From a disease of well-being and opulence it has become the disease of malaise and discomfort. Type 2 diabetes, and its most feared risk factor, obesity, hit the most disadvantaged socioeconomic groups hardest. This emerges not only from the comparison between countries, but also within the same state: in whichever city you live, the probability of meeting a person with diabetes will vary according to the average wealth of the neighbourhood. The situation was brought into focus by the Italian Society of Diabetes meeting at Panorama Diabete 2023, whose 2023 slogan was Predict to prevent. An extremely urgent operation, that of prevention, diabetes being in exponential growth, with about 4 million Italians with a diagnosis, to which must be added another million people with the disease, but not diagnosed, and another 4 million with a condition of increased risk for diabetes and its complications, the so-called pre-diabetes.
We need political measures
Just as the British Medical Journal was publishing an article entitled “A health economy for all” in which the father of the concept of unequal health Michael Marmot writes: «Continuing with neoliberal economics will not solve the problems of inequality and climate change»in Riccione the scientific society Sid reflected on need for more political than health measures to stem the tragic impact that education, work, income, but also the physical environment and housing and social contexts have on diabetes and people’s health. This means taking the health issue seriously.
Incidences and mortality double in the South
“Looking at the GDP maps with the Istat data relating to 2021 and those of the prevalence of diabetes, an almost exact correspondence emerges” explained Marco Baroni of the University of L’Aquila. At the top of the ranking, regions such as Valle d’Aosta (with diabetes at 3.2%), Veneto (3.4%) and Lombardy (3.6%) and, at the bottom, the South with Calabria and Basilicata arriving at 8%. Similar data on mortality, which doubles in the south. So much so that, explains the president Sid Angelo Avogaro, «the task of the diabetologist today is now also to look at all the emerging risk factors, including the social and environmental context, which favor the progression towards diabetes. Too many still do not belong to diabetes centres, the hope is that this will become increasingly feasible with proximity medicine and health homes”.
Unequal health in the city
Data from Rome from the Health city institute show that, contrary to what one would expect from a disease that sees age as one of the main risk factors, diabetes is more present not in the districts with the highest old age index such as Parioli or Prati but in the young and disadvantaged municipality VI. The same happens in Turin, where Graziella Bruno’s data show that prevalence doubles in disadvantaged neighborhoods. «Among the passengers who get on the tram in Turin in the wealthier neighborhoods below the hill, only 4 out of 100 have diabetes; in the poorest suburbs north of the city they are 8 out of 100» writes Enrico Costa in the preface to the beautiful essay by Luca Carra and Paolo Vineis «Biological capital. The consequences of social inequalities on health.
Education and work
Data from Piedmont also show that the level of education is a determinant of unplanned hospitalization for emergencies in type 2 diabetes. US data show that those with low schooling and living below poverty levels have a higher incidence of diabetes and obesity and a reduced life expectancy. As for work, those who are unemployed have a 70% increased risk of developing type 2 diabetes and the risk of experiencing complications is also higher in those who are not employed. Complications are not only a health problem, but also an economic one: the management costs of a patient with diabetes are around €3,000 a year, but the figure must be multiplied by four, by six and by nine when a , two and three complications.
Physical and social environment
«Exposure to greenery has a protective function for diabetes and many other diseases; not having access to free spaces, as happens to those who live in the urban suburbs, increases the risk of developing diabetes» he explained Agostino Consoli, past president of the Sid, recalling a recent study that appeared in the New England Journal of Medicine conducted on nearly 5,000 women with children which showed that simply transferring from a disadvantaged neighborhood to another it resulted in an improvement in glycemic control and body mass index. L’noise pollutionthe continued one of traffic, increases the risk of diabetes, and then there is light pollutionwhich can lead to weight gain, obesity and eventually diabetes, as shown by a large Chinese study that appeared in Diabetologia. Many pollutantsthen, are endocrine disruptors and have an obesogenic action, i.e. they induce the accumulation of weight, as well as acrylamide (in addition to being obesogenic, it is also carcinogenic), produced not only in industrial processes but also by cooking processes such as frying and the grilling.
Lifestyle, nutrition and body weight
Finally, with regard to food choices, studies also reveal an intuitive phenomenon: as income decreases, the food cart shifts towards carbohydrate-rich foods and low in fruits, vegetables and good proteins. “Income plays a key role in food choice,” she said elected president of Sid, Raffaella Buzzetti of the Umberto I Polyclinic in Rome. “We need to support those who have fewer cultural tools and less education, proving capable of reaching even those who are not inclined to seek serious and reliable information about lifestyles”. Acting on which is so effective as to lead in some cases to the regression of the disease. Then, there’s prevention: if tomorrow the entire Italian population became normal weight, people with diabetes would go from 4.5 million to 500 thousand. «We need to act on primary prevention, teach healthy lifestyles, make citizens understand that there is no option B, there is only option A for one’s health. Clearly then there are purely political choices that go beyond the medical-health context and concern the environment, urban planning, the social» concludes Avogaro who recalls: «Diabetes lost on the health system for 8-10 billion euros out of a total 110 billion, that’s no small amount».
Is social unease configured as a criterion for identifying specific weaknesses? For Italian diabetologists, the answer is yes, despite all the difficulties in identifying it. “We must ask ourselves – they say – about which governance of health for the socially disadvantaged”. There is a but. Scientific societies can produce evidence and bring reflections and proposals, but not implement the necessary political, economic and social interventions. Also, as you well denounced Maria Triassi of the Federico II University between the general pause, “health interests conflict with those of the food industries and the legislator does not intervene on this”. Sid does not shy away and as usual takes a position on these very decisive issues. The title of the next congress, in fact, will be Predict to plan. Until then, as diabetologists bitterly admit, “better to be educated, rich and live in a nice green neighborhood.”
Photo by Robin Stickel on Unsplash