Introduction

                The Special Diabetes Program for Indians grants money to tribes for the purpose of diabetes health care and prevention. Each tribe is required to implement at least one Best Practice from the SDPI guidelines and report on each of the Key Measures for that particular Best Practice. The Best Practices that the Winnebago Tribe of Nebraska has chosen to implement are Physical Activity for Diabetes Care, Nutrition for Diabetes Prevention and Care, Youth and Type 2 Diabetes Prevention and Treatment. These Best Practices were chosen based off the current resources the tribe has to offer such as a newly constructed Wellness Center, along with appropriately educated staff to carry it out, such as a Registered Dietitian, Kinesiologist, Personal Trainers, etc.

                The Target Group that was selected for these Best Practices were 3rd-6th grade students with a BMI in the 85th percentile or greater, from Winnebago Public School and St. Augustine School. This group was chosen based off of the high prevalence of overweight and obesity in this age range (57% n=113/198) and that it appears, this is the youngest age in which the students are able to follow direction and make conscious efforts to embrace positive and healthy habits.

 

Methodology

                The youth diabetes prevention program that is operated by Winnebago’s Special Diabetes Program for Indians incorporates not only the Physical Activity Best Practice Key Measures, but Key Measures from the Nutrition, and Youth and Type 2 Diabetes Best Practice. Youth Staying Healthy curriculum along with Native Wellness is also incorporated into the program to make it quite comprehensive. The program occurs after school hours (3:45pm-4:30pm) while the school year is in session. Otherwise, it occurs in the mornings (10:00am-12:30pm) during the summer months. Each program lasts for 9 weeks and includes the following: 1 recruitment week, 1 pre-assessment week, 6 weeks of exercise programming, 5 days of Youth Staying Healthy Curriculum, 2 days of Native Wellness, and 1 post-assessment week.

                Recruitment for the program occurs 1 week prior to the pre-assessment week. Recruitment is done via phone calls and text messages, emails, letters, face-to-face meetings with the Target Group students, and face-to-face meetings with parents of Target Group students. One of the more successful ways the program has been able to get parents to reach out with the interest of enrolling their child(ren), is by sending a letter to the parents of all students that fall into the Target Group (3rd-6th grade students with a BMI in the 85th percentile or greater). The letter explains that based off of their child’s height and weight their BMI puts them at risk for certain morbidities. It is then encouraged that the parent contact the Whirling Thunder Diabetes Program to enroll into the program or work 1 on 1 with a personal trainer. There has been numerous parents that have contacted the program explaining they received a letter and are interested in having their child(ren) participate in the program.  

 

 

Week 1 Recruitment:

·         5 Personal trainers each recruit 6 Target Group students for a total of 30. Breaking up the groups into 6 students per staff member allows for better instruction, better learning, increased enthusiasm for participation, better adherence, less distractions or teasing, which consequently, can lead to better fitness levels, and lower BMI’s.

·         Some Target Group students that are making good progress, or exhibit a strong desire to continue in the program are retained for another round of the prevention program. In this instance there would be less than 30 new Target Group students recruited.

Week 2 Pre-assessment week:

·         Personal Trainers hold face-to-face meeting with parents and/or Target Group student.

o   During these meetings an overall explanation as to what the Physical Activity portion of the program is trying to accomplish is given to the Target Group students and parents.

o   Several forms are required to be signed by the parents including: facility waiver/liability, participant form, A1C consent, medical history, and HIPAA.

o   Physical activity behavioral goals are established at this time with parents and Target Group student.

·         Personal Trainers perform required testing and measurements during this week. This includes: height, weight, body fat percentage, skeletal muscle mass, body fat mass and any fitness testing (pushups, shuttle run, pullups, etc.)

·         The programs Registered Dietitian holds face-to-face meetings with parents and/or Target Group student.

o   During these meetings an overall explanation as to what the Nutrition portion of the program is trying to accomplish is given to the Target Group students and parents.

o   Nutrition behavioral and clinical goals are established at this time with parents and Target Group student.

o   Medical nutrition therapy and nutrition education are delivered to the Target Group students.

·         A RN, CDE or Lead Educator performs A1C and blood pressure readings.

Week 3-8 Physical Activity programming:

·         For 6 weeks the Target Group students will be in 5 groups of 6 individuals doing various physical activity programming with the Personal Trainers.

·         Physical activity programming is held on M-Th for the 6 weeks, and lasts 45 to 60 minutes.

·         The physical activity programming includes, but is not limited to:

o        Free weight circuit

o        Cardio circuit

o        Pool circuit

o        Group cycling

o        Agility/speed circuit

o        Machine weight circuit

o        X-Box Kinect

o        Zumba

o        SPARK Games

o        PE Sports

o        Obstacle Courses

o        Kickboxing

o        Rock Climbing

o        Fitness Races

o        Hiking

o        Biking

 

·         On 5 Wednesday’s, during the 6 weeks of the Physical Activity programming, the Registered Dietitian and a Registered Nurse teach the Youth Staying Healthy curriculum to the Target Group students.

·         On two non-consecutive days throughout the 6 weeks of Physical Activity programming, a Native Wellness presentation is given to the Target Group students by 2 of the Personal Trainers that received training in Native Wellness curriculum.

 

Week 9 Post-assessment week:

·         Personal Trainers hold face-to-face meeting with parents and/or Target Group students.

o   During these meetings behavioral goals are revisited and an update on progress is made.

·         Personal Trainers revisit testing and measurements during this week. This includes: height, weight, body fat percentage, skeletal muscle mass, body fat mass and any fitness testing (pushups, shuttle run, pullups, etc.)

·         The programs Registered Dietitian holds face-to-face meetings with parents and/or Target Group students.

o   During these meetings nutrition behavioral and clinical goals are revisited with parents and Target Group students, and an update on progress is made. 

