The type 2 diabetes epidemic, a global health issue, is severe in the US Associated Pacific Islands (USAPI) jurisdictions. Although a post-World War II US Navy survey of the Pacific islands found no cases of diabetes, subsequent population surveys have shown a dramatic increase in diabetes (1). In 2007, the estimated prevalence of diabetes for the US population (adults aged 20 years or older, diagnosed and undiagnosed) was 10.7% (2). Although USAPI diabetes surveillance data are limited, the 2001-2003 estimated prevalence for Guam was 11% (adults aged 18 years or older, diagnosed) (3); in 2002, the estimated prevalence for Pohnpei, an island state in the Federated States of Micronesia (FSM), was 24.4% (adults aged 25-64 years, fasting blood glucose [FBG] ≥110 mg/dL) (4) and for the Republic of the Marshall Islands (RMI) was 29.8% (adults aged 15-64 years, FBG ≥110 mg/dL) (5); in 2006, the estimated prevalence for the Republic of Palau was 38.9% (all ages, FBG ≥110 mg/dL) (6); and in 2004, the estimated prevalence for American Samoa was 47.3% (adults 25-64 years, FBG ≥110 mg/dL) (7).

In the USAPI, the proportion of people with diabetes who report self-care practices to prevent complications often falls below US levels. For instance, in Guam, 2001-2003 estimated prevalence of measured hemoglobin A1c (twice annually) was 56.7% and daily self-monitoring of blood glucose (SMBG) was 32.2%, significantly lower than US estimates for measuring hemoglobin A1c (65.9%) and daily SMBG (58.3%) (3). The rates of diabetes complications are also high. For example, in 2002 and 2003, the incidence of lower limb amputations secondary to diabetes for the RMI was 79.5 per 100,000 population (8), and lower limb amputations were performed on people as young as 30 years. When standardized to the 2001 European population, the amputation incidence rate in the RMI was approximately 400 per 100,000.

Population health approaches designed to improve diabetes outcomes in health care systems and to support and sustain healthy lifestyle choices can help prevent or delay diabetes and related complications (9,10). Improving population health depends on identifying and influencing the multiple health determinants (eg, socioeconomic position, physical environment, health care access) that can influence the health of a broad population (11). Population health interventions that use policy and environmental approaches can directly affect health behaviors or influence social norms (12). These potentially low-cost, high-reach approaches can lay the groundwork for future interventions, helping to reverse the increasing prevalence of diabetes and other chronic diseases (12).

In 1986, the Centers for Disease Control and Prevention (CDC), Division of Diabetes Translation (DDT) established partnerships with the USAPI to form diabetes prevention and control programs (DPCPs). The DPCPs use funding from CDC cooperative agreements to develop expertise in diabetes prevention and control, establish systems to define the prevalence of diabetes, identify gaps in diabetes care, evaluate limited intervention projects, and develop partnerships to leverage resources and extend outreach.

In the last few years, DDT professional staff reassignments interrupted the building of collaborative relationships with the USAPI DPCPs, promulgating uncertainty related to collective diabetes prevention goals. In an effort to realign the collaborative relationships and assess shared diabetes program goals, representatives from DDT and USAPI DPCPs met in September 2007. Using the Essential Public Health Services framework (13) as a conceptual foundation, we discuss the assessment process and describe several culturally specific, community-based diabetes prevention and control strategies established by the USAPI. We also explore the importance of acknowledging the interface between Western science-based practices and indigenous knowledge as an effective population health approach in indigenous populations.

Six USAPI jurisdictions have formal relationships with the United States: the US flag territories of American Samoa and Guam; the Commonwealth of the Northern Mariana Islands (CNMI); and the FSM (includes the islands of Chuuk, Kosrae, Pohnpei, and Yap); Republic of Palau; and the RMI, which are freely associated with the United States through compact agreements (1) (Figure 1). The population centers spread across 104 inhabited islands, covering an expanse of ocean larger than the continental United States. This geographic span, dependence on US and international aid, poorly maintained and equipped health care facilities, reliance on off-island tertiary and specialty care, and shortages of health care professionals create daunting health care challenges (1).

The prevalence of diabetes in the USAPI is increasing because of the islands' rapid population and economic growth, coupled with ongoing transition from traditional ways of life (eg, communal farming and fishing) to Westernization (eg, more consumerism, with increased reliance on imported convenience foods, less physical activity) (1,14). Furthermore, a higher prevalence of obesity, 1 of the most common predisposing factors for type 2 diabetes (15), has followed on the heels of Westernization.

