The social determinants of the incidence and management of type 2 diabetes mellitus: Are we prepared to rethink our questions and redirect our research activities

Abstract

This paper discusses the role played by social determinants of health in the incidence and management of type 2 diabetes mellitus (diabetes) among vulnerable populations. This issue is especially important in light of recent data from Statistics Canada indicating that mortality rates from diabetes have been increasing among Canadians since the mid-1980s, with increases being especially great among those living in low-income communities. Diabetes therefore appears – like cardiovascular disease – to be an affliction more common among the poor and excluded. It also appears to be especially likely to afflict poor women. Yet we know little about how these social determinants of health influence diabetes incidence and management. What evidence is available is provided and the case is made that the crisis in diabetes requires new ways of thinking about this disease, its causes, and its management

Full text

The social determinants of the incidence and
management of type 2
diabetes mellitus
: are we
prepared to rethink our questions and redirect our
research activities?
Dennis Raphael
York University, Toronto, Ontario, Canada
Susan Anstice
Ryerson University, Toronto, Ontario, Canada
Kim Raine
University of Alberta, Edmonton, Alberta, Canada
Kerry R. McGannon
University of Iowa, Iowa City, Iowa, USA
Syed Kamil Rizvi
York University, Toronto, Ontario, Canada
Vanessa Yu
York University, Toronto, Ontario, Canada
An expanding literature is examining the
dimensions of health inequalities in
industrialized nations (Acheson, 1998;
Raphael, 2002a). Specific focus is on
dimensions of social exclusion that reflect
increasing income, housing, and food
insecurity associated with the weakening of
the welfare state (Canadian Council on Social
Development, 2001; Health Promotion
Atlantic, 2001; Raphael, in press). Diabetes
mellitus (diabetes) ± like cardiovascular
disease ± is an affliction more common
among the poor and excluded (Chaturvedi
et al., 1998; Hux et al., 2002). A few studies in
Canada have included income as a relevant
variable in the incidence of diabetes, but
these studies lack adequate
conceptualization of the role social
determinants of health play in diabetes
incidence (Raphael, 2002c). Also, conceptual
and empirical analyses have not been carried
out in a way that has income as a
determinant of the risk factors usually
associated with diabetes morbidity and
mortality.
This paper outlines what is known about
the social determinants of type 2 diabetes and
challenges health researchers and workers to
begin asking different questions as to the
causes of its incidence and the factors
affecting its management. It does not include
examination of the possible role that genes
play in the incidence of diabetes. McDermott
argues that the evidence for such a role is
limited as compared to issues of social and
material deprivation. She also considers how
an emphasis on biological determinism as an
explanation of the late twentieth century
epidemic of diabetes distracts from
consideration of the types of social and
economic issues we raise in this paper
(McDermott, 1998).
Diabetes: definition, incidence,
and management
Diabetes is a common chronic disease that
affects over two million Canadians. All forms
of diabetes are characterized by the presence
of high blood glucose (hyperglycemia) due to
defective insulin secretion, insulin action, or
both. During an acute episode, coma and
even death may result from blood sugar that
is very high or very low, due to medication
overdoses. Chronic hyperglycemia may lead
to serious complications including damage to
the heart, kidneys, eyes, nerves and blood
vessels (Canadian Medical Association and
Canadian Diabetes Association, 1998). The
treatment for diabetes rests on blood glucose
(glycemic) control to be achieved with diet,
exercise and (if necessary) medications ± the
``three pillars'' of the diabetes management
regimen (Canadian Medical Association and
Canadian Diabetes Association, 1998).
Health Canada reports that diabetes is the
seventh leading cause of death in Canada,
claiming 5,000 lives annually (Health Canada,
The Emerald Research Register for this journal is available at
http://www.emeraldinsight.com/researchregister
The current issue and full text archive of this journal is available at
http://www.emeraldinsight.com/1336-0756.htm
[x]
International Journal of Health
Care Quality Assurance
incorporating Leadership in
Health Services
16/3 [2003] x±xx
#MCB UP Limited
[ISSN 1336-0756]
[DOI 10.1108/13660750310486730]
Keywords
Diabetes, Health services,
Research work, Social factors
Abstract
This paper discusses the role played
by social determinants of health in
the incidence and management of
type 2 diabetes mellitus (diabetes)
among vulnerable populations. This
issue is especially important in light
of recent data from Statistics
Canada indicating that mortality
rates from diabetes have been
increasing among Canadians since
the mid-1980s, with increases
being esp ecially gre at among th ose
living in low-income communities.
Diabetes therefore appears ± like
cardiovascular disease ± to be an
affliction more common among the
poor and excluded. It also appears
to be especially likely to afflict poor
women. Yet we know little about
how these social determinants of
health influence diabetes incidence
and management. What evidence is
available is provided and the case is
made that the crisis in diabetes
requires new ways of thinking about
this disease, its causes, and its
management.

1999). It is estimated that by 2010, close to four
million Canadians will have this disease.
Some $9 billion is spent annually on diabetes
care in Canada. Diabetes is a challenge
because it is subject to the ``rule of halves'' ±
only half of all cases of diabetes are
diagnosed, only half of those diagnosed are
treated, and only half of those having
treatment are managed successfully
(McKinlay and Marceau, 2000). Little is
known about the determinants that help put
Canadians into each of these important
halves.
Diabetes is classified into two main types:
1 type 1, gestational diabetes (GDM); and
2 type 2 (Canadian Medical Association and
Canadian Diabetes Association, 1998).
Type 1 diabetes usually develops during
childhood and its onset is generally acute. It
occurs when the pancreas fails to produce
insulin, often as a result of auto-immune
damage and pancreatic beta-cell destruction.
Gestational diabetes is a temporary condition
of glucose intolerance during pregnancy and
is often a precursor to type 2 diabetes later in
life. Type 2 diabetes usually develops during
adulthood, although age of incidence is
decreasing and results from predominant
insulin resistance with relative insulin
deficiency to a predominant secretory defect
with insulin resistance. Onset can be
insidious as insulin secretion may decline
gradually. Type 2 diabetes affects
approximately 90 percent of Canadians
diagnosed with diabetes (Canadian Diabetes
Association, 2000) and is the primary focus of
this paper. In Canada, Type 2 diabetes is
appearing at younger ages (Canadian
Medical Association and Canadian Diabetes
Association, 1998).