·         A RN, CDE or Lead Educator performs A1C and blood pressure readings only on Target Group students that had elevated A1C and/or blood pressure readings from the pre-assessment week.

·         Assessment letters are sent out to parents at the end of the 9 week program which detail gains/losses in body fat percentage, skeletal muscle mass, and body fat mass. The letter also makes note of any abnormal measurements in the A1C and Blood Pressure tests, and recommends a follow up with the Diabetes Program’s RN, CDE for further explanation and potential appointment with a physician.

SDPI staff participation:

 

·         SDPI Program Director/Kinesiologist

·         Registered Dietitian

·         Personal Trainers x 3

·         Data Entry Clerk

 

Non-SDPI staff participation:

 

·         Registered Nurse, CDE – Tribal Diabetes Program

·         Registered Nurse – Public Health Nursing

·         Lead Educator – Tribal Diabetes Program

·         Personal Trainers x 2 – Tribal Diabetes Program

 

Results

A contracted version of the aforementioned program was first implemented in January of 2014. The contracted version lacked the pre and post-assessment weeks, along with the native wellness training days. Using the contracted version of the program, the following results were obtained comparing screening data from FY 2013 to FY 2014. 61% (n=46/75) of Target Group population were recruited into SDPI programming. 62% (n=24/46) of the recruited lowered their BMI percentile or stayed the same. BMI was used as a measuring tool because the program did not have a high grade body compositional analysis machine at the time. 100% (n=14/14) of the students in the target population with a BMI percentile that exceeded the range of expected values (off the chart) lowered their BMI percentile to 99 or lower.

 

Using the complete version of the aforementioned outlined program that started in October of 2014, a comparison was made of the earliest body composition screening with the latest body composition screening for each of the target group population. The range of time between body composition screenings ranged from 3-5 months apart. 5 different scores were recorded, weight, skeletal muscle mass, body fat mass, body mass index, and percent body fat. 3 of those scores were analyzed, skeletal muscle mass, body fat mass, percent body fat.  The data shows 68% had an increase in skeletal muscle mass, 37% had a decrease in body fat mass, and 42% had a decrease in body fat percentage. The mean changes for the program participants that showed improvement is as follows:

 

Cumulative Mean Improvement

Skeletal Muscle Mass (lbs)

Body Fat Mass (lbs)

Body Fat Percentage (%)

+1.3

-2.44

-1.45

 

Data was analyzed per group to determine whether here was a significant difference in improvements among groups.

 

Percent Improvement by Group

Skeletal Muscle Mass

Body Fat Mass

Body Fat Percentage

Group 1

67%

33%

50%

Group 2

63%

37.5%

62.5%

Group 3

56%

44%

44%

Group 4

100%

43%

43%

Group 5

71%

43%

29%

(This table represents the percent of each group that showed increases in skeletal muscle mass, and decreases in body fat mass and body fat percentage.)

 

 

Mean Improvement by Group

Skeletal Muscle Mass (lbs)

Body Fat Mass (lbs)

Body Fat Percentage (%)

Group 1

+1.1

-2.85

-0.9

Group 2

+1.72

-2.43

-1.65

Group 3

+1.53

-2.78

-1.45

Group 4

+1.68

-0.76

-1.0

Group 5

+0.84

-3.3

-2.1

(This table represents the mean improvement for skeletal muscle mass, body fat mass, and body fat percentage of each group.)     

 

Conclusion

                A trend that has been shown over multiple years (2011-2014) since school screening data has been collected, is that the target group population with the highest BMI percentiles (>=99%), that participate in SDPI programming, have shown the greatest reduction in BMI. This trend holds true comparing screening data from FY 2013 to FY 2014 where 100% (n=14/14) of the students in the target population with a BMI percentile that exceeded the range of expected values (off the chart) lowered their BMI percentile to 99 or lower. While BMI percentile was not taken into account when analyzing the data collected from the complete program that started in October 2014, it is possible that the groups that made the most progress were potentially the groups with largest amount of high BMI percentile (>=99%)  target population members.

                It is clear from the data analysis that the majority (n=26/38 or 68%) of the target group population gains skeletal muscle mass during the program. This may be attributed to an increased demand on muscles when individuals in overweight and obesity categories become more active. The body mass that is being carried by the target group population may cause enough excess stress to instigate an adaptation of muscle gain more rapidly than it would of individuals with a lower BMI.

42% (n=16/38) of the target group population lost body fat percentage during the complete program. Considering that the majority of the individuals in the target group population have likely been trending upwards in body fat mass and body fat percentage for a number of years, it is very encouraging to see almost half of those be able to halt, or even reverse that trend downward. For any of the target group individuals that did not show progression, it is important to consider other factors. Not all of the target group population individuals attend all of the possible program sessions. There is potential for a positive correlation between amount of sessions attended and the amount of progress made. This is a variable to consider in future data analysis. Also, while the exercise programming is fairly standardized between the groups, there is enough variation that it could explain the differences between the groups, as well as the group leader’s ability to motivate the target group population to work hard. There are also external factors out of the control of the program such as the target group population diet when they are at home adipex without perscription . A common effect of increased exercise is an increase in appetite. Individuals in the target group population may go home after programming and eat more than usual to compensate for their activity. This is why including a nutrition component into the program is of utmost importance.

37% (n=14/38) of the target group population lost body fat mass during the complete program. All of the same factors in the above paragraph must be considered for this piece of data also.

In conclusion, data analysis needs to occur for a greater length of time to determine any long term successes or failures, along with factoring in other variables such as program attendance percentages than can be compared with progress made or not made.

 

 

Our Location

Winnebago, Nebraska - United State of America