Title: “Bad Sugar” from the California Newsreel Documentary Series
Unnatural Causes: Is Inequality Making Us Sick?1 – A Discussion Guide for
Health Professional Students
Prepared by: Olivia Carter-Pokras Ph.D., Alexander Fischer, Sonja Williams,
Shani H. Woolard, Elizabeth Lee-Rey M.D., Kristin Fabbro
Acknowledgements: The authors gratefully acknowledge funding from the
National Heart Lung and Blood Institute’s Cultural Competence and Health
Disparities Academic Award grant program (Carter-Pokras, Fischer, Lee-Rey,
Fabbro), and the University of Maryland College Park School of Public Health
(Williams) as well as comments by dental, medical, and nursing students at the
University of Maryland Baltimore, and public health students at the University of
Maryland College Park.
(For the discussion facilitator)
Session Goals(s):
This small group discussion is intended to acquaint health professional students
with examples of specific health disparities that affect communities in the United
States, bring to their attention the role that social determinants of health play in
these disparities, and foster discussion regarding solutions and action that can
be taken to eliminate these health disparities and promote health equity.
Learning Objectives:
1. Describe the nature, extent, and type of health disparities in the United
States.
2. Describe and assess health disparities in diabetes along lines of race and
class.
3. Evaluate social determinants of health and other underlying factors related
to the root causes of disparities in diabetes.
Session Summary:
This is a 28 minute film segment entitled “Bad Sugar” from the documentary
series Unnatural Causes: Is inequality making us sick, followed by a 30 minute
small group discussion to explore examples of health disparities and pathways
by which social conditions affect physiology and health outcomes. This film
focuses on the Pima and Tahono O’odham Indian tribes of southern Arizona,
who are marked with the distinction of perhaps the highest rates of Type 2
diabetes in the world. Chronic disease is explored as the body’s response to a
sense of hopelessness for the future, a condition arising from decades of
1
UNNATURAL CAUSES: Is Inequality Making Us Sick? Produced by California
Newsreel with Vital Pictures. Presented by the National Minority Consortia.
www.unnaturalcauses.org; www.newsreel.org
poverty, oppression, and historical trauma. Bad Sugar examines possible new
political, social, and educational approaches that empower communities to take
control of their own destinies in regaining health where strictly medical
interventions have failed. The small group case discussion will be facilitated by
medical, health professional, and/or epidemiology faculty or graduate students.
Faculty may wish to use this documentary segment to supplement curriculum
materials on primary, secondary, and tertiary prevention of diabetes and/or as a
case study for eliciting pertinent social and environmental risk factors in history
taking. Facilitators will have familiarized themselves with material in the video
and readings as well as the Unnatural Causes Action Toolkit. Facilitators may
also have completed “A Physician’s Practical Guide to Culturally Competent
Care” and/or “Culturally Competent Nursing Care: A Cornerstone of Caring,”
designed as training programs for providers to increase cultural competence
through case studies about awareness of racial and ethnic disparities in health,
and through curricula about accommodating increasingly diverse patient
populations and improving the quality of health care services given to diverse
populations (available at: http://www.thinkculturalhealth.org). Students will be
provided the background readings at least one week in advance of discussion.
Readings:
1. Kuehn BM. Poor hit hard by diabetes. JAMA. 2007 Oct 24/31; 298(16):
1858. Available at: http://jama.ama-assn.org/cgi/reprint/298/16/1858
2. Hampton T. Food insecurity harms health, well-being of millions in the
United States. JAMA. 2007 Oct 24/31; 298(16): 1851-1853. Available at:
http://jama.ama-assn.org/cgi/reprint/298/16/1851
3. Wilde PE. Federal communication about obesity in the Dietary Guidelines
and checkoff programs. Obesity 2006; 14(4): 967-973. Available at:
http://www.obesityresearch.org/cgi/reprint/14/6/967
4. Garcia AA. Benavides-Vaello S. Vulnerable populations with diabetes
mellitus. Diabetes. 2006 Dec; 41(4): 605-623.
5. Conti KM. Diabetes Prevention in Indian Country: Developing nutrition
models to tell the story of food-system change. J Transcult Nurs 2006;
17(3): 234-245.
Suggested Readings for Dental Students:
1. Ship JA. Diabetes and oral health: an overview. J Am Dent Assoc 2003;
134: 4S-10S. Available at:
http://www.ada.org/prof/resources/pubs/jada/reports/suppl_diabetes_02.p
df
2. Vermillo AT. Dental considerations for the treatment of patients with
diabetes mellitus. J Am Dent Assoc 2003; 134: 24S-33S. Available at:
http://www.ada.org/prof/resources/pubs/jada/reports/suppl_diabetes_05.p
df
Discussion Questions:
As the documentary shows, the extremely high rates of diabetes in the Pima and
Tahono O’Odham American Indian communities represent just one example of
health disparities (Carter-Pokras & Baquet, 2002) that affect our local, national,
and world-wide communities. We would like to get your feedback to better
understand your thoughts on the social determinants of health that affect rates of
disease, the health disparities that affect our communities, and what action we
can take to eliminate these disparities.
