Refugees: Neighborhood Deprivation Ups Type 2 Diabetes Risk

Troy Brown, RN

April 28, 2016

The risks for type 2 diabetes and death are increased among refugees who immigrated to high-deprivation neighborhoods in Sweden, compared with native Swedes, and those risks are even higher in refugees from lower-income countries, a new quasi-experimental study has found.

"Neighborhood effects are especially important for vulnerable populations, such as immigrants. Studies have consistently shown that immigrants to Sweden, as elsewhere, have an increased risk of diabetes and mortality compared with the native population and higher incident diabetes after migration from a lower-income country. Moreover, incidence might be higher in refugees than in immigrants more generally," the researchers, led by Justin S White, PhD, Philip R Lee Institute for Health Policy Studies, School of Medicine, University of California, San Francisco, explain.

Dr White and colleagues report their findings in an article published online April 27 in Lancet Diabetes & Endocrinology.

Second author Rita Hamad, MD, department of medicine, Stanford University School of Medicine, California, told Medscape Medical News: "This study contributes importantly to several ongoing conversations in society today. In part, it speaks to the ongoing refugee crisis in Europe and suggests that investing in support for these vulnerable groups early on may have beneficial effects for them and for society decades later.

"It also speaks to a broader conversation about inequality and suggests that the deprived areas in which people live may have huge implications for their health beyond simply their own individual characteristics. This echoes findings from a previous study out of Stanford last week, in which researchers found that the relationship between income and life expectancy in the US is strongly associated with where people live," she added.

High- and Moderate-Deprivation Neighborhoods Up T2D Risk by Almost 40%

The researchers studied data from 61,386 refugees aged 25 to 50 years who immigrated to Sweden between 1987 and 1991 and followed participants until 2010. A large number of refugees came to Sweden during these years, primarily from the Middle East and North Africa. The country's policy at this time was to distribute these refugees between major cities to avoid straining local job markets with unemployed immigrants. To be sure that they were identifying only new cases of type 2 diabetes, the researchers excluded any individuals who had been diagnosed with type 2 diabetes in the previous 5 years.

Many of the refugees were first assigned to moderate-deprivation (45%) and high-deprivation (47%) areas, which the authors say indicates that housing was most available in these areas during the arrival period.

Neighborhoods were assessed via small-area market statistics (SAMS) — a commonly used definition in Swedish research — which establishes boundaries by homogeneous building types, such as high-rise buildings.

For immigrants assigned to moderate-deprivation or high-deprivation SAMS, the odds of type 2 diabetes increased by 25% and 39%, respectively, compared with those assigned to a low-deprivation SAMS.

After assessing neighborhoods, the investigators then adjusted for individual characteristics, which they measured in the year of the participants' initial placement, including 5-year age categories, sex, educational completion, marital status, region at time of initial placement, family size, and region of origin.

In these adjusted analyses, the increased risk for type 2 diabetes remained but was smaller: 15% for those in moderate-deprivation areas and 22% for those in high-deprivation areas.

Stratification of the adjusted model by region of origin did not identify significant differences.

"Even Short-term Exposure Can Have Long-term Implications"

"On the one hand, we were not surprised [by these results], since there is a rich literature that suggests the potentially important health effects of neighborhood factors such as employment opportunities, psychosocial stress, food availability, and walkability," Dr Hamad told Medscape Medical News.

"On the other hand, about half of these refugees ended up moving from the area to which they were first assigned, and we still saw effects of this size. This suggests that even short-term exposures to highly deprived conditions can have long-term implications for people's health and well-being," she added.

"Social and contextual factors beyond medical care are potentially important determinants of diabetes. If we treat individuals clinically but ignore the places in which they live, our impact on their health and well-being will be substantially reduced," she explained.

"Patients living in deprived neighborhoods may require additional resources and attention. Physicians can also work closely with social workers or community organizations to ensure the best outcomes for their patients. Finally, doctors can play important roles as advocates in disadvantaged communities."

Better Response Needed to Refugee Crisis to Reduce Long-term Health Impacts

Understanding and addressing the underlying causes and mechanisms of increased health risks for those who live in deprived neighborhoods is challenging, write Nigel Unwin, PhD, Chronic Disease Research Centre, the University of the West Indies, Barbados, and MRC Epidemiology Unit, University of Cambridge, United Kingdom, and Ian R Hambleton, PhD, MRC Epidemiology Unit, University of Cambridge, in an accompanying commentary.

"Although White and colleagues' study clarifies little about the mechanisms of the increased risk associated with moving to a deprived area, it emphasizes the need to understand them to inform preventive interventions. The findings also support the notion that the most effective approaches to prevention will entail addressing both neighborhood and individual level factors," Drs Unwin and Hambleton explain.

"In discussing the findings of this study, it is too easy to forget the extreme suffering and loss experienced by so many of the participants. Martin Luther King once wrote, 'A great nation is a compassionate nation,' " they add.

"Today, there is too little evidence of greatness in most of Europe, as it stutters a response to the challenge of the largest movement of refugees since World War II," they assert.

"This study is a reminder that where people are allowed or forced to settle will have consequences for their health and well-being for years to come," the two doctors conclude.

The authors and commentators have disclosed no relevant financial relationships.

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Lancet Diabetes Endocrinol. Published online April 27, 2016. Abstract


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