2: No. 1, January 2005
Toward Prevention and Control of Type 2 Diabetes: Challenges
at the U.S.-Mexico Border and Beyond
Barbara A. Bowman, PhD, Frank Vinicor, MD, MPH
Suggested citation for this article: Bowman BA, Vinicor F. Toward prevention and control of type 2 diabetes:
challenges at the U.S.-Mexico border and beyond. Prev Chronic Dis [serial
online]. 2005 Jan [date cited].
Available from: URL:
Type 2 diabetes makes a compelling case study for public health action (1).
The disease respects no boundaries. It is increasingly common — occurring in both
developed and developing countries (2), in men and women, at
earlier ages than in past decades, and in persons of every
race and ethnic group, with a high prevalence in Hispanic/Latino
Americans and in other minority groups, including non-Hispanic blacks, American Indians, Alaska Natives, Asian Americans, and
Native Hawaiian and other Pacific Islanders (3). As noted by Martorell (4) and Saldaña (5), family history and genetic factors
appear to further increase the risk for type 2 diabetes in
Hispanic/Latino Americans. In the United States, the prevalence
of diabetes was estimated to be 18.2 million people (6.3% of the
population) in 2002 (3), with dramatic increases predicted in the
The determinants of type 2 diabetes are largely understood. Two of the most important risk factors, obesity and physical inactivity, are
modifiable. The natural history involves progression from prediabetes, a condition in which blood glucose metabolism is
abnormal (although not yet in the diabetes range), to the
development of type 2 diabetes. The rate of progression from prediabetes to type 2 diabetes is between 3% and 10% per year
(7). However, progression from prediabetes to diabetes can be
prevented or delayed with sustained weight loss and increased
physical activity (8,9). The magnitude of the change needed for
primary prevention of type 2 diabetes is relatively modest: a
7% to 10% weight loss and sustained moderate physical activity, at least 30
minutes per day (10). Today, the number of adults with prediabetes in the United States is estimated to be at least 41
Type 2 diabetes leads to devastating health and economic consequences for
individuals, their families, and society. The most serious complications include
blindness, kidney disease, lower-limb amputations, and acceleration of coronary
heart disease and stroke (3). After type 2 diabetes is
diagnosed, treatment requires an increasingly intensive and complex regimen to
control glucose, blood pressure, and lipids, in addition to ongoing
preventive care for the eyes, kidneys, and feet (11). Health
care and complications attributed to diabetes are costly: in 2002, the total
cost of diabetes was estimated to be $132 billion, $92 billion of which was spent on direct medical costs and $40 billion
of which was spent on indirect costs, including disability, work loss, and premature
mortality (12). Clearly, ongoing access to high-quality health care is a paramount concern for preventing complications
and death from diabetes. Such care is expensive, and much of the
cost of drugs and supplies is not reimbursed, even for those with
insurance coverage (13). While it is improving, the quality of
clinical care for people with diabetes still falls short of
established guidelines (14). Because of continued increases in the
prevalence of obesity, the outlook for the future is ominous
— the health system will likely be overwhelmed by type 2 diabetes
The population groups at increased risk for diabetes,
including Hispanic/Latino Americans, suffer a disproportionate
burden of disease, further exacerbated by poverty and lack of
access to health care (3,16). What public health responses are
likely to be effective in reducing the present and future
consequences of type 2 diabetes in population groups, such as
people living along the U.S.-Mexico border? And, how long will it
take to begin to turn the tide?
As detailed by Cohen et al in the series of articles from the
Border Health Strategic Initiative, the solution to type 2
diabetes control must begin in the community (17). Extensive
dialogue is a first step in engaging communities and identifying
the priorities for community action. The papers by Cohen and
associates demonstrate how communities and researchers can
— and must — collaborate to assess targets for
intervention and develop sustainable solutions to control type 2
diabetes. Insights gained from these interventions also can guide the
development of effective community-based approaches for primary
prevention of type 2 diabetes. Community-based
participatory research and mobilization are critical to create
the evidence base for elimination of health disparities, as shown
in a recent compendium of papers describing the experience of
Racial and Ethnic Approaches to Community Health (REACH) 2010 communities (18).
But having evidence is not enough. Improving the
public’s health will require rapid translation and
dissemination of effective, community-based strategies for
diabetes prevention and control and the commitment to sustain and
reinforce these interventions (19). As shown by this promising
initiative (17), collaboration across and within national and
state borders and communities will be essential and must involve
the entire community: where people live, work, play, and go to
school. Improved clinical care alone will not be sufficient. One
strategy now being implemented uses the essential public health
services as strategic levers to strengthen the public health
response to diabetes (20). Development, implementation, and
evaluation of such strategies are needed urgently. We anticipate
that publication of the papers by Cohen et al, which describe
many challenges and some successes, will inspire readers of
Preventing Chronic Disease to share their own lessons
learned and promising approaches for public health action to
prevent and control type 2 diabetes.
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Corresponding author: Barbara A. Bowman, PhD, National Center
for Chronic Disease Prevention and Health Promotion, Centers
for Disease Control and Prevention, Mail Stop K-40, 4770 Buford
Highway NE, Atlanta, GA 30341. Telephone: 770-488-5414. E-mail: BBowman@cdc.gov.
Author affiliations: Frank Vinicor, MD, MPH, National Center
for Chronic Disease Prevention and Health Promotion, Centers
for Disease Control and Prevention, Atlanta, Ga.
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