Southwest American Indian Research Articles

Epistasis Between HLA-DRB1*16:02:01 and SLC16A11 T-C-G-T-T Reduces Odds for Type 2 Diabetes in Southwest American Indians.

We sought to identify genetic/immunologic contributors of type 2 diabetes in an indigenous American community by genotyping all study participants for both high resolution HLA-DRB1 alleles and SLC16A11 to test their risk and/or protection for T2D. These genes were selected based on independent reports that HLA-DRB1*16:02:01 is protective for T2D and that SLC16A11 associates with T2D in individuals with BMI<35kg/m2, and here test the interaction of the two loci with a more complete dataset and perform a BMI sensitivity test. We define the risk-protection haplotype of SLC16A11, T-C-G-T-T, as allele "2" of a di-allelic genetic model with three genotypes, SLC16A11*11, *12, and *22, where allele "1" is the wildtype. Both earlier findings were confirmed. Together in the same logistic model with BMI≥35, DRB1*16:02:01 remains protective, 0.73, while SLC16A11 switches from risk to protection OR = 0.57 (*22) and 0.78 (*12), respectively; an added interaction term was statistically significant (OR = 0.49 with *12). Bootstrapped (b=10,000) statistical power of interaction, 0.4801, yielded mean OR = 0.43. Sensitivity analysis demonstrated the interaction significant in BMI range 30-41. To investigate the epistasis we used the primary function of the HLA-DRB1 molecule, peptide binding and presentation, to search the entire array of 15mer peptides for both the wildtype and ancient human SLC16A11 molecules for a pattern of strong binding that was associated with risk and protection for T2D. Applying computer binding algorithms suggests the core peptide at SLC16A11 D127G, FSAFASGLL, might be key for moderating risk for T2D with potential implications for T1D.

Summarizing Implementation Support for School-Based COVID-19 Testing Programs in Southwest American Indian Communities.

American Indian communities have been disproportionately affected by the COVID-19 pandemic, with school closures exacerbating health and education disparities. Project SafeSchools' COVID-19 school-based testing program utilized federal and state funding to provide weekly pooled testing with follow-up rapid antigen testing to students and staff from the White Mountain Apache Tribe and Navajo Nation. The project provided partner schools with training and continual logistical and technical support to aid in school-based testing and adherence to state and local reporting requirements. Using the EPIS (Exploration, Preparation, Implementation, and Sustainment) framework, we identified facilitators and barriers to successful program function. While community support and buy-in were essential for successfully implementing school-based testing in these communities, communication, school staff turnover, and funding are among the most significant challenges. Community partnerships in American Indian communities involving schools and local health authorities can successfully implement testing protocols by remaining flexible and working together to maintain strong lines of communication.

"If you're down, you know, get up, be proud of yourself, go forward": Exploring Urban Southwest American Indian Individual Resilience.

The diverse American Indian and Alaska Native (AI/AN) population suffers health inequities perpetuated by colonialism and post-colonialism. The urban AI/AN population is steadily increasing in part because of federal policies relocating AI/AN away from tribal lands. However, studies of AI/AN urban communities are rare, and efforts to understand and ameliorate health inequities in AI/AN communities typically emphasize deficits rather than capacities. Resilience is an important resource in this context but mainstream, rather than community-derived definitions of resilience, predominate. The present study used multi-investigator consensus analysis in a qualitative study to identify urban American Indian (AI) derived concepts and construct a definition of resilience. The study included 25 AI adults in four focus groups in three urban locales in the southwestern United States. Four resilience themes emerged: 1) AIs built strength through toughness and wisdom; 2) the value of traditional 'lifeways' (i.e., elements of traditional culture that help people navigate their journey through life); 3) the importance of giving and receiving help; and 4) the interconnectedness of Native lifeways, family relationships, and tribal and urban communities. Themes overlap with extant resilience conceptualizations but also provide unique insights into structure and function of urban AI resilience in the Southwest United States.

