The growing and disproportionate burden of type 2 diabetes experienced by racial and ethnic minority groups in the United States demands a refocusing of public health research and interventions if health outcomes are to improve. Public health research and practice must address the social production of diabetes, broaden the boundaries of how diabetes risk and causation are understood and articulated, and establish community health models that reflect the changing complexion and sociopolitical dynamics of contemporary urban communities. Relying on the traditional one-on-one clinical relationship that has characterized diabetes care in the past will not eliminate the diabetes epidemic in racial and ethnic communities.
Emerging rates of type 2 diabetes (hereafter referred to as diabetes) around the world presage a pandemic of this debilitating and costly chronic disease.1 Despite decades of a national emphasis on improving minority health among racial and ethnic minority groups in the United States,2 including African Americans, American Indians or Alaska Natives, Hispanic Americans, Asian Americans, and Pacific Islanders, the current state of diabetes incidence and prevalence and its associated complications in these groups is sobering at best. In reality, this situation requires emergency action. Recent data released by the Centers for Disease Control and Prevention (CDC) indicate that Black non-Hispanic, Mexican Americans, and residents of Puerto Rico are 2.0 times as likely as non-Hispanic Whites of similar age to have diabetes3 and that American Indians and Alaska Natives are on average 2.6 times as likely as their non-Hispanic White counterparts to have diabetes.4,5 Type 2 diabetes tends to affect women, older adults, residents of urban areas, and persons of low socioeconomic status at higher rates.6,7 Racial and ethnic minority communities in both developed and developing countries appear to experience excessive rates of diabetes complications (e.g., visual loss, lower extremity amputations and end-stage renal disease)-rates 1.5 to 4 times higher than those observed among comparable White communities.8-11
The rise in the prevalence of type 2 diabetes coincides with the national and international rise in obesity.5,12-14 The co-emergence of the type 2 diabetes and obesity epidemics, as well as the complexities of their etiologies, in populations that are arguably socially, economically, and politically vulnerable demand a critical refocusing of public health research and practice.15-17 If the goal in the United States is to eliminate the health disparities noted in Healthy People 2010,18 public health professionals must be willing to reexamine and critique the core assumptions of how we have traditionally explained and intervened on diabetes in minority groups and to uncover the biases in our ways of knowing.
In this commentary, we review findings and perspectives from the CDC's Division of Diabetes Translation's (DDT's) program experience and publications from the epidemiological, social science, community intervention, and popular literature that might facilitate our reevaluation. The depth and breadth of the literature are promising and provocative. The research stimulates questions that help frame the formation of next steps in reducing, and ultimately eliminating, the burden of diabetes in disproportionately affected populations. For example, in what instances are cultural, socioeconomic, and political forces more powerful and predictive of health behaviors than individual choice?19-23 What are feasible public health interventions and policies in light of the location of-and inherently political nature of-public health? How can public health professionals actively engage interdisciplinary social science perspectives in contextualizing the gender, class, and racial distribution of diabetes?24-26 How well have our community-based public health strategies kept pace with the changing demographics and destabilization of many urban communities? Are public health professionals regularly and systematically refining their program planning to ensure their program's relevance and effectiveness in rapidly changing communities?
We suggest that the conceptual lens through which diabetes prevention and control is typically viewed must shift beyond the individual and personal choice. Diabetes prevention and control must examine the social production of risk for diabetes;22,23,27 that public health professionals must broaden epidemiological paradigms and theories of disease causation beyond the narrow focus of biomedicine;25-29 and that they must reexamine the assumptions of community models from which diabetes interventions are designed and implemented.30-32 A full discussion of these issues and other challenges to the prevention and control of diabetes in racial and ethnic minority communities clearly exceeds the scope of this commentary, but we identify major issues and concepts.