Title: “Bad Sugar” from the California Newsreel Documentary Series Unnatural Causes: Is Inequality Making us Sick? – A Discussion Guide for Health Professional Students
(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. 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 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. Facilitators will have familiarized themselves with material in the video and readings as well as the provided 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.pdf
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.pdf
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 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?
· 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 chance?
o How are a person’s chances affected if they have access to good public school 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?
· Poverty in the American Indian communities resulted from 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 Native people.
· 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, people are living at or below the poverty level, but are still closer to resources than on American Indian reservations, in which community members are far from these resources, like access to health care.
· 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 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?
· 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 even be able to afford the health care and other services vital to good health as needed.
· 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?
· 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.
· An example of doing the best with the given commodity foods was “fry bread,” an unhealthy dietary adaptation.
· Their native culture appeared to be lost, and was seldom brought out, except in the cases of special ceremonies.
5. How did politics, 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, either locally or even more broadly?
· 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 in the Arizona Water Rights Act of 2004 after tremendous effort on the part of the affected American Indian tribes.
· Possible discussion probes:
o Anti-tabacco initiatives
o Health insurance provision
o Cancer screenings, etc.
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 its ability to prevent diabetes?
· 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 of 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?
· 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 long-term 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 focus 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?
· 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?
· With the return of the water, the communities are returning to farming and rebuilding the local economy. Physical construction of the necessary communities and institutions are beginning.
· Dr. Warne proposes that the community must begin to take control of itself, 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 further go about creating 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?
· 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. The need for social work and changes in social policy need to be looked at for making the necessary community- and society-based changes, so that members can benefit. What risk factors for diabetes are discussed in the video? What are additional risk factors for diabetes?
· 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.
(SOURCE: NIDDK website)
12. Does the thrifty gene theory explain the higher rate of diabetes among the Pima? What does the video say about this?
· “Around the world, indigenous people suffer from diabetes at 2-5 times the rate of non-indigenous people“ (Paradies, 2007)