Greater burden on vulnerable
populations
An examination of the distribution of
diabetes in the population reveals a
disproportionate burden among low-income ±
including aboriginal ± Canadians. Recent
data from the Institute for Clinical
Evaluation Sciences indicate that in Ontario
the risk of diabetes is four times greater
among low-income women than that seen
among high-income women (Hux et al., 2002).
The rate for low-income males is
40 percent higher, and among lower-middle-
income males, 50 percent higher than the
well-off, still very significant figures. Cross-
Canadian data indicate that the prevalence of
diabetes among Canadians aged 45-64 years
with household incomes of $10,000-29,999 is
twice (6 percent) that of those living in
households with incomes of $60,000 or more
(3 percent) (James et al., 1997). Similar
findings are seen in the UK (Riste et al., 2001).
Wilkins and colleagues provide striking
evidence in the September 2002 issue of
Health Reports of how increases in mortality
rates from diabetes among Canadians since
the mid-1980s have been especially great
among Canadians living in urban low income
communities (Wilkins et al., 2002). These
researchers link the causes of death and
postal code data with census data to provide
profiles of mortality rates in urban Canadian
neighbourhoods classified into income
quintiles. Wilkins et al. (2002, p. 19) describe
the findings regarding mortality associated
with diabetes in urban Canada as follows:
For diabetes among males, mortality rates for
most quintiles decreased from 1971 to 1986,
but then increased from 1986 to 1996. Because
the increases in the latter period were
especially large for the poorest quintiles, the
inter-quintile rate differences widened from
1986 to 1996. For diabetes among females,
mortality rates for all quintiles declined from
1971 to 1986 and then changed little from 1986
to 1996, except for the poorest quintile, in
which rates increased rapidly. Therefore, the
inter-quintile rate difference was
considerably greater in 1996 than it had been
in 1986. The trends with respect to the overall
rates and socio-economic disparities in
diabetes mortality are disquieting and
deserve further study.
Similar findings concerning morbidity and
mortality among low-income communities
are apparent in the USA and UK (Riste et al.,
2001; McKinlay and Marceau, 2000). Diabetes
therefore appears ± like cardiovascular
disease ± to be an affliction more common
among the poor and excluded. Evidence of
increasing income inequality among
Canadians and increasing numbers of low
income families during the past decade
directs special attention to the potential
effects of low income upon the health and
wellbeing of those living with diabetes
(Canadian Institute for Health Information,
2002).
Social determinants of health and
diabetes: potential contributions to
understanding
Virtually nothing is known about the causes
of recent increases in morbidity and
mortality among the Canadian population in
general, and the low-income population in
particular. The presence of the metabolic
[xi]
Dennis Raphael,
Susan Anstice, Kim Raine,
Kerry R. McGannon,
Syed Kamil Rizvi and
Vanessa Yu
The social determinants of the
incidence and management of
type 2
diabetes mellitus
: are
we prepared to rethink our
questions and redirect our
research activities?
International Journal of Health
Care Quality Assurance
incorporating Leadership in
Health Services
16/3 [2003] x-xx

syndrome has been identified as a significant
indicator of a predisposition to diabetes (as
well as cardiovascular disease). Presence of
three or more of the following identify the
syndrome:
1 abdominal obesity: waist circumference
> 88cm in women;
2 hypertriglyceridemia: 150mg/dL
(1.69mmol/L);
3 low high-density lipoprotein (HDL)
cholesterol: < 40mg/dL (1.04 mmol/L) in
men and < 50 mg/dL (1.29 mmol/L) in
women;
4 high blood pressure: 130/85mm Hg; or
5 high fasting glucose: 110mg/dL
(6.1mmol/L) (Ford et al., 2002).
Conventional thinking among health care,
public health workers, and disease-oriented
associations attributes increases in the
presence of the metabolic syndrome and
increases in morbidity and mortality to
changes in dietary and physical activity
patterns among Canadians (Ford et al., 2002).
This is similar to traditional thinking
concerning cardiovascular-related issues
(Raphael, 2002c). Yet, this dominant ``health
behaviors'' paradigm takes little account of
the increasing literature concerning the
importance of the social determinants of
health in population health in general and
the incidence and management of diseases
such as diabetes in particular. Brunner and
Marmot (1999) point out that 90 percent of the
variance in occurrence of metabolic
syndrome observed in the UK Whitehall
studies cannot be accounted for by
conventional behavioral risk factors. The
literature on societal determinants of health
can contribute to understanding of the causes
of diabetes morbidity and mortality.
The social determinants of health
framework presented by Bruner and Marmot
is helpful for illuminating the potential
contributions of these concepts for
understanding the incidence and
management of type 2 diabetes (Brunner and
Marmot, 1999). The framework also
illuminates the gaps in conceptualizing the
causes of type 2 diabetes and related
management issues. In this model, proximal
causes of morbidity, mortality and wellbeing
are identified such as pathophysiological
changes and organ impairment, and
neuroendocrine and immune responses.
Slightly more distal behavioral
antecedents such as health behaviors (e.g.
diet, physical activity, tobacco use, etc.) are
also identified in this model. Of importance
to the present discussion are the even more
distal antecedents of disease such as
psychological responses to work and social
environments which themselves result from,
are reproduced as, aspects of social structure.
The model also identifies the direct effects on
mortality, morbidity, and wellbeing of
material factors that accumulate across the
lifespan.
These model components are common to
most conceptualizations related to
population health (Health Canada, 2001;
Marmot and Wilkinson, 2000; Raphael,
2002b). However, in the diabetes area, these
more distal factors ± with very few
exceptions (McKinlay and Marceau, 2000;
Riste et al., 2001) ± are rarely, if ever,
considered by health researchers, public
health workers, and disease-oriented
associations. Virtually all diabetes research
and health discourse is limited to the
proximal issues of health behaviors,
pathophysiological changes and, in some
cases, neuroendocrine and immune
processes. There is a need to address these
other societal determinants of health relative
to diabetes incidence and management.
