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DIABETES AND THE PIMA
Type II Diabetes Mellitus and the Pima Indians
Diana Pinney
Concordia University, Nebraska
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DIABETES AND THE PIMA
Abstract
This paper explores the history and causation of the high prevalence of type II diabetes mellitus
in the Native North American population, most notably the Pima Indians of Arizona. This topic
is explored through the lens of public health and its domains. There have been many theories and
explanations for this issue, from the postulated ‘thrifty gene’ to identifiable genetic markers for
obesity, diabetes, and changes in the socioeconomics of Native peoples. What is not questioned
is the need to understand this issue for the betterment of a population subjugated by history.
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DIABETES AND THE PIMA
Type II Diabetes Mellitus and the Pima
Type II Diabetes Mellitus
Type II diabetes mellitus has many monikers and in the past was called either adult onset
diabetes or non-insulin dependent diabetes mellitus (NIDDM). University of Michigan Health
System (U of M, 2006) Type II diabetes is characterized by the body’s inability to produce
enough of the hormone insulin in the pancreas, or to effectively use insulin to lower the body’s
blood sugar level. (U of M, 2006) After food is digested into glucose (blood sugar), insulin
delivers glucose to cells for use and lowers blood sugar. National Institute of Diabetes and
Digestive Kidney Diseases (NIDDK, 2011) Type II diabetes occurs when the body does not
absorb enough insulin to lower blood sugar and the pancreas can no longer overproduce it. When
insulin resistance occurs, one will have high blood sugar and also too much insulin in the
bloodstream. (NIDDK, 2011)
Type II diabetes is more prevalent in some populations than others, most notably the
Pima Indians of the American southwest. Fifty percent of Pima adults have diabetes. (NIDDK,
2011) Type II diabetes is controllable with diet and exercise which are the main aims of
prevention programs for at risk populations such as the Pima Indians. Centers for Disease
Control and Prevention (CDC, 2011)
Diabetes is not just a problem in Native American populations. Today, 25.8 million
people in the United States (8.3% of the population) have diabetes. American Diabetes
Association (ADA, 2011) According to Jared Diamond (2003), health care costs for diabetes is
over 100 billion dollars in the United States and “at its present rate of increase, within a few
decades will be one of the world’s most commonest diseases and biggest public health problems”
(p. 599).
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Genetic Basis For Diabetes and Other Biomedical Factors
Understanding the prevalence of diabetes type II in Native American populations is not
without ethical consideration. It is helpful to understand prevention and control of a disease
through genetic groupings of populations. While there is some evidence of shared genetic
predispositions in the peoples of the southwest, it is important to bring to light certain
implications. According to McGregor (2010), “the biological claims of racial difference have
been scientifically discredited; nevertheless, racial and ethnic classifications have been
resuscitated and gained importance in genomic research.” (p. 23) McGregor (2010) argues that
grouping people into races for the purpose of biomedical research is awkward, as the idea of race
as genetic basis is not a scientific reality. McGregor (2010) also mentions the negative
connotation of grouping people genetically as it is linked to unethical eugenic studies.
“Researchers are seeking genetic determinants of disease; doing so draws attention away from
the social and economic inequalities that drives much of the health disparities in the minorities of
the Unites States.” (McGregor, 2010, p. 23) That said, there is evidence that type II diabetes is
influenced by genetics.
Following with McGregor’s (2010) assertion that genetic dispositions have found some
resurgence in biomedical research, Leong & Wilding (1999) found that, “obesity, particularly
truncal obesity, is closely correlated to the prevalence of diabetes…” (p. 221) Obesity can be
correlated with the onset of type II diabetes (Tuomilehto et al, 2001), and has been genetically
linked. (Hansen, et al., 1998)
To further bring resonance to this claim, a study of an overweight intervention group by
Tuomilehto et al. (2001) found that 1 year of weight loss reduced the risk of diabetes by 58% in
comparison to the control group.
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DIABETES AND THE PIMA
While obesity can be genetically linked, so can diabetes. Populations of African
Americans, Alaska Natives and American Indians have a high prevalence of this disease.
(NIDDK, 2011) There is also some evidence that the genes of the Pima leave them susceptible to
quickly gaining weight from sugar-laden foods. (Hanson et al., 1998) Studies have also
discovered ‘gene variants’ that increase one’s chances of developing type II diabetes. (NIDDK,
2011) This evidence suggests that biological factors synthesized with socio-economic issues and
lifestyle choices may help in understanding the high prevalence of type II diabetes in the Pima.
J.V. Neel hypothesized that a “thrifty genotype” existed. (Ravussin, 1993) Neel’s idea
was that individuals that are genetically more likely to be obese or develop diabetes have a
switch that is related to times of traditional subsistence when there were periods of feast or
famine. In times of plentiful food, the body would frantically store calories which would be
detrimental if one was switching from farming to processed foods. (Ravussin, 1993) This theory
has not necessarily been discredited (although the roots of its assumptions have some ethical
implications as mentioned earlier), but expounded upon by genetic studies. (Hansen et al., 1998)
The shocking statistics of diabetes in Native American populations (most notably the
Pima Indians of Arizona) can be linked to genetics and a long history of changes in traditional
subsistence.
