then reads the back. This card is categorized under B for body parts. She says, "Under the B. Unhealthy blood vessel. It is clogged from too much fat in the blood."
Diabetes Bingo attracts elders and youth.
Participants are listening intently and concentrating on their boards. The serious information is going into their memory banks. As Marisa holds up and reads more cards, they learn more:
"Your A1C tells you and your doctor what your average blood sugar levels have been for the past 90 days."
"Don't use antibacterial soap on your feet. It dries the skin too much."
"Fat in the blood makes it harder for insulin to do its job."
It is quiet in the room as participants listen and focus on their boards. As the game progresses, they hear 17 facts on how to prevent diabetes or its complications. Then the fun part kicks in: "Bingo!" says Marilyn Hisday. Everyone claps, Marisa verifies the win, then Marilyn checks out the prize table and chooses a car wash kit.
The Lower Sioux Tribe Diabetes Program started the bingo class about two years ago. The White Earth Diabetes Project developed the game, which features illustrations aimed at Native American audiences. Marisa says it is effective because it is repetitious. She meticulously reads every word on the back of each card. Participants may hear the same information a few times during a one-hour game, then again when they attend the following month.
Lower Sioux Tribe Diabetes Bingo group.
The repetition coupled with a fun, relaxed atmosphere, helps people memorize the facts. "When I read the cards, a lot of times the participants say the information along with me," says Marisa. And when she is in her office, she often overhears clients who have attended diabetes bingo passing on information to others. "Once I heard someone say, ‘Did you know that the pop you're drinking has 20 teaspoons of sugar in it?'"
Diabetes bingo offers another venue for presenting diabetes information, one that works for many community members. Marisa sees it as a great opportunity. "Many times I intersperse additional information in the game, like facts about high blood pressure and how it affects a person's body. It isn't always the most enjoyable thing to talk about, but I find if I do it during diabetes bingo, it's a little less intense."
Diabetes Bingo has helped Joseph Good Thunder.
Joseph Good Thunder has been attending Diabetes Bingo at the Lower Sioux Tribe since it started about two years ago. He has diabetes, high blood pressure, and other diabetes complications. He says the diabetes bingo class has helped him.
"I learn something new every time I come here. The repetition helps. I have learned to check my toes and the bottoms of my feet every day to make sure I don't have any ulcers. I check my blood sugar three times a day. I keep a record and bring it with me to my doctor appointments which I go to every three months. I get my eyes checked as my doctor recommends. I have a regiment."
Joseph has cut back on the amount of food he eats, walks 3 – 5 times a week for one hour, and has lost 30 pounds.
Lifestyle Balance class participants.
The Indian Health Board (IHB) of Minneapolis is one of the largest urban Indian health centers in the Nation. It serves over 3,000 American Indians and Alaska Natives. Two of its classes are funded by the Special Diabetes Program for Indians (SDPI). One class is called Lifestyle Balance and is funded by an SDPI Diabetes Prevention Initiatives grant. The other class is called Diabetes Basics and is funded by an SDPI Community-Directed grant.
IHB Diabetes Program Director Lois Brown, RN, PHN, says a key to being successful when addressing health disparities in urban settings is being flexible to remove barriers. "Transportation can be a barrier, and participants may relocate," explains Lois. "We offer transportation to clinic visits and classes. And for clients who may relocate, we offer courses that can be completed within ten weeks, as well as one-on-one classes."
Participants sample healthy meals.
Another key to success is compassion, especially when discussing diabetes complications. "It's common for participants to experience fear, sadness, and depression from memories of family members' complications," explains Lois. These emotions usually surface after a few classes, when participants have built rapport and trust amongst each other. "During the first few classes, people share their knowledge of a connection between sugar and diabetes," says Sammy Gardeen, RD, LD, who teaches the Diabetes Basics class. At about week three, the discussions become more personal. "Participants start opening up. They share their own stories of how diabetes has affected their lives."
During a week four Diabetes Basics class, the topic was complications: heart attacks, comas, and amputations. There was shock and sadness in the room, as well as silence and a few tears. One participant broke the silence by wondering aloud what he should do. He put his head in his hands, clearly distraught. Sammy set her notes down. "When you are feeling overwhelmed, don't be afraid to get counseling, go for a walk, or call a friend." One woman said, "But I'm all alone," and another participant quickly replied, "You've got us."
Diabetes Basics teacher Sammy Gardeen.
Offering heartfelt support and a sense of unity is another key to success. "We let people voice what is in their hearts. We hear each other out," explains Sammy. "Our staff are not the only teachers. Our participants teach each other and us, as much as we ever teach them."
White Earth Podiatry Clinic on Wheels.
The White Earth Reservation is the largest in the state of Minnesota, encompassing over 1,000 square miles and serving about 11,000 people through its IHS health clinic. When its diabetes program first received SDPI Community Directed Program funding in 1999, staff could not envision where they would be in 13 years. At the time there was only one small fitness center serving the entire tribe and no podiatrist. Today the program has implemented numerous activities to support its Physical Activity and Foot Care Best Practices. "We have an excellent diabetes prevention and management program. We are on track," said LaRaye Anderson, Diabetes Program Coordinator.
