Background
This unit will discuss the Navajo Nation’s epidemic with diabetes. The school district that will be partaking in this unit is my place of employment, Kayenta Unified School District. Most of the classrooms are populated by Native American Indians. The majority of the Native American Indians are Navajos. There are a few who are members of other Native American Tribes in the school district. Some students are descendants and are enrolled with other Native American Indian Tribes such as the Hopi Nation, the Ute Tribe, and other Pueblo Tribes that are adjacent to the Navajo Nation Reservation.
Kayenta is located in the northeastern part of Arizona and on the Navajo Nation Reservation. It is the gateway to one of the most beautiful eight wonders of the world, the land formation called Monument Valley. Film makers and tourists all travel to this location to embrace the beauty of one of Mother Earth’s natural creations.
The Kayenta Service Area encompasses 4,500 square miles of beautiful red rock country on the northern portion of the Navajo Reservation. http://citehealth.com/dialysis-centers/arizona/cities/kayenta/four-corners-dialysis-clinic-kayenta
At the Kayenta Elementary School, there are five grade levels in our school which range from kindergarten to fourth grade. Since our school has adopted Arizona College Career Readiness Standard, the unique design of this curriculum changed our way of selecting resources. The transition of direct instruction to guided and facilitated instruction has awaken our creativity to teach with many questions in mind. This type of teaching requires teachers to revisit their teaching style of delivery. Not only is the style of delivery changed, but the type of strategies used will help students deepen their understanding of diabetes.
Content: Overview of diabetes and the pancreas
How can sugar be so threatening to Native American Indians? The program director from the local community’s clinics and the Diabetes Program stated that diabetes was around in the mid 1900’s, but it was not a huge problem like it is today. They indicated how diabetes is treated is basically the same as earlier, but how fast the medical facility finds out which patient has diabetes is faster than before.
Anatomy of the Pancreas: Where is the pancreas located in our body? It is important for young children to begin to know the anatomy of a human body. The pancreas is estimated to be around six inches long and lays across the back of the abdomen, towards the rear of the stomach. The head of the pancreas is on the right side of the abdomen and is connected to the duodenum (the first section of the small intestine) through a small tube called the pancreatic duct. The narrow end of the pancreas, called the tail, extends to the left side of the abdomen. 6
Structures (cells of the pancreas and cell): The pancreas contains clusters of cells called Islets of Langerhans, which include alpha cells and beta cells. There are more beta cells than alpha cells. Sherwood explains this in percentage. “The pancreas is an organ composed of both exocrine and endocrine tissues. The exocrine portion secretes a watery, alkaline solution and digestive enzymes through the pancreatic duct into the digestive tract lumen. Scattered throughout the pancreas between the exocrine cells are about a million clusters, or islands, of endocrine cells known as the islets of Langerhans. … 7
Beta cells: What is a beta cell? Beta cells produce insulin. According to Sherwood, “…beta cells, which are the site of insulin synthesis and secretion and constitute about 60% of the total islet mass.” 8
Alpha cells: The alpha cells produce the hormone glucagon and make up 25% of the islet mass. The alpha cell is at normal level until the secretion of glucagon is needed. When that happens the liver makes sugar called glycogen. Glycogen then enters the blood stream to balance out the sugar level. Other cells are also present in the Islets of Langerhans:
Less common (making up 10% of islet mass), the delta cells are the pancreatic site of somatostatin synthesis. The least common islet cells (1% of islet mass), the F cells, secrete pancreatic polypeptide, which plays a possible role in reducing appetite and food intake,…(The remaining 4% of islet mass consists of connective tissue, blood vessels, and nerves) 9
Ducts: The exocrine cells of the pancreas generate enzymes to help process food. These enzymes are secreted through tubes called ducts. The ducts are connected through the length of the pancreas and empty the fluids containing enzymes into the duodenum. The duodenum is the beginning part of the small intestine.
The endocrine part of the pancreas is made up of islets of Langerhans. These cells release hormones. Unlike the exocrine, it does not release anything into the ducts. The products of the islet cells are released into the bloodstream.