Effects of a One-Week Intensive Wellness Camp on Dietary Behaviors among Southwest American Indian Youth

American Indians (AI) suffer the highest rates of diabetes in the United States (US); a chronic disease that is increasingly prevalent among AI children and is associated with increased risk of cancer. A summer camp was developed to improve disease risk-reducing behaviors, including diet, among AI youth in Arizona. The aim of this study was to examine the efficacy of a one-week intensive summer health camp conducted from 2016 to 2019 on change in dietary behaviors and compliance for Dietary Guidelines for Americans (DGA) among AI youth. AI children aged 10 to 15 years from several Arizona tribes participated in one-week intensive residential camps. Participants engaged in a week of experiential learning focused on healthy eating and physical activity. Twenty-four hour dietary recalls were collected from AI youth by trained staff six weeks before and six weeks after camp. T-tests were conducted to analyze differences in mean intake pre-and post-camp. Diet recalls for 45 children (boys = 19, girls = 26) were included in the current analysis. Results showed a statistically significant reduction in median intake of total fat by 19.5% (P-value = 0.01), and saturated fat by 14.9% (P-value = 0.01). Further, a statistically significant decrease in median energy intake of 18.7% (P-value = 0.002), a 22.9% decrease in total fat (P-value = 0.01), and 22.3% reduction in saturated fat was observed among boys only. However, post-camp, a higher percentage of girls met guidelines for fruit intake (54% vs 26%), percent saturated fat (23% vs 16%), calcium (7% vs 0%) and whole grains (15% vs 0%), while a higher percentage of boys met guidelines for vegetables (63% vs 50%) and sodium (25% vs 23%). The AI health camp was effective at reducing energy intake (kcals/day), total fat (g/day) and saturated fat (g/day) among participants aged 10 to 15 years. The camp was observed to be more effective at decreasing energy, total fat, and saturated fat intake among boys.

Cancer-Related Symptom Management Intervention for Southwest American Indians.

Simple SummaryQuality of life during, and even after, cancer treatment is greatly affected by cancer symptoms that include pain, fatigue, and changes to mental state and activities of daily living, to name a few. American Indians living in the Southwestern United States have cancer experiences which may be different than the general population and have long been understudied. A randomized controlled trial designed to test the impact of a culturally tailored intervention on the management of individual cancer symptoms was implemented. Outcomes included improvement in pain, depression, fatigue and loss of function management in adult American Indians. Study evaluations at post-test show a significant improvement in scores from pre-test and compared to the control group, demonstrating increased knowledge levels in managing cancer-related symptoms. Study findings guide researchers towards a better understanding of the meaning and impact of cancer symptoms for American Indian cancer survivors, thus their improving care and quality of life.There is limited literature related to culturally embedded meanings of cancer and related symptoms among American Indians. A culturally appropriate intervention to improve management of cancer-related symptoms, including pain, depression, fatigue and loss of function, was tested. Two-hundred and twenty-two adult American Indians with cancer were recruited from eight Southwest sites for a randomized clinical trial. The intervention group received tailored education, a toolkit with a video, and participated in discussion sessions on cancer symptom management; the control group received information on dental care. Pre- and post-test questionnaires were administered to control and intervention groups. Measures included socio-demographics, cancer-related symptom management knowledge and behavior, and quality of life measures. Male cancer survivors reported poorer self-assessed health status and lower scores on quality-of-life indicators as compared to female cancer survivors. Significant improvement was reported in symptom management knowledge scores following the intervention: management of pain (p = 0.003), depression (p = 0.004), fatigue (p = 0.0001), and loss of function (p = 0.0001). This study is one of the first to demonstrate a change in physical symptom self-management skills, suggesting culturally appropriate education and interventions can successfully enhance cancer-related symptom management knowledge and practice.

Functional variants in cytochrome b5 type A (CYB5A) are enriched in Southwest American Indian individuals and associate with obesity.

ObjectiveThis study aimed to identify genetic variants enriched in Southwest American Indian (SWAI) individuals that associate with BMI.MethodsWhole genome sequencing data (n = 296) were used to identify potentially functional variants that are common in SWAI individuals (minor allele frequency ≥10%) but rare in other ethnic groups (minor allele frequency < 0.1%). Enriched variants were tested for association with BMI in 5,870 SWAI individuals. One variant was studied using a luciferase reporter, and haplotypes that included this variant were analyzed for association with various measures of obesity (n = 917‐5,870), 24‐hour energy expenditure (24‐h EE; n = 419), and skeletal muscle biopsy expression data (n = 207).ResultsA 5′ untranslated region variant in cytochrome b5 type A (CYB5A), rs548402150, met the enrichment criteria and associated with increased BMI (β = 2%, p = 0.004). Functionally, rs548402150 decreased luciferase expression by 30% (p = 0.003) and correlated with decreased skeletal muscle CYB5A expression (β = −0.5 SD, p = 0.0008). Combining rs548402150 with two splicing quantitative trait loci in CYB5A identified a haplotype carried almost exclusively in SWAI individuals that associated with increased BMI (β = 3%, p = 0.0003) and decreased CYB5A expression, whereas the most common haplotype in all ethnic groups associated with lower BMI and percentage of body fatness, increased 24‐h EE, and increased CYB5A expression.ConclusionsFurther studies on the effects of CYB5A on 24‐h EE and BMI may provide insights into obesity‐related physiology.