There are diabetes fitness centers offering free personal training at four of the tribe's villages. Clients can work out with trainers or participate in group classes of Zumba® fitness, kick boxing, kettlebell, pole walking, step aerobics and boot camp fitness. Several 5K run/walks and regular blood sugar, A1C, blood pressure and kidney screenings are offered each year. Diabetes program staff collaborate with other programs to offer healthy snacks and schedule the 5K run/walks at the same time as community gatherings like powwows.
Healthy Living Bingo session.
Healthy Living Bingo is held monthly in each village. About 40 adults and children attend each month and learn how to prevent diabetes – how to attain healthy blood pressure, cholesterol and blood sugar numbers, how to eat healthy using My Plate and the importance of regular physical activity. Diabetes Bingo, which focuses on preventing diabetes complications, is also held monthly in each village. About 25 people attend and learn how to prevent diabetes complications by managing their blood sugars, taking medications as prescribed and keeping medical appointments.
In fitness centers and community gathering rooms, brightly colored posters of Aimee Smith, a young White Earth fancy shawl dancer, decorate the walls. Diabetes program staff developed the poster with the words "White Earth Dancing to Defeat Diabetes." Staff also developed a logo featuring a cyclist, a runner and a traditional dancer accompanying the phrase "Exercise is medicine."
White Earth Diabetes Program member lifting weights.
A podiatry surgeon travels to villages in a mobile clinic giving foot checks and handing out breathable socks, orthotics and special shoes, a direct result of the tribe's diabetes program implementing the Foot Care Best Practice. "We were concerned with the lack of a podiatrist and the high number of amputations, so we chose the Foot Care Best Practice to address this," said LaRaye. "In the ten years since the tribe has contracted with the podiatry surgeon, amputations have decreased and awareness has increased on the importance of preventing ulcers and maintaining good foot care."
Diabetes staff evaluates activities by gathering assessments and evaluations. GPRA (Government Performance Results Act) numbers and diabetes audit information allow staff to assess the program's impact. On one fitness program evaluation form, a client wrote what she accomplished after only two months: "I can put on my own socks and shoes. I can fasten my seat belt. I have been able to stop taking two medications, saving me $170 each month!"
Another client reported: "In one year, I lost 150 pounds! I am walking without my walker and started gardening again. I feel responsible for my health and have faith in myself."
White Earth Diabetes Program members participating in a 5K walk.
Many clients have commented that the professional, helpful staff is key to learning about diabetes prevention and management. "They are kind to all who walk through the fitness center doors," said a client.
Although many community members have lost weight, obesity and overweight continue to be a challenge at White Earth. "We are building on what we have learned," says LaRaye. "It takes empathetic, professional and energetic staff, which we have. And it takes time, so we are working now with our sights on future goals. The obesity and overweight numbers are challenges that face everyone in the United States. I feel we are on the right path in educating our people and offering opportunities to participate in fitness no matter what a person's fitness level or interests are."
Mississippi Choctaw Diabetes Prevention Program.
The Mississippi Band of Choctaw Indians (MBCI) was awarded its first SDPI grant in 1998. The Community Directed Diabetes Prevention Program initially began with three staff members. In the beginning, staff conducted many community events such as walks, blood sugar screenings and health fairs. In 2004, the Demonstration Project (now the SDPI Diabetes Prevention Initiative) was added to the Mississippi Choctaw Diabetes Prevention Program.
Fourteen years after being awarded its first SDPI grant, MBCI/SDPI Program Manager Darlene Willis looks back at what she and her staff have learned. "We have matured professionally," she says. "We were always focusing solely on prevention of diabetes. It was like I had tunnel vision. I paid very little attention to the management aspect of diabetes."
About three years ago, Darlene took a closer look at the program, assessing its structure and personnel. She read every word of the grant application. "I had an epiphany," recalls Darlene. "I realized I was listed as the person responsible for the grant operations of the program. I thought, 'This is mine.' I realized I had complete autonomy over the program and, at that moment, the tunnel vision of doing just diabetes prevention activities lifted."
Mississippi Choctaw Diabetes Prevention Program poster session.
She decided to call a meeting of "the minds," everyone who was providing diabetes care within the SDPI grant programs. This included physicians, podiatrists, dietitians, and the CDE. She says it was a pivotal point in the program's structure. Darlene said to the group, "We are here today because we have one thing in common, DIABETES. We receive grant funding for diabetes prevention and management. We all need to begin to work together for better results. NOW is the time to begin to work in unison for our people's sake."
Darlene carefully reviewed the Diabetes Audit and realized improvements and adjustments were needed. With the help of the hospital's Clinical Applications Coordinator (CAC), she began to understand what needed to be done. The CAC was initiating the "Improved Patient Care Committee" through IHS Improving Patient Care Model. The IPC model led to establishing the "I Care Team" within the hospital which led to the birth of "Diabetes Wellness Day" in coordination with the Retinopathy Clinic.
