The primary focus of diabetes management is centred around medical and behavioural modifications However, factors which determine outcomes in diabetes sometimes revolve around where people are born, live grow and age. As much as influencing medical and behavioural factors are important, it is also vital to address factors like income, education, housing and access to nutritious food, employment insecurity, low educational attainment and poor living conditions as these have a huge bearing on the results of the disease. These factors are collectively called social determinants and are central to the development and progression of diabetes.
Individuals with lower income and less education are 2 to 4 times more likely to develop diabetes than more advantaged individuals. This works in a cyclical process and constant pressure to make ends meet leads to chronic high levels of anxiety and stress leading to unhealthy behaviour like smoking, drinking, use of illicit drugs, self-destruction and neglect. Coupled with this is unhealthy eating and lower levels of much needed exercise, all of which contribute to deleterious consequences. Chronic stress by itself is a harbinger of further health problems.
The disadvantaged person further may not be able to access health related resources which are necessary to manage diabetes in a strict manner and this may lead to a further downward spiral. In health care systems that are not able to effectively support people with diabetes, sourcing of medications like insulin maybe an issue which eventually is fatal. Further limitations in employment opportunities and less productivity along with low educational attainment may further preclude opportunities to access resources.
Social determinants have assumed more importance as in this day and age, we do live in a more `obesogenic environment`. This consists of a more sedentary lifestyle and availability of more energy rich foods. Leading a healthy lifestyle is more expensive. In addition, poor women are more vulnerable to poor nutrition during pregnancy which can raise their child’s vulnerability to the risk factors for diabetes later in life. Since the prevention of type 2 diabetes centers around behavioural and lifestyle modifications of diet and exercise, economically disadvantaged people have less access to it. This leads to a vicious cycle.
The consequences are far from ideal as this puts considerable amount of strain on the already stretched economy as poor health leads to poor productivity and a lower GDP. Though this is glaring in the developing world, the developed world is far from escape. Increasing unemployment with the shift in global economic dynamics have left thousands in the lurch who will be difficult to manage.
The problem with diabetes is that it is a lifelong disease and is severely affected by a person`s day to day activities. It is a difficult disease to manage on the long run, with huge numbers being undiagnosed and presenting late in the cycle. So even with astute clinical and behavioural management, if the social determinants are not taken care of, then the outcomes maybe poor.
The solution is not simple and needs cross functional coordination across government bodies, private players, organisations like WHO, IDF etc. Mobile Health does have a role to play here in improving accessibility to healthcare, keeping in mind the buying capacity of economically disadvantaged people. But the hidden cost of poverty which lies in travel and paying premium for facilities which is taken for granted for more privileged people will far offset the cost of mobile health. Up scaling of mobile health will definitely drive costs down making this more and more affordable. With the current ever expanding penetration of mobile internet even in areas previously `communication blind` will open up opportunities for healthcare. Secondly, targeted education of the population using innovative strategies is of immense value.