With 96 million people with diabetes, China has one of the highest rates of diabetes in the world1. More than half of the people with diabetes live in cities, and Shanghai rank among the largest urban areas in China. In Shanghai, with a population of 23.8 million people2, it is estimated that 12.6% have diabetes3.
The People’s Municipal Government of Shanghai and the Shanghai Municipal Commission of Health and Family Planning are committed to tackle the growing urban diabetes challenge
As a consequence, the city is taking active measures to increase the focus on prevention and treatment of type 2 diabetes and other chronic diseases. Shanghai therefore welcomes relevant input based on academic research and innovative partnerships.
Shanghai Diabetes Institute will lead the initial research for Cities Changing Diabetes in collaboration with the global academic institution, University College London (UCL) from the UK.
“The Cities Changing Diabetes partnership will provide a solid foundation for identifying future initiatives of high impact to tackle urban diabetes in Shanghai” said Professor Jia Weiping of the Shanghai Diabetes institute.
Lars Rebien Sørensen, chief executive officer of Novo Nordisk welcomed the global leadership Shanghai shows in the fight against urban diabetes: “It is my hope that by working in partnership through Cities Changing Diabetes, we can complement and support the city’s objective to reduce the growing type 2 diabetes burden and tackle this urgent problem”.
Various insights into vulnerability for type 2 diabetes and diabetes-related complications have emerged from the research, the most important of which are highlighted below.
Family relationships play an important role in the management of diabetes for participants in Shanghai. People with diabetes rely on their family for support and care in matters concerning their treatment. Among participants, familial support is shown to be a highly positive element in diabetes management and control. On the other hand, diabetes can become a justified exemption from household duties because of ‘sick’ status.
When diabetes becomes a burden, it is a burden inflicted upon the whole family or household. This in turn creates feelings of guilt or shame for the individual with diabetes who has brought ‘trouble’ upon the family. Participants describe much anxiety over inconveniencing their family with their health needs and care, especially in the presence of complications. As diabetes is accepted as being hereditary, many participants worry excessively about the genetic inheritance they are leaving to their children.
For many participants in Shanghai, the memory of an age of material poverty is still fresh in their minds. They recollect times of hunger and scarce food resources, but also recollect how everything has changed since the reform and China ‘opening up’. People’s material lives have improved greatly during this period and they have taken full advantage of the abundance of food resources. In this sense, diabetes can be understood as a disease of wealth, or excessively lavish tastes for sugar and fatty foods.
Many participants believe they developed diabetes due to the extreme dietary changes that they have experienced throughout their lives. It was frequently expressed that the knowledge of diabetes and how to prevent it would have altered their past behaviour drastically. It is a sad irony for many that today, with such vast availability of food, they have to adhere to such strict and bland diets because of their disease.
In Shanghai, many participants experience negative beliefs around diabetes as well as significant societal disapproval. This impacts diagnosis, care provision, and physical and mental wellbeing of those affected. At times the diagnosis severely prevents people with diabetes from accessing help and support. In part, this seems to be due to the stigma felt (linked to the perception that diabetes is a condition of the elderly and ‘weak’), especially when a diagnosis of diabetes is made at a young age. Furthermore, a sense of stigma becomes enacted where individuals develop strategies to avoid drawing attention to themselves and their condition.
Peer support is very difficult to access for some participants in Shanghai, simply because they do not know who else has the condition, and they do not want to draw attention to themselves. The psychological implications of the experience of shame, which prevents individuals from engaging in certain social activities due to the anticipation of being stigmatised, have profound consequences for health and overall sense of wellbeing.
Stigma is also closely linked to the understanding of diabetes as a genetic condition that is passed on to one’s children. For example, in one case, the daughter of a participant did not tell her fiancé’s family about her mother’s diabetes for fear her in-laws would discriminate against them (due to the potential of passing on the condition) and call off the prospective marriage.
The participants in Shanghai had the perception that all chronic diseases, including diabetes, are inherited. In addition, they believe that diabetes can be caused or aggravated by bad dietary habits and there was a sense that it is easier to manage diabetes by regulating diet and diabetes medication once it has been diagnosed rather than to be pre-emptive. There also seemed to be a greater sense of fear of the risks of diabetes complications than of diabetes itself, and this fear frequently acts as an incentive to modify unhealthy habits or behaviours.
There seems to be an inversely proportional relationship between scientific and non-scientific explanations of diabetes and medicines with regard to cost-effectiveness. Participants perceived conventional medicine as being effective, but concluded that it is difficult to understand how it works and that it is often financially prohibitive. In addition, biomedical pharmaceuticals are looked upon with a degree of scepticism because of potential side effects while, alternative or complementary medicine is easier to understand and more accessible in spite of any perceived inferiority with regard to contemporary medicine.
“Shanghai is an important city, and in the top five largest cities globally, it acts as a model for many cities across the world.
For over a decade now Shanghai has had a plan in place for chronic disease prevention and control. A huge amount is being done backed by significant healthcare resources, yet the number of patients and complications are increasing. That shows the force of the urban diabetes challenge for us.
The dynamics driving urban diabetes in Shanghai are complex: growing wealth, changing lifestyles and an ageing population, alongside a rising number of younger people getting the disease. Also fast-paced working lives can stand in the way of the management and treatment of diabetes. We all have more to learn, and more we can do. Through in-depth learning and connecting our knowledge, Cities Changing Diabetes can help us to improve even further the effectiveness of taking on diabetes in our city.“