No. 2, April 2004
Social and Cultural
Barriers to Diabetes Prevention in Oklahoma American Indian Women
Christopher Taylor, MS, RD, Kathryn S. Keim, PhD, RD, LD, Alicia Sparrer,
MS, RD, LD, Jean Van Delinder, PhD, Stephany Parker, PhD
Suggested citation for this article: Taylor C,
Keim KS, Sparrer A, Van Delinder J, Parker S. Social and cultural barriers to
diabetes prevention in Oklahoma American Indian women. Prev Chronic
Dis [serial online] 2004 Apr [date cited]. Available from: URL: http://www.cdc.gov/pcd/issues/2004/
The prevalence of diabetes is disproportionately higher among minority
populations, especially American Indians. Prevention or delay of diabetes in
this population would improve quality of life and reduce health care costs.
Identifying cultural definitions of health and diabetes is critically
important to developing effective diabetes prevention programs.
In-home qualitative interviews were conducted with 79 American Indian women
from 3 tribal clinics in northeast Oklahoma to identify a cultural
definition of health and diabetes. Grounded theory was used to analyze
The women interviewed defined health in terms of physical functionality and
absence of disease, with family members and friends serving as treatment
promoters. Conversely, the women considered their overall health to be a personal
addressed individually without burdening others. The women presented a
fatalistic view of diabetes, regarding the disease as an inevitable event
that destroys health and ultimately results in death.
Further understanding of the perceptions of health in at-risk populations
will aid in developing diabetes prevention programs.
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The American Indian people and culture have sustained serious hardships
throughout the last 2 centuries; their greatest struggle, however, may be impending. The rate of diabetes is disproportionately higher in minority
populations, especially the American Indian population (1-4). Indian Health
Service (IHS) national outpatient data indicate that the age-adjusted
prevalence rate of diabetes among American Indians is an estimated 88.7 per
1000 for individuals older than 15 years (5). In the Oklahoma City
area, the largest of IHS areas, the age-adjusted prevalence rate of diabetes
is 60 per 1000 individuals (3), indicating that American Indians are 2.43
times more likely to have diabetes than the general population at 39 per
1000 individuals (6).
Furthermore, national data indicate age-adjusted prevalence rates are
greater for American Indian women (12.0%) compared to American Indian men
(9.7%) (3). Lee et al observed in an Oklahoma sample that 38% of American Indian men had diabetes
compared with 42% of American Indian women (7).
Diabetes is a multifaceted disease that is reaching epidemic proportions
in the American Indian community (1). If diabetes could be prevented or
delayed in this population, the benefits in quality of life and health care
cost savings would be considerable. Rhoades et al estimated 882 years of
productive life lost due to diabetes mellitus over a 3-year period among American Indians receiving health care services
from IHS (8). Diabetes results in compromises to longevity and quality of life
and in economic disadvantages. Health care costs for treatment of
non-American Indian patients with diabetes in 1994 were 2.4 times greater
than non-American Indian controls, with long-term complications accounting for 38% of the costs
(9). Through a Monte Carlo study based on American patients with diabetes, intensive blood
sugar control was estimated to produce a 3% reduction in health care costs
over 30 years (10).
Additionally, Oklahoma Behavioral Risk Factor Surveillance System data
demonstrated a significantly greater number of days of disability and poor
physical health for patients with diabetes compared to control subjects
without diabetes (11). These data have obvious ramifications for workplace
productivity. Success at delaying or preventing the onset of diabetes will
reduce the costs of diabetes treatment and prolong an individual's potential
to be a contributing member of the economy.
A greater understanding of American Indian perceptions of health and
diabetes is paramount to the success of diabetes prevention programs among
these populations (12-15). Perceptions of the inevitability of diabetes
within the reservation environment have been reported (16-18). Perceptions
of health among American Indian elders in an urban setting have also been
presented (19). Data is lacking on the relationship of diabetes to health
and the social environment as well as the perception of the feasibility of
diabetes prevention. This study used in-depth qualitative interviews to
ascertain a cultural definition of health and diabetes from American Indian
women residing outside a reservation setting. The information learned will
be used to plan culturally appropriate nutrition education and health
promotion programs aimed at preventing or delaying the onset of diabetes
among American Indians in Oklahoma.