Drawing on this model, it would appear
that societal determinants of health could
influence diabetes morbidity and mortality
in at least two broad ways. First, these
determinants may influence the incidence ±
and therefore the prevalence ± of the disorder
among the population and its sub-
populations. Second, these determinants may
influence the successful management of the
disorder. At the very minimum, societal
determinants of health will influence the
adoption of behaviors that contribute to the
incidence and successful management of
diabetes. But there is also increasing
evidence that societal determinants of health
± especially aspects of material deprivation ±
may directly influence the incidence and
management of this complex disorder
through a variety of biological,
psychological, and social pathways across
the life-span. As argued by Kuh and
Ben-Shlomo (1997, p. 3):
The prevailing aetiological model for adult
disease which emphasizes adult risk factors,
particularly aspects of adult life style, has
been challenged in recent years by research
that has shown that poor growth and
development and adverse early
environmental conditions are associated with
an increased risk of adult chronic disease.
Raphael (2002c) brought together much of
this work on the societal determinants of
cardiovascular disease and during that work
began to locate a similar literature related to
diabetes. But the literature on societal
determinants of diabetes is more dispersed
[ xii ]
Dennis Raphael,
Susan Anstice, Kim Raine,
Kerry R. McGannon,
Syed Kamil Rizvi and
Vanessa Yu
The social determinants of the
incidence and management of
type 2
diabetes mellitus
: are
we prepared to rethink our
questions and redirect our
research activities?
International Journal of Health
Care Quality Assurance
incorporating Leadership in
Health Services
16/3 [2003] x-xx

than that seen for cardiovascular disease.
Also, the diabetes area has not benefited from
having very well known authorities such as
Sir Michael Marmot and George Davey Smith
± both of whom have written extensively on
the life-course approach to the incidence of
cardiovascular disease ± working on these
issues in relation to diabetes.
The societal determinants of the
incidence of diabetes
Raphael shows that societal determinants of
health are linked with each other and that
income plays an especially important role
(Raphael, 2002c). Income influences the
quality of early life, levels of stress,
availability of food and quality of diet,
physical activity participation, degree of
social exclusion, and so on. Shaw et al. (1999,
p. 65) state that:
Health inequalities are produced by the
clustering of disadvantage ± in opportunity,
material circumstances, and behaviors
related to health ± across people's lives.
Benzeval et al.'s argument that societal
determinants of health such as income
influence health through three main
mechanisms ± material deprivation during
early life and adulthood, excessive
psychosocial stress, and the adoption of
health-threatening behaviors ± proved useful
for considering the social determinants of
cardiovascular disease. These mechanisms
may be useful for identifying how societal
factors influence the incidence and
management of diabetes among vulnerable
populations (Benzeval et al., 1995). McKeigue
(1997) and Lawlor et al. (2002) show how early
material deprivation predicts diabetes in
later life.
Material deprivation and the
incidence of diabetes
Material deprivation refers to the differences
individuals experience in exposures to both
beneficial and damaging aspects of the
physical world (Lynch et al., 2000). These
exposures accumulate over the course of the
lifespan and are determined in large part by
the amount of income people have available
to them (Shaw et al., 1999). Individuals who
suffer from material deprivation have
greater exposures to negative events such as
hunger and lack of quality food, poor quality
housing, inadequate clothing, and poor
environmental conditions at home and work.
In addition, individuals suffering from
material deprivation have less exposure to
positive resources such as education, books,
newspapers, and other stimulating
resources, attendance at cultural events,
opportunities for recreation and other
leisure activities that contribute to human
development over the lifespan. How might
these factors be related to the eventual
incidence of diabetes during adulthood?
Recent studies have shown that
intrauterine-growth retarded and low
birthweight babies are at a higher risk of
developing diabetes in adulthood. And
growth retardation and lower birth weight
are frequently consequences of poor early
nutrition associated with low income
mothers' living in materially-deprived
conditions (Leger et al., 1994; Phipps et al.,
1993). The thrifty phenotype hypothesis
suggests that poor nutrition in early life
leads to poor foetal and infant growth and
produces permanent changes to glucose
metabolism. These changes eventually lead
to development of the metabolic syndrome
and diabetes (Hales et al., 2001).
These changes of reduced insulin secretion
and insulin resistance when combined with
obesity, physical inactivity and advancing
age make individuals highly susceptible to
diabetes. Numerous studies have supported
this hypothesis (McCance et al., 1994; Leger
et al., 1994; Jaquet et al., 2000). Beringue et al.
(2002) provide evidence that the mechanisms
involve insulin resistance rather than
decreased insulin secretion in adults.
Clearly, compromised foetal growth at birth
may be associated with diabetes in
adulthood.
Wimbush found that middle-class mothers
were more likely to participate in social and
recreational activity groups than were
low-income mothers (Wimbush, 1988). More
recently, Brown et al. (2001) found further
support for the notion that mothers of lower
socio-economic status spent less time each
week in active leisure. Brown et al. (2001)
speculated that part of the reason for these
findings related to women of lower socio-
economic status being unemployed or under-
employed, the likes of which resulted in
fewer social networks and connections to the
community. Social and community supports
have been found to be extremely important
facilitators for physical activity and leisure
opportunities for mothers of young children
of all socioeconomic backgrounds (Frisby
et al., 1997). Thus, these findings further
reinforce the need to better understand the
role of material and social forces that
underpin constraints to physical activity and
[ xiii ]
Dennis Raphael,
Susan Anstice, Kim Raine,
Kerry R. McGannon,
Syed Kamil Rizvi and
Vanessa Yu
The social determinants of the
incidence and management of
type 2
diabetes mellitus
: are
we prepared to rethink our
questions and redirect our
research activities?
International Journal of Health
Care Quality Assurance
incorporating Leadership in
Health Services
16/3 [2003] x-xx

leisure participation, particularly for low-
income mothers living in poverty who are at
risk of, or who have, Type 2 diabetes.
Lifespan models of chronic disease risk
that take into account life periods after very
early childhood are being developed for
numerous chronic diseases (Davey Smith
and Hart, 2002; Davey Smith and Gordon,
2000; Davey Smith et al., 2001; Kuh and
Ben-Shilmo, 1997). These conceptualizations
are much more advanced for the
cardiovascular area, but it appears that
common mechanisms may underlie both
these diseases (Brunner and Marmot, 1999).
One key aspect of life-course models is the
role played by stress. Another is the adoption
of unhealthy behaviors.