The USAPI annual per capita health care expenditure ranges from $140 in Chuuk to $1,032 in Guam; this stands in stark contrast to the annual US per capita expenditure of $5,711 (Table 1). Most islands depend on DDT funds to support their DPCPs. The average DDT funding award for the USAPI is $106,082, which covers administrative and staffing costs with modest support for community programs and outreach. Funding levels vary across jurisdictions depending on Congressional appropriations for the DDT competitive grant awards for DPCPs in the 50 states, territories, and island jurisdictions. Despite the persistent health care funding challenges amidst the growing epidemic of diabetes, the USAPI DPCPs have shown consistent capability and creativity in establishing partnerships across multiple sectors to leverage resources and broaden community outreach.

Several key outcomes with implications for future DDT and USAPI DPCP partnership practice emerged from this meeting. The open dialogue maintained throughout the meeting allowed DDT representatives to acknowledge the DPCPs' contributions toward a shared CDC-USAPI vision of preventing diabetes and its complications among the people of the USAPI. The information shared affirmed the USAPI DPCPs' commitment to community-based diabetes prevention focused on the strengths of each jurisdiction's cultural system. DDT representatives also gained appreciation for the USAPI DPCPs' skill in creatively leveraging scarce financial resources.

Using the EPHS framework, participants shared examples of integrated, intersectoral approaches in their jurisdictions. These approaches illustrated the creativity and resourcefulness of USAPI DPCPs in developing partnerships, applying policy and environmental interventions, and strengthening connections within the traditional cultural systems (Table 2).

These USAPI approaches also provide a link for supporting future DDT partnership practices that move beyond categorical single-sector diabetes programming to support efforts that build on strengths and assets of the USAPI partners and communities. The USAPI DPCPs cultivate partnerships with community, academic, and faith-based organizations, committed leadership (elected officials and traditional), and other public health system partners working toward sustainable community-based health promotion and disease prevention efforts. Examples of these approaches include

The meeting offered an opportunity for the DDT representatives, working with the meeting facilitator and USAPI DPCP participants, to realign collaborative relationships and common goals for continued USAPI capacity building. The stories shared during the meeting highlighted the success of using local cultural strength and knowledge to enhance opportunities for health promotion and diabetes prevention within USAPI communities. Recognizing the value of sharing these success stories with broader audiences that are also interested in addressing health disparities in their populations, the group presented an overview of island diabetes prevention efforts, called Casting Our Nets for Diabetes Prevention and Control — Pulling in Our Stories, at the DDT national conference, May 5-8, 2008, in Orlando, Florida. This was the first time the USAPI DPCPs have formally and collectively shared their stories about resourceful partnerships with CDC and other partners.

The USAPI DPCPs face challenges in building capacity for diabetes prevention not shared by mainland DPCPs. Nevertheless, the USAPI DPCPs have leveraged their community connections to enhance and support policy and environmental interventions. The connecting element among indigenous cultures is a strong traditional sense of unity with the environment (16). Approaches to health issues surrounding indigenous peoples need to consider their cultural knowledge and worldview. As the links between modern health problems and separation of people from their natural environment become clearer, the interface between cultural knowledge and Western-based science, coupled with participatory approaches, may help identify broad-ranging approaches to population health. Facilitating collaborative, equitable partnerships across the interface may also be a key element in empowering communities to effectively address the social and environmental determinants of health.

The USAPI DPCPs strive to create a balance between the diverse traditions that have shaped and sustained the USAPI with Western science's evidence-based practices. This emphasis on balancing cultural knowledge and science provides the USAPI DPCPs opportunities to create strong, sustained partnerships with a shared vision: to transform social and environmental conditions to support healthy people living in healthy island communities. The Palau Ministry of Health added a service to its EPHS framework that addresses this vital concept: "Ensuring cultural integration in disease care, health protection, and health promotion" (21). The USAPI, with their development of innovative approaches to building capacity for diabetes prevention and control, may be in a unique position to contribute to the evolving knowledge and science base needed to reduce the prevalence of diabetes and other chronic diseases in populations around the world.

We are grateful for the involvement of several Pacific island representatives during this project, including Lynn Tenorio and Father Ryan Jimenez, Commonwealth of the Northern Mariana Islands; Kipier Lippwe, Federated States of Micronesia; Roselie Zabala and Frances N. Espres, Guam; Johannes Sermai and Donny Andrike, Republic of the Marshall Islands; and Megan Fong, Henry Ichiho, and JoAnn Tsark, Papa Ola Lökahi. We also thank Mr John Dax Moreno for sharing his artistic talent in the development of the US Associated Pacific Islands Essential Public Health Services graphic illustration.