Six cities are looking at urban diabetes from a new perspective

A pioneering study challenges scientific stance on urban diabetes by looking beyond the biomedical aspects and examining the social and cultural factors that shape type 2 diabetes in cities.

Social, cultural and economic factors play a much bigger role in the spread of urban diabetes than previously thought, according to new research commissioned by the pioneering Cities Changing Diabetes (CCD) programme.

The study findings show that diabetes vulnerability in cities can be linked to everything from financial and geographical constraints to traditional perceptions of health and body size – challenging current scientific understanding of the problem.

“By largely focusing on biomedical risk factors for diabetes, traditional research has not adequately accounted for the impact of social and cultural drivers of disease,” explained David Napier, Professor of Medical Anthropology at CCD programme partner University College London (UCL). “Our pioneering research will enable cities worldwide to help populations adapt to lifestyles that make them less vulnerable to diabetes.”

Reshaping the diabetes debate

Led by Professor Napier’s research team at UCL, 740 face-to-face interviews were conducted with at-risk and diagnosed people living in five major cities – Copenhagen, Houston, Mexico City, Shanghai and Tianjin. Johannesburg has since joined the programme and is currently conducting their research. Vancouver is expected to join in 2016.

Coupled with top-line quantitative data, the so-called ‘vulnerability assessments’ helped researchers build a clearer picture of why certain people in certain urban environments are more susceptible to diabetes and its complications – and provide the foundation for potential solutions to the growing problem.

“The insights we have gained from the Cities Changing Diabetes research have fundamentally changed the way we think about diabetes in our city,” said Dr Armando Ahued Ortega, Minister of Health, of Mexico City. “This new understanding of sociocultural risk factors will guide the development of increasingly efficient and targeted public health policies to support the health and wellbeing of our citizens.”

Investing in a solution

Prompted by the findings, Novo Nordisk has pledged to support the continued programme with a 20 million US Dollar investment of expert resource and research funds by 2020.

“We have a longstanding commitment to provide more than just pharmaceuticals to the fight against diabetes,” says CEO Lars Rebien Sørensen“Research of this nature illustrates precisely why we initiated Cities Changing Diabetes – to fundamentally change the trajectory of the disease through targeted actions informed by new understanding.”

A tale of five cities – CCD research findings

75 field workers in five cities across four continents have collectively spent 1,100 hours conducting 740 face-to-face interviews lasting 1,5 hours on average in order to complete the research that shape and inform the Cities Changing Diabetes actions currently under development in the five initial study cities. In Johannesburg, 42 retired nurses will collect data across the city

Mexico City – one of the world’s largest megacities

• Diabetes is the leading cause of death in the country, and three quarters of adults in Mexico City are overweight or have obesity1^[i].
• Social and cultural factors that increase diabetes vulnerability in Mexico City include gender roles which see women neglect their own health for fear of being seen as ‘burdensome’ or ‘vulnerable’.
• Diabetes vulnerability in the city may also be exacerbated by insufficient medical insurance among disadvantaged communities.
• Many people in Mexico City believe that diabetes is caused by stress and strong negative emotions. Low understanding, myths and a lack of available information about diabetes are key challenges to overcome.

Copenhagen – the green and healthy capital

• Only one in 20 people are thought to have diabetes in Copenhagen^[ii] – a relatively low prevalence compared to the global average of one in 11^[iii].
• The life expectancy of people in Copenhagen varies significantly between districts in the city and by as much as seven years.
• People not in employment are seven times more likely to have diabetes than those in employment while people with a university education are three times less likely to have diabetes than those without.
• In Copenhagen, diabetes is often not highest in a person’s hierarchy of need, given many other social and health issues such as unemployment, financial difficulties and loneliness.

Houston – the fastest-growing city in the US

• The prevalence of type 2 diabetes in Houston is estimated to be 9.1% of whom one in four people is undiagnosed.
• One in three people in Houston have obesity.
• Because vulnerability can be seen to affect both those with and without financial constraints, the traditional notion of disadvantage being equal to vulnerability is no longer the rule in Houston.
• Social and cultural factors including long commutes and time poverty are more important contributors in diabetes vulnerability than previously thought.
• For some people in Houston, vulnerability may be influenced by adherence to local food traditions whereas in others it may result from distrust in the healthcare system.

Shanghai – a rapidly expanding industrial megacity

• More than 23 million people live in Shanghai4 and the average life expectancy is 82 years of age^[iv].
• The prevalence of diabetes among people over the age of 35 is 17.6%. It is thought that one in three people living with diabetes is unaware of their condition^[v].
• Strongly held beliefs about the condition impact on the prevalence, prevention, diagnosis and management of type 2 diabetes in Shanghai. Many study participants attached particular importance to the hereditary nature of the condition impacting on their behaviour and decision making and thus their vulnerability to diabetes.
• Type 2 diabetes is associated with significant stigma and societal disapproval in Shanghai. Because it is sometimes considered a condition of the elderly or the weak, a diagnosis may lead people to withdraw from social settings and hide the condition from family and friends thereby limiting their access to help and support.

Tianjin – a fast-rising global metropolis

• Tianjin is one of the world’s fastest growing large cities and is home to 11 million people^[vi]. Almost 10% of the city’s population have type 2 diabetes and it is thought that only half of these people are diagnosed^[vii].
• Today’s abundance of food, coupled with the fact that people of Asian descent have an increased risk of developing health problems than other ethnic groups, means that even moderate weight gain represents a significant risk for type 2 diabetes in the city.
• Financial constraints are challenging for those with the condition. This has led to a market for alternative, less expensive treatment options and counterfeit drugs, compromising the quality of treatment.
• Diabetes complications hold more fear for many people than the condition itself. As a consequence, some study participants only changed their behaviour after the onset of complications – making general prevention and management of type 2 diabetes a significant challenge.

Johannesburg & Vancouver – the next cities to conduct CCD studies

Studies are currently under way in Johannesburg, the biggest city in South Africa who joined the Cities Changing Diabetes programme in April 2016 in. Vancouver is currently establishing the partnership groups who will proceed to develop urban diabetes studies in the diverse West-Canadian city.

To learn more about urban diabetes

VIDEO: Watch David Napier, lead researcher from UCL, explain why urban diabetes demands new ways of looking at old problems.

Follow #urbandiabetes

Download CCD Study findings

Visit Cities Changing Diabetes

^{[i] Barquera et al. Preliminary report ERDM-DF. Instituto Nacional de Salud Pública; 2015
[ii] Holm et al., Andersen G, Diderichsen F. Cities Changing Diabetes. Rule of Halves analysis for Copenhagen. Department of Public Health, University of Copenhagen and Steno Diabetes Center. 2015.
[iii] International Diabetes Federation. IDF Diabetes Atlas 2015 update, 7th edn. Brussels, Belgium: International Diabetes Federation, 2015 update.
[iv] China.org. Negligible drop in Shanghai average life expectancy. 2015; http://www.china.org.cn/china/2015-02/12/content_34803656.htm.
[v] Novo Nordisk, Data on file. 2015.
[vi] UNDESA. United Nations Department of Economic and Social Affairs. World Urbanization Prospects, the 2014 Revision, Highlights. 2014. 978-92-1-151517-6.
[vii] Novo Nordisk, Data on file. 2015}