Psychosocial stress and the
incidence of type 2 diabetes
Brunner and Marmot (1999) present a model
that provides potential insights into the role
stress plays in the incidence of chronic
disease. They identify potential pathways by
which the stress of living under difficult
living conditions becomes translated into
incidence of both diabetes and
cardiovascular disease. As discussed later, at
the very minimum, exposure to psychosocial
stress influences the adoption of behaviors
such as poor diet and inactivity, all
associated with greater likelihood of type 2
diabetes during adulthood.
But the direct effects that stress has on
metabolic and physiological pathways that
make an individual susceptible to type 2
diabetes may be of more potential value. Two
neuroendocrine pathways that involve the
release of hormones may contribute to the
incidence of this disorder. The sympathetic
adrenal pathway involves the release of
noradrenaline from the sympathetic nerve
endings and adrenaline from the adrenal
medulla into the blood stream. These
hormones affect the target organ of the heart
since it is under the control of both the
autonomic nervous system and adrenaline
levels in the blood. These hormones increase
the heart rate, metabolic rate, blood pressure,
respiration rate, and produce
vasoconstriction, sweating and dryness of
the mouth.
The second pathway comes into play a few
minutes or maybe even a few hours after an
initial stressor stimulus. It causes the release
of hormones from the hypothalamus,
pituitary gland and the adrenal glands and is
known as the hypothalamic pituitary adrenal
axis. The activity of this axis begins in the
brain with the release of corticotrophin-
releasing factor from the hypothalamus. This
hormone causes the release of the
adrenocorticotropic hormone from the
pituitary gland into the circulation. This
hormone stimulates the release of cortisol
from the adrenal gland. Cortisol is an
antagonist of insulin and increases the levels
of blood glucose and also causes the release of
fatty acids from fat tissues. The role of stress
in the occurrence of the metabolic syndrome
± specifically insulin resistance ± and the
incidence of diabetes has been under-
researched (Brunner and Marmot, 1999).
Concerning the relationship between
psychosocial stress and the metabolic
syndrome, Brunner and Marmot (1999, p. 33)
argue that:
... this cluster of risk factors may be the
product of altered activity of the HPA
(hypothalamic-pituitary-adrenal) axis in
response to long-term exposure to adverse
psychosocial circumstances.
There is a historical link between lower
socioeconomic status and increased
adrenocortical activity. Destitute people of
nineteenth century England who were
subject to chronic malnutrition were found to
have larger than normal sized adrenal glands
(Sapolsky, 1992). Brunner and Marmot's
(1999) conclusion that the presence of the
metabolic syndrome is strongly predicted by
income and social status would suggest its
presence would also be related to societal
determinants of health associated with
income such as food security, housing
uncertainty and social exclusion, among
other factors.
Adoption of unhealthy behaviors
and the incidence of diabetes
The behavioral risk factors for the incidence
of diabetes are well known: poor nutrition
and sedentary lifestyle are associated with
obesity (Canadian Medical Association and
Canadian Diabetes Association, 1998). There
are also barriers to successful management
of the disorder:
.poor meal planning/poor diet;
.tobacco smoking; and
.physical inactivity (Canadian Medical
Association and Canadian Diabetes
Association, 1998).
All of these behaviors are associated with
lower income and social status. However,
much of the diabetes health literature
assumes that these behavioral patterns are
adopted through voluntary lifestyle choices
[ xiv ]
Dennis Raphael,
Susan Anstice, Kim Raine,
Kerry R. McGannon,
Syed Kamil Rizvi and
Vanessa Yu
The social determinants of the
incidence and management of
type 2
diabetes mellitus
: are
we prepared to rethink our
questions and redirect our
research activities?
International Journal of Health
Care Quality Assurance
incorporating Leadership in
Health Services
16/3 [2003] x-xx

(Wilkinson and Marmot, 1999). It is becoming
increasingly clear that patterns of health
behaviors are strongly shaped by the social
and economic environments in which people
live. Stress produces behaviors aimed at
ameliorating tension such as high
carbohydrate and fat diets, and tobacco use
(Wilkinson, 1996). Meal planning (and
engaging in physical activity) may be
difficult when concerns about meeting basic
needs of housing, food, and clothing intrude
on daily activities (Travers, 1996).
It should not be surprising then that
individuals faced with low income or other
stress inducing issues such as
unemployment or underemployment, racism,
insecure or unaffordable housing would have
difficulties maintaining ``healthy lifestyles''.
This would especially be the case for those
managing their diabetes. A sole emphasis by
the diabetes health community on explaining
unhealthy behaviors as a matter of
individual choice may be counter-productive
in the battle against the effects of this
disease. First, these behavioral factors may
not account for the majority of variance
associated with the incidence of diabetes or
its successful management. Second, it leads
towards a ``blaming the victim'' approach
whereby those with disadvantage are blamed
for adopting means ± admittedly unhealthy ±
for coping with their difficult life situations.
Third, an emphasis solely on individual
choice fails to address underlying issues of
why disadvantaged people adopt these
behaviors.
An extensive analysis of the determinants
of adults' health-related behaviors such as
tobacco use, physical activity, and healthy
diets, found these behaviors were predicted
by poor childhood conditions, low levels of
education, and low status employment
(Lynch et al., 1997). The study also found that
poor socioeconomic conditions during early
life make it less likely that people feel they
have control over their lives ± a factor that
can contribute to illness. Identifying some of
the possible pathways to type 2 diabetes such
as material deprivation, excessive
psychosocial stress, and adoption of health
threatening behaviors suggests value in
applying a societal determinants of diabetes
approach. Certainly, such an analysis would
contribute to our understanding of why and
how diabetes is an especially important issue
for low income and other vulnerable
populations. Considering the increasing
numbers of low income families living in
urban Canada, such a focus seems especially
important (Canadian Institute for Health
Information, 2002).
The societal determinants of the
successful management of diabetes
As noted, Wilkins et al. (2002) have
documented the exceptional increases in
diabetes mortality among Canadians living
in low-income communities. The risk of the
disease is especially related to low income
among women. Virtually nothing is known
about the causes of such increases. One
possibility may be that increasing difficulties
in day-to-day living among people living in
disadvantaged circumstances are
contributing to difficulties in disease
management. The diabetes management
regimen is considered ``among the most
demanding regimens of any chronic illness''
(Callaghan and Williams, 1994). The regimen
is associated with a number of lifestyle
changes that people with diabetes often find
difficult to incorporate into their everyday
lives (Maclean and Oram, 1988). Anstice
(2002) argues that there are many reasons to
believe that adherence to the diabetes
management regimen may be especially
challenging for members of low-income
families, and particularly for low-income
mothers who are living with diabetes. Many
are also unable to find time or safe spaces for
exercise or to afford blood sugar testing
equipment to better manage their diabetes.
