A Narrative Literature Review on Uncontrolled Diabetes in America

This narrative literature review investigates the factors contributing to uncontrolled diabetes among indigenous populations in America, highlighting a higher prevalence of both type 1 and type 2 diabetes compared to non-indigenous groups, leading to increased cardiac and renal complications. Key contributing factors include genetic predispositions, lifestyle choices, dietary habits, and obesity. The review also identifies gaps in healthcare access and insurance coverage as significant barriers to diabetes management within these communities. Notably, a lack of research incorporating the perspectives of indigenous individuals themselves is identified as a crucial gap. Future research aims to address this gap by exploring the experiences and perspectives of indigenous Americans regarding uncontrolled diabetes, which can inform more culturally sensitive and effective diabetes control strategies and healthcare policies. The review underscores the importance of person-centered approaches in addressing this critical health disparity.

Running head: A NARRATIVE LITERATURE REVIEW
A Narrative Literature Review
Name of the Student
Name of the University
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Abstract
Diabetes is a chronic disease which is characterised by an increase in the blood glucose level
within the body. Some of the common types of diabetes are type 1 diabetes mellitus or insulin
dependent diabetes mellitus, type 2 diabetes mellitus or insulin independent diabetes mellitus
and gestational diabetes. The paper mainly aims of conduct a narrative literature review based
on the reasons underlying the uncontrolled diabetes among the indigenous population
residing in America. The analysis of the literary articles highlighted that the rate of
occurrence of both type 1 and type 2 diabetes are higher among the indigenous Americans in
comparison to the non-indigenous population. This unmanaged diabetes is the main reason
behind increase in the tendency of cardiac and renal complications among the indigenous
group of people. The main factors contributing to high rate of occurrence of diabetes and
uncontrollable nature of diabetes among indigenous population are genetic factors, life style
factors, food habits and obesity. Furthermore the analysis of the literary articles also
highlighted that there are lack of proper healthcare insuranceandother healthcare facilities
among the indigenous group which makes the diabetes unmanageable. However, the analyses
of the literary articles also identifiedcertain gaps in the literature. The main gaps in the
literature are, no studies have yet been conducted in order to ascertain the reason for
uncontrolled diabetes from the perspective of the indigenous population who are the main
victims of diabetes. So the future research will be based on analysing the reasons underlying
the uncontrolled diabetes among the indigenous Americans from their perspectives. Knowing
the perspective of the indigenous people will help to frame diabetes control strategy with a
person centred approach and will also help the government to revamp their health care policy
accordingly.

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Table of Contents
Introduction................................................................................................................................3
Narrative Literature Review.......................................................................................................3
Unmanaged diabetes among indigenous Americans..............................................................3
Factors contributing unmanaged diabetes among indigenous Americans.............................5
Genetic factors...................................................................................................................6
Dietary habits.....................................................................................................................7
Obesity...............................................................................................................................8
Summary of the review..............................................................................................................9
Aims of the current research....................................................................................................10
Research Questions..................................................................................................................10
Summary of the hypothesis......................................................................................................10
References................................................................................................................................12

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Topic: Uncontrolled diabetes in indigenous America
Introduction
Diabetes is a chronic disease under which the body either fails to produce insulin that
is required to the necessary glucose uptake from the blood (type 1 diabetes mellitus or insulin
dependent diabetes mellitus) or glucose concentration within the blood becomes unresponsive
to the insulin concentration (type 2 diabetes mellitus or insulin independent diabetes mellitus)
[1]. According to the federal data published by the Centre of Disease Control and Prevention
(CDC) Diabetes (2018), indigenous Americans have greater chances of developing diabetes
than any other U.S racial or ethnic groups. The federal data highlight that diabetes-related
kidney failure in indigenous Americans has reduced by 54% during 1996 to 2013. However,
the rate of diabetes is still uncontrolled among indigenous Americans [1]. The following
paper aims to analyse the factors contributing towards the development of diabetes among the
indigenous American population and how these factors is making the overall diseased
condition unmanageable. The conduction of the narrative review will help analyse the gaps in
the literatures and these gaps will to frame the future research prospective based on discrete
aims and objectives. The narrative review will mainly follow thematic analysis of the literary
articles.
Narrative Literature Review
Unmanaged diabetes among indigenous Americans
According to the reports published by the Centre of Disease Control and Prevention
(CDC), more than 100 million U.S adults are living with diabetes and pre-diabetes. As per the
reports of CDC, during the end of 2015, 30.3 million Americans had diabetes and it made
9.4% of the total U.S population and 84.1 million people have pre-diabetes and if this

