COLLABORATIVE US-MEXICO BORDER DIABETES PREVENTION AND CONTROL PROJECT

LIST OF ACRONYMS

BHC Binational Health Councils

BMI Body Mass Index

CDC Centers for Disease Control and Prevention

DCP Diabetes Control Programs

FPG Fast Plasma glucose

HbA_1c Hemoglobin A1C

IFPG Impaired Fast Plasma Glucose

IMSS Mexican Institute for Social Security/Instituto Mexicano del Seguro Social

ISSSTE Institute for Social Security Services for the Employees of the State

NDEP National Diabetes Education Program

PAHO Pan American Health Organization

PINREHD President Clinton’s Initiative on Racial and Ethnic Health Disparities

RFP Request For Proposal

SSA Secretariat of Health

SUDDAN Statistical Software

TDH Texas Department of Health

US United States

USMBDPCP U.S.-Mexico Border Diabetes Prevention and Control Project

USMBHA U.S.-Mexico Border Health Association

X. Budget 29

LIST OF APPENDIXES

1. U.S. – Mexico Border Map
2. General Assembly Approved Resolution
3. 57^th Annual Meeting and List of Previous Annual Meetings
4. USMBHA Publications - Journal of Border Health, News, and 1998-1999 Annual Report
5. Letters of Support and Financial Agreements
6. Diabetes Initiative U.S.-Mexico Border - List of Participants
7. Diabetes Survey Questionnaire
8. Consent Form
9. Test Results Notification Letter and Form
10. Interviewer Training Manual
11. Healthy People Year 2000 and 2010 Diabetes Objectives and Programa de Salud del Adulto y del Anciano
12. Biographical Sketches
13. Budget Justification
14. Indirect Cost Rate Agreement / 1998 Audited Financial Statements / IRS Letter of Determination
15. Intervention Program: Five-Year Plan Proposal for Review

I. ABSTRACT

The United States-Mexico Border Health Association (USMBHA) in collaboration with the United States/Mexico Border Diabetes Prevention and Control Project Work Group (USMBDPCP) is requesting funds for a binational diabetes prevention and control project on the United States-Mexico border that begin with an evaluation of the burden of diabetes on the border (Phase 1) and expands into a program implementation (Phase 2), using the results from Phase 1. The USMBDPCP is responding to President Clinton's Initiative on Racial and Ethnic Health Disparities, as well as the Mexican Secretariat Adult and Elderly Health Program strategy in which diabetes is a national health priority. Diabetes has also been declared a binational border priority by the USMBHA General Assembly in a resolution to develop diabetes control infrastructure on the border.

The purpose of the project is to diminish the impact of diabetes on the border population by conducting activities in two related and chronological phases (prevalence study and intervention program).

Phase 1 will assess the prevalence of diabetes, related behavioral risk factors, and access the health services for the border population. The information collected through this household survey will serve as a guide for the development of diabetes education and training activities in Phase 2. These programs will be culturally appropriate and will include the participation of community health workers (promotores) and primary healthcare providers. Initial planning and promotional activities needed for Phase 2 will take place concurrent with Phase 1. A complete description of the first year activities is in the work plan.

Activities for years two through five will include implementation of community interventions, capacity building, and program evaluation. The household survey will be repeated in the fifth year of the project.

The USMBHA and the USMBDPCP Work Group have obtained considerable financial support for this proposed project. The commitment of $275,000.00 in matching funds and In-kind support of $913,380.00 have been obtained to date and we expect to obtain additional funds before the end of the project for Phase 1. The USMBHA and the USMBDPCP Work Group are requesting $735,630.00 from the Center of Disease Control and Prevention (CDC) to fund this project.

II. PROJECT RATIONALE AND NEED

A. Introduction

This project provides an opportunity for CDC and the four US Border Diabetes Control Programs, the Secretariat of Health (SSA) and the six Mexican Border States to proactively engage in a binational collaborative effort to study the prevalence of diabetes along the border and use this information to develop and implement health promotion programs. For the US side, this project also offers an opportunity to address Healthy People 2000 and 2010 Objectives^1,2 and President Clinton's Initiative on Racial and Ethnic Health Disparities (PINREHD). The USMBDPCP is responding to the SSA’s strategy of the Adult and Elderly Health Program³ stated in its national priority health program.

The border area includes a large minority population that suffers from many health disparities including a high prevalence of diabetes. Our proposal is consistent with the President’s approach: elimination of disparities and prevention orientation in border sister cities. Mexico’s Secretariat of Health commitment to diabetes prevention and control is demonstrated by the Official Guidelines of Diabetes (Norma Oficial Mexicana)⁴. The aim of the Official Mexican Norm is to standardize the criteria and procedures for the prevention, diagnosis, treatment, and control of diabetes. Through this project, it will be possible to strengthen the SSA’s Diabetes Guidelines, and to reduce the burden of diabetes and related risk factors along the border. The USMBDPCP Work Group project will also serve as a model for future binational approaches to other chronic diseases.

Several diabetes studies have been conducted on both sides of the U.S.-Mexico border with considerable variation in the prevalence estimates for diabetes and high-risk behaviors^5,6. These variations are due to the use of various methodologies, and therefore, provide an incomplete picture. But, less is known about their health care access patterns because many U.S. residents use both systems of health care. It is imperative to obtain accurate data to detect the prevalence of diabetes, extent of high risk behavior and health care access patterns for the U.S.-Mexico border if we are to reduce the health disparities in this population.

B. Socio-demographics and economic profile

A conventional description of the border includes the area extending 100 km (60 miles) on each side of the 3400 km (2040 mile) international boundary between the US and Mexico⁷ (Figure 1). The border area includes the southern portions of four US states (Arizona, California, New Mexico, and Texas) and the northern portions of six states of Mexico (Baja California, Chihuahua, Coahuila, Nuevo Leon, and Tamaulipas). According to the 1990 census of both countries, the total population of the border region is 9,089,508. Of this population, 5,199,930 (57%) live in 24 U.S. counties, and 3,889,578 (43%) live in 39 Mexican municipalities⁸. The average Hispanic population living on the US border counties is 70%, ranging from 20.4% in San Diego, California (a multiethnic population) to 97.2% in Star County, Texas⁹. The overall population growth rate for the US-Mexico border is higher (3.1% for Mexico and 2.4% for the US)⁸, on both sides than the national rate of each country. In other words, this means that the US border will double in 29.2 years and the Mexican border will double in 22.6 years if the current conditions remain the same* .