Studies have found that, for families living
in poverty, meeting food needs is a persistent
problem (Fitchen, 1988; Radimer et al., 1992).
Furthermore, it is commonly reported that
during times of acute food shortage mothers
in low-income families will compromise their
own food intake in order to provide more for
others (Graham, 1993; Hamelin et al., 2002;
Tarasuk et al., 1998). The fact that women
bear children and frequently have
responsibility for caring for the health needs
of their family suggests another mechanism
by which gender may play a role in the
incidence of diabetes. Prospective mothers
may skimp on their own nutritional needs in
order to provide food for the rest of their
family. This may be associated with lower
birthweight and greater likelihood of their
offspring developing diabetes in later life.
Since good nutrition is considered the
cornerstone of good diabetes management, it
may be that mothers with diabetes who live
in low-income families experience
exceptional food problems that challenge the
dietary management of their own diabetes
(Anstice, 2002). A small body of qualitative
[xv]
Dennis Raphael,
Susan Anstice, Kim Raine,
Kerry R. McGannon,
Syed Kamil Rizvi and
Vanessa Yu
The social determinants of the
incidence and management of
type 2
diabetes mellitus
: are
we prepared to rethink our
questions and redirect our
research activities?
International Journal of Health
Care Quality Assurance
incorporating Leadership in
Health Services
16/3 [2003] x-xx

research indicates that the material context
of everyday life helps shape personal
experience of diabetes, and further that acute
financial constraints may present barriers to
successful management. Mason (1985) found
that among people living in socially
disadvantaged areas in Scotland, those faced
with acute financial constraints made
decisions that did not necessarily prioritize
their diabetes management. Miewald (1997)
studied low-income clients at a US clinic and
found that both financial constraint and
shortcomings of low-income neighbourhoods
challenged participants' adherence to a
dietary regimen. She notes that:
Lack of access to inexpensive grocery stores
and tight food budgets ... made it difficult for
clients to make changes in their eating habits
(Miewald, 1997, p. 359).
Studies have also found low amounts of
leisure-time physical activity to be strongly
associated with low income (Stachenko et al.,
1992; Steenland, 1992), low education
(Sternfeld et al., 1999), and low socio-
economic status (Blanksby et al., 1996;
Mensink et al., 1997). Furthermore, the lowest
participation rates are found among the poor
and women of child-rearing age, many of
whom are the same people (Frisby et al.,
1997). While literature in this area tends not
to explore physical activity participation
from a critical or social determinants of
health perspective, it has been noted that
physical activity is heavily dependent on
financial resources and cultural capital
(Kidd, 1995). In support of this, research links
material and structural circumstances (e.g.
living in disadvantaged neighborhoods with
more crime) to lower levels of physical
activity (Wimbush, 1988; Lindstrom et al.,
2001).
Despite this, the complexity of the
relationship between the foregoing social
determinants and physical activity practices
has not been adequately addressed. Thus, not
surprisingly, little information exists on low-
income families, physical activity, and
diabetes management. However, the results
of a participatory action research study in
Canada ± The Woman's Action Project ±
found that low-income women identified a
lack of access to physical activity in their
community as a major factor inhibiting the
development of healthy lifestyles for
themselves and their families (Frisby et al.,
1997). Focus groups confirmed that although
women in this income bracket desired
benefits from physical activity participation
similar to those of women in higher income
brackets, low-income women experienced
social, financial, health and personal
problems that impeded their involvement.
The Canadian literature on the difficulties
of diabetes management faced by vulnerable
populations is small. Anderson and
colleagues examined the diabetes experience
of low-income immigrant women and found
also found that the constraints of low income
helped shape management decisions
(Anderson, 1991, 1998; Anderson et al., 1993,
1995). The researchers contend that an
immigrant woman with diabetes who lacks
access to material resources is in a
paradoxical situation:
On the one hand, she is expected to take
responsibility for carrying out her care. On
the other hand, she does not have access to
the resources that would allow her to do so
(Anderson, 1991, p. 111).
Anderson's research focused on the role of
ethnicity in women's experiences of diabetes;
it is probable that other low-income women
face this self-care paradox.
An investigation by Anstice (2002) provides
further evidence of the importance of this
area of inquiry. In her grounded theory
study, Anstice used multiple, in-depth, one-
on-one interviews with three Toronto women
to explore the question: How do sole-support
mothers who live on income support describe
their everyday experiences of diabetes
mellitus? She found that financial
vulnerability, characterized by income
inadequacy and a sense of precariousness,
was manifested in experiences of housing,
food and transportation difficulties. This
everyday context profoundly shaped diabetes
management decisions. For example, food
problems associated with income inadequacy
such as household food shortages were
described as major barriers to implementing
the dietary recommendations of the diabetes
management regimen. Uncertainty
concerning the adequacy of other societal
determinants of health such as housing
certainly plays a role as well in poor dietary
management. These insecurities certainly
create an early childhood environment not
conducive to the healthy development of
children (Hertzman, 1999; Keating and
Hertzman, 1999) ± another area profoundly
under-researched by those concerned with
the health effects of diabetes.
Implications for the further study
of the social determinants of
diabetes
These kinds of hypotheses would suggest that
if the appropriate analyses were completed,
[ xvi ]
Dennis Raphael,
Susan Anstice, Kim Raine,
Kerry R. McGannon,
Syed Kamil Rizvi and
Vanessa Yu
The social determinants of the
incidence and management of
type 2
diabetes mellitus
: are
we prepared to rethink our
questions and redirect our
research activities?
International Journal of Health
Care Quality Assurance
incorporating Leadership in
Health Services
16/3 [2003] x-xx

income and social status would have direct
association with the presence of both the
metabolic syndrome and the presence of
diabetes in populations independent of the
health behaviors usually identified as the
primary causes of diabetes. Indeed, there is
evidence that this is the case. Wamala et al.
