A reconsideration of the origins of the type 2 diabetes epidemic among Native Americans and the implications for intervention policy

Ethnic Density as a Key Factor to Narrow Health Disparities: A Case of American Indians and Alaska Natives

Out of all the racial groups in the United States, people who identify as American Indian and Alaska Native (AI/AN) have disproportionately worse health as a result of living in poverty. The preponderance of research connects poor health with a socioeconomic perspective, which might create prejudice against AI/AN. As already known, AI/AN's high rates of obesity, diabetes, and stroke in comparison with that of other ethnic groups are mainly derived from their impoverished economic conditions that have forced them to consume the food distributed by the U.S. government. When minority health is discussed generally, the ethnic density perspective explains a minority population's positive health despite low socioeconomic status. This perspective helps researchers and practitioners understand the connections of psychological and social factors with physical health and demonstrates positive health effects on minority groups. Despite the high correlation between ethnic density and health having been validated, little to no research has explored AI/AN's health from this perspective. Using 13,064 electronic health records, this research tests the relationship between AI/AN density and health outcomes. This article introduces an innovative analytical strategy (i.e., a data mining technique), which is ideal for discovering frequently appearing health outcomes in a group. The finding reveals positive relationships between health outcomes and AI/AN density.

Mexican American Intergenerational Research: Transformative Model of Occupational Therapy

Thirty-seven interviews of Mexican American women who crossed the border into the United States during the era of the Mexican Revolution of 1910 were analyzed using constructivist grounded theory methods. The intent is to expand the occupational therapy profession's occupational consciousness and cultivate cultural humility. Four themes emerged from the data: suffering, work, yearning for an education, and compassion for others. The findings suggest that environmental barriers such as hierarchy (patriarchy and discrimination) and physical barriers (limited access to built environments, lack of nonexploitative work opportunities, and hostile educational institutions) prevented occupational participation. Small acts of resistance through everyday living (finding joy, playing, self-sufficiency, and community organizing) were identified as facilitators of occupational participation. The research findings challenge proposed assumptions found within the occupational therapy literature: (1) humans and occupations exist as separate from their environments, and (2) work, productivity, and leisure contribute positively to health. The Transformative Model of Occupational Therapy is introduced as a decolonized framework that inextricably links individual health to community and global health. The model centers play, social participation, work, and education as occupations that contribute to the common good. These occupations are kept in equilibrium within the Four Pillars of Culture (self-determination, compassion, sustainability, and language) or the cultural values identified and derived from the stories.

The global diabetes epidemic and the nonprofit state corporate complex: Equity implications of discourses, research agendas, and policy recommendations of diabetes nonprofit organizations

Important insights have been gained from studying how corporate social actors -- such as Big Tobacco or Big Food -- influence how global health issues are framed, debated, and addressed, and in so doing contribute to reproducing health inequities. Less attention has been paid to the role of nonprofit organizations (NPOs), even when all too often NPOs actively contribute to these inequities through normalizing discourses and practices that legitimize establishment views, poor public policies and existing relations of power. Our study attempts to fill this gap by assessing the influence on global health inequities of major NPOs -- specifically three disease associations -- whose mission includes preventing type 2 diabetes (henceforth diabetes) or reducing inequities in the global diabetes epidemic. No longer considered a "disease of prosperity", diabetes is known to affect the poor and racialized minorities disproportionately, in countries at all levels of income. While the contribution of the social and political determinants of health is well established, major NPOs ostensibly committed to eradicate, or at least moderate the effects of, diabetes give short shrift to these determinants, framing them at best as the context that promotes behaviours that combine with genetic predispositions to drive the inequitable, global distribution of diabetes. Drawing from Marxian theory and critical discourse analysis, we assess publicly available information - on educational and policy prescriptions, funding sources, corporate affiliations, funded research and social media presence -- pertaining to one Canadian, one US and one international NPO to identify discourses and practices that may contribute to the global, unequal distribution of diabetes and elaborate on their implications for health equity more broadly.

Birthweight and cardiometabolic risk patterns in multiracial children

BACKGROUND/OBJECTIVES

Prenatal growth, which is widely marked by birthweight, may have a pivotal role in affecting the lifelong risk of cardiometabolic disorders; however, comprehensive evaluation of its relations with childhood cardiometabolic risk patterns and the ethnic and gender disparities in national representative populations is still lacking. The aim of this study was to evaluate the associations between birthweight and comprehensive patterns of cardiometabolic risk in a nationally representative sample of children and adolescents.