Primary Disease Prevention for Southwest American Indian Families During the COVID-19 Pandemic: Camp in a Box.

The goal of the American Indian Youth Wellness Camp in a Box was to engage, educate and empower families to improve their health and overall well-being during the COVID-19 pandemic. Camp in a Box was a 9-week program, inclusive of a 1-week intensive camp component followed by an 8-week booster component with content focused on nutrition, mental health and physical activity education. The Camp in a Box is a Tribal/Urban Indian-University partnership, and materials were developed to replace an existing weeklong residential camp and to comply with social distancing guidelines. Fourteen American Indian families from Tribal/Urban Indian communities in the southwestern United States participated (36 children aged 2–18 years; 32 adults). The intensive camp week included daily materials for families to complete together, Monday through Friday. Materials were provided for approximately 4 h of activities per day. The booster sessions began after camp week and included approximately 4 h of supplementary activities designed to be completed at any time most convenient for the family over the course of the week. Activities were designed to encourage interaction among family members with materials and supplies for parents and youth to participate. Self-reported outcomes suggested that families changed their eating habits to include more vegetables, less sweets and junk food. Parents reported an increase in family physical activity and that the activities brought the family closer together. Our Camp in a Box program was feasible and well-received until school began. During camp week, 100% of recruited families participated; at Booster Week 8, ten families (71%) remained enrolled and active. Camp in a Box is a feasible alternative to residential camps for promotion of health behaviors associated with metabolic disease prevention among American Indian families. In contrast to residential camps for youth, Camp in a Box offers an opportunity to engage the entire family in health promotion activities.

We Don’t Talk about It: Cancer Pain and American Indian Survivors

Pain is a common symptom among cancer survivors, yet is rarely talked about by American Indians. Understanding the reasons for reduced communication by American Indian cancer survivors is important for healthcare providers, family members, and others providing treatment and support for cancer symptoms. Thirteen focus groups with Southwest American Indian adult cancer survivors were audiotaped and transcribed as part of a randomized intervention to remove barriers to cancer symptom management. Constant comparative methods were employed in the data analysis, topic categories were grouped for comparison, and final assessment followed Grounded Theory methods. Findings were categorized into two major groupings: communication with family members and communication with health care providers. Within these two groupings, three themes emerged to describe cancer pain experiences and communication barriers: (1) We don’t talk about it, (2) Respect for healthcare providers; and (3) Culturally prohibitive topics on death and pain experiences. Not talking about their cancer diagnosis and cancer-related pain leaves many American Indian cancer survivors without much-needed social support, contributing to reduced treatment compliance and access to healthcare. Findings have implications for educational interventions and quality of life improvement for American Indian and other underrepresented communities.

Barriers to Telemedicine Implementation in Southwest Tribal Communities During COVID‐19

