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The Pacific Islander Diabetes Prevention Program (PI-DPP), is a year-long, evidence-based lifestyle change program recognized and supported by the Center for Disease Control and Prevention (CDC). PI-DPP was formed through a partnership between the Association of Asian Pacific Community Health Organizations (AAPCHO) and the Pacific Islander Center for Primary Care Excellence (PI-CoPCE) as a project funded by the CDC DP17-1705 grant to scale the CDC National DPP in underserved areas. Currently, PI-DPP consists of 11 sites throughout the U.S. and U.S. Affiliated Pacific Islands (USAPI). 

Aligning with DPP success standards, participants aim for 5% body weight loss, 150 weekly physical activity minutes (PAMs), and lower HbA1C values. 

Listen in each week as we highlight PI-DPP sites. Mililani Leui, Program Manager of PI-DPP, sits down with site representatives to hear about their community stories and program impacts. 

This week we spoke with George Cruz of Marianas Health (MHS). MHS is a local healthcare service provider in the Commonwealth of the Northern Mariana Islands (CNMI) and is based out of the island of Saipan. Marianas Health offers the Hafa Initiative Program (Health Education Awareness and Fitness Activities) to the islands of Saipan, Tinian, and Rota. In this episode, George and Mililani speak about the importance of outreaching to outer islands in the CNMI as well as discuss the impact of community partnerships in advancing diabetes prevention and promoting healthy lifestyles.

Lifestyle Coach Certification event held by Marianas Health Services (MHS), HAFA Initiative
Photo Courtesy of MHS

George: Hafa Adai, my name is George Cruz. I am the Administrator for Marianas Health and its subsidiary agencies here in the CNMI, specifically on the island of Saipan. 

Mililani: My name is Mililani, and I am the Program Manager for PI-DPP. 

The first question we have for you is, why is a program like this important for the community you serve?

George: We have a high prevalence of pre-diabetes and diabetes here in the CNMI. The unfortunate part of this is we just haven’t had an accurate survey or census done on pre-diabetes and diabetes for the past maybe 20, 30 years to really show this, but we all know, the whole entire community knows that pre-diabetes and diabetes itself too is a huge issue that plagues our families, plagues our community. And so, that’s why having this program, the PI-DPP program, for us here, we call it the HAFA initiative, is very important to address these issues. Because we’re seeing it now affecting not just the elder or what we call our Manåmko’, but especially our workforce, and those that are in younger age, as low as elementary school.

(Top) Lifestyle Coach (LC), Marlene Cruz, conducts a session with her Thursday HAFA 19 Cohort at San Roque Parish, Saipan. (Bottom) Lifestyle Coach, Grace Napitan, co-coaches her Saturday HAFA 20 Cohort with fellow LC, Marlene Cruz, at Marianas Health.
Photo Courtesy of MHS

Mililani: Why is it important to tailor the program to your community’s specific needs? 

George: So, here in the CNMI, we have a high percentage of individuals who are on Medicaid. And so, we actually… It’s about 68% of our population is on Medicaid. 

And so, this tells us two things. Number one, we have a community that is at or below the poverty level; and two, that means we have a majority of our community who have only completed high school or nothing beyond that. When it comes to health, health issues, questioning the doctors, things like that, about their health issues, they take it pretty much as it comes. And so, whatever they’re told, they’re told, and they don’t see or know of any additional ways for them to control their chronic disease, whether it’s hypertension, COPD, and in this case, diabetes. 

When it comes to their health, we need to make sure that we make it simple. And that’s one of  the things I love with the PI-DPP program and all of the subjects and the topics that it goes over, is it makes it very, very simple for people to understand. Whether you have your master’s degree, or you’re a 72-year-old elder here on the island with only an elementary education, they are able to understand the concept of what’s being discussed. 

The other part of it being, we need to tailor it if we didn’t take the program from CDC and tailor it to the Pacific Island, they would not be able to relate to it. Because if we’re talking about the snowstorm and we’re talking about squash and all of these different vegetables and stuff that we don’t have on the island, they’re going to say, “Well, what is that? I can’t afford that.” And so, it’s very important that we make the program very relatable to the everyday life of our locals. 

And the interesting thing with all the Pacific Islands is that we’re all a melting pot. So, here in the CNMI, you’re not just going to find Chamorros or Carolinians, you’re going to find Chuukese, Pohnepians, Palauans. So, we’re all very intermixed all throughout the islands because our history is that we’re seafarers, right? We’re fishermen so we keep going around the islands. And so, it’s very important that even the things that are done in Palau, we need to relate it to here in the CNMI as well. And so, those are the reasons why I feel that having the program tailored to the Pacific Island is important. 

