Childhood obesity is usually linked to overeating, fast food, and insufficient exercise. Now, researchers have found one more thing to add to the list. A study by the Children’s Hospital of Philadelphia has shown there are several genetic variants connected with adult obesity that are also detected in childhood obesity, including two new variants never associated with obesity before. These variants are said to increase the risk of obesity in children in the first few years of life. How these variants cause obesity is still not known, but according to the Associate Director of the Center for Applied Genomics, it is possible they affect the intestine. Childhood obesity has tripled in the United States over the past few decades, but human genetics have remained static, leading researchers to believe there are still environmental causes of obesity as well.
The researchers collected data from 14 studies conducted in the United States, Canada, Europe, and Australia. They scanned the genomes of 5,530 obese and 8,300 non-obese children. Findings displayed eight new signals of genetics associated with childhood obesity. For validation purposes, researchers studied these signals in 2,000 additional obese and 4,000 non-obese children; they found two signals associated with childhood obesity. Since it is possible for the signals to be picked up from the surrounding genes, additional research must be done in order to confirm the genes giving off the signals are actually the same genes responsible for childhood obesity. Additionally, further research could eventually lead to treatments for obese children.
About one in 88 children are diagnosed with autism, but it is possible that 10% of affected children will outgrow their diagnosis by the time they are teenagers. April was National Autism Awareness Month, which put a start on new research regarding the causes of the disorder.
One study presents a theory that mothers who are obese or have diabetes during pregnancy will see a higher rate of autism in their children. Researchers from the University of California, Davis observed 1,004 children ages two to five involved in the Childhood Autism Risks from Genetics and the Environment (CHARGE) study between the years of 2003–2010. There were 517 children with autism, 172 children with other developmental disorders, and 315 normally developing children included in the study.
According to the study, the findings showed obese mothers were 67% more likely to have a child with autism and more than twice as likely to have a child with another developmental disorder than a mother of normal weight. Additionally, mothers with diabetes are 2.3 times more likely to have a child with a developmental disorder, but there wasn’t any statistically significant difference in having a child with autism.
There is still no real answer to what actually causes autism, according to Paula Krakowiak, the lead author of the study. But one research takeaway is a little bit of common sense: pregnant women must take care of themselves in order to keep their babies healthy and avoid the risk factors of autism.
The United States is in the midst of an epidemic. Obesity rates across the country are staggering, having increased dramatically over the last 25 years. Research suggests that more than one third of adults, or over 72 million people, were obese in 2005–2006.1
Though there was no significant change in obesity numbers between 2003–2004 and 2005–2006 for men or women, this does not negate the need to direct attention and intervention efforts into mitigating the effects of obesity and addressing the underlying reasons for its high prevalence.2 And while this problem runs rampant among adults, it has been steadily encroaching upon children and is particularly disproportionate among minorities.
Defining obesity: a refresher
According to the Centers for Disease Control and Prevention (CDC), the body mass index (BMI), which correlates with body fat, determines overweight and obesity ranges using weight and height. An adult with a BMI of 25–29 is considered overweight; a BMI of 30 or higher is considered obese.3 BMI is calculated by weight in kilograms and height in meters squared (kg/m2); for English measurements, use lb/in2 x 703. BMI charts are also widely available on the Web, including at the CDC website (www.cdc.gov).
Obesity has been linked to a number of chronic health conditions, including diabetes, cardiovascular disease, and some forms of cancer, as well as increased health care expenditures—it simply costs more to be obese.4 In particular, an obese person spends $1,429 more in medical bills compared to a person of a healthy weight. The annual obesity expenditure in the United States is an estimated $147 billion dollars.5
While the pervasiveness of obesity is troubling in and of itself, some of the more shocking statistics are found amongst minority populations. A 2009 CDC Morbidity & Mortality Weekly Report revealed that from 2006–2008 African Americans had 51% higher prevalence of obesity compared to Caucasians, with Hispanics having a 21% higher prevalence.6 African American and Hispanic women seem to be particularly vulnerable and representative among these numbers. Recent data show racial and ethnic obesity disparities for women, but not for men. Non-Hispanic black and Mexican American women were more likely to be obese than non-Hispanic white women. For men in general, obesity prevalence rose from 27.5% in 1999–2000 to 32.2% in 2007–2008.2
The disproportionate instances of obesity within minority populations may have roots in a number of factors. However, none can be addressed without examining the effects of U.S. health disparities, as well as the impact of social determinants of health. Two overarching national public health goals in the United States are to increase healthy life expectancy at all ages and to eliminate health inequalities according to gender, race or ethnicity, education or income, disability status, geographic location, and sexual orientation.7 But persistent health disparities—inequalities in health outcomes because of social disadvantages—have been an ongoing challenge within minority communities, hindering those national goals.4 According to Carter-Pokras & Baquet (2002), any health disparity should be viewed as a chain of events signified by a difference in environment; access to, utilization of, and quality of care; health status; or a particular health outcome that deserves scrutiny.8 Education and income levels contribute to disparities, but living conditions and behavioral risk factors also impact health.