During Diabetes Wellness Day, a patient is provided a foot exam, eye exam, exercise instruction, diabetes education, nutrition assessment, depression screening, height/weight/blood pressure measurements, labs, dental exam, and immunizations. "Diabetes Wellness Day is all-inclusive. It is like one-stop shopping for our patients. It takes only a couple of hours for patients to receive services that, if scheduled one at a time, could take an entire year to complete. Patients love it and the Diabetes Audit Report improved tremendously," says Darlene.
Man holding list for improving program.
The MBCI SDPI Program has grown to eleven staff members. Diabetes prevention activities are still a big part of it. For example, the SDPI DP Initiative recruits, assesses, and diagnoses patients for pre-diabetes, then enrolls them in a 16-week intensive diabetes prevention class.
The MBCI SDPI-funded Community Directed Diabetes Prevention Program also is lessening the impact of diabetes by implementing two Best Practices (Foot Care and Eye Care). "For so long, we focused on prevention activities. We are now putting extra effort into implementing the Best Practices. It's new for us, but someday it will be as automatic as doing diabetes prevention activities," says Darlene.
"We are always looking for better ways of doing things because our goal is to improve the health care of our patients. We love to share our ideas with others and we will always welcome others' ideas. One thing I do is always reflect back to the mission and vision of the Choctaw Health Department which is to 'raise the status of the Choctaw people to the highest level possible'. This mission keeps me focused."
Shoshone-Paiute Diabetes Program
The Shoshone-Paiute Diabetes Program, located in Owyhee, Nevada, was first awarded funding from the Special Diabetes Program for Indians (SDPI) in 1997, and has been conducting diabetes prevention and management activities for 15 years. At the end of 2011, staff looked back on what they had recently accomplished:
- Tribal community members harvested organic food from the tribe's "Hoop House" a hot house built from large hoops and plastic. Youth through elders helped build the Hoop House, moving soil, tilling, planting, caring for and harvesting produce. The Hoop House is located next to a community church, which hosted a December pot roast dinner featuring organic new potatoes and onions from the garden.
- Depression screening and eye care best practices were implemented. Statistics from the optometry program showed that 747 patients were seen in the tribe's optometry clinic from September 2011 to October 2011. (There are approximately 2,000 people living in the Owyhee and surrounding areas.)
- Rez Yoga reported that as many as 17 people attended the twice-weekly classes. Attendees say that it helps them be more flexible, build muscle and reduce stress.
- The December Diabetes Health Fair held on December 15 had 95 participants. To show that health benefits can be obtained by walking for only 10 minutes twice a day, the walk/run part of the day was divided into two parts: a morning 10-minute and an afternoon 10-minute walk/run. Between the walk/runs, a lunch featuring a pita-pocket taco named "Ya ah Be Sha Pi-ta-co" was served. It contained rinsed lean ground beef seasoned with spices, home-made pinto beans, lettuce, tomatoes and low-fat cheese. A reservation restaurant, Taste of Heaven Kountry Kitchen, has added the "Ya ah Be Sha Pi-ta-co" to its menu that includes other items listed under a new category: Healthy Heart Options.
The Power of Digital Storytelling
Student at computer typing her digital story script.
When Port Gamble/S'Klallam Tribal member Tleena Ives and her sister first watched Tleena's digital story, they cried. Her story is called "Tleena's Paddle." In it she compares her journey of losing 100 pounds to a traditional canoe paddle on the waters of the Coast Salish people. While watching, Tleena realized she had a story to tell, one that could help people. She also acknowledged the pain she had gone through, and that the pain was temporary. "When I see the pictures of me struggling, I know that they were just moments. They were not permanent. I realized I can overcome adversity."
Joe Law, Health Promotion Coordinator for the Portland Area IHS, says being profoundly affected by your own digital story is not uncommon. "A person sees that it is their own story. ‘This happened to me, and this is what I did to overcome it.' It's empowering." Joe has been teaching Native community members how to produce digital stories since 2010. Other IHS Area Health Promotion Disease Prevention (HPDP) Coordinators teach it as well. Joe has taught before, but had no video production experience before he started teaching digital storytelling.
Two women participating in a story circle.
Joe says digital storytelling is becoming more common. It is relatively inexpensive. Production software can be downloaded off the internet. The visuals can also be downloaded, or photographed with small cameras or phones. The only equipment the Portland Area IHS needed to buy was a microphone.
Here are the steps students take to produce their digital stories:
- Write and read a 5-minute piece that incorporates student's name, and a few words like rez and frybread. This "free writing" exercise gets students comfortable with writing and sharing their writing.
- Write a script, either a Public Service Announcement or a personal story. Teachers help with editing it to 300 words.
- In a "Story Circle," each student reads their script. When students hear other students' personal stories, they often change their stories to more personal ones.
- Gather photos to match script. These are personal photos, or copyright-free photos from the internet.
- Record their scripts in pairs. Doubling up seems to help students be more confident about having their voices recorded.
- Put their audio and photos together using free editing software.
- Keep their stories to share with friends and family members, and/ or post on websites or YouTube.
Student editing his video.
