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Medicare: Glaucoma testing and nutrition therapy now covered
Source: Diabetes Forecast
Publication date: 2002-05-01
There's good news for Medicare beneficiaries with diabetes: The federal health insurance program now covers a yearly glaucoma
detection eye exam and medical nutrition therapy. The benefits, which took effect on January 1, are being lauded by many medical
and health experts as positive steps toward preventing complications caused by diabetes.
According to the National Institutes of Health, glaucoma affects about three million Americans. In half of these cases,
glaucoma goes undetected. Many experts believe that early detection and treatment are key to preventing blindness.
Coverage for this new glaucoma-screening exam extends to all Medicare recipients with diabetes, as well as those who have
a family history of glaucoma. Additionally, high-risk groups such as African Americans aged 50 and older are eligible, as
they are five times more likely to develop glaucoma than Americans of European descent.
In addition to eye complications, many people with diabetes experience problems with their diets. In an effort to help
those with diet problems, Medicare also now covers medical nutritional therapy for beneficiaries with diabetes, as well as
for those with kidney disease.
According to the Washington Post, "an estimated 4.5 million recipients with diabetes and 110,000 with kidney disease
are eligible for individualized medical nutrition therapy." This new benefit came about after a study by the Institute
of Medicine revealed that nutrition therapy, which consists of consultation with a registered dietitian, "was cost-effective
for the nation's elderly and improved their quality of life."
For more information, call 1-800-MEDICARE (1-800-633-- 4227) to speak to a Medicare Customer Representative.
Copyright American Diabetes Association May 2002
© 2002, YellowBrix, Inc.
Native Americans Bring Traditions to the Fight
Source: American Diabetes Association
Publication date: 2002-04-09
For Tribes, Traditions May Be Key to a Healthier Future: In Indian Country, the Battle Against Diabetes Draws on Native
Traditions -- and Emerging Ideas About 'Culturally Appropriate' Public Health
By Mary Annette Pember Special to The Washington Post Tuesday, April 9, 2002; Page HE01
Lorelei DeCora, an Indian Health Service (IHS) nurse and member of the Ho-Chunk (or Winnebago) tribe, had just spent the
day in a South Dakota hospital ward in which every patient was a Native American being treated for diabetes-related problems.
As she walked out, she noticed the clinic floor littered with pamphlets about how to prevent and treat type 2 diabetes. Suddenly
she had a simple realization: "This ain't working." Pamphlets do not change lives.
Yet in the Native American community, and among other U.S. minority groups, a great many lives must change if the epidemic
of type 2 diabetes is to be stopped or even slowed. Prevalence of the disease, which is often related to a high-fat diet and
insufficient exercise, has more than tripled since 1990, and it now affects about 17 million Americans. Last week federal
health officials recommended that all overweight adults, and some others at elevated risk, get tested for "pre-diabetes"
to prevent the damage that full-blown diabetes can wreak.
But in the United States, minorities are anywhere from two to six times more likely than whites to develop type 2 diabetes,
according to the Centers for Disease Control and Prevention. Native Americans are about three times more likely than whites
to have the disease, according to the Agency for Healthcare Research and Quality. The National Institutes of Health (NIH)
says that some groups of American Indians have the highest rates of diabetes in the world, with 50 percent or more of adults
in some Native American subpopulations affected.
The latest medical research shows that lifestyle treatments -- improving diet and increasing exercise -- are more effective
than medications at preventing and treating the disease. For many this is good news, suggesting the epidemic can be addressed
without expensive drugs or risk of side effects. But getting people to make these changes has proved quite difficult, especially
in communities of color. The problem may lie in the fact that lifestyle and eating habits -- where and when we eat, what we
eat and what we do when together -- are closely tied to who we are as people, as members of certain families, social groups
and cultures.
In mainstream clinical settings, Native Americans are often labeled "noncompliant" -- as patients unwilling
to help themselves by making changes in diet or taking medications. Practitioners frequently conclude that the patients simply
don't care about their health. This view, according to DeCora, fails to acknowledge the way cultural background may discourage
or even prevent compliance with a common course of treatment. For example, she said, the idea that family members come first
and one's own needs come second is deeply embedded in native cultures. This may lead some tribe members to feel it's selfish
to make self-care a priority. According to findings by Toni Tripp-Reimer, professor at the University of Iowa College of Nursing,
Native Americans may fear that having diabetes reflects a failure to live properly and to be strong of spirit, causing shame
-- and reluctance to pursue treatment or even reveal their diagnosis to others.
