Sociocultural Factors

Although much of the focus of research into the etiology of diseases such as diabetes is usually on the biomedical risk factors, and the unraveling of molecular mechanisms, sociocultural factors can also play a major role. The impact of urbanization and westernization has already been referred to above. For many societies the switch from traditional lifestyles to modern, urban lifestyles has altered dietary habits, markedly reduced physical activity, and changed many of the long-established social norms, resulting in an explosion of diseases such as type 2 diabetes and obesity. In the Pacific island of Nauru, diabetes was almost unheard in the early part of the 20th century, but by the 1970s and 1980s was affecting 1 in 4 of the adult population (40). Indians living in large cities have 4 times the prevalence of diabetes seen in their rural counterparts (30,32), whereas in Cambodia, the prevalence of diabetes is twice as high in an urban population as in a rural population (35).

The influence of the environment is not limited to the westernization of lifestyle, but even within apparently similar environments, measures of socio-economic status are related to diabetes. A study from the north of England found that the prevalence of type 2 diabetes was nearly 30% higher in people living in areas with the worst quintile of deprivation scores, compared to those in the most affluent areas (104). Interestingly, there was no association between the prevalence of type 1 diabetes and deprivation. Similar findings were reported in a study based on a diabetes register in Scotland (105). Those in the most deprived areas were approx 60% more likely to have type 2 diabetes than were those in the least deprived areas. Once again, no association with deprivation was observed for type 1 diabetes. In a study based in general practice in Spain, the same relationship was observed for type 2 diabetes, with the strength of the association being stronger in women than in men (106).

In contrast, the impact of poverty and socioeconomic status operates in the opposite direction in the developing world. In a study from the south of India, those in the high income group were twice as likely to have diabetes as were those in the lower income group (107). Similarly, a large study from China showed that the prevalence of diabetes was higher in those with the highest income (34).

How can this apparent paradox be resolved? The most likely explanation is that measures of socioeconomic status are markers for different health-related behaviors in different settings. In the developed world, where automation and mechanization are features of life across the socioeconomic gradient, those in areas of deprivation have poorer access to healthcare and to health information, and may consume less healthy diets because of the low cost of energy-dense, high fat foods. Hence the risk of diabetes is higher in lower socio-economic areas. In the developing world, however, poorer people will often be employed in manual work, and have only limited access to labor-saving devices. Living in rural and more traditional environments is also likely to be associated with consuming more traditional diets incorporating more fruit and vegetables. Thus, in this setting, it is the wealthy, with ready access to labor-saving devices and westernized food, who run the highest risk of developing type 2 diabetes.

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