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condition is not treated then it may give rise to type 2 diabetes mellituswhich has no cure
[13]. The rate of occurrence of diabetes is comparatively higher among the indigenous people
of America. This increased rate of diabetes is further associated with lack of proper
management of diabetes which leads to an increase in the adverse health related outcomes.
Unmanaged diabetes is the reason behind increased rate of stroke and myocardial infraction
among the Eskimo women and Aleut men. The unmanaged diabetes also increases the overall
mortality rate of diabetic Alaska Native in comparison to the diabetic population of the U.S.
Unmanaged diabetes is further transformed into gestational diabetes which lead to an increase
in the rate of morbidity and mortality. Prolong unmanaged diabetesincrease the rate of insulin
resistance which is mostly observed among the indigenous Mexicans and the Caribbean in
the Central or South America this increases the vulnerability of developing type 2 diabetes
mellitus [15].
(Source: 16)

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(Source: 16)
Factors contributing unmanaged diabetes among indigenous Americans
Factors contributing to diabetes among the indigenous Americans include genetic
predisposition, obesity, diet and lack of proper physical activity. Stress is also indicated as an
important factor behind the uncontrolled diabetes among the indigenous Americans [2]. Apart
from the common lifestyle factors, the consequences which increase the tendency of
developing diabetes among the indigenous Americans include high blood sugar level during
pregnancy and women giving birth to high birth weight babies (more than 9 pounds). This
tendency increases the chances of developing gestational diabetes among the ethnic women
of America [2].Moreover, the indigenous Americans like the Hispanic/Latino, Cuban,
Dominician, Mexican, Puerto Rican, Central American and South American are more likely
to smoke cigarette at an uncontrollable amount in comparison to the non-indigenous
American population. The tendency of smoking cigar is higher among the Cubanindigenous
groups and the Mexican population which further makes diabetes uncontrollable [15]. Among
the Hispanic Latino the smoking tendencies are high among men who are above the age of 40
and in young adults the smoking tendencies are equal among both male and female which

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increase the susceptibility of developing type 2 diabetes, which in the later stages of life
become unmanageable due to unhealthy lifestyle [15].The Native Americans also have a
tendency of high consumption of alcohol and the reason highlighted against this is increase
stress and lack of proper employment. Consumption of alcohol makes blood glucose level
unmanageable and thereby leading towards the development of unmanaged diabetes [10].
Genetic factors
According to the study conducted by Hales and Barker, genetic factors or genetic pre-
disposition is an important reason behind increased tendency of uncontrolled diabetes among
the Native Americans. The genetic predisposition is mainly guided by the hypothesis of
“thirty genotype”. According to this hypothesis, people with “thirty genotype” are more
efficient in restoring food as fat during prolong feast periods. The thirty genotype hypothesis
mainly deals with instant secretion of insulin after consuming meal. This is again guarded by
the survival advantage during the period of prolong starvation. This thirty genotype
advantage is mainly dominant over the ethnic Americans and this one time advantage among
the ingenious Americans has transformed into a disadvantage during the course of time. the
detrimental effects of “thirty genotype” hypothesis is increasing the tendency of developing
insulin resistance which in turn is increasing the tendency of developing type 2 diabetes
mellitus (T2DM) [3]. In relation to the genetic factors underlying the increase in the trend of
diabetes among the indigenous Americans, it can be said that American Indian or the Alaska
Native adults are 2.4 times more vulnerable in comparison to the white adults to be diagnosed
with diabetes. The Alaska Native women have double the chances of death from diabetes in
comparison to the non-Hispanic white women as recorded by the 2013 survey of U.S
Department of Health and Human Services Office of Minority. This vulnerability mostly
stays in the domain of developing type-2 diabetes. During the course of time, type-2 Diabetes
becomes unmanageable [15].

