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Cook&TillmanThesis 1
NATIVE FOOD SOVEREIGNTY: A BEST PRACTICE PROPOSAL TO PREVENT
DIABETES IN ADOLESCENT TOHONO AND PIMA INDIAN
By Douglas G. Cook & Tanya M. Tillman
A Project
Submitted in Partial Fulfillment
of the Requirements for the Degree of
Master of Science
in Nursing:
Northern Arizona University
August 2011
Approved:
______________________________
Linda Paul, Chair
______________________________
Karine Crow, Committee Member
______________________________
Vicki Black-Bishop, Committee Member
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ABSTRACT
NATIVE FOOD SOVEREIGNTY: A BEST PRACTICE PROPOSAL TO PREVENT
DIABETES IN ADOLESCENT TOHONO AND PIMA INDIAN
Douglas Cook & Tanya Tillman
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ACKNOWLEDGEMENT
We want to say thank you to our project committee chair Linda Paul and our
committee members Karine Crow and Vicki Black-Bishop for their guidance and
facilitation in the completion of our thesis project.
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TABLE OF CONTENTS
List of Tables………………………………………………………………………………..6
List of Figures……………………………………………………………………………….7
List of Appendix…………………………………………………………………………….8
CHAPTER 1: THE RESEARCH PROBLEM AND PURPOSE
Background………………………………………………………………………….9
Significance of Problem……………………………………………………………10
Current Approaches to the Problem………………………………………………..12
Description of the Setting………………………………………………………….13
Population Affected by the Problem……………………………………………….13
Research Question…………………………….…………………………………...14
Conceptual or Theoretical Framework xx
CHAPTER 2: LITERATURE REVIEW
Evidence Based Practice and Standards of Care for Diabetes Mellitus
Body Mass Index and Diabetes
Diabetes in population adolescents
US verses Mexico population
Native Food Sovereignty………………………………..
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Promotoras (mahkai and Himdag)…………………………………………
Summary………………………………………………………………..
CHAPTER 3: PROJECT DEVELOPMENT
Tohono Cultural Competencies
Available Resources
Nurse/Tohono healer
Western Medicine Advisory Role
Himdag Restoration Team
Hot Spots
Desired Cultural/physiologic Outcome
Summary
CHAPTER 4: IMPLEMENTATION
Implementation of proposed best practice
Center of Excellence Foundation
Evaluation protocol
5. CONCLUSION AND BENEFITS OF THE PROJECT.................................
Interpretation of Evaluation Findings
Limitations of the Study…………………………………………………….
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Conclusions and Recommendations……………………………………..
REFERENCES…………………………………………………………………………..
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LIST OF TABLES
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LIST OF FIGURES
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LIST OF APPENDIX
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CHAPTER 1
THE RESEARCH PROBLEM AND PURPOSE
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
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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).
Significance of the Problem
The Pima/Tohono 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
populations by the 1950s. In 1965, systematic diabetes screening became part of a
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
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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
out of the wild seeds. That is food!” (Underhill, 1979).
Current Approaches to the Problem
The arms brought to bear in the fight against obesity and NIDDM is the latest
evidence-based nutrition principles and treatment modalities as outlined by the American
Diabetic Association. However, the message to reduce caloric and carbohydrate intake has
been repeated time and time again with little to no effect, along with increasing physical
activity. 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 Diabetes Association, 2002).
Fortunately, non-medical interest groups, a revitalization of popularity of 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
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Tohono O’odham Community Action (TOCA) is a community-based organization that
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).
Native Food Sovereignty is referred to as returning to traditional diet. 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.
Description of the Setting
The Tohono O’odham Nation consists of four geographic locations in Southern
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
53,000-acre Salt River – Maricopa Indian Community is home to approximately 7,200
people that consist of Pima and the culturally distinct Maricopa Indian (Curtis, 2003).
Population Affected by the Problem
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
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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
Southward migration from Canada (Curtis, 2003).
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).
Pima/Tohono culture incorporates Himdag, which translates to “our path” (Woods,
Blaine, & Francisco, 2002). Himdag provides an assessment of the individual’s critical
balance between mental, physical, and spiritual health it (Martinez, G. A. (2005). Himdag
is a gift that cannot be claimed by any other Indian Tribe or Nation and it demands respect
for those that hold it (Martinez, G. A. (2005). The concept represents the pathway
(holistic/lifelong journey), which preserves the member’s strength, affords protection, and
fosters wellness for the Tohono people. The concept represents much more than culture as
it incorporates everything that makes the individual unique as an individual and a member
of the greater Tohono Nation (heritage, history, values, traditions, customs, beliefs, and
language). Also used as a verb, Himdag means to “be able to walk”. The concept
integrates values, language, arts, kinship, games, the environment, mobility, and medicinal
plants in a force that connects the individual to self and the tribe (Martinez, G. A. (2005).
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Research Question
Will changing to a culturally traditional diet (I) be as effective as other interventions
(C) for glycemic control (O) (hemoglobin A1C 5.7-6.4) in Pima/Tohono O’odham
adolescents (P) diagnosed with Pre-diabetes?
Conceptual or Theoretical Framework:
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
(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
effective in controlling obesity. In turn, controlling obesity in a population is the single
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.
Therapeutic/Integrative/Complementary Health Strategies: The proposed health
strategy could not be simpler, which focuses on behavior modification to promote
nutritional sovereignty and increased physical activity. The decline in nutritional health of
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the Tohono paralleled the abandonment of the native diet and adoption of Western culture
that threw Himdag out of balance for the people.