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The data contained herein represent a portion of a larger study that involved
a series of 3 sessions with each study participant. The first session
included demonstration of informed consent, completion of a demographic
questionnaire and a rank-order assessment of life concerns, and training for
a 4-day weighed-food record collection. During the second interview, the
participants responded verbally to questions from the Cultural Structure
of Health and Diabetes questioning guide (Table
1) and completed a free food sort of previously determined most commonly
consumed foods. The food sort allowed participants to group foods based on their own classifications. The final session included a weight valuation interview
to identify the cultural perceptions of body image and
a trichotomous food sort of the most commonly consumed foods. In this sort,
participants sorted food into groups based on their perceptions of health
value and fat and sugar content. The research protocol was reviewed and
approved by the Institutional Review Board at Oklahoma State University and
the executive counsels for the cooperating tribes.
Five female American Indian interviewers were hired to conduct the
in-depth interviews. Each interviewer completed a one-day course on subject
recruitment, interview structure, data collection techniques, and response
recording. The training consisted of equipment usage, essential techniques
of qualitative interviewing (listening and directive questioning
skills, for example) and the logistics of the qualitative interviews. The interviewers
were compensated $100 for training and $125 for each participant who
completed 3 interviews.
Women of at least one quarter American Indian blood, between ages 18 and 65 years, who were not pregnant or lactating, were eligible
for the study. A diagnosis of chronic disease, including diabetes, did not
prevent inclusion; however, women diagnosed with chronic diseases that have
an impact on appetite (including women receiving cancer treatment) were
excluded from the study. Women were recruited proportionately from tribal
health clinics in northeast Oklahoma using a non-probablility sampling
design. To increase participation rates, women who successfully completed
the interview process received $125.
Key informants and the American Indian interviewers at each of the
clinics recruited potential subjects for the research study. Articles were
published in tribal newsletters and newspapers to promote the study. Women
interested in participating were referred to one of the interviewers to
receive more information, determine eligibility, and schedule interviews.
Additional subjects were recruited from tribal diabetes education programs
and the 3 tribal general health clinics.
Data collection and analysis
This study reports results of the interviews during the second session,
in which participants responded verbally to questions from the Cultural
Structure of Health and Diabetes questioning guide (Table 1). Questions from
previous research (20) were modified to identify cultural perceptions of
health and diabetes. Questions focused on areas of interest that were
consistent with the objectives of the study, such as perceived causes,
treatments, and efficacy of diabetes prevention behaviors. Key informants
within each clinic reviewed the questions for cultural sensitivity prior to
their administration. Results based on each interviewer's session with the
first participant served as a pilot; responses were analyzed as the data
became available and appropriate changes were made to the questioning
Two researchers analyzed the verbatim transcripts from the audiotapes
during data collection. Grounded theory guided
analysis of the transcripts (21). An initial list of code words was derived
from recurring themes in the transcripts (Table
2). Then, key concepts or recurring themes derived from the qualitative
interviews were integrated into the questioning guide using the method of
constant comparisons. The transcripts were reviewed throughout the
interviewing process. Code word definitions were drafted to encompass the
meaning of text segments. When new themes recurred in the transcripts, they
were either assigned a new code word or a subcategory of an existing code
word. Furthermore, the questioning guide was modified to capture more detail
about the emerging themes. Text segments were coded with the corresponding code
words using Ethnograph (version 5.04, Qualis Research Associates, Denver, CO). Following open coding, axial coding was used to identify
subcategories with code words (21). The final step, selective coding,
provided the means to assess the relationship among constructs and to assess
how concepts were related to their constructs to establish an overall
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Eighty-one American Indian women completed the qualitative interviews.
Two transcripts were not available because of technical failure of the
recording devices, resulting in 79 usable interviews. Demographic
characteristics of the sample are provided in
Table 3. The mean age of the women was 43 ± 11 years while mean degree of
American Indian blood was 65%. Though the sample was collected from 3 tribal
health clinics, 16 different tribal affiliations were reported, making
analysis by tribe impractical. Of the 79 women, 26 (33%) reported a previous
clinical diagnosis of diabetes. Approximately 70% reported education beyond
high school; however, 72% indicated an annual household income of less
Twenty-nine unique code words were developed during the open coding of
the transcripts (Table 2). Text segments coded for each code word were then
analyzed to establish subcategories and relations among code words. The
results of the analysis for code words associated with health and diabetes
are presented below.