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Dietary habits
There is a strong relationship with the dietary habits and the development of diabetes
and its gradual transformation into uncontrolled mode of disease. Starting from food quality
to intake of food, dietary habits play an important role in determining the health status of a
population both physically and psychologically [4]. In the Native American culture, food
plays an important role under social situations starting from everyday life to religious
ceremonies and celebration. The change in the dietary habits and cultural of the native
Americans after coming in contact with the Euro-Americans impacted the overall health
status of the indigenous Americans [5]. During the latter half of the 20th century, the
government of America started limiting access of the traditional food to indigenous
Americans. So in order to cope up with this restricted source of food, the native Americans
started thriving of high fat and simple carbohydrate food as an alternative to high fibre and
complex carbohydrate food. The prevalenceof this food habit till now has increased the rate
of occurrence of diabetes among the indigenous Americans and difficulty in management
[5].The family food environment of the indigenous Americans also promotes the
development of diabetes. The family food habits are further modulated by the work status of
both men and women. In families where mothers are also working, the children are less likely
to consume fresh fruits and vegetables and this and this alleviate the burden of developing
diabetes [5]. At present the Native Americans mainly thrive on refined carbohydrate, fat and
sodium with very little intake of fruits and vegetables. The traditional food consumed by
indigenous Americans mainly includes mutton, tortillas, potatoes, eggs, deserts and fry
breads. All these food are rich in starch and cholesterol. Increase in the fat and carbohydrate
content of the food cause increase in the tendency of developing T2DM which in majority of
times have no cure thus regarded as uncontrolled diabetes [4].

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Obesity
Obesity is another determining factor behind the increase in the tendency of
developing diabetes among the indigenous Americans. The native inhabitants residing in the
South American, are mostly from Spanish origin (during the pre-Columbian age) [6]. Apart
from the people from Spanish background, several other ethnic groups from different cultural
backgrounds and socio-economic status have inhabited these territories. This ethnic group
residing in the Southern part of America are the victims of the uncontrolled diabetes. The
main reason highlighted against this uncontrolled weight. This uncontrolled weight is mainly
attributed to poor or unhealthy diet or lack of physical exercise. All these increase the
tendency of developing high level of blood cholesterol and blood pressure and this in turn
make diabetes unmanageable [9]. The indigenous Americans, especially the Latin Americans
of South America have high blood cholesterol level along with risk of developing cardio-
vascular disease. All these are non-modifiable risk factor underlying diabetes. The presence
of these non-modifiable risk factors makes diabetes mellitus unmanageable. The native of
South America have high salt intake in their diet along with increase in the intake of alcohol.
This unhealthy consumption of alcohol increase body mass index which in turn increase
vulnerability of diabetes and makes diabetes mellitus unmanageable. The South Americans
have poor socio-economic condition like lack of basic amenities in life and also lack proper
medical insurance and other public health services. Thus their disease is treated in low-
complexity hospitals or in isolated medical centres. These poor socio-economic conditions
make these communitiesbecome victims of uncontrolled body weight. One of the important
side-effects of uncontrolled body weight is high susceptibility in developing diabetes and the
overall management of diabetes mellitus difficult [6].
The rate of obesity among the indigenous people in America is as high as the rate of
obesity among the non-native US population. Among the North American natives, there are