DeCora thought about the problem. Then, like her ancestors, she decided to pray until an inspiration came. It came while
she was attending a Sun Dance, a days-long ritual of fasting, dancing and communing with both nature and spirits. She focused
her meditations on the Sun Dance tree. The tree was forked, one side carrying a figure of a buffalo and the other a figure
of a man. Both were cut from the same buffalo hide. The tree represents good and evil and the delicate balance among men,
animals and Earth. During her prayers, a message came to her: "The answer lies in our traditions. The answer to everything
we are facing lies within our traditions."
Talking Circles
While growing up on the Winnebago reservation in northeastern Nebraska, DeCora remembers seeing "talking circles,"
groups in which tribe members sat in a big circle and talked about community problems and issues. These circles demonstrate
the native view of the interconnectedness of life, the cycle of life and death and balance in the natural world. Most tribes,
embracing an oral rather than a written tradition, share tribal lessons of history, ceremony and cultural life in the form
of stories told and retold in group settings. Talking circles remain an important part of many native cultures today.
In 1998, six years after her inspiration, DeCora joined researcher and University of Minnesota professor Felicia Hodge,
who had secured a grant from the NIH's National Institute of Nursing Research to develop and test talking circles as part
of a community diabetes program. Hodge, a Wailaki woman from California, had been conducting research using a similar model
among Native American cancer patients.
In the study, conducted at four rural tribal sites in South Dakota and Nebraska, adult diabetics and those at risk of
developing the disease received information about diabetes via talking circles, storytelling and native health practitioners.
Findings -- which were released to the NIH in March but not yet published -- indicate that people in these groups, which
met once a week for two or three hours over a period of three months, showed a significant decrease in fatalistic attitudes
toward diabetes, plus an increase in general knowledge of the disease and improved overall health.
Fatalism Kills
Fatalism -- the belief that disease is inevitable and that no medical care or personal changes can forestall death --
can be a powerful barrier to treatment. Winnebago Health Service Nurse Michelle Smith vividly remembers encountering it in
her very first diabetes patient.
"I was very excited and enthusiastic about helping the tribe overcome diabetes," she said. "I spent a long
time preparing for his visit, accumulating IHS and NIH literature on lifestyle change and facts about caring for diabetes.
I was loaded for bear."
The patient, a young Ho-Chunk, appeared at her office door and leaned against the jamb with his arms crossed over his
chest. He made it clear he would not enter the office.
"Just tell me this," Smith recalled him saying. "How long before I go on insulin, how long before I need
dialysis and how long before I die?"
While that may be a dramatic demonstration of fatalism, it does represent a widely held feeling -- and one that can be
dangerously predictive. Those who feel medical care is hopeless often do not receive it, and so their condition worsens, making
their condition hopeless indeed. By the time physical symptoms of diabetes -- fatigue, blurry vision, persistent infections
-- develop to the point where medical intervention is required, the body has usually suffered from years of excess blood glucose,
leading to irreversible damage to heart, kidneys, lungs and other vital organs. Dialysis, amputation and/or heart failure
often follow. This scenario is so common in native communities that it feeds the perception that diagnosis is an inescapable
death sentence.
Yet the researchers' work showed that talking circles kept the fatalism at bay -- and helped improve the participants'
health. The trick now was to take the research back to the people.
In Practice
Inspired by DeCora's research, Georgia Gomez, a tribal community health representative and emergency medical technician
on the Winnebago reservation, worked with Smith to produce a program she calls "Team Up." Funded by a small grant
from the tribe, the three-day program is conducted at a Sioux City, Iowa, hotel and conference center, about 20 miles from
the reservation. Participants are fed a controlled diabetic diet with an emphasis on traditional foods, and receive education,
exercise demonstrations and emotional and spiritual counseling by local native leaders, all in the setting of a talking circle.
Blood sugar testing is conducted throughout the program to provide tangible proof, in the form of lower blood glucose levels,
that even brief and moderate changes in diet and exercise can have immediate impact.
For many, the final circle was emotionally powerful. One woman choked back tears: "If my own people can care enough
about me to go to all this trouble, I can care enough to take care of my diabetes." In honor of the event, women in the
Winnebago community produced a star quilt that contains the names of those who have died from diabetes complications.
Gomez, a diabetic herself, brings a fierce personal commitment to her campaign. Her mother, Mabel Denny St. Cyr, died
on dialysis in January, her kidney disease a complication of diabetes.