SUBJECTS/METHODS

Prospective analyses were performed using data from 28 153 children 0 to 15 years in the National Health and Nutrition Examination Survey from 1999 through 2014. We defined childhood cardiometabolic disorders using standard definitions for obesity, high blood pressure, hyperglycemia and dyslipidemia.

RESULTS

Five birthweight categories <2.5, 2.5-3.0, 3.0-3.5, 3.5-4.2 and ⩾4.2 kg accounted for 8.2%, 17.9%, 35.7%, 27.9% and 10.4% of the population, respectively. In all children, with increasing birthweight, we observed significantly increasing trends of the risk of general and central obesity (P for trend <0.01) and significantly decreasing trends of the risk of high systolic blood pressure (SBP), high HbA1c and low high-density lipoprotein cholesterol (HDL-C) (P for trend <0.05). The associations were independent of current body mass index (BMI). In addition, we found that the relations of birthweight with high waist circumference in Black children showed U-shape, as well as high SBP in Mexican and Hispanic children. Moreover, we found that the associations of low birthweight with high SBP and low HDL-C appeared to more prominent significant in boys, whereas the inverse association with high HbA1c was more evident in girls.

CONCLUSIONS

Our data indicate that birthweight is significantly related to childhood cardiometabolic risk, independent of current BMI, and the associations exhibit race and gender-specific patterns.

Stress Exposure and Physical, Mental, and Behavioral Health among American Indian Adults with Type 2 Diabetes

American Indian (AI) communities experience disproportionate exposure to stressors and health inequities including type 2 diabetes. Yet, we know little about the role of psychosocial stressors for AI diabetes-related health outcomes. We investigated associations between a range of stressors and psychological, behavioral, and physical health for AIs with diabetes. This community-based participatory research with 5 AI tribes includes 192 AI adult type 2 diabetes patients recruited from clinical records at tribal clinics. Data are from computer-assisted interviews and medical charts. We found consistent bivariate relationships between chronic to discrete stressors and mental and behavioral health outcomes; several remained even after accounting for participant age, gender, and income. Fewer stressors were linked to physical health. We also document a dose-response relationship between stress accumulation and worse health. Findings underscore the importance of considering a broad range of stressors for comprehensive assessment of stress burden and diabetes. Policies and practices aimed at reducing stress exposure and promoting tools for stress management may be mechanisms for optimal health for AI diabetes patients.

Promoting Physical Activity Among Native American Youth: a Systematic Review of the Methodology and Current Evidence of Physical Activity Interventions and Community-wide Initiatives

Promoting physical activity using environmental, policy, and systems approaches could potentially address persistent health disparities faced by American Indian and Alaska Native children and adolescents. To address research gaps and help inform tribally led community changes that promote physical activity, this review examined the methodology and current evidence of physical activity interventions and community-wide initiatives among Native youth. A keyword-guided search was conducted in multiple databases to identify peer-reviewed research articles that reported on physical activity among Native youth. Ultimately, 20 unique interventions (described in 76 articles) and 13 unique community-wide initiatives (described in 16 articles) met the study criteria. Four interventions noted positive changes in knowledge and attitude relating to physical activity but none of the interventions examined reported statistically significant improvements on weight-related outcomes. Only six interventions reported implementing environmental, policy, and system approaches relating to promoting physical activity and generally only shared anecdotal information about the approaches tried. Using community-based participatory research or tribally driven research models strengthened the tribal-research partnerships and improved the cultural and contextual sensitivity of the intervention or community-wide initiative. Few interventions or community-wide initiatives examined multi-level, multi-sector interventions to promote physical activity among Native youth, families, and communities. More research is needed to measure and monitor physical activity within this understudied, high risk group. Future research could also focus on the unique authority and opportunity of tribal leaders and other key stakeholders to use environmental, policy, and systems approaches to raise a healthier generation of Native youth.

Radical contextualization: contributions to an anthropology of racial/ethnic health disparities

There is indisputable evidence of deep and persistent racial/ethnic inequalities in health status and health care in the USA. Growing awareness of these disparities has fueled a cross-disciplinary debate about appropriate approaches to racial/ethnic disparities in public health research and policy discourse, yet anthropologists have been marginalized in this discourse. What does the current work of anthropologists have to offer that is most useful in the crucial work of understanding and eliminating health disparities? We examine anthropological research and practice that constitute core contributions to an anthropology of racial/ethnic health disparities. We identify the following themes: (1) using ethnography as a tool for new inequality knowledge; (2) studying up; and (3) formulating alternative models of biosocial pathogenesis. These elements of anthropological methods, theory and practice can contribute to a better understanding of the social processes that underpin racial/ethnic health disparities and help identify opportunities for interrupting them.