These disparities become more notable considerations as the minority population increases. A U.S. Census Bureau population profile of 2010 indicates that over the past decade America’s population has grown by 9.7%, accounting minorities for 92% of that growth. The number of Hispanics grew approximately 43%, with the Asian population at the same rate, and the African American population increased in number by 11%. The total minority population increased 29% over the past decade, and now comprises approximately one-third of the American population.9,10
Evidence also suggests a relationship between socioeconomic status, income, education, and higher rates of overweight and obesity.1 Members of minority communities often reside in more urban areas, and these areas may provide limited or no access to healthy options for food, physical activity, or security. Residents in low-income urban areas are more likely to report greater neighborhood barriers to physical activity, such as limited opportunities for daily walking or exercise and reduced access to stores that sell healthy foods, especially large supermarkets.11
Nurses in the fight against obesity
Public health nurses are effective in responding not just to the needs of the majority population, but also allowing for, even ensuring, the inclusion of minority segments. Aware of the unique challenges these populations face, nurses can educate—and advocate—for change where they work and live. After all, isn’t the term “public” indicative of representation of diversity among the population?
Obesity is a complex problem, and finding the root causes will help to inform possible solutions. Contributing to the problem is a lack of income and education, cultural differences, environmental changes, learned behaviors for coping, and food advertisements. From an economic perspective, people purchase foods they can afford; they are not necessarily thinking about the future consequences of those choices. And with lower-income populations—also consistently disproportionately composed of minorities—affordable healthy food alternatives should be strongly advocated, (i.e., farm cooperatives, farmers’ markets, free community nutrition workshops, etc.). Safety concerns might also make it hard for people to walk about their neighborhoods and for children to go out and play; nurses can inform their patients of known safe exercise areas and other community resources, like high school gymnasiums or free athletics classes at a public park or YMCA.
The influence of social factors, access to quality food and exercise, and individual factors around maintaining a healthy weight must be addressed. Each has an indirect and direct influence on behavioral choices and may ultimately impact weight. Individual-level characteristics (including income, cultural preferences, and genetic predisposition) contribute to macro-level considerations (neighborhood services, government health initiatives, education, etc.). These all feed the obesity epidemic, the significance of which public health nurses cannot overlook. Structures that affect physical activity behaviors and dietary choices are emerging as important and are potentially amenable to public health intervention efforts.
Yet, nurses cannot fight alone. A collaborative effort must be sought to help sustain community programs, which means establishing dialogue and partnerships between all stakeholders. Key legislative offi cials, health care providers, local businesses, community residents, journalists, educational administrators, nursing organizations—all must rally to address the problem of obesity systemically. The CDC’s Division of Nutrition, Physical Activity, and Obesity and the American Obesity Society (www.obesity.org) have online resources to help nurses and other health care professionals combat obesity. On an individual level, nurses can assess their own living, working, social, and other environments. They can engage and advocate for their immediate community and, ultimately, their state and country. Nurses working in public health facilities can be especially influential, as they may treat patients with the fewest resources. Educating one’s patients—whether through simple instructions during an exam, dispersing informational brochures, or even volunteering to speak at local schools and community centers—is the fi rst step in prevention.
Though health care is not yet available to all at this moment in history, public health nurses can reduce the impact of obesity on the nation’s most vulnerable populations.
References
C.L. Ogden, M.D. Carroll, M.A. McDowell, and K.M. Flegal, “Obesity among adults in the United States—No Statistically Significant Change Since 2003–2004,” NCHS Data Brief No 1, National Center for Health Statistics (2007). Accessed 2011. www.cdc.gov/nchs/data/databriefs/db01.pdf.
K.M. Flegal, M.D. Carroll, C.L. Ogden, and L.R. Curtin. “Prevalence and Trends in Obesity Among US Adults, 1999-2008,” The Journal of the American Medical Association, 303, no. 3 (2010): 235–241. Accessed 2011. doi:10.1001/jama.2009.2014.