(1999) studied precursors of the metabolic
syndrome among Swedish women. They
found that low education (a proxy for lower
income) was associated with a 2.3 times
greater likelihood of the presence of the
metabolic syndrome even after accounting
for age, family history, smoking, lack of
exercise, and alcohol consumption. In
Canada, Choi and Shi (2001) found that
income status differences produced a
26 percent greater excess risk of diabetes
among low-income Canadians independent of
other behavioral risk factors. Similar
findings can be inferred, but were not
explicitly presented, in the ICES diabetes
report (Hux et al., 2002).
Clearly, there is a need to analyze
available data within the life-course
frameworks suggested by these models and
empirical findings. These would require
statistical analyses that were firmly
grounded within a life-course perspective.
Much of the available analyses take a less
complex risk-factor approach by which
income is treated as one of many risk
factors to be considered, rather than as a
determinant of the behavioral risk factors
themselves. If data that would allow for
these analyses to be carried out are not
available, mechanisms need to be developed
to gather and analyze such data.
Canada has been a world leader in
conceptualizing the social determinants of
health. Yet recent initiatives in preventing
chronic disease and promoting health appear
to be relegating these concepts to the
sidelines in favor of healthy lifestyle choices.
This appears to be especially the case in the
approaches being taken by the new Chronic
Disease Prevention Alliance of Canada and
the Healthy Living Initiative of the Federal
Government (Chronic Disease Prevention
Alliance of Canada, 2003; Health Canada,
2003). The crisis in diabetes appears to call
for new ways of thinking about and
redirecting our research activities in regards
to this disease. Are health workers and
researchers up to this challenge?
References
Acheson, D. (1998), Independent Inquiry Into
Inequalities in Health, Stationery Office,
available at: www.official-documents.co.uk/
document/doh/ih/contents.htm
Anderson,J.,Wiggins,R.,Rawjani,R.,
Holbrook, A., Blue, C. and Ng, M. (1995),
``Living with a chronic illness: Chinese-
Canadian and Euro-Canadian women with
diabetes ± exploring factors that influence
management'', Social Science and Medicine,
Vol. 41 No. 2, pp. 181-95.
Anderson, J.M. (1991), ``Immigrant women speak
of chronic illness: the social construction of
the devalued self'', Journal of Advanced
Nursing, Vol. 16 No. 6, pp. 710-17.
Anderson, J.M. (1998), ``Speaking of illness: issues
of first generation Canadian women ±
implications for patient education and
counseling'', Patient Education and
Counseling, Vol. 33 No. 3, pp. 197-207.
Anderson, J.M., Blue, C., Holbrook, A. and Ng, M.
(1993), ``On chronic illness: immigrant women
in Canada's workforce ± a feminist
perspective'', Canadian Journal of Nursing
Research, Vol. 25 No. 2, pp. 7-22.
Anstice, S. (2002), Diabetes and Disadvantage:
Everyday Experiences of type II Diabetes
Among Sole-support Mothers Living on
Income-support, University of Toronto, Public
Health Sciences, Toronto.
Benzeval, M., Judge, K. and Whitehead, M. (1995),
Tackling Inequalities in Health: An Agenda
for Action, Kings Fund, London.
Beringue, F., Blondeau, B., Castellotti, M.C.,
Breant, B., Czernichow, P. and Polak, M.
(2002), ``Endocrine pancreas development in
growth-retarded human fetuses'', Diabetes
Care, Vol. 51, pp. 385-91.
Blanksby, B., Anderson, M. and Douglas, G.A.
(1996), ``Recreational patterns, body
composition and socioeconomic status of
western secondary school students'', Annals
of Human Biology, Vol. 23, pp. 101-12.
Brown, P.R., Brown, W.J., Miller, Y.D. and
Hansen, V. (2001), ``Perceived constraints and
social support for active leisure among
mothers with young children'', Leisure
Sciences, Vol. 23, pp. 131-44.
Brunner, E. and Marmot, M.G. (1999), ``Social
organization, stress, and health'', in Marmot,
M.G. and Wilkinson, R.G. (Eds), Social
Determinants of Health, Oxford University
Press, Oxford, pp. 17-43.
Callaghan, D. and Williams, A. (1994), ``Living
with diabetes: issues for nursing practice'',
Journal of Advanced Nursing, Vol. 20,
pp. 132-9.
Canadian Council on Social Development (2001),
Equality, Inclusion and the Health of
Canadians: Submission to the Commission
ontheFutureofHealthCareinCanada,
Canadian Council on Social Development
(CCSD), available at: www.ccsd.ca/pubs/
2001/romanow/ccsdsubmission.pdf
Canadian Diabetes Association (2000), Diabetes,
available at: www.diabetes.ca
[ xvii ]
Dennis Raphael,
Susan Anstice, Kim Raine,
Kerry R. McGannon,
Syed Kamil Rizvi and
Vanessa Yu
The social determinants of the
incidence and management of
type 2
diabetes mellitus
: are
we prepared to rethink our
questions and redirect our
research activities?
International Journal of Health
Care Quality Assurance
incorporating Leadership in
Health Services
16/3 [2003] x-xx

Canadian Institute for Health Information (2002),
Charting the Course: A Pan-Canadian
Consultation on Population and Public Health
Priorities, Canadian Institute for Health
Information (CIHI), available at:
www.cihi.ca/cihiweb/en/downloads/
cphi_charting_jun2002_e.pdf
Canadian Medical Association and Canadian
Diabetes Association (1998), ``1998 clinical
practice guidelines for the management of
diabetes in Canada'', Canadian Medical
Association Journal, Vol. 159 No. 8
(supplement), pp. S1-29.
Chaturvedi, N., Jarrett, J., Shipley, M.J. and
Fuller, J.H. (1998), ``Socioeconomic gradient
in morbidity and mortality in people with
diabetes: cohort study findings from the
Whitehall study and the WHO multinational
study of vascular disease in diabetes'', BMJ,
Vol. 316 No. 7125, pp. 100-5.
Choi, B.C.K. and Shi, F. (2001), ``Risk factors for
diabetes mellitus by age and sex: results of the
National Population Health Survey'',
Diabetologia, Vol. 44 No. 10, pp. 1221-31.
Chronic Disease Prevention Alliance of Canada
(2003), Who We Are, available at:
www.chronicdiseaseprevention.ca/content/
about_cdpac/mission.asp
Davey Smith, G. and Gordon, D. (2000), ``Poverty
across the life-course and health'', in
Pantazis, C. and Gordon, D. (Eds), Tackling
Inequalities: Where Are We Now and What
Can Be Done?, Policy Press, Bristol.