Canadian residential schools and urban indigenous knowledge production about diabetes

The construction of illness as an inscription on the body of colonization figures importantly among Indigenous community-based service and health care providers. While residential schools and diabetes have both been characterized as products of colonization, little work has been done to examine how they are connected to and informative for health provider practice. The research data presented in this article come from a collaborative urban Indigenous community-based study examining the legacy of negative relationships with food that was instilled in residential schools and used in diabetes intervention. I illustrate how residential school disciplined eating, providing a context for understanding the contemporary production of Indigenous health knowledge and practice in the urban setting, and the diet-related management of diabetes.

Early environmental factors, alteration of epigenetic marks and metabolic disease susceptibility

The environmental conditions that are experienced in early life can profoundly influence human biology and long-term health. Early-life nutrition and stress are among the best documented examples of such conditions because they influence the adult risk of developing metabolic diseases, such as type 2 diabetes mellitus (T2D) and cardiovascular diseases. It is now becoming increasingly accepted that environmental compounds including nutrients can produce changes in the genome activity that in spite of not altering DNA sequence can produce important, stable and transgenerational alterations in the phenotype. Epigenetic changes, in particular DNA methylation and histone acetylation/methylation, provide a 'memory' of developmental plastic responses to early environment and are central to the generation of phenotypes and their stability throughout the life course. Their effects may only become manifest later in life, e.g. in terms of altered responses to environmental challenges.

Diabetes in pregnancy among indigenous women in Australia, Canada, New Zealand and the United States

Recently proposed international guidelines for screening for gestational diabetes mellitus (GDM) recommend additional screening in early pregnancy for sub-populations at a high risk of type 2 diabetes mellitus (T2DM), such as indigenous women. However, there are criteria that should be met to ensure the benefits outweigh the risks of population-based screening. This review examines the published evidence for early screening for indigenous women as related to these criteria. Any publications were included that referred to diabetes in pregnancy among indigenous women in Australia, Canada, New Zealand and the United States (n = 145). The risk of bias was appraised. There is sufficient evidence describing the epidemiology of diabetes in pregnancy, demonstrating that it imposes a significant disease burden on indigenous women and their infants at birth and across the lifecourse (n = 120 studies). Women with pre-existing T2DM have a higher risk than women who develop GDM during pregnancy. However, there was insufficient evidence to address the remaining five criteria, including the following: understanding current screening practice and rates (n = 7); acceptability of GDM screening (n = 0); efficacy and cost of screening for GDM (n = 3); availability of effective treatment after diagnosis (n = 6); and effective systems for follow-up after pregnancy (n = 5). Given the impact of diabetes in pregnancy, particularly undiagnosed T2DM, GDM screening in early pregnancy offers potential benefits for indigenous women. However, researchers, policy makers and clinicians must work together with communities to develop effective strategies for implementation and minimizing the potential risks. Evidence of effective strategies for primary prevention, GDM treatment and follow-up after pregnancy are urgently needed.

Developmental origins of obesity and type 2 diabetes: molecular aspects and role of chemicals

Obesity is a leading risk factor for impaired glucose tolerance and type 2 diabetes (T2D). Although the cause of the obesity epidemic is multi-factorial and not entirely clear, the recent acceleration in incidence is too rapid to be accounted for only by genetics, the wide availability of calorie-rich foods, and increasingly sedentary lifestyles. Accumulating data suggest that the important causes of the obesity epidemic may be related to developmental and early life environmental conditions. The concept of the developmental origins of health and disease (DOHaD) suggests that adverse influences early in development, particularly during intrauterine life, may result in permanent changes in the physiology and metabolism of the infant, which in turn result in an increased risk of non-communicable diseases in adulthood. For example, undernutrition during pregnancy and rapid postnatal weight gain are associated with obesity and T2D in the adult offspring. Moreover, increasing evidence suggests that early-life exposure to a wide range of chemicals has a significant impact on the causes of metabolic disorders. Although the underlying molecular mechanisms remain to be determined, these factors can affect epigenetic processes, such as DNA methylation, allowing the developmental environment to modulate gene transcription. The objective of this review article was to summarize recent progress in the biomedical implications of the DOHaD concept, focusing on the pathogenesis of obesity and T2D, and to discuss a future direction for preventive strategies from a public health perspective.