Centers for Disease Control and Prevention, “Defining Overweight and Obesity,” (2010). Accessed 2011. www.cdc.gov/obesity/defining.html.
A. Stratton, M.M. Hynes, and A.N. Nepaul. “The 2009 Connecticut Health Disparities Report,” Connecticut Department of Public Health (2009). Accessed 2011. www.ct.gov/dph/cwp/view.asp?a=3132&q=433794.
Diana Holden. Fact Check: The Cost of Obesity. “Fit Nation” coverage, February 2010. CNN. com, accessed 2011. www.cnn.com/2010/HEALTH/02/09/fact.check.obesity/index.html.
L. Pan, D.A. Galuska, B. Sherry, A.S. Hunter, G.E. Rutledge, W.H. Dietz, and L.S. Balluz. “Differences in Prevalence of Obesity Among Black, White, and Hispanic Adults—United States, 2006–2008.” Centers for Disease Control and Prevention. Morbidity & Mortality Weekly Report 58, no. 27 (2009): 740–744. Accessed 2011. www.cdc.gov
Sam Harper and John Lynch. “Trends in Socioeconomic Inequalities in Adult Health Behaviors Among U.S. States, 1990–2004.” Public Health Reports 122 (2007): 177–189.
Olivia Carter-Pokras and Claudia Baquet. “What is a ‘Health Disparity’?” Public Health Reports 117 (2002): 426–434.
“The Census: Minority report,” The Economist, Accessed March 31, 2011. www.economist.com/node/18488452.
“Population Profi le of the United States.” U.S. Census Bureau. Accessed 2011.
J.L. Black and James Macinko. “Neighborhoods and Obesity.” Nutrition Reviews 66, no. 1 (2008): 2–20.
The eight-year-old girl in Dr. Sheila Davis’ qualitative study on childhood obesity weighed 205 pounds.
The little girl and 16 other children and their parents were meeting with Davis and her research team. Why, Davis asked her, do you want to lose weight? “Because I don’t want the earth to move,” the girl replied. “When I jump rope, the children say it feels like an earthquake.”
The obesity epidemic currently sweeping the United States is a particularly poignant problem for the nation’s children. A full 30% of all kids age six to 19 are overweight, and their numbers have doubled in the last decade, according to the Centers for Disease Control and Prevention (CDC).
Among minority populations in this country, the numbers are even more alarming. Statistics from the CDC show that more than 33% of Hispanic/Latino boys are overweight, as are 35.7% of African-American boys and 51.2% of Mexican-American boys. As for female children, 30.1% of Hispanic/Latino girls, 46.4% of African-American girls and 36.7% of Mexican-American girls are overweight.
“We Really Have a Problem”
Davis, PhD, RN, a professor in the School of Nursing at the University of Mississippi Medical Center, is the founder of the university’s Cardiovascular Risk Reduction in Children (CRRIC) Committee, which is studying the obesity epidemic among African-American children in Mississippi. The state leads the nation in obesity and heart disease rates and is among the top 10 in chronic renal failure and diabetes.
“We really have a problem here,” says Davis, who is African American, “but we’re influencing the world.”
CRRIC has conducted descriptive studies of the prevalence of obesity and cardiovascular symptoms among 250 children in grades 3, 4 and 5 in inner city schools in Jackson, Mississippi. The studies found that 39% of the boys and 49% of the girls were in the 85th BMI (body mass index) percentile or higher.
In a separate CRRIC study of third- and fourth-graders in the smaller Mississippi town of Canton, 46% of boys and girls were in the 85th percentile or higher for BMI. Along with that, they had blood pressure problems. Their families, especially grandparents, also showed cardiovascular symptoms of high blood pressure and diabetes.
Overweight children have a harder time learning. They are often teased mercilessly—one little girl quietly told Davis that her nickname was “gorillahead.” As a result, they are either reluctant to enter into class discussions or they assume the disruptive role of class clown.
“We knew that intervention was indicated and unless we intervened, these kids were going to follow their families [into poor health],” Davis says.
Why Johnny Can’t Lose Weight
Nurses across the nation are playing critical roles in the front lines of the battle against childhood obesity. In schools, clinics and even in their own churches and community groups, they are helping children and their families learn to make healthier choices about food and exercise.
Rudy Valenzuela, MSN, RN, FNP
The near future of school nursing will be one of secondary prevention, Davis believes. Students will increasingly be hypertensive and diabetic. More than ever, school nurses will be dispensing medicine, giving insulin and preaching the importance of good diet and physical fitness.