The Pima of Arizona
Archaeologically linked to the Hohokam of Mexico, the Pima have lived in the Sonoran
desert near the Gila River in southwestern Arizona for 2,000 years. National Institute of Diabetes
and Digestive and Kidney Diseases. (NIDDK, 2007) Historically, the Pima organized irrigation,
which provided them with yields of wheat, beans, squash, and cotton. Today, their agriculture
DIABETES AND THE PIMA
has turned small scale (necessitated by a water rights battle), and has turned to that of
economically viable modern convenience.
The Spanish missionary, Marcos de Niza, made contact with the Pima in 1539.
Rebellions occurred in the late 1600s to the mid 1700s in response to Spanish mining, forts,
ranches, and the eventual European farmers who found this land highly advantageous. Holding
with the continuity of most Native American history, the Pima were pushed onto a reservation
incomparable in size to the 3.5 million acres they were used to subsisting on. The Pima
population exceeded the carrying capacity of this land and some migrated from the Gila River
area to the Salt River area forming another population. (NIDDK, 2007) The Gila River
population is the one discussed here.
Epidemiology of Type II Diabetes Mellitus in Pima Indians
Environmental Factors and Subsistence Change
Between 1990 and 1998, it was found, “the Pima Indians in Arizona currently have the
highest recorded prevalence of diabetes in the world. On average, American Indian and Alaska
Native adults are 2.6 times more likely to have diabetes than non-Hispanic whites of similar
age.” (CDC, 2011)
The forced creation of a reservation was devastating as Pima life was centered on the
Gila River. The river was inevitably diverted upstream by non-native farmers to irrigate their
intensive farming productions. The presence of the Gila River was one of the sole reasons the
Pima were able to subsist in this arid land. (Ravussin, 1993) “The traditional Pima diet changed
rapidly from naturally grown produce to commercially processed foods, and physical activity
decreased tremendously.” (Ravussin, 1993, p. 234) Times of drought and famine collapsed the
Pima traditional mode of subsistence and obliterated their economy. This issue brought a water
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rights battle to the courts, which found in favor of the Pima and was enacted in 2005. (Archibold,
2008) Although the battle over water rights has seemingly been satisfactorily solved (and slowly
implemented), the shift to a non-traditional diet and the irrevocable effects of the Gila River
diversion has detrimentally affected the traditional ways and eating habits of the Pima.
The prolonged acculturation (influential interaction with a different society) of the Native
Americans changed some groups’ methods of traditional subsistence and adversely affected their
health. (Wirsing, 1985) According to the Pima’s resident diabetes specialist, Leonard Sanders,
“the Pima’s sister tribe in Mexico, which has kept up farming and eating off the land, has normal
rates of the disease. “ (Archibold, 2008)
With the destruction of their farming practices, the Pima subsistence changed from beans
and squash to a high sugar and high fat laden diet that this group’s systems were not used to
handling. The Pima were forced by colonialism to give up traditional subsistence and participate
in a market economy. As their shared historical characteristics show, the high rate of type II
diabetes can be epidemiologically linked to this interruption of their traditional life ways.
Social and Behavioral Factors of Type II Diabetes in Pima Indians
In order to keep type II diabetes in check, patients are advised to eat less calories and lose
weight. (Gohdes, 1988) In reference to the health belief model of social and behavioral factors
and the prevalence of type II diabetes in the Pima Indians, according to Gohdes (1988), there are
many reasons why diet counseling is difficult. One reason is, “the usual diet prescription has
been unrelated to patients’ cultural and economic status.” (p. 189) Also, “diet has been presented
in ways that are difficult for low-literacy learners to understand and implement.” (p. 189) Eating
habits are cultural and have continuity through generations (Gohdes, 1988) and, as stated earlier,
for many generations, the Pima diet has changed from subsistence farming to modern
DIABETES AND THE PIMA
convenience. It has been found that the Pima of Mexico are leading a more ‘traditional’ life and
have less obesity and type II diabetes than the Pima of the Southwest. (Ravussin, et al., 1994)
Not only does culture influence diet, economics also determine food choices. High caloric,
processed foods are cheaper than fruits and vegetables. (Gohdes, 1988) These factors are placed
into context and determined meaningful to patients before an effective diet plan is enacted.
As a part of the health belief model, self-efficacy has also been shown to assist with
controlling type II diabetes. “The British Medical Journal suggested that building self-esteem
actually helped a group of Native Americans manage their obesity and diabetes better than did
conventional counseling about diet and exercise.” (Epstein, 2003) In reference to the ecological
model of health behavior, “the social environment in which individuals live influences
behavior.” (Krueter, et al., 2006) Choices made generation-to-generation affect a culture, but
these choices are made based on the economic and social environment.
