The Environmental Factors of Diabetes
a report by Araceli Camargo and Elahi Hossain
2022
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Introduction
By 2030, 552 million people will be diagnosed with diabetes with 95% being cases of Type 2 diabetes. Type 2 diabetes (T2D) is a metabolic disorder, which prevents the body’s ability to regulate glucose, it can turn into a lifelong condition, when it is not caught early or left untreated. T2D can also go on to affect the function of the heart, nervous system, circulatory system, digestion, and sleep/wake cycle.
We are going to use diabetes as a case study to produce three learnings.
Genetics are not the full story when it comes to non communicable diseases such as diabetes.
Understand that disease prevention and even cure is not just in the confines of medical institutions.
The need for geospatial studies to understand the interlink between diabetes and place.
It is now common within scientific literature to talk about health at a population level, including the distribution or prevalence of a specific disease (source). For example, it can be expressed that diabetes is more prevalent in African American and Indigenous populations than in their white counterparts (source) (source1).
However, is this the most accurate language we can use to detail the phenomena of both disease and racial injustice? It would be more effective to speak of the racialisation of Black and Indigenous Peoples as that encompasses the various strategies of racism, including geospatial factors. It is now well documented that those who are racialised are more likely to live in areas of high pollution as well as deprivation (source).
Furthermore, simply saying Black or Indigenous Peoples experience T2D at a higher rate, leaves room for further racialisation as it could add to the narrative of genetic determinism, which blames a person’s biological make-up for disease rather than considering ecological factors.
Therefore, we are recommending that we start to focus on where disease is clustering to extend the conversation of disease into environmental justice.
Defining The “Where”
When we reference where we mean a geospatial location, which can be an area, neighbourhood, or city.
Secondly, part of a where or location is the experiences, activities, and events that take place.
Thirdly, where also includes governance, how a place ends up being planned and designed is down to government practices (are there landfill sites or roundabouts or is it mainly pedestrianised).
Fourth, we must also consider the social organisation of location, is a place of low or high equitability, for instance.
Finally there are different habitats within a location; a workplace, school, home, etc.
Genetics is Only One Dimension of Type 2 disease
Genes are a unit of heredity, meaning they store biological information that is passed down from one generation to another, including the susceptibility of a disease (source).
This has led disease like T2D to be studied from the perspective of genes (source). In more recent years the western diet has also been highlighted as a factor in the aetiology of T2D.
However, we must also look at another crucial dimension, geography. Research indicates how geographical location also plays a role in the development of T2D (source). A recent study highlighted how the significant geographical variation in global distribution of T2D is linked to air pollution (source).
Given that distribution of air pollution is driven by systemic racial strategies, it is very important that we take geospatial factors into consideration when studying the aetiology of T2D (source).
Microbiome, Air Pollution And Type 2 Diabetes
Our gut environment is made up of microbes that mitigate all biological processes, from digestion, immune response, metabolic and even brain function (source).
The microbiome is now being considered the study of disease (source). The interplay between the microbiome and air pollution in disease pathology are increasing, this work is highlighting that air pollutants, such as nitrogen oxides and ozone have the potential to alter the microbes in the gut environment, which in turn increases the risk for T2D through inflammatory pathways (source).
This presents yet another consideration for an ecological framing of T2D.
An ecological map for Type diabetes
Below is a mapping of different types of pollutants and their link to T2D. It is important that the research into diabetes starts to include other pollutants aside from air pollution to build a more robust ecological view of the disease.
Other Ecological Factors
As we mentioned, social organisation of a place is also part of the geospatial definition. These factors should also be considered when looking at an ecological approach to diabetes
Type of Work
The type of work a person does can affect their exposure to environmental pollutants as well as impact other determinants of health such as access to good sleep quality.
Example
A bus driver is sedentary, exposed to high levels of air pollution, and can be involved in shift work, which affects sleep/wake cycle.
Risk to Diabetes
Sedentary behaviour is linked to T2D, air pollution contributes to T2D through various pathways, and shift work can change metabolic function which can contribute to T2D.
Home Conditions
Does a home have mould or other indoor pollutants. Is the home noisy or quiet?
Example
Social housing often does not have great ventilation or quality materials, both which contribute to indoor air pollution. Also many who live in social housing live in crowded conditions which also exposes people to noise and light pollutants
Risk to Diabetes
Noise, air, and light pollution contribute to T2D through various pathways.
Family Organisation
Does a person live in a single parent home, do they have financial and home security, do they live with various generations?
Example
A single parent living with home and financial insecurity. Having to do multiple trips on public transport due to caretaking and work engagements.
Risk to Diabetes
The multiple and even longer trips on public transport can expose people to higher levels of air pollution and noise. Both pollutants have multiple pathways to T2D.
Diabetes Prevalence in London
(source)
The darker areas indicate higher prevalence of diabetes. As it can be seen the distribution is not even, this requires further investigation both at a data and community level. We should look at the various pollutants alongside deprivation and see how they correlate with the geographic distribution of diabetes.
Additionally, we should consider community based studies that investigate the lived experience to uncover other ecological factors that contribute to diabetes. For instance, a community that lives with high levels of pollutants and also performs essential work would be a relevant study.
Essential workers are over exposed to air pollution due to their type work (drivers, TfL workers, hygiene workers) as well as experience sleep disruptions due to shift work, which put them more at risk of diabetes (source). Given that many essential workers cluster in specific areas due to economic reasons, the lived experience of an essential worker is relevant to geospatial studies of diabetes.
Health Justice Considerations
Changing the language to “the racialisation of X” rather than just saying “X group is more at risk”. This is to be specific that it is the strategies of racism that put people at risk not a person’s skin colour.
When we speak of environmental justice we are also speaking of health justice.
As diabetes has clear geospatial aetiology, which in turn is influenced by racism strategies, we have to consider its justice paths.
Part of the justice movement has to leave room for discussing the aetiology of disease, as disease is in part a manifestation or extension of racial injustice.
Recommendations for Urban Health
Public health programmes should include strategies for reducing the exposure to pollutants.
Public health programmes should evolve from behavioural or dietary campaigns and interventions, as a good diet requires a certain income and access to resources. Additionally, we are learning that diabetes aetiology goes beyond diet.
There should be investment into further ecological studies to fully understand how place and diabetes interlink.
Public health organisations should be collaborating with urban planning organisations to ensure that pollutants are stopped.
Public health organisations should be campaigning for clean air and the reduction of other pollutants as part of diabetes prevention strategies.
Environmental agencies should be in collaboration with public health and urban planning organisations to prevent exposure to environmental polluters.
ABOUT THE AUTHORS
Araceli Camargo
Araceli is lead scientist at Centric Lab and a cognitive neuroscientist focused on how people interact with urban environments. Araceli Camargo is of Indigenous American descent and holds an MSc in Cognitive Neuroscience from King’s College London.
Elahi Hossain
Elahi is lead researcher at Centric Lab. Elahi has a keen interest in medical technology and his role at Centric is to research the neurobiological links between people and the external environment. Elahi holds an MSc in Behavioural Science and is a PhD Candidate in Neuroscience at University College London.