Diabetes, pre-diabetes and insulin resistance screening in Native American children and youth

OBJECTIVES

Early identification of pre-diabetes and insulin resistance (IR) provides an important window of opportunity for diabetes prevention. Little is known about the prevalence of pre-diabetes and IR in Native American (NA) youth. We designed a cross-sectional, community-based study of NA children to estimate the prevalence of diabetes, pre-diabetes and IR and their association with other diabetes risk factors.

STUDY DESIGN

NA children (5-18 years) were screened with body mass index (BMI), blood pressure, oral glucose tolerance test (OGTT), lipids, insulin and highly sensitive C-reactive protein (hsCRP), and calculated homeostatic model assessment of IR (HOMA-IR).

RESULTS

Mean age of the cohort (n=201) was 10.8 ± 3.8 years (± s.d.; 94/107 M/F). BMI percentile for age and sex (BMI%) was elevated (≥ 85 th percentile) in 58.6% of 5-11 years and 51.1% of 12-18 years, and positively correlated with HOMA-IR, blood pressure, triglycerides and hsCRP (P<0.05). The prevalence rate for pre-diabetes and diabetes were 6.5% (3.5-10.8%) and 1.0% (0.1-3.6%), respectively. Mean HOMA-IR was greater in the older than younger age group while prevalence of pre-diabetes was the same. Those with pre-diabetes and diabetes had a greater HOMA-IR, abdominal circumference and BMI% than normal youth.

CONCLUSION

In the first prospective, community-based screening for pre-diabetes, IR and diabetes in United States NA youth using OGTT, while the number of diabetes cases was low, pre-diabetes was found in a significant number of youth, particularly in those with BMI ≥ 95 th%. As proportions of pre-diabetes were similar in 5-11 and 12-18 year olds, diabetes risk begins early in NA youth.

The twin epidemics of poverty and diabetes: understanding diabetes disparities in a low-income Latino and immigrant neighborhood

In the United States, low-income immigrant groups experience greater health disparities and worse health-related outcomes than Whites, including but not limited to higher rates of type 2 diabetes (T2DM). The prevention and adequate management of T2DM are, to a great extent, contingent on access to healthy food environments. This exploratory study examines "upstream" antecedent factors contributing to "downstream" health disparities, with a focus on disparities in the structural sources of T2DM risk, especially food environments. Our target group is Latino immigrants receiving services from a non-profit organization (NGO) in Northern California. Methods are mixed and data include focus groups and surveys of our target group, interviews to NGO staff members, and estimation of the thrifty food market basket in local grocery stores. We find that while participants identify T2DM as the greatest health problem in the community, access to healthy foods is severely restricted, geographically, culturally, and economically, with 100% of participants relying on formal or informal food assistance and local food stores offering limited variety of healthy foods and at unaffordable prices. While this article is empirical, its goal is primarily conceptual--to integrate empirical findings with the growing literature underscoring the sociopolitical context of the social determinants of health in general and of T2DM disparities in particular. We propose that interventions to reduce T2DM and comparable health disparities must incorporate a social justice perspective that guarantees a right to adequate food and other health-relevant environments, and concomitantly, a right to health.

Ethnic Groups as Migrant Groups: Improving Understanding of Links Between Ethnicity/Race and Risk of Type 2 Diabetes and Associated Conditions

Most members of minority ethnic/racial groups in affluent western societies are recent immigrants or immediate descendants thereof. The health implications of ethnic groups also being migrant groups are important but often not fully explored. Research demonstrating developmental influences on the risk of type 2 diabetes and associated conditions suggests that migrants will differ in disease risk compared with the general population. It also leads us to expect intergenerational differences in disease risk within many minority ethnic/racial groups. Differences in health behaviors between ethnic/racial groups are also expected to change over time following migration, including across generations, but do not necessarily follow a simple model of acculturation. Understanding the ways in which the biosocial heritage of migrant groups interacts over the long term with migrants' new environments is central to understanding differences in disease risk that are identified as ethnic or racial and also highlights heterogeneity in risk within ethnic groups.

