Diabetes mellitus in the Ute Indian tribe

Diabetes mellitus is a universal disease that appears to have a higher prevalence among certain ethnic groups. Many north American Indian tribes have been recognized in studies to have unusually high percentages of diabetes. In many of these studies obesity was also found to be very common. The purpose of this study was to (1) describe the prevalence of diabetes among members of the Ute Indian tribe, and (2) explore possible relationships that might exist between weight indices (percentage of ideal weight, ponderal index, weight alone, and skinfold thickness) and blood glucose. This was done in the hopes of establishing guidelines for further diabetes screening and treatment programs among this particular tribe. The subjects were 282 Ute Indians on the Ute-Ouray Indian Reservation, raging in age from - to 84, who voluntarily attended Diabetes Detection clinics held on the reservation between April 23 and April 27, 1973. The subjects were measured for height, weight, and skinfold thickness, and then they were given a glucose load of 100 gm in the form of a carbonated beverage. One hour later capillary blood samples were collected and blood glucose levels were determined using Dextrositex reagent strips and Reflectance Meter (Ames Company). Blood values were compared to diagnostic standards, and diabetics were identified as have 1-hour glucose tolerance values of greater than 251 mg/100 cc. In addition to the data collected, the ponderal index and percentage of ideal weight were calculated. All data were tabulated and processed by computer. Thirty-one of those screened where known to have diabetes. Sixteen new cases of diabetes were found. Prevalence for the total sample was 16.7%, Without known diabetics included, 6.4% of the remaining samples were found to be diabetic. Prevalence of diabetes rose with age over 30 years. Weight indices (ponderal index, weight, and skinfold thickness) were not found to have a high correlation with blood glucose levels. This finding precludes the hope of predicting elevated blood glucoses by means of measurement of weight indices. On the basis of the research findings, it became invent that the dietary intake of the diabetic and non-diabetic alike need to be scrutinized to assess what influence diet may have in explaining the frequency of obesity and diabetes in the Ute tribe.

DIABETES MELLITUS IN THE UTE INDIAN TRIBE by Celia Mary Hansen Woodcock A thesis submitted to the faculty of the University of Utah in partial fulfillment of the requirements for the degree of Master of Science College of Nursing University of Utah June 1974 UNIVERSITY OF S, U PER V ISO Ry of UTAH GRADUATE SCHOOL e 0 M MITTEE A P PRO V A L a thesis submitted by Celia Mary Hansen Woodcock I have read this thesis and have found it to be of satisfactory quality for 111&11 (/ 3 11'7'1 ) master's a m",'d, ;/ degree, Date a � �J:?ti£'1¢q, __ _ Sue E. Huether Chainnan, Supervisory Committee �:. read ,hi, ,h,·,i, and havo {> J\,� --r 2_1[{';£ Date IO�'O _�: }� __ r- j/ ;/ 10: be 01 <ati'la£ '\ Marvin r' I 'Y -£ute� L. Rallison Ml'rnber, Supervisory Committee I havp read this thesis and have found it to be of satisfactory quality for degree. _771���.JL{ Date 0 ____ _ Barbara M. Prater Member, Supervisory Committee a master's UNIVERSITY OF UTAH GRADUATE SCHOOL FINAL READING APPROVAL To the Graduate Council of the U n ive rs ity of Utah: .-Celi;:LJ1ill;�Y. Han.s.e.n.Jio..o...<k.o.c.L i n its final form and have found that (1) its format, citations, and bibliographic style are consistent and acceptable; (2) its illustrative materials including figures, tables, and I have read the thesis of ______ charts are in place; and (3) the final manuscript is satisfactory to the Supervisory Committee and is ready for submission to the Graduate School. _�d- ZJi£ldt! ti--= � ,--", ,_ Sue E. Huether Member, Supervisory Committee Approved for the Major Department Bonnie C. Clayton Chainnan IDean ;; Approved for the Graduate Council Dean of the Graduate School __ _ _ ACKNOWLEDGHENTS I wish to express my thanks to those who have aided me In completing this study: Barbara M. Prater, HD, MS; Spec! Sue Huether, RN, MS; ~1arvin L. Rallison, MD. appreciation goes to the Utah Diabetes Foundation and its staff that assisted and supported me in gathering this data, and especially to the Ute Tribal Council for their permission to use material. To Charles Wells, Service Unit Director, Ute and Ouray Indian Health Center, for his coordinating efforts with the Ute Tribal Council. TABLE OF CONTENTS Page ACKNOWLEDGr.'IENTS • • LIST OF IV. METHODOLOGY RESULTS DI • • • • • • • • • • • • • • ION • • • • • • • REFERENCES • • • • • VITA • • • • • • • " vii • • • • • • • 1 • • • • • • 4 • • • • • • • • • • • • • • • 8 21 • • • • .. 31 • • • • • • • • • 33 • • • • • • • • • • • • • • • iv vi • • • • • • • • • APPENDIX • • • • • Chapter I. INTRODUCTION III. • • • • • • • • • • • • • • ABSTRACT • II. .. • • • • • • • • • • • • 38 LIST OF TABLES Table Page 1. Blood Glucoses According to Age and Sex • • • • 2. Blood Glucose within Sam 9 Is for Known Diabetics • • • • 11 J. Prevalence of Diabetes by Age and Sex. • • • • 13 4. Prevalence of Diabetes by Age and Sex (Known Diabetics Removed) • • • • • • • • 14 5. Prevalence of Borderline Diabetics by Age and Sex • • • • • • • • • • • • • • • • • • • 16 6. Prevalence of Probable Diabetios by Age Sex • • • • • • • • • • • • • • • • • • • 17 Percentage Desirable Weight by Age and Sex 20 7. e • • • • • • • • • • • • .. • • ABSTRACT Diabetes mellitus is a universal disease that appears to have a hi groups. er prevalence among certain ethnic Many North American Indian tribes have been recog- nized in studies to have unusually high percentages of diabetes. In many of these studies obesity was also found to be very common. The purpose of this study was to: (1) describe the prevalence of diabetes among members