The border area contains a mix of Hispanic and non-Hispanic cultures, including the Native Americans. For some states, the Hispanic influence reaches far from the actual border region and encompasses practically the entire state (e.g., New Mexico). In other states, the non-Hispanic influence extents deeply into the culture and is causing the adoption of many habits traditionally associated with an affluent society; such is the case for many of the cities in the six northern states of Mexico. Most cities along the US side of the border are heavily influenced culturally, economically, and socially by the populations that live on the Mexican side.

Poverty rates are very high even with economic development that has resulted with the North American Free Trade Agreement (NAFTA). According to several reports the US border area has at least five of the poorest counties in the United States¹⁰. Most of the US counties have higher percentages of populations living under the poverty level. For example, for some border counties, 60 percent of the residents are below the federal poverty level and conditions are even worse on the Mexican side of the border¹⁰. Colonias¹¹ (human settlements lacking basic sanitation services, also known in Mexico as Marginalized Areas) are common on both sides of the border and can best be described as third world in nature (non potable water, open sewage, unsanitary living conditions and disproportionate health disparities).

These social-economic conditions bring high unemployment rates with an estimated 33% of the Hispanic population without health insurance. Due to these conditions, the Federal Government of the United States has designated all border counties in the Rio Grande area "medically under-served areas". Therefore, they qualified for special public health funding⁶.

Due to the lack of health insurance for a large number of the US population, several studies have documented that approximately 30% of this population cross the border to the Mexican side to receive health care, and 60% for dental care services. Approximately 60% of the Hispanic population purchases medications on the Mexican side since they are 40-50% cheaper than in the US side¹².

3. Diabetes Epidemiological Profile Overview

Among Hispanic persons in the US, the Third Health and Nutrition Examination Survey (NHANES III) estimated that type 2 diabetes (diagnosed and undiagnosed) is present in 2.3% of persons aged 20-39 years, 13.2% of persons aged 40 to 49 years, 26.0% of persons aged 50 to 59 years, 29.3% of persons aged 60 to 74 years, and 29.7% of persons aged 75 years and greater¹³. There is a clear ethnic disparity in the burden of diabetes given that both the incidence and prevalence of type 2 diabetes are 2-3 times greater in Mexican Americans than in non-Hispanics¹⁴. Type 2 diabetes is associated with a host of other risk factors, including hypertension, obesity, unhealthy diet, and physical inactivity. Previous investigations found that Mexican Americans exhibit a greater prevalence of certain type 2 diabetes-associated conditions, including obesity and hypercholesterolemia, and higher rates of some adverse complications¹⁵ (renal failure¹⁶, amputations, peripheral vascular disease), and type 2 diabetes-associated mortality, than non-Hispanic white persons with diabetes¹⁷. Although lower rates of cardiovascular complications were once reported for some southwest Hispanics, Arizona Hispanics now exhibit comparable incidence rates of heart disease and stroke as the larger non-Hispanic white population ¹⁸.

The 1993, National Chronic Disease Survey (Encuesta Nacional de Enfermedades Crónicas) conducted in Mexico by the National Epidemiology Office (Direccion General de Epidemiologia) assessed the prevalence of diabetes and related risk factors. The survey estimated that 7.2% of the population between 20 and 69 years of age had diabetes. However, in the 60 to 69 year-old-group, the prevalence of diabetes was more than 20%. Among individuals 60 years of age and older with diabetes, 75% reported being diagnosed with the disease before the survey¹⁹.

In Mexico, the 1996 National Mortality Report revealed that 77% of deaths were due to non-communicable diseases. Of these 32% were due to diabetes, high blood pressure, cerebrovascular and cardiovascular disease combined¹⁹. In addition, the diabetes mortality rates increased in all Mexican border states from 1993 to 1996, ranging from 5.2% in Baja California and Coahuila to 13.1% in Chihuahua. In 1997, data from the Mexican hospital surveillance network (Red Hospitalaria de Vigilancia Epidemiológica) that compiles hospital discharge data from 67 hospitals with more than 100 beds nationwide, showed that hypertension and diabetes ranked 3^rd and 4^th respectively among the 20 most common discharge diagnoses²⁰. The data reflect the significant impact that chronic diseases in general, and diabetes specifically, have had on total mortality rates of Mexico.

The following table shows the cumulative mortality rates along the U.S.-Mexico border states and its counties/municipalities. As can be seen, these rates for the most part of the border region are higher than the national figures⁸.

Diabetes Mortality Annualized Crude Rates Per 100,000 Population in the Border Region, 1992-1994
UNITED STATES		MEXICO
STATE/COUNTY	RATE	RATE	STATE/MUNICIPALITY
U.S.	20.8	33.3	Mexico
California	13.2	35.7	Baja California
San Diego	10.6	31.1	Tijuana
Imperial	10.7	43.0	Mexicali
Arizona	17.6	36.3	Sonora
Yuma	20.6	45.4	San Luis Rio Colorado
Santa Cruz	12.8	37.1	Nogales
New Mexico	24.4	35.9	Chihuahua
Luna	43.4	20.2	Ascencion
Dona Ana	23.8	49.7	Juarez
Texas	23.3	35.9	Chihuahua
El Paso	25.6	49.7	Juarez
Texas	23.2	46.2	Coahuila
Maverick	30.6	66.0	Piedras Negras
Texas	23.3	32.6	Nuevo Leon
Webb	32.5	50.1	Anahuac
Texas23.	23.3	39.6	Tamaulipas
Webb	32.5	56.4	Nuevo Laredo
Cameron	30.0	45.0	Matamoros
Source: PAHO, Mortality Profiles of the Sister Communities on the United States-Mexico Border – 1992-1994, Pan American Health Organization, Washington, D.C. 1999, pg 289. NOTE: Letters in bold represent country and/or state.

 

4. Diabetes Control on the Border

Any efforts to control diabetes in border states must address the cultural diversity of this region. Currently, there are few site-specific data that can be used to guide community-based interventions. Specifically lacking are accurate estimates of the prevalence of diabetes and its complications among the population that lives along the border. Most importantly for primary and secondary prevention, knowledge of the risk factors for diabetes and its complications among persons who reside along the border is limited. Because many of these residents receive their medical care on both sides of the border, a better understanding of patterns of health care delivery is also crucial for developing culturally appropriate interventions.

E. Mexican Health Care System Overview

The Mexican Health Care System is composed of different institutions that provide public and private services to all Mexican residents. Among the agencies that are part of the public health system are the Mexican Institute for Social Security (IMSS); Institute for Social Security Services for the Employees of the State (ISSSTE) and the 32 State Health Services. The first two institutions provide services to employees and the latter (State Health Services) is responsible for providing health services to the uninsured population²¹.