"I could choose to be overwhelmed, but I choose to take my pain and grief and do something in a good way," she
said. "We are obligated and responsible to make a way for those who come after us. Not only does this have to be a prayer,
it has to be an act."
Beyond the three-day program, other changes are taking place among the Winnebago. The tribe's "Whirling Thunder"
program provides free wellness and fitness classes to the community, including children. Tribe members have free access to
a gym with exercise equipment, an outdoor running track, walking path and swimming pool. Tribal employees are allowed one
paid hour to exercise during the work day. Reintroducing traditional foods to Ho-Chunk society is also part of the effort.
"Children of the Wicawas" is a project in which children learn traditional gardening, food preparation and preservation
methods. DeCora's project has published a cookbook featuring modern updates of traditional Ho-Chunk foods, such as buffalo
and rice soup, buffalo pie and a modern twist on Lakota dried meat and chokecherries. "Before we can start talking about
nutrition," DeCora says, "we have to renew the spiritual connection our people had with food as a gift from the
creator. It makes sense for us to renew our bodies with that traditional source." None of which means daily life, or
the lifestyle decisions everybody must face, has become easy of insulin resistance in Native Americans.
Mary Annette Pember, a Cincinnati-based writer specializing in Native American affairs, studied culturally appropriate
disease interventions during her fellowship in child and family policy at the University of Maryland, College Park.
© 2002 The Washington Post Company
New Guidelines Urged for Diabetes
Thu Mar 28, 3:01 AM ET
By LAURAN NEERGAARD, AP Medical Writer
WASHINGTON - Most middle-aged people should be tested during their next visit to the doctor to find if they have "pre-diabetes,"
a type of high blood sugar that puts them at superhigh risk of getting full-blown diabetes, say new guidelines.
Almost 16 million Americans have pre-diabetes, the government announced Wednesday. It said, however, that simply walking
30 minutes a day and dropping a little weight can delay, if not prevent, onset of illness. But first, those people must learn
they're at risk.
"Most people with pre-diabetes don't know they have it," said Judith Fradkin of the National Institutes of Health
(news - web sites). "The important thing is to find it so you can treat it."
Some 17 million Americans have diabetes, 8 percent more than previously estimated, the government announced. The updated
figure reflects new census data.
Some people are born with diabetes. But most have Type 2 diabetes, an illness that develops, often in middle age, when
their bodies lose the ability to turn blood sugar into energy.
It is a leading cause of blindness, kidney failure, amputations and heart disease and kills 180,000 Americans each year.
Proper therapy can ease those complications, yet experts say one-third of diabetics (news - web sites) do not know the disease
is festering silently in their bodies.
In addition, doctors have long known that a condition called impaired glucose tolerance, in which blood sugar levels gradually
rise, was an early warning sign of impending diabetes. But because diabetes screening is not routine, it was not known how
many people have it or how to alert them to take steps to prevent the full-blown disease.
Wednesday's new data estimates 16 million Americans over age 40 have impaired glucose tolerance, which the government
renamed pre-diabetes to make it easier for people to understand.
New guidelines recommend that millions of middle-aged people get tested during their next regular doctor visit to see
if they have either pre-diabetes or the full disease. According to the guidelines, from the American Diabetes Association
and the NIH:
Everyone 45 or older should consider getting tested. Testing is strongly recommended if those people are overweight.
Doctors should consider testing younger adults if they are significantly overweight and have another risk: a diabetic
relative; bad cholesterol; high blood pressure; diabetes during pregnancy or gave birth to a baby bigger than 9 pounds; or
belong to a racial minority group.
If the test is normal, repeat it every three years. If the test finds that the patient has pre-diabetes, a major study
last year found that walking 30 minutes a day and dropping about 15 pounds can cut in half the risk of getting the disease.
"We're talking about significant benefits that can be derived from modest exercise," Health and Human Services
(news - web sites) Secretary Tommy Thompson said. "You don't have to be working up a big sweat in the gym or become a
long-distance runner to gain the benefits of exercise."
Taking a daily pill called metformin also reduced the risk by almost a third in that study. But the new guidelines conclude
there is not enough data on the benefits and risks and thus do not recommend routine preventive medication.
The guidelines are published in the April issue of the journal Diabetes Care.
Posted on AP on 9/9/2001
TRIBAL HOSPITAL TREATS DIABETES
By ALISA BLACKWOOD, Associated Press Writer
SACATON, Ariz. (AP) - He shakes the rattle in rhythmic pulses and sings a melodic Tohono O'odham prayer song, asking the
creator to hear the group and to have mercy and forgiveness.