of the Ute Indian tribe, and (2) explore possible relationships that might exist between weight indices (percentage of ideal weight, ponderal index, weight alone. and skinfold thickness) and blood glucose. This was done in the hopes of establishing guidelines for further diabetes screening and treatment programs among this particular tribe. e subjects were 282 Ute Indians on the Ute-Ouray Indian Reservation, rang1ng in age from 9 to 84, who voluntarily attended Diabetes Detection clinics held on the reservation between April 23 and April 27, 1973. The subjects were measured for height, weight, and skinfold thickness, and then they were given a glucose load of 100 in the form of a carbonated beverage. One hour later capillary blood samples were collected and blood glucose levels were determined using Dextrostix reagent strips and a Reflectance Meter (Ames Company). Blood values were compared to diagnostic standards, and diabetics were identified as having I-hour glucose tolerance values of greater than 1 mg/IOO cc. In addition to the data collected, the ponderal index and percentage of ideal weight were calculated. All data were tabulated and processed by computer. Thlrt diabetes. one of those screened were known to have Sixteen new cases of diabetes were found. Prevalence for the total sample was diabetics included, 6.4% 16.7%. Without known of the remaining sample were found to be diabetic. Prevalence of diabetes rose with age ovep 30 years. Weight indices (ponderal index, weight, and skinfold thickness) were not found to have a high correlation with blood glucose levels. of pr This finding precludes the hope icting elevated blood glucoses by means of measure- ment of weight indices. On the basis of the research findings, it became evident that the dietary intake of the diabetic and nondiabetic alike needs to be scrutinized to assess what influence diet may have in explaining the frequency of obesity and diabetes in the Ute tribe. viii CHAPTER I INTRODUCTION Diabetes mellitus is a universal disease that appears to have a higher prevalence among certain ethnic groups. Many North American Indian tribes have been recog- nized to have unusually high percentages of diabetes. In those tribes studied thus far, frequency rates have varied but are well above the 2% rate of diabetes found in the general North American population. 1 - 6 The Cocopah Indians of the southwestern regions of the United States are reported to have an over-all population frequency of diabetes of 17%.7 In studies in the Pima tribe 34% of the subjects had 2-hour glucose tolerance test values of l60mg/ 100 ml or above. 8 Abnormal glucose tolerance test results prevailed in the Cherokee and Senecas of pectively.9,lO 14% and 20% res- The Alabama-Coushatta tribe in Texas is reported to have a diabetes prevalence of 10%.11 Although comparison of data between tribes is difficult due to varying testing and data collection methods, it is quite apparent that diabetes among these tribes is present in rates well above national averages. Many of the studies mentioned above also found obesity very common in tribal members and not just those 2 dtagnosed as being diabetic. 1 - 7 ,9- 1 3 A highly significant correlation was found between overweight and plasma glucose levels among females of the Yuman tribe, especially those ages 25-45 (£ = 0.001 .43).-) Cocopah 7 coefficient of found in the and a multiple correlation However, no sign of association was or Seneca. lO The Ute tribe living on the Ft. Duchesne-Ouray Reservation in Eastern Utah has not previously been studied for prevalence of d1abetes or of obesity. Initial descriptive studies are necessary to establish a foundation for further inquiry into aspects of the disease that might more directly affect the Ute tribe. Of particular inter- est is the factor of obesity as mentioned above. If a significant relationship could be established between increased tncidence of diabetes and degree of obesity in a sample of a particular population (in this case, the Ute tribe), guidelines for screening could be established. These guidelines could include weight indices for detecting or predicting diabetics in the tribal population. The present study proposes first, using a sample size of 282 out of a total population of 1,500 Utes, to describe the prevalence of diabetes among tribal members. The study will then explore possible relationships that may exist between weight indices (percentage of ideal weight, ponderal index, weight, and skinfold thickness) and blood 3 glucose levels in the hopes of establishing guidelines for further screening and treatment programs among t Indians. Ute CHAPTER II METHODOLOGY The subjects of this study were 282 Ute Indians livi on the Ute-Ouray ReservatIon located in the Uintah in area of Eastern Utah. from 9 years to 84 years. The subjects ranged in age Each person voluntarily attended Diabetes Detection clinics held in various towns on the Reservation between April These clinics were unde~ 23 and April 27, 1973. the direction of the Diabetes Center, Salt Lake City, Utah, and through the permission of the Ute Tribal Council. Screening of each participant took slightly over I hour to complete. Age, height, and weight were deter- mined and recorded, and then left triceps skinfold thickness was determined using Lange skinfold calipers. It has been found that "in any particular age group of men or of women, the thickness of the layer of subcutaneous fat is related to the percentage by weight of fat in the body,,,14 and also to total body weight. located one-half w 15 The measurement site was down the arm between the tip of the acromion process of the scapula and the olecranon process of the ulna. the side. Measurement was made with the arm relaxed at The sktnfold parallel to the long axis was 5 picked up between the left thumb and forefinger of the observer, clear of any underlying muscle, and was measured at this point. Although subscapular skinfolds have been own to have a eater correlation with weight than the trtceps measurement,14- 16 attention was directed to arm measurement which could be made without any objection on the part of the subjects or compromise of modesty. Average skinfolds for men are 1.3 centimeters, increasing slightly with age from 1.1 cent1meters at 1.4 centimeters between 25-44 18-24 years to a high of years, thereafter declining to 1.1 centimeters at the oldest age range, W~nen 75-79 average 2.2 cent1meters for all age groups. est value, 1.B centimeters being fo~nd years. The low~ in the youngest age groups, and values increas1ng consistently thereafter with age to a high of 2.5 55-64 75-79 years. 