If we reduce obesity by 25.0% by 2045, 149,000 cases of type 2 diabetes can be avoided, and almost 1.5 billion dollars in healthcare expenditure saved


The vulnerability assessment reveals new knowledge about why some people – disadvantaged or non-disadvantaged – are vulnerable to developing type 2 diabetes by exploring some of the social and cultural factors behind vulnerability in Houston.

Various insights into vulnerability to developing type 2 diabetes have emerged from the research; some of the most important are highlighted below.

Perceived changes and transitions at societal and community level as well as individual level lead to uncertainties and a sense of instability. Expanding cities such as Houston are, by definition, in flux and often unstable, which can easily exaggerate existing social stressors: for example, existing services change, move or are shut down, with concrete consequences for those relying on them.

Change and transition in Houston are experienced both practically (e.g. where a new influx of people crowds a neighbourhood), and psychologically (e.g. where that influx causes distress in residing individuals). Furthermore, the changing faces of neighbourhoods and society concern many, though some felt that “things were improving”.

In Houston, the notion of food as a ‘nourishing tradition’ has a profound impact on the way food is perceived and what certain meals and dishes mean for community coherence. Heritage is strongly interwoven with food in Houston, and traditional foods carry meaning beyond nutrition and diet. For many participants, food and food-related rituals constitute an essential social connector that relates people to a common identity. These foods and related rituals are also perceived as ‘comfort’ food.

Therefore, cooking and offering these foods creates a sense of community and connectivity, and providing this kind of food becomes a way of caring for oneself, others and a common culture or heritage.

However, because these foods and beverages are seen as part of a cultural identity that cannot and should not be changed, there is also a common justification among participants that following certain habits, whether healthy or not, is warranted.

The concept of ‘time poverty’ is highly relevant in a city such as Houston, where long working hours combine with long commutes and living in neighbourhoods where basic amenities are not readily accessible.

Time poverty fundamentally impacts the way people live their lives. It impacts social relations, neighbourliness, healthy living strategies, etc. and it is embedded into everyday life and practices: the way people work, live and eat. It is a kind of cultural time poverty. Among some of the participants, a longing for more social activities and social interactions in the community is interlinked with the notion of cultural time poverty.

Being time-poor means having to carefully manage free time, and often requires ‘trade-offs’ in order to complete everyday tasks. Thus, a hierarchy of demand (or need) is created, into which work, daily chores, management and, ultimately, leisure activities are organised. In order to create a situation in which diabetes and other chronic conditions can be successfully prevented, sufficient time and energy must be allocated to healthier living, and this should be reinforced beyond the individual at organisational and institutional levels.

The comparison of ‘self’ and ‘other’ is a fundamental way in which people make sense of their immediate social environment. As a result, normative body images shift in settings where body size increases or decreases in a significant proportion of a group of people.

But in scenarios where body weight across a group changes noticeably, the classification of self as ‘not as bad’, ‘healthier than’, ‘fitter than’, etc can have a detrimental effect on weight perception and management. When the normative body images change, so do the perceptions of what a ‘healthy body’ might look like.

Many Houston participants make references to the bodies of others as ‘big’ (just like their own), or ‘even bigger’ (where they feel noticeably slimmer than peers). As is the case with ‘nourishing traditions’, the relative notion of self in relation to peer appearance serves as justification for and validation of the status quo in Houston.


Three cases that exemplify some of the key insights into vulnerability to type 2 diabetes and its complications are presented here.

Three cases from Houston

Meet Carlos

Meet Carlos

•   55 years old
•   Private health insurance
•   Obese
•   Family history of diabetes
•   Hispanic

About Carlos

Carlos is a 55-year-old IT network engineer who lives in Houston together with his wife. He has worked for the same company for the past 16 years and regularly works over 40 hours a week. Each day, Carlos commutes to work and travels mostly by car.

He feels that his health is very much linked to his being severely overweight and thinks there is a problem with his metabolism because he cannot otherwise explain his weight problem.

In general, Carlos feels that he eats healthily. Typical meals in Carlos’s household will consist of pasta with rice and “a meat which would be either chicken or beef, and bread, and some kind of vegetable, either you know, something green. It’ll either be a salad or green peas, green beans, something like that”. At home, they mainly drink soda as he finds the tap water is ‘yellow at times’ and he believes the water is potentially unsafe to drink.

Currently, Carlos has no ongoing diagnosed health concerns. To him, being healthy means being the right body weight, eating correctly, getting exercise and going to the doctor for regular check-ups. The latter two pose a problem for him.

After work he is usually too tired to exercise: “I think a lot of the issue is, I think, that by the time I get done with work, I really don’t want to exercise. I’m really at – I’m just tired”. Carlos also tends to put the wellbeing of other members of his family first. He says that he is not focusing on his own health needs, which, as he puts it, “may be a macho thing [...] I don’t get sick, you know”.

Carlos and diabetes risk

Diabetes is an important topic in Carlos’s household since his cousin passed away three years ago from diabetes complications. Importantly, Carlos might very well go on to develop diabetes because of a combination of biological risk factors (BMI, family history) and social and cultural factors (such as nourishing traditions).

Also, he does not realise how much at risk he actually is: he thinks diabetes affects mostly “poor people” whereas his family is doing well financially. Added to this, various social and cultural factors impact his ability to live a healthier life. All these combine to make him very vulnerable to developing diabetes.

Why is Carlos’s case interesting?