Tribal communities across the United States face significant health and mental health disparities, including rates of suicide that far exceed those of nontribal communities.1 Timely access to health care is limited across most rural areas in the United States, particularly in remote tribal communities.2, 3 It is likely that the COVID-19 pandemic will exacerbate disparities among American Indian tribes, particularly when coupled with existing barriers to access health services.4 In their commentary, Kakol et al (18 April 2020)5 summarized historical and ongoing ramifications of colonization on Southwestern American Indian tribes from an infectious disease perspective, including challenges confronting those communities amidst the COVID-19 pandemic. They comment on the need to expand telehealth to rural Southwest American Indian communities, adding to the burgeoning literature on COVID-19 that emphasizes telehealth approaches, namely telemedicine, as a means of improving access to physical and mental health care, while maintaining social distancing.6-10 Yet, Kakol et al omit the important consideration that broadband Internet access—required to deliver care to patients from a distance—is a barrier to rural patients, no matter how quickly providers are upskilled to deliver it. This is of particular concern in tribal communities. To illustrate this concern, we summarized broadband Internet service data from the 2018 American Community Survey estimates11 for census tracts within the Navajo Nation, the largest American Indian tribe in the United States. We found that 58.1%-87.7% of households in Navajo Nation census tracts reported not having broadband Internet service, compared to 19.6% nationally (Figure 1). Access to broadband Internet service is not only a concern for the Navajo Nation; it is a challenge facing most tribal communities in the United States.12, 13 Even if tribal members can access the Internet at public spaces (eg, local library or school), these locations are far from ideal for telemedicine visits, especially telemental health. The Navajo Nation spans approximately 17,544,500 acres, occupying portions of Arizona, Utah, and New Mexico in the United States (left); and percent of households in Navajo census tracts reporting no access to broadband Internet service (right). Source: Authors’ analysis of data from 2018 American Community Survey 5-year estimates. Without access to technology needed for telemedicine, members of rural American Indian communities are distinctly disadvantaged. Aside from barriers to access, the acceptability and effectiveness of telemedicine among tribal communities must be considered.14 With this in mind, we agree with Kakol et al that telehealth expansion has the potential to improve access to care. However, substantial progress must be made toward increasing broadband Internet service on tribal lands before the potential of telemedicine to serve geographically dispersed but tightly woven communities, such as the Navajo Nation, can be realized.

2018-P: Whole-Genome Sequence Identifies Potentially Functional Variants in Cytochrome B5 Type A (CYB5A) that Associate with Obesity in Southwest American Indians

Southwest American Indians (SAI) suffer from a high obesity prevalence. We previously reported that rs7238987, in cytochrome B5 type A (CYB5A), strongly associated with increased body mass index (BMI) in a population-based study of SAI. CYB5A plays a role in fatty acid oxidation (FAO) and reductions in FAO have been linked to weight gain. However, in vitro studies did not confirm a functional effect of this variant. Therefore, the goal of the current study was to assess variation across the entire CYB5A locus to identify the causal variant contributing to obesity in this population. Genotypic data from a custom Axiom genotyping array on 7,700 SAI was merged with whole-genome sequence data from 335 SAI to impute variation within and 10,000 bp surrounding the CYB5A gene. This region contained 316 variants with a minor allele frequency &amp;gt;0.01; 3 variants had a Combined Annotation Dependent Depletion (CADD) score &amp;gt;10 (top 10% most likely to be deleterious) and a BMI association P ≤ 0.001 (adjusted for age, sex, birth year and the first 5 genetic principle components). Among these potentially deleterious variants, the obesity-risk T-allele in rs548402150, also significantly associated (P = 0.00003) with decreased CYB5A expression in skeletal muscle from biopsy data (n=207). Therefore, rs548402150 was prioritized for functional studies. This C/T variation falls within a CTCF consensus site in the 5’-UTR, which could have the ability to effect gene expression levels. In vitro luciferase reporter assays were used to assess altered promoter activity in human skeletal muscle cells. A 30% decrease in luciferase expression was identified for the promoter carrying the obesity-risk T-allele compared to the non-risk C-allele (P = 0.003). In summary, the further exploration of CYB5A using imputed data has identified a potential casual variant for the observed decreased CYB5A expression and increased risk of obesity in this population. Disclosure S.E. Day: None. M. Traurig: None. P. Piaggi: None. P. Kumar: None. S. Kobes: None. R.L. Hanson: None. C. Bogardus: None. L. Baier: None.

Usual Dietary Intake and Adherence to Dietary Recommendations among Southwest American-Indian Youths at Risk of Type 2 Diabetes