The proposed strategy is to reduce and slide medical Western intervention to a
subservient/advisory role as a tool for the people to restore Himdag. In the traditional
Tohono way, people would walk and run to great the rising sun each morning. This act
was exercise, but it was viewed as Himdag…not exercise. Helping individuals, families,
and the community reclaim traditional physical activities (singing, walking, running,
playing games) will increase physical activity. Helping the people reclaim the native diet
will put them in-line with the American Diabetes Association’s recommendation for a high
fiber, low caloric diet rich in vegetables and lean protein sources (American Diabetes
Association, 2002).
IproposetrainingyoungTohonoadultsaslayhealthcoaches.Thetraining
objectiveistorestoreHimdagandcurriculumdevelopmentwillbeleadbytheelder
Tohonoandmahkai;Westernmedicalexpertswillberelegatedtoanadvisoryrole.
Westernmedicinecanrelegateitsresources(IndianHealthServiceresources)toan
epidemiologictooltoidentifyhotspotsofobesityanddiabeteswithinthecommunity
andtotrackclinicalchanges(improvement/declinesinobesity/diseaserates).A
Tohonoteamthatconsistsofmahkiandlayhealthcoachwillmaintainclosecontact
withidentifiedpatientstohelpthemrestoreHimdag.Supportiveresourcesinclude
theNativeSeedsSearch,anon-profitorganizationthathasledagrassrootseffortto
protect,preserve,andpropagatenativeSonoranfoodcropsandtoencourageNative
PeoplestoeatNativefoods(NativeSeedSearchon-line,2010).TheTohonoO’odham
employedcasinorevenuestobuildaculturalcenterandmuseum.TheTohono
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O’odhamCommunityAction(TOCA)isacommunity-basedorganizationthatstrives
torestoreculturalandphysicalhealthtothedesertpeople.Oneofthemainprinciples
ofTOCAistheconceptof“NativeFoodSovereignty”(TOCAon-line,2010).Other
resourcesinthecommunitythatcanbeutilizedarethecommunitycollege,hospital,
andseveraloutpatientclinicsmanagedbytheIndianHealthServices(UnitedStates
PublicHealthService).IproposethisprogrambebaseoutofTohono O'odham
Community CollegeinSells,Arizona.
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CHAPTER 2
LITERATURE REVIEW
A literature review focused on the central clinical question: Will changing to a
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.
Evidence Based Practice and Standards of Care for Diabetes Mellitus
Body Mass Index and Diabetes
Schulz, Bennett, Ravussin, Kidd, Kidd, Esparza, et al. (2006) conducted research
that demonstrated an environmental component to obesity (measured by BMI) and type-2
diabetes (diagnosed by OGTT) in the Pima Indian. This correlation 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
Mexican Pima females (statistically similar to incidence in non-Pima Mexicans). The
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
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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
by controlling obesity and increasing physical activity level.
Thearle, Bunt, Knowler, and Krakoff (2009) conducted a correlation descriptive
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
preventing type-2 diabetes by controlling childhood obesity.
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Diabetes in population adolescents
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
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
re-enforces the importance of interventions directed at diabetes prevention in the Pima
Indian youth.
US verses Mexico population
Native Food Sovereignty
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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
and assigned the participant to one of the five stages of change outlined by the TTM (pre-
contemplation, contemplation, preparation, action, and maintenance). Measurement scales
measured TPB; participant attitude for following a PBD was measured using a 4-item scale
(“bad” to “good”, “harmful” to “beneficial“ “unpleasant” to “pleasant”). The study
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.
However, attitude was found to be a strong predictor of behavioral change in adopting a
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
can provide direction in facilitating change in the Pima/Tohono adolescent population.
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 correlation descriptive study collected survey data from 162 Pima Indians who
were asked to identify their diet as “Indian”, “Anglo” or “Mixed”. The study also contained
a longitudinal component where non-diabetic participants were later diagnosed with that
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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
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.
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Promotoras (mahkai and Himdag)
Summary
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CHAPTER 3
PROJECT DEVELOPMENT
Tohono Cultural Competencies
Available Resources
Nurse/Tohono healer
Western Medicine Advisory Role
Himdag Restoration Team
Hot Spots
Desired Cultural/physiologic Outcome
Summary
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CHAPTER 4
IMPLEMENTATION
Implementation of proposed best practice
Center of Excellence Foundation
Evaluation protocol
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CHAPTER 5
CONCLUSION AND BENEFITS OF THE PROJECT
Interpretation of Evaluation Findings
Limitations of the Study
Conclusions and Recommendations
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REFERENCES
American Diabetes Association (2002). Evidence-based nutrition principles and
recommendations for the treatment and prevention of diabetes and related
complications. Diabetes Care, 25 (1), 202-212.
Martinez, G. A. (2005). My Desert Encounter with Himdag. Tribal College Journal , 17(2),
54. Retrieved from EBSCOhost .
Native Seeds Search on-line, 2010, http://www.nativeseeds.org
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 and
Support Healthy Choices, retrieved on 20 Feb 2010 from
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
traditional and Western environments on prevalence of type 2 diabetes in Pima
Indians in Mexico and the U.S. Diabetes Care, 29(8), 1866-1871. Retrieved from
CINAHL Plus with Full Text database.
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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
of energy intake vs expenditure. (Paper). International Journal of Obesity, 27, 12.
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
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