Physiology of the Pancreas: When the body is fed a process of storing the useful molecules in food begins. It is regulated by a process called negative feedback. This feedback explains how the blood sugar level is balanced. First, as the food passes through the digestive tract, the exocrine cells do their work. The enzymes of digestion releases glucose/sugar from food, which is absorbed into the blood stream. This increases the blood glucose levels. The islet of Langerhans which has the beta cells is alerted of the excessive sugar in the blood. The beta cell starts to release the hormone insulin. This insulin is released into the blood. Then the insulin targets body cells including the liver. Keep in mind that the liver stores sugar in a form called glycogen. In addition, the muscle cells is another place that glycogen can be stored. Once the sugar is pulled out of the blood, under the control of insulin, a decrease of sugar occurs in the blood. The beta cells then stop making insulin, in response to the negative feedback signal of low glucose.
The second way the pancreas function is when the body is not in taking food. In between meals, a body will sense a low blood glucose level. 10 When sugar from food is not immediately available, the liver will make its own supply of sugar in a process called gluconeogenesis. Since the body has a low level of sugar, it will have low levels of insulin. Low insulin causes an increase in gluconeogenesis in the liver. A second hormone is responsible for the release of glucose from storage. The alpha cells in the islets of Langerhans release glucagon into the blood. Glucagon is another hormone which is antagonistic to insulin. The glucagon triggers neoglucogenesis from liver glycogen storage. As this happens, a release of fresh glucose enters the blood. In this way, the blood glucose levels can rise, even when food is not being digested. The increase of glucose suppresses glucagon function by alpha cells and this process turns off the cycle.
Diabetes: If insulin is released from the pancreas, but does not function as it is supposed to, the sugar in the bloodstream increases to a level that is not healthy. Then it becomes a disease called diabetes. The amount of glucose in the blood sometime rises so that that some of it escapes into the urine. Production of sugary urine is one of the symptoms that tell a person of an onset of diabetes.
There are two types of diabetes. The first is Type I diabetes. “Type 1 diabetes mellitus is an autoimmune process involving the erroneous, selective destruction of pancreatic beta cells by inappropriately activated T lymphocytes.” 11The reason behind the cell ‘self-attacking’ is not clear. It might be genetic cause or environmental. Because the beta cells are destroyed, the cell cannot make insulin to balance out glucose. This type of diabetes used to be mostly associated with juveniles and for that reason it used to be called juvenile diabetes. The treatment for this diabetes is insulin shots.
Type 2 diabetes is a hormonal disease in which the cells of the body become resistant to the insulin produced in the pancreas. The cause of type 2 diabetes is also unknown, but it can be related to a person’s diet, amount of exercise, and genetics. In Type 2 diabetes the insulin released from the pancreas is not recognized by the body cells, preventing sugar storage. The glucose stays in the blood stream because insulin is not effective at storing sugar. This is called insulin resistance. When glucose concentration in the blood gets high, the kidneys cannot retrieve all the glucose so it is excreted into the urine. When there is such a high level of glucose in urine, the kidneys cannot absorb a lot of water. This leads to excessive urination and causes dehydration. With enough time, high glucose blood level can cause nerve damage to the eyes and outer body tissues, and of course kidney damage. Also, this high glucose level can wear down the cardiovascular system. 12
Prevention and treatment of diabetes: Treatment and/or prevention for Type 2 diabetes could be better in the future by enforcing a screening and prevention program. 13 It is known through studies and Kayenta clinic presentations that a change of diet and exercise can prevent the onset of prediabetes and control type 2 diabetes. What is prediabetes? It is the malfunctioning of the glucose tolerance that does not quite fit the criteria for diabetes. Exercising and losing a minimal weight of 5% to 7% can make a huge difference in regulating or balancing the sugars in the blood stream.14
Other prevention advice that many Navajos hear from the Kayenta Diabetes Project is to reduce and manage your stress. As David Sledge, MD, medical director of diabetes management at The Ochsner Clinic Foundation in Baton Rouge, La indicated, stress makes your glucose levels rises. Then the stress hormones like epinephrine and cortisol enters your blood stream. The example of making energy to survive or fight-or-flight response kicks in. However people with diabetes have to regulate the sugar level because of food. When stress hormones are added on, the cells are working overtime to store sugars. We need to teach 4th grade students that both physical and emotional stress can prompt an increase in these hormones, resulting in an increase in blood sugars. Stress management is a treatment or preventative treatment for type 2 diabetes.