Joe says it is a balancing act to motivate students to tell stories that are uniquely their own. "I don't try to pull a certain type of story out of them," he explains. Instead he says, "Tell us what you want to tell."
The results range from PSAs on diabetes prevention to personal stories on how a divorce or alcohol abuse has affected the storyteller. In most cases, the storyteller is positively changed by this opportunity to share. Joe says when many students watch their videos, they realize they may have failed at times but they have also succeeded. They realize they have some control over the stories of their lives. They think, "Wow, I can do it."
If you are interested in putting on a digital storytelling workshop in your area, contact your IHS Area HPDP Coordinator.
Whiteriver Healthy Heart Program Builds Trust and Positive Relationships
Whiteriver Healthy Heart Program
The SDPI Healthy Heart Program at the Whiteriver Indian Health Service started at the onset of the Healthy Heart Demonstration Projects, in 2005. From the beginning, the Healthy Heart Program had its own place, across the parking lot from the hospital. Over the years, the staff has prioritized the development of positive, trusting relationships between case managers and participants.
Kristy Klinger, Healthy Heart Project Coordinator, explains, "We have a dedicated place where people can go, and be asked, 'How is your life going? What is working for you? What are you willing to work on? How can we help you?"
She says extra effort is made to see participants at their scheduled time, to avoid making them wait to see their case managers. Appointments are usually 30-60 minutes long.
"By seeing participants right away, and not being rushed when we meet with them, we are showing them that they are respected. This fosters trust, and creates an opportunity for ongoing, open communication."
The relationship of trust goes beyond the exam room and the Healthy Heart office. Participants have passed on diabetes and heart health information to family members and friends.
Elderly woman talking to her provider.
"I have heard stories of participants telling their support people about us, our program, and what they've learned."
As a result, there have been increased numbers of people making and keeping their appointments, and attending Healthy Heart activities held in the community, such as nature walks, traditional weaving, and community gardening.
"Their participation and enthusiastic attitudes show they believe in the Healthy Heart Program. It shows they trust us, and because they trust us, they have ownership in the program. They see the Healthy Heart Program as their program."
Woman glazing baked pack rat.
More members of the San Carlos Apache Tribe are trying traditional foods like cholla (cactus) buds, acorn dumplings, pack rat, and quail -- thanks to the Traditional Western Apache Diet Program. The White Mountain Tribe, Tonto Apache Tribe, and Yavapai-Apache Nation are also participating in the program. The goal of the program is to analyze the pre-reservation Western Apache diet. It is a first step in encouraging tribal members to return to a more traditional diet.
To expand awareness and support, three San Carlos Apache Tribal staff prepared a special lunch for Tribal Chairman Terry Rambler and his staff. “We want to get more support from the Tribe by reconnecting people to traditional foods and Mother Earth. This food heals your body,” explained Department of Forest Resources Staff Twila Cassadore.
Twila and Health Educator Daylene Anderson created the menu of pico de gallo with cholla buds, spinach salad with currants and pine nuts, acorn dumpling and elk soup, quinoa topped with baked quail, baked pack rat glazed with agave, mini whole wheat fry bread topped with zucchini, corn, and tepary beans, blue corn crepes stuffed with cream cheese and prickly pear, and fresh squeezed lemonade with chia seeds. Most dishes represented what Western Apaches ate before reservations were created. No sugar, salt, or white flour was used.
People sitting at lunch table.
Twila had been gathering seeds for weeks. Twila and her family members had also spent days hunting pack rat and quail. Twila and Daylene were up early that day to prepare the meal.
When Chairman Rambler and four staff entered the room and sat down, Twila and Daylene brought out the first course, pico de gallo topped with cholla buds, served with blue corn chips. The guests started sampling right away. Immediately, the conversation focused on the past. “My grandma used to catch catfish, huge ones. We used to wrestle them out of the water,” recalled Chairman Rambler.
While guests sampled additional dishes, Seth Pilsk, Department of Forest Resources Staff, talked about the program. “We want to get the Apache diet back to the community. Not because it’s healthy, but because it’s super-healthy.”
Three women looking at traditional food.
He explained that the program has identified over 200 harvestable foods on San Carlos Apache land. A nutritionist is analyzing the diet, and discovering that it is indeed super-healthy – high in healthy fats, and low in saturated fat and cholesterol. “We have also found that it is very high in fiber,” said Seth.
After the meal, guests gathered around a table displaying seeds, nuts, flours, and celery root. Guest Kevin Cassadore said, “We are learning our culture, the roots of who we are. We can say, ‘We are Natives and this is the kind of food we eat.’”
In the weeks following the lunch, Traditional Western Apache Diet Program staff began weekend outings to teach tribal members how to identify and gather traditional foods.
Jennie Quon demonstrated how to make a lower-calorie cheesecake.
In early November 2012, the 16-week SDPI-funded Diabetes Prevention Program at the Indian Health Center of Santa Clara Valley located in San Jose, California, came to an end. Two classes totaling nearly 30 people were graduating the program just in time to put their new knowledge and skills to work: Thanksgiving, Christmas and New Year's celebrations were fast approaching. Could the groups stay motivated through the holidays, the months to follow and for the rest of their lives?