Cultural definition of health
The American Indian women who took part in this study defined health
predominantly in terms of lifestyle behaviors. Individuals performing
positive behaviors — such as consuming a "healthy" diet,
exercising, and not smoking — were considered healthier than those who did
not. Being overweight was also considered to reflect negatively on health
Health was also defined in terms of the presence or absence of disease.
For example, when individuals were asked to define their current health,
they sometimes mentioned the presence or absence of several chronic
conditions, including arthritis, diabetes, heart disease, and cancer. In the
absence of a chronic disease, individuals considered themselves to be
healthy. Even if clinically diagnosed with disease, individuals did not
perceive diminished health until there was a physical feeling of illness.
Until an individual perceived a feeling of illness, they considered their
health to be satisfactory. One woman said, "I haven't been throwing-up
sick in years, but a little cold here and there." This was especially
true of diabetes, as the women interviewed did not consider the disease to
be severe until it was manifested through long-term complications.
Another indicator of health status was defined through physical
functionality. The women considered poor health to be an impairment of one's
ability to perform daily tasks: "Oh, my current health. I feel like I'm
pretty healthy. I can still lift up things and get around." The women
viewed being healthy as having the capacity and energy to perform daily
tasks and other activities. However, certain accommodations were made
for age. Furthermore, the women expected health to decline with age; many
defined their health status according to expectations for their current age.
One woman described feeling "not too good about my health and myself.
It seems like I've been more tired. But I guess that's just this age."
Cultural definition of diabetes
Diabetes was defined most commonly in terms of long-term complications,
which were often tied to fear and concern. The most frequently noted
complication was amputation, expressed by one woman as "becoming a
member of the stub club." Some women were confused about diabetes and its symptomology and long-term complications. Many women were unclear about
long-term complications; some women said that dialysis and blindness were
symptoms of diabetes. Confusion about hyperglycemia and hypoglycemia — and
which one indicated diabetes — also existed. The women expressed the belief
that hypoglycemia is an early symptom of diabetes that later converts to
Similarly, others expressed a fear of diabetes, calling it a "scary
disease." Diabetes was portrayed as devastating. As one participant
said, "It ruins your health, and ultimately it will kill you."
Furthermore, diabetes was considered a malicious disease. One woman stated:
"Diabetes is scary. It's a scary process. It's demeaning. I think it is
a very, very cruel breakdown of your system." The perception existed
that a body being "out of balance" causes diabetes, and an error
in the inner workings of the body results in a blood sugar imbalance.
"Fatalism" (16) toward diabetes and its complications was a strong
theme among the women. One woman said, "I knew it was going to happen,
but when it did happen, it was a surprise to me. And I felt like I was
doomed." The women interviewed expressed the concern that being of American Indian
descent leads to a belief in increased susceptibility to diabetes as well as
a belief in the inevitability of getting diabetes. Furthermore, the women feared having
diabetes for an extended period of time without being diagnosed. The
American Indian social network also fostered apprehension about diabetes, as
most of the interview participants knew someone with the disease.
Another prominent concern among the American Indian women was the
possibility of their own or a family member's diagnosis of diabetes.
Interestingly, the women were more concerned about their children being
diagnosed with diabetes than about their own possible diagnosis. Their
statements about children being at risk reflected an overall concern for
children developing diabetes. The women were also concerned about other
family members, including siblings, spouses, and parents.
The women expressed the idea that after an individual is diagnosed with
diabetes, his or her lifestyle behaviors must change. Diabetes was perceived
to require thorough, demanding care. Appropriate care involved eating right,
taking medicine, and doing "what the doctor tells you to do." The
women regarded diabetes care and behavior change as solely the
responsibility of the individual.
When asked if it was possible to prevent diabetes, many of the women
responded in terms of personal behaviors that may prevent or help delay the
onset of diabetes. These responses centered on changing behaviors that cause
diabetes, such as eating a poor diet and not exercising. To explore those
responses, we asked further questions about when potential
preventative behaviors should begin, and a portion of the respondents
indicated the need to reach young children. Other participants with
a more fatalistic view of diabetes suggested that diabetes was inevitable in
individuals with a strong family history of the disease.
Barriers to diabetes prevention and treatment
Some interview participants indicated that frequent visits to their health
care professionals represented an appropriate method of diabetes prevention.