ABSTRACTBackgroundAmerican Indians are disproportionately affected by obesity and diabetes, and American-Indian youths have the highest prevalence of obesity and diabetes among all ethnic groups in the USA.ObjectivesThe purposes of this study were to assess the usual dietary intake in American-Indian youths who attended a wellness camp program; adherence to the Dietary Guidelines for Americans 2015–2020 (DGA) and to the Healthy People 2020 Objectives; and to compare pre- and postcamp reported diets.MethodsA total of six 24-h dietary recalls were conducted in person with American-Indian youths (aged 10–15 y; n = 26) from 3 different Southwest tribes. Three recalls were conducted before the wellness camp, and 3 were conducted after the camp. A series of 2-factor ANOVA were conducted, using a mixed model, to compare the nutrition differences before and after the health camp using a statistical program, R.ResultsAdherence to federal dietary recommendations was low, with few of the youths meeting the DGA recommendations for fruits (15%, average serving 0.69 cup/d) and vegetables (35%, average serving 0.59 cup/d). All of the participants exceeded the DGA recommended limit on empty calories. Nutrient analysis of total fat intake showed a significant decrease in intake after the camp, F (1, 52) = 5.68, P = 0.02.ConclusionsDiet is a modifiable risk factor for obesity and chronic diseases such as type 2 diabetes and needs to be an integral part of any healthy lifestyle intervention. The camp-based nutrition education had a positive effect on youths, as observed through the total fat intake decreasing after camp. To reinforce nutrition education, future nutrition education should involve parents, be delivered beyond the week at camp, and encompass social determinants of health and access to healthy foods.

451. High Rates of Hospitalization due to Skin and Soft-Tissue Infections in a Southwest American Indian Population

BackgroundSkin and soft-tissue infections (SSTIs) involve the skin, subcutaneous tissue, fascia, or muscle. Hospitalizations due to SSTIs represent a significant health disparity for American Indians (AI), but specific literature is limited. We characterized SSTI hospitalizations at our critical access hospital that exclusively serves an AI population in the American Southwest.MethodsWe identified patients hospitalized (admitted or transferred) with an SSTI from June 2017 to May 2018. Relevant cases underwent chart extraction for demographics, SSTI characteristics, laboratory and microbiologic data, relevant history and co-morbidities. All variables were summarized using descriptive statistics. Odds ratios and P-values with two-tailed tests were used to identify risk factors for multiple SSTI episodes.ResultsDuring the study period, 289 unique individuals comprised 343 SSTI hospitalizations / episodes (18% of the 1,883 total hospitalizations). The unadjusted annual rate of SSTI hospitalization was 2,018 per 100,000. There were 13 cases of necrotizing fasciitis (NF) with an unadjusted rate of 76 per 100,000 per year. Only 183 episodes (53%) had a wound culture performed, with 84% positive for a pathogenic organism, compared with 287 episodes (84%) with a blood culture performed, of which only 7% were positive for a pathogen. Methicillin-resistant Staphylococcus aureus (MRSA), methicillin-sensitive SA (MSSA)and/or Streptococcus pyogenes accounted for 74.9% (n = 125) and co-infection with these three organisms accounted for 22.2% (n = 37) of positive wound cultures (n = 167). An SSTI in the last year (49%), diabetes (41.9%), alcohol abuse (40%) and hypertension (39%) were common among all 289 individuals. Diabetes (OR 3.3, P < 0.01), hypertension (OR 2.8, P < 0.01), renal disease (OR 2.7, P < 0.05), previous SSTI (OR 3.0, P < 0.01) were associated with a higher risk of multiple SSTI hospitalizations.ConclusionThe incidence rate of SSTI hospitalization in this Southwest AI population was 9-times greater than the general US population and 4-times greater than prior reports in Southwest AI. The NF rate was >10-times the general US population rate. We describe common co-morbidities among these SSTI episodes and potential risk factors for repeat hospitalization. Disclosures All authors: No reported disclosures.

Characteristics of American Indian Female Caregivers on a Southwest American Indian Reservation.

American Indian (AI) caregivers have been excluded from national survey efforts. Drawing from a 2012 survey administered on the Hopi Reservation in northern Arizona, 20% of adults are caregivers. More information is needed to guide program development tailored to Hopi needs. In a University-Community collaboration, a 58 question survey was administered to self-identified caregivers of a family member about amount and type of care provided, difficulties, caregiver health, and desired support services. Characteristics of caregivers and their experiences were described. Forty-four (44) female Hopi caregivers were interviewed from June-October 2017, mean age of 59years (± 12.6) with mean 5.5year (± 4.4) history of providing care. Over 84% provided care to either a parent or grandparent. Most caregivers provided transportation (93.2%), housework (93.2%), and medical related care (72.7%). Caregivers stated they had difficulties with not having enough time for family and or friends (88.6%), financial burdens (75.0%), and not having enough time for themselves (61.4%). The most frequently identified difficulty was stress (45.5%). Caregivers would like additional services, with 76.7% asking for training. Over 77% would not consider placing their relative in an assisted living facility. Compared to national data, Hopi female caregivers are older, provide more care hours/week, more caregiving duties, and for a longer number of years. Stress is the most reported difficulty, although lower than national levels. As caregivers are resistant to placing the recipient in assisted living, educational efforts should focus on training caregivers to assist the care recipient and decreasing caregiver stress.

