Diabetes: The Case for Considering Context

Jan 27, 2015, 9:00 AM, Posted by

At Virginia Commonwealth University School of Medicine, Briana Mezuk, PhD, is an assistant professor in the Department of Family Medicine and Population Health, Division of Epidemiology; and Tiffany L. Green, PhD, is an assistant professor in the Department of Healthcare Policy and Research. Both are alumnae of the Robert Wood Johnson Foundation (RWJF) Health & Society Scholars program.

Approximately 30 million U.S. adults currently have diabetes, and an additional 86 million have pre-diabetes. The incidence of diabetes has increased substantially over the past 30 years, including among children. Estimates place the direct and indirect costs of diabetes at a staggering $218 billion annually.1 Like many other diseases, disparities on the basis of race and income are apparent with diabetes. Non-Hispanic blacks, Hispanics, Native Americans, and socioeconomically disadvantaged groups are more likely to develop diabetes than non-Hispanic whites and socioeconomically advantaged groups. 

Despite the enormous economic and social costs associated with diabetes, it remains a struggle to apply what we know about diabetes prevention to communities at the highest risk. We have robust evidence from randomized controlled trials that changing health behaviors, including adopting a healthy diet and regular exercise routine and subsequent weight loss, will significantly lower the risk of diabetes. Unfortunately, these promising findings only appear to apply to the short-term. Even worse, results from community-based translation efforts have been much more modest than expected, and show only limited promise of reducing long-term diabetes risk. In response, leaders at the National Institutes of Health have noted that many efforts at translating clinical findings into community settings are “limited in scope and applicability, underemphasizing the value of context.”2

What do we mean by context? Simply that health inequality does not occur in a vacuum. Where people live and work affects their exposure to stress, their ability to cope with stress—and consequently their mental and physical well-being. Moreover, some researchers have suggested that what appears to be a “race” effect—racial differences in diabetes risk—can be substantially explained by a “place effect.”3  That is, the stress of living in resource-poor neighborhoods is a primary driver of racial and socioeconomic differences in diabetes risk. Despite this evidence that diabetes-related disparities originate at the intersection of physical, psychosocial, and biological context, to date limitations on data have made it extremely challenging for population health researchers to investigate these issues.

On the other end of the spectrum, clinical research related to diabetes prevention often fails to incorporate theoretical perspectives and knowledge from the social sciences, hampering efforts to disseminate and implement interventions in communities at high risk of developing the disease.

To bridge these two important perspectives, we designed the Stress and Sugar Study (SASS), a pilot investigation aimed at understanding the role of context in diabetes risk, particularly among disadvantaged populations. Our target sample was Non-Hispanic Blacks with pre-diabetes living in Richmond, Virginia—a city that, like many in the United States, is racially segregated and has a large safety-net (socioeconomically disadvantaged) population. This target sample is one exemplar of a population at high risk of developing diabetes, and thus understanding the drivers of diabetes risk in this population specifically will inform translation efforts.

In SASS we sought to characterize the context of participants’ lives at three levels: (a) their physical context (i.e., access to healthy affordable food, resources for physical activity, neighborhood crime); (b) their psychosocial context (i.e., exposure to stressors, self-regulatory coping behaviors, mental health); and (c) their biological context (i.e., hypothalamic-pituitary-adrenal axis reactivity, hemoglobin A1c). 

One important innovation of our study is that we both empirically measured stress reactivity using laboratory-based methods and conducted personal interviews to assess stress exposure, coping behaviors, and mental health. Analysis is ongoing, but so far the two most significant findings from the study are that self-reported stress exposure is strongly related to overeating and eating high fat/sugar foods as a means of coping with stress; and that blunted stress reactivity is associated with higher hemoglobin A1c (a marker of diabetes risk). 

SASS is one example of what the physical and psychosocial context of a high-risk population looks like, and we propose that these contexts must become a central organizing theme of diabetes prevention efforts, if they are to be effective. Most SASS respondents were highly interested in improving their health; however, their ability to turn desire into action was hampered on almost a daily basis by stressors (particularly related to financial, employment, and housing instability) and constrained opportunities to cope with these stressors in a healthy way.

Although preliminary, our findings suggest that health-behavior-change programs must begin to address the complex ways in which neighborhood context, stress, and health behaviors intersect in order to be effective among high-risk populations. Without this grounding principle, we fear that implementation of standard diabetes prevention efforts may perversely widen, rather than narrow social disparities—similar to the unintended consequences smoking cessation programs have had on widening socioeconomic disparities in tobacco use. 

While our study is not representative of all populations at risk for diabetes, the experience of SASS participants serves as one exemplar of what we believe is a cross-cutting need to explicitly integrate physical, psychosocial, and biological context into efforts to prevent and eliminate racial disparities in diabetes.

The Stress and Sugar Study was funded by the Virginia Commonwealth University Center for Clinical and Translational Science.


1.      American Diabetes Association. Economic costs of diabetes in the US in 2012. Diabetes Care 2013 36(4): 1033-1046. [Return to text]

2.      Glasgow RE, Vinson C, Chambers D, Khoury MJ, Kaplan M, Hunter C. National Institutes of Health Approaches to Dissemination and Implementation Science: Current and Future Directions. Am J Public Health. 2012;102:1274-1281. [Return to text.]

3.      LaVeist TA, Thorpe RJ, et al. Environmental and socioeconomic factors as contributors to racial disparities in diabetes prevalence. J Gen Intern Med 2009;24:1144-1148. [Return to text.]

This commentary originally appeared on the RWJF Human Capital Blog. The views and opinions expressed here are those of the authors.