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Closing the gap

Tracie Collins, M.D., M.P.H., is wrapping up a Twin Cities-based study on the effectiveness of walking therapy for people with diabetes and peripheral artery disease. (Photo: Scott Streble)

U researchers combat health disparities that put some groups at higher risk for diabetes

Her motivation is no secret. Tiffany Beckman, M.D., M.P.H., became an endocrinologist because of the ever-rising rate of diabetes in American Indians.

“People are having heart attacks, strokes, getting their legs cut off, going blind, going on dialysis,” says Beckman, who is an enrolled member of the Leech Lake Band of Ojibwe. “It’s a terrible problem, and American Indians are disproportionately affected by the disease.”

As a medical student, Tracie Collins, M.D., M.P.H., couldn’t help but wonder what had happened to the amputees she saw being wheeled into the hospital every day.

“It appeared to be more minorities who had lost their limbs, like African Americans, Native Americans, and Latinos,” she says. “So in the back of my mind, I’m wondering, ‘What’s going on here?’”

Students on the Pine Ridge Indian Reservation take a

And while childhood obesity is increasing across the country, Mary Story, Ph.D., R.D., points out that it’s not rising at the same rate across all ethnic groups.

“In the United States, obesity is much higher among African American, Hispanic, and Native American youth compared with white youth,” Story says.

So what is going on? Health disparities are prevalent, even if they’re not obvious to many of us. Even Minnesota — which consistently tops the charts nationally in many health measures, including high rates of health insurance and low rates of premature death — has serious inequities.

Health disparities between the “haves” and “have-nots” in Minnesota are some of the deepest in the nation, says Kola Okuyemi, M.D., M.P.H., who directs the Medical School’s three-year-old Program in Health Disparities Research.

“You have a population that is lagging behind — in health status, health access, and health-care outcomes,” he says.

For instance, the infant mortality rate for African American babies here is twice that of European American babies, Okuyemi says. And for American Indian babies, the infant mortality rate is three times higher.

“Those rates are actually closer to what you’d find in developing countries,” he adds.

University of Minnesota faculty members affiliated with the Medical School’s Program in Health Disparities Research — and the Health Disparities Working Group, its sister program in the School of Public Health (SPH) — are addressing a wide range of issues, from social determinants of heart disease to targeted ways to help minority populations quit smoking.

And a critical mass of researchers here, including Beckman, Collins, and Story, is tackling health disparities related to diabetes, with a chance to significantly reduce the toll of this disease and its complications.

The hard — but better — solution

American Indian endocrinologist Tiffany Beckman, M.D., M.P.H., is finding natural ways to treat her patients who have diabetes. (Photo: Scott Streble)

As an American Indian endocrinologist, Beckman says she looks for natural approaches to treating diabetes. And that means teaching her patients about nutrition and physical activity rather than scratching out prescriptions.

“We use pharmacology as somewhat of a Band-Aid approach for many, many diseases, unnecessarily at times,” says Beckman, an assistant professor of endocrinology and diabetes at the University and a Medical School alumna. “I like to try to find the most holistic approaches to disease. Because I know that they’re out there.”

Her latest research project is an MRI-based study that tracks how Native American women respond to pictures of different foods. Reward pathways in the brain tend to light up when people see sweets and fattening foods, but Beckman is hoping that eventually that can be changed — ideally, through cognitive restructuring, replacing dysfunctional thinking with a better approach.

“It’s very time- and labor-intensive, but I think the outcomes pay for that time a million-fold,” she says.

In another study Beckman is completing that was funded through the National Institutes of Health’s Native Investigator Development Program, she led a study showing that American Indians from two tribes in the Northern Plains who spoke their native language were 1.5 times more likely to have type 2 diabetes than those who did not speak the native language. But that wasn’t true for members of another tribe in the Southwest.

“It highlights that there are immense cultural differences between tribes,” she says. “Type 2 diabetes is obviously a lifestyle issue related to nutrition and exercise, but it’s also related to cultural factors, and more work needs to be done in that area.”

And as one of 14 American Indian principal investigators in the country — out of about 35,000 total PIs — Beckman is stepping up to that responsibility. It’s a big job, but her patients’ successes — one man lost 120 pounds naturally — keep her motivated.

“I love being able to take patients off of their diabetes drugs after they’ve lost the weight,” she says.

A way to prevent amputation

Collins, who noticed as a student that amputees were more often people ethnic minorities than whites, has spent the better part of her career investigating the science behind that observation.

One risk factor for amputation is peripheral artery disease (PAD), which occurs when fatty plaques build up in a person’s blood vessels and cause poor circulation in the legs. And sure enough, Collins’s statistical research verified that African Americans were twice as likely to have PAD as Latinos and European Americans.

And she felt that doctors should do a better job of managing the disease in general. “We were so focused on neuropathy [nerve damage] and other causes of limb loss that we really were ignoring the vascular component unless it was time to amputate,” says Collins, an associate professor of general internal medicine.

People with diabetes are particularly affected by PAD; an estimated one in three diabetics over age 50 has it, according to the American Diabetes Association (ADA). Diabetes also is the No. 1 risk factor for PAD.

With extreme highs and lows in blood sugar levels that people with diabetes experience, Collins explains, blood vessels tend to lose resiliency and often don’t dilate they way they should, and that can lead to occlusion, or blockage.

Previous studies had found that medically supervised walking therapy could improve symptoms and function for people with PAD, but Collins thought that seemed inconvenient for patients and burdensome for medical personnel.

Plus, those studies had excluded people with diabetes, which seemed counterintuitive to Collins. “Of all the patients to include in these studies, it should be the diabetics,” she says.

Now she’s wrapping up a three-year study funded by the ADA evaluating the effectiveness of homebased walking therapy for people with PAD and diabetes. Results aren’t in yet, but it’s the largest study on home-based walking to date and the first to focus on diabetics who have PAD.

An intervention designed by Mary Story, Ph.D., R.D., is teaching Native American families about ways to prevent childhood obesity through nutrition and exercise. (Photo: Scott Streble)

Early intervention

For decades, Story has been studying how food choices relate to obesity risks in American Indians, and she always has counted on tribal partners for advice.

“Our philosophy has always been that we’re guests on the reservation, and we can provide the research expertise, but we work really closely with the tribe,” says Story, a professor of epidemiology and community health in the SPH. “We might know the scientific methods to use, but we don’t know how to really tailor it to adapt to the culture and the conditions on the reservation.”

That philosophy holds true today for Story’s NIH-funded Bright Start obesity prevention study with kindergarten and first-grade students on the Pine Ridge Indian Reservation in South Dakota.

The intervention her team designed involves an overhaul of the school lunch program and an infusion of more time for students to be physically active during the school day. It also includes “family nights,” meant to teach parents healthier practices, including serving reasonable portions, counting calories, and making physical activity a fun part of their kids’ day.

The families who attend those events have been extremely motivated to make changes, says Bright Start project director Mary Smyth, M.S. Some parents told Smyth about their teenage children who already had been diagnosed with type 2 diabetes — almost unheard of a few years ago, Story adds. And at the beginning of the study, the researchers found that a third of the children entering kindergarten were overweight or obese.

Although there are many factors that make it tough to reduce obesity on a reservation, like limited access to healthy foods, food insecurity, and lack of opportunities for physical activity, Story remains optimistic about the possibilities for change through Bright Start and other initiatives.

“There are many challenges, but we have found that there are also many opportunities because of the level of concern that parents have for their children,” she says. “They really want them to grow up healthy.”

By Nicole Endres

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