17 centimeters at ing to 2.0 centimeters at years, then fall- subject was administered 100 grams of glucose as carbonated drink (Glucola) irrespect1ve of the time of the last meal. It might be noted that screening was done in mid-morning, mid-afternoon, and mid-evening to approximate at least 2 hours since the last meal eaten by the subject. One hour later a capillary blood sample was collected by fin2erstix. measured us~ng Capillary blood glucoses were Dextrostix Reagent Strips and a Reflectance Meter (Ames Company, Division of Miles Laboratories, 6 Incorporated, Elkhart, Indiana). The reflectance meter utilizes an electro-optical system for measuring the degree of color development on Dextrostix Reagent Strips in reaction to a drop of whole blood. The amount of light reflected from the reacted reagent strip is measured and a direct readout in milligrams of glucose per 100 ters of blood. lS ~illili­ Correlation of blood glucose values obtained with this method with those obtained with an Autoanalyzer method have been reported to be very high {£ = .98).19 Blood glucose values were then compared to diagnos- tic standards taking into consideration the fact that glucose levels in capillary blood after a glucose load are 20-50~g%higher than venous samples. 20 Guidelines were also obtained from studies by Pickens, et al., of capilla~y blood glucoses in mg/IOO ml in children ages 1 through 13. 21 Values for diagnosis as a diabetic were conservative (251 mg/IOO ml or higher), but values between nondiabetic (less than 170 mg/IOO ml) and diabetics were categorized as borderline (170-200 mg) and likely diabetic (201-250 mgl 100 ml). Nondiabetic . • • Borderline Like Diabet:c • .• • • · ·· • · ·• less than 170 mg/IOO ml 170 to 200 mg/IOO ml 201 to 250 mg/IOO ml 251 ng/IOO ml or above 7 All subjects with blood glucoses above 170 mg!lOO ml were referred for further workup through the Ute and Ouray Indian Health Clinic. In addition to the data collected, the ponderal index and percent e of ideal weight were calculated. The index was determined on a calculator from the ponde formula: heiGht! -V weight. Ponderal indexes have been found to have linear relationships with height and welght 22 and a similar relationship to height alone. 23 Average ponderal indexes in men are 12.4 and in women 12.15. 17 Percentage of the ideal weight of each subject was determined from the scale established by the Metropolitan Life Insurance Company as a normal scale. 2 4 normal age There is no eight-weight scale for the Ute Indians as a group, nor could this researcher find any scale established for any other American Indian tribe. Normal weight ranges for the purpose of this study were classified as being up to 125% of the subject's ideal weight. From 126% to 150% ideal weight was classified as moderately obese, and greater than 151% was classified as grossly obese. All data obtained in the screening clinics were tabulated and processed by computer. Regression analysis was performed on the total sample and then by sex. CHAPTER III RESULTS Individual blood glucose measurement values were tabulated in Table 1 according to and sex. betics were recorded by age on the same table. Known dia(Known diabetics all had blood glucose determinations, but not all subjects were administered a glucose load. Of the 10 who were admintstered glucose loads, 6 had I-hour glucose tolerance tests of greater than 0 mg/IOO mI. Three dia- betics had I-hour values within nondiabetic ranges--less than 170 mg/IOO mI. One subject was not able to retain the glucose load and results do not represent proper loading effects.) Thtrt (Table 2.) one of the Ute Indians to have diabetes prior to screening. diabetes (blood glucose values were found. (N = 282) was 16.7%. were known Sixteen new cases of eater than 251 mg/IOO ml) Combined totals revealed considered diabetics. examine~ 47 subjects who were Prevalence for the tot sample Prevalence in all female subjects was 16.5%, and in all male subjects was 16.9%. It was noted that of those tested (not previously being din sed as diabetics), 17 subjects had I-hour glu- cose levels of between 171 mg/IOO ml and 200 mg/IOO mI. TABLE 1 ood Slucoses according to age and sex Fe~nale e Blood value 71- 80 81- 90 91-100 101-110 111-120 121-130 131-140 141-150 151-160 161-170 171-180 181-190 191-200 201-250 1-300 301-350 351-400 Subtotal 0-9 1 1 10-19 20-29 30-39 2 1 6 2 2 5 3 7 5 5 6 1 2 3 1 2 1 4 2 50-59 60-69 70-79 80-89 1 1 3 3 9 1 2 1 4 1 1 1 3 3 1 6 1 1 2 1 2 1 3 1 1 1 2 2 1 1 1 1 1 1 2 1 1 2 1 1 1 1 1 1 2 17 Known D.M. r s Total 40-49 2 17 Total 6 7 14 18 22 15 15 4 10 5 6 4 1 5 4 2 1 44 30 4 21 2 10 8 2 6 4 1 7 139 19 44 34 23 17 10 10 1 158 -.D TABLE 1 (Continued) Male Age Blood value 0-9 102 2 2 1 71- 80 81- 90 91-100 101-110 111-120 121-130 131-140 141-150 151-160 161-170 171-180 181-190 191 00 201-250 251-300 301-3.50 3 -400 1,01-450 2 1 1 20-29 30-39 2 3 3 3 3 3 3 1 4 4 1 40-49 50-59 60-69 70-79 80-89 1 1 4 2 3 2 4 3 3 1 1 2 3 3 1 1 1 1 2 1 1 4 1 1 3 1 1 1 1 1 1 1 1 2 1 2 1 2 2 1 Subtotal Known D.M. s 12 Total 12 T Total 6 6 10 11 14 10 11 5 13 7 3 1 2 4 2 3 2 2 1 1 8 30 1 27 1 19 2 13 4 4 31 28 21 17 12 1 2 1 2 112 12 I--' o 11 TABLE 2 Blood glucose levels for known diabetics within sample Subject No. 395 216 259 261 285 325 Fasting 131 132 L+16 182 100 Gm load Sex 160 90 90 86 170 270 F' M F M F F 470 350 104 460 124 a 360 146 290 85 300 146 M F F M 251.