Another way nurses can help change unhealthy eating habits is by teaching children to cook nutritious meals. With so many mothers working outside the home, children are increasingly cooking for themselves. Their choices gravitate toward quick, easy options high in fat and salt: instant noodles, hot dogs, grilled cheese and fried eggs. Aided by a grant, Davis’ CRRIC will soon be teaching healthy cooking to children in Canton.
It’s an urgent need all over the country. Children are not getting their recommended daily servings of fruits and vegetables. An alarming 51% of children and teens eat less than one serving of fruit per day, the CDC reports, and 29% eat less than one daily serving of vegetables that are not fried.
“We’re not opposed to ‘fast food,’ but the original fast food is fruit—prepackaged, portable, high in vitamins and minerals,” Davis contends.
Rudy Valenzuela, MSN, RN, FNP, director of clinical services and health promotion at Regional Center for Border Health in San Luis, Ariz., says that all too often the schools themselves are part of the problem. It’s a basic matter of economics, he explains, with the poorest schools finding ways to cut corners and increase income that ultimately jeopardize student health. It’s no surprise that the majority of obese children attend poor schools.
School nurses and community health nurses can influence policy to make their schools offer healthier choices, Valenzuela says. His advice:
Push to have junk food snack machines removed from schools. If the machines are an immovable budget booster, lobby for smaller portion sizes or a switch to healthy alternatives.
Question the availability of soft drinks and sweetened juices and the lack of healthier drinks, like bottled water.
If physical education has been eliminated, present the school board with health data urging its return. Or offer alternative forms of exercise that can be easily incorporated into the school day, along with water breaks.
Keep an eye on cafeteria serving sizes and quality. As budgets get squeezed, schools increase the carbohydrates because they are cheaper to provide.
“I think that nurses are in a great position to offer advice,” adds Valenzuela, who is president of the National Association of Hispanic Nurses. “We are the most trusted profession in the United States. The voice of a nurse is a strong voice, and I think that people listen to it [once we get] the voice out there.”
Healthy Eating Begins at Home
Nurses must also recruit parents to their cause, Davis emphasizes. “If you educate and support them, they’ll form that groundswell and they will demand changes.” In fact, she says, if any progress is going to be made in fighting the childhood obesity epidemic, it will have to start in the home.
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“Kids are going to have far more access to sweets in the home than they ever will in the school,” she points out. “The school is a structured, scheduled environment. At home it’s a much greater temptation.”
Davis says children in her CRRIC studies watch at least two to three hours of television every evening during the school week, and on weekends it’s considerably more. The cartoons and sitcoms that African-American children in particular watch are full of commercials for high-sugar, high-fat products that they then encourage their parents to buy.
“Dinner in a bag” is an increasing reality for busy families of all economic situations, she adds. “It’s becoming much more of the culture to pick up something in a bag on the way home, and you eat out of the bag in front of the tube. And the stuff in the bag is going to be higher in sodium.”
Davis laughingly calls fast-food dinners “calming the beast”—like soothing a cranky child with a bottle of Pepsi or a bag of chips during a hectic errand run. But they also can be an inexpensive meal for families on tight budgets. The problem is further compounded by a disproportionately low number of large chain grocery stores in minority and low-income neighborhoods, which severely limits these communities’ access to healthy, fresh food choices.
Even so, parents often underestimate the health risks of excess weight in their children, according to an American Obesity Association survey. And CRRIC studies found that parents had little notion of how much physical activity their children needed in order to become physically fit.
Nurses in pediatricians’ offices, clinics and schools who are attuned to these dynamics can do much to help educate parents. School nurses already contact parents when their children’s health screenings cause concern. Take it a step further, Davis suggests, by giving them information packets that offer practical and attainable ways they can help reduce health risks for their families.
For example, the American Diabetes Association, in partnership with Abbott Laboratories, has created “Weight Loss Matters,” a toolkit designed to help health care professionals teach their patients that obesity and a sedentary lifestyle put them at increased risk for type 2 diabetes. The kit includes monthly tip sheets on how to get started losing weight and eating a more healthy diet, plus brochures on topics such as portion control, physical activity and FAQs about weight and health. They can be easily downloaded from the ADA’s web site, www.diabetes.org.
Culture and Carbohydrates
Both Davis and Valenzuela believe minority nurses can be particularly effective in waging the war against childhood obesity in communities of color. Health fairs at schools, community centers and churches are useful venues for getting the word out to the community at large. Have a nutritionist demonstrate recipes, give out informational materials and offer tips for quick-but-healthy dinners and snacks.