The SSA is the head of the health sector with participation of the General Health Council (Consejo General de Salud). The SSA’s Under-Secretariat of Disease Control and Prevention will be responsible for the Mexican part in the USMBDPCP.

6. Conclusion

In conclusion, although this proposal focuses on Phase 1 of the project, determination of the prevalence of diabetes, its risk factors, and patterns of access to health services in this region, the data collected will be critical to planning the program intervention phase of the project (Phase 2). An outline of the pilot effort to prepare for Phase 2 is included in this protocol so that interventions based on data gathered in Phase 1 may be more effectively implemented on a larger scope.

The USMBHA, also known as the Asociación Fronteriza Mexicano-Estadounidense de Salud (AFMES), is a nonprofit binational Association of public health professionals and other professionals interested in border health issues. The El Paso Field Office of the Pan American Health Organization (PAHO) serves as the USMBHA Secretariat. It provides technical and administrative support for the operation of the Association. It is uniquely positioned to collaborate with the CDC and the SSA in helping meet the requirements of the U.S.-Mexico Border Diabetes Initiative.

The USMBHA is uniquely suited to meet the needs of the proposed initiative since it is the only public health organization formally constituted in Mexico as well as the United States. The USMBHA has a fifty-seven year history of developing, implementing, providing administrative support to and evaluating binational programs. There are no other organizations along the US-Mexico Border with the history and structure to undertake this binational effort.

The USMBHA has a long history of responding to the health needs of the predominant Hispanic/Latino border population residing in a region stretching from the Gulf of Mexico to the Pacific Ocean along the United States’ southernmost border. Since its inception in 1943, the USMBHA has been involved in identifying and resolving health issues affecting border communities in both the United States and Mexico. Areas of specific focus include infectious disease control and prevention, chronic diseases with emphasis on diabetes control, environmental health, substance abuse, and other related issues including health care reform and service delivery.

The USMBHA is comprised of more than 500 active members, from more than 300 organizations. Representatives of more than 15 professional disciplines are represented in the membership, including physicians, epidemiologists, psychologists, sociologists, behavioral scientists, health educators, and health promoters. The USMBHA has a 57-year tradition of networking and facilitating the integration of health and allied social services. The USMBHA has functioned as a liaison between federal, state, and local governments as well as private organizations working in border health programs.

The USMBHA is a bicultural organization with a highly versatile structure conducive to successful conferences. It consists of four basic components: a) Conference Groups (Federal, State, Local and University); b) Technical Sections for the general membership; c) Binational Health Councils; and d) Standing Committees.

The USMBHA’s membership reflects the ethnic composition of the border region. The USMBHA has led the effort to strengthen Hispanic/Latino leadership in public health in both the U.S. and Mexico border communities. The USMBHA promotes respect of the cultural and linguistic diversity of the region, and has fostered solutions for the special needs of border populations.

B. Regional Leadership in Skill and Capacity Building and Technical Assistance

Throughout its entire fifty-seven year history of service to border communities, the USMBHA has emphasized the skill building of health and allied social service professionals, the provision of technical assistance and the building of institutional capacity. A sample of some of the specific training activities designed and implemented by the USMBHA over the last two years illustrates this tradition: Since January of 1995, the USMBHA has coordinated and operated almost 100 courses, seminars and symposia on a variety of topics including HIV/AIDS, tuberculosis, immunizations, substance abuse, principles of epidemiology, proposal development, and health care reform. An estimated 5,000 health and allied social service professionals have attended these training workshops. Representatives from state and local health departments and community-based organizations from both sides of the border have attended these events. The benefits derived from these training activities have accrued at both the individual and institutional levels, with staff acquiring new skills and perspectives and organizations delivering more efficient and effective services.

In 1998, the USMBHA presented courses and workshops on capacity building development that were attended by more than 1,000 professionals from the U.S.-Mexico border region. This targeted training was for AIDS/HIV organizations specifically designed to increase the institutional capacity of organizations that serve the adolescent and young adult Latino/Hispanic population. As a direct result of these workshops, measurable improvements in the quality of service provision have been confirmed.

The USMBHA's Annual Meeting location alternates every other year between Mexico and the United States. In 1998, the USMBHA held its 57th Annual Meeting in Monterrey, Mexico (Appendix 1-List of Previous Annual Meetings and 1999 Annual Meeting Program) with an estimated annual attendance of 600 people participating. The overall purpose of these meetings is to bring together health professionals from both sides of the border to discuss pertinent issues and to formally develop joint Annual Meeting Resolutions²² that address specific issues identified through consensus and conference workshops. For instance, the 55^th USMBHA General Assembly approved a resolution to address diabetes issues along the border (Appendix 2 – USMBHA Resolutions). This resolution calls for an action to develop a binational epidemiological surveillance plan in order to develop a border diabetes profile that will allow the design of appropriate strategies for the control and prevention of diabetes and its complications.

The Annual Meetings are designed to expose participants to a bicultural environment, increase skills, raise awareness on border health, share information on binational issues, and promote networking. The Annual Meetings have stimulated the development of many groundbreaking binational collaborative initiatives such as Project CONSENSO (1991), the Sister Cities Project (1992-1995), Ten Against TB (1995 to date), Border XXI – Environmental Health Projects, the U.S.-Mexico Diabetes Border Initiative, and Binational Infectious Disease Sentinel Surveillance

C. Raising Awareness and Influencing Policy

The USMBHA has been at the forefront of the movement to address the health care needs of border communities. The BHA’s longstanding efforts to publicize, educate and advocate for border health issues has contributed to policy changes in the US border states of Texas, New Mexico, Arizona, and California and their Mexican border state counterparts (Baja California, Chihuahua, Coahuila, Nuevo Leon, Sonora and Tamaulipas). In 1991-1992, largely because of the USMBHA’s efforts, each of these state health departments instituted a Border Health Office. In 1995, as a result of the pursuits of the USMBHA and its membership, the United States Congress passed a bill creating the U.S.-Mexico Border Health Commission which includes direct participation of the Secretary of Health and the four U.S. Border Commissioners of Health.

In most recent times, the USMBHA has been raising awareness on the importance of chronic diseases, including diabetes along the border. During its Annual Meetings and work of its Binational Health Councils along the border, diabetes has been addressed as a major border and binational health concern. Also, USMBHA has supported the diabetes prevention Paso a Paso/Step by Step project.

