This story is part of our ongoing series on the Social Determinants of Health, and where they connect and interact with the Developmental Origins of Health and Disease. Here we explore the social determinants of type 2 diabetes. The many factors that influence the trajectory of this disease include the built environment, access and affordability of healthy food, legacy health risks carried from previous generations, advertising and cheap availability of junk food, and more.   
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People who have type 2 diabetes (T2D) are often seen as not having done enough to eat right, exercise enough and keep their weight in check. There is a huge stigma attached to T2D that few other diseases carry. The negative stereotypes reflect the idea that they brought it on themselves or they are poor and uneducated. That’s not only unfair, it’s not true.  

 The 442 million people worldwide who currently live with the disease can’t all be failing on a personal level. There must be more to the story.  

T2D is a very complex disease, with many social, environmental and biological factors. There are overlapping influences of genetics, community environments and public policy – all of which play a part in an individual’s risk. These influences involve living conditions, environmental pollution, stress, inadequate sleep, genetics, sex, and race and ethnicity.   

The Built Environment 
The environment around us is clearly linked to our health. It is one of the main Social Determinants of Health. The built environment affects our ability to be healthy in numerous ways. It determines our exposure to pollution, fast food, farmers markets, grocery stores, walkable areas, drinking water quality and stress levels – to name a few. All of these factors either contribute to or temper diabetes risk, and each has been studied for their contributions. For example, The Lancet studied the link between T2D and living in a “food swamp” where fast food, junk food outlets and convenience stores outnumber healthier options. They found  a clear connection. Several studies have recently linked air pollution to increased prevalence of T2D. The chemicals and fine particles cause inflammation in the lungs and other parts of the body and create changes to the microbiome in ways that contribute to T2D. Note that areas with the most food swamps, food deserts and air pollution happen to be in racial minority and less affluent neighborhoods - the same communities that also have a disproportionate burden of T2D.  

Race, Sex and Genetics  
American Indians and Alaska Natives have the highest rates of diabetes of all racial and ethnic groups in the U.S., followed by Black, Hispanic and Asian Americans. To understand why, it’s helpful to understand the inequities many of these communities face - including discrimination, racism and systemic disenfranchisement. Racism is a very serious threat to public health.  (Read more here).  

Men are almost twice as likely as women to have T2D. It may be that men tend to ignore their symptoms more than women. But research has shown that men’s fat distribution is more around their mid-sections where it is considered to be more dangerous for T2D risk.   

Women with polycystic ovary syndrome (PCOS) are often insulin resistant and therefore more prone to developing T2D. PCOS is a complex endocrine disorder. Current estimates are between five to ten percent of U.S. women have PCOS and millions are potentially unaware.  

Developing diabetes while pregnant, known as gestational diabetes (GD), can create several health complications for moms and their babies. Gestational diabetes raises the mother’s risk for high blood pressure and preeclampsia, a life-threatening birth complication. It also puts her at higher risk for T2D later in life. Having T2D going into pregnancy is another risk factor for developing preeclampsia. Babies born to mothers with GD are also at higher risk of developing obesity and T2D later in life. This intergenerational transfer of risk is at the heart of the Developmental Origins of Health and Disease (DOHaD) research.  

Where social determinants meet the developmental origins 
The work at the Moore Institute focuses on the biological changes and health outcomes that occur as a result of nutritional, environmental and social exposures in the womb, during infancy and early childhood. The science of DOHaD illustrates the biological mechanisms that cause disease risk to be passed from one generation to the next. For example, we know that undernutrition during early pregnancy affects the development of all major organs. When the fetus experiences a shortage of nutrients, it will prioritize nutrients for the heart and brain (the heart and brain suffer nonetheless), which means other organs essentially get short changed. They develop less robustly, and become vulnerable to disease risks the fetus carries into life after birth. When exposed to certain social, environmental and nutritional factors outside the womb, that baby becomes either more or less likely to develop a disease like T2D as an adult.  

Taking a DOHaD perspective, T2D has many potential causes and outcomes. Exposures that a woman of reproductive age experiences can influence the health of her future baby. Taking a step further back, exposures she experienced as a toddler can affect the health of her future baby. And if we go even farther back, we get to the heart of it: environmental exposures, social stress or inadequate nutrition the developing egg was exposed to inside her mother’s developing ovaries (while her mother was in the womb of her own mother) can affect the future child born from that egg.

A child that develops T2D as an adult because of an exposure her or his grandmother or great grandmother experienced has an intergenerational outcome that was passed down as a legacy risk. There are many legacy risks, like our grandparents’ exposure to DDT, the hydrogen bomb, poverty, slavery, famine and war. Studies have shown that the effects of the Civil War persist to this day, as do the lingering effects of racist policies and the misogynistic treatment of women.  

There are many reasons why someone may be prone to developing T2D, and multiple influences that determine the course of the disease. Someone can be born with an innate risk because of inadequate nutrition or exposure to gestational diabetes in the womb and then be born into an environment that normalizes the behaviors and dietary influences of a typical U.S. city. Can you really blame them if they develop T2D? If junk food companies are marketing their products more aggressively to Black and Latino youth, can you really blame them for taking part in their immediate culture – especially when those same foods are addictive by design? Many cultures have had their education and traditional foodways disrupted by colonization and assimilation. Are they to blame for having the highest rate of T2D in the nation? These are important questions to ask in a world that stigmatizes a person for their diabetes but refuses to shift the underlying causes. The juxtaposition of fast food ads with a weight watchers or gym membership ad, followed by an ad for diabetes medication is confusing at best. While good people work to address and help solve the epidemic of T2D, it would behoove us all to not blame the victims.  

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