For More Information and ResourcesAmerican Obesity Association www.obesity.orgCDC National Center for Chronic Disease Prevention and Health Promotion www.cdc.gov/nccdphp/dnpa/obesityAmerican Public Health Association—Minorities and Obesity Campaign http://www.apha.org/programs/resources/obesity/obesityparenttools.htm
In African-American and Hispanic communities, 60 to 70% of people attend church at least twice a month, Davis points out. This makes churches a prime setting for conducting health education. “Nurses can play a pivotal role in a church or community-type setting,” she emphasizes. “I get a lot of calls to go to various community settings to preach, as it were, health to families. Once you get yourself out [in the community], people will call. Most people are aware of the obesity epidemic, [even though] they may blame it on DNA and everything else.”
Minority nurses’ knowledge of a community’s culture—from urban African American to rural Mexican—can also give them an advantage in helping children and families who are struggling with obesity. For example, the traditional Mexican diet is low in carbohydrates; American Indians for centuries have eaten food low in carbohydrates and fat. But as these cultures have assimilated into the dominant society, they have adopted its less healthy eating habits, Valenzuela says.
“Hispanic nurses are well aware of the regional and cultural diet. If they’re creating a diet plan or nutritional plan for kids in the schools or clinic or at home, they can question the family in their own language,” he notes. “Secondly, they also know the dietary habits of the family, so they can be culturally sensitive in regards to the food intake.”
For example, a Hispanic nurse might point out that a corn tortilla has less than half the fat of a flour tortilla. Working with a nutritionist, he or she could present easy, quick meal plans that are healthy and traditional.
Unfortunately, says Valenzuela, “carbohydrates are really cheap compared with protein. [For a low-income family,] it’s easier to buy bread than to eat meat.” That’s one of the hurdles to better eating, he adds: finding a way to modify the diet and still make it affordable. Yuma County, where Valenzuela’s clinic is located, has a 50% poverty rate.
The effect of high-sugar, high-fat foods on Hispanic and Mexican cultures has been devastating, Valenzuela continues. Since the late 1970s, the obesity rate has more than doubled for Mexican-American boys age six to 11 and nearly tripled for boys in their teens. It has also doubled for Mexican-American girls. Hispanic children have become increasingly overweight at a similar rate.
Practicing What You Preach
To make a difference against such daunting odds, nurses should set an example in their own diet and fitness choices, Valenzuela believes. “How many [nurses] are obese or smoke or do not exercise?” he argues. “Nurses are [responsible for] restoring and maintaining health—that’s what we’re about. And because we center on the person and also the environment around the person, nurses should be living by example.”
Valenzuela, who is studying for a doctorate in nursing, would like to see more Hispanic nurses at the master’s and PhD levels who can get involved in research and academics relating to nutrition, obesity and other health issues. There is also a need for more culturally and linguistically competent nurses to provide care for Hispanic patients. The need is critical, he says: Hispanics are a large and growing population in the United States. In Arizona, for example, Hispanics comprise 25% of the population; in Yuma County, nearly 50%; and in San Luis, more than 90%.
In Mississippi, meanwhile, CRRIC’s team of doctors, physiologists, nutritionists and nurses are tracking early biomarkers—as well as psychological, social and cultural indicators—that warn of impending pathology. They are using the information to build a model to track the children from an early age. Davis is optimistic that once the research is complete the model can be extended beyond Mississippi and applied nationwide.
“This is a living experience for me,” adds Davis, whose six siblings are all diabetic. “I know how these children are going to end up unless we intervene aggressively. It’s a powerful enough foe for me as an adult. I can’t imagine what it [must be] for the child.”
Culturally sensitive cancer prevention brochures from the Southcentral Foundation Alaska Native Women’s Program”
Majestic mountain peaks, abundant wildlife and unlimited natural beauty have made Alaska a vacation dreamland for millions of people from all over the world. But while tourists come and go, America’s northernmost state is also home to thousands of indigenous peoples, including Aleuts (people native to the Aleutian Islands), Eskimos (natives who live primarily in Alaska’s coastal regions) and many smaller tribal groups. Collectively, Alaska Natives constitute one of the smallest ethnic minority populations in the U.S.—only about 2 million people in the entire country.
