A ’Close’-Up Look at Diabetes In Cities

A ’Close’-up look at diabetes in cities

With many years of personal and professional experience in the diabetes field, patient advocate Kelly Close and her colleague Emily Regier from Close Concerns offer their perspective on Cities Changing Diabetes1. We asked them what they find exciting about the research and what benefits it could bring to people who are at risk of developing or already living with type 2 diabetes.

In your opinion, why is there a need to focus on type 2 diabetes in cities?
The sheer number of people with type 2 diabetes in cities –two-thirds of patients – makes it a worthwhile area of focus. A number of factors related to urban life, such as air pollution, poor walkability and easy access to junk food, can also put people at particular risk for the disease. We have learned from the Cities Changing Diabetes programme that cities represent excellent ‘laboratories’ for sociological research and policy change: they concentrate a diverse group of people in a single location, and city governments can often be more effective and less hampered by ideology than their state or national counterparts.

The Cities Changing Diabetes programme has propelled a conversation about how urban environments can contribute to type 2 diabetes risk and how there is a need to bring together a variety of actors – from urban planners to community health workers to a range of patients at every end of the socioeconomic spectrum – to address this issue.

How does the Cities Changing Diabetes research differ from previous research?
This research incorporates the social and cultural components of diabetes risk to a much greater extent than most academic studies we have seen. We think the thorough interviews and the conscious effort to incorporate the complexity of everyday life make this research an outstanding complement to randomised controlled trials (RCTs), which seek to isolate single causes and purposely exclude much of the complexity of everyday life.

The RCTs are invaluable in assessing a range of interventions, of course, but we may also need different types of studies to fully understand why so many patients continue to do poorly despite scientific advances. This research will hopefully provide insights about human behaviour that can inform better approaches to diabetes prevention and urban health.

What initial findings from the Cities Changing Diabetes research excite you and why?
We were excited to see that some of the cities did much better than the ‘rule of halves would predict. For example, almost everyone diagnosed with type 2 diabetes in Copenhagen receives treatment – stats like these give us hope that this can be done. We were also glad to hear that at least in Copenhagen, it is more a matter of enabling patients to use existing health resources than building the infrastructure from scratch. While most of the other findings were more sobering than exciting, we were impressed by the quality of the research and its ability to apply rigorous scientific methods to the complexities of the real world.

We think the concept of ‘vulnerability’ that goes beyond economic scarcity and biological risk is one of the more fascinating findings. For example, the research emphasises that financial constraints include not only absolute poverty that prevents people from accessing basic resources, but also perceived constraints that limit people's capacity to be proactive and hopeful about their future.

In Houston, one of the study cities, researchers found that even people with health insurance, economic advantages, and few clinical risk factors can still be vulnerable to type 2 diabetes due to factors like time constraints and social isolation.

Why is this interesting?
We think that this is not necessarily intuitive to society although from a patient perspective, it makes complete sense and we are very happy to see this finding highlighted. The social isolation piece in particular is very important and very addressable and being able to show the importance of time constraints to patients and healthcare providers could be critical. We have never heard that in all our study of diabetes but it rings so very true.

The research is helping make everyone smarter – and indeed, the urgency of what needs to be done is even greater. Although type 1 diabetes is not the focus of Cities Changing Diabetes, some valuable insights for type 1 will also undoubtedly emerge – we believe the social isolation and time constraints noted above may well be two valuable examples.

Have you heard any reactions to Cities Changing Diabetes by people living with diabetes?
We have heard very positive feedback from the broader diabetes community about the inclusion of social and cultural determinants of diabetes in the discussion. We also appreciate that including patients’ perspectives to a greater degree should be one of the main goals going forward. While we haven’t heard a lot of patient impressions yet, we know there will be great enthusiasm.

Inviting more patient advocates to participate in future Cities Changing Diabetes Summits will be a valuable step. We also think patient feedback would be valuable in informing the proposed solutions as much as possible. Continued efforts to create awareness about the initiative to the public will be an important part of this, as many people living with diabetes or pre-diabetes are probably not yet aware of the programme at this point.

What change do you foresee that an initiative like Cities Changing Diabetes can have for people living with type 2 diabetes?
Our hope is that this research can lead to pilot programmes in cities in the relatively near future that can directly improve the lives of people with type 2 diabetes. Examples could include community health centres, peer support programmes, efforts to create more walkable neighbourhoods, policies to make healthy food more affordable and appealing, and much more.

Longer term, we can imagine a world in which cities are built and governed with health as a top priority, which would have an enormous impact on public health even beyond those currently living with type 2 diabetes. We hope to see this research result in far more concerted focus on pre-diabetes. We heartily applaud your work, we thank you for your remarkable focus and drive, and we hope to see the extensive resources already applied increase even further.

About Close Concerns
Close Concerns is a healthcare information company founded by Kelly Close in 2002. Close Concerns' mission is to improve patient outcomes by making researchers, clinicians, scientists, companies, patients, and families smarter about diabetes and obesity.

For more information, see https://www.closeconcerns.com/

This article was featured in the latest issue of Novo Nordisk’s sustainability magazine TBL Quarterly, ‘The Urban Issue’. Read the full issue here: http://bit.ly/1PHa07n