Prevalence of Type Two Diabetes in the American SamoaKristen MathewTufts University Type Two Diabetes Prevalence in the American SamoaProblem StatementAll around the globe, more and more populations are moving away from their traditional heritage as the effects of modernization enter into their societies. Type 2 diabetes is a disease characterized by insulin resistance and the body’s inability to metabolize glucose. Over 422 million people around the world have diabetes, and the Pacific Island Region constitutes roughly 36 percent of these cases (World Health Organization 2016).  Unfortunately, the ramifications of socioeconomic modernization have become increasingly pronounced in the islands of the American Samoa.  For centuries the American Samoa remained in relative isolation, unaffected by the lifestyles of mainland countries.  However, today the influences of colonization and subsequent socioeconomic modernization have rapidly dragged the American Samoa into the modern era. The United States Territory of the American Samoa lies in the Pacific Ocean, halfway between Hawaii and New Zealand, and is one population in which the prevalence of type 2 diabetes is drastically higher than the global average. Type 2 diabetes and its associated consequences present significant health risks to both individuals and societies in this area. As such, it is crucial to address the biological, cultural, and social factors that have contributed to the escalating prevalence of type 2 diabetes in the American Samoa, and heightened the importance of addressing this issue as a public health problem.  Epidemiology In the American Samoa today, there has been an increasing trend in the prevalence of type 2 diabetes in both males and females.  Prevalence defines the proportion of the American Samoan population that has type 2 diabetes at a specified time. A study done in 2016 by the World Health Organization indicates that, based on blood measurements, the overall prevalence of diabetes in the American Samoa is 25.5 percent, with a slightly higher prevalence in men, 27.3 percent, than women, 23.4 percent (DePue, Goldstein, Rosen, 2016).  This statistic is concerning especially when taking into account the fact that the prevalence of diabetes in the global population is only 13 percent.  Furthermore, even in the United States, only 9.4 percent of the population is diagnosed with type 2 diabetes (American Diabetes Association 2015).  It is important to make this issue a public health priority and consider what factors are contributing to this shocking rate of diabetes.  Additionally, a large percent of the American Samoan population is labeled at risk for type 2 diabetes. A 2015 assessment by the National Institute for Health found that 70 percent of the population aged 25-64 have one or more of the major risk factors for diabetes, described as, “clinical obesity, high blood pressure, diets of insufficient quantities of fruit and vegetables, and/or low levels of physical activity” (Ichiho, Roby, Ponausuia, & Aitaoto, 2015).  Alarmingly, 40 percent of the population between 25 and 44 years of age had three or more of these risk factors, putting them in the high risk category for type 2 diabetes (Ichiho, et al., 2015).  There is a need for upstream, preventative measures to decrease the widening margin of Samoans at risk for diabetes. For example, greater nutrition education for both children and adults would likely improve proper diet and exercise habits. Risk factors for this disease have also been observed at increasingly younger ages.  More and more American Samoan adolescents are showing increased risk for type 2 diabetes as obesity, a major risk factor for diabetes, continues to be on the rise.  In May 2015, the American Samoa Obesity Study Committee completed a report to the Directors of the Department of Health which revealed that 45.6 percent of all students in American Samoan public schools were either overweight or obese (DePue, et al. 2016).  Although the prevalence was lower for young students, it increased steadily with age.  This data highlights the fact that this health issue is widespread, and rooted in all age groups across the American Samoan population. Incidence describes the rate at which new cases occur in a population during a specified period of time. In American Samoa, the incidence of type 2 diabetes has increased from an estimated 6.4 percent of the adult population in 1978 to its current 25 percent in 2017 (Lin, Naseri, Linhart, & Morrell, 2016).  Essentially, in the past 40 years, there has been a quadrupling of diabetes incidence in the 25-34 age group of the Samoan population.  It is clear that the increasing number of American Samoans with diabetes is not slowing, and thus has yet to be effectively addressed by public health initiatives.The morbidity pattern has also shifted significantly over the past three decades. Where infectious diseases were previously the major cause of morbidity, noncommunicable diseases related to widening modernization and lifestyle changes now predominate. Of these noncommunicable diseases, type 2 diabetes has proven to be the second leading cause of mortality in the American Samoa (Lin, et al., 2016).  Type 2 diabetes in the American Samoa is an issue that should be recognized as a public health priority in order to establish public health initiatives to reduce the risk factors and social determinants that have exacerbated this disease.  Biological Risk Factors According to the American Diabetes Association, type 2 diabetes is a chronic disease which can be defined by “high glucose levels and complications with insulin regulation” (Type 2 Diabetes, 2015).  