Furthermore, the women perceived diabetes screening as a method of diabetes
prevention in the absence of changing lifestyle factors. Issues of denial
and avoidance of diagnosis were also strong, providing an additional
challenge to diabetes prevention and treatment. Despite efforts to increase
public awareness and opportunities for diabetes screening, women still
avoided screening. Because an individual was considered to be in good health
in the absence of physically feeling ill or the clinical diagnosis of a
chronic disease, avoiding a visit to a health care professional (thus
avoiding a screening) freed the individual from diagnosis and evaded the
need for self-care — despite a personal suspicion of having the disease. One
woman mentioned "[t]here might be a tendency for people to suspect it
but not want to have it confirmed maybe." In such situations, care
for diabetes is delayed and the likelihood of long-term
Furthermore, individuals did not express personal concern about diabetes
until they were themselves facing diagnosis. If a positive diagnosis was
made, those women expressed a strong sense of denial. One participant
mentioned a family member who was "in denial, and won't go to the
doctor, and then it gets worse, and then they'll go after it starts getting
too bad." Individuals often postponed care until they perceived a
physical ailment, likely indicative of long-term complications.
Supporting social structure
The women mentioned many sources of social support and information. They
cited health care professionals as only one of many sources of information
about health and diabetes. Community and family members served as considerable sources of
both information and misinformation. Misconceptions ranged
from the idea that individuals with diabetes are forced into strict dietary
modifications with a complete absence of sugar to the idea that diabetes can
be "gotten rid of, if you take care [of yourself]." The women
obtained much information about diabetes prevention, symptoms, and treatment
from discussions with — or observation of the treatments received by —
immediate or extended family and friends. Shared knowledge within these
circles does not reflect the current state of diabetes care, but defers to an
older pedagogy of diabetes care.
In addition to serving as sources of information, families were portrayed as
mediators of health self-care. Many self-care concerns are rooted in the
women's family caregiver roles, especially as gatekeepers of healthy meals.
Their roles are challenged by having to make personal lifestyle behavior
changes. For example, American Indian women are responsible for providing
meals that satisfy the entire family. If their health requires dietary
changes, they find it unacceptable to put their needs above the wants or
needs of the family unit, greatly reducing the likelihood of behavior
When asked how the family could aid in diabetes prevention efforts, familial
and parental support was most commonly reported. Family discussions about
health and diabetes as well as family attendance of educational sessions
were indicated as methods of family involvement in diabetes prevention.
However, one woman indicated that when she suspected she might have
diabetes, her family discouraged screening because they thought it unlikely
she would be diagnosed with the condition. This demonstrates both the
positive and negative social environment affecting diabetes prevention and
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The qualitative method used in our study demonstrates an attempt to
obtain a cultural definition of health and diabetes from American Indian
women. The pervasiveness of diabetes was readily apparent: most participants
had at least one family member or friend with diabetes. Although one
third of the participants had diabetes, the responses received from those
without diabetes mirrored the responses of those with diabetes. An analysis
of responses stratified by diagnosis of diabetes would provide little
Many factors — historical, political, sociocultural, and
geographical — impact health perceptions among American Indians (19).
Challenges abound in trying to define health as American Indians perceive
it, especially through the lens of Western medicine. A gap exists between
the discernment of a biologically defined chronic disease and the more
culturally relevant presence of physical symptoms; this gap presents a
strong barrier to accurate assessment of personal health status (18,22,23).
In one study of Diné (Navajo) families with asthmatic children, asthma is
perceived by the families as a series of individual episodic reactions
requiring attention instead of an underlying physiological chronic
inflammatory condition (23); the findings of the Diné study agree with our
findings. Hatton reported that elderly American Indians define their health
in terms of the absence or presence of various chronic diseases (19). These
results also concur with perceptions found in our sample. Also in the Hatton
report, the capacity of individuals to perform activities of daily living
and take care of themselves was regarded as an important aspect of personal
health assessment (19); this capacity was deemed important by our study
participants as well.
Of particular interest was the mutual dependency of the cultural
definitions of health and diabetes. The women in our study held the belief
that being unhealthy was discernable by physically feeling ill. Interviews
with older American Indians residing in urban areas considered themselves to
be healthy in the absence of any outward, perceivable sign of illness (19).
