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Question 3:  Why Do Aboriginal People Have So Much Diabetes?

Many scholars have attempted to answer this question.  Their views can be divided into two categories: 

1) genetic and environmental factors

2) socio-politico-economic and cultural factors.  The following sections will focus on exploring the intersections and impacts of these broad categories.

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Source: Health Canada website and Media Photo Gallery, Health Canada, http://www.hc-sc.gc.ca Reproduced with the permission of the Minister of Public Works and Government Services Canada, 2006.

 

Nature and nurture -

genetic and environmental theories of type 2 diabetes in indigenous peoples

Genetic and environmental theories of type 2 diabetes in indigenous peoples are formed on the knowledge that the disease was unknown in them prior to 1940 [1].  Current hypotheses assume that indigenous peoples, who more recently left the hunter-gatherer lifestyle, share a gene or genes which make them collectively susceptible to type 2 diabetes.  In addition to being genetically susceptible, hypotheses also assume that indigenous peoples have experienced fundamental lifestyle changes since World War II [1].  It is the combination of genetic susceptibility and lifestyle change which serves as the premise for genetic and environmental theories of type 2 diabetes in indigenous peoples.

 

The most prominent theory used to explain the disproportionate prevalence of type 2 diabetes in indigenous peoples is the “Thrifty Gene Hypothesis“, which will be discussed below.  It will serve as a representative of genetic-environmental theories upon which globalizing processes can be incorporated.  The argument will be articulated as it is laid out in the scientific literature.  However, it is important to bear in mind that there is a danger of promoting racist discourses by emphasizing the racialized category of “indigenous“ or “Aboriginal“ as a proxy for genetic differences [2]

 

In 1962, Dr. James Neel, a prominent geneticist, proposed the “thrifty gene hypothesis“ in order to explain the unprecedented rise of obesity and type 2 diabetes in the Pima Indians.  The hypothesis begins with an assumption that indigenous people share a susceptibility gene which is the result of evolution in a hunting-gathering environment.  (Peoples of European descent, who left the hunting-gathering lifestyle earlier, may be presumed to have lost or attenuated such a gene.)  Thrifty genes act to conserve energy.  When an individual with thrifty genes takes in food, that food is converted to glucose.  Insulin is released by the body to store excess glucose for use at a later time.  Keeping the susceptibility gene constant, Neel then considered its effects in a hunting-gathering population versus that in a sedentary, westernized society.[3]

 

A hunting-gathering lifestyle does not favour excess food consumption.  The majority of time is spent in subsistence with intermittent feasts, and occasional famines.  During times of food abundance, the ability to “save“ excess energy for famine (i.e., be thrifty) would confer a selective advantage, and the genes would spread throughout the population [1].  Currently, most indigenous peoples live sedentary, westernized lifestyles.  Food is plentiful, and little physical work is required.  However, the thrifty genes are still in action.  They promote too much insulin, obesity, and type 2 diabetes [1].  The formerly adaptive thrifty gene is a maladaptive remnant of a hunting-gathering lifestyle.

 

Colonialism, modernization, and development:  the role of globalization in type 2 diabetes in indigenous peoples

I.  Diabetes is a western disease

The era we currently live in has been described by terms such as, “coca-colonization“ or “McDonaldization“.  Adjectives, such as these, are used “tongue-in-cheek“ to describe the economic, cultural, and political domination of nation-states by “western“ powers, most prominently the United States.   Westernization is another word to describe modern colonial practices.  Although much more subtle than British imperialism more than a century ago, past practices and current practices of colonialism share the features of marginalization and domination.  As with most practices of domination, the reach is broad, and the grasp includes the diets of the oppressed peoples [4].  In reference to Canadian indigenous peoples, Kelm (1998) states:  “The bodies of Aboriginal people have been central players in the drama of colonization...  Sustained contact with Europeans fundamentally altered the physical health of the First Nations...“ [5].

