The Vulnerability Assessment reveals new knowledge about why some people in Copenhagen are vulnerable to developing type 2 diabetes and its complications, despite equal access to healthcare, preventive services and healthy initiatives in the community. Furthermore, the research reveals that diabetes is not the biggest concern in an everyday life where other social and health issues are more predominant.
Various insights into why some people are vulnerable to type 2 diabetes and its complications have emerged from the research; some of the most important are highlighted below.
Vulnerability in Copenhagen is closely associated with the Danish term ‘manglende overskud’, which translates as lack of energy. Several issues in everyday life impact on people’s ability to focus on their health, influencing their vulnerability to developing diabetes and diabetes-related complications. Other social and health issues, such as comorbidities, unemployment, financial difficulties, major life events and loneliness, often influence people’s daily decisions, leaving no energy to care for their health or even their diabetes. Social and health issues are interlinked, and diabetes is not the highest in the hierarchy of everyday issues.
The research indicates that people at risk of developing type 2 diabetes do not perceive diabetes as a severe health risk compared to other diseases. Some perceive diabetes as a ‘healthy disease’ due to the likelihood of being independent of medication if the condition is managed well.
Lack of information and knowledge are often cited as key barriers to people taking action in relation to diabetes. However, findings from participants in Copenhagen challenge the notion that lack of knowledge is a barrier to preventing diabetes and its complications. Insights from the research indicate that people are aware of diabetes risk factors and diabetes-related complications, and that they have sufficient knowledge.
In addition, the majority of participants are unaware of the prevention services available through the healthcare system. Based on the research, people face different challenges in relation to leveraging the healthcare system.
Often, to access healthcare services in Denmark, people require a referral from a general practitioner (GP). The fact that GPs serve as gatekeepers to information and services can act as a barrier to people accessing preventive services such as community health centres. The inconvenience of the procedure of requesting a referral means that many people miss out on the benefits of available services.
Having a family is of great importance. People value regular interaction with their family members as well as the feeling of being loved and of importance. In the face of difficulties, relatives and friends provide a support structure that people see as being essential to their wellbeing. In the absence of social support, people can experience difficulties with basic everyday tasks such as getting out of bed in the morning or preparing a home-cooked meal.
Living alone was also an indicator of vulnerability in the research, with a number of participants experiencing difficulties with being on their own. Living alone can influence the participants’ ability to take care of their own health. In general, many of the participants find it unsatisfying to eat alone and, consequently, they do not bother preparing a proper meal. Instead they end up choosing easy solutions such as bread, frozen products or takeaways.
Participants also seem to be more motivated to participate in social activities, physical exercise classes or attending the gym when they have someone to join them.
Three cases that exemplify some of the key insights into vulnerability to type 2 diabetes and its complications are presented here.
• 60 years old
• Public health insurance
• Early retirement due to cancer
• Type 2 diabetes
Sanne is 60 years old and lives on her own in an apartment in the district of Valby.
She was diagnosed with type 2 diabetes in 2005 and, as a result of her diabetes, she has developed inflammation of the nerves in her feet. Despite this, she says that: “Diabetes doesn’t take up much thought in my everyday life. What matters the most is the pain caused by my other conditions”. Besides type 2 diabetes, Sanne suffers from bone marrow cancer (multiple myeloma), which causes her intense pain every day. Consequently, she stays alone at home most of the day due to her conditions.
When Sanne was first diagnosed with type 2 diabetes, she did not take proper care of herself and her diabetes. Now she feels that she must live with the consequences. As she puts it: “I’m well aware that if my leg needs to be chopped off one day, then it’s probably my own fault, right? It isn’t something that worries me – just a part of my life”.
Her other diseases prevent her from exercising, and she does not have any energy to cook proper meals for herself. She often tends to go for easily prepared and less nutritious meals, such as bread with cold cuts or ready-made meals from the supermarket. On days when she is feeling particularly ill, she orders takeaways, although she says: “I’m not the type who loves to go out and eat unhealthy stuff, but on days when I feel very ill, I have to order food from outside. That’s when my weight goes up – because of all that deep-fried stuff”.
Apart from health professionals, Sanne does not see many people during the day. Her friends and her sister visit her a couple of times a year. When her friends are visiting, they do the cooking and they take into account that she has diabetes.
Sanne and risk of diabetes complications
Sanne is aware of her risk of developing serious diabetes complications. Because of her cancer, which causes her pain, she does not have the energy to focus on her diabetes. This makes her extremely vulnerable to getting serious fluctuations in blood sugar and complications.
Sanne’s case demonstrates how multiple diseases can have enormous implications for self-management of diabetes. It also highlights how comorbidities can isolate a person in their home.
• 51 years old
• Public health insurance
Michael is a 51-year-old unemployed man who lives together with his 39-year-old girlfriend, Anna, in a small house in Tingbjerg in the district of Brønshøj/Husum.
They are both overweight, and Michael is aware of his risk of developing diabetes, especially after Anne was diagnosed with type 2 diabetes a few months ago. He believes that the diagnosis will have a positive and healthy effect on them, as they now have a reason to make healthier choices.
However, on a daily basis he does not give it a lot of thought. Being unemployed and a job-seeker takes up a lot of his time and energy in his everyday life. Sometimes being unemployed gets too much for him. When this happens, Michael’s motivation with regard to eating healthier weakens, and he ends up using food as a comfort: “If you’re having an emotional downturn because you have difficulties finding a job, then somehow you eat more compulsively and maybe you eat more than what’s good for you”.