Developmental plasticity and developmental origins of non-communicable disease: theoretical considerations and epigenetic mechanisms

There is now evidence that developmental influences have lifelong effects on cardiovascular and metabolic function and that elements of the heritable or familial component of susceptibility to cardiovascular disease, obesity and other non-communicable diseases (NCD) can be transmitted across generations by non-genomic means. In animals the developmental environment induces altered phenotypes through genetic, physiological (especially endocrine) and epigenetic mechanisms. The latter include DNA methylation, covalent modifications of histones and non-coding RNAs. Such 'tuning' of phenotype has potential adaptive value and may confer Darwinian fitness advantage because it either adjusts the phenotype to current circumstances and/or attempts to match an individual's responses to the environment predicted to be experienced later. When the phenotype is mismatched to the later environment, e.g. from inaccurate nutritional cues from the mother or placenta before birth, or from rapid environmental change through improved socio-economic conditions, risk of NCD increases. Such mechanisms are also thought to play roles in ageing and early onset of puberty, reinforcing a life-course perspective on such adaptive responses, especially the detrimental later effects of trade-offs. Epigenetic changes induced during development are highly gene-specific and function at the level of individual CpG dinucleotides in both gene promoter and intergenic regions. Evidence is accruing that endocrine or nutritional interventions during early postnatal life can reverse epigenetic and phenotypic changes induced, for example, by unbalanced maternal diet during pregnancy. Elucidation of epigenetic processes may permit perinatal identification of individuals most at risk of later NCD and enable early intervention strategies to reduce such risk.

Natural selection at genomic regions associated with obesity and type-2 diabetes: East Asians and sub-Saharan Africans exhibit high levels of differentiation at type-2 diabetes regions

Different populations suffer from different rates of obesity and type-2 diabetes (T2D). Little is known about the genetic or adaptive component, if any, that underlies these differences. Given the cultural, geographic, and dietary variation that accumulated among humans over the last 60,000 years, we examined whether loci identified by genome-wide association studies for these traits have been subject to recent selection pressures. Using genome-wide SNP data on 938 individuals in 53 populations from the Human Genome Diversity Panel, we compare population differentiation and haplotype patterns at these loci to the rest of the genome. Using an "expanding window" approach (100-1,600 kb) for the individual loci as well as the loci as ensembles, we find a high degree of differentiation for the ensemble of T2D loci. This differentiation is most pronounced for East Asians and sub-Saharan Africans, suggesting that these groups experienced natural selection at loci associated with T2D. Haplotype analysis suggests an excess of obesity loci with evidence of recent positive selection among South Asians and Europeans, compared to sub-Saharan Africans and Native Americans. We also identify individual loci that may have been subjected to natural selection, such as the T2D locus, HHEX, which displays both elevated differentiation and extended haplotype homozygosity in comparisons of East Asians with other groups. Our findings suggest that there is an evolutionary genetic basis for population differences in these traits, and we have identified potential group-specific genetic risk factors.

Nutrition, epigenetics, and developmental plasticity: implications for understanding human disease

There is considerable evidence for induction of differential risk of noncommunicable diseases in humans by variation in the quality of the early life environment. Studies in animal models show that induction and stability of induced changes in the phenotype of the offspring involve altered epigenetic regulation by DNA methylation and covalent modifications of histones. These findings indicate that such epigenetic changes are highly gene specific and function at the level of individual CpG dinucleotides. Interventions using supplementation with folic acid or methyl donors during pregnancy, or folic acid after weaning, alter the phenotype and epigenotype induced by maternal dietary constraint during gestation. This suggests a possible means for reducing risk of induced noncommunicable disease, although the design and conduct of such interventions may require caution. The purpose of this review is to discuss recent advances in understanding the mechanism that underlies the early life origins of disease and to place these studies in a broader life-course context.

Long-term maternal high-fat feeding from weaning through pregnancy and lactation predisposes offspring to hypertension, raised plasma lipids and fatty liver in mice

In rodents, adverse prenatal nutrition, such as a maternal diet rich in fat during pregnancy, enhances susceptibility of the offspring to hypertension, type 2 diabetes and other features of the human metabolic syndrome in adulthood. However, previous experimental studies were confined to short-term modifications of the maternal diet during pregnancy and/or lactation periods, a situation uncommon in humans. Moreover in humans, the offspring may also consume a high-fat diet, which may take them beyond the range to which their development has adapted them to respond healthily. We examined in C57 mice the effects on offspring of feeding their mothers a high-fat (HF) or standard chow (C) diet from weaning through pregnancy and lactation, and whether there are additive phenotypic effects of feeding the offspring an HF diet from weaning to adulthood (dam-offspring dietary group HF-HF). This group was compared with offspring from HF-fed dams fed a C diet from weaning to adulthood (HF-C) and offspring from C-fed mothers fed the C or HF diet (C-C and HF-C, respectively). HF-HF, HF-C and C-HF adult female offspring were heavier, fatter, and had raised serum cholesterol and blood pressure compared with C-C female offspring. We observed a similar trend in male offspring except for the HF-C group which was not heavier or fatter than male C-C offspring. Histology showed lipid vacuoles within hepatocytes in the HF-HF, HF-C and C-HF but not the CC offspring. Serum C-reactive protein was elevated in female (C-HF and HF-HF) but not in male offspring. Elevated blood pressure in the HF-C and C-HF groups was attenuated in the HF-HF group in males but not in females. These findings indicate that long-term consumption of an HF diet by the mother predisposes her offspring to developing a metabolic syndrome-like phenotype in adult life, although cardiovascular effects of an HF diet are related to sex specificity in the HF-HF group.