+. F 255 271 286 350 358 M L~12 ood glucose F F M F F Time laEse PC 382 391 136 L~07 217 290 303 305 3 314 343 362 357 189 No load postmeal F F M M M M M F F F F F' M F aCi',) u b·J ec t no. 254 vomited. I 3-1/2 hrs 4 hrs presupper 3 hrs 1/2 hr 1/2 hr 6 hrs 6-1/2 hrs 3 hrs 3 hrs 2 hrs 15 mins 15 mins prelunch 84 240 112 180 440 250 120 220 134 210 230 340 156 105 12 Nine subjects had levels of between 201 mg/IOO ml and 250 mg/IOO mI. By the standards set by the evaluation criteria, 6.8% were found to be borderline diabetics and 3.6% were found to be probable diabetics. iminating known diabetics from the sample, 6.4% of the remaining sample were found to be d1abetics (N rate of 8% and females a rate of = 251). Males had a 5%. It has been found that the prevalence of diabetes rises continually with increased age in the general North American population with highest percentages of diabetics in the 45-64-year-old age range. Percentages of diabetes rise rapidly over the age of 45. Only under the age of 25. 25 5% of diabetics are Prevalence of diabetes for the total sample increased with age over age 30. In those age 30 and over, the praev.alence of diabetes was fQund to be 26%. A male, age 24, was the only subject under the age of 30 known to have diabetes. of the females 30 betics, and 24. Of the total sample, 27.4% ars and older were diagnosed as diaof the males 30 years and older were diagnosed as diabetics. The newly diagnosed female dia- betics over age 30 accounted for 9.2% of the female population over 30. Newly diagnosed males who were over the age of 30 made up (Tables 3 and 4.) .9% of the male sample over 30. Within the same sample category, 8.9% of the males and 11.5% of the females had abnormal glucose levels between 171 mg/IOO ml and 250 mg/IOO ml after 1 hour 13 TABLE 3 Prevalence of diabetes by e and sex Pema1e Hale Examined Age (for d Diabetics % Examined Diabetics 70 0- 9 0 0 0.0 2 0 0.0 10-19 12 0 0.0 17 0 0.0 20-29 31 1 3.2 4Lt- 0 0.0 30-39 28 2 7.1 34 5 11.8 40-J-+9 21 7 33.3 23 3 13.0 50-59 17 5 29.4 17 9 52.9 60-69 12 5 41.7 10 4 40.0 70-79 1 1 10 5 50.0 80-89 2 0 1 0 0.0 Total 124 21 16.9 158 26 16.5 0-29 Lt 3 1 2.3 63 0 0.0 81 20 24.7 95 26 27.4 12)[ 21 16.9 158 26 16.5 30 T Total Total N = 282 ( one subject age unkno\<Jn-normal value) 14 TABLE 4 Prevalence of diabetes by ~ge and sex (known diabetics removed) riale Age Examined Di etics Female C'.,' /b Examined c/ Diabetics 70 0- 9 0 0 0.0 2 0 0.0 10-19 12 0 0.0 17 0 0.0 ,20-29 30 0 0.0 44 0 0.0 30-39 27 1 3.7 30 1 3.3 L[0-49 19 5 26.3 21 1 4.8 r:;O-59 13 1 7.7 10 2 20.0 60-69 8 1 12.5 8 2 25.0 70-79 1 1 100.0 6 1 16.7 80-89 2 Q 0.0 1 0 0.0 Total 112 9 8.0 139 7 5.4 0-29 42 0 0.0 63 0 0.0 70 9 12.9 76 7 9.2 112 9 8.0 139 7 5.4 30 + Total 15 but were not diagnosed as diabetics. (Tables 5 and 6.) The mean weight of the entire sample was found to be 17705 pounds 0 Females alone averaged 17001 pounds, and males averased 186.8 pounds. Mean skinfold thickness for females was 28 mm. Males had a lower mean value of 23 mm. (Vltal Health Statistic data from the National Health Survey reports average sktnfold thicknesses for the white American population to be 13 mm for males and 22 mm for females.)l? The Ute mean is considerably above the means for the general whtte American populace. Ponderal indexes for the white American population average slightly higher for males than for females with values of 12.1+ and 12.2 respectively. Since women are generally less muscular and have less robust Skeletons than men, their lower ponderal index is due entirely to their greater adiposity. Generally, a fall in ponderal index in middle adult life reflects weight increases, whereas the rise at s 75-79 years shows weight loss exceeds stature. 17 The Ute women had a ~ean ponderal index of 11.1 which points to even more extreme adiposity. Men of the tribe were also well below the white American mean with an o,verage ponderel index of 11.6. In evaluating the entire sample by means of regI"essian analysis, ponderal index had a relatively high correlation with weight (£ = -.66) and skinfold thickness 16 TABLE 5 Prevalence of borderline diabetics by age and sex Hale Age Examined Female Dia ... betics (border) d % Examined Diabetics (border) % 0- 9 0 0 0.0 2 0 0.0 10-19 12 1 8.3 17 0 0.0 20-29 30 2 6.7 L+L+ 6 13.6 30-39 27 1 3.7 30 2 6.7 J+O-l~_9 19 1 5.3 21 1 4.8 50-59 13 0 0.0 10 1 10.0 60-69 8 0 0.0 8 0 0.0 70-79 1 0 0.0 6 0 0.0 80-89 2 1 50.0 1 1 100.0 112 6 5.4 139 11 7.9 lt 2 3 7.1 63 6 9.5 70 3 L+.3 76 5 6.6 112 6 5 .~- 139 11 7.9 Tot 0-29 30 + Total 17 TABLE 6 Prevalence of probable diabetics by ace and sex Female Hale e Examined Probab diabetics % Examined .Probable diabetics % 0- 9 0 0 0.0 2 0 0.0 10-19 12 0 0.0 17 0 0.0 20-29 30 0 0.0 44 2 4.6 30-39 27 2 7.4 30 1 3.3 t+O-L+ 9 19 0 0.0 21 1 4.8 50-59 13 2 15.4 10 0 0.0 60-69 8 0 0.0 8 1 12 • .5 70-79 1 0 0.0 6 0 0.0 80-89 2 0 0.0 1 0 0.0 Total 112 4 3.7 139 .5 3.6 J~2 0 0.0 63 2 3.1 70 4 5.7 76 3 4.0 112 ~. 