How to keep eating healthy and being physically active were the topics of these final classes. Dietitian Jennie Quon began the classes by showcasing accomplishments. She asked each participant how their lives had changed since attending the first classes in July. Answers included: "I read food labels and stopped drinking five pops a day." "I park further away from work, and I walk during my breaks." "I am using a manual wheelchair instead of a motorized one." "I say 'yes' to my children whenever they ask me to go out and play with them." (This man lost over 15 pounds!)
To stay motivated, Jennie suggested that participants call the staff, call each other, read magazines and inspirational materials, keep daily food and exercise journals, and not get discouraged when there are setbacks. "You have come a long way," she said. "This is not the end of your healthy journey. It's just the start of your life-long healthy lifestyle."
Simon and Andrea Morales (Chickasaw) developed the habit of walking.
When Andrea Morales (Chickasaw) and her husband, Simon Morales, started attending the Diabetes Prevention (DP) Program at the Indian Health Center of Santa Clara Valley in July 2012, they both had pre-diabetes and high blood pressure, which run in their families. Their reasons for joining were to learn to eat better, exercise more, lose weight and be good role models for their children and grandchildren.
Both changed habits during the 16-week DP Program. "I used to eat big portions," said Simon. Now he eats regular-sized portions with more fruits and vegetables.
Andrea added, "We walk a lot. The grandkids say it's time to go for a walk, so we walk with them and our dogs around the park at least every other day."
Both have lost weight: Simon has lost 20 pounds, and Andrea has lost 10.
During the final DP Program class in November, both were confident they will continue with their new habits through the holiday season. The two methods they most likely will use to stay on track are motivating each other and talking to the Center's staff. "We push each other, and the staff are great," said Andrea.
Three senior women lifting light weights.
There's a senior (age 55 and older) fitness movement going on at the Pascua Yaqui Tribe near Tucson, Arizona. It’s spreading to more seniors and inspiring countless adults, children, grandchildren, and great-grandchildren. The instigators are unstoppable because they are seniors -- seniors who have been energized and know firsthand the benefits of being fit.
Senior fitness and dance instructor Nancy Duran, LPN, has witnessed this explosion of senior fitness. “We started a dance class five years ago.” At first there were six regular dancers. “Now we have over twenty.”
The seniors dance their traditional and hip hop styles. In 2013 they came in first place for their “Gangnam Style” dance in the Annual Indian Council of Aging Conference Aerobic Competition.
Group of seniors sitting in chairs and playing volleyball.
They also participate in weekly fitness classes at the Liogue Senior Center and diabetes program fitness classes and volleyball games at the tribal wellness center. The volleyball games are just like regular games, but seniors are required to remain seated. Some games are so heated that seniors forget that one rule and fly out of their seats, losing the point.
Many of the seniors participate in all of the senior physical activities. “We’re trying to encourage other seniors. We want to show them that we can still move. If we just sit, we start having pain. When we exercise, we feel better. My circulation, my heart, my moods, everything feels better,” explains Maria Bustamante.
The seniors know they are community role models and can influence younger people to view aging in a positive light. “We’re doing this to show people who will be seniors in a couple of years that it’s important to keep moving,” says Maria (Bustamante).
“I’m doing this for my grandchildren, so they know that when they get older, they can still be active,” adds Maria Molina.
Group of senior women in traditional dress.
Maria Flores has benefited from the fitness classes. She has heart disease and diabetes in her family. She started joining the fitness classes, choosing healthier food, and eating less food. “I do chair volleyball, dancing, and the fitness classes. I’ve made dramatic changes. Before I didn’t care. I was depressed. Now I know it’s up to me to feel better.” Maria has lost 35 pounds.
Maria (Flores) is 62 years old and has 14 grandchildren and 4 great-grandchildren. Many of them come to see her when she dances for the Tutulis (Beautiful) dancers. Like other seniors, Maria hopes younger family and community members are seeing what being a senior can mean: being active, fit, and happy.
Tucson Indian Center class about benefits of exercise.
Every Wednesday morning a group of Native people from a variety of tribes gathers at the Tucson Indian Center for camaraderie, a healthy snack, diabetes prevention information, and a walk. This is not a round-the-block stroll: It's a brisk walk of over two miles.
On one Wednesday morning, Diabetes Prevention Program Coordinator Arcenio Trujillo sets out coffee, yogurt and bananas, and writes "Getting Our Second Wind" in big letters on the white board. Clients enter this downtown Tucson building, help themselves to snacks and coffee, and get caught up with friends.
This is the Tucson Indian Center Walking Group. They have been meeting for about two years. When the group first started, there was one walker. Now there are up to 20 walkers.
Erolinda Ramon, Tohono O'odham Nation, has been walking with the group for several months. "It's friendly. Arcenio is a good speaker," she explains.
Native group walking in downtown Tucson.
Today Arcenio is using long words: anaerobic and aerobic. He writes the words on the white board. Before anyone's eyes can gloss over, he explains that when you keep your heart rate up for over 30 minutes, the body enters an aerobic, fat burning state. When your body switches from anaerobic to aerobic, it is getting its second wind.