The disjointed impression among our respondents that long-term complications
are symptoms of disease (instead of the consequences of poor diabetes
control) may be explained by the perception that one is not unhealthy unless
a perceptible feeling of illness is present. When our study participants
faced a clinical diagnosis of diabetes, they delayed self-care until
long-term complications — accompanied by a decrease in physical
function — became evident. To these women, long-term complications
serve as the only tangible evidence of illness. It is this strong reliance
on physical symptomology that provides a great obstacle to diabetes
prevention, screening, and care.
A strong sense of inevitability pervaded the many ideas surrounding the
pursuit of health and prevention of diabetes among our American Indian
sample. Many, but not all, participants believed that diabetes
is inevitable and ultimately leads to death, especially for individuals who
have strong family histories of the disease. Previous research with the Gila
River Indian Community describes these feelings of inevitability as
"fatalistic" attitudes that moderate the perception of diabetes
prevention and may serve as additional barriers to adopting prevention
behaviors (16). Kozak reported an overall sense of surrender to diabetes,
which was viewed as an inevitable, uncontrollable disease that resulted in
death (16). Additionally, Judkins reported "highly fatalistic attitudes
and verbalizations" about diabetes among the Seneca, accompanied by a
feeling of powerlessness against the disease (17). It has been theorized
that fatalism has developed as a social coping mechanism to deal with the
severity of the diabetes epidemic and the resulting compromised quality of
life (16). Compensatory mechanisms built into cultural personality to deal
with environmental and personal stress may precipitate denial or avoidance
behaviors (17). A sense of inevitability may ultimately result in a
decreased propensity to take necessary steps for disease prevention, which
is often misconstrued by the administrators of Western medicine as
Additional barriers were evident in the prevention and treatment of
diabetes in these American Indian women. Family dynamics play a critical
role in health care in American Indians (22). With a shift from traditional
economic strategies to mainstream business practices, traditional American
Indian families are shifting toward more Western nuclear families, which has
an impact on family dynamics (22). Additionally, family resistance to
alterations in dietary habits serves as an additional barrier to diabetes
prevention and care in American Indian women. To achieve successful behavior
change, nutrition education and diabetes prevention programming must involve
the family unit. To what extent will family obligations or positive social
support structures within Native American communities allow self-care
behaviors? How receptive are American Indian individuals to external
support, and what is their capacity to overcome barriers for health
promotion? These questions — as yet unanswered — require more
In addition to conflicts between healthy lifestyle behaviors and family
obligations, avoidance of diabetes screening serves as an additional barrier
to diabetes treatment. The women expressed an inclination to avoid screening
even if they harbored suspicions of having the disease. Many diagnoses were
reported while women were seeking medical treatment for unrelated reasons.
If a clinical diagnosis is made, denial is likely, especially when no
physical symptoms are apparent. Similarly, Huttlinger et al reported a case
of a Diné woman who was taken to the doctor for a routine check-up against
her will and subsequently diagnosed with diabetes (18). Though vehemently
claiming she felt fine, she had to undergo amputation because of the serious
progression of her uncontrolled diabetes. This case demonstrates the
family's role in encouraging women to seek care and how the lack of the
physical signs of disease can hinder treatment.
There are several limitations of the current study. First, American Indian women were hired from local American Indian communities to
conduct the interviews, regardless of previous experience in qualitative
interviewing techniques. Despite training in such techniques, they varied in
the amount they probed interview participants on topics important to the research team. To address
this concern, transcript reviewers analyzed interview tapes soon after
retrieval and provided feedback to interviewers as additional training and
guidance. Second, because transcript reviewers functioned as the research
instrument, the lens through which reviewers read the transcripts provided
bias. To address this concern, transcripts were read by the 2 researchers
independently from each other and then discussed until consensus was reached on coding. We achieved an inter-rater reliability of
more than 90%. Furthermore, the lack of responses related to traditional
healing practices and the role of spirituality may have been due to the
recruitment of participants through tribal health clinics and is not likely
representative of all American Indian cultures. Though snowball
sampling aided in recruitment, participants recruited from the health
clinics may have been more likely to seek medical treatment through the
health clinics than through traditional healing practices. Finally, the sample was
derived through non-probability methods. Though these methods may decrease
the generalizability of the findings, they are often needed to identify
individuals from an at-risk population (19).