8.9 139 16 11.5 030 Tot + 18 ). Weight also correlated with skinfold thickness to a lesser degree (£ = .Stl). Prediction of blood glucose levels fron these three indices was not feasible o ood glucose correlation with weight: r = .10 Blood glucose correlation with ponderal index: r -.0)+ Blood zlucose correlation with skinfold thickness: r = -.03 Regression analysis of the separated sexes showed higher correlatton of weight indices (weight, ponderal index, and skinfold thickness) to be among the women. Ponderal index correlated with weight and skinfold thickness with values of £ = -.80 and £ = -.62 respectively. Weight correlated It!ith skinfold thickness at an r of .68. Correlation between weight indices and blood glucose were nonslcntflcant. (.See beloH.) Blood glucose correlation with weight: £. = .11 Blood glucose correlatIon with ponderal index: r = -.15 Blood glucose correlation with skinfold thickness: r - - hnqlysts of variance with blood glucose as the dependent variable revealed that age was the variable most predictive of blood glucose level but only at a very low level of shared variance (£2 .1020). Combination of all 19 remaining variables allowed accurate prediction of blood glucoses only 12.1% of the time (£2 = .1213). dictive values of all variables for separat higher in females = .162 males), but no B ificant pred lish for females, £2 Combined presexes was = .1047 for tive value was estab- in either sex. The prev ence of diabetes was examined in relation to the decree of obesity in each sex and each age group. The mean percentage of desirable weight enabled determinine rates of obesity in the tribe. No significant association of diabetes with obesity (percentage of ideal weight above 125%) was found. The mean of the sample was 130% which, for the purposes of this study, is within the moderately obese range. Of the 250 subjects assessed for height and weight, 35.2% were moderately obese, and obese. It was not tendency to be 17.2% were grossly that female diabetics showed a slight ossly overweight. Females over the age of 30 were obese twice as often as males over the age of 30. (Table 7.) {.r;\pILE 7 Percentage desirable wei a;;e 3nd sex Per'c,:-mtlr"e 0:' desir:..-:..ble IS 12 6~~-1 S O~~ Less th=~n 12S~~ ~Jeic:ht or :nore Total Total (" jU eXa'Jl. 0.0 13 0 8 1.5.7 20 63 8 11.8 20 0 31 Total 1r.-29 ~ow ex':1~"1. dZL~,-b. c1 17 0 51 I \ Total 29 t"C e ~ I o. ,,', o. diab. :; o. 30 + :J o. ~~ 2~ o. ~\~ 0 .. diab. c;1 /v O1er:'leicht 0 0.0 5.5.0 9 12.2 31.0 9 8.0 39.0 0.0 0 0.0 64.0 ~ 2.8 Ii-/. 17.1 62.0 32 .5 1.5.6 14 10.1 63.0 0.0 22 0 0.0 0" 0.0 61.0 el exa:n. diab. ;0 0.0 8 0 0.0 1 5.0 3 0 0.0 33 1 3.0 11 0 0.0 0.0 22 0 0.0 0 7 22.6 33 2 6.0 ,.J .51 7 13.7 .5.5 2 3.6 37 0 0.0 35 0 ") ;v o. eXB.:::l. 38 cr! ~ I ~ l3 0 >-"' 112 T ~) ~, ~c/.. I I ' ...... ~I 30 .D 8 0 (.) T 82 "..J 53 3 5.7 21 .5 23.8 119 12.6 88 .., ..J 3.4 L~3 5 11.6 I \ Total 23 250 23 1~" 7 ,,0 9.2 • i.j. i\) o CHAPTER IV D SION The purpose of this study was to: (1) describe the prevalence of diabetes among members of the Ute Indian tribe, and (2) explore possible relationships existing between weight indices (percentage of ideal weight, p eral index, weight alone, and skinfold thickness) and blood cose. Establishing guidelines for further d1~- betes screening and treatment programs among this particu tribe would be a helpful measure for use by the Ute Indian alth Service~. Although numerous studies have been published on prevalence rates 1n various North Amerlcan Indian tribes, this researcher was unable to find previous studies describing prevalence of diabetes in the Ute tribe. n each instance the frequency of diabetes was found to be above the rate in the general, white, North A~erican edominantly population as previously reported by W~lkerson and Krall in Oxford, Massachusetts (2.0%)26 and by O'Sullivan and associates in Sudbury, Massachusetts (1.8%).27 The Ute ians studied were found to have a signlfi- cantly higher prevalence (beyond the .001 level) of diabetes than that found n the general North American Caucasian 22 Tribal rate was 16.7% as opposed to an population. expected frequency rate of 1.8 to 2.0%. There is specu tion that the large number of known di etics who visit clinics might have tended to skew the prevalence rates. Removal of known diabetics from the sample did drop the frequency to 6.35%, but the prevalence rate is still significantly hi er than the general North American popu- lation (beyond the .001 level of significance). The particular testing procedure utilized in the study differed from other studies published thus far and makes intertribal comparison difficult. However, the diagnostic criteria used in this study were conservative (greater than 1 mg/IOO cc indicated a diagnosis of dia- betes), and, therefore, those subjects diagnosed as diabetics were less likely to have had blood glucose levels that could not be repeated. Fast was not requir prior to glucose loadinG, but all subjects were tested at a point in time apprOXimating a 2-hour fast at mid-morning, mid-afternoon, and mid-evening. Hayner and associates have reported that glucose tolerance tests performed 1, 2, and 3 hours after a meal y1 results which are not hieher than results from a subject who has fast approximat lence rates. overnight. 28 Therefore, a 2-hour fast would not seem to affect preva- 23 Prevalence of diabetes in the tribe increased with after the age of 30 years. Twenty-six percent of those over 30 were known or found to have diabetese percentage distribution of diabetes by An estimated in the general North American population is noted to be highest in the 45-64 range, this being 42% of the total. The next largest category was 65 years and over with 26% of the total. a~e Approximately 5% are under the age of 25, and 13% between the ages of and 44 years. Prevalence rates rise continually with age up to 65-74 years. extreme rapid at ages over 45. 25 The rise is Although the age incre- ments used in this study differ from the Diabetes Source Book, there is a similar trend in the Ute tribe for increased prevalence with an increase in age. Highest prevalences were among Utes in their fourth, fifth, or sixth dec es of life. Of those tested, males tended to have higher percentages in the 40-49-year-old range, but females great range (53% and males and f surpassed males in the 50-59-year-old respectively). evalence rates for es of all ages were close (17% for males, 16.5% for females), which is a departure from predicted crude prevalence rates for each sex. Females are predicted to have prevalence rates of one-fourth higher than males. Weight indices were assessed for the purpose of ascertaining a possible positive correlation of increased 24 weight increments and increased blood glucose values. There is no significant evidence that obesity causes tes, although there are obviously many obese people v-lho do develop diabetes. Studies have found that glucose stimulated hyperinsulinemia is a characteristic of obese rats 29 and also of obese humans. 