Davey Smith, G., Grunnell, D. and Ben-Shlomo, Y.
(2001), ``Life-course approaches to
socioeconomic differentials in cause-specific
adult mortality'', in Leon, D. and Walt, G.
(Eds), Poverty, Inequality and Health: An
International Perspective, Oxford Universtiy
Press, New York, NY, pp. 88-124.
Davey Smith, G. and Hart, C. (2002), ``Life-course
approaches to socio-economic and behavioral
influences on cardiovascular disease
mortality'', American Journal of Public
Health, Vol. 92 No. 8, pp. 1295-8.
Fitchen, J. (1988), ``Hunger, malnutrition, and
poverty in the contemporary United States:
some observations on their social and
cultural context'', Food and Foodways, Vol. 2,
pp. 309-33.
Ford, E., Giles, W. and Dietz, W. (2002),
``Prevalence of the metabolic syndrome
among US adults: findings from the Third
National Health and Nutrition Examination
Survey'', Journal of the American Medical
Association, Vol. 287 No. 3, pp. 356-9.
Frisby, W., Crawford, S. and Dorer, T. (1997),
``Reflections on participatory action research:
the case of low-income women accessing local
physical activity services'', Journal of Sport
Management, Vol. 11, pp. 8-28.
Graham, H. (1993), Hardship and Health in
Women's Lives, Harvester Wheatsheaf,
Hemel Hempstead.
Hales, C., Nicholas and Barker, J.P. (2001), ``The
thrifty phenotype hypothesis'', British
Medical Bulletin, Vol. 60, pp. 5-20.
Hamelin, A.-M., Beaudry, M. and Habicht, J.-P.
(2002), ``Characterization of household food
insecurity in Quebec: food and feelings'',
Social Science and Medicine, Vol. 54 No. 1,
pp. 119-32.
Health Canada (1999), Diabetes in Canada:
National Statistics and Opportunities for
Improved Surveillance, Prevention, and
Control, Minister of Public Works and
Government Services, Ottawa,
Health Canada (2001), The Population Health
Template: Key Elements and Actions That
Define a Population Health Approach,
Strategic Policy Directorate, Population and
Public Health Branch, Health Canada,
available at: www.hc-sc.gc.ca/hppb/phdd/
pdf/discussion_paper.pdf
Health Canada (2003), Healthy Living Strategy,
Health Canada, available: www.hc-sc.gc.ca/
english/media/releases/2003/2003_14.htm
Health Promotion Atlantic (2001), ``Social and
economic inclusion'', Health Promotion
Atlantic, Vol. 7 No. 1, pp. 8-14.
Hertzman, C. (1999), ``Population health and
human development'', in Keating, D.P. and
Hertzman, C. (Eds), Developmental Health and
the Wealth of Nations: Social, Biological and
Educational Dynamics, Guilford Press,
New York, NY, ch. 2.
Hux, J., Booth, G. and Laupacis, A. (2002), The
ICES Practice Atlas: Diabetes in Ontario,
Institute for Clinical Evaluative Sciences
(ICES), and the Canadian Diabetes
Association, available at: www.ices.on.ca/
James, R., Young, T.K., Mustard, C. and
Blanchard, J. (1997), ``The health of Canadians
with diabetes'', Health Reports, Vol. 9 No. 3,
pp. 47-52.
Jaquet, D., Gaboriau, A., Czernichow, P. and
Levy-Marchal, C. (2000), ``Insulin resistance
early in adulthood in subjects born with
intrauterine growth retardation'', The
Journal of Endocrinology and Metabolism,
Vol. 85 No. 4, pp. 1401-6.
Keating, D.P. and Hertzman, C. (Eds) (1999),
Developmental Health and the Wealth of
Nations, Guilford Press, New York, NY.
Kidd, B. (1995), ``Confronting inequality in sport
and physical activity'', Avante, Vol. 1, pp. 1-19.
Kuh, D. and Ben-Shilmo, Y. (Eds) (1997), A Life
Course Approach to Chronic Disease
Epidemiology, Oxford University Press,
Oxford.
Lawlor, D., Ebrahim, S. and Smith, G.D. (2002),
``Socioeconomic position in childhood and
adulthood and insulin resistance: cross-
sectional survey using data from British
[ xviii ]
Dennis Raphael,
Susan Anstice, Kim Raine,
Kerry R. McGannon,
Syed Kamil Rizvi and
Vanessa Yu
The social determinants of the
incidence and management of
type 2
diabetes mellitus
: are
we prepared to rethink our
questions and redirect our
research activities?
International Journal of Health
Care Quality Assurance
incorporating Leadership in
Health Services
16/3 [2003] x-xx

women's heart and health study'', Vol. 325
No. 12.
Leger, J., Levy-Marchal, C., Bloch, J., Pinet, A.,
Chevenne, Phillips, D.I., Hirst, S., Clark, P.M.,
Hales, C.N. and Osmond, C. (1994), ``Fetal
growth and insulin secretion in adult life'',
Diabetologia, Vol. 37 No. 6, pp. 592-6.
Lindstrom, J., Hasnon, B.S. and Ostergren, P.O.
(2001), ``Socioeconomic differences in leisure-
time physical activity: the role of social
participation and social capital in shaping
health-related behavior'', Social Science and
Medicine, Vol. 52, pp. 441-51.
Lynch, J.W., Kaplan, G.A. and Salonen, J.T.
(1997), ``Why do poor people behave poorly?
Variation in adult health behaviors and
psychosocial characteristics by stages of the
socioeconomic life course'', Social Science &
Medicine, Vol. 44, pp. 809-19.
Lynch, J.W., Smith, G.D., Kaplan, G.A. and
House, J.S. (2000), ``Income inequality and
mortality: importance to health of individual
income, psychosocial environment, or
material conditions'', BMJ, Vol. 320,
pp. 1220-4.
McCance, D.R., Pettitt, D.J., Hanson, L.R.,
Jacobsson, L.T.H. and Knowler, W.C. (1994),
``Birth weight and non insulin dependant
diabetes mellitus: thrifty genotype, thrifty
phenotype, or surviving a small baby
genotype'', BMJ, Vol. 308, pp. 942-5.
McDermott, R. (1998), ``Ethics, epidemiology, and
the thrifty gene: biological determinism as a
health hazard'', Social Science & Medicine,
Vol. 47 No. 9, pp. 1189-95.
