There are 12,000 Apache Indians on the White River Arizona 1.6 million acre reservation. They are a stable enclosed population with a managed Indian Health -Care System. NIDDM has been detected in 506 Apaches (70% women) ranging in age from 15-90 years. In the 400 deliveries in 1991, 8% of women (31 patients) had gestational diabetes (GDM) or previously unrecognized NIDDM. In that year there were 41 Whiteriver hospitalizations for pregnancy complications for a total of 95 days at a cost of $40,009 ($402/day) excluding labor, delivery and postpartum. These costs also exclude helicopter transfer to tertiary care hospitals and expensive neonatal intensive care unit charges. For recognized diabetics, there is no designated diabetes clinic at the hospital and no patients except a few pregnant women have glucose meters. Diabetes complications are high: 65% hypertension, 9% diabetic renal disease, 23 patients on hemodialysis, 18% retinopathy, 4% amputations. We have elected to address the problem of diabetes in utero, the earliest stage of life and propose to conduct a White Mountain Apache Diabetes project for mothers and infants. Our hypothesis-based proposal has three specific aims that would integrate a model diabetes program that could be replicated throughout the IHS along with clinical research studies to elucidate the pathogenesis of NIDDM in this Athapaskan Tribe that differs ethnically, linguistically and culturally from the Pima. This is the first ever prospective study of pregnant NIDDM and their babies. We will enroll 75 diabetic women and 400 controls. Data analysis will relate all maternal risk factors to maternal and infant outcomes to age 1 yr.
Specific Aims : 1) To establish a community-based preconception counseling clinic for Apache women age 15-45 years and an early (first trimester) screening program to detect unrecognized diabetes in all 400 Apache pregnant women each year, 2) To set up a Diabetes Pregnancy Clinic using a cost effective ambulatory team approach with 4 positive interventions: (a) lower caloric intakes in obese pregnant women, (b) glucose self-monitoring 4 x a day throughout pregnancy, (c) monthly HbAlc determinations, (d) maternal daily counting of fetal movements from 30 weeks to term to decrease or prevent stillbirth; 3) To correlate the relationship of insulin resistance, pre-existing hypertension, hypertriglyceridemia and upper segment obesity (the insulin resistance syndrome) with adverse maternal/infant outcomes. Our two hypotheses are: 1) In utero umbilical intravenous hyperalimentation due to fetal exposure to high maternal glucose and lipid concentrations carries a non-genetic liability for insulin resistance, obesity and diabetes in Apache offspring. 2) The metabolic stress of pregnancy will permit documentation of maternal degree of obesity, unrecognized pre-existing hypertension, hyperinsulinemia, abnormal hypertriglyceridemia and diabetes (insulin-resistance syndrome). The presence of acanthosis nigricans will be tested as a skin marker for insulin resistance. We hope to improve the care of Apache mothers and infants at a much reduced cost.