I remember one question somebody asked a participant, before she became a participant, it goes, “You said it’s for Pacific Islanders.” And she goes, “But I’m Filipino, so do I not qualify?” I go, “No.” I said,  “You’re living in the Pacific, in any of the islands of Pacific. You’re a Pacific Islander. You have to change your food habits and everything because you came here to the CNMI.” She goes, “Yes.” I said, “There you go. So, you’re a Pacific Islander. “

Mililani: Is there any background information you would like to share to reinforce the importance of this program for your community? 

George: We’ve been also trying to reach out to our other island communities, Rota and Tinian. I always think about this. I always have to remind our team, our LCs, our lifestyle coaches. I said, “If Saipan is in a bad situation compared to Guam or compared to Hawai’i, what more Rota and Tinian?” They’re probably in a worse situation because they lack access to, number one, definitely, healthy fruits and vegetables at an inexpensive price, and number two is also the lack of access to basic healthcare needs. 

And so, when you have those two issues, it becomes a huge, huge challenge not just for us, but the community as a whole, right? Because again, if you grew up somewhere, even if it’s a small town or a small island, it’s still home, and you learn the ways. Growing up, you learn how to cultivate the land, or how to adjust yourself in the community, and just things around. And it’s home.

Yes, we go off to get a degree or get exposed to the world, but we always come back home. And one of the things, speaking to a lot of the communities on both islands, in Rota and Tinian, was… It says, “You know, Mr. Cruz, I don’t want to leave home. I don’t want to leave. This is where I grew up. This is where I want to die, but I can’t even get proper medical treatment here or medical care. I can’t even get… Food is so expensive.” 

They need our help just as much as those on Saipan, even though it’s the most populated among our four islands. We know that they need it, they need that type of support and resources there. 

MHS 2020-2022 Impact Report
Photo Courtesy of PI-DPP

Mililani: What impact has your site had on the communities you serve? 

George: Well, one of the things I’m very happy that AAPCHO and the PI-DPP program has provided us sites is the impact report. When I look at this and I show this to the LCs and also our community stakeholders, the insurance companies, it really just shows that there’s at least an opportunity, there’s a resource out there in the community to help prevent rather than just treat. And that’s always one of the things that I’ve always been involved in for the past 20, 30 years was on prevention, prevention, prevention. You know it’s so hard to measure prevention versus treatment. But, I love this impact report because I can see how it is preventing the on-set of diabetes and even those with diabetes, who are in the program, we see how they’re controlling their A1C, [which] has gone down dramatically. Their blood pressure has gone down. And so, these are just some of the amazing results. 

We have over 150 participants who enrolled and we have over 678 pounds of total weight loss. That’s amazing. And we have 425,000 total physical activity minutes. And this is amazing because when we looked at a lot of the participants when they first started, they were clocking in 30 minutes a week, 90 minutes a week. And they thought that was good. They thought that they were doing pretty well. But then, when they compared it, we started tracking it. And you know, our goal was 150, they were like, “Wow!” And then, to see that increase from like I said 30 to 90 minutes a week to 300 to 500 of minutes a week, that’s just, again, a small sign that our community’s mindset is changing. 

We got to stay physically active and watch what we consume, both drinking and eating. And when we put those two equations together, then we get a good outcome which is weight loss, reduction in our blood pressure, reduction in our A1Cs, and things like that. And so, I’m seeing these results, it’s really, really amazing. 

And just, again, looking at the impact report, the average participant has lost eight pounds, they’ve lost 4.5% of their body weight. We have more participants that are now paying attention to their lifestyle. And, again, that’s the goal of the whole program, right, the HAFA Initiative, the PIDPP program, the curriculum, is to really help people in the long-term. Not just short-term gain, but the long-term sustainability of their health. 

Marianas Health, along with Master Lifestyle Coach Cecilia Sigrah, from Kosrae Community Health Center, certifies new Lifestyle Coaches in December 2022.
Photo Courtesy of MHS

Mililani: What are some of your site’s challenges and/or best practices for recruitment, retention and general programming? 

George: No matter what, how well-prepared we are, well-equipped we are, whatever it may be, there’s always going to be challenges. And the number one challenge for us, for me, in our program is lifestyle coaches. We have a lot that are very dedicated in the beginning, and unfortunately, life always throws a curveball. 

And here on the islands, especially when it comes to, unfortunately, death in the family, even if it’s your third cousin and fifth cousin, they’re still your cousin. When that happens, pretty much, the family takes off. A lot of times within that time, you lose that momentum. And so then, we start to lose coaches. 

Here, also, when a family gets sick, unlike in the States and stuff where sometimes there’s group homes, or they put them at the hospital, our hospital is very small. It’s only an 86-bed capacity hospital. So, here, what, again, the tradition is the youngest or the oldest drops everything, whether it’s school, work, even family sometimes, and they have to focus on taking care of their mom, their dad, or whoever the sick one is in the family. 

Diabetes Prevention “Waves.” Volunteers raise diabetes awareness by holding banners for the HAFA Initiative along the roadside.
Photo Courtesy of MHS

Number two is we’re getting better at it, but it is the retention part. 