One of the strongest arguments for the role of colonialism in the type 2 diabetes epidemic in indigenous peoples, is the fact that type 2 diabetes was virtually unknown prior to colonization.  No oral or written evidence exists to suggest that indigenous peoples experienced diabetes [6][7].  As previously described, the Pima Indians are one of the most extensively studied indigenous groups.  There exist two major groups of Pima Indians who share a common ancestry.  One group is in Arizona, and the other in Mexico.  The group in Arizona leads a “western“ lifestyle; whereas the group in Mexico leads a more “traditional“ lifestyle.  The Arizonan Pima show one of the highest rates of type 2 diabetes in the world (54% men, 37% women; please note the increased prevalence in men is unusual, but correct) [8].   Conversely, their relatives in Mexico have lower rates of 6% and 11%, respectively [8].  These findings support that environmental changes related to westernization have had a major role in the growing diabetes trend in indigenous populations [8].

 

 

Changes in the environment as a result of colonization and westernization have been dramatic when compared with traditional indigenous life ways.  Westernized societies have dietary intakes vastly different from those practiced traditionally by indigenous peoples.  The largest changes are found in the increase in animal fats and carbohydrates, especially secondary to processed foods [8].

 

 

Economic globalization has lead to widespread patterns of processed food consumption.  This is evident in the number of McDonalds restaurants worldwide [9].  “Fast food“ is synonymous with westernization.  However, these foods have little nutritional value when compared to traditional dietary staples, and they have contributed greatly to the rise in non-communicable diseases, such as type 2 diabetes [4]

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J. Hopkins

 

Indigenous peoples are aware of how colonialism has affected them at a level as fundamental as nutrition.  Unfortunately, there are few alternatives at present.  The wide-scale socioeconomic changes associated with westernization have impacted traditional foods and physical activities in a way that is not easily fixed [4].  Issues of land rights, equity, and self-government are intricately entwined with current health problems.  As Zimmet (2000) alludes to, the inability to access lands, and therefore traditional foods and activities, prevents indigenous peoples from incorporating traditional life ways into current practice.  All of these problems associated with colonialism are exacerbated by the processes of modernization and urbanization, which will be discussed in the following section.

 

II.  The role of modernization and urbanization in type 2 diabetes

Worldwide, rates of diabetes are significantly higher in urban populations than rural populations [10].  Urbanization increases the risk of diabetes in genetically susceptible individuals, such as indigenous peoples, independent of diet [8].  Reasons cited for this include stress and reduced physical activity.

Stress has been studied in minority groups, including indigenous peoples and immigrants.

Stress may come from a variety of sources:

  • Leaving known environs

  • Leaving family

  • Belonging to a marginalized group

High levels of stress are associated with:

  • Urbanization (which may lead to decreased physical activity)

  • Migration

Both of which may increase the risk of type 2 diabetes [11][8].

 

 

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John K. Hillers, 1879

Reduced physical activity associated with urbanization increases the risk of type 2 diabetes ([8].  Changes in activity (i.e., a decrease in caloric output) can be attributed to changes in occupation and transportation.  As Lieberman describes, urbanization moves people into cities where occupations tend to involve less physical activity.  And as these occupations tend to pay more than agriculture, more money is available for luxury goods, such as vehicles.  Wiedman describes how the “acculturation to an industrial technology often results in dramatic increases in type 2 diabetes mellitus“ [9].  This further decreases the amount of time devoted to energy expenditure.  Thus a repeating cycle of more money leading to more food and less physical activity, leading to more time to make money creates a lifestyle where obesity and diabetes develop.  To make matters worse, the effects are most devastating on the poor [9].  These practices of urbanization, industrialization, and poverty are in large part due to the forced “civilization“ of indigenous peoples.  Government policies in the past forced the relocation of Aboriginal peoples to reserves, and attempted to assimilate and acculturate them into “civilized“ North American society [12].

To learn more about the role of poverty in health click here.

There is some suggestion that a traditional lifestyle may therefore be protective against type 2 diabetes.  In an interesting study conducted on Australian Aborigines, individuals with type 2 diabetes were moved from an urbanized, western environment to one with traditional foods and activities.  The result was normalization of blood sugar and insulin levels [1].  The lab values associated with “traditional“ food and activities are comparable to groups which currently maintain hunting-gathering lifestyles, such as the !Kung and Ache [9].