"It's like your body goes from easy listening to heavy metal music. It's like it runs out of quick fuel, but doesn't panic because there is stored fat to burn. It's like your body starts burning the delicious bacon!" says Arcenio.
The clients can't help but envision their bacon being burned. They laugh. They know they will be walking for over an hour, at a quick pace.
The start of the walk is a warm up. The group waits at several corners for stoplights, then picks up the pace. They turn left, and start climbing steps. Hearts are pumping strongly as they cross the Snake Bridge, walk through the mouth of the snake, then out the tail. There's an automatic rattling sound as the walkers exit the tail.
Native walkers climbing steps.
The second bridge is called the Basket Bridge, beautifully made to look woven. The group zips across it, does a ritualized turn around, and heads back. At this point, they have been walking over 30 minutes. Each walker can visualize the bacon melting away.
Back at the Tucson Indian Center, Isabella Enriquez, Tohono O'odham Nation, checks her pedometer. "It says 5,208 steps! Two point eight miles," she says. Arcenio explains that, while walking this distance is good, all walking will help prevent and manage diabetes. "Park farther away. Walk fast to the store. Get out of the bus one stop before your stop and walk the rest," he suggests.
Erolinda listens to Arcenio. "He cares about the way we live, and wants us to improve our health. I've learned a lot from him."
Two Tucson Indian Center women walkers.
Native people living in and near Tucson, Arizona, are finding a way to become fit, or keep their fitness regimens going strong. Once a week they can join a walking group held at the Tucson Indian Center in downtown Tucson.
Both Isabella Enriquez, Tohono O'odham Nation, and Erolinda Ramon, Tohono O'odham Nation, started regular walking about two years ago. Isabella was in the Center's Lifestyle Balance class when she joined the walking group. For a while she was the only client in the group. She walked the over 2-mile course with the Diabetes Prevention Program Coordinator, Arcenio Trujillo.
"She would show up even when it was freezing cold!" recalls Arcenio.
Erolinda started walking when she was in the SDPI Healthy Heart Program at the San Xavier Health Clinic. She has diabetes, and, at that time, had severe pain in her feet. "I've had a hard time controlling my diabetes. But the walking helps me," she says.
Tucson Indian Center staff and clients.
Erolinda has lost weight, no longer needs insulin shots, and eats more fruits and vegetables and fewer sweets. "My blood sugar has come down and I've been feeling real good," she says.
Isabella walks up to seven miles a day. She has become stronger and improved her balance. She has lost weight, and eats more fruits and vegetables and less high-fat food. She cut back on soda and drinks more water.
These lifestyle changes have helped Isabella feel better. "At one time, I couldn't even move. But now I don't feel pain so much. I don't feel depressed. I don't have diabetes. I'm 67, and feel like I'm getting younger!"
Every week Isabella and Erolinda join the Center's walking group, which has grown from one participant to about 20. The two women have made regular walking a part of their lives.
Edmund Francis teaching water aerobics.
Montell Elliott, the Diabetes Prevention Program Coordinator at the Warm Springs Tribe located in Central Oregon, says participants are in the "call to action" phase of diabetes prevention and management. The tribe has both an SDPI Diabetes Prevention (DP) program and a Community-Directed program, which makes it possible to offer many activities aimed at helping community members increase physical activity and lose weight. The reason the offerings are full of participants is because the grants have been able to build on initial stages. "Native communities have seen grant programs come and go," explains Montell, "but the SDPI programs have been here for nearly 12 years."
She says the first years were spent addressing the" fatalistic" belief many of her clients had about diabetes. "Many believed that they would automatically get diabetes, that there was nothing they could do," recalls Montell. For several years, program activities focused on teaching that diabetes could be prevented or delayed. Montell says the program staff is still teaching the Lifestyle Balance 16-week diabetes prevention curriculum, and now participants are believing the information and acting on it.
Christel Leonard in the Functional Fitness class.
The SDPI program staff is ready for the "action phase" with a number of weight loss and physical activity classes including:
- Lifestyle Water Aerobics which is led by Edmund Francis and Jeri Kollen and held in a huge, hot-spring-fed pool.
- Diabetes Prevention that helps participants stay motivated and deal with setbacks to healthy lifestyle changes, develop and monitor weight loss plans and sample healthy snacks like low-fat cheese and bean burritos.
- Functional Fitness that is super-tough and motivates participants to keep heart rates up by exercising for one minute at multiple "stations" including a semi-tire-flipping station.
- Senior Fitness where seniors ages into their 90s do low-impact exercises involving cardio, strength training and Zumba®.
Diabetes Prevention Program Class.
Weight loss results are coming in. Many DP program participants have lost weight and gained muscle. Edmund Francis, who participated in the DP program in 2007, comes from a family in which both parents have histories of cardiovascular disease and diabetes. Because of what Edmund learned in the DP program, he has limited processed foods and eliminated the consumption of alcohol. He does not have diabetes. Now Edmund is the Tribal Wellness Coordinator.