The Elephant in the Room: The Invisibility of Poverty in Research on Type 2 Diabetes

Over two hundred years of anecdotal, epidemiological, and experimental evidence indicate that poverty breeds disease. This holds true for type 2 diabetes, which both in the United States and other developed nations disproportionately occurs, cripples, and kills among the poor. In this article we examine rhetorical strategies used in 30 journal articles indexed under type 2 diabetes and poverty. As we show, poverty is rarely highlighted in this literature as a causal factor. Instead, explanations for diabetes among poor people overwhelmingly emphasize features of patients—their biology, behaviors, psychology, culture, or other “risk factors”—while ignoring, reframing or neglecting the links between poverty and disease. By so doing, these discursive strategies naturalize higher rates of diabetes among poor persons, legitimize relations of domination in the larger society, and encourage only research projects, treatment practices and health and social policies that do not challenge existing social relations. We discuss the implications of these discursive practices for medical research and care, and for social and public health policies.

How much can a large population study on genes, environments, their interactions and common diseases contribute to the health of the American people?

I offer a critical perspective on a large-scale population study on gene-environment interactions and common diseases proposed by the US Secretary of Health and Human Services' Advisory Committee on Genetics, Health, and Society (SACGHS). I argue that for scientific and policy reasons this and similar studies have little to add to current knowledge about how to prevent, treat, or decrease inequalities in common diseases, all of which are major claims of the proposal. I use diabetes as an exemplar of the diseases that the study purports to illuminate. I conclude that the question is not whether the study will meet expectations or whether the current emphasis on a genetic paradigm is real or imagined, desirable or not. Rather, the question is why, given the flaws of the science underwriting the study, its assumptions remain unchallenged. Future research should investigate the reasons for this immunity from criticism and for the popularity of this and similar projects among laypersons as well as among intellectuals.

Non-genomic transgenerational inheritance of disease risk

That there is a heritable or familial component of susceptibility to chronic non-communicable diseases such as type 2 diabetes, obesity and cardiovascular disease is well established, but there is increasing evidence that some elements of such heritability are transmitted non-genomically and that the processes whereby environmental influences act during early development to shape disease risk in later life can have effects beyond a single generation. Such heritability may operate through epigenetic mechanisms involving regulation of either imprinted or non-imprinted genes but also through broader mechanisms related to parental physiology or behaviour. We review evidence and potential mechanisms for non-genomic transgenerational inheritance of 'lifestyle' disease and propose that the 'developmental origins of disease' phenomenon is a maladaptive consequence of an ancestral mechanism of developmental plasticity that may have had adaptive value in the evolution of generalist species such as Homo sapiens.

Exploring the thrifty genotype's food-shortage assumptions: a cross-cultural comparison of ethnographic accounts of food security among foraging and agricultural societies

The "thrifty genotype hypothesis" has become firmly entrenched as one of the orienting concepts in biomedical anthropology, since first being proposed by Neel (1962 Am. J. Hum. Genet. 14:353-362) over 40 years ago. Its influence on inquiries into the evolutionary origins of diabetes, lactose tolerance, and other metabolic disorders can hardly be underestimated, as evidenced by its continued citation in many top scientific and medical journals. However, its fundamental assumption, that foragers are more likely to experience regular and severe food shortages than sedentary agriculturalists, remains largely untested. The present report tests this assumption by making a cross-cultural statistical comparison of the quantity of available food and the frequency and extent of food shortages among 94 foraging and agricultural societies as reported in the ethnographic record. Our results indicate that there is no statistical difference (P < 0.05) in the quantity of available food, or the frequency or extent of food shortages in these reports between preindustrial foragers, recent foragers, and agriculturalists. The findings presented here add to a growing literature that calls into question assumptions about forager food insecurity and nutritional status in general, and ultimately, the very foundation of the thrifty genotype hypothesis: the presumed food shortages that selected for a "thrifty" metabolism in past foraging populations.

