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Where stress, diabetes, and culture converge

A UMD study explores the link between stress and high diabetes rates among Native Americans of the Midwest

(Illustration: Nicholas Wilton)

By Gene Rebeck

Sociologist Melissa Walls, Ph.D., wants to make something clear: She’s not the story behind the $2.8 million National Institutes of Health research grant that she, a Medical School, Duluth colleague, and two other researchers were awarded last fall.

The story, as she sees it, is about adults her team will be working with to examine the ties between stress and type 2 diabetes among Native Americans — the population with the highest diabetes rate in the world.

“I consider them co-investigators,” says Walls, who is leading the five-year study. “They are equal partners.”

Walls, who studies the social aspects of disease among indigenous people, is Ojibwe herself, with many relatives on the Bois Forte reservation on Lake Vermilion in northern Minnesota. Bois Forte is one of the five Midwestern indigenous communities participating in the study. (Walls shares the names of participating communities only when they ask to be named publicly.)

The longitudinal study will follow a cohort of 250 people for four years, periodically monitoring their self-reported stress levels and measuring their blood sugar and cortisol levels. Chronically elevated levels of cortisol, a stress hormone, can increase blood sugar and inhibit the effects of insulin, leading to or compounding diabetes.

Improving Native Americans’ health

Walls, a University of Minnesota, Duluth graduate, earned a Ph.D. in sociology at the University of Nebraska, Lincoln. She returned to Duluth in 2007 as an assistant professor in the sociology department, where she earned grants for studying American Indian health. The work connected her with research partners in the Medical School, and she joined its faculty in 2011. “It was a natural fit,” Walls notes, given that improving Native American health is among the school’s priorities.

Collaborating with Walls on the current study are professor Mustafa al’Absi, Ph.D., director of the Duluth Medical Research Institute at UMD and an expert on the biological and physiological mechanisms of stress; sociologist Les Whitbeck, Ph.D., Walls’s mentor at Nebraska; and Kelley Sittner Hartshorn, Ph.D., from Oklahoma State University.

The project grew out of a diabetes study called mino giizhigad (“good day” in Ojibwe). On that study, Walls worked with Doris Isham, a diabetes nurse at Bois Forte. Isham told her that although her patients conscientiously took their medications and gave themselves shots, they were far less likely to exercise or eat healthier diets. It was almost as if they were giving up. “To me,” Walls says, “it sounded like depression or apathy.”

That insight led her to consider how stress affects type 2 diabetes in American Indian communities. Type 2 diabetes is the fourth-leading cause of death among indigenous Americans and a major contributor to cardiovascular disease, the No. 1 killer in this population. American Indians and Alaska Natives are more than twice as likely as other Americans to have diabetes.

While many studies have looked at type 2 diabetes among U.S. indigenous people, little has been written about the connection between diabetes and stress. “We know that stress and diabetes are related — [stress] impacts your ability to control diabetes, your health behaviors,” says Walls, who wants to learn more about how stress affects treatment compliance and disease progression.

Dealing with stress—past and present

Her goal is to develop treatment protocols for indigenous people that take into account their culture and history. This population copes with a disproportionate number of stressors, says Walls, naming several: economic disadvantage, unemployment, community violence, discrimination, and the long-term effects of historical traumas.

Walls is particularly interested in the last one — how catastrophic experiences in a group’s past affect its current members’ emotional and physical health. For indigenous people, she says, particularly those who live on reservations, historical trauma is bound up with cultural loss. What happened in the past, she argues, is related to contemporary stressors.

Her mentor, Whitbeck, codeveloped a “historical-loss scale” based on such questions as how often participants think about loss of land, language, tradition, and other aspects of their culture. “In some cases, 25 percent of our sample was thinking of these certain losses more than daily,” says Walls, describing a previous study she and Whitbeck conducted.

To get a true sense of the stressors indigenous people struggle with requires a deep engagement with them and their way of life, says Walls. In the current study, she and her team will be working with research councils in each community. The councils, which will include at least one member with type 2 diabetes, a tribal elder, and a service provider working with type 2 patients, will help develop questionnaires, recruit participants, and collect data. This inclusive approach, Walls says, “acknowledges the community as an equal partner in the research process.”

Bois Forte elder and community leader Stan Day has worked with Walls in the past and will serve on the community research council. “It’s a special thing for me to work for my people in any capacity that I can,” says Day. “I also have diabetes. It’s a double concern.” like Walls, he believes that the loss of land and culture is still affecting his people. “It’s something we have to heal from,” he says.

Walls hopes her team’s results aid that healing. “This is a basic research grant, but our long-term goal is always translating that basic research into something that’s actually usable and tangible. every little bit we do brings awareness.”

By Gene Rebeck, a freelance writer based in Duluth.

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