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Cook and Tillman Thesis
Cook and Tillman Thesis
Cook and Tillman Thesis
A Project
Master of Science
in Nursing:
August 2011
Approved:
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ABSTRACT
ACKNOWLEDGEMENT
I want to say thank you to our project committee chair Linda Paul and our other
committee members Karine Crow and Vicki Black-Bishop for their direction and guidance
TABLE OF CONTENTS
List of Tables………………………………………………………………………………..6
List of Figures……………………………………………………………………………….7
List of Appendix…………………………………………………………………………….8
Background………………………………………………………………………….9
Significance of Problem……………………………………………………………10
Definition of Terms xx
Research Question…………………………….…………………………………...14
Summary………………………………………………………………..
Available Resources
Nurse/Tohono healer
Hot Spots
Summary
CHAPTER 4: IMPLEMENTATION
Evaluation protocol
Cook & Tillman Thesis 6
REFERENCES…………………………………………………………………………..
Cook & Tillman Thesis 7
LIST OF TABLES
Cook & Tillman Thesis 8
LIST OF FIGURES
Cook & Tillman Thesis 9
LIST OF APPENDIX
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CHAPTER 1
Background
For centuries, the Tohono O’odham and Pima Indians successfully “lived with” the
Sonoran desert of present day Southern Arizona and Northern Mexico. Genetically and
culturally similar, the two bands of American Indian were able to coax enough calories
from the native plants and animals that shared this harsh desert habitat. The two bands
shared the foods grown by the Pima along the Gila River or gathered from the desert by the
Tohono. The diets of these two bands of desert people consisted of cultivated beans, native
seeds, desert plants, small-game animals, and deer. For years, the Tohono were known as
the “Papago”, a Spanish word that means “bean eater” which reflected the staple protein
source of the Tohono diet: tepary beans and mesquite bean pods (Underhill, 1979).
Digging miles of canal ditches to irrigate crops and crossing long distances of desert
to gather water and wild foods translated to a very high caloric energy expenditure lifestyle
for both the Pima and Tohono. Knowledge of how to live with the desert, rather than on the
desert, provided the tribes with foods to sustain the tribal communities (Tataranni, Harper,
Snitker, Parigi, Vozarova, et. al., 2003). The desert provided the “people” with a low fat,
low caloric diet. Dietary carbohydrates came from desert seeds and vegetation: prickly pear
cactus pads, cholla cactus pods (Underhill, 1979). Agave cactus and cultivated corn on the
Gila River supplemented the diet with some plant starch. To survive the Sonoran Desert
environment, the physiology of these desert dwellers adapted to a physically active lifestyle
and a low calorie/low fat diet. The same physiology that made it possible for the desert
Cook & Tillman Thesis 11
people to survive and “live with” the Sonoran Desert now threatens the tribes with near
extinction from the ravages of obesity and non-insulin dependent diabetes (NIDDM).
The Pima Indians have one of the highest obesity rates of any cultural group in the
world (Schulz, Bennett, Ravussin, Kidd, Esparza, et al., 2006). As in many other obese
populations, increased rates of IDDM correlates with an increase in body mass index
(BMI). At the turn of the 20th century, the Pima continued to practice subsistence
agriculture and the Tohono continued to hunt and harvest desert foods as these populations
had done for centuries. Literature reveals the presence of NIDDM at that time was either
non-existent or unrecognized; the truth was most likely the former, although the latter
would probably have been true had the population suffered from the disease. In the 1930s,
water from the Gila and other desert water sheds and water tables were tapped and diverted
to irrigate non-Indian farms and quench the thirst of the growing populations of Phoenix
and Tucson (Pavkov, Hanson, Knowler, Bennett, Krakoff, et. al., 2007).