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prevalence of childhood and young adult obesity. This places them at higher percentile of
developing diabetes. Mainly type 2 diabetes mellitus is common among the natives residing
in North America. The increase in the tendency of weight gain lead to an increase in the body
mass index making the overall health-related condition for diabetes unmanageable. Among
the natives residing in North America, the American Indians of the Plains states are the most
studied and storied groups [7]. One of the earliest investigations suggest that these native
Americans are born with high body weight and are mainly concentrated in North Dakota,
South Dakota, Nebraska and Iowa. Here prevalence of obese individuals is 2.5 times higher
than the other parts of America or among the non-indigenous American population.
Moreover, North Dakota, South Dakota and Nebraska are located in the extreme north
western part of North America underlying the southernmost border of Canada. These regions
are mainly regarded as outskirts of America which lacks standard health or treatment
facilities and lack of disease awareness. This trend makes obesity unmanageable.
Unmanageable obesity transform into unmanageable diabetes mellitus, mainly type 2
diabetes mellitus [7].
Summary of the review
The summary of the review mainly highlighted that genetic pre-disposition, unhealthy
dietary habits, increase trend of obesity unhealthy lifestyle leading to lack of proper
management of the disease are main reason behind the increase in the prevalence of the
uncontrolled diabetes among the indigenous Americans. The analysis of the literary articles
in the form of narrative review highlighted that the scenario is more or less identical both in
South American and in North American indigenous population. However, in South
American, the healthcare set-up is extremely poor and thereby causing unmanageable
condition for diabetes further. Among the type of diabetes, gestational diabetes and type 2

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diabetes mellitus are more popular. However, the review failed to identify the proper
evidences regarding effective management of the disease. The analysis of the literature
further highlighted that there are no significant studies conducted from the perspective of the
indigenous Americans regarding their opinions of unmanageable diabetes. Having proper
knowledge about the reason underlying the disease development and lack of proper
management of the disease from the indigenous perspectives will help the government to
frame proper strategies towards effective prevention of diabetes with a person centred
approach.
Aims of the current research
To analyse the reasons underlying the uncontrolled diabetes among the indigenous
Americans from their perspectives.
Research Questions
 What is health education status of indigenous people about diabetes control in
America?
 Whether the lack of proper health-care setup among indigenous communities is the
reason underlying uncontrolled diabetes
 Whether the lack of proper job opportunities is the reason behind high alcohol
consumption, smoking and obesity leading to unmanageable diabetes
 Do the indigenous population receive proper government support in terms of health
insurance to treat diabetes?
Summary of the hypothesis
Diabetes especially T2DM have higher prevalence among the indigenous population
of American in comparison to the T1DM. Theincrease in the prevalence of both type 1 and

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type 2 diabetes over indigenous Americans causes an overall increase in the burden of the
disease among the American population. In the United States, the increase in the trend of
diabetes and lack of proper management of diabetes has caused increase in the healthcare cost
by $2108 per patient per year [16]. This in nearly twice that of the non-diabetic patient’s
disease management cost. The overall economic burden of the disease management is
associated with direct cost of the medical care along with indirect cost of the decrease in the
overall professional productivity. Moreover, unmanageable diabetes mellitus lead to increase
the rate of mortality and morbidity. The increase in the direct cost of the disease is associated
with microvascular and macrovascular complications like coronary artery disease,
hypertension, myocardial infarction, peripheral vascular disease, end-stage renal disease and
retinopathy [11]. Thus, proper management of the disease is primitive in reducing the overall
disease burden along with reduction in the overall cost of care. The management of the
diabetes while done with a person-centered approach helps to increase the overall outcome of
the care effective disease management. This person-centered approach in the management of
diabetes among the indigenous Americans can be done if the strategies of disease
management are framed through the analysis of the perspective of the indigenous Americans.
Analysis the perspective of the indigenous Americans in the domain of their unhealthy food
habits, reasons underlying smoking and the government and health-related support they
receive from government will help to ascertain the gap in disease management. Then framing
the disease management strategies accordingly through bridging the gap will help in
obtaining the desired outcomes [12].

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References
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Type 2 diabetes and cardiovascular disease: have all risk factors the same
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behavioral interventions.Diabetes care. 2012 Dec 1;35(12):2681-9.

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