``Sialim Tago Jiosh E-Tonalic O-Himetha.''
Those who know the song join in quietly.
About 10 people sit in a circle around Gerard Kisto, a traditional practitioner who leads various American Indian healing
ceremonies, including the free weekly talking circle at the Hu Hu Kam Memorial Hospital for those afflicted with diabetes.
The talking circle is one of several ways the tribe and hospital are seeking solutions to the high rate of diabetes on
the Gila River Indian Reservation, 40 miles southeast of Phoenix.
By offering traditional American Indian practices in combination with Western medical treatment, the hospital staff hopes
diabetes sufferers will be more willing to educate themselves about the disease and seek treatment.
``The hospital can provide medicine to balance them, but the traditional practices can help balance them spiritually and
emotionally,'' said Dr. Don Warne, a family physician who helped develop the diabetes support group.
Nine percent of American Indians have diagnosed diabetes, according to a division of the National Institutes of Health
(news - web sites). On the Gila River Indian Reservation, where the population comprises two tribes, the Pima and the Maricopa,
the rate of diabetes is much higher; among Pimas, 50 percent of the population has diabetes, the NIH reports.
Warne, who is Lakota, said the hospital's talking circle is based on traditional American Indian talking groups and is
a place where communication is encouraged and supported in a respectful atmosphere.
``In modern medicine, we're focused on issues of confidentiality,'' Warne said. ``That's important, but they start to
feel isolated within their disease. We wanted to create a forum for people who wanted to talk about it.''
Before the ceremony begins, the group meets with a doctor from the hospital who discusses medical information about diabetes.
Kisto then begins the talking circle by unrolling a hand-woven square rug and setting up an ``altar'' on the floor. He
lays out a wooden rattle, drum sticks, a tobacco pouch, an eagle bone whistle and an eagle feather.
He cannot burn sage or other purifying herbs as he normally would in other traditional ceremonies because this one is
inside a hospital building with fire alarms and Western building codes.
Kisto does what he can to compensate, turning off the fluorescent lights to create an intimate, comforting and safe atmosphere.
At the end of his opening blessing, he picks up the eagle feather and hands it to the person on his left.
He reminds the group to speak from their hearts. ``Whenever you're holding the eagle feather, you're truthful in the words
that you talk,'' Kisto said. ``We as native people regard this bird as being so sacred because ... it flies so high to the
creator and carries a lot of wisdom. It can tell if you're being honest or not.''
Participants take turns holding the feather and talking about their struggle with diabetes - how difficult it is to stay
away from sugar and carbohydrates at a child's birthday party, their pride in improving exercise habits or sharing worries
about a family member or friend with diabetes.
They understand that what is said stays within the group.
``Generally Native Americans ... turn inward. So consequently, they're more quiet,'' said Leonard Fairbanks, a Choctaw
who lives in Chandler and participates in the group. Other members of the talking circle decline to talk outside the circle
to maintain their privacy.
Diabetes sufferers do not produce or properly use insulin, a hormone that converts sugar, starches and other food into
energy. The unused sugar in the bloodstream is corrosive and can cause complications including kidney failure, blindness,
nerve damage and a loss of circulation that can lead to amputations. Among American Indians, amputation rates are three to
four times higher than the general population, according to the American Diabetes Association.
Scientists believe Pimas - who long ago relied on farming, hunting and fishing for food - are now predisposed to developing
diabetes because of high-fat diets and a genetic tendency to retain fat, once helpful in times of famine.
The hospital provides free treatment of basic services - physicals and eye exams, for instance - to anyone enrolled in
a federally recognized tribe. It is working to provide a variety of services other than strictly medical to help those struggling
with diabetes. A $1 million wellness center opened in April with exercise equipment, yoga and tai chi classes, and free transportation
to the center.
``The tribe is really taking an active role in trying to prevent diabetes among its community members,'' said Dr. Sheila
Tann, former director of the Diabetes Education Center at the reservation. ``The solutions need to come from within and the
tribe is working very hard to do that.''
Only about 10 people regularly participate in the hospital's diabetes talking circle. Doctors hope that as word of the
program spreads, that number will grow.
``Diabetes doesn't affect people just physically. It also affects them emotionally, spiritually and mentally,'' Warne
said. ``When they come to me, they come with anger, depression and spiritual concerns, asking `Why would the creator let this
happen?'''
Without addressing those spiritual questions, Warne said many patients won't take their medication.
``It's the traditional interventions that are needed to provide balance.''
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