McKeigue, P. (1997), ``Diabetes and insulin
action'', in Ben-Shilmo, Y. (Eds), ALife
Course Approach to Chronic Disease
Epidemiology, Oxford University Press,
Oxford, pp. 78-100.
McKinlay, J. and Marceau, L. (2000), ``US public
health and the twenty-first century: diabetes
mellitus'', The Lancet, Vol. 356, pp. 757-61.
Maclean, H. and Oram, B. (1988), Living with
Diabetes: Personal Stories and Strategies for
Coping, University of Toronto Press, Toronto.
Marmot, M. and Wilkinson, R. (2000), Social
Determinants of Health, Oxford University
Press, Oxford.
Mason, C. (1985), ``The production and effects of
uncertainty with special reference to diabetes
mellitus'', Social Science and Medicine, Vol. 21
No. 12, pp. 1329-34.
Mensink, G.B.M., Losse, N. and Oomen, C.M.
(1997), ``Physical activity and its association
with other lifestyle factors'', European
Journal of Epidemiology, Vol. 13, pp. 771-8.
Miewald, C.E. (1997), ``Is awareness enough? The
contradictions of self-care in a chronic
disease clinic'', Human Organization, Vol. 56
No. 3, pp. 353-63.
Phipps, K., Barker, D.J., Hales, C.N., Fall, C.H.,
Osmond, C. and Clark, P.M. (1993), ``Fetal
growth and impaired glucose tolerance in
men and women'', Diabetologica, Vol. 36
No. 10, pp. 973-4.
Radimer, K., Olson, C., Green, J., Campbell, C.
and Habicht, J.-P. (1992), ``Understanding
hunger and developing indicators to assess it
in women and children'', Journal of Nutrition
Education, Vol. 24, pp. 36S-45S.
Raphael, D. (2002a), ``Addressing health
inequalities in Canada'', Leadership in Health
Services, Vol. 15 No. 3, pp. 1-8.
Raphael, D. (2002b), Poverty, Income Inequality
and Health in Canada, Centre for Social
Justice Foundation for Research and
Education (CSJ), available at:
www.socialjustice.org/pubs/income&
Health.pdf
Raphael, D. (2002c), Social Justice is Good for our
Hearts: Why Societal Factors ± Not Lifestyles ±
Are Major Causes of Heart Disease in Canada
and Elsewhere, Centre for Social Justice
Foundation for Research and Education
(CSJ), available at: www.socialjustice.org/
pubs/justiceHearts.pdf
Raphael, D. (in press), ``A society in decline: the
social, economic, and political determinants
of health inequalities in the USA'', in
Hofrichter, R. (Ed.), Health and Social Justice:
A Reader on Politics, Ideology, and Inequity in
the Distribution of Disease, Jossey-Bass,
San Francisco, CA/John Wiley & Sons,
New York, NY.
Riste, L., Khan, F. and Cruickshank, K. (2001),
``High prevalence of type 2 diabetes in all
ethnic groups, including Europeans, in a
British inner city. Relative poverty,
history, inactivity, or twenty-first century
Europe?'', Diabetes Care, Vol. 24, pp. 1377-83.
Sapolsky, R.M. (1992), Stress, the Aging Brain, and
Mechanisms of Neuron Death, MIT Press,
Cambridge, MA.
Shaw, M., Dorling, D., Gordon, D. and Smith, G.D.
(1999), The Widening Gap: Health Inequalities
and Policy in Britain, The Policy Press,
Bristol.
Stachenko, S.J., Reeder, B.A., Lindsay, E.,
Donovan, C. and Lessard, R. (1992), ``Smoking
prevalence and associated risk factors in
Canadian adults. Canadian Heart Health
Surveys Research'', Canadian Medical
Association Journal, Vol. 146, pp. 1989-96.
Steenland, K. (1992), ``Passive smoking and the
risk of heart disease'', Journal of the
American Medical Association, Vol. 267,
pp. 94-9.
Sternfeld, B., Ainsworth, B.E. and Quesenberry,
J.C.P. (1999), ``Physical activity patterns in a
diverse population of women'', Preventive
Medicine, Vol. 28, pp. 313-23.
Tarasuk, V., Beaton, G.H., Geduld, J. and
Hilditch, S. (1998), Nutritional Vulnerability
and Food Insecurity among Women in
Families Using Food Banks, Toronto.
[ xix ]
Dennis Raphael,
Susan Anstice, Kim Raine,
Kerry R. McGannon,
Syed Kamil Rizvi and
Vanessa Yu
The social determinants of the
incidence and management of
type 2
diabetes mellitus
: are
we prepared to rethink our
questions and redirect our
research activities?
International Journal of Health
Care Quality Assurance
incorporating Leadership in
Health Services
16/3 [2003] x-xx

Travers, K.D. (1996), ``The social organization of
nutritional inequities'', Social Science &
Medicine, Vol. 43 No. 4, pp. 543-53.
Wamala, S., Lynch, J. and Horsten, M. (1999),
``Education and the metabolic syndrome in
women'', Diabetes Care, Vol. 22 No. 12,
pp. 1999-2003.
Wilkins,R.,Berthelot,J.-M.andNg,E.(2002),
``Trends in mortality by neighbourhood
income in urban Canada from 1971 to 1996'',
Health Reports,Vol.13,Supplement,
pp. 1-28.
Wilkinson, R. and Marmot, M. (1999), Social
Determinants of Health: The Solid Facts,
World Health Organization (WHO),
Copenhagen, 32.
Wilkinson, R.G. (1996), Unhealthy Societies:
The Afflictions of Inequality, Routledge,
New York, NY.
Wimbush, E. (1988), ``Mothers meeting'', in
Wimbush, E. and Talbott, M. (Eds),
Relative Freedoms: Women and Leisure,
Open University Press, Milton Keynes,
pp. 60-74.
[xx]
Dennis Raphael,
Susan Anstice, Kim Raine,
Kerry R. McGannon,
Syed Kamil Rizvi and
Vanessa Yu
The social determinants of the
incidence and management of
type 2
diabetes mellitus
: are
we prepared to rethink our
questions and redirect our
research activities?
International Journal of Health
Care Quality Assurance
incorporating Leadership in
Health Services
16/3 [2003] x-xx