D. Information Dissemination

The USMBHA plays a major role in disseminating information on border health issues through its quarterly and annual publications: The Journal of Border Health, Noticias/News and its Annual Report (Appendix 3 - Publications). Immediate circulation of the publications is estimated to be 1,000 with an estimated readership of 4,000. Several articles dealing with chronic diseases and diabetes have been published in the Journal. The USMBHA Newsletter has been publishing information on a number of diabetes activities taking place along the border.

In addition, through the USMBHA’s training manuals, many health and allied social service professionals have benefited from USMBHA’s skill building and capacity building activities. Also, the Annual Meeting and the quarterly meetings of its 12 Sister City Binational Health Councils (BHC) play an important role at the local level in promoting information exchange and networking along the Border (Appendix 4 – U.S.-Mexico Border Map). The BHC's are:

• Imperial Valley, California – Mexicali, Baja California
• San Diego, California – Tijuana, Baja California
• Yuma, Arizona – San Luis Rio Colorado, Sonora
• Nogales, Arizona – Nogales, Sonora
• Cochise County, Arizona – Agua Prieta
• Columbus, New Mexico – Palomas, Chihuahua
• Las Cruces, New Mexico – El Paso, Texas – Cd. Juárez, Chihuahua
• Presidio, Texas – Ojinaga, Chihuahua
• Eagle Pass and Del Rio, Texas – Cd. Acuña and Piedras Negras, Coahuila
• Laredo, Texas – Nuevo Laredo, Tamaulipas
• McAllen, Texas – Reynosa, Tamaulipas
• Brownsville, Texas – Matamoros, Tamaulipas

The USMBHA's web page (www.usmbha.org) has become another source for information dissemination throughout the border region and beyond. The site includes sections such as Annual Meeting information publications, links to other web pages, and a calendar of events, amongst its headings.

To support the works of the USMBDPCP, the USMBHA created a U.S.-Mexico Border Diabetes Electronic Bulletin Board.

E. Recognition for Work

Through the years, the USMBHA has received several awards and/or recognition for its work promoting the improvement of border health. A partial list of these outstanding mentions is shown below.

• 1997 Healthier Communities Honorable Mention for outstanding efforts to improve community health status from the Healthcare Forum.
• 1996 Recognition Award of Excellence for its work on Substance Abuse along the border from the National Rural Institute on Substance Abuse and Center for Substance Abuse Treatment.
• 1996 The Outreach Sourcebook for its work on tuberculosis outreach activities from the Health Resources and Services Administration.
• 1994 Outstanding Community Health Promotion Program Award for its participation in the Nuestros Ninos Binational Project from the U.S. Department of Health and Human Services.
• 1990 Community Health Promotion Award for its participation in the Paso a Paso Program from the Texas Department of Health.

Several letter of support acknowledging the work of the USMBHA and endorsing it as an agency with the technical and administrative capabilities are enclosed to confirm the above (Appendix 5).

IV. COLLABORATION AND COORDINATION AMONG PROJECT PARTICIPANTS

A. Description of the USMBDPCP Work Group

Membership: The USMBDPCP Work Group is composed of representatives from the following: PAHO, USMBHA, SSA, Division of Diabetes Translation, the Diabetes Control Programs of Arizona, California, New Mexico and Texas, the El Paso Del Norte Foundation, and the El Paso Diabetes Association, and the Mexican Border States of Baja California, Chihuahua, Coahuila, Nuevo Leon, Sonora, and Tamaulipas. (Appendix 6 – Membership List)

Accomplishments and Progress: The program managers of the Diabetes Control Programs (DCP) in the US border states, explored with Mexico the level of interest in developing a regional diabetes prevention and control project. The response was positive and after several teleconferences the concept of the binational project was created with original participation of the SSA, PAHO, the USMBHA and representatives from all ten border states. After the concept paper was written, four planning meetings of the USMBDPCP took place in Juarez, Chihuahua, Mexico. Representatives from SSA and US-Mexico border states DCPs, USMBHA, and the El Paso Diabetes Association attended these meetings. The meetings were productive and the participants agreed to jointly submit a proposal for funding assistance. The protocol for the household survey has been developed with input from the SSA and all four U.S. Diabetes Control Programs.

2. In Kind Contributions

The Arizona DCP and other programs have conducted a similar survey in the border community of Douglas, Arizona. In fact, that survey formed the basis for this proposed, expanded survey along the entire US-Mexico border. Arizona spent approximately $100,000 to conduct and analyze their survey in 1998.

El Paso Diabetes Association approached the El Paso del Norte Health Foundation in El Paso and it dedicated $3,575,025 ($850,445 for first year) to the USMBDPC Project (Appendix 7 – In Kind Contributions Agreements).

TDH has redirected $60,000 to fund the field test for the household survey (Appendix – Texas Dpartment of Health Commitment). The field test is in progress (Appendix 7 – In Kind Contributions Agreements).

The Texas DCP is redirecting $390,000 ($300,000 state revenue and $90,000 federal funds) for the community interventions of this project in the Lower Rio Grande Valley, Laredo, El Paso, and Eagle Pass (Appendix 7 - In Kind Contributions Agreements). Staff from these programs will interact and

coordinate activities with their Mexican counterparts in sister cities and use the "Diabetes Today" planning model and materials from the national Diabetes Education Program (NDEPP).

The New Mexico Diabetes Control Program is redirecting $80,000 to the hiring of the U.S. national coordinator. An RFP has been released for this function (Appendix 7 – In Kind Contribution Agreements).

All of the State Diabetes Control Programs have comprehensive and extensive expertise in designing surveillance systems, developing, implementing, and evaluating community interventions; therefore, they will be providing technical assistance as needed.

The Paso Del Norte Foundation and the El Paso Diabetes Association have collaborated on several projects and are recognized leaders in the diabetes community of El Paso, Juarez, and South East New Mexico.

V. PRIORITY PROGRAM ACTIVITIES AND PROGRAM OBJECTIVES

A. Program Purpose

The purpose of this project is to diminish the impact of diabetes of the border population by conducting activities in two related and chronological phases. The first is a prevalence survey and other related health parameters (behavioral risk factors and access to health services) among residents aged 18 years and older along the U.S.-Mexico border. The second is the development of an implementation program for diabetes prevention and control. Survey data will be used to help the development of binational intervention programs more fully.