To survive, the Pima and Tohono began to transition away from their native diet to
a higher caloric/fat Western diet. In 1930, 21 Pima were diagnosed with diabetes, which
correlated to the incidence in the general US population. Unfortunately, obesity and the
incidence of diabetes in the Pima trended upward until both greatly overshadowed other
longitudinal study of the Pima shortly after obesity and diabetes were identified as the
population’s major health issues (Pavkov, et. al., 2007). Today, the Pima are one of the
most obese populations in the world and suffer a rate of NIDDM that is five times higher
than that of the general population (Schulz, et al., 2006). The longitudinal evidence that
Cook & Tillman Thesis 12
The signing of the Gadsden Purchase that transferred ownership of much of the
Tohono and Pima lands from Mexico to the United States was transparent to most Indians
living in the area at the time. After the international borders were drawn, there remained a
population of Pima living in the Sierra Madre Mountains of Mexico. Unlike their brothers
and sisters to the north, the Mexican Pima continued to live and eat the same way they had
for centuries. Comparison studies of both Pima populations reveal that the Mexican Pima
population did not realize the upward trend in obesity and diabetes that the US Pima
population did. In a comparison study of the two populations, Schultz, et al., (2009),
articulated that, “…the age- and sex-adjusted prevalence of type 2 diabetes in the Mexican
Pima Indians (6.9%) was less than one-fifth that in the U.S. Pima Indians (38%) and
similar to that of non-Pima Mexicans (2.6%). The prevalence of obesity was similar in the
Mexican Pima Indians (7% in men and 20% in women) and non-Pima Mexicans (9% in
men and 27% in women) but was much lower than in the U.S. Pima Indians (p. 1866).”
Fortunately, the evidence from the longitudinal studies has shown that the incidence
of diabetes in the various adult age group populations of the Pima has either leveled out or
has actually shown a decrease. Unfortunately, recent studies have shown that incidence of
both obesity and diabetes has begun to trend upward in the population of Pima children
(Pavkov, et. al., 2007). The next casualty in the battle against obesity and diabetes is the
children of the desert people. The evidence that correlates diet and lifestyle to obesity and
diabetes is well validated. The challenge for healthcare providers working with the
lifestyle and diet. Healthcare providers must turn to tactics that celebrate and encourage the
cultural strengths of the desert and river people in order to return the people to health.
Modern conveniences and an endangered culture now threaten the survival of one of the
most resilient and hearty populations the world has known. In her 1930 biography, Chona,
a 90 year-old Tohono woman articulated the answer, “Wheat flour makes me sick! I think
it has no strength. But when I am weak, when I am tired, my grandchildren make me gruel
The arms brought to bear in the fight against obesity and NIDDM is the latest
Diabetic Association. However, the message to reduce caloric and fat intake has been
repeated time and time again with little to no effect. The traditional approach to the issue of
obesity has had limited success in reducing BMI and the risk for developing diabetes. This
lack of success at preventing obesity and diabetes has forced the hand of medicine to one of
treatment. The addition of medicines to the fight is an approach fraught with compliance
issues and the number of Pima that require renal dialysis remains steady (American
Indian culture, and the infusion of casino monies augment medical strategies to encourage
lifestyle changes. The Native Seeds Search is a non-profit organization that has led a
grassroots effort to protect, preserve, and propagate native Sonoran food crops and to
encourage Native Peoples to eat Native foods (Native Seed Search on-line, 2010). The
Tohono O’odham employed casino revenues to build a cultural center and museum. The
Cook & Tillman Thesis 14
strives to restore cultural and physical health to the desert people. One of the main
principles of TOCA is the concept of “Native Food Sovereignty” (TOCA on-line, 2010).
Medical interventions have realized only moderate success in treating the effects of
diabetes and little success in preventing the disease. The next step is to integrate and marry
medical, nursing, cultural, and community strategies to empower the Tohono culture to
cure itself.
Arizona that includes the main reservation, the San Xavier District, the San Lucy District,
and Florence Village. The nation covers more than 2.7 million acres and is home to 24,000
people. The Pima make up two main communities on Arizona’s Gila and Salt Rivers.
Approximately 11,000 Pima live on the 550,000-acre Gila River Reservation while the
people that consist of Pima and the culturally distinct Maricopa Indian (Curtis, 2003).