12 ,3 0 -35 This disturbance is thought to be due primarily to the effects on glucose upt rather than the action of insulin,3 6 -37 and it is ieved to be due to the increased size of adipose cells in the obese person. 38 The increased rate of release and oxidation of fatty acids in enlarged adipose cells 1s thought to explain impaired glucose tolerance in both maturity onset diabetes and in obesity.39 glucose utilization has been suggested. Antagonism to Nonesterif1ed fatty acids,31,32,3L~,39 synalbumen,4 0 endocrine hormones, and proinsulin 3l ,3 2 have all been mentioned as possible antagonists. \fuatever the antagonist causing the glucose intolerance in the obese person, there may be an ultimate hyperplasia of pancreatic islets so that a glucQse load produces excessive insulin levels. such antaeonism became greater than the ability of the islets to compensate, carbohydrate tolerance might eventually become abnormal-_ 3Ll a condition existing in latent subchemical or chemical- e diabetics. It is likely that the dura- tion of obesity rather than the d ee of obesity would 25 affect carbohydrate tolerance more significantly,4 1 and it has been shown that reduction of weight results in a reduction of insulin levels in the obese person. 7 ,lOThe indices investigated for correlation with obesity were chosen for ease of attaining their measurement, minimal compromise of modesty, and feasibility for further use by other services in later screenings. is self-explanatory. Weight Fat fold-weight correlations are satisfactorily high, indicating that compressed double fat folds do explain a useful proportion of the interpersonal weight variance. 15 The main problem faced in using tricep Hpinch" measurements is obviously technique and the variance of technique between examiners. Three different examiners measured sk1nfold thicknesses at various times during the week using the same Lange caliper. All three had received the same instruction on how to make the measurements. Ideally, one person would do all skinfold screening to assure consistency of measurements. The triceps method is technically more difficult in both lean and obese individuals, but use of the more consistent and higher correlative subscapular measurements was precluded by the fact that it could not be done without the disrobing of the subjects and without causing a compromise of modesty. The Ute sample means for skinfolds in both and females were considerably above the general white ~ales 26 population averages~ Females had measurements of 28.5 mm, and the male mean Has 23 mm. White males averaged 13 mm, and white females averaged mm. Both mean measurements point to excess total body Height in the tribe (by white standards) • is tendency was also echoed by the fact that the mean percentage of ideal weight for the sample was 130%--placi the tribal sample as a group in a moderately obese status, again, by white standards. Calculation of accurate ponderal indexes was totally dependent upon correct use of the calculator and recording of the data by the researcher. Values were calculated more than once to assure accuracy. Multiple regression analysis of weight, ponderal index, and skinfold thickness was incorporated into analysis of eight variables (age, sex, height, weight, skinfold thickness, hematocrit, blood glucose, and ponderal index). Analysis of variance with blood glucose as the dependent variable did not place the three weight indices in preferential position for predicting blood glucose. In fact, age was the variable most predictive of blood glucose but at a very low level of shared variance. These findings preclude the hope of predicting elevated blood glucoses by means of measurements other than the routine glucose tolerance test on the Ute tribal members. Had weight, ponderal index, and skinfold 27 thickness shown a high shared variance with blood glucose, the ti~e and cost of screeninG of diabetes amo the tribe v-Iould have been lessened, enabling "zeroing inn on frankly obese people as probable diabetics. Although the study's question of possible relationship bet1rJeen weight indices and blood glucose values was not confir~ed, other interesting facts were noted that might be of help to the Ute Health Service and tribal health aides in treatment of kno"ftJn and newly-found diabetics. From calculation of percentage of ideal weight it was noted that female diabetics showed a sli be ossly overweight. t tendency to The question arises, was this weight gain precipitant to the diabetes, or was this a normal characteristic of the culture? it In either instance, pears that careful scrutiny of nutritional intake is warranted in diabetic females. As mentioned before, reduc- tion of weight could possibly decrease the severity of the diabetes. Also, with weight gain above recommended per- centages, the diabetic is compounding the probability for complications diabetes and of obesity--especially cardiovascular problems. Arteriosclerotic heart disease is of such significance in the diabetic patient that it now accounts for the majority of deaths in the general North American diabetic population. Many studies of dietary factors in atherosclerosis in recent years have en base 28 to the fact that dietary restriction is necessary and should be aimed at carbohydrates and fats. tion may improve the diabetic state while c Weight reduccreasing ications. Training the diabetics on the Ute Reservation in di practices raises other questions. c1 st Does the finan- us of the diabetic Ute allow the proper eating habits to be instigated? How can traditional