Over time, this disease can cause serious damage to the heart, blood vessels, eyes, kidneys, nerves, and many more essential organs within the body. There are multiple biological risk factors which contribute to the high prevalence of diabetes in the American Samoa. Clinical obesity or overweight status is one major biological risk factor for type 2 diabetes. The World Health Organization defines overweight as “having a body mass index (BMI) equal to or more than 25kg/m2 and obesity as a BMI of over 30kg/m2” (World Health Organization 2016). In general, this is a result of the fatty tissue in an individual causing their cells to become resistant to insulin. An excess of fatty tissue can cause adipose cells to release inflammatory chemicals into the bloodstream, which can affect insulin responsive cells and lead to reduced sensitivity (Orenstein, et. al., 2016). Both nutrition and physical activity are major factors contributing to obesity. Physical activity can help control weight while also utilizing glucose as energy, therefore making cells more sensitive to insulin. In addition, a recent study done in 2016 by Brown University reports that a variation in the Samoans genome which contributes to increased in fat storage may explain why Samoans have some of the world’s highest levels of obesity (Orenstein, et al., 2016).  These findings hint at a possible evolutionary explanation.  Centuries ago, the Samoan people were island hoppers, sailing to and establishing homes on new islands every few decades. These people likely faced serious food insecurity during these periods of time. Thus, natural selection likely advantaged the individuals who had the gene that helped them to efficiently store energy and fat. However, today this genetic variant may actually be causing harm as levels of overweight and obese American Samoan citizens continues to rise.  Individuals with this gene appear to have a 35 percent higher chance of being obese than those without the variant (Orenstein, et al., 2016).The complications of diabetes can become seriously life-threatening if allowed to persist for too long without proper care. Some of the potential debilitating complications of diabetes include heart disease, neuropathy, and kidney damage.  Prolonged diabetes typically begets cardiovascular issues such as heart disease, heart attack, stroke, high blood pressure, and narrowing of arteries (Yuan, Manson, & Changzheng 2017).  Over time, high blood glucose from diabetes can damage blood vessels, as well as the nerves that control the heart and blood vessels.  The excess blood sugar in diabetes patients can injure the walls of blood vessels and arteries all over the body, also affecting the heart muscle (Yuan, et al., 2017). Eventually, chronic diabetes can damage nerves to the point that there is loss of feeling or numbness in the limbs. Diabetes can also cause damage the blood filtering system in the kidneys, and lead to kidney failure or disease (Yuan, et al., 2017).  It is clear that type 2 diabetes has serious public health implications, and therefore the increase of this harmful disease should intensify the importance of making this problem a major public health issue in today’s society.Social Determinants Social determinants of health describe how “the conditions in which people are born, grow, live, and work” affect their health (WHO: Social determinants of health 2017). Socioeconomic status, and its influence on health and nutrition, is one factor which has influenced the increasing prevalence of type 2 diabetes in the American Samoa.  The traditional Samoan diet which once consisted of mostly organic foods including taro, breadfruit, coconut, bananas and seafood has now been replaced by Western foods such as white bread, white rice, noodles, and fatty meats (Seiden, Hawley, Schulz, & Raifman, 2016).  The lower prices of non-traditional staple foods are stifling the production and consumption of local food products.  For Samoans of low socioeconomic status, it is easier to acquire imported meats of cheap prices and low nutritional quality than their native, more expensive counterparts.  Low-fat, traditional proteins such as fish or indigenous chickens often cost 15 to 50 percent more than imported meats such as turkey tails, and mutton or chicken parts (Healthful Food Availability in Stores and Restaurants 2014).  A large proportion of the food in American Samoa is imported, which results in higher prices.  However, fast-food chains and convenience stores offer a cheap and convenient alternative.  The imported meats offered by an increasing number of US-based fast food restaurants in the American Samoa have replaced seafood as primary sources of protein and fat.  Moreover, the processed foods offered by these establishments tend to be much higher in fats, sugars and salt.  Furthermore, according to surveys done by the World Health Organization in 2016, more than 80% of the adult American Samoan population eats less than three servings a day of fruits and vegetables (Seiden, et al., 2016).  Changes in Pacific Island nations’ food trade policies have also been implicated in the American Samoa’s nutrition transition. Food imports, compared to total imports, has risen to about 35 percent in the American Samoa. The desire to achieve and maintain membership in global trade organizations such as the World Trade Organization has led Pacific Island nations to maintain markets open to other nations exports, regardless of concerns about food quality and nutritional health issues. In fact, in late 2011, the Government of Samoa rescinded its import ban on turkey tails, which are known for their extremely high fat content, in order to facilitate entry into the World Trade Organization (Seiden, et al., 2016).  For American Samoans of low socioeconomic status, it is much easier to access these cheaper, unhealthier foods that are sold in local markets.The geography of the American Samoa is one primary social determinant.  The location of the American Samoa as a small group of islands in the middle of the Pacific Ocean makes it especially vulnerable to natural disasters including cyclones and tsunamis.  Oftentimes, such disasters leave the farmland areas in poor conditions with flooded fields and uprooted plants. One example of this occurred in April 2015, in which a cyclone battered the pacific islands.  