He also believes that diabetes is ‘the healthiest disease’ because you can become independent of insulin if you manage your diabetes well: “It’s the healthiest disease because if you lose weight, the disease will disappear”.
Both Michael and Anna would like to lose weight by participating in physical exercise activities, but membership fees for the gym are expensive. Some local exercise facilities are free of charge, including an exercise class for women only. Both Anna and Michael prefer activities where they are able to participate together or with someone they know well to help keep them motivated.
“If we were to participate in an organised activity, then we would have to participate together […]. The motivation is lacking when you have to go alone”.
Michael and diabetes risk
Being overweight makes Michael feel at risk of developing diabetes. However, he does not give it any thought during his everyday life, as thinking about it makes it unbearable on top of all his other issues.
Michael’s case shows that being aware of one’s risk does not necessarily translate into leading a healthy lifestyle. Issues in everyday life, such as unemployment, may have a greater influence on one’s mental and physical ability to make healthy choices.
• 55 years old
• Public health insurance
• Type 2 diabetes
Karen is a 55-year-old woman who lives alone in the Tingbjerg and has two grown-up children.
Karen was diagnosed with type 2 diabetes one year ago, but it has not made a great impact on her everyday life as she does not experience any physical signs of her condition. For this reason, Karen has difficulty accepting her diagnosis.
In the past five years, she has lost several close family members, and when the feeling of loss takes over, it becomes a challenge for Karen to manage her diabetes. “I think about what I’m supposed to eat and what I should avoid, and then sometimes it just doesn’t matter when I’m sitting alone and thinking about life”, she says.
Karen’s GP wants her to lose weight, and Karen knows which lifestyle changes she has to make, but she has difficulty transforming her knowledge into action. As she puts it: “I hear the same story every time: ’Mind your diet, mind your diet’, and then I say: ... of course I know what I’m supposed to eat and what I’m not allowed to eat, right?”
She does not enjoy cooking and eating alone. Consequently, she does not cook hot meals for herself at home. Instead, she eats bread with butter and cheese every day because it is easy to prepare. She associates this kind of meal with quality of life. She is therefore not willing to sacrifice this by eating something healthier. “You have to feel alive”, she says. Her two grown-up sons are very aware of their mother’s monotonous diet and invite her over for supper at least once a week to make sure that she eats a cooked meal. They also call her daily to ensure that she is alright and not engrossed in depressive thoughts.
A few years ago, she was injured in a traffic accident and still struggles to walk as a result. Currently, Karen is participating in a free 12-week diabetes-exercise course offered by the local community health centre. She enjoys this because she has the opportunity to exercise with other people similar to herself, either with physical limitations or large body size. She previously tried to attend a local gym, but she never felt comfortable there among the slim young fitness users and their condescending stares. “I wanted to do some exercise, but I didn’t like going to the gym because I was overweight. I have tried – but people stare as if there’s something wrong with you”.
Karen is worried about becoming inactive again when the 12-week course ends, as she knows that she will most likely not continue the exercises at home on her own.
Karen and diabetes
Karen knows that her unhealthy lifestyle has consequences and that it is one of the reasons why she has diabetes, but making drastic lifestyle changes is just too difficult for her right now. Transforming knowledge into action is difficult for her.
Karen’s case shows the importance of support from family and friends, and how living alone can influence self-management of type 2 diabetes.
In Copenhagen, the prevalence of diabetes is 5.1%. With respect to the Rule of Halves, about one in four people with diabetes is unaware of their condition, thus have not got a diagnosis. Despite the fact that almost everybody who is diagnosed with diabetes receives care, about half of those receiving care do not achieve treatment targets. Lastly, 40% of those achieving treatment targets do not achieve the desired outcomes – living a life free of diabetes-related complications4.
Despite the relatively low prevalence of diabetes in Copenhagen, the research reveals that 10–20% of the population is at high risk of developing type 2 diabetes4.
The risk of developing type 2 diabetes is especially elevated in two districts of Copenhagen compared to the more affluent inner city area, despite the close proximity of only 7 km4.
Research reveals that there are major socioeconomic differences in the prevalence of type 2 diabetes and the risk of developing it in Copenhagen. Citizens with low levels of education have twice the prevalence of high-risk scores and diabetes compared to citizens with higher levels of education, the rate of high-risk scores and diabetes among citizens not employed is significantly higher than that among employed citizens of the same age, and populations with a non-western background have twice the prevalence of diabetes compared to populations with a western background.4
4. Holm AL, Andersen GS, Jørgensen ME, Diderichsen F. Cities Changing Diabetes. Rule of Halves analysis for Copenhagen. Department of Public Health, University of Copenhagen and Steno Diabetes Center. 2015.
The research was performed by Department of Public Health, University of Copenhagen and Steno Diabetes Center, led by professor Finn Diderichsen and associated professor Ulla Christensen.
Read more about the research and results in Copenhagen in Urban Diabetes – Understanding the challenges and opportunities.
The Rule of Halves research was conducted based on existing quantitative data from registries and surveys. Findings were used to identify locations and define profiles as a basis for the qualitative research. Two ‘high-risk’ locations were defined through the quantitative research.
The two ‘high-risk’ locations Brønshøj/Husum and Valby served as a basis for recruiting participants for the qualitative vulnerability assessment. People at increased risk of developing type 2 diabetes or with existing diabetes were identified. All participants matched at least two of the following factors: male gender, over 45 years of age, short education, unemployed, BMI >30, non-western background and cohabitation status (living alone). In total, 24 citizens at risk and 26 people with type 2 diabetes were interviewed by trained fieldworkers in their homes.