There are many levels of opportunity to interrupt poor cultural food choices. Diet is a
major part of health and diabetes control and is highly involved in the intrapersonal and
interpersonal levels of the economic model of health behavior.
Boyce and Swinburn (1993) completed an enthohistoric gathering of traditional Pima
foodstuffs. They found that following this diet (containing less fat and more carbohydrates than
the current diet) “may help decrease the incidence of diabetes.” (Boyce & Swinburn, 1993, p.
369) Institutional settings, such as schools, have the opportunity to provide a population with
healthy food choices. In reference to the public policy level of the economic model, in order to
help bolster the Pima’s destroyed traditional lifeways and assist their entrance into the market
economy, “the United States government influenced Pima food choices as national government
food distribution programs began supplying them with American staples such as eggs, lard,
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DIABETES AND THE PIMA
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cheese, fruit juices, and pasta.” (Manahan et al., 1994. p. 415) Public policies can be used in a
more positive way in relation to the Pima. Diabetes counselors are already relegated to their
population. (Archibold, 2008) Perhaps with the inclusion of ethnographers, the Pima (notably the
younger, more disconnected generations) may be assisted in gaining a newfound pride of their
traditional lifeways and subsistence.
Over half (51%) of Native Americans living on reservations in 1989 were below the
poverty level. (Story et al., 1999). Poor socioeconomic situations also negatively influence health
and health choices. (MacGregor, 2010) Not only is the Pima’s current diet drastically different
from their traditional one, but pre-made foods have created less work time and increased
sedentariness. (MacGregor, 2010) These noted sociocultural changes in the Pima society,
coupled with genetic factors have led to the epidemic of diabetes.
Biostatistics of Type II Diabetes Mellitus
Similar effects of changes in traditional diet are occurring in other aboriginal
populations also. The Nauru of Micronesia, native New Guineans and Aboriginal Australians
are examples of other groups experiencing epidemics of obesity and diabetes rates (Diamond,
2003).
According to Story et al., (1999) the Pima’s diet of one hundred years ago “consisted of
about 70-80% carbohydrate, 8-12% fat, and 12-18% protein; the current Pima diet consists of
about 47% carbohydrate, 35% fat, 15% protein, and 3% alcohol.” (p. 751) Fruits and vegetables
are eaten less (the basis of Pima traditional diet) while an increase of fats used for cooking and
consumption in commodity food is significantly higher.
Biostatistical data taken of 1,704 elementary school aged Native American children from
a study by Grier and Kumanyika (2006) shows that in communities in New Mexico, the obesity
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rate is 26.8% for boys and 30.5% for girls. Over the years, this rate has been climbing and is
much higher than national averages. (Grier & Kumanyika, 2006) As stated earlier, obesity is
directly linked to type II diabetes mellitus, and most likely also has genetic factors related to its
onset. (Hanson et al., 1998)
This data has been used to compare the prevalence of obesity in small populations as
compared to the national average in order to ascertain risk and vet possible intervention methods.
Another study by Hanson et al. (1998) attempted to genetically link diabetes and high
body mass index of the Pima Indians. Of 1,338 people who had participated in a previous study
and were chosen for genetic scans, 69% had diabetes. They found “strong evidence that on
chromosome 11q there is a locus influencing susceptibility to both obesity and type II diabetes.”
(p. 1133)
This data is very interesting as there is shared genetic evidence for the prevalence of
obesity and diabetes in the Native American populations of the southwest. Diabetes can therefore
not be merely explained by socio-economic factors and lifestyle choices and understood instead
as a complex issue with biologic and other influences. This is interesting because, as previously
stated, grouping people by shared genetic traits is a problematic path of explanation and may be
more aptly described using the sociological lens of public health.
These numbers are important. 16.1% of American Indians and Alaska Natives have
diabetes. 95% of these diabetes cases are type II. American Diabetes Association (ADA, 2012)
Between 1994 and 2004, there was a 68% increase in diabetes in the young Native population
aged 15-19 years. (ADA, 2012). Pima Adolescents drink twice as many soft drinks as compared
to the national average and fatty foods are often chosen for their low price and extended shelf
life. It has also been found that Pima youths spend more time watching television than white
DIABETES AND THE PIMA
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children who also play more sports. (Story et al., 1999) These numbers are important because
they so simply demonstrate the epidemic of type II diabetes within a certain group of people.
This situation necessitates continued genetic and sociological study coupled with interventions
involving nutrition and exercise, which are proven ways to control or prevent type II diabetes.
(CDC, 2011)
In conclusion, obesity affects the human body in a way that makes one more susceptible
to diabetes type II. Weight loss and lifestyle change can dramatically change this risk. There are
also proven genetic factors (including obesity) that create populations with a higher prevalence
of diabetes. Identifiable genetic markers, the continuing poor socioeconomic situation of the
Pimas, their neglect by the United States government and the available cultural food choices
directly relate to the prevalence of obesity and type II diabetes in their population.
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DIABETES AND THE PIMA
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