Intense rainfall and winds up to 130 mph left a large proportion of the vegetation in American Samoa uprooted and destroyed (DePue, et al., 2016).  Frequent occurrence of natural disasters during the cyclone season, from November to April, pose an enormous threat to the stability of the American Samoan agriculture and fishing industries.  Thus, this population has increasingly come to rely on unhealthy, cheaper foods imported from other countries.  Additionally, in the transition from traditional to modern ways of life, many poor health behaviors have arisen in the American Samoa community.  The most prevalent issues include the overconsumption of unhealthy foods combined with low levels of physical activity. In the American Samoa there has been a widespread adoption of modern jobs and technology in exchange for traditional agriculture-based livelihoods. The rising predominance of modern factory or office work has brought about a significant decline in the daily exercise of most American Samoans. The implementation of several tuna canning factories on the island has resulted in less traditional fishing occupations, and more and more Samoans working in such factories (Lin, et al., 2016).  The factory jobs that a majority of the populations now occupies contrasts greatly with traditional Samoan ways of life.  Many American Samoans have modernized their lives by exchanging family canoes for motorboats and using cars rather than walking. This transition to modernized forms of transportation has serious health consequences because many people in this population are not getting the amount of physical exercise they need.There are also numerous cultural factors that contribute to the high prevalence of diabetes. Purchasing imported goods from wealthier countries has become a sign of high social status in the Samoan community, while consumption of native foods have decreased in popularity. After the United States first took control of the American Samoa, missionary wives and other western women began counseling the Pacific Islanders on the “proper way” to feed their families (Hou, et al., 2016).  However, many of the imported products received by the American Samoans are foods that are disliked by other countries due to controversial ingredients and extremely high fat content. One example of such foods are imported mutton flaps from New Zealand which are said to contain “40 grams of fat per 100 grams of meat” (Healthful Food Availability in Stores and Restaurants 2014).  Today, daily overconsumption of these foods puts individuals at serious risk for noncommunicable diseases, including type 2 diabetes.  Selection of Population The American Samoa consists of a group of 5 islands in the South Pacific Ocean and is considered an unincorporated and unorganized territory of the United States. For centuries, the inhabitants of the American Samoa were sheltered from the outside world, which enabled their social, cultural and economic way of life to maintain its sustainably and develop untouched. When the Europeans arrived in the 17th century, the Pacific Islanders were described as “strong, muscular and in good health” (Hou, et al., 2016). However, in the 1900s, the United States gained control over what is now known as the American Samoa and rapidly moved the nation into the 20th century within the span of a few years. As the indigenous American Samoan population replaced their traditional style of living with a more modern way of life, striking health changes have occurred. Calling attention to this specific population, in which diabetes is disproportionately prevalent, will help establish an environment in which public health initiatives can be put into place to root out the factors that contribute to this disease.  According to surveys done by the World Health Organization, 25.5 percent of the American Samoan population today is diabetic (one of the highest rates in the world), while nearly 60 percent of the population is overweight or obese (World Health Organization 2016).  The percentage of diabetics in the American Samoa is alarmingly higher than the 13 percent global average (World Health Organization 2016). It is important to consider biological and social factors to determine why the prevalence of the American Samoans with type 2 diabetes is alarmingly high.   While geographic isolation physically separates the population from mainland continents, it also inadvertently creates a food desert in which access to healthy foods is a significant challenge. The population of the American Samoa has experienced rapid and widespread lifestyle changes with increases in caloric intake, high sodium and saturated fats, as well as minimal levels of physical activity.  A dietary survey of the island’s population has shown a mean caloric intake of about 5100 calories per day. Of these calories, 48% was taken as carbohydrate, 37% as fat, and 15% as protein (Lin, et al., 2016).  These diets are considered incredibly poor by established nutritional standards, and have likely exacerbated the American Samoan’s vulnerability to diabetes and obesity. Moreover, the cultural encouragement of imported foods and excess body size in conjunction with the genetic characteristics of the Samoans has also increased their susceptibility to diabetes.  Through public health interventions following the levels of the socio-ecological model, it may be possible to decrease the incidence of type 2 diabetes in the American Samoan society. Preventative initiatives should be established to decrease the widening margin of Samoans at risk for diabetes. Widespread nutrition education for both adults and adolescents could improve proper diet and exercise habits.  These biological, cultural, and social determinants provide a basis for understanding how type 2 diabetes has become increasingly prevalent in the American Samoan population, and why this problem must become a public health priority.  

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