American cancer research society

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: alex.clark@ualberta.ca.

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