2. Objectives

B1. Prevalence Study – Household Survey

1. Determine the prevalence of diabetes among residents aged 18 years and older for the US-Mexico border and each side of the border by using the fasting plasma glucose (FPG) test and Hemoglobin A1C (HbA₁c).
2. Determine the prevalence of behavioral risk factors for diabetes by using an in-person survey and anthropometric measurements.
3. Assess individual accessibility, barriers, and opportunities to health care for diagnosis and follow-up care through the in-person survey.
4. Analyze the data and develop reports for reference and recommendations based on the study findings.

B2. Intervention Program – Binational Diabetes Prevention/Control Demonstration Models

The first year of interventions will focus on community assessment, capacity building, planning and general awareness activities. These community programs will collaborate with their Mexican counterparts in the planning and implementation of binational activities.

1. Convene a binational work group to continue reviewing the data and the development of binational diabetes prevention and control programs.
2. A Pilot Project will be developed for improving diabetes care and for those at risk of developing diabetes to be used in Phase 2 of the project.

A. Work Plan Overview

This Work Plan outlines the steps that will be undertaken to conduct a prevalence study along the U.S-Mexico border population. The results of the study will guide the development of the strategies that will best address the needs of the border population. The proposed study is the result of a series of meetings that were held in Ciudad Juarez, Chihuahua, Mexico with participation of representatives from both federal governments (CDC and SSA), the 10 U.S.-Mexico border states, PAHO, the USMBHA, El Paso del Norte Health Foundation and the El Paso Diabetes Association.

While the prevalence study is taking place, and until the study results are ready, it is proposed that the USMBDPCP Working Group continue meeting to outline an implementation program that will address the needs of the border populations in order to prevent and control diabetes along the border. The USMBDPCP Work Group will, at the same time, initiate a series of literature and program model reviews in order to identify and select the materials that best fit the needs of the border population. Training, health promotion, and prevention of diabetes will be conducted along with an awareness campaign among the general public and health providers. All these activities will be developed taking into consideration language and culture of the border population.

The USMBHA will coordinate the proposed binational activities along the border.

1. Determine the prevalence of diabetes among residents aged 18 years and older for the US-Mexico border and each side of the border by using the fasting plasma glucose (FPG) test and HbA₁c.

Study Design: A population-based survey using multi-stage cluster sampling will result in prevalence estimates for each side of the border and for the border as a whole with state-specific estimates. On the US side of the border, hispanic state-specific estimates will be obtained as well. Individual states may elect to over-sample their populations to obtain county or community-specific prevalence estimates.

Sampling Methodology: The 1990 Mexico census and US will provide the basis for population estimates and denominators of rates; with an estimated design effect of 2, desired confidence intervals of +/- 2%, an estimated participation rate of 70%, and an estimated diabetes prevalence of 9%, approximately 1,506 (Mexico) and 1,412 (US).

In US counties or Mexican municipalities contiguous with the US-Mexico border, communities with a population of at least 2,500 persons will be eligible for selection. Census tracts, the primary sampling unit, will be selected within four population size strata of communities: 2,500-9,999 persons, 10,000-49,999 persons, 50,000-199,999 persons, and greater than 199,999 persons. In the United States, census tracts within communities will be divided into two strata based on 1990 population estimates of ethnicity: > 80% Hispanic and < 80% Hispanic. Blocks within census tracts will be randomly selected and mapped and potential households will be given identification numbers. Potential households will include single family homes, individual units that are part of multi-family dwellings, and any potentially habitable structure or location. Households within blocks will then be randomly selected. Persons in selected households will be enumerated by an adult household informant who may or may not be selected to participate. Household enumeration data will include name, gender, age, and family relationships. One individual aged 65 and older in each enumerated household will be selected by protocol to participate in the survey. If no persons ages 65 and older are found in the selected household, one individual aged 18 to 64 years will then be chosen as participant.

Random selection of subjects and extensive efforts to gain their participation should result in a respondent group similar to the population from which the sample is derived. To ensure the integrity of our population-based estimates, comprehensive protocols will be followed to ensure 1) that selected households will be enumerated; and 2) that every effort will be made to gain the participation of selected subjects. For example, protocols will be developed for logging contacts with household informants and selected subjects. The number of attempts to contact individuals will be outlined.

Diabetes Survey: The USMBDPCP Work Group has already developed and reviewed the survey for this prevalence study. This survey includes 65 questions. It is composed of the following sections: Household census, individual health status, access to health care, diabetes knowledge, diet, physical activity, life styles (drinking, smoking), and others (Appendix 8 – Diabetes Survey).

Human Subjects Considerations: Approval will be sought from the CDC Human Subjects Review Committee, from each US state’s Institutional Review Board, and an informed consent form will be obtained from each participant. The Ethics Committee of the Mexican Secretariat of Health will review this proposal and make recommendations as appropriate (Appendix 9 - Consent Form).

Field test of protocol: TDH has been coordinating the field test of the protocol which includes the development of training manuals (Appendix 10 – Interviewers Training Manual) and tracking forms, field test of the survey and a laboratory component. The field test will include interviews and laboratory testing on 20 individuals in El Paso, Texas and a similar number in Juarez, Chihuahua, Mexico. The objective of the field test is to test and refine the entire protocol before undertaking the border-wide survey.

Quality Control and the performance of the interviewer will be monitored through periodic field observations by the research team and regular consultation with the State Field Coordinator. In addition, a 10% random sample of subjects will be contacted by the State Field Coordinator within three to four weeks of the interview and asked to repeat selected questions in the survey.

2. Determine the prevalence of behavioral risk factors for diabetes by using an in-person survey and anthropometric measurements.

The Diabetes Survey includes several sections related to the assessment of behavior risk factors for diabetes (Appendix 8). These sections are related to nutritional habits, physical activity, access to health care, and associated conditions related to diabetes. An analysis of each risk behavior will help determine the main risk factors that are predisposing the development of diabetes among the border population. The findings will guide the development of the 5-year implementation binational/border program.

Interviews: Interviewers will administer the survey in-person at subjects’ homes or another appropriate location if this is more convenient for the subject. An adult aged 18 years or older will be chosen by protocol from among the adults residing in the household listed on the enumeration form. The survey will be explained, and, if the household member agrees to participate, a consent form will be read to and signed by the participant before proceeding with the interview and anthropometric measurements. The survey (Appendix 8) will be administered by interviewers who are experienced in community work and specifically trained for this study. The US interviewers will be bilingual. In the US, the participant will choose which language he/she prefers to use during the consent process and interview. Anthropometric measurements will be taken by the interviewers of each participant. After the interview is completed, diabetes educational materials will be provided.