 

 

 

III.  Public health policy - a structural adjustment policy or in need of structural adjustment?

Canadian public health programs, although continually evolving, are based on a traditional medical model where disease is the focus.  Little time and money is devoted to holistic practices which take into account an individual’s or community’s social, cultural, political, and economic circumstances.  Problems are exacerbated by the hierarchical power structure within the public health system which has been imposed upon Aboriginal peoples [13].  Programming is mostly designed outside of the local Aboriginal community.   The result is that it often goes against indigenous health structures[13], and ignores indigenous perceptions of the illness experience.  In an interesting study, Bruyere and Garro interviewed 20 Nehinaw (Cree) individuals, 10 men and 10 women, about their experiences with health and health care systems. 

  • "While health professionals tend to localize diabetes within individual bodies, the participants viewed diabetes as rooted in collective experience and in historical processes that have impinged on (A)boriginal people and are beyond their control.  A sense of the loss of autonomy and the continuing threat to being and remaining Nehinaw pervaded these interviews" [14].

 

Similar research exists for Sioux, or Dakota, peoples.  Lang describes an extensive study of Dakota narratives of illness.  Type 2 diabetes is described as “a new disease that has come to us“.  The relationship between changes in food ways leading to the increase in diabetes is recognized by the Dakota, but there is a sense that Aboriginal medicine is unable to do anything about it:  “I think that diabetes has to be treated by white man’s medicine.  We don’t have treatment for this“ [15].  As is illustrated in these brief statements, there is a sense of collective identity and shared experience as a result of being Dakota.  This sentiment is echoed by a Nisga’a man:  “’When we talk about the poor health of our people, remember, it all began with the white man’“ [5].  Unfortunately, most public health plans do not incorporate or acknowledge the importance of a collective aboriginal identity, and the sense that Europeans are a cause of collective poor health.

 

Bond, a public health practitioner and Aboriginal person living in Australia, focuses on Aborigines’ perceptions of illness and their interactions with public health.  She makes a direct connection between the politics of colonialism and public health which promote the culture of the dominant group.  She cites her frustration with what she describes as the “epidemiological gaze“, a reference to the use of racial categorization in medicine and public health, and how:

  • "the perception of Aboriginality as nothing more than a label, a health risk, and predictor of unhealthy behaviours within Indigenous public health practice reinforces stereotypical ideas of Aboriginality, demonises those who possess it, and disconnects Aboriginal people from their own identities in a manner similar to past oppressive policies of colonization, assimilation, segregation and integration" [16].

 

1.

What does this quote from Bond mean to you?

2.

What are other ways in which medicine can be considered colonialist?

The World Health Organization has become a major guiding force for the health policies of nation-states.  It is therefore encouraging that the direct and indirect connections between globalization and health have been recognized in the development of a framework for analysis and action [17].  The framework recognizes the importance of direct representation of vulnerable populations in health policy and decision-making processes.  And although little time is spent describing the implementation of such a framework, it is necessary to start from somewhere. 

Ultimately, making globalization work for the benefit of health requires a fundamental change in current approaches to economic issues at both the national and the international levels.  At the national level, policies need to be designed explicitly to maximize the well-being of the population, rather than assuming that this will automatically be achieved by policies oriented towards economic growth, supplemented by “add-ons“ such as safety nets and the protection of health and education spending.  At the international level, global rules, the activities of intergovernmental organizations, and the external policies of the governments of major developed countries need to be directed towards removing constraints to, and maximizing the incentives for, developing country governments to pursue these policies [17].

 

Perhaps, though, this policy does not go far enough, and should encourage the use of traditional ways, and acknowledgement of identities which impact on people’s perception of health and illness, which, as described above, is essential to indigenous peoples.  As McNeill and colleagues state so clearly,

  • "human rights, population health and indigenous ethics can complement traditional perspectives.  There is a need, both within health care education and in policy development, to consider issues from individual as well as wider social and cultural perspectives and to address disparities in power as part of a broader understanding of bioethics" [18].