Another community member, Anna Hurtado (Warm Springs), attends water aerobics and a fitness class. She has diabetes and has recently lost about 15 pounds. She says her legs hurt sometimes, but it's a good hurt. "They get sore because I'm exercising them," she says. Anna is 74 years old.
Two women at the Denver Indian Health and Family Services discussing how to lose weight and practice diabetes self care.
It's a typical morning for Allene Stanley (Cheyenne River Sioux). By ten AM she has walked over 1400 steps -- some of them up a hill to get more of an aerobic workout. She has eaten a small orange instead of drinking a glass of orange juice. She has not even thought of having a "Diet Dew" because all soda is gone from her house. Just seven weeks ago, Allene started her days differently. Her eating habits weren't as good and daily exercise was not a habit. But she has been attending the Denver Indian Health and Family Services (DIHFS) program Fork n' Road once a week for almost two months and has changed many of her eating and exercise habits.
Diabetes Program Manager Kathy Canclini, MN, RN, CDE, and other staff of this urban clinic started the program, funded by the Special Diabetes Program for Indians (SDPI) Community Directed Grant Program, in January 2010. The clever name, Fork n' Road, reflects the program's focus of making better lifestyle choices by improving eating habits (fork) and increasing exercise (road) to lose weight and prevent or manage diabetes.
"We had a 91 percent obesity rate," explains Kathy. "The Best Practice we chose was Weight Management. We were inspired by the Best Practice and we used the Division of Diabetes Treatment and Prevention's Balancing Your Life and Diabetes curriculum."
DIHFS staff member showing a client how to use exercise equipment.
Like most urban Indian clinics DIHFS has a client population with characteristics common to Natives living in big cities, diversity being the most prominent. "I would guess that 80 to 90 percent of tribes are represented among our clients, from Native Hawaiians, to Alaska Natives, to members of tribes in Maine" says Kathy. Many of the center's clients do not have health insurance. Some are travelling and some live in Denver for a while, then move.
DIHFS staff view these challenges as positives. "Our clients appreciate meeting other Native people. They appreciate how we sincerely care for them, how we slow things down, taking time to provide many hours of diabetes education classes, as compared to two hours at non-Indian hospitals or clinics. They appreciate how we honor and respect their values."
The foremost value among their clients is family. Diabetes Prevention Specialist Kristen Curcija, MPH, says, as a non-Indian, she has learned a lot about the values of her Native clients. "I have learned how much they value their families and how our teaching has a ripple effect throughout their families. Everyone is so open and sharing. We hear their heartbreaking stories of how diabetes has impacted their cousins, their aunties. After listening, I started to understand the enormity of the love and care our clients have for each other."
In addition to learning about values, staff have learned what works to put on a successful weight loss program at their urban Indian clinic. Here are some of their tips:
DIHFS staff member reviewing Choose Your Foods: Exchange Lists for Diabetes with a client.
- Use a team approach involving all staff from the clinic and the diabetes program. "The clinic refers patients to us, and we refer clients to the clinic" says Kathy. "We establish a relationship with the clinic patients and they are more likely to come to our classes."
- Develop a program name, logo. Think creatively to name your program and develop your logo – have fun with it! Use the logo on materials to foster an identity for your program. You are welcome to borrow the name and logo Fork n' Road if it will help you market your program.
- Consider creating a contract for staff and clients to sign at start of classes. The DIHFS Fork n' Road Program Behavior Contract includes the statement: I promise to enjoy myself during class.
- Include interactive activities. While waiting for other clients to arrive participants play catch with an inflated "Weight Loss Toss-Up Ball", which has nutrition and exercise questions printed on it. Participants are encouraged to provide the answers.
- Repetition helps. Staff never assume clients know information about nutrition, like how to read labels. They teach, then teach again as needed -- repetition works!
- Expect and celebrate the small changes clients make, like switching from whole milk to skim milk, being able to decrease medications (as ordered by the provider) due to weight loss, wearing smaller-sized clothing, walking around a park and eating more fruits and vegetables. "We are delighted when our clients make eating habit changes and even more excited when we see them smiling, laughing, and feeling better about themselves" says Lorraine Gill, RD, MA, CDE.
- Be delighted by your clients' huge successes, like dramatic drops in A1C, LDLs and lower BMIs. Some DIHFS clients' A1Cs have dropped from 14 percent to under 7 percent!
- Evaluate to show clients' successes. During the first and last classes, clients complete a form developed by the DIHFS Diabetes Program called "Assessment and Evaluation of Healthy Behaviors". Participants give themselves a rating from "rarely" to "regularly" (1-5 Likert scale) regarding nutrition and exercise habits. For Best Practice outcome grant reporting, staff compare before and after class scores. In the last class staff use the SDPI In Review, which asks participants to assess their current habits to show them how much progress they have made and what changes they need to focus on in the future.
- Conduct follow-up assessments. At six and 12 months after the program, clients are re-evaluated for weight, BMI, body measurements and Healthy Behavior Ratings. Again, the team celebrates and/or re-motivates the participant with ongoing support.
DIHFS staff members posing with a successful Fork n' Road Weight Management Program client.