Clinical Data Collection: Following completion of the interview, anthropometric measures of height, weight, waist and hip circumference and blood pressure will be obtained. Interviewers will be trained to obtain these measures according to a standardized protocol. Equipment such as scales and sphygnomanometers will be calibrated per protocol. Each participant's height will be assessed without shoes using a stationary stadiometer. Each participant's weight, wearing light street clothing and without shoes, will be assessed on a portable scale calibrated weekly. They will take waist measurements at the level of the umbilicus, and hip circumferences at the maximal protrusion of the gluteal muscles. The measurements will be used to estimate the Waist/Hip ratio.

Laboratory Component: This survey will use the current guidelines for diagnosing diabetes based on FPG testing. An additional specimen will be collected from each participant for centralized testing of HbA₁c. The determination of HbA₁c will be useful for participants who are known diabetic, as the level of HbA₁c will provide a measure of long term glycemic control. HbA_1C levels will also be obtained and refrigerated for testing at a central lab. FPG testing will not be centralized, but a sample of FPG specimens from each participating lab will be split and sent to a single reference lab for quality control.

At the interview visit, the participant will be given instructions on fasting and an appointment for an FPG test. After the subject has his or her blood drawn, a voucher worth $10.00 redeemable at a local grocery store will be provided. A transportation pass will be given to the participant for transportation to the clinic if needed. FPG specimens will be sought from all participants. Participants will not be asked to refrain from taking medications on the morning of the test. To avoid hypoglycemic episodes for those participants who are diabetic and on pharmacologic treatment, special emphasis will be given to performing their phlebotomy early in the morning close to their usual breakfast time. Precautions will also be explained to them to avoid such episodes.

Phlebotomy and test results: Participants living ten miles or more from the clinic site will have their blood drawn at home if they are unable to travel to the clinic. When the participant arrives at the clinic or the survey personnel arrive at his/her home, his/her signature will be verified by signing a daily list of attendance. A phlebotomist will inquire, using a standardized script, if the participant has fasted for 8 hours. If not, an appointment will be rescheduled if possible. If the participant had fasted, a sample will be drawn for FPG and HbA_1c. Persons with symptoms of hypoglycemia will be asked to drink fruit juice and will be referred to a healthcare facility. The participant will then receive the incentive. Results of the test will be provided only to those participants who test positive, either by mail or personal contact as appropriate. The results will be provided within a month of receiving the test. Persons taking diabetes medication with a FPG <50mg/dl will be referred to a healthcare facility.

3. Assess individual accessibility, barriers, and opportunities to health care for diagnosis and follow-up care through the in-person survey

The study survey will explore the option, if any, that each interviewee has to access health care services for diagnosis, treatment, and health promotion for diabetes. This study will facilitate the development of strategies that would address possible solutions to the problem based on the available resources on both sides of the border.

Classification and Reporting Findings: The field supervisor will contact State health officials and community sources in each area to obtain a list of clinics and/or doctors that will be used for referral. Persons with a FPG > 126mg/dl will be provisionally classified as having diabetes and referred to a health care facility for confirmatory testing (repeat FPG). Those with a provisional classification of diabetes will be counted as cases for the purpose of this prevalence survey. Persons with a previous diagnosis of diabetes will only be referred to a healthcare facility if they had not had a clinic visit for diabetes in the last year, had a FPG > 250mg/dl, FPG < 50 or state that they are currently not receiving care for their diabetes. Persons stating that they are taking diabetes medication daily, even if FPG <126mg/dl, will also be counted as cases of diabetes. Persons with a FPG > 110mg/dl and < 126mg/dl will be provisionally classified as having impaired fasting glucose (IFG) and will be referred to a health care facility for follow-up (Appendex 9). Participants for whom a referral is recommended will be notified in person by a community health care worker (promotora) to increase response to the referral, unless they prefer to be notified by letter only. Participants with test results greater than 333 mg/dl will receive immediate notification and referral to medical services for care²².

4. Analyze the data and develop reports for reference and recommendations based on the study findings

Data Management for Analysis: The survey instrument will be formatted to be read by the Teleform Reader Software to automate data entry. The completed survey will be sent to TDH in Austin by the State Field Coordinators where the Teleform Reader will be used to enter the data. The data will be cleaned by running frequency distributions, checking for outliers, and verifying answers on the original survey when necessary.

A weighting factor will be applied to each subject to adjust for non-response and the probability of selection. The weights will be scaled so that the weighted count of people will be equal to the total sample size, and the weighted proportions of people sampled in each strata (state, community size, and census tract ethnicity category) matches the border population, as estimated by the 1990 census. SUDAAN software will be used to adjust for the complex survey design.

Analysis: A team composed of two persons from Mexico and the US and a representative from the USMBHA will be identified to coordinate analysis of the survey, including validation of data. These persons should have a background in data management and analysis and will meet face to face at least twice for 2-3 days to plan and develop the principal analyses of the collected data.

The analysis will focus on estimating prevalence rates for individual states on each side of the border and the border as a whole. Analysis by race/ethnicity (US only), gender and age group will also be performed and compared to previous estimates from Mexico and the US. Health care access and patterns of use of health services will be examined and will be particularly useful for the program implementation (Phase 2) component of the project. The descriptive analyses will be examined carefully for respondents with and without diabetes. Further analysis will examine the association between diabetes and anthropometry [including waist/hip ratio and body mass index (BMI)], level of physical activity, and dietary habits. Patterns of health care access, health services, and diabetes clinical management will also be examined, providing a determination of need for persons diagnosed and persons not diagnosed with diabetes particularly relevant to intervention/program planning and evaluation.

In addition, it is anticipated that the results of this survey will be useful for integrating public health and the clinical interventions of other groups committed to decreasing racial/ethnic disparities in chronic disease control in a unique area which is increasingly important to both Mexico and the US.

Dissemination of Data: Preliminary findings of the survey analysis will be made available to the USMBDPCP Work Group for review. Based on the USMBDPCP review, a final report will be prepared and distributed. This report will include, but not limited to, the following: methodology, findings, and conclusions. This report will be widely distributed in Mexico and the United States.

The information obtained from the analysis of the survey will guide the program intervention phase. Data will be presented to community leaders so they can participate in the planning process for community-based interventions. These data will also establish baselines for measuring the effect of the interventions.

Data will be disseminated in the national surveillance reports of Mexico and the US (i.e., Boletín Epidemiológico de Mexico of the Mexican Secretariat of Health, the Morbidity and Mortality Weekly Report of CDC, and PAHO´s Field Office and USMBHA Websites). A number of papers will be prepared for submission to a peer-review publication appropriate for this type of study.