According to the 2000 U.S. Census, there are nearly 100,000 Alaska Native and American Indian (AN/AI) people living in Alaska. By no means a homogeneous population, this group breaks down into numerous subgroups, each with its own distinct culture and, in many cases, its own language or dialect. In fact, the Women of Color Health Data Book, published by the Department of Health and Human Services’ Office of Women’s Health, estimates that there are more than 300 languages spoken among American Indians and Alaska Natives.
Unfortunately, awareness of Alaska Natives and their health care needs is extremely limited outside their home state. Down in the “lower 48,” as Alaska residents call the continental U.S., medical researchers and health care providers have traditionally lumped Alaskan Natives together with American Indian tribes from other parts of the country, even though they live thousands of miles apart and have different cultures and living environments.
The good news is that as researchers delve deeper into investigating the disparities in health outcomes between Americans of color and the white majority, Alaska Natives are finally being addressed as a group with its own identity. The bad news is that this research clearly indicates that Alaska Natives face many of the same serious health problems, in varying degrees, as minority populations in the rest of the nation.
“Overall, [the health issues here] are very much like those for people of color in the rest of the United States—they just differ in magnitude,” says Kathleen Kinsey, RN, BSN, MPA. “For example, Alaskan Natives’ smoking and obesity problems are greater.” Kinsey, an American Indian nurse originally from Washington state, is administrator of nursing services for Mt. Edgecumbe hospital in Sitka, Alaska, part of the Southeast Alaska Regional Health Consortium (SEARHC).
Here’s a closer look at what nurses interested in working in Alaska need to know about the major health care issues affecting Alaskan Native communities, both historically and in the context of current initiatives to close the minority health gap in the 21st century.
Alaska Native Health 101
Heart Disease [N Elia – These headings under the main subhed are sub-subheds. Please format this section the same way you did the section called “The Present” in the “One Name, Many Faces” article in the previous issue.]
For decades, the number one cause of death for Alaska Natives was infectious diseases. But as medical advances brought these illnesses increasingly under control, the mortality picture shifted toward chronic conditions. Today, one of the leading killers of Alaska Natives is heart disease, as it is for the rest of the U.S. population. According to the American Heart Association (AHA), 25.2% of all American Indian and Alaska Native males who died in 1999 suffered from heart disease or stroke. Women fared even worse, with 27% of all deaths attributed to these causes.
Interestingly, even though the Centers for Disease Control and Prevention (CDC) still rank it as the number one cause of death for Americans as a whole, the mortality rate for cardiovascular disease (CVD) in the United States has dropped by more than 50% during the past 40 years. Experts say much of this decrease is a direct result of improved medical technology and earlier diagnosis. But during this same period, according to the Indian Health Service, the incidence of CVD among Alaska Natives and American Indians rose dramatically.
In fact, Indians and Alaska Natives between the ages of 35 and 44 have a CVD risk at least two times higher than that of their Caucasian counterparts. Even though this gap diminishes with age, it doesn’t disappear: AN/AI people in the 55-64 age group are still 1.5 times more likely to suffer from heart disease than whites of the same age.
Researchers and health professionals alike point to increased tobacco use as one of the key factors contributing to this disparity. Both the AHA and the American Lung Association (ALA) report that nearly 40% of all American Indian and Alaska Native men and women over the age of 18 smoke regularly, compared with only about 26% of Caucasians in the same age bracket.
Obesity
Why the rising occurrence of heart disease among young Alaska Natives? Is smoking the lone contributing element? Health experts who work in Alaska Native communities believe changing dietary habits are also to blame.
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In recent years, many Alaska Natives have moved away from their traditional diet of seafood and game to embrace fast food and prepackaged meals, especially in the state’s more urban areas. (According to 1990 figures, 69% of Aleuts and 50% of Eskimos in Alaska live in cities.) As the food choices increased, so did Alaska Natives’ weight. Just two or three generations ago, malnutrition had been a pressing concern. But as AN communities became more urbanized, or as native people left their villages for larger cities, their diets began to include more saturated fats and processed foods.
Former U.S. Surgeon General Dr. David Satcher declared obesity a national epidemic in 2001 when research revealed that 60% of all Americans were overweight or obese. But the Alaska Native population has been hit especially hard. SEARHC routinely conducts a health survey of the various AN communities and tribes it serves. Its most recent survey (April 1998) found that 46% of adult participants were overweight. For such a small sample, that’s a staggering statistic. Additionally, SEARHC found that one in three youths in Alaska qualify as overweight, compared with one in five for the country as a whole.
