IntroductionInnovative approaches are needed to reduce cardiometabolic risk among American Indian women with a history of gestational diabetes. We assessed beliefs of Oklahoma American Indian women about preventing type 2 diabetes and cardiovascular disease after having gestational diabetes. We also assessed barriers and facilitators to healthy lifestyle changes postpartum and intervention approaches that facilitate participation in a postpartum lifestyle program.MethodsIn partnership with a tribal health system, we conducted a mixed-method study with American Indian women aged 19 to 45 years who had prior gestational diabetes, using questionnaires, focus groups, and individual interviews. Questionnaires were used to identify women’s cardiometabolic risk perceptions and feasibility and acceptability of Internet or mobile phone technology for delivery of a postpartum lifestyle modification program. Focus groups and individual interviews were conducted to identify key perspectives and preferences related to a potential program.ResultsParticipants were 26 women, all of whom completed surveys; 11 women participated in focus group sessions, and 15 participated in individual interviews. Most women believed they would inevitably develop diabetes, cardiovascular disease, or both; however, they were optimistic that they could delay onset with lifestyle change. Most women expressed enthusiasm for a family focused, technology-based intervention that emphasizes the importance of delaying disease onset, provides motivation, and promotes accountability while accommodating women’s competing priorities.ConclusionsOur findings suggest that an intervention that uses the Internet, text messaging, or both and that emphasizes the benefits of delaying disease onset should be tested as a novel, culturally relevant approach to reducing rates of diabetes and cardiovascular disease in this high-risk population.

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Objectives To examine the relationships between prepregnancy diabetes mellitus (DM), gestational diabetes mellitus (GDM), and prepregnancy body mass index (BMI), with several adverse birth outcomes: preterm delivery, low birthweight (LBW), and macrosomia, comparing American Indians and Alaska Natives (AI/AN) with other race/ethnic groups. Methods The sample includes 5,193,386 singleton U.S. first births from 2009-2013. Logistic regression is used to calculate adjusted odds ratios controlling for calendar year, maternal age, education, marital status, Kotelchuck prenatal care index, and child's sex. Results AI/AN have higher rates of diabetes than all other groups, and higher rates of overweight and obesity than whites or Hispanics. Compared with AI/AN, whites (OR 0.77) and Hispanics (OR 0.86) are less likely to experience preterm delivery, but blacks are more likely (OR 1.20). Blacks are also more likely than AI/AN to experience low birthweight (OR 1.88), while macrosomic babies are less likely among whites (OR 0.86), blacks (OR 0.41), or Hispanics (OR 0.63) compared with AI/AN. Neither overweight nor obesity predict preterm delivery for AI/AN, in contrast to other groups, while diabetes predicts increased odds of preterm delivery for all groups (DM OR 1.65 – 21.9; GDM OR 1.09 - 1.17). Being overweight predicts reduced odds of LBW for all groups (OR 0.81 – 0.95), but obesity is not predictive of LBW for AI/AN. Diabetes status also does not predict LBW for AI/AN; for other groups, LBW is more likely for women with DM or GDM. Overweight, obesity, DM, and GDM all predict higher odds of macrosomia for all race/ethnic groups. Significance This study, the first to examine pregnancy outcomes as a function of both overweight/obesity and diabetes simultaneously among AI/AN, found that in contrast with other race/ethnic groups, AI/AN maternal BMI does not predict preterm delivery and AI/AN diabetes status does not predict low birthweight. In other respects, the relationships for AI/AN are similar to those for other groups: diabetes increases the odds of preterm delivery; overweight reduces the odds of low birthweight; and overweight, obesity, and diabetes are all associated with increased odds of macrosomia. Thee\se results suggest interventions that address maternal health disparities among AI/AN can have important impacts on children's health in this neglected population.

Research misconduct and consequential harms have been inflicted upon American Indian/Alaska Native communities for decades. To protect their people and culture and to retain oversight over research, many Native communities have established tribal health research and institutional review boards. The Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY) Study showcases a successful, trusting research collaboration with tribal nations and academic investigators in Oklahoma. In 2006, the TODAY Study investigators proposed a modification of the study protocol to collect biological specimens from participants for genomic analyses and indefinite storage. Partnering American Indian tribal nations elected not to participate in the genomics collection and repository proposal. Reasons included 1) protection of cultural values, 2) concerns regarding community anonymity, 3) a potential threat to tribal services eligibility, 4) broad informed consent language, and 5) vague definitions of data access and usage. The nations believed the proposed genomics analyses presented a risk of harm to their people and nations without clear benefit. Since the 2006 proposal and the advancement of genomics research, many tribal communities in Oklahoma, appreciating the potential benefits of genomic research, are developing policies regarding oversight of/access to data and biological specimens to mitigate risks and provide members and communities with opportunities to participate in safe and meaningful genomic research.

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