1. It was stated that physician and health policy consultant, Dr. Donald
Warne, “might like to prescribe affluence.” What was meant by that? What
does “affluence” buy you? What does it take to become affluent?
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People who are affluent are more likely to have access to healthy food,
be able to afford healthier substitutes, have safe places to exercise,
access to health care, and health insurance.
Affluence buys people the flexibility and the time to take care of
themselves and their health.
Financial insecurity brings stress resulting in impaired blood sugar
control from hormone production (cortisol and epinephrine).
Possible discussion probes:
o Does the U.S. afford everyone the same chances to good
education, housing or jobs?
o How are a person’s chances affected if they have access to
good public schools or if they do not?
o Looking at the bigger picture, what determines which
neighborhoods have good schools and which do not?
o What would it mean to provide everyone with a good education?
2. Upscale cities in Arizona have a 5% prevalence rate of diabetes, while less
affluent towns have a rate of about 11%. Still some poor American Indian
reservations have a 50% diabetes prevalence rate. What do you think
explains these stark differences?
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Poverty in the American Indian communities resulted from a destroyed
economy when water and consequently other natural resources were
redistributed to white farmers and taken away from the Pima through
the enactment of discriminatory policies that favored white landowners
over American Indians.
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There is poor availability of healthy foods to choose from, because
without water the Pima could no longer grow their food, thereby
becoming reliant on the U.S. food commodities program, which did not
introduce fresh fruits or vegetables until 1999.
In less affluent towns, although people may be living at or below the
poverty level, they reside closer to certain resources such as access to
health care than rural areas and American Indian reservations.
Dr. Syme says that the common denominator for populations that tend
to suffer from higher-than-normal diabetes rates is “people who have
been dispossessed of their land and of their history; they haven’t been
able to recreate it.”
3. The video states that transportation takes about an hour (roundtrip) to buy
fresh fruits and vegetables. What do you think this means to the Pima and
Tahono O’odham in terms of accessing health care? Does your state have
similar issues in rural communities?
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Long distances to travel and/or limited public transportation in rural
areas make grocery shopping and accessing health care difficult,
particularly for people living with disabilities.
There are limited medical facilities in rural areas. These issues are
similar in other rural communities. Resources may be difficult to
access in urban areas as well.
Community members may not be able to afford health care and other
services vital to good health.
Possible Discussion Probes:
o Are there similarities between the concerns addressed in the
video and your community?
o How might these issues translate to the inner city or other
populations?
4. What are the underlying factors for diabetes and diabetes complications
described in the video? What cultural factors are identified in this video?
What lifestyle changes have the Pima and the Tahono O’odham had to
make? What were the assumptions made by the federal government about
the Pima Indian culture and traditions?
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Underlying factors include poverty, unhealthy diet, sense of
hopelessness for the future, sense of lack of control, and lack of
regular exercise.
The Pima and the Tahono O’odham changed their entire diet after their
main source of water was cut off; they no longer could grow native
foods.
Government commodity foods did not include native foods, and lacked
for the most part fresh produce, resulting in forced unhealthy diet.
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An example of doing the best with the given commodity foods was “fry
bread,” an unhealthy dietary adaptation.
In the video, their native culture appeared to be lost, and was seldom
brought out, except in the cases of special ceremonies.
5. How did politics (i.e., activities or affairs engaged in by the government),
play into the increase in diabetes among the Pima people? Was any
positive political action taken to benefit the Pima people? Can you give an
example of when politics have influenced health outcomes (either positively
or negatively) in your community?
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The negative impact of the diversion of the Gila River resulted in
starvation and dependence on government commodity foods.
Commodity foods were considered positive political action in the short
term because the Pima were fed, yet negative in the long term
because of the resulting diabetes prevalence rates.
Positive political action as the government returned the water with the
Arizona Water Rights Act of 2004 after tremendous effort on the part of
the affected American Indian tribes.
Possible discussion probes:
o Can you give an example of positive political action in our state
(e.g., Anti-tobacco initiatives, Health insurance provision,
Cancer screenings)?
6. The video showed that some of the Tahono O’odham were under the
impression that diabetes is “just part of growing up,” that they were
“eventually going to get it.” How can health professionals change
perceptions of community members to take a more positive view of their
ability to prevent diabetes? Should health professionals take a more active
role in influencing government policies affecting vulnerable communities?
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Diabetes education can provide community members with the personal
skills to prevent diabetes.