1. Convene a binational work group to continue review of the data and the development of binational diabetes prevention and control programs

The USMBDPCP Work Group described above will be convened to initiate discussion for the development of the intervention phase. The intervention design process will be developed through a participatory process that will involve a series of meetings, outline the strategies to be used to implement a binational diabetes prevention and control plan with participation of both sides of the border. It is important to mention that this plan will be approved through a consensus process.

2. Pilot Projects will be developed for improving diabetes care and for those at risk of developing diabetes to be used in Phase 2 of the project

The following is proposed for consideration by the USMBDPCP Work Group for discussion. It is important to keep in mind that the proposed interventions will include the following:

• Diabetes literature review: Review the available literature to identify successful interventions for diabetes among the Hispanic population and adapt them to the border region.

• The Community Health Workers (promotores) models: Promotores are community leaders who are respected in their community and can promote health within that community. Promotores are culturally sensitive to the needs of the population they serve. They promote healthy living for educating about how to prevent disease and by helping community residents understand and access health services²².

• This project will propose to involve them in diabetes health education.

• The USMBHA Sister Cities Model: Based on the recommendations of the USMBDPCP Work Group, the two border cities come together and collaborate on identifying health concerns in their border community. Once they have identified and selected specific health concerns, they make appropriate recommendations to address possible solutions for prevention and/or control, for example, the current work with diabetes. For the demonstration interventions, six Sister City areas are proposed. They include at least one pair in each of the ten border states and they are:

• Imperal County, California/Mexicali, Baja California
• Nogales, Arizona/Nogales, Sonora
• Luna, New Mexico/Ascención, Chihuahua
• El Paso, Texas/Las Cruces, New Mexico/Juarez, Chihuahua
• Eagle Pass, Texas/Piedras Negras, Coahuila
• Webb, Texas/Anuahuac, Nuevo Leon
• Brownsville, Texas/Matamoros, Tamaulipas

• Integrated Diabetes and Hypertension: The SSA is piloting an innovative program which has as its goal to improve identification and treatment of hypertension in diabetics. This could serve as a model for improved integration for management of chronic diseases.

• Diabetes Education Program (NDEP): The CDC and the National Institute of Diabetes, Digestive and Kidney Diseases of the National Institutes of Health are developing in collaboration with Hispanic organizations a diabetes education campaign targeting persons of Hispanic origin. This campaign, which is part of the NDEP, has as its goal to increase the public’s awareness of diabetes and encourage self-management among persons with diabetes. This, in turn is consistent with the Surgeon General’s goal of decreasing racial and ethnic disparities in health status.

• Support Groups/Club de Diabeticos: Promote the development of diabetic support groups to improve and change life style habits such as diet, physical activity, medication compliance, etc.

• Training Curricula: Below there are two sample descriptions of possible training models to be taken into consideration by the USMBDPCP.

Diabetes Today is a nontraditional interactive training course for health care providers and community leaders that is based on the involvement of the community in the planning process-from defining the problem to implementing and evaluating various interventions or programs. The mission of this training course is to provide health care professionals, including physicians, diabetes educators, dietitians, health educators, pharmacists, dentists, community health advocates, nutritionists, health administrators, community organizers, and other diabetes advocates with experiential knowledge in promoting community owned interventions to reduce the burden of diabetes. The course applies the principles of community organization and development to the prevention of diabetes and its complications at the community level and, at the same time, promotes linkages between the consumer, provider and the relevant health enabling systems and bodies, such as medicare, medicaid, and social support systems.

The Coordinated Approach to Child Health (CATCH) is an elementary school based program designed to reduce risk factors associated with diabetes and cardiovascular health. Over 5,000 ethnically diverse third to fifth grade students participated in the program, which consisted of modifying cafeteria food, promoting physical activity, classroom education, and family involvement. The results indicated an increase in moderate to vigorous physical activity, a significant reduction in fat and sodium in school lunches, and an increase in knowledge. The curricula and materials are interrelated and complimentary to the other components, child friendly, fun, interactive, age appropriate, challenging, teacher friendly, meets the national school health education standards, and provides opportunities for the entire community to become involved.

Phase 1 - Survey

Planning Process

Implementation Process

VIII. EVALUATION PLAN

For the purposes of this proposal, the Evaluation Plan will include Process and Outcome Evaluation. Process evaluation is defined as the ongoing assessment and documentation of the planning, development, and implementation phases of the project. Outcome evaluation is defined as the attempt to find out whether a prevention effort made a difference in the lives of clients or in the community.

The area to be included in this proposal is limited to the definition of the border described in Section IIB.

A. Phase 1 – Prevalence Study

• Process

• Recruitment of personnel

• Binational Coordinator (Bilingual)
• National Coordinators (one Mexican and one US)
• 10 State Field Coordinators (one per state)
• Interviewers (Bilingual for US only)

• Personnel Training

• Field Test in Juarez and El Paso
• Survey review based on field test
• Training manuals for interviewers
• Interviewers training
• Establishment of agreements with laboratories for blood samples analysis
• Printing and distribution of survey in English and Spanish as appropriate
• Survey database development
• Survey data collection

• 3,794 interviews completed

• 1,958 on the Mexican side
• 1,836 on the U.S. side

• Laboratory based analysis
• Data analysis
• Preliminary report of results
• Final report containing the following:

- data analysis

• diabetes prevalence profile of the U.S.-Mexico border and separately for Mexico and the US border
• identification and analysis of risk factors
• identification and analysis of barriers and opportunities to access health care
• recommendations for the development of a diabetes prevention and control demonstration program for the U.S.-Mexico border
• identification of the sites in which demonstrations will take place

• Information Dissemination through the SSA, CDC, USMBHA and PAHO publications
• Submit a paper to a peer-review journal for publication

• Outcome Evaluation

• Diabetes morbidity prevalence determination
• Determination of diabetes risk factors for the border
• Identification of barriers to health care access
• Obtain a baseline with the first survey results to compare with the new survey results after five years to verify how the health status regarding diabetes has been modified

B Phase 2 – Intervention Process

• Process Evaluation

Initiation Stage

• Mobilize support and resources
• Develop intervention capacity
• Begin documenting intervention’s development
• Begin thinking about evaluating intervention

Planning Stage

• Convene the USMBDPCP Work Group
• Convene Program Planning Meetings as needed
• Provide simultaneous interpretation and translation of documents as needed
• Make decisions by consensus
• Determine nature and extent of problem
• Investigate alternative approaches
• Develop theoretical framework
• Develop initial implementation plan

