Intended for healthcare professionals


Social aetiologies of type 2 diabetes

BMJ 2018; 361 doi: (Published 27 April 2018) Cite this as: BMJ 2018;361:k1795
  1. Lauren Carruth, assistant professor1,
  2. Emily Mendenhall, assistant professor2
  1. 1School of International Service, American University, Washington, DC, USA
  2. 2School of Foreign Service, Georgetown University, Washington, DC
  1. Correspondence to: L Carruth lcarruth{at}

For millions, type 2 diabetes is a disease of crisis and displacement not poor lifestyle choices

Diabetes kills more people around the world than HIV/AIDS, tuberculosis, and malaria combined, and most of these deaths occur in low or middle income countries.1 For many patients in these countries, insulin resistance may be better understood as a consequence of crisis, displacement, and trauma, rather than as a product of poor dietary or lifestyle choices. We must therefore reconsider our epidemiological understanding of risk for type 2 diabetes, and reform clinical advice in response.

Evidence shows that experiences of violence and marginalisation shape the risks and experiences of type 2 diabetes around the world,23 particularly among indigenous, colonised, and forcibly displaced populations.4567 More specifically, the humanitarian crises, food insecurity, and consumption of food rations that have often resulted from colonisation and displacement have important effects on the epidemiology and clinical management of type 2 diabetes.45

Most contemporary medical and public health discourses on diabetes, however, emphasise individual dietary and lifestyle choices in driving risk and management over the social aetiologies of disease beyond patients’ control.

Chronic forms of stress and experiences of trauma or violence exacerbate and help explain the remarkably high rates of type 2 diabetes among indigenous peoples compared with the general population in many countries.67 For centuries, Native Americans were forcibly displaced, resettled onto segregated reservations, stripped of livestock holdings and agricultural or grazing lands, forcibly sedentarised, and had traditional foods replaced with rations of sugar, refined flours, powdered milk, and lard.67

The Pima of North America have the highest diabetes rates in the world.8 In 1924, Pimas in Arizona in the US were forcibly resettled onto a reservation, while most Mexican Pimas continued farming and raising livestock. Arizona Pimas have long relied on ration cards and food subsidies for mostly energy dense, low quality, highly processed foods, while Mexican Pimas’ diets and lifestyles changed less over the same period.9 Consequently, Pimas in Arizona now have much higher rates of diabetes and obesity than those in Mexico.8

Why does this matter? The food people consume and behaviours people choose are not solely or even predominantly a consequence of autonomous free will or choice.10 Most people who are impoverished or food insecure consume what they can easily access, prepare, and afford. Dietary choices are even more constrained when people rely on food rations or other restrictive benefit programmes. Furthermore, exercise is difficult for people who work long hours or lack safe and culturally appropriate activities. The recent extraordinary rise in global diabetes prevalence does not therefore reflect a sudden rise in gluttonous, lazy, or irresponsible behaviours.1 Body weight and lifestyle may be contributing—not causal—factors for increasing diabetes rates in communities with long histories of social disruption.

The millions of indigenous people, asylum seekers, displaced persons, and irregular or undocumented migrants from low and middle income countries with rising diabetes rates typically have few dietary choices and few resources with which to undertake the kinds of behaviour changes recommended by clinicians.

Like many Native American groups, Somalis in the Horn of Africa have also been partitioned, forcibly displaced and resettled, sedentarised, and dispossessed of their grazing land and livestock; many now consume diets high in sugar and processed grains from food rations.11 But most current research and programmes target only populations in Western countries or urban populations with high rates of obesity. Little is known about populations such as Somalis, who face chronic diseases related to lifetime exposures to humanitarian crisis, displacement, and food insecurity.

Anthropological research, however, suggests that experiences of crisis and dislocation, as well as the undernutrition and dietary changes that result, may radically shape diabetes risk and people’s ability to manage the disease. Diabetes in Somalis may be a consequence of chronic and acute stresses on people’s immune and inflammatory response systems because of lifetime exposures to hunger and crisis.12 These populations may therefore be at unexpectedly high risk of diabetes—a fear articulated by clinicians working in parts of Africa and in humanitarian crises, who now see increasing numbers of diabetic patients.13

We therefore need to identify and address the social aetiologies of type 2 diabetes—not just the anthropometric measures and insulin resistance that result—so that we can improve prognoses in these populations. We must advocate for changes to foreign and domestic policies that limit people’s access to healthy food and healthcare as well as for equitable provision of early diagnosis and care.

Clinicians should look beyond presumptive behaviour change models in type 2 diabetes to the alternative clinical presentations and challenges to clinical management so prevalent among patients who are affected by crisis, displacement, and food insecurity. Health interventions that do not focus on individual behaviour change but instead offer social support and social and psychological services, as well as clinical care, may help patients manage their symptoms and the stress that contributes to their illness.1014 Myopic conceptions of diabetes that narrowly focus on anthropometrics, diet, and lifestyle can miss alternative patterns of risk and disease, set up patients to fail, and worsen existing health inequities.


  • Competing interests: We have read and understood BMJ policy on declaration of interests and have no interests to declare.

  • Provenance and peer review: Not commissioned; externally peer reviewed.


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