Social policy can be influenced to make healthy diet, exercise, and
health care more accessible.
There are health benefits in believing and engaging in advocating for
better conditions that promote health. Historical trauma needs to be
dealt with and one of those ways is to find power, which then
influences sense of action and ability.
7. Epidemiologist Dr. S. Leonard Syme states that “we are not paying enough
attention to prevention.” Is Dr. Syme referring to primary, secondary, or
tertiary prevention? Is primary prevention the key? In your training as
health professionals, is primary prevention emphasized over secondary
and tertiary prevention? Why or why not?
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Primary prevention involves the protection of health by measures that
eliminate or reduce the causes or determinants of departures from
good health, such as healthy diet and regular exercise (Diabetes
Prevention Working Party 2005).
Secondary prevention consists of early detection of precursors to
disease, and prompt effective intervention to correct these departures
from good health, such as early intervention in the cases of impaired
fasting glucose and impaired glucose tolerance (Diabetes Prevention
Working Party 2005).
Tertiary prevention consists of measures to reduce or eliminate longterm impairments, disabilities, and complications from established
disease and prevent or delay subsequent events, by such means as
regularly checking blood glucose levels and taking insulin injections
when necessary (Diabetes Prevention Working Party 2005).
Epidemiologist Dr. Syme says, “Things like diabetes get our attention,
but by focusing on diabetes itself, we are missing the underlying
phenomenon, and that’s really the important stuff.” If emphasis is not
placed on primary prevention, there will continue to be new diabetes
cases at rates that will not diminish.
8. Using the Pima and Tahono O’Odham communities as an example, how
can we educate community members about diabetes?
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We need to educate communities earlier in diabetes prevention
education, making healthy choices in diet, exercising regularly, and
looking for signs for early detection of diabetes.
We must educate communities to give them the means to effect
changes in social policy, business ventures, and resource availability.
We must think of how policies, such as the Gila River diversion, result
in disinvestments as the Native American communities faced, and to
link education initiatives to the larger framework of social determinants
of health framework that have a huge impact on the choices people
have in the first place.
We must place more focus on society than on the individual, and on
how as a society we need social and economic policies that provide
everyone with the same chances and opportunities to make healthy
choices.
9. Were any “innovative initiatives for health equity” shown in the video, and
what did they involve? What (additional) “innovative initiatives for health
equity” could be put in place?
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With the return of the water, the affected communities are returning to
farming and rebuilding the local economy. Physical construction of the
necessary communities and institutions are beginning.
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Dr. Warne proposes that the community must begin to take control,
which will happen as greater success in workforce and economic
development lead to improvements in health care systems, education
systems, and social policy.
Possible Discussion Probes:
o How can health professional students help create needed
changes?
Additional Questions of Interest:
10. What sort of cultural competence would health professionals need in
approaching work with the Pima and Tahono O’odham given their social
situation?
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With a social determinant framework, health professional workers must
consider where a person is coming from and explore what barriers and
buffers might exist.
Health professional workers cannot assume that these communities
are going to have easy access to the necessary means for fully taking
care of themselves. In the video, Terrol says that growing up they had
one spigot for water outside their home growing up and from there they
did everything from washing to cooking. It cannot be assumed that
community members can make improvements in diet and exercise
without the necessary resources.
11. What risk factors for diabetes are discussed in the video? What are
additional risk factors for diabetes?
According to the National Institute of Diabetes and Digestive and Kidney
Diseases (NIDDK), risk factors for diabetes include (those discussed in
the video are italicized):
 Parent, brother, or sister with diabetes.
 Alaska Native, American Indian, African American, Hispanic/Latino,
Asian American, or Pacific Islander.
 Had gestational diabetes, or gave birth to at least one baby weighing
>9 lbs.
 Blood pressure >=140/90 mm Hg, or has been told that has HBP.
 Abnormal cholesterol. HDL cholesterol (“good” cholesterol) <35 mg/dL,
or triglyceride level>250 mg/dL.
 Physical inactivity (i.e. exercise<3 times/week).
 Polycystic ovary syndrome (PCOS)—women only.
 Impaired glucose tolerance (IGT) or impaired fasting glucose (IFG).
 Other clinical conditions associated with insulin resistance (e.g.,
acanthosis nigricans).
 History of cardiovascular disease.
12. The thrifty gene theory was proposed in 1962 by geneticist James Neel to
explain higher rates of obesity and diabetes among Native American, Mexican
American, African American, Australian Aborigine, or other indigenous groups.
This theory postulates that certain genes have evolved to maximize metabolic
efficiency, lipid storage and food searching behavior, and that in times of
abundance these genes predispose their carriers to diseases caused by
excess nutritional intake, such as obesity. According to this theory, this
genotype would have been advantageous in the past during periods of famine,
but, now is too efficient and disadvantageous for high fat, high carbohydrate,
and low fiber diets, and relative inactivity. Does the thrifty gene theory explain
the higher rate of diabetes among the Pima? What does the video say about
this?