Carlos’s case gives an example of a participant who, though apparently healthy, has a high risk of developing a range of chronic conditions such as type 2 diabetes. In the absence of diagnosed diabetes risk factors (other than obesity), he might easily slip through the net of standard diabetes screening protocols.

Meet Eve

Meet Eve

• 50 years old
• Private health insurance
• Overweight
• Hypertension
• Caucasian

About Eve

Eve is a 50-year-old married teacher from a quiet, middle-class residential neighbourhood in Atascotica, Houston, where she and her family have lived for the past 20 years. It is a ‘tight-knit’ community, where residents know each other very well and a lot of the social activities are centred around the community of the local Baptist church, where she is an active member.

There are no grocery stores nearby, only a couple of fast-food restaurants, a couple of nicer restaurants and some gas stations.   

Eve loves to entertain, and especially in the summer months she and her husband will have friends over for a meal “at least once or twice a week”. Eve enjoys cooking and would like to have people over more regularly, but “everybody out here is really, really busy”.

When she cooks for her family during a typical busy week, she focuses on convenience and ease. Typically, a meal will consist of “some sort of meat, some kind of starch, and one or two vegetables” and the main drink is homemade tea. Eve is aware that what she eats can affect her health. Her father had high blood pressure and she has been diagnosed with prehypertension. However, she also feels very strongly about being able to make her own decisions regarding diet, which has, in part, spurred her to run two miles a day.

It is clear that Eve is quite knowledgeable about health yet, in principle, not risk-aware. She is, for example, not aware of the fact that her BMI approaches the category of obesity: “I don’t know where they come up with those numbers, but according to the charts, I’m overweight”.

To her, the fact that she can regularly run signifies that she is healthy: “I typically run 2 miles a day. I can’t say my diet is the healthiest. I do have a passion for co-Southern comfort foods and I probably drink a little too much alcohol. But other than that, yeah, I’m healthy”.

Eve and diabetes risk

Eve feels that she could be at risk of diabetes if she led a sedentary lifestyle, but diabetes does not pose a significant threat to her: “When you think of someone dying early, you think of them dying from cancer, heart disease, you know, strokes. You’re, you’re not really thinking about diabetes”. This makes her, in combination with several significant biological risk factors, surprisingly vulnerable to developing diabetes.

Why is Eve’s case interesting?

This case is interesting as it gives an example of a participant clearly at high risk of developing type 2 diabetes who does not fall into the typical target population for intervention and who shows that fundamental knowledge and access to resources alone do not translate into diabetes risk awareness, behavioural change and good health outcomes.

Meet Jaclyn

Meet Jaclyn

• 35 years old
• Public health insurance
• Obesity
• Family history of diabetes
• HIV-positive
• African-American

About Jaclyn

Jaclyn lives in the Settegast area of Houston together with her three children and her grandfather, in a house owned by both of them. She is currently unemployed but makes a little income from baking, though it is not sufficient. The family also receives food stamps, and sometimes Jaclyn finds it difficult to buy food, though she “makes it work”.

At 35 years old, Jaclyn’s overall health is very poor. She was recently diagnosed with HIV, has asthma and has obesity. She feels that her days are shaped by her being unwell. When she has a good day, she can go and play with her children and be active. However, because of her medical conditions and her weight problems, this is a rare experience for her.

Besides taking care of herself, she also has to take care of her elderly grandfather and her three children, two of whom have been diagnosed with mental health disorders.

While her diet is in part constrained by financial considerations, she does try to cook healthy food and provide vegetables, especially because her sons are also overweight. She feels that her diet, in combination with what she describes as relatively high activity levels, have prevented her from developing diabetes – unlike the rest of her family. Although she is quite aware of what she should be eating, due to her current financial situation she says they “can’t go and get those good fruits and vegetables, you know like we gotta settle for canned food”. Jaclyn is planning to grow her own fruit and vegetables because “it’s healthier. I [...] can control what pesticides to and not put on ‘em”. However, this is pending due to her health, financial constraints and possible move to another location.

Her understanding of diabetes is quite good, as “literally everyone” in her family has diabetes except for herself and her children. She, therefore, checks her children’s blood sugar levels regularly. Her mother and grandmother both died from diabetes-related complications while many of her relatives control their blood glucose levels with medication.

Jaclyn and diabetes risk

Though Jaclyn knows what she should or could do in principle to improve her condition, the stressors of being unemployed and caring for an elderly grandfather and three children, two of whom have diagnosed mental health disorders, negatively impact her ability to take concrete action. The combination of biomedical factors and various stressors in her everyday life makes her very vulnerable to developing diabetes.

Why is Jaclyn’s case interesting?

Jaclyn’s case represents a participant who is vulnerable to developing type 2 diabetes due to social and economic disadvantage and multiple pre-existing health conditions.


Rule of Halves

The prevalence of type 2 diabetes is 9.1% in Houston. According to the Rule of Halves for Houston, about one in four people with type 2 diabetes is not diagnosed. Of those who are diagnosed, 22% do not receive treatment, and of those that do receive treatment one in 10 does not achieve treatment targets.

Obesity is one of the primary drivers of growth in the prevalence of type 2 diabetes, and is a significant public health issue in Huston, with 32% of adults self-reported as obese4.

4. Texas: Institute for Health Policy, The University of Texas School of Public Health. Health of Houston Survey. HHS 2010 A First Look. Houston. