Type 2 Diabetes [Part II]

Risk Factors and Social Determinants of Health of T2DM

Risk factors and social determinants of health that can affect the prevalence and control of T2DM include the following elements: Lifestyle, education, built environment, income, mental health and social and community contexts, healthcare, and natural environment.

Lifestyle

Lifestyle-associated risk factors include inactivity, smoking, unhealthy food consumption, vitamin D deficiency, and most importantly, obesity (Cullmann et al., 2012; Manson et al., 2000; Zimmet et al., 2001). Those who lead a sedentary lifestyle are more likely to develop vitamin D deficiency due to their lack of exposure to sunlight, which can be detrimental to “glucose intolerance, insulin secretion, and [the development of] T2DM” (Nikooyeh et al., 2011). With technological innovations and the development of countries, obesity and sedentary lifestyles have become more prevalent, leading to the increased morbidity and mortality of the disease. 

Mental Health and Social Relationships

Positive relationships in social and community contexts can bring a positive mental health effect, but if not, individuals can experience symptoms such as depression and anxiety. The effects of these mental health problems can be especially detrimental to patients with T2DM because T2DM is a disease that usually relies on the patient’s self-care and consistency to be properly treated. For instance, for a patient with severe T2DM, insulin shots have to be taken daily to prevent dangerous consequences. Mental health can interfere with this self-treatment such as leading an inactive lifestyle, developing eating disorders, and reaching out to alcohol and other drugs critical to T2DM development (Center for Disease Control and Prevention [CDC], 2021b).

Natural Environment

Environmental air pollution can increase the risk for many causes of type 2 diabetes mellitus (Meo et al., 2015). Air pollutants such as PM_2.5, PM₁₀, Nitrogen dioxide, and other traffic and smoking-associated molecules are the primary air pollutants leading to the increased risk of disease development (Park & Wang, 2014; Wang et al., 2014). These pollutants can cause “inflammation, abnormalities in glucose homeostasis, [and] insulin resistance” that can eventually lead to the development of T2DM (Meo et al., 2015, p. 125). Problems in glucose homeostasis and insulin resistance can cause blood sugar levels to rise. These air pollutants can also increase the risks of complications such as cardiovascular disease and chronic or acute respiratory disease related to T2DM (Krämer et al., 2010; Pearson et al., 2010). Residents of urban areas are highly exposed to air pollutants compared to those in rural areas. This standard was used in a study to see its correlation with the prevalence of T2DM, and the study found that populations in urban areas and rural areas had 15.4% and 11.7% of T2DM prevalence, respectively (Lee et al., 2010).

Built Environment

Features that encourage physical activity, such as walkability and green spaces, decrease diseases development risk (Amuda & Berkowitz, 2019). A systematic review found that those who lived in the greenest neighborhood quartile had a lower risk of developing diabetes because increased walkability was associated with decreased incident hypertension and obesity, leading to the decrease in T2DM and complications (Chandrabose et al., 2018; Dalton et al., 2016). In addition, there was a strong association between the food retail environment and diabetes risk. This is most likely because increased availability of healthy food decreases the T2DM risk while the presence of fast-food and convenience stores can lead to higher T2DM risk and prevalence (Den braver et al., 2018). In numerous studies, the prevalence of obesity and T2DM were greater in neighborhoods with more fast food outlets in comparison to those with exposure to restaurants and/or cafeterias (Sarkar et al., 2018). In addition, those residing in areas with proximity to healthy foods showed greater insulin resistance (Kern et al., 2018). This factor is closely related to the effects of income on diabetes prevalence because fast-food chains tend to be more affordable compared to restaurants that provide healthier food. To support this claim, a study was conducted to measure the effects of neighborhood deprivation rates on obesity and diabetes prevalence. Neighborhood deprivation accounts for different standings in income, housing, education, employment, and more. This study showed that a greater degree of neighborhood deprivation was associated with higher BMI and factors that led to a higher prevalence of T2DM (Pachucki et al., 2018). 

Education

Educational programs and policies are crucial in determining the prevalence of T2DM. This education can include a wide range from building fundamental knowledge to emotional self-regulation (Hahn & Truman, 2015). Education is effective in decreasing the risk of T2DM because it enhances the sense of personal control that can lead to a healthier lifestyle, and also allows people to take in the information necessary to ensure better health outcomes (Mirowsky & Ross, 2005). Educational status varies greatly between low-income or racial and ethnic minority populations and higher-income or majority populations, which can have a lasting effect on the overall public health of the community and the individuals. Higher average grade achievement and higher education are both closely associated with lower rates of risk behaviors such as smoking, use of drugs and alcohol, unhealthy food consumption, and more. A study of adults older than 25 years found that the prevalence of risk behaviors is inversely proportional to the years of education, further supporting the importance of educational achievement for subsequent health outcomes (Cutler & Lleras-muney, 2010; Winkleby et al., 1992). These behaviors are critical to the development of type 2 diabetes as explained in the previous slides. Wages and income are standards that cause an effect on diabetes development as they provide access to health-related resources such as healthy food, a safe environment, and healthcare. These resources are essentials to early detection of diabetes, prevention of diabetes, and treatment of diabetes (Murnane, 2007). 

Age and Income

Most of the patients impacted by type 2 diabetes are older than 65 years old. However, recently, an increase in childhood obesity has made T2DM more prevalent among patients younger than 25 years old (Weigensberg & Goran, 2009). This phenomenon is especially detrimental as for younger patients, their complex phenotypes lead to decades of intensive management to prevent complications (Constantino et al., 2013). Young patients were also found to be more susceptible to rapid B-cell loss, with up to 50% loss when they are first diagnosed (Holman et al., 2008; Zeitler et al., 2012). These factors make their age much more vulnerable to this disease.

Over 80% of type 2 diabetes patients reside in low or middle-income countries, but since 1980, every single country has observed a significant increase in the disease prevalence (NCD Risk Factor Collaboration (NCD-RisC, 2016). 20 years from now, it is expected that 70% of the disease would occur in developing countries and developed countries such as the United States and Japan (Wild et al., 2004). 

References [Part I, II, and III]