Diabetes Care, Dec 2004 v27 i12 p3024(1)
The American Cancer Society, American Diabetes Association, and American
Heart Association joint statement on preventing cancer, cardiovascular
disease, and diabetes: where are the social determinants? (Observations)
Alexander M. Clark; Kim Raine; Dennis Raphael.


By focusing on shared causes of diabetes, cardiovascular disease, and
cancer, the recent joint statement (1) from the American Diabetes
Association, American Cancer Society, and American Heart Association is to
be welcomed. However, while the statement draws attention to the importance
of influencing lifestyle behaviors, treatments, health systems, and the
law, these diseases also share social causes that the statement does not
address or acknowledge. The social determinants of these diseases are well
recognized and documented in the research literature. These include social
inequalities related to income differences and social exclusion, insecure
and poor quality employment, lack of social support, poor literacy and lack
of education opportunities, and addictions that result from all of the
preceding (2).

Not surprisingly, people from socioeconomically deprived communities are
more likely to be exposed to these social risk conditions, such that these
risk conditions swamp the effects of lifestyle choices. The primary
modifiable behavioral risk factors for diabetes and cardiovascular disease
are also heavily determined by social conditions (3), while individual and
social risk factors tend to compound each other by clustering together (4).
In effect, lifestyle choices may be more appropriately referred to as
lifestyle chances for the proportion of the population with inadequate
access to resources for initiating changes. Compounding this, people from
socioeconomically deprived communities tend to benefit least from existing
and new health services and treatments (5).

Thus, due to the clustering of these behavioral, systems-related, and poor
social conditions, people living in socioeconomically deprived communities
are more likely to develop diabetes and cardiovascular disease, are at
considerably higher risk of further and more rapid disease progression, and
have the least resources and most barriers to subsequent health
improvement.

In addition to recommending steps to support willingness to change
modifiable behavioral and system risk factors, governments, decision
makers, and clinicians need to promote individual and community capacity to
live healthier lives and support health policies and legislation that
tackle both individual and societal or structural causes of the social
conditions that give rise to these common diseases.

ALEXANDER M. CLARK, PHD (1)

KIM RAINE, PHD (2)

DENNIS RAPHAEL, PHD (3)

From the (1) Faculty of Nursing, University of Alberta, Edmonton, Alberta,
Canada; the (2) Center for Health Promotion Studies, University of Alberta,
Edmonton, Alberta, Canada; and the (3) Department of Health Policy and
Management, York University, Toronto, Ontario, Canada.

Address correspondence to Alexander M. Clark, PhD, University of Alberta,
4th Floor Clinical Sciences Building, Edmonton, Alberta T6G 2G3, Canada.
E-mail: [log in to unmask]

References

(1.) Eyre H, Kahn R, Robertson RM, Clark NG, Doyle C, Hong Y, Gansler T,
Glynn T, Smith RA, Taubert K, Thun MJ: Preventing cancer, cardiovascular
disease, and diabetes: a common agenda for the American Cancer Society, the
American Diabetes Association, and the American Heart Association.
Circulation 109:3244-3255, 2004

(2.) Wilkinson R, Marmot M: Social Determinants of Health: The Solid Facts.
Copenhagen, World Health Organization, 2003

(3.) Raphael D, Anstice S, Raine K, McGannon KR, Rizvi SK, Yu V: 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? In Leadership in Health Services. Vol. 16, no. 3. 2003

(4.) Kostenuik JG, Dickinson HD: Tracing the social gradient in the health
of Canadians: primary and secondary determinants. Soc Sci Med 57:263-276,
2003

(5.) Macintyre S, Ellaway A, Cummins S: Place effects on health: how can we
conceptualise, operationalise and measure them? Soc Sci Med 55:125-139,
2002

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