When clients finish the Fork n' Road Program they are presented with a certificate of graduation and are then eligible to join the Crossroads Program, which focuses on the rest of the Diabetes Self-Management Education. Crossroads is a program primarily offered to clients with diabetes, although all are welcome to attend. Staff chose not to do separate classes for those with diabetes and those without diabetes because nutrition, exercise and behavior change education is applicable to all.
DIHFS staff members talking to a client.
During the first moments of the Fork n' Road diabetes education class at the Denver Indian Health and Family Services (DIHFS) clinic, Charlene Irani appeared to not be a happy camper. Her arms were crossed as if she was prepared for a preaching. "I was afraid and emotional. I did not want to be there. I thought, 'If you're going to tell me what to do, then I'm not listening.' "
Fast forward seven weeks to the last day of the once-a-week classes and Charlene is laughing and telling stories. She says the classes were not what she expected. "Talking to staff was like talking to a friend," she recalls. "We would tell a story and then Kathy (Canclini, Diabetes Program Manager) would tell a story and we could all relate. The staff didn't talk down to us. That's why we were able to share."
After the first several minutes of class, arms are uncrossed, smiles start appearing, more voices contribute. There are people from the Navajo, Seminole, Sioux and other tribes. It quickly becomes obvious that this diabetes nutrition and exercise class is not like the 2-hour program of a nearby hospital. It caters to the values and needs of Native Americans from diverse tribes, those who have insurance and those who don't; and it provides information in a way Native clients appreciate – not rushed but applicable to body, mind, spirit, emotion and family.
Meet three people who participated in the DIHFS Fork n' Road Program:
DIHFS staff member evaluating a client.
Robin Colombe (Rosebud Sioux)
"I grew up in Nebraska and came to Denver 40 years ago when I was 22. I found out I had pre-diabetes about five or six years ago. I had insurance at the time and was told that my blood sugar was high. But I was given no education. Soon after that I was diagnosed with diabetes.
"I lost my insurance and came to DIHFS. They are the ones who educated me about how to manage diabetes. After the first few classes I learned what I had to do to get my blood sugar under control. I learned how to read labels and the correct portion sizes. When I go out to eat I learned that I should eat half of what I order. I do that now.
"My habits have changed. I don't drink pop. I drink water, milk, or low-calorie drinks. I am trying to eat more vegetables. I eat more low-salt foods to help my blood pressure and my A1C level has dropped."
DIHFS client reading the nutrition facts of All-Bran Crackers Multi-Grain.
Geraldine Thomas (Navajo)
"I grew up in Gallup, New Mexico, and came to Denver in 1989. I don't have diabetes, but it's in my family. My A1C level was high and I had pre-diabetes. I was overweight and wanted to lose weight; I didn't want to get diabetes. I thought, "I refuse to accept diabetes. I am going to do something about it.' I was in the Fork n' Road Program two years ago.
"At first, I was embarrassed that I was a person who might get diabetes and lose limbs. I didn't want to talk about diabetes. But the staff helped me. Kathy had compassion in her heart for Native people. She never put anyone down. And Kristen taught us exercises we could do at home, without special equipment or extra expense. They both showed us that diabetes could be avoided or managed and we could live long, healthy lives.
"I learned about nutrition and avoiding diabetes – how to read food labels, the correct portion sizes, how to add more fruits and vegetables to your diet. Pound by pound, weight started coming off. I've lost 16 pounds in two years! I used to wear size 16 and now I wear size 12! My A1C went from 6.5 to 5.9.
"Now I share with my children and grandchildren. I talk about the importance of knowing your A1C level, about how to avoid diabetes and what symptoms to watch for. I estimate I have talked to 15 friends and family members about how to stay healthy. God has helped me get on this healthy, positive path and I hope I am passing it on."
DIHFS client taking a walk.
Charlene Irani (Seminole/Kiowa)
"I grew up in Oklahoma and moved here in 1985. My mother and brother died from diabetes complications and my sister has diabetes. When I found out I had it, I cried. I didn't want my life to be like other family members who had diabetes. But I didn't know what to expect or what to do. I wanted to learn everything I could so I could help myself be healthy with diabetes.
"In the classes, I learned to eat regular-sized portions. I learned how much sugar is in pop and fruit juice, so I stopped drinking them. I stopped eating fried foods. Now I bake and boil meat and chicken. I eat less peas and rice, and more broccoli and spinach.
"I have lost 35 pounds! I walk three times a week for about one and a half miles, and I can breathe easily! And, I'm getting better sleep. I feel more rested.
"I'm trying to share what I've learned. I've told my friends' grandchildren, 'Look! My lunch is colorful. It has an apple in it and no pop.' I'm happy that the grandchildren stopped drinking pop.
"When I was 43, I was diagnosed with an aneurism and was told I didn't have long to live. Now I'm 54 and I feel great. God gave me this extra time, time that I wasn't expecting I would have. I want to give back. I am a volunteer for Native cancer research. I also volunteer to help get water filters to homes on the Pine Ridge Reservation. I want to live a long time so I can continue to help others."