Autoantibodies against PFDN2 are associated with an increased risk of type 2 diabetes: A case-control study.

The adaptive immune system is involved in type 2 diabetes mellitus (T2DM), indicating the presence of unidentified autoantibodies that might be useful biomarkers for emerging immunomodulatory therapy. A prior microarray study with a small number of participants suggested the association of novel autoantibodies with T2DM in Southwest American Indians. We therefore sought to determine whether antibodies against 14 target proteins are associated with T2DM in a large case-control study. Participants were adults (age 20-59y) of Southwest American Indian heritage. Plasma antibodies against 14 possible target proteins were measured in 476 cases with T2DM of less than 5years duration and compared with 424 controls with normal glucose regulation. Higher levels of antibodies against prefoldin subunit 2 (PFDN2) were associated with T2DM (P=.0001; Bonferroni-corrected threshold for multiple tests=0.0036 [α=0.05]). The association between anti-PFDN2 antibodies and T2DM remained in multivariable logistic regression (odds ratio 1.27; 95% confidence interval, 1.09-1.49; per one SD difference in anti-PFDN2 antibody). The odds of T2DM were increased in the highest anti-PFDN2 antibody quintile by 66% compared with the lowest quintile. Differences in anti-PFDN2 antibodies were most prominent among cases with earlier onset of disease (ie, age 20-39y) compared with controls. Anti-PFDN2 antibodies are associated with T2DM and might be a useful biomarker. These findings indicate that autoimmunity may play a role in T2DM in Southwest American Indians, especially among adults presenting with young onset of disease.

Relationships Between Smoking Behaviors and Cotinine Levels Among Two American Indian Populations With Distinct Smoking Patterns.

Smoking prevalence, cigarettes per day (CPD), and lung cancer incidence differ between Northern Plains (NP) and Southwest (SW) American Indian populations. We used cotinine as a biomarker of tobacco smoke exposure to biochemically characterize NP and SW smokers and nonsmokers and to investigate factors associated with variation in tobacco exposure. American Indians (N = 636) were recruited from two different tribal populations (NP and SW) as part of a study conducted as part of the Collaborative to Improve Native Cancer Outcomes P50 project. For each participant, a questionnaire assessed smoking status, CPD, second-hand smoke exposure, and traditional ceremonial tobacco use; plasma and/or salivary cotinine was measured. Cotinine levels were (mean ± 95% confidence interval [CI]) 81.6 ± 14.1 and 21.3 ± 7.3 ng/ml among NP smokers and non-mokers, respectively, and 44.8 ± 14.4 and 9.8 ± 5.8 ng/ml among SW smokers and nonsmokers, respectively. Cotinine levels correlated with CPD in both populations (p < .0001). Cotinine ≥15 ng/ml was measured in 73.4% of NP smokers and 47.8% of SW smokers and in 19.0% of NP nonsmokers and 10.9% of SW nonsmokers. Ceremonial traditional tobacco use was associated with higher cotinine among NP smokers only (p = 0.004). Second-hand smoke exposure was associated with higher cotinine among NP non-smokers (P < 0.02). More secondhand smoke exposure was associated with smoking more CPD in both populations (p = 0.03-0.29). Linear regression modeling mirrored these findings. High prevalence of smoking in the Northern Plains and high cotinine levels among nonsmokers in both regions highlights the tribal populations' risk for tobacco-related disease. There is a high prevalence of smoking in Northern Plains American Indians. Among Northern Plains and Southwest nonsmokers, relatively high cotinine levels, representative of high tobacco exposure, suggest considerable exposure to second-hand smoke. It is critical to highlight the extent of second-hand smoke exposure among the Northern Plains and Southwest American Indians and to enhance efforts to initiate smoke-free policies in tribal communities, which are not subject to state-level polices.