“I grew up in an Aleut community in Kodiak, Alaska, on what was basically a subsistence diet of fish and venison,” says Kathy Belanger, RN, BSN, CNOR, nurse manager of surgical supply services at the Alaska Native Medical Center in Anchorage. “I didn’t eat beef until I was in the sixth grade. Our eating habits have gotten much worse and as that changed, so did the health of our people.”
Diabetes
Not only does obesity increase people’s risk of developing cardiovascular disease, it can also increase their likelihood of suffering from diabetes—the sixth leading cause of death in the U.S. Most racial and ethnic minority groups have been disproportionately affected by this serious chronic disease and its related conditions, such as renal failure, amputations and blindness. However, the disparity gap for Alaska Natives is narrower than for other Americans of color. For example, Hispanics and American Indians have two to six times the incidence rate of diabetes compared to Caucasians. Alaska Natives, on the other hand, are also more likely to have diabetes than whites, but their incidence rate is less than twice as high.
Still, the number of cases diagnosed each year in AN communities continues to climb. According to the Women of Color Health Data Book, the rate of diabetes mellitus in Alaska Natives has grown tenfold in the past 30 years. Not surprisingly, the disease is less common in the more remote villages where people maintain their subsistence-like diets.
Tuberculosis
While obesity and diabetes are relatively recent health problems for Alaska Natives, AN communities have been battling tuberculosis for generations. Indeed, TB was once called “the scourge of Alaska.” According to a report recently published on http://www.tribalnews.com/, an online AN/AI news source, when the state first started recording the number of TB cases in 1952, officials were stunned to learn that there were nearly 400 cases per 100,000 Alaskans. But the epidemic was far worse for Alaska Natives, with more than 1,800 cases per 100,000. Throughout the past 50 years, Alaska’s health care providers have struggled to treat and prevent the spread of this highly infectious disease.
Although never completely eradicated, up until the 1990s health experts believed the disease was on the decline. Unfortunately, it rebounded with mutated, drug-resistant forms, and Alaska is once again the hardest-hit state. In 2000, the CDC reports, there were 17.2 TB cases per 100,000 people in Alaska—the highest incidence in the nation. The 108 new cases reported that year represented a 75% increase over 1999 statistics.
“As a nursing student working in public health, I was surprised at the number of TB cases, especially among children,” Belanger remembers. “Today, I still see the isolation signs when I walk through the hospital.”
The threat of tuberculosis is greatest for Alaska Natives who live in the farthest reaches of the state. A full 90% of adults age 60 and older in remote Alaskan territories have had positive TB skin tests. Of those positives, approximately 10% develop active cases, which can pose a significant public health risk if left untreated or partially treated.
Cancer
A new study published this year in the journal Alaska Medicine confirms that cancer has moved up from second place to become the leading cause of death for the Alaska Native population. In particular, Alaska Natives are now 40% more likely to die of lung cancer than white Americans, and their risk of colorectal cancer is also greater. Breast cancer rates are also high among Alaska Native women, especially those who live in remote areas with limited access to health care facilities that can provide screening and early detection. Again, doctors and nurses point their fingers at the high rate of tobacco use in AN communities and the steady movement away from traditional foods as key factors behind the rise in this once-rare disease.
In the 1950s, cancer was hardly found among the aboriginal peoples of Alaska, according to TribalNews.com. But in 1988, former Alaska Native Medical Center Director Robert Fortuine drew statewide attention to the fact that rising rates of cancer and heart disease were directly linked to a drastic change of diet and lifestyle among Alaska Natives. Low-income people were especially at risk, he noted, because “they tend to eat more inexpensive meats like bologna and hot dogs.” These types of foods lack the healthier, unsaturated oils found in such traditional staples of the Alaskan Native diet as fish, seal, whale and walrus.
However, the results of the Alaska Medicine study did contain some good news: Alaska Natives are less likely to die from prostate cancer, leukemia, lymphoma and uterine cancer than members of other racial and ethnic groups.
HIV/AIDS
Although this deadly infectious disease is on the rise among Alaska Natives, the actual number of cases reported throughout the past 20 years is still quite low when compared with the rest of the U.S. population. According to the ALA, which tracks AIDS-related respiratory diseases, Native Americans as a whole represent less than 1% of all AIDS cases in the nation.
Culturally sensitive cancer prevention brochures from the Southcentral Foundation Alaska Native Women’s Program
“The low incidence of AIDS [in Alaska Natives] might be because of our lifestyle,” suggests Belanger. “The village setting with its small group of people is not necessarily exposed to the risk behaviors associated with the big cities. But that is changing as well.”