• Propose program for undertaking the implementation of phase 2
• Literature review and identification of diabetes prevention and health promotion models
• Diabetes training curricula
• Awareness campaign

Pilot-Testing Stage

• Monitor intervention to detect problems
• Solve implementation problems
• Redefine implementation plan
• Refine evaluation plan
• Continue education for training personnel and the community

Implementation Stage

• Monitor intervention to detect problems and immediate needs
• Monitor support for and satisfaction with intervention
• Monitor intervention effects
• Monitor capacity
• Refine intervention (if necessary)

Stabilization Stage (ongoing)

• Demonstrate value to funding sponsors, stakeholders, and community
• Enhance capacity
• Defend budgets and resources in the face of competing claims for resources
• Assess and sustain intervention effects

Dissemination Stage

• Assess project sustainability
• If considering expansion, expand resources and engage in Initiation Stage tasks

• Number of trained health providers
• Number of health educational materials developed
• Number of health educational materials distributed

• Number of health providers delivering diabetes care

• Outcome Evaluation

• For the US side, the Healthy People Year 2000 and 2010 Objectives will be used as a reference to evaluate the impact of this project (Appendix 11 – Healthy People Year 2000 and 2010 Diabetes Objectives)
• Other measurements will be:
• Number of partners enrolled in the Diabetes project
• Number of new cases diagnosed with diabetes
• Number of diabetes deaths by year, sex, age, and type of diabetes
• Number of diabetes-related complications prevented based on hospital records
• Knowledge, attitude and behavior change

The USMBHA

• Nominate a person to be the Binational Coordinator (see below) who will be chosen in consultation with the Binational Project Steering Committee (see below).
• Be the fiscal agent and assume accountability for the project before the funding agency. This function includes activities such as disbursement of funds to appropriate agencies in Mexico and the US to undertake the survey and implementation of the program as agreed upon.
• Organize binational meetings according to the recommendations of the Binational Project Steering Committee.
• Facilitate and assure timely completion of the project according to the protocol.

• Representatives from all the project partners (Mexico, USMBHA, US) will consist of

- Binational coordinator

- Both national coordinators

- A representative from each participating border state

• The Binational Steering Committee will have the role of making technical decisions regarding the project. Decisions taken will be communicated to the Binational Coordinator for action. In addition, the Binational Steering Committee will:

- monitor the project progress through regular reports received from the Binational coordinator

- choose a chairperson to convene conference calls and meetings

• Be a member of the Binational Project Steering Committee.
• Coordinate the project in collaboration with Binational Project Steering Committee and the National coordinators.
• Keep the Binational Project Steering Committee informed on the progress of the project according to the work plan.
• Maintain fiscal responsibility for the overall project management.
• Facilitate communication between US and Mexican counterparts.
• Overcome financial and technical problems which might arise during project implementation.
• Provide regular progress reports to the funding agencies and the Steering Committee
• Monitor that the project is conducted in a standardized way on both sides of the border

• One from Mexico and one from the US.
• They will be responsible for overseeing activities in all states on their side of the border.

• Be a member of the Binational Steering Committee.
• Develop a national work plan in coordination with the Binational Steering Committee.
• Implement the work plan on their side of the border.
• Communicate with their counterpart on the other side of the border through the binational coordinator.
• Manage the funds according to the protocol and the needs of the individual states.
• Training of the survey teams will be provided in a standardized way in each of the states according to the protocol.
• Assure that the survey and implementation of the program is being conducted in a standardized way in each of the states.
• Assure that laboratory specimens are being sent to the designated centralized laboratory in a timely manner and according to protocol.
• Assure that surveys are being collected in a timely manner and data entered according to protocol.
• Assure that quality control is being conducted in each state.

• Develop the work plan with the National Project Coordinator for the state survey and program implementation.
• Recruit interviewers for the state survey team or teams and promotores for program implementation as appropriate.
• Train interviewers and promotores as appropriate.
• Verify that the necessary state resources are available to conduct the survey.
• Assign participant lists to survey interviewers.
• Maintain a register of interviews and verify completion of the follow-up laboratory visit.
• Collect completed surveys and check for errors and forward to the National Coordinator.
• Assure that all survey participants have signed informed consent forms.
• Assure that laboratory specimens are sent to appropriate laboratory according to protocol.
• Assure that all persons requiring referral according to their classification (see above Methods) are given correct instructions.
• Assure that all interviewers and laboratory personnel are compensated.
• Roles for promotores will be defined based on the proposed program for a particular community at a later stage.

Interviewers

• They will be trained and hired by State Field Coordinators to do the following:

- Identify the households to be interviewed according to the study design and list provided by the

State Coordinator.

- Identify potential participants within these households according to sampling protocol

- Explain the purpose of the study to potential participants.

- Obtain informed consent by obtaining participant or witness signature.

- Administer the survey to participant and conduct the anthropometric measurements and blood

pressure measurement.

- Give clear and adequate instruction to participant for follow up laboratory component (in home

or at centralized location).

- Review the survey with the participant to assure that all information collected is correct.

- Register the encounter in the registry maintained by the State Field Coordinator and give the

completed survey to the State Field Coordinator.

- Review the completed survey with the State Field Coordinator.

- Distribute diabetes educational materials.

Promotores will be recruited once the Implementation program is completed.

Professional Consultation will be recruited as needed.

24. BUDGET

REFERENCES

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2. DHHS/PHS. Developing Objectives for Healthy People 2000. Washington, DC. 1997.
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4. SSA. Norma Oficial de Diabes. Mexico, 1999
5. Harris MI, Flegal KM, et al. Prevalence of diabetes, impaired fasting glucose tolerance in U.S.

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6. Sharp, J. the Texas Comptroller of Public Accountants. Health Chronic Conditions in the Bordering the Future: Challenge and Opportunity in the Texas Border Region. 1998. Texas Comptroller of Public Accountants. 105-122

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16. Pugh JA, Stern MP, Haffner SM, et al. Excess incidence of treatment of end-stage renal disease in Mexican Americans. Am J Epidemiology, 1988;127:135-144.
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18. Arizona Department of Health Services. Arizona Health Status and Vital Statistics, 1995. Phoenix 1996.

19. A/Dirección General de Epidemiología. Encuesta Nacional de Enfermedades Crónicas, 1993. México, 1997.

20. Red Hospitalaria de Vigilancia Epidemiológica, Direccion Nacional de Epidemiologia, 1997 (get exact reference).
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