Introduction

Introduction Bill Broyles (bio) and Rein Vanderpot (bio) This special issue of Journal of the Southwest is dedicated to Agnese Nelms Haury. She was an avid traveler, humanitarian, philanthropist, avocational anthropologist, and friend. In Article 1, David A. Yetman takes us along as he and Agnese Haury make a trip through South America. Aggie was a fan of David's long-running television series In the Americas and The Desert Speaks, which he hosted for many seasons, and she was an inveterate traveler. In Article 2, Gary Paul Nabhan recounts Aggie's love of the desert. She supported a number of desert researchers, including David and Gary, as well as launching or sponsoring a number programs and projects at the Southwest Center, the Agnese N. Haury Institute of Court Interpretation, the Center for the United States and the Cold War, the Laboratory of Tree-Ring Research, and the Agnese and Emil Haury Southwest Native Nations Pottery Vault at the Arizona State Museum. Then we shift our focus to one of the most enigmatic groups of Southwest American Indians: the Hia-Ced O'odham. Never numbering more than several hundred, they lived modestly in the extremely arid low Sonoran Desert of far southwestern Arizona and northwestern Sonora, Mexico. Some researchers even thought they had faded into history, dying out or being absorbed by other cultures. Robert Hackenberg wrote, "They failed to survive the nineteenth century,"1 and Bernard Fontana reported, "The [Sand Papago] nomads of western Pimería Alta no longer exist as cultural entities."2 But the persistence of people claiming to be Hia-Ced O'odham plus increased research into their history, such as David Martinez's 2013 article "Hiding in the Shadows of History: Revitalizing Hia-Ced O'odham Peoplehood,"3 in this journal, have brought them renewed attention with calls for recognition of their identity and for appreciation of their culture and history. To that end, we here offer fresh material about the Hia-Ced O'odham,4 [End Page 396] once known as People from the Sand or Sand Papago. In Article 3 we present, for the first time, letters written by Thomas Childs Jr. to avocational archaeologist Norton Allen. At age 14 Childs had met and then traveled with Hia-Ced O'odham throughout their territory, and he later married one of them and remained part of her larger family until his death in 1951. We also discuss, in Article 4, Childs's correspondence with historian Richard Van Valkenburgh and anthropologist Henry F. Dobyns. In Article 5 we offer a view of Hia-Ced O'odham homelands through David Burckhalter's photographs and Paul Mirocha's map of places they lived, found water, farmed and hunted, traveled, and conducted ceremonies. One of Childs's daughters, Fillman Childs Bell, interviewed a number of Hia-Ced O'odham as part of a study of Quitobaquito Springs Cemetery in Organ Pipe Cactus National Monument, Arizona. Those interviews were included in an unpublished National Park Service report, but they are important in understanding the Indians' himdag (lifeways), geography, and personalities, so we publicly present them here in Article 6. Article 7 features family photographs of Hia-Ced who were descendants of those who had lived at Quitobaquito or were mentioned in Fillman Bell's Quitobaquito report. We also ask the question "Who were Tom Childs and Fillman Bell?" and in Article 8 present an answer largely in Fillman's own words and those of her husband, Oscar Bell. In Article 9 we offer an adaptation from Harry Winters Jr.'s remarkable compendium of O'odham place names, written with his lifelong enthusiasm for O'odham geography and people.5 His research illuminates rich layers of meaning and history in those names, including the Hia-Ced O'odham. Then, in Article 10, archivist Lisa Duncan gives you an insider's account of organizing a major collection of American Indian information gathered and donated to the University of Arizona Libraries' Special Collections by anthropologist Henry F. Dobyns. Comprising over 500 boxes of papers, correspondence, and reports, it required two years to sort, organize, and catalog into a usable collection. It contains Dobyns's correspondence with both Thomas Childs and Fillman Bell...

Exercise Intervention Improves the Metabolic Profile and Body Composition of Southwestern American Indian Adolescents.

The Southwestern American Indian population carries a high prevalence of metabolic syndrome and obesity, placing this group at higher risk than the general population for developing early type 2 diabetes and cardiovascular disease, likely impacting overall lifespan. This study aims to evaluate the impact of early lifestyle interventions which promote healthy eating and regular exercise on risk factors contributing to the development of the metabolic syndrome among the adolescent Zuni Pueblo population. We describe a prospective, single site, community-based cohort study performed among sixty-five adolescent Zuni Indians aged 13.9 ± 1.7 years who were recruited between March 2011 and January 2014. The study intervention consisted of a targeted, tri-weekly exercise regimen with nutritional counselling, and the primary study outcomes included changes from baseline in metabolic profile (fasting lipids, A1c), vital signs (blood pressure, resting heart rate) and anthropometric characteristics of the study group. 41 participants have anthropometric data measured at baseline and after completion, biochemical data are available from 30 participants, and body composition data from 26 patients. Using the paired Student's t-test with Bonferroni correction, significant improvements were shown in pediatric BMI percentile, fasting lipid profile, A1C, total body fat, and fat free mass after six months of exercise and nutritional intervention. A simple, standardized fitness program among Southwest American Indian adolescents was effective at reducing fasting lipids and adiposity, as well as improving glycemic indices over the course of six months.