The Tohono O’odham and Pima Indians have lived on the Sonoran Desert in
present Sonora Arizona and Mexico for centuries. Today the two tribes are geographically
and politically separate, but continue to share close genetic, religious, and cultural
similarities. The two tribes are in fact, two bands of the Uto-Aztecan language family of
American Indians, which includes the Shoshone, Paiute, and Comanche. Archaeological
evidence shows that this language band of American Indians located to the present day
Western United States via a Northward migration from Latin America. The Uto-Aztecan
Cook & Tillman Thesis 15
language family of American Indian remains genetically and culturally independent from
the Athabaskan language family of American Indians (the Navajo, several bands of
Apache, and many others) who came to inhabit many of the same lands following a
The two tribes of Uto-Aztecan Indians that came to call Southern Arizona home
think of themselves as one people. In fact, the word O’odham translates to “people”. Both
tribes historically referred to the Pima, who settled in the Gila River valley and adopted an
agricultural culture, as the Akimel O’odham, which translates to “river people”. The word
Tohono translates to “desert” and reflects the more nomadic lifestyle (moving to co-locate
with seasonal water sources and food) of the people who practiced a hunting/gathering
existence in the Desert Islands of the Sonoran desert foothills (Underhill, 1979).
Research Question
(C) for glycemic control (O) (hemoglobin A1C 5.7-6.4) in Pima/Tohono O’odham
It is well established that obesity and diabetes remains America’s major health
concern. The US Surgeon General made the first call to action against these maladies
nearly a decade ago. Today’s US Surgeon General has joined the First Lady, the National
Institutes of Health, and the Secretary of the US Department of Health and Human Services
Cook & Tillman Thesis 16
(HHS) in putting plans to combat obesity and improving nutrition at the top of our Nation’s
health care strategy (OPHS Press Office, 2010). Obesity and diabetes touches every
community. Both have reached epidemic proportions in most American ethnic groups.
Unfortunately, epidemiologic reviews of American populations reveals that the Tohono and
Pima Indian communities in Arizona have the highest rates of obesity and Type 2 diabetes
of any population in the world (Schulz, Bennett, Ravussin, Kidd, Esparza, et al., 2006). The
literature is replete with studies that confirm that exercise and a low caloric/low fat diet is
most effective strategy in reducing type 2 diabetes in that population. The need to modify
behavior to control obesity and promote exercise is greatly magnified in the Tohono/Pima
population.
resources needed to establish a National Obesity and Diabetes Center of Excellence. The
Indian communities in Southern Arizona are home to an obese population with a high
incidence of diabetes, have access to community welfare funding streams (casino money),
and are in close proximity to institutions of higher medical education (schools of medicine,
pharmacy, and nursing). The communities are also home to a community college, a
hospital, and several outpatient clinics managed by the Indian Health Services (United
States Public Health Service). A large cultural center and native foods restaurant was
agencies (at varying levels) and numerous non-governmental organizations based in and
around Southern Arizona are focused on Native food, cultural, and health initiatives.
Unfortunately, the above resources remain fragmented and mostly operate independently of
Cook & Tillman Thesis 17
each other. An obesity and Diabetes Center can take lead venture and coordinate the above
As a best practice, I believe the Obesity and Diabetes Center can maintain
community vision by focusing on behavior modification that leads to lifestyle changes (diet
and physical activity). Federal funding is available specifically for this venture via T32
Research Training Grants. I propose that the Center of Excellence act as the agent that
keeps all agency efforts grounded on the same goal of reducing obesity and diabetes.
Coordinated initiatives to teach the propagation, harvesting, and preparation of native food
stuffs and the practice of traditional walking/running events can be the center of each
effort. I propose that the Center for Excellence be based at the Cultural Center and the
Hospital in Sells, Arizona. The Center of Excellence would ensure the cafeteria at the
hospital in Sells (and at the Indian Schools) would offer a menu with a large sampling of
Native foods prepared by Natives. To encourage self-reliance and to target the population’s
health requirements, I propose the Center use Federal funding and take lead venture to
establish vocational training in cultural nutrition, nursing assistant, and establish a college
of nursing.