 

Social and cultural interpretations of disease often vary widely between indigenous and non-indigenous peoples.  For example, Aboriginal concepts of disease, such as that of the Ojibwa in southern Manitoba may be at odds with current medical practices.  The Ojibwa have a belief that only symptoms need to be treated, so if symptoms are absent, such is the case with most people with diabetes, no treatment is needed [19].  This leads to issues of “compliance“ or “adherence“ to prescribed treatment regimens.  It is essential to understand these broad cultural perceptions if public health programs are to be successful in indigenous communities.

 

1.

How would you answer Abequa's questions?

2.

What resources are available to help you?

3.

Are these questions a physician can answer?

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1. Szathmáry, EJE Non-insulin dependent diabetes mellitus among aboriginal North Americans. Annual Reviews of Anthropology. 1994; 23: 457-82.

2. Fee M. Racializing narratives: obesity, diabetes and the ‘Aboriginal’ thrifty genotype. Social Science & Medicine. In press (2006), 10 pages.

3. Neel JV. Diabetes mellitus: a ‘thrifty’ genotype rendered detrimental by ‘progress’? American Journal of Human Genetics. 1962; 14: 353-362.

4. Zimmet P Globalization, coca-colonization and the chronic disease epidemic: can the Doomsday scenario be averted? Journal of Internal Medicine. 2000; 247: 301-310.

5. Kelm ME. Colonizing bodies: Aboriginal health and healing in British Columbia, 1900-50. Vancouver: UBC Press; 1998.

6. O’Dea K. Diabetes in Australian Aborigines: impact of the western diet and life style. Journal of Internal Medicine. 1992; 232: 103-117.

7. Martin DD, Shephard MDS, Freeman H, Bulsara MK, Jones TW, Davis EA, Maguire GP. Point-of-care testing of HbA1c and blood glucose in a remote Aboriginal Australian Community. Medical Journal of Australia. 2005; 182: 524-527.

8. Abate N, Chandalia M. The impact of ethnicity on type 2 diabetes. Journal of Diabetes and Its Complications. 2003; 17: 39-58.

9. Lieberman LS. Dietary, evolutionary, and modernizing influences on the prevalence of type 2 diabetes. Annual Reviews in Nutrition. 2003; 23: 345-77.

10. International Diabetes Foundation. Diabetes Atlas. 2nd Edition. Executive Summary. Brussels: International Diabetes Foundation; 2003.

11. Mooy JM, de Vries H, Grootenhuis PA, Boutler LM, Heine RJ. Major stressful life events in relation to prevalence of undetected type 2 diabetes: the Hoorn study. Diabetes Care. 2000; 23: 197-201. As cited in: Abate N, Chandalia M. The impact of ethnicity on type 2 diabetes. Journal of Diabetes and Its Complications. 2003; 17: 39-58.

12. Olson B. Meeting the challenges of American Indian diabetes: anthropological perspectives on prevention and treatment. In: Trafzer CE, Weiner D, editors. Medicine ways: disease, health, and survival among Native Americans. Walnut Creek, California: AltaMira Press; 2001: 163-184.

13. Crowshoe R, Manneschmidt S. Akak’stiman: a Blackfoot framework for decision-making and mediation processes. Calgary: University of Calgary Press; 2002.

14. Bruyere J, Garro LC. ’He travels in the body’: nehinaw (Cree) understandings of diabetes. The Canadian Nurse. 2000; 96: 25.

15. Lang GC. ’Making Sense’ about diabetes: Dakota narratives of illness. Medical Anthropology. 1989; 11: 305-327.

16. Bond CJ. A culture of ill health: public health of Aboriginality? Medical Journal of Australia. 2005; 183: 39-41.

17. Woodward D, Drager N, Beaglehole R, Lipson D. Globalization and health: a framework for analysis and action. Bulletin of the World Health Organization. 2001; 79: 875-881.

18. McNeill PM, Macklin R, Wasunna A, Komesaroff PA. An expanding vista: bioethics from public health, indigenous and feminist perspectives. The Medical journal of Australia. 2005; 183 (1): 8-9.

19. Waldram JB, Herring DA, Young TK. Aboriginal health in : historical, cultural, and epidemiological perspectives. Toronto: University of Toronto Press; 1995.

All references for this section