Research T2D development. Many communities lack healthy

Research on the
prevention and management of type II diabetes (T2D) in America has
traditionally centered around biomedical, pathophysiological, and lifestyle
factors. Hepatic glucose overproduction and a lack of physical activity, for
instance, have been well-studied as both risk factors for the disease and
potential treatment targets (Cornell, 2015). More recently, however, research
has recognized the need to more closely examine the role of the social
determinants of health in T2D prevention and management. On the most basic
level, these determinants can impact the behaviors related to the development
and progression of the disease. More significantly, however, research suggests
that these determinants can impact the incidence and prevalence of the disease
directly via complex physiological, social, and psychological avenues (Clark,

Although researchers
are continuing to unearth new correlations between various social factors and
T2D, evidence strongly suggests that three broad categories of these
determinants are especially central to the development of the disease: one’s neighborhood
and built environment, economic stability, and ability to access quality health
care (Clark, 2014). Preliminary findings have suggested that other social
determinants such as education level and social and community support may also
play a role in T2D development, but further research needs to be conducted in
order to make stronger conclusions about these factors (Hyman et al., 2017).

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The quality of one’s
neighborhood and built environment appears to be a strong predictor of T2D
development. In many rural and urban communities with inadequate socioeconomic
and political infrastructures, residents face various significant barriers to
healthy living and T2D prevention. A lack of transportation makes it almost
unfeasible for many individuals to access goods and services like quality food,
educational resources, and opportunities for physical activity (Hill et al.,
2013). This transportation-mediated material deprivation has been shown to
correlate significantly with T2D incidence. Such a lack of transportation can
also severely impede access to healthcare, and pre-diabetic symptoms and the
lifestyle habits that contribute to them can hence progress largely unchecked (Hill,
Nielsen, & Fox, 2013).

Food insecurity – a
condition wrought by a combination of many social factors including the quality
of one’s environment – has also garnered special attention as a key contributor
to T2D development. Many communities lack healthy food options altogether, and
others make it difficult for residents to access healthy food due to inadequate
transportation systems. To this end, food-insecure households have been shown
to be at an almost 50% greater risk for developing T2D than food-secure
households (Gucciardi et al., 2014).

A lack of
neighborhood safety has also been shown to contribute significantly to the
development of T2D. Evidence has strongly indicated one plausible pathway
through which this effect is mediated; communities with high crime rates often
have a depleted employment, business, and recreational infrastructure, which
can lead to a reduction in the availability of many health-promoting goods and
services (Clark, 2014). As a whole, then, it would appear that one’s
neighborhood and environment strongly impacts his or her risk for developing
T2D through a variety of complex pathways.

In addition to neighborhood
and environmental factors, economic stability has been documented as a strong risk
factor for T2D. Studies have repeatedly suggested that T2D incidence is
socioeconomically graded, especially with respect to income. For instance, men
in the lowest income category in the U.S. have been shown to exhibit an almost
twofold greater risk of developing T2D than those in the highest income bracket
when controlling for such factors as exercise habits, weight, and literacy
(Hill, Nielsen, & Fox, 2013). Similar significant correlations have been
observed between an increased risk for T2D and other economic factors like
employment status, immigration status, and housing quality (Hill et al., 2013).
Plausible explanations for these associations have centered on disadvantaged
individuals’ limited ability to afford healthy food and insurance and the
possible psychological and biological effects of chronic stress on these
individuals (Walker, Smalls, & Egede, 2015).

A wealth of research
has also demonstrated that health care and health care access are crucial
determinants of T2D development. Many residents in low-SES communities face
limitations in the access to and/or availability of quality medical resources
and services. These areas often do not have the resources to provide primary or
specialty care for residents, and this has been shown to result in the
unmitigated progression of pre-diabetic symptoms and maladaptive lifestyle
habits in residents (Hill et al., 2013). Even in areas with access to care, poor
quality of care can increase the risk for T2D. For instance, poor
physician-patient interactions, influenced by factors like a lack of cultural
competence, have been linked to an increased risk of T2D development in
patients (Hyman et al., 2017).

Although there is extensive
research focusing on how social determinants affect the development of T2D,
there is comparatively less research examining how these determinants directly
affect the health outcomes of patients already living with the disease. Hence,
this is an area that warrants much future research and inquiry (Hill, Nielsen,
& Fox, 2013). Evidence does, however, point to a great degree of overlap in
how social factors impact the basic experiences of individuals at risk for and
suffering from T2D. Certain social determinants can greatly increase the risk
of individuals developing T2D through specific pathways, and if these
individuals fully develop the disease, these factors are thought to contribute
to adverse health outcomes through these same pathways (Clark, 2014). For
instance, a lack of health care access appears to adversely impact the
experience of T2D patients much in the same way it poses a risk to prediabetic
individuals. Patients in areas without primary or specialty care access report
worse symptom management and glycemic control just as prediabetic individuals
in similar areas report worse symptom progression (Walker, Smalls, & Egede,

In addition to the
evidence implicating social factors in the development and management of T2D, a
growing realization of the inability of current care models to address these
factors has spurred recommendations for population-level interventions
specifically targeting the social determinants of health. Traditional treatment
methods for T2D have typically focused on clinical strategies aimed at reducing
symptoms through medication regimens and behavioral changes. These strategies,
however, have been limited in their inability to account for other non-medical
influences on patient behaviors (Hyman et al., 2017). By tackling factors like
employment insecurity, low-income status, and low health care literacy at the
policy level, researchers hope that there can be a more sustainable means for
impeding high American T2D incidences (Clark, 2014).

A main focus of this
reform is aimed at conducting further research and collecting more data on
non-medical factors affecting T2D incidence and progression at the population
level. This would, in turn, help shape policies and therapeutic interventions
to better address the disease. A primary target for this effort is the
Affordable Care Act (ACA). Researchers have called for the expansion of the
ACA’s standardized collection of population data to offer a more comprehensive
picture of non-medical social determinants (Hill et al., 2013). At the
population level, this would allow providers to visualize certain social trends
concurrently with the development of diabetes in high-risk communities. Thus,
they would be able to make quick, evidence-based clinical decisions for
patients in real time based on the specific social challenges they face (Hill,
Nielsen, & Fox, 2015).

Enabling more
comprehensive data collection would also allow healthcare systems to implement
specific community level interventions for high-risk populations. For instance,
health systems and civic structures can use data to proactively discern
specific groups at risk for T2D that would especially benefit from new
community resources such as affordable food markets, community health workers,
and accessible transportation options (Hill, Nielsen, & Fox, 2013). The
implementation of these resources would undoubtedly be costly, however, and the
immediate financial cost would appear to be a significant limiting factor for
this policy-level reform (Walker, Smalls, & Egede, 2015). Although
preliminary studies have indicated that these reforms are better suited to
sustainably treat T2D, further research would need to be conducted to elucidate
at least two key understandings before widespread change can be enacted: how
specific health interventions might directly impact health outcomes for
diabetic and pre-diabetic patients and how these interventions can be enacted
in a cost-efficient manner (Hill et al., 2013).