To be successful as a best practice, the center would need to keep its finger on the
pulse of every agent in the community. Furthermore, the Center of Excellence’s foundation
medical/nutritional principles that outlines the control and treatment of diabetes as:
maintaining metabolic outcomes (blood glucose, lipid, blood pressure), preventing chronic
improving food choices, and fostering willingness to change via cultural and lifestyle
Cook & Tillman Thesis 18
factors (ADA, 2010). The standard to control obesity and diabetes via evidence-based
practice is well established. What is missing is the best practice of coordinating all the
CHAPTER 2
LITERATURE REVIEW
culturally traditional diet (I) be as effective as other interventions (C) for glycemic control
(O) (hemoglobin A1C 5.7-6.4) in Tohono O’odham adolescents (P) diagnosed with Pre-
diabetes. The literature survey employed a Medline and Cline Library database search of
full-text English language articles published within the last 10 years. Key search terms
included: Type 2 diabetes; glycemic control; Tohono O’odham, Pima Indian native diet;
and behavior modification. Database title hits and abstract reviews were reviewed for
relevance to the key search terms. Applicable articles were retrieved and integrated in a
synthesis table to facilitate information recall utility. A critical review of targeted articles
follows:
Pavkov, Hanson, Knowler, Bennett, Krakoff, & Nelson (2007) examined Type 2
diabetes incidence trends in the Pima Indian between 1965 and 2003. This non-
experimental descriptive study followed 8,236 Pima Indians ( 5 years of age) over three
13-year time periods and employed two physiological criteria to define diabetes: 1) 2-h
plasma glucose concentration 200 mg/dl, and 2) hypoglycemic treatment. The study
participants did not initially meet either criterion for the disease and were followed over
time to see if they would later exhibit the pre-determined criteria during a subsequent
wellness examination. The longitudinal data revealed that of the 8,236 non-diabetic study
participants, 1,005 would develop the disease on follow-up. Interestingly, the study
revealed different disease incident trends among different age groups. Over the course of
the study, the body mass index (BMI) in the population increased by 19%, but the research
Cook & Tillman Thesis 20
disclosed that the incidence of Type 2 diabetes increased in the 5-14 year group, decreased
in the 25-34 year group, and remained stable in all other age groups. This study clearly
showed that the trend of rising incidence of the disease is limited to the population’s youth
who exhibited a six-fold increase over the course of the study. The study is useful in that it
Indian youth.
study that established a strong correlation between childhood factors found in 76 Pima
Indian youths and the onset of type-2 diabetes in adulthood. Childhood factors studied
included waist circumference, body mass index (BMI), systolic blood pressure (sBP),
diastolic blood pressure (dBP), fasting glucose, and 2-hr oral glucose tolerance test
(OGTT) data collected during routine wellness exams. Type-2 diabetes was diagnosed
using criteria of acute insulin response (AIR), which was determined by intravenous
glucose tolerance test, and insulin action (M), which was measured by fasting plasma
glucose levels following alternating intravenous infusions of glucose and insulin. An oral
glucose tolerance test (OGTT) excluded diabetics from study enrollment. The longitudinal
data revealed that insulin secretion and insulin action have deteriorated before impaired
glucose regulation manifests. The data revealed that 2-hr OGTT, waist circumference, and
BMI were the strongest predictors while sBP, dBP were relatively weak factors for the
prediction of type-2 diabetes. This study supports the correlation (co-vary) of childhood
obesity (independent variable) and the onset of type-2 diabetes in adulthood for the Pima
Indian population. This study further supports the premise of the clinical question of
Schulz, Bennett, Ravussin, Kidd, Kidd, Esparza, et al. (2006) conducted research
diabetes (diagnosed by OGTT) in the Pima Indian. This correlational descriptive study
assessed and compared data that measured the incidence of obesity and type-2 diabetes in
genetically similar populations (Pima Indian) that are subject to different environmental
conditions (population living in the United States and population living in Mexico). The
study established a type-2 diabetes rate of 5.6% in Mexican Pima males and 8.5% in
incidence of diabetes in the studied US Pima male population was 34.2%, and 40.8% in the
US Pima female population. Although genetically similar, the two populations of Pima
Indian have a significantly different incidence of diabetes. The study concludes the
correlation between the higher physical activity level and lower dietary energy intake in the
Mexican Pima with the lower incidence of type-2 diabetes. The study suggests a striking
example of environmental factors (diet and exercise) and the incidence of diabetes. The
study provides solid evidence in the efficacy of preventing the disease in the Pima Indian
Brett and Davison (2010) drew upon Theory of Planned Behavior (TPB) and the
Trans-theoretical Model (TTM) to examine the link between fostering behavioral change in
adolescents to adopt a plant-based diet (PBD). This cross-sectional study followed 204
college students from a large public university in the northeastern United States. The
researchers defined a PBD as a diet dominated by fresh or minimally processed plant foods.