foods of the tribe be incorporated in this diet change? The health the tribal members could be very valuable aides resource ersons in assessing these questions because they have firsthand experience with their people and can avoid many barriers that might be encountered by outside investiors. It mi t be noted that at the same time this particular study was being conducted, a nutritional surv~y of the sample was conducted by two nutritionists working with the Diabetes Center. helpful in assess members and cou Results of this study might be usual eating habits among tribe give the Ute Health Service more back- ground information in realistically approaching the diabetics in the tribe concerning their diets. The results of this study suggest that further investigation needs to be done to possibly give more definite cuidelines for care and diagnosis of the diabetic 29 in the Ute tribe. It appears that diabetes is a multifac- torial disease among the Utes and needs scrutiny along many paths. The following is a list of recommended studies: 1. A study of genetic factors that might affect the Ute's predisposition to diabetes. a) Is there an obvious familial pattern of the disease? b) Does this fact point to an autosomal recessive trait in a homozygous condition as sUGGested in other studies? c) Does diabetes show more prevalence among full-blooded Utes than mixed-bloods? Would this indicate that inbreeding increases the likelihood of genetic traits being manifest ~nore 2. frequently? A study of the dietary habits o'f the diabetic and nondiabetic. a) Has refined modern foods had an effect on the tribe? b) Has modern diet increased the penetrance of a diabetes-producing gene causing the high prevalence of diabetes among the Utes? c) Can elevated blood glucoses be related to dietary habits? 30 3. A study of environmental factors that might indicate increases in the prevalence of diabetes. L~. A study of characteristic complications found in the diabetic Ute with the hope of improving these persons' physical welfare. 5. A study of duration and onset of diabetes in tribe members that would facilitate being able to focus on particular age groups and particu~ar instances where care is most needed. 6. A study of plasma insulin responses to glucose loads to ascertain if obesity influences resistance to insulin to a greater or lesser degree than thought to in the white population. 7. Establishment of a height-weight chart and ideal weight chart for the tribe in order to better assess the physique found in obese Utes. APPENDIX 'lOCR"l CH"Rll"[O CC:"" UINTAH AkO O\.tRAY r:Jlfr'!lCY 'ORT OUCKUtlt. UU.K April 16, 1974 Celia H. ,.Toodcock 318 South 12th East #1 Salt Lake City, Utah 84102 Dear Miss Woodcock: UUHU- Jkr, (ILIOn TJ.\:eIL 8U~1~t~S CO~.1o;11 T[E HOMEl •.1. $[CA)~l''':V W. CJ.-tAPO~·~t tl'>TF.~ FFH.C J.,. GAny P")t*;\Vi'";.·~fJ £lWYN y!r;- :>,("'I~"'jI!It C('~~f.~h.H,;' r.:-:~tr;J. Dt,;:'t'~d.ff fRANCI~ ~~~',lU' "',"S,;U . • [~ .. r. I have just received your second letter requesting permission from the Ule Tribe to write your thesis from data obtained through the Diabetes Detection Program held on the reservation last April. Since IRHI> 'V,yas kind enough to do the program for us and since th(~ data obtained should be documented and recommendations given for better control of Diabetes, I see no objection to the thesis based on the anonymity of the Ute Tribe. You hereby have the tribe's approval to proceed. Besides tribal anonymity, the only other request He have is that you cooperate with Mr. Charles Wells of the Indian Health Clinic. AO~I'IISTRATIV<: lRfHE (leH AO"'I'hI';il "AltVI: CfFI':I~ RIRI<I(;[ 1'0'''';;0(11 r ... 'URn "tlltRT l. t,r;OSE Sorry for our oversight in granting permission to you sooner. I sincerely hope we have not hampered too much the completion of your thesis. Tf<llUl,A::COt,lI<T.l,"T GEnAL:> We congratulate you on your efforts. M"~TI~;£Z CMll' OF peliCE ROSEIlT C CllAPOOSr [C\.lC,,110N • [~l'lOYIII Sincerely, un HRSCS1Ht ---t, fw ()\~~1;j~:' J. IHSLEY J(NSEN SUPEFl"'t"SO':: f.hiNTOUNCf OlkNIS A. :.o'J'.HR BLISikl.SS OeV[lo",.[Nt OrflC[1t TRI8AL M.l'IAG£RS HiT£RPRIS~ LMC/m HSHR W. CUCH, JA FRANK B ,I,',AOWCH!$ OIJT~OOR pr('.R["TI)H ARTHUR V. ImOWN ......... >;[il. U\i(S,TCCJiC RICHM<D N. JOt/ES MANAGER, urIT". JIM PflTIEII ilI'IAN.i.:.lp, '" fI~YTL[ HOll.Oill' ';(SOHT DALE SLADE. JACK RI)Clo.l,t,N \lTf tt!(,U'CH AtrRrO !'ARRIETTE LAI ;;L<-/~ Chapoose, cliafrDk3n Tribal Business Committee cc: Charles J. Wells U&O Indian Health Clinic ~o:. 32 DEPARTMENT OF HEALTH, EDUCATION, PUHl.IC HEAL Til AND WELFARE SFR VICE U&O Ind ian Heal th Cen ter P. O. Box ')67 Roosevelt, Utan 8'w66 April 23, 197'1· Celia H. Woodccck 318 South 12tn ~1.st /1 Sal t Lai<e City, Ut3. h 3 1';'102 Dear Hiss. Hoodcock: RegCirdi.ng sien to n?"!lC the Ute Inni2.n Tri be in yC'J.T Diabetes thesis, pe2-'f".ission is r.ereby • ~\;':-Icit f l!.'. Ch3.po,:;sc 2nd I referred. to in O'.lr 1 ct :'ers of :\ ?1.' i l 2.6 an'l 15 J ";2.3 th c anonymity of :-:",3.t:ler t:13'1 the Tribe's na::')e. Usin:; nu:nbe2~s of the s ,;]_11 be okay but their n-:::.mes should remain anony:nous. l If you have further questions on this, pleQse advise. Sincerely, CX'arc.-1u} /t~tP-<1 J. :.J~ Charles Service Unit uirector cc: Lester C:-Bpoose, UIT REFEHENCES lSmlth, Charline G.: Culture and Diabetes among the Upland Yuman Indians. Depavtment of Anthropology, Univers-tty of Utah, Dissertation, August 1970. 2Smith, Charline G.: Cultural Factors and Diabetes among the Upland Yuman Indians, Report of Pilot Study, 1968. Department of Anthropology, University of Utah, December 15, 1968. 3Mayberry, R. H., Lindeman, R. D.: A survey of chronic disease and diet in Seminole Indians in Oklahoma. Amer~.can Journal of Clinical Nu tri tion, 13: 127-34, 1963. 4S a iki, J. H., Rlmoin, D. L.: Diabetes Mellitus among the Navajo. Archives of Internal Medicine, Volume 122, July, 1968, pp. 1-9. 