Walking a Tight Rope: social class differences in the everyday management of type 2 diabetes Shane O'Donnell PhD candidate UCD School of Sociology Scoil na Socheolaíochta UCD Newman Building Áras Newman , Belfield, Dublin 4 Belfield, Baile Atha Cliath 4 T +353 1 716 8510 sociology@ucd.ie F +353 1 716 1125 www.ucd.ie/sociology
“Diabetes in crisis?”
What is type 2 diabetes? • Characterised by inability to control glucose – Body has become insulin resistant • Diagnosed in later life • Obesity • Managed though exercise, diet and medication • Complications: Nerve damage ,blindness, kidney Failure, stroke
Diabetes in Ireland • 4.5% of the Irish Population diagnosed. • State spends 350m every year on diabetic related interventions 60% of government funding is spent on preventable complications
Discourse surrounding diabetes epidemic so far… • “Disease of lifestyle” -high carb diet, increasingly sedentary “(N1):There is this caricature or stereotype of an obese slob who deserves no attention for their multiple medical disorders.... Why isn't there an adequate prevention program for obesity and diabetes? Its because the medical profession, the policy makers and society as a whole see it as broadly their own fault...The obese person is subject to enormous discrimination”
Social Class and Diabetes • mortality 230 % greater in lowest socioeconomic groups compared to highest – poverty features in only 23 articles out of a total of 3000 articles in diabetes causation and management literature. (chuafan: 2004)
Education and Diabetes • Strong evidence from RCT’s and systematic reviews that education interventions are valuable – Diabetes self management education promotes adherence to regimen and improve quality of life – Results vary across different social contexts – Social groups most in need least likely to derive benefit
Inequality, stress and diabetes – Wilkinson’s Psychosocial Model • Contemporary health affected through social position embedded in hierarchical structure of society • Stress derived from low social status • Greater levels of inequality = higher rates of illness, phychological distress and other social problems • Encourages competition, weakens social cohesion • Flee or fight response
Psychosocial framework: Diabetes management and control Direct impact Indirect impact Lower social status Lower sense of self worth Chronic stress Alcoholism, substance abuse, comfort eating Insulin resistance Sub-optimum glucose control Sub-optimum glucose control
Social Status, Stress and the workplace • Stress derives from three main areas : early childhood experiences, relationships with significant others, the workplace. • Whitehall study involving over 10,000 civil servants (Marmot et al: 2004) • Health declines in stepwise gradient the further the individual is from top of civil service rank. • Could not be explained by conventional risk factors like diet and lack of exercise • Stress due to lack of control and authority decision making was shown to be key factor.
Relative Rates of cardiovascular disease in Whitehall
• In sum, Low control at work= -higher levels of depression -Sleep loss -increased insulin resistance/Hba1c -higher cholesterol
Life course studies and diabetes • Wide range of longitudinal studies and meta analysis shows links between low SES in childhood, especially in women • Accumulation of stressful life events and low social support linked to worse glucose outcomes • Depression “the great undiagnosed complication of diabetes” 40% more at risk CVD
Lack of control over ones life = lack of control over one’s blood sugars • Stress and managing type II diabetes is a disaster. So if you have financial worries; about relationship with your partner; about keeping a job that will always come ahead of keeping a track on how your sugars are doing, how you are complying with your going out for three walks a day how you are complying with taking your medication. We would see all the time a person who has reasonable control... something goes on in their life and their sugar goes off. So it is a disaster for managing a chronic illness (-endocrinologist • People who are poorly managing their diabetes I would say a large amount of them are suffering from depression… although I wouldn’t call it depression because depression means its kind of treatable …its think its just a low level of self esteem… Now I wonder… is that a normal reaction to events that you don’t wont to be there (G.P)
• To explore social class differences in the everyday experiences of living with type 2 diabetes • Interview both lower and higher socioeconomic groups. • Qualitative semi structured interviews
Thank you for your time
Bibliography • Bibliography • Anderson, R., Fitzgerald, J., Gruppen, l., Funnell, M., & Oh, M. (2003). The Diabetes Empowerment Scale-Short Form (DES-SF) d. Diabetes cARE , 26 (5), 1641-1642. • Anderson, R., Funnell, M., Butler, P., Arnold, M., Fitzgerald, T., & Feste, C. (1995). Patient empowerment. Results of a randomized controlled trial. Diabetes Care , 18 (7), 943-949. • Balanda, K., & Wilde, J. (2001). Inequalities in Mortality: A Report on All-Ireland Mortality Data. Dublin: The Institute of Public Health. • Balanda, K., Fahey, L., & Jordan. (2006). Making diabetes count: a systematic approach to estimating population prevalence on the Island of Ireland. Dublin: The institute of public health in Ireland. • Bates, A. (2010). Ensuring Profitable Patient Programmes : Using Analytics and Metrics to Improve the Bottom Line. New York: Eulararis. • Brunner, E., & Marmot, M. (1999). Social Organization, Stress, and Health. In R. Wilkinson, & M. Marmot, Social Determinants of Health (pp. 6-30). oxford: Oxford University Press. • Flick, U. (2002). An introduction to Qualitative Research. London: Sage. • Friel, S., Harrington, Thunhurst, C., Kirby, A., & McElroy, B. Standard of healthy living on the Island of Ireland. Dublin: Safefood Ireland. • Funnell, M., Nwankwo, R., Gillard, M., Anderson. R, M., & T.S, T. (2005). Implementing an Empowerment-based Diabetes Self Management Education Program. The Diabetes Educator , 31 (53). • Lynch, J., & McCarthy, A. (2002). Health Literacy,Policy and Strategy. National Adult Literacy Agency. • Lynch, J., Kaplan, G., & Salonen, J. (1997). Why do poor people behave so poor? Variation in adult behavior and phychological charcteristics by stages of the socioeconomic lifecourse. Journal of Social Science and Medicine , 44 (6), 809-819. • Manderson, L., & Kokanovic, R. (2009). "worried all the time": distress and circumstances of everyday life among immigrant Australians with type 2 Diabetes. Chronic Illness , 5 , 21-32. • Raphael, D., Anstice, S., Raine, K., McGannon, K. R., Rizvi, S. K., & Yu, V. (2003). The social determinants of the incidence and management of type 2 diabetes mellitus: are we prepared to rethink our questions and redirect our research activities? Leadership in Health Services , 16 (3), 10-20. • Schillnger, A., Grumbach, K., Piette, J., Wang, F., Osmond, D., Daher, C., et al. (2002). Association of Health Literacy with Diabetes Outcomes. The Journal of Medical Associaiton . • Wang, & Shcmid. (2007). Regional Differences in health Literacy in Switzerland. University of Zurich: Institute of social and preventative medicine.
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