Diet / Navajo Culture’s role in Diabetes: Today medical personal and staff that work with diabetes prevention advise that a balance of healthy food and exercise help control diabetes. The belief of balancing food intake and exercise hold true in the Navajo culture. Robert S. Young of Diabetes as a Disease of Civilization: The impact of Culture Change on Indigenous Peoples, explains how the Navajo culture views a healthy body. A healthy body ties nature, spiritual, physical, and mental understanding of existence.15 In order for a body to be healthy, one practices respect of body. As young Navajo people, parents and elders direct us to choose food that will not harm us. Foods that are naturally grown are best to eat verses food that come in cans or packages are risky because it is not all natural. In addition our elders taught us to be balance spiritually. One has to run to the dawn each day. This allows your mind to intake a new positive beginning. A fresh mind set helps your body replenish itself. By having a new outlook for the day, an individual is balanced and able to make good healthy choices for the entire day. Today’s traditional beliefs and attitudes among Navajo are different from long ago. Since the United States government issued commodity foods donated by the Department of Agriculture (USDA), the traditional way of collecting food and storing food changed. The dependence on canned or packaged food causes many Navajos to not plant and find fresh food. Today Navajo rely on packaged and canned food because it is easier to store for later use. The old way of drying and preserving native food is not practiced in Navajo culture. Local health centers are beginning to share the information that eating high amounts of processed food causes weight gain. The weight gain leads to unhealthy living. Extra calorie intake is not balanced out with regular exercising. This dangerous cycle of eating, weight gain, and lack of exercise is recognized by diabetes prevention team. So teaching children about calorie count is the next best option to healthy living.
Weight loss by calorie count is definitely one effective method of non-drug prevention. Annals of Internal Medicine journal showed that reducing a 15% to 20 % of weight loss through calorie count is a good goal to start with. A manageable goal of 15% to 20% gives one success and endurance to continue a better lifestyle.
A high fat diet interferes with insulin action. “It is biologically plausible that high-fat diets promote weight gain, which then promotes insulin resistance. There is a large body of evidence that supports this view. In addition, there is growing evidence that obesity plays a central pathogenic role in the development of diabetes. This means that any dietary factor that promotes weight gain will likely promote the development of diabetes. The ubiquitous role of fat in fuel metabolism, energy and fat balance, and structure and function of cell membranes and also as a ligand for nuclear receptors that influence gene expression, make it highly plausible that both the total amount and type of dietary fat play an important role in insulin action, weight maintenance, and prevention of diabetes.” 16
The U.K. Prospective Diabetes Study showed ”that the quality of blood glucose control plays a central role in the development of micro- and macroangiopathy in type 2 diabetes and that improved glycemic control clearly reduces the occurrence of secondary diabetes complications”. 17 There are three findings in this research. Patients increase their self-perception. Food, glucose level and well-being were recorded on a daily basis. Next finding was promotion of self-reflection. Patients had to record what worked well and did not work well with their blood glucose monitoring. What factors cause the levels to change? Imagine the discussion that helps them make better food choice. The last finding was the enhancement of self-regulation. Patients discuss how to use self-monitoring of blood glucose to help with diary entries to improve metabolic control and assess the probabilities of achieving set goals. All three findings assisted patients in having a balanced sugar level.
Choosing complex carbohydrates (whole grain, cereals) verses simple sugars (sweets) can help in control of diabetes. Study shows that a low glycaemic index diet with bigger amounts of fiber and smaller amounts of processed whole grain products seems to improve glycaemic and insulinaemic responses and lower the risk of Type 2 diabetes. The old saying of eating simple or complex carbohydrates is not a good indicator of getting Type 2 diabetes. 18
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