I just had one of my students in my class, just last week, she says she really wants to continue, but now she’s taking care of her mother-in-law who’s on dialysis. Just things like that, those are always our biggest challenges. 

Best practices for recruitment, one of the two things that have worked out for us. First we started just recruiting on our own, and we did okay. But then I said, you know what, we need to reach out. We need to work on the organization that’s on all three islands, that can support us. And so, we reached out to the Diocese of Chalan Kanoa, which is the Catholic Church, and they have fourteen parishes; one on Tinian, two in Rota, and eleven on Saipan. And so, I was like, “Wow, that’s the best way to do this.” So, we had a meeting with all the priests and we educated them about the HAFA Initiative. We actually even did our health checks with them, finding out some of them really needed to also join the program. So, I was like, “Father, I think your blood pressure’s kind of high. You need to start getting this. Your A1C is a little bit high.” 

And so, we started getting a good response on that. We are at five parishes, one in Rota, and then four on Saipan. And then, just this past year, as one of our other partners, we added the college. So, we only have one college here in the CNMI, Northern Marianas College. And so, we added them as a partner, and so that’s been very successful because they have campuses on all three islands. And so, that has been great in regards to also helping us recruit because now we opened up classes on the campus at NMC. Some best practices is looking at both faith-based as well as educational institutions as part of our recruitment and retention.

And many times, unfortunately, we’ve had a lot of our LCs who fell in that situation, So, that’s been a huge issue because we’ve had a lot of areas, businesses, community organizations, government agencies, who have really been interested and wanting to start the program, the curriculum, in their organization, but we just lack the coaches. 

The Team from Marianas Health present on the HAFA Initiative/PI-DPP Program to the Pastors and staff of the Diocese of Chalan Kanoa, and integrate physical activity minutes during their presentation.
Photo Courtesy of MHS

Mililani: What future projects and/or goals does your site have for advancing diabetes prevention and  promoting healthy lifestyles? 

George: One of the things that we’re working on as part of our long-term sustainability is to work with the two major foundations here on island. One of them is the Joeten Foundation, and then the other is the Tan Siu Lin Foundation. And with that, that should hopefully help sustain us for about two to three years for the program because the majority of it is compensating our lifestyle coaches because it does take a lot of time. 

And all of our coaches have full-time jobs, so this is an extension of what they’re doing. But they’re committed to it because they see the effects for not just the community, but even their own family. They said their kids who have been eating rice and this and that, they’re now controlling it because they, as lifestyle coaches, as mothers or as fathers, have been more aware of what they were doing negatively with their kids by giving them three scoops of rice, spam, and all this. And again, we’re not saying don’t eat it. We’re just saying, “Hey, now moderate, maybe once a week. And instead of three scoops of rice, go one and a half scoop, or one scoop of rice.” Just things like that. Again, gradual modifications in their kids’ lifestyle. 

And so, even though it is for the program, we’ve all been seeing the positive effects on our kids. Hopefully, through these foundations, they can provide the financial support for us to continue this, still continue to offer it for free, for the population, for the community on all three islands. And I think, the great thing as well is as of February 1st, Marianas Health, our HAFA Initiative program, we got the CDC recognition for our program. The good thing is, again, with Marianas Health, we’ve been in the community for over 20 some years, and we’re Medicare certified, Medicaid certified, so we meet a lot of these national and local state standards. It’s an evidence-based program that shows that you can control, and/or prevent, or delay the onset of type two diabetes. That’s number one.

Number two is we’re really trying to beef up our community health checks, and this is a way for us to recruit participants out in the village. So, instead of them coming to the clinics, let’s go to them. So, we have a team that goes out twice a month to different parts of the villages, and we just set up tents, set up shop in the middle of the village. We always advertise. We put out flyers at least a week ahead, letting them know that we’re going to be in the area. And, of course, we do it on the Saturday when everybody’s home and stuff like that so we can get the best turnout. We do health checks with A1C, blood sugar, body fat content, BMI, and then we also do possible referrals. If a person hasn’t seen a provider in a while, we help them, refer them to a provider, especially if they’re high risk of hypertension or, again, pre-diabetes or diabetes. And then, we try to get them into the program right away as well.

We thank Marianas Health’s George Cruz for speaking with us during this week’s segment. Please stay tuned for our next site highlight!

To learn more about MHS and the HAFA Initiative, please visit their website at https://marianashealth.com/index.html and https://www.hafainitiative.com/, and their Facebook and Instagram. 

To support MHS in their pursuit of diabetes prevention and promoting healthy lifestyles, please contact George Cruz at george_c@marianashealth.com for more information. 

Be sure to learn more about George’s work and check out why he is an #AANHPIhealth Hero!  

Facebook: @marianashealth

Instagram: @marianashealthpage