The cultural constructs of cancer-related fatigue among American Indian cancer survivors.

Cancer-related fatigue (CRF) is a common symptom experienced by cancer survivors. Persistent fatigue can last years after cancer treatment. CRF's origin is unknown, and there are no validated treatments. Cultural constructs (definitions, meaning, and explanations) may vary the presentation and treatment choices related to fatigue. Identifying and categorizing CRF terms and experiences among racial, ethnic, and non-English speaking groups may provide a fuller understanding of CRF to guide tailoring of interventions. We report on the cultural constructs of CRF as reported by American Indian cancer survivors. A study of Southwest American Indians collected qualitative data on cancer survivors' experiences of fatigue. Focus groups (n = 132) at urban clinics and rural reservation sites in the Southwest collected qualitative data on cancer survivor experiences with fatigue. The sessions were audiotaped and transcribed verbatim. During analysis, common themes were coded and formed into categories following Grounded Theory analytical procedures. Relationships between categories were examined. CRF was described by survivors as an entity that comes into the brain, "drains life" from the body, and creates long-lasting suffering, pain, and stigma. We review the cultural constructs of fatigue and CRF's relationship to "being out of balance." There is a need for culturally appropriate education concerning fatigue, techniques for reducing fatigue, and support for American Indian cancer survivors and other vulnerable populations.

ABCC8 R1420H Loss-of-Function Variant in a Southwest American Indian Community: Association With Increased Birth Weight and Doubled Risk of Type 2 Diabetes.

Missense variants in KCNJ11 and ABCC8, which encode the KIR6.2 and SUR1 subunits of the β-cell KATP channel, have previously been implicated in type 2 diabetes, neonatal diabetes, and hyperinsulinemic hypoglycemia of infancy (HHI). To determine whether variation in these genes affects risk for type 2 diabetes or increased birth weight as a consequence of fetal hyperinsulinemia in Pima Indians, missense and common noncoding variants were analyzed in individuals living in the Gila River Indian Community. A R1420H variant in SUR1 (ABCC8) was identified in 3.3% of the population (N = 7,710). R1420H carriers had higher mean birth weights and a twofold increased risk for type 2 diabetes with a 7-year earlier onset age despite being leaner than noncarriers. One individual homozygous for R1420H was identified; retrospective review of his medical records was consistent with HHI and a diagnosis of diabetes at age 3.5 years. In vitro studies showed that the R1420H substitution decreases KATP channel activity. Identification of this loss-of-function variant in ABCC8 with a carrier frequency of 3.3% affects clinical care as homozygous inheritance and potential HHI will occur in 1/3,600 births in this American Indian population.

“All My Tears Were Gone”: Suffering and Cancer Pain in Southwest American Indians

ContextAlthough minority patients with cancer are more likely to be undermedicated for cancer pain than non-Hispanic whites, little is known about the experience of cancer pain in American Indians (AIs). ObjectivesTo describe the experience of cancer and cancer pain in a sample of southwestern AIs. MethodsEthnographic interviews were conducted with 13 patients and 11 health care providers, caregivers, and community members; two questionnaires were used to collect demographic and pain data. ResultsBarriers to pain control among AIs included difficulties describing pain, a belief that cancer pain is inevitable and untreatable, and an aversion to taking opioid pain medication. Prescriber inexperience also was cited as a barrier to pain management. AIs described a strong desire to protect their privacy regarding their illness, and many felt that expressing pain was a sign of weakness. The inability to participate in spiritual and cultural activities caused AIs distress, and some discontinued treatment or missed chemotherapy appointments to engage in these activities. ConclusionResults revealed new knowledge about the cancer pain experience in AIs. The observation of the close relationship between treatment compliance and the patient's ability to participate in ceremonial and spiritual activities provides new insight into the problem of incomplete cancer treatment in this population. The finding that AI patients have a multidimensional conceptualization of pain will assist clinicians with obtaining more detailed and informative pain assessments.