5Ede , M. C.: Diabetes and the way of life on an Indian Reservation. Guy Hospital Heport, 115: LLS5 -61, 1966. 6Siever, M. L.: Disease Patterns among Southwestern Indians. Public Health Reports, Volume 81, Number 12, December, 19 , pp. 1075-83. enry, R. E., Burch, T. A., Ben~ett, P. H., Miller, M.: Diabetes in the Cocopah Indiane. Diabetes, Volume lR, Number 1, January, 1969, pp. 33-37. 8Bennett, P. H., Miller, M.: Diabetes Mellitus in Indians of the Southwestern United States. In Diabetes, Proceedings of the 7th Congress of International Diabetes Federation, Buenos Aires, August 23-28, 1970, R. R. Rodriguez, J. Vallance-Owen, editors, Exerpta Medicus, 1971, International Congress Series, number 231, pp. 3182~ .• tein, J. H., West, K. M., Robey, J. M., Tirador, D. F., McDonald, G. W.: The high prevalence of abnormal glucose tolerance in the Cherokee Indians of North Carolina. Archives of Internal Medicine, 116:842-45, 1965. 10Frohnan, L. A., Doeblin, T. D., Emerllng, F. G.: Diabetes in the Seneca Indians, plasma insulin responses to oral carbohydrates. Diabetes, Volume 18, Number 1, pp. 38- Lt3. 34 IlJohnson, J. E., McNutt, C. W.: Diabetes Mellitus in an tcan Indian population isolate. Texas Reports on Biolo~y and Medicine, 22,110 (1964). 12Genuth, S. M., Bennett, P. H., Miller, M., Burch, T. A.,: Hyperinsulinism in obese diabetic Pima Indians. Metabolism, 16:1010-15, 1967. 13Parks, J. H., Waskow, E.: Diabetes among the Pima Indians of Arizona. Arizona Medicine, Volume 18, Number 4, April, 1961, pp. 99-106. 14S1oan, A. W., Shapiro, M.: Comparison of skinId measurements with three standard calipers. Human Biology, :29-36, February, 1972. 15Garn , S. M., Rose, N. N., McCann, M. B.: Relative values of different fat folds in nutritional study. The American Journal of Clinical Nutrition, 24:December, 1971, pp. 1380-81. 16Nalina, H. M.: Sk1nfold-body weight correlations in Negro and white children of elementary school age. The American Journal of Cllntcal Nutrition, 25:September, 1972, pp. 861-63. 17 Sklnfolds, Body Girths, Anthropometric Indices of Adults, United States, 1960- • Vital and Health Statistics, U.S. Department of Health, Education, and Welfare, Public Health Service, Publication Number 1000, eries 11, Number 35. p. 33. t Biacromia~l~D~i-a-m-e~t-.e-r-,--a-n-d~S~elected : Direction Manual, Reflectance Meter, ~m-e-s~C~o-.-,~DMi~v~i~s-l~Jo-n--·-of Miles Laboratories, Incorporat , Elkhart, Indiana. 19Jarrett, H. J., Keen, H., HardWick, C.: "Instant" ood sugar measurements using Dextrostix and a Reflectance Meter. Diabetes, Volume 19, Number 10, 1970, pp. 724-26. 20Marble, Alexander: Laboratory procedures useful diagnosis 9nd treatment. In Joslin's Diabetes Mellitus 11th Edition, Chapter 8, Alexander Marble, Priscilla ~TIite, Robert F. Bradley, Leo p. Krall, editors, Lea and Febiger, Philadelphia, 1971. 35 21 Diabetes Mellitus: Theory and Practice. Max ~llenberg, Harold Hifkin, editors, McGrawakiston Publication, New York, 1970, Hill Rook Company, p. }.j}?O. s tzer, Carl C.: Some re-evaluations of build blood pressure study, 1959 as related to deral tndex, somatotype and mort ity. The New Journal of Medicine, Volume 274, February 3, 66, the ponland pp. 254- 23Huber, Neil M.: Ponderal index and height. American Journal of Physical Anthropology, 31:171-76. 24 : Build and Blood Pressure udy, 1959, Soc1~ty of Actuaries. Metropolitan Life Insurance Company Statistical Bulletin, 40, 3 (NovemberDecember) 1959. Donald, G. W.: Diabetes Source Book. U.S. Department of Health, Education and Welfare, Public Health Serv~ce, Division of Chronic Disease, Publication Number 116R, 1964 (Revised 1968). 26Wilkerson, H. L. C., Krall, L. F.: Diabetes in a New En~land Town, a study of 3,516 persons in Oxford, Massachusetts. Journal of Americal Medical Association, Volume 135, Number 4, September 27, 1947, pp. 209-16. 27 0 ullivan, J. B., Williams, R. F., McDonald, G. W.: prevalence of Diabetes Mellitus and related variables--a Population study in Sudbury, Massachus ts. Jour of Chronic Dis eas e, Volume 20, 1967, pp. 235-43. 1 2<SHaY:1.er, • ,'3., l/IJaterhouse, Alice H., Gordon, ta: The one hour oral cose tolerance test. Vital and Health St~tistics, Series 2, Number 3, 1963. t ern, J., J 0 h n son, p. R., Gr e e nil,,] 00 d , H. H • e., , L. M., Hirsch, J.: Insulin resistance and pancr ic insulin r ease in genetically obese ZucKer rat. oceedings of the Society of Experimental Biology and Medicine, 139: -69, January, 1972. 3 errant, P. e., Nevile, R. W. J., Stewart, G. A.: Insulin secretion in obesity: The effect of reduction of hody wei t. Dtab alogia, 5, 192-200. 36 31Karam, J. H., Grodsky, G. M., Forsham, P. H.: ~ecretion in obesity, pseudodiabetes? 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A.: Glucose kinetics in human obesity. Diabetologia, 2, 96-103 (1966). Itschuneit, H.: Obesity and Diabetes Mellitus. Proceed the 7th Congress of International Diabetes Federation, Buenos Aires, August, 1970, R. H. Rodriguez, J. Vallance-Owen, editors, Exerpta Medicus, 1971, International Congress Series, Number 231, pp. 526-40. 38Salans, L. B., Zarnowski, M. J., Segal, R.: ect insulin upon cellular character of rat adipose ttssue. Jour of Lipid Research, Volume 13, 1972, pp. 61639Rand1e, P. J., Garland, P. B., Newsholme, E. A., es, C. N.: The glucose fatty acid cycle in obesity and maturity onset Diab es Mellitus. Annals of the New York Academy of Science, 131:324-33, October 8, 1965. L1-0;; J.l1.S, L. B. , Knittle, J. L., Hirsch, J.: The role of adi ose cell size and adipose tissue insulin senstttvtty in the carbohydrate intolerance of human o~es~ty. Journal of Clinical Investigation, Volu~e 47, 19 , pp. 153- 37 41 : Obesity and diabetes. Lancet, June 12, 1965, pp. 1260-61. 42 Bradl ,R. F.: Cardiovascular disease. In Joslin's Diabetes Mellitus, 11th Edition, Chapter 15, Alexander Marble, frisc a White, Robert F. Bradley, Leo p. , editors, Lea and Feblger, Philadelphia, 1971.