The PBD is not a vegetarian diet, but merely follows a limited consumption of meat, eggs,
and dairy. The study employed surveys to determine the participants’ readiness for change
Cook & Tillman Thesis 22
and assigned the participant to one of the five stages of change outlined by the TTM (pre-
measured TPB; participant attitude for following a PBD was measured using a 4-item scale
demonstrated that an individual’s decision to follow a PBD is different than simply adding
more fruits and vegetables to the diet. This difference is in-line to making a lifestyle
change. Stages of change were not found to be a significant predictor of adopting a PBD.
PBD. The research findings relevant to the clinical question are the importance of attitude,
subjective norms, and perceived behavioral control in readiness to adopt a BPD. This study
Williams, Knowler, Smith, Hanson, and Roumain, et al., (2001), examined the
correlation between a Western diet and the development of type-2 diabetes in the Pima
Indian. This correlational descriptive study collected survey data from 162 Pima Indians
who were asked to identify their diet as “Indian”, “Anglo” or “Mixed”. The study also
with that disease. The results revealed that study subjects with a higher intake of complex
carbohydrates, dietary fiber, insoluble fiber, and vegetable proteins were from the Indian
versus the Anglo or mixed diets. Adjusted for age and sex, the data showed that the risk of
developing diabetes was 2.5 times higher in the Anglo-diet group, and 1.3 times higher in
the mixed-diet group, than in the Indian-diet group. The study suggests a correlation
between higher incidences of type-2 diabetes in Pima Indian populations that follow an
Cook & Tillman Thesis 23
Anglo-based diet. This study supports the premise of the clinical question and supports a
return to a traditionally native diet to decrease the incidence of diabetes in the Pima Indian.
Cook & Tillman Thesis 24
CHAPTER 3
PROJECT DEVELOPMENT
Cook & Tillman Thesis 25
REFERENCES
Northwestern University Library, Edward S. Curtis's "The North American Indian," 2003.
http://digital.library.northwestern.edu/curtis/
Office of the Surgeon General Press Release, 28 Jan 2010, HHS Secretary and Surgeon
General Join First Lady to Announce Plans to Combat Overweight and Obesity
http://www.hhs.gov/news/press/2010pres/01/20100128c.html
Pavkov, M., Hanson, R., Knowler, W., Bennett, P., Krakoff, J., & Nelson, R. (2007).
Changing patterns of type 2 diabetes incidence among Pima Indians. Diabetes Care,
30(7), 1758-1763. Retrieved from CINAHL Plus with Full Text database.
Schulz, L., Bennett, P., Ravussin, E., Kidd, J., Kidd, K., Esparza, J., et al. (2006). Effects of
Indians in Mexico and the U.S. Diabetes Care, 29(8), 1866-1871. Retrieved from
Tataranni, P. A., Harper, I. T., Snitker, S., Parigi, A. D., Vozarova, B., Bunt, J., Bogardus,
C., & Ravussin, E. (Dec 2003). Body weight gain in free-living Pima Indians: effect
p. 1578. Retrieved February 15, 2010, from Academic OneFile via Gale:
http://libproxy.nau.edu:2124/gtx/start.do?prodId=AONE&userGroupName=nauniv
Thearle, M.S., Bunt, J.C., Knowler, W.C., and Krakoff, J., (2009). Childhood predictors of
adult acute insulin response and insulin action. Diabetes Care, 32 (5), 938-943.
http://www.tocaonline.org/About_TOCA/About_TOCA.html
Underhill, R. M. (1979). The Papago and Pima Indians of Arizona. Palmer Lake,
Underhill, R. M. (1979). Papago woman. Long Grove, Illinois: Waveland Press, Inc.
Williams, D. E., et al (2000). Indian or Anglo Dietary Preferences and the Incidence of
Diabetes in Pima Indians. Diabetes 49.5 (2000): A39. Academic OneFile. Web. 15
Mar. 2010.
Wyker, B. A., & Davison, K. K., (2010). Behavioral change theories can inform the
Education and Behavior, 22 (6), 1-10, Retrieved from CINAHL Plus with Full Text
database.