Diagnostic controversy: gestational diabetes and the meaning of risk for pima Indian women

Gestational diabetes is the one form of this well known, chronic disease of development that disappears. After the birth of the child, the mother's glucose levels typically return to normal. As a harbinger of things to come, gestational diabetes conveys greater risk for later type 2 (previously "non-insulin dependent") diabetes in both the mother and child. Thus, pregnant women have become a central target for prevention of this disease in the entire Pima population. Based on ethnographic interviews conducted between 1999 and 2000, I discuss the negotiated meanings of risk, "borderline" diabetes, and women's personal knowledge and experiences of diabetes, particularly during the highly surveilled period of pregnancy. I also highlight the heterogeneity of professional discourse pertaining to gestational diabetes, most notably the debate surrounding its diagnosis. Significantly, women's narratives reveal the same set of questions as is raised in the professional debate. Implications for diabetes prevention and for balancing the increased surveillance of pregnant women with clinical strategies that privilege their experience and perspectives are also discussed.

Situating stress: lessons from lay discourses on diabetes

In response to the serious toll diabetes takes on health and resources, researchers increasingly are examining physical and psychological pathways that affect and are affected by diabetes, including stress. Although biomedical researchers and practitioners are beginning to recognize the association between stress and diabetes onset and management, laypersons have long-standing and extensive insights into the multiple ways in which stress is associated with the diabetes disease process. In this article, we examine lay perspectives on stress and diabetes among a multiethnic sample of 80 adults. Participants suggest varying arenas in which stress intersects with diabetes, including stress as implicated in the origin of diabetes, as a threat to maintaining glycemic control, as a challenge to self-management, and as a precursor to and a consequence of diabetes complications. An improved understanding of such perspectives may enhance appropriate disease management and develop a more valid conceptualization of stress in research efforts.

The prevalence of overweight adults living in a rural and remote community. The Bella Coola Valley

OBJECTIVE

To determine the prevalence of overweight adults living in the Bella Coola Valley.

DESIGN

A retrospective chart review of all people attending the Bella Coola Medical Clinic, and residing in the Bella Coola Valley.

MAIN OUTCOME MEASURES

Weight (killograms) and body mass index (BMI).

RESULTS

More than 92% of clinic charts had a recent measurement of weight and 65% of clinic charts had height measured; accordingly, we were able to calculate the BMI on 65% of the clinic population. Over 50% of the adults residing in the Bella Coola Valley are considered overweight (BMI > 27, the Health Canada definition) and only 25% have a BMI within an acceptable range (20.0 to 24.9). Proportionately more Aboriginal people are overweight (65%) than non-Aboriginal people (47%); men and women were similarly overweight (56% and 53%, respectively); and proportionately more people were overweight with increased age. The prevalence of being overweight in people aged 65 years and older is 66%. As weight increased so did the prevalence of diabetes mellitus, hypertension, hypercholesterolemia, diverticular disease, dyspepsia/gastroesophageal reflux disease (GERD), alcohol issues, asthma, depression, coronary artery disease, and eczematous dermatitis. There was no relationship between increasing weight and atrial fibrillation, cerebrovascular disease, inflammatory arthritis, hypothyroidism, chronic back/neck pain, peripheral vascular disease, chronic obstructive lung disease, congestive heart failure, and cancer.

CONCLUSION

Living in a remote community does not protect against obesity and the complications of obesity. Obesity is present in a greater proportion of Aboriginal people. The treatment and prevention of obesity in rural populations of differing ethnicity may need to be individualized.

Coping with stress among Aboriginal women and men with diabetes in Winnipeg, Canada