Much of this change has occurred rapidly over the past ten years. From 1992 to 1993, the CDC recorded a nearly double jump in the total number of AIDS cases in American Indian and Alaska Native communities—from 445 to 818. Just two years later, that figure hiked to 1,333 cases, of which less than 400 were reported in Alaska. By June 2001, the number of cases had again nearly doubled, reaching a total of 2,433. Additionally, at least 25% of new AIDS cases in Alaska are reported by young people.
Alaskan health officials remain uncertain as to how any future spread of the immune-attacking disease will develop, but they do acknowledge that at-risk behaviors appear to be on the rise. For example, alcohol and drug use is abundant among Alaska Natives. In fact, the SEARHC survey respondents listed alcohol and drugs as their leading health care concerns.
While alcohol abuse is disproportionately high among American Indians, the SEARHC survey concluded that the drinking habits of Alaska Native teens do not differ significantly from those of their counterparts in the majority population. But Alaska Native youths use marijuana at nearly twice the rate of whites. Moreover, suicide rates among Alaska Natives are four times higher than in the rest of the United States, with AN males between the ages of 15 and 34 at the higher risk.
Access Issues
As serious as these illnesses all are, one of the most critical health crises facing Alaska Natives is not a disease at all—it’s lack of access to health care services. While the larger cities, such as Anchorage and Juneau, offer a reasonable choice of health care options, native people who live in outlying areas and remote villages are often cut off from even the most basic care. Transportation can become a formidable obstacle when emergencies or acute care issues arise, especially during the winter.
“Our facility is located in a region where the only way to get into town is by plane or boat, which can take several hours,” explains Kinsey. “For many people, they’re only making the trip to the hospital because they have an acute health care need.”
The state government, however, is taking steps to bridge these access gaps. One solution has been to provide outlying areas with community health aides, who work under the guidance of physician consultants. While they’re not nurses, the aides are trained in a wide range of health care assessment skills, from baby wellness to trauma.
In addition, new advances in telecommunications technology are enabling more hospitals and clinics to reach out across the miles and bring their services directly to remote communities. Although it’s still a relatively new option, Kinsey says SEARHC has begun to use telemedicine as a means to help villages maintain their health. Doctors and nurses can now provide patients with one-on-one consultations via telephone, videoconferencing and even cyberspace, as more villages gain computer access.
“We need to ask how we can keep health care delivery in the villages and support them in real time,” Kinsey emphasizes. “I think telemedicine is an important issue for this region, especially because I don’t see transportation improving significantly.”
But geographical isolation is not the only problem that can limit Alaska Natives’ access to quality health care. Cultural differences can also be a significant barrier, especially when Alaska Native patients are hospitalized. Because the state’s health facilities typically have many staff interpreters or bilingual providers, language isn’t usually an obstacle per se. However, the way in which Alaska Natives speak is different from what most Americans are used to, which can often lead to communication breakdowns.
For example, says Kinsey, Alaska Natives often talk slowly with pauses, and they communicate through storytelling with the most important elements at the end of the speech. “Nurses should expect to sit and listen to patients and not talk over them. That’s probably the biggest cultural difference,” she advises. Belanger adds that nurses should look beyond the surface response to make sure Alaska Native patients truly comprehend their instructions for treatment and follow-up care. “Natives are trusting people and they may say they understand, but that isn’t always the case,” she says. “In training new nurses, we tell them what clues to look for to see if the native patient is really understanding what they say.”
Wanted: Alaska Native Nurses
This need for cultural competence training is extremely important given the fact that the majority of Alaskan hospitals’ nursing staff comes from outside the state. Furthermore, the University of Alaska Anchorage School of Nursing estimates that American Indians and Alaska Natives make up more than 15% of the state’s total population but only 2% of Alaska’s registered nurses.
The school hopes to change this situation through its Recruitment and Retention of Alaska Natives into Nursing (RRANN) Program, launched in 1999. RRANN offers Alaska Native students in associate and baccalaureate degree programs a variety of resources, including tutoring, mentoring, support groups and “student success facilitators,” to aid them in completing their nursing studies and transitioning into the workforce.
Kinsey, too, has been working to increase the number of Alaska Natives in SEARHC’s nursing rosters. She helped establish an LPN program to assist Alaska Natives’ entry into the profession. From there, the nurses are encouraged to pursue a degree leading to RN status. “Right now, we have eight employees signed up for the LPN program and we expect all of them to move on to the RN program,” she notes. “Of those eight, half are Alaska Natives.”