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The thrifty gene hypothesis has recently been challenged.
Worldwide, “indigenous people suffer from diabetes at 2-5 times the
rate of non-indigenous people“ (Paradies, 2007)
Famines have occurred too infrequently and involve insufficient
mortality to favor selection of thrifty genes (Speakman 2007).
“More than 250 genes have been studied as possible causes of type-2
diabetes, but together these genes explain less than 1% of diabetes
prevalence worldwide.” (Paradies, 2007)
"Poor diet, reduced physical activity, stress, low birth weight and other
factors associated with poverty all contribute to the high rate of
diabetes in these groups” (Paradies, 2007)
The video supports the view that the high rates of diabetes among the
Pima and indigenous people across the globe are rooted in social
disadvantage rather than a genetic pre-disposition specific to
indigenous populations.
13. Are there alternative hypotheses to explain the higher rates of diabetes
among the Pima that are consistent with the story told in the video?
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One alternative hypothesis (Developmental Origins, Fetal Origins,
Barker or Thrifty Phenotype hypothesis) suggests that type 2 diabetes
originate in developmental plasticity, in response to under nutrition
during fetal life and infancy (Barker 2002, De Boo 2006, BMJ
collection).
Other general discussion questions:
14. What are some other health issues that disproportionately affect
populations?
15. Who do you think should have the major responsibility of decreasing the
healthcare gap seen amongst underserved populations? (Federal
government, state government, individual healthcare practitioners, etc.)
16. What role do you think you (the student) hold in eliminating these
disparities? What can you do now to make America more aware of these
inequities? How will these inequalities affect you in your profession?
Questions specific for dental students:
17. What is the role of dentists in prevention of diabetes or diabetes
complications?
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Secondary prevention begins with dentists being familiar with and
being able to recognize the oral manifestations of diabetes: burning
mouth syndrome, candidiasis, dental caries, gingivitis, glossodynia,
lichen planus, neurosensory dysesthesias, periodontitis, salivary
dysfunction, taste dysfunction, xerostomia.
Dentists should counsel patients with diabetes in improving glucose
regulation, maintaining oral and nutritional health, monitoring glucose
daily, and routine care from medical professionals (Ship 2003).
18. What do you think the role of the dentist is in regards to diabetes
medications?
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Dentists need to be familiar with medications used for diabetes, ask for
updates on medical history, work with physicians, change medications
if needed before certain procedures (e.g., antibiotics), and check blood
sugar levels (Vermillo 2003).
19. What do you think the role of the dentist is with regards to social policy
and advocacy on behalf of their diabetic patients?
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Dentists can be advocates for recognizing that if communities are
impacted by poor dental health, then it is an opportunity to identify
what kinds of structures and resources need to be in place for that
community.
References:
Barker DJP, Eriksson JG, Forsén T, Osmond C: Fetal origins of adult disease:
strength of effects and biological basis. Int J Epidemiol 2002; 31: 1235–39.
BMJ Collection: http://www.bmj.com/cgi/collection/barker_hypothesis?page=1;
Carter-Pokras O, Baquet C. What is a health disparity? Public Health Reports
2002;117:426-432.
Diabetes Prevention Working Party for the National Public Health Partnership.
Prevention of type 2 diabetes: a background paper. 2005 Jan. Available
at:
<http://www.dhs.vic.gov.au/nphp/publications/research/diabetes_preventio
n_bg_jan05.pdf>.
De Boo HA and Harding JE. The developmental origins of adult disease (Barker)
hypothesis. Aust N Z J Obstet Gynaecol 2006; 46 (1): 4–14.
Neel JV. Diabetes mellitus: a "thrifty" genotype rendered detrimental by
"progress"? Am J Hum Genet 1962; 14: 353–62.
Paradies YC, Montoya MJ, and Fullerton SM. Racialized genetics and the study
of complex diseases: the thrifty genotype revisited. Perspectives in
Biology and Medicine 2007; 50 (2): 203-327.
<http://muse.jhu.edu/journals/perspectives_in_biology_and_medicine/v05
0/50.2paradies.pdf>.
Ship JA. Diabetes and Oral Health: An overview. J Am Dent Assoc 2003; 134:
4S-10S.
<http://www.ada.org/prof/resources/pubs/jada/reports/suppl_diabetes_02.
pdf>.
Vermillo AT. Dental considerations for the treatment of patients with diabetes
mellitus. J Am Dent Assoc 2003; 134: 24S-33S. Available at:
http://www.ada.org/prof/resources/pubs/jada/reports/suppl_diabetes_05.p
df