Many Aboriginal peoples are widely exposed to stress in their lives. This exposure to stress appears linked not only to their contemporary and immediate life circumstances (e.g., marginal economic and at-risk living conditions) but also to their historical, cultural, and political contexts. Recently, diabetes has become prevalent in many Aboriginal communities worldwide. The purpose of the present study was to gain a better understanding of the ways in which Aboriginal peoples with diabetes cope with stress. The study used a series of focus groups among First Nations and Metis women and men with diabetes in Winnipeg, Manitoba, Canada. Based on our cross-thematic analyses of the data, three overarching themes were identified: (1) individual and collective strengths of Aboriginal peoples with diabetes must be recognized and utilized to facilitate healing from or coping with the experience of stress and trauma; (2) healing must be accomplished holistically by maintaining balance or harmony among mind, body, and spirit; and (3) effective ways of coping with stress and healing from trauma potentially promote positive transformations for Aboriginal peoples and communities at both individual and collective levels. Also, sub-themes of stress-coping and healing that underlie and further describe the above three overarching themes emerged from the data. These include: (a) interdependence/connectedness, (b) spirituality/transcendence, (c) enculturation/facilitation of Aboriginal cultural identity, (d) self-control/self-determination/self-expression, and (e) the role of leisure as a means of coping with stress and healing from trauma. Accordingly, our deeper analyses resulted in the development of an emergent model of stress-coping and healing among Aboriginal peoples with diabetes, which is presented as a dynamic system in which the three overarching themes are embedded in the five specific themes of coping/healing. This evidence-based emergent model appears to provide some important insights into health policy and program planning for Aboriginal peoples with diabetes and their communities.

The twin placenta: framework for gross analysis in fetal origins of adult disease initiatives

Current data strongly support that a wide variety of adult health risks are influenced by intrauterine life events. Twins may have the same (identical, monozygous) or different (fraternal, dizygous) genes, but their relationship to their outside world, via their placentas, is rarely equal. Monochorionic twins and dichorionic twins both resemble and differ from singletons. In the balance between the similarities and the differences, we may find the answer to the interpretation of twin studies, and appropriately apply them to the 'fetal origins' hypothesis.

An examination of stress among Aboriginal women and men with diabetes in Manitoba, Canada

In this study, a series of focus groups were conducted to gain an understanding of the nature of stress among Canadian Aboriginal women and men living with diabetes. Specifically, attention was given to the meanings Aboriginal peoples with diabetes attach to their lived experiences of stress, and the major sources or causes of stress in their lives. The key common themes identified are concerned not only with health-related issues (i.e. physical stress of managing diabetes, psychological stress of managing diabetes, fears about the future, suffering the complications of diabetes, and financial aspects of living with diabetes), but also with marginal economic conditions (e.g. poverty, unemployment); trauma and violence (e.g. abuse, murder, suicide, missing children, bereavement); and cultural, historical, and political aspects linked to the identity of being Aboriginal (e.g. 'deep-rooted racism', identity problems). These themes are, in fact, acknowledged not as mutually exclusive, but as intertwined. Furthermore, the findings suggest that it is important to give attention to diversity in the Aboriginal population. Specifically, Métis-specific stressors, as well as female-specific stressors, were identified. An understanding of stress experienced by Aboriginal women and men with diabetes has important implications for policy and programme planning to help eliminate or reduce at-risk stress factors, prevent stress-related illnesses, and enhance their health and life quality.

Death, taxes, public opinion, and the Midas touch of Mary Tyler Moore: accounting for promises by politicians to help avert and control diabetes

Anthropologists have begun to publish ethnographic accounts of policy-making, but few have studied medical or health matters, despite broad acceptance in anthropology that "biopower" permeates contemporary societies. This article presents some findings from an ethnographic study of how diabetes gained recognition as a pressing public health problem in Canada. It underlines the importance of statistics for constituting power within and across nation states. Statistics imbricate people and things distributed across vast distances, but they still need to be generated and invoked by individuals to engender effects--as illustrated in this article by the contributions of researchers, aboriginal leaders, and an American actress, Mary Tyler Moore--in this case, the development of Canadian government policies justified in the name of averting and controlling diabetes. To make sense of these findings, subtle differences between two concepts coined by Michel Foucault, "biopower" and "governmentality," seem significant.

Sweet blood and social suffering: rethinking cause-effect relationships in diabetes, distress, and duress

I draw upon anthropological engagements with bioscience and embodiment in order to unpack current approaches to defining and preventing diabetes mellitus. The analysis stems from the conviction that carefully considering the symbolic frames through which we conceive of diseases, their origins, their distribution, and their consequences will assist us in planning and implementing interventions to improve population health. I argue that research and interventions focused on the sweetness of blood would benefit from rethinking intersections between diabetes, distress, and duress. In many instances, the lived experience of diabetes is consonant with an understanding of distress (i.e., "social suffering") that expands conventional understandings of population health problems. Diabetes incidence is rising worldwide, but it is rising especially rapidly in Aboriginal and other disadvantaged populations. Notably, diabetes is now three to five times more common in Canada's First Nations population than it is in its non-Aboriginal population. Yet as recently as 50 years ago, diabetes and associated health problems were rare in these groups. To come to grips with such transformations and disparities is to advance the population health research agenda.