Diabetes and the social determinants of health


Yesterday I talked about a hamper we gave to a single senior who is struggling with her low-income as well as her diabetes. Today, I’m going to talk a little bit more about how her low-income has an impact on her health.

Not many people understand the role that income plays in their health.  On the surface, I think most people assume that it has at least a small, probably temporary, impact.  Sure, if you’re broke, you probably can’t eat all the fruits and vegetables Canada’s Food Guide suggests, but is it really going to harm you in the long-term? As long as you exercise a little bit and stay away from fatty foods, too much alcohol, drugs and tobacco you should be OK right?

The answer is found in a large body of research on the social determinants of health that describe how things like not having enough to eat, substandard or no housing and especially income determine how long you’ll live and how likely it is that you’ll have chronic health conditions. For the Canadian context check out what the Public Health Agency of Canada has to say.

Many people, based on their observations and conventional wisdom, believe that behaviours like not getting much exercise, smoking and poor diet are the best way to predict if someone is going to be healthy or sick.  People are often surprised that how much money you make is often the better indicator for your health, and that when you look at who is sick and who is healthy things like smoking, poor diet and lack of exercise fall to the wayside when you’re comparing people who are higher income and lower-income.

Looking at who has cardiovascular disease, and especially type 2 diabetes income becomes very important as a recent fact sheet by Canadian academic Dennis Raphael and his colleagues highlights.

In their words:

Type 2 Diabetes is a complex, chronic condition resulting from the body’s inability to either adequately produce and/or effectively utilize insulin. It accounts for 90% of cases of diabetes in Canada. The mechanisms by which type 2 diabetes comes about are not well understood.

Traditional explanations focus on genetic and lifestyle causes, but increasing evidence is coming to support the view that type 2 diabetes is primarily a disease of material and social deprivation associated with poverty and marginalization. If not controlled, it can lead to serious complications such as heart disease, kidney failure, lower limb amputation and blindness.”

Looking at two very large public health surveys, the Canadian Community Health Survey (CCHS) and the National Population Health Survey (NPHS) they found lower-income people are more likely than higher income people to develop type 2 diabetes by a significant amount.  That’s even after taking into account things like diet and excercise.

Facts and figures are always interesting, but in addition to crunching the numbers they also talked to low-income people with type 2 diabetes to understand how their income affects their ability to cope with the disease.

Two of the people they talked to said:

“On welfare I lived in a rooming house. We had four or five people using one fridge. I couldn’t leave anything in the fridge, it disappeared. And the things the dieticians tell you — I know they mean well, but I just couldn’t afford it… Once I did go to a food bank, but the stuff they give you is the stuff I’m not supposed to have… I used to get a hundred and something [dollars in special diet supplement] but now they cut it back to sixty something.” [man, unable to work, income provided by the Ontario Disability Support Program].

“I look at which food is cheaper because my money is very small, so after giving rent, I just have a little bit of money. Sometimes, after the 20th [of the month] my money is finished. It’s very tight. So then I buy rice, and some protein and eggs. But when I eat cheap rice my sugar goes up… Sometimes I borrow money because I have to be conscious about my health… Sometimes my daughter’s school wants money for things. But I don’t have it. How can I give? And I feel very sad. I try to manage. Sometimes I use my daughter’s child benefit. And sometimes I don’t buy. Last month my money was finished but I had no food at my home and I didn’t buy any. I didn’t eat. And sometimes I need shoes, but I don’t buy them because I have to pay for food. Food is my basic need.” [42-year-old married woman].

These are familiar scenarios to many of our patrons and they are familiar to my coworkers and I as we go through our intake procedure each day.  We’d like to think that by giving people food we’re helping them but for many of the people we see each day any relief we can provide is largely temporary.  Income is key, and addressing a lack of food today with what food we can provide, does not necessarily mean that next week, or next month,  people will not be hungry. And, as researchers studying the social determinants of health find, that lack of income and hunger have major consequences in the long term.

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8 Responses to “Diabetes and the social determinants of health”

  1. Dennis Raphael Says:

    the fact sheet is available at:


    • Amanda Says:

      Your work on the social determinants of health is amazing and inspiring! As a student in the MHSc/ MSW program at the University of Toronto, I have benefited greatly from your tremendous insight!

      • Matt Cooper Says:

        Thank you. We feel that it’s an important point to raise with the public because of the huge impact it has on all of us. Is it something that is discussed often in your studies?

  2. Joan Rawlins Says:

    Excellent article and very timely given the economic deprivation which more persons are now experiencing.

  3. Day 5: The Gift of Health « Hofemergencyfoodassistance's Blog Says:

    […] theme in our 12 Days series is ‘Health’. As we’ve talked about many times before (here, here, and here), we see the effects of poverty on people’s health every day here at food […]

  4. “Poor People Can’t Cook,” and Other Myths | Hofemergencyfoodassistance's Blog Says:

    […] and food security obtains. (Though a social indicators of health framework is a good place to start.) Neither of the above studies established a causal relationship between income and nutrition, […]

  5. First Days and a Typical Day at the Food Hamper Program | Hofemergencyfoodassistance's Blog Says:

    […] of the diversity of our clientele. There are three dietary considerations we see the most. Because people with less money typically experience worse health, many of our patrons suffer from chronic diseases like diabetes. (In short,  Many […]

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