Article Type : Short communication
Authors : Bando H
Keywords : Diabetes mellitus (DM); Social determinants of health (SDOH); American Diabetes Association (ADA); World Health Organization (WHO); LCD promotion association (JLCDPA)
Clinical practice for diabetes mellitus requires
bio-psycho-social aspects. For continuing adequate health care, the perspective
of social determinants of health (SDOH) has been recognized as indispensable
intervention target for evaluating health equity. SDOH include socio-economic
situation, neighbourhood and physical circumstance, food environment, health
care, social context with social support capital and relationship. For
contextual factors, American Diabetes Association (ADA) established the writing
committee and reviewed the detail of SDOH. They included Healthy People 2020,
Social Determinants of Health of WHO, the County Health Rankings Model and
others. Thus, enough understanding of environmental and social factors would be
necessary for diabetes.
In recent years,
non-communicable diseases (NCDs) have become widespread along with changes in
medical and social structures. They include diabetes, obesity, hypertension,
dyslipidemia, cerebrovascular accidents (CVA), and cardiovascular diseases
(CVD). These diseases are very common and may cause various clinical
complications. Among them, diabetes is especially crucial disease in the
clinical setting of primary care [1].
Authors and
collaborators have continued clinical practice and research for long. The
overall area includes diabetes, primary care and integrative medicine. For
effective regimen for NCDs, low carbohydrate diet (LCD) has been introduced to
medical and health area [2]. Three types of LCD were proposed as super-LCD,
standard-LCD, petite-LCD including carbohydrate ratio as 12%, 26%, 40%,
respectively [3]. Furthermore, we established Japan LCD promotion association
(JLCDPA) and developed LCD in Japan as medical and social movement.
During our practice and
activities, an important and common clinical concept has been present. It is a
bio-psycho-social perspective, and the basis for medical care in any area [4].
In this paper, social perspective on diabetes will be described.
Health care has been
gradually emphasized on value-based care and population-based health outcomes.
Consequently, the perspective of social determinants of health (SDOH) has been
recognized as indispensable intervention target for evaluating health equity
[5,6]. Most recently, crucial problem of pandemic infection has been persisting
worldwide concerning the COVID-19. It has brought highlighted unequal situation
related to racial minority groups and disproportional communities. In responses
to these simultaneous occurrence, some proposals of SDOH have been published by
professional medical organizations, including American College of Physicians,
Society of General Internal Medicine, American Academy of Pediatrics, National
Academy of Medicine, and other medical associations [7,8]. Further, their calls
to action would focus on the improvement of the determinants at the levels of
the organization, individual and policy [9].
For clinical practice
for diabetes, several fundamental problems have been present such as economic
costs, incidence and prevalence and disproportionate burden in the population
[10]. American Diabetes Association (ADA) proposed a statement formerly on
socioecological determinants of type 2 diabetes mellitus (T2DM) and prediabetes
[11]. From the viewpoint of SDOH, to understand and to advance the health
improvement opportunities will be obtained for diabetic patients. Consequently,
ADA has convened the writing committee for diabetes toward the purpose of
informing SDOH broadly. It includes the relationship with SDOH and diabetes
risk/outcomes, and various literature review concerning SDOH [11].
When searching for
medical literature for the keyword of SDOH, the results include several
categories concerning SDOH [12]. They are i) socio-economic situation
(occupation, income, education), ii) neighborhood and physical circumstance
(building environment, residence condition, toxic exposure in the environment),
iii) food environment (accessibility for food, insecurity for food), iv) health
care region (affordability, accessibility, quality), v) social context (social
support, social capital and budget, social relationship). These factors and
their linkages are investigated in the light of health care and community-based
perspective.
To recognize the
definitions of some key words would be important. Diabetic risks and outcomes
are not same but different, in which multiple contributors exist such as
clinical, biological, social and other related factors [13]. Lots of scientific
literatures showed the adverse influence of health disparities related to
diabetes [14]. In order to investigate the matter of healthy equity, enough
understanding of environmental and social factors would be required, in which
50-60 % of outcomes of health problems can be included. Those environmental and
social factors have been collectively recognized as SDOH.
For contextual factors,
the writing committee of ADA has reviewed the detail of SDOH in the light of
terminology and classifications. They included Healthy People 2020 [15], Social
Determinants of Health of WHO, the County Health Rankings Model and others.
Common elements in the frameworks are economic and socioeconomic determinants
as foremost. In the case of food SDOH factors, they are divided into several
groups, such as material circumstance, neighborhood environment, built
environment, economic stability and independent category [15].
As related to the
perspective of SDOH, a statistic marker of the adherence has been observed
concerning the problems of actual satisfactory intake of medicine. The number
of the patients with diabetes mellitus is increasing across the world. From the
data of World Health Organization (WHO) (2020), adults aged 18 yo and older had
diabetes mellitus as 8.5% in 2014. An increase of 5% was observed in premature
mortality from diabetes during 2000-2016. In the countries with
lower-middle-income level, the premature mortality rate due to diabetes
gradually increased during this period. Furthermore, diabetes became the direct
cause in 2016 as 1.6million deaths and hypertension was the cause in 2012 as
2.2 million deaths worldwide [16]. High blood glucose or hyperglycemia has been
the common situation of uncontrolled diabetes, and it will bring serious
complications to various systems in the body.
United States Center
for Disease Control and Prevention showed the increasing number of adults
diabetic patients, who take pills, insulin or both [17]. On the other hand,
higher ratio of them seemed to have inadequate adherence and acceptance due to
the shortage of the knowledge [18]. Consequently, sufficient information about
diabetes has to be learned in order to continue optimal glucose variability
with satisfactory medication adherence.
Concerning the
medication adherence of diabetic patient, a review on knowledge of diabetes and
actual practice was investigated [19]. For the analysis, 18 articles were
included, with the result that the knowledge level did not guarantee the
medication adherence for health-seeking practice. Some factors were observed
that predicting the information level and actual practice are probably from
sociodemographic characteristics [19].
In summary, this
article introduced some clinical matters of SDOH and its related perspective
concerning diabetes mellitus. Diabetes and endocrine diseases have
characteristics of long period treatment, in which patient and medical staff
can understand bio-psycho-social situation and cooperate together. This article
will hopefully become a useful reference in the clinical diabetic practice.
The author declares that they have no conflicts
of interest.
The author does not
have any funding concerning our medical research.