Health as if everybody counted blog
Diabetes in Canada: Parts of the story
Shortly before this past Christmas, with minimal publicity, the Public Health Agency of Canada released a valuable collection of facts and figures on Diabetes in Canada. It points out (for instance) that in the decade after 1998/99, the prevalence of diabetes among Canadians increased by 70 percent (to 2.4 million), with a predicted increase in prevalence to 3.7 million by 2018/19. Further, "although only 3.1% of all deaths in Canada were attributed to diabetes in 2007, more than a quarter (29.9% of individuals who died had diabetes in 2008/09. Diabetes itself does not typically lead directly to death, but the complications associated with diabetes do." Thus, prevalence figures substantially understate its overall contribution to the burden of illness borne by Canadians; that contribution includes cardiovascular disease (the most frequent complication), eye disease, kidney disease, increased infection from minor injuries and a variety of other conditions.
The report's importance in drawing attention to the magnitude of the diabetes-related burden of illness is beyond question, yet its contribution to understanding that burden from a health equity perspective is limited. For the most part the authors adopt a conventional risk factor approach to the causes of diabetes, starting (predictably and non-controversially) with a description of overweight and obesity, and the contributions of limited physical activity and unhealthy eating. A list of self-reported barriers to physical activity is reproduced, as is a list of factors influencing food choices that includes nutritional knowledge, perceptions of healthy eating, media advertising and "lower socio-economic status and social inequity," which is not further explored.
The report's treatment of socioeconomic gradients is similarly descriptive, confined to gradients among adult Canadians across Canada, stated by income quintile and education level, in self-reported obesity, physical inactivity, inadequate fruit and vegetable consumption, and daily tobacco smoking. Curiously, data on socioeconomic gradients in actual prevalence of diabetes are not presented, although according to Canadian Community Health Survey data prevalence of Type 2 diabetes in the lowest household income group (income less than $15,000) is more than four times as high as in the highest income group (over $80,000). According to the authors of this last study, "individual risk behaviours do not explain a substantial part of the income association," suggesting "that the diabetes burden associated with poor health behaviours should be looked at through the lens of socioeconomic conditions."
Finer-grained examinations of how socioeconomic conditions affect the origin, management and prognosis of diabetes can be found in several places. The Toronto diabetes atlas project of the Institute for Clinical Evaluative Sciences produced a multi-volume mapping of diabetes prevalence and a range of neighbourhood characteristics; just two of the 140 maps generated by the project are shown here. To oversimplify a complex set of findings, the project found that higher-income neighbourhoods generally had lower prevalence of diabetes. Prevalence was especially high in low-income neighbourhoods outside the downtown core, with high proportions of recent immigrants and members of recent minority groups. These neighbourhoods tended to have lower population densities, poor walkability, limited access to public transit and long distances to stores selling fresh fruits and vegetables (the 'food desert' problem) and other so-called healthy resources like parks. Conversely, high incomes seemed to have a protective effect against diabetes, even in neighbourhoods where adverse outcomes would be expected based on place-related characteristics. "We noted a striking mismatch," the authors concluded, "between areas of Toronto where healthy resources were most needed and where they were located."
the simple arithmetic impossibility of eating a healthy diet for many people living on low incomes if they are also paying market prices for housing. Indeed, a series of interviews by York University's Dennis Raphael and colleagues (1) with people trying to manage diabetes in Toronto on incomes below Statistics Canada's Low-Income Cutoff (LICO) found food insecurity and inability to afford an adequate diet widespread "even with almost two-thirds [of participants] living in some form of government-assisted housing or shelter." Two recent articles (2,3) by Claudia Chaufan and colleagues similarly explore the interaction of low incomes, limited availability (and high local prices) of healthy food, high transportation costs and other variables like insecure employment in a Latino and immigrant neighbourhood in Northern California, concluding that structural factors limit the relevance of health and lifestyle education interventions – a point that should by now be familiar, but nevertheless merits continued repetition. One interview respondent summed up the range of problems: "You know, it's a full time job to be poor."There is also, as I have pointed out in previous postings,
Variables like those identified in the Toronto and Northern California studies are not prominent in the PHAC report, beyond brief generic discussion of healthy food choices and of the built environment. New York-based researchers Rodrick and Deborah Wallace have eloquently compared individualized explanations of obesity that focus on imbalance between caloric intake and exercise to "the remark by US President Calvin Coolidge on the eve of the Great Depression that 'unemployment occurs when large numbers of people are out of work' ... and as Raphael pointed out in a holiday posting on his Social Determinants of Health listserv, the word "poverty" appears nowhere in the PHAC report. (I checked; it doesn't.) That report remains useful, yet at the same time shows how very much still needs to be done to integrate social justice and social determinants into the everyday worldview of public health professionals.
(1) Raphael D, Daiski I, Pilkington B, Bryant T, Dinca-Panaitescu D, Dinca-Panaitescu S. A toxic combination of poor social policies and programmes, unfair economic arrangements and bad politics: the experiences of poor Canadians with Type 2 diabetes. Critical Public Health 2011 [online publication] (full text unfortunately not available for open access).
(2) The Twin Epidemics of Poverty and Diabetes: Understanding Diabetes Disparities in a Low-Income Latino and Immigrant Neighborhood. Journal of Community Health 2011;36:1032-43, (full text unfortunately not available for open access).
(3) Chaufan C, Constantino S, Davis M. 'It's a full time job being poor': understanding barriers to diabetes prevention in immigrant communities in the USA. Critical Public Health 2011 [online publication] (full text unfortunately not available for open access).