Despite these limitations, the congruency of the data to other reports of
perceptions of diabetes among other American Indian groups provides support
for our findings (19). Though results similar to ours have been reported,
they were derived from reservation-living American Indian groups; we have
identified perceptions of health and diabetes among a sample population
outside the reservation setting. Our findings indicate a more comprehensive
approach to the underlying issues in health promotion and diabetes
prevention than previous reports. Previous reports did not address the
interrelationships of perceptions of health nor did they discuss issues of
diabetes prevention. We have attempted to address some of these issues;
however, each new issue presents new unanswered questions, indicating a need
for further investigation of the cultural definitions of health and
Efforts to identify disparities in health perceptions and worldviews are
essential for developing nutrition education interventions that precipitate
behavior change (24-26). Previous research and multi-site programs,
including Awakening the Spirit: Pathways to Diabetes Prevention &
Control (American Diabetes Association) and the National Diabetes
Prevention Program (National Institute of Diabetes, Digestive and Kidney
Diseases), have demonstrated improved diabetes prevention and
treatment by targeting specific lifestyle behaviors within the context of
American Indian communities (27-29). American Indian communities vary widely
in tribal affiliation and location; future researchers must identify the
characteristics of each American Indian population studied to ensure they meet the community's specific needs (30). The importance of solid
formative data on a population is paramount, especially considering that a
large portion of research is conducted on reservations. Furthermore, the
extent to which the perceptions held by American Indian women in Northeast
Oklahoma are congruent with other American Indians within and outside of
Oklahoma needs to be examined to assist in designing effective education
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Funding for this research was provided by the Okalahoma Center for the
Advancement of Science and Technology and the Dean's Incentive Fund at
Oklahoma State University. We thank the tribal health clinics
and interviewers for their support and guidance in the research process.
Corresponding Author: Kathryn S. Keim, PhD, RD, LD, 301 Human Environmental Services, Department of
Nutritional Sciences, Oklahoma State University, Stillwater, OK 74078.
Telephone: 405-744-8293. E-mail: firstname.lastname@example.org.
Author Affiliations: Christopher Taylor, MS, RD, Department of
Nutritional Services, Oklahoma State
University; Alicia Sparrer, MS, RD, LD, Harris Methodist Fort Worth
Hospital; Jean Van Delinder, PhD, Department of Sociology, Oklahoma State
Parker, PhD, Cooperative Extension Service, Oklahoma State University.
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Cultural Structure of Health and Diabetes: Questioning Guide for
Interviewing Oklahoma American Indian Women about Cultural Perceptions of
Health and Diabetes, 2003
||Describe your current health to me.
||Describe how you feel about your health.
||What, if any, health concerns do you have?
||What are the major health concerns of other Indian women you know?
||What do you think is the leading cause of death for Indian women in the United States?
||What comes to mind when I mention diabetes?
||Let's discuss diabetes a bit.
What do you think causes a person to get diabetes?
Why do you think these things (mentioned above) cause diabetes?
If eating right, describe how people should eat.
What keeps people from eating right?
If exercise, what should they do and how often?
What keeps people from getting exercise?
How did you find the information that you just told me?
||What do you think happens to a woman once she develops diabetes?
||Can you think of anyone who is at risk for developing diabetes? (Is he or she Indian?)
||How can a person tell if he or she has diabetes? How do they feel?
||Tell me about anything that you know of that might keep a woman from developing diabetes.
Why do you think these things (mentioned above) prevent diabetes?
Where did you find this information?
If read, where? Books, magazines (which ones)?
If heard, where? From whom?
||What may prevent a woman from doing the things that may prevent diabetes?
||What treatments are there for diabetes that you know about? If diet, describe the diet.
||Who are you concerned about developing diabetes?
What are the reasons that you are concerned about this person(s)?
||What can parents or family do to help prevent this person/child from developing diabetes?
||What can the tribe or community do to help prevent this person/child from developing diabetes?
||How do you feel about diabetes?
||What is your greatest fear about diabetes?
||What control do you think a person has over diabetes?
||Can you prevent diabetes?
When can a person begin to do these things to prevent diabetes?
||How would you describe a traditional (Indian) diet (the old way of eating)?
What would you think of shifting the diet back toward the old ways Indians used to eat?
Do you think eating a more traditional diet would help Indians prevent diabetes?
|| Is there anything else would you like to tell me about diabetes?