Understanding the social factors that contribute to diabetes: a means to informing health care and social policies for the chronically ill

Abstract

Social determinants of health are the conditions in which individuals are born, grow, live, work, and age. Increasingly, they are being recognized for their relationship to the soaring incidence of Type 2 diabetes in the US, as well as the opportunities they present for us to counter it. Many current Type 2 diabetes interventions focus on biologic and behavioral factors, such as symptoms, diet, and physical activity. However, it is equally important to address the influence of physical and social environments, which may include low income, employment insecurity, low educational attainment, and poor living conditions, on health outcomes. Section 4302 of the Patient Protection and Affordable Care Act of 2010 offers an opportunity to improve data collection and policy development to more effectively identify populations at high risk for developing Type 2 diabetes and to proactively refer them to appropriate social support services that may ultimately support reduction of health disparities. Expanding the scope of this legislation to include data that incorporate social determinants would improve the ability of clinicians and health systems to engage and to treat patients with chronic conditions, such as Type 2 diabetes, while expanding policymakers' ability to conform to the legislation's intent of shaping efforts to reduce chronic conditions nationwide.

Figure 1

The sociobiologic cycle of diabetes. ¹Social determinants of health encompass factors such as income, education, housing, and access to nutritious food. ²Lifestyle factors incorporate dietary choices, physical activity levels, and access to primary health care services. ³Biologic responses refer to increased allostatic load, cortisol, blood pressure, and blood glucose levels, while psychological responses connote increased depression and anxiety, as well as decreased self-esteem, energy, and motivation. ⁴Managed condition implies individuals are able to ensure their diabetes is approximately controlled by clinical standards. ⁵Social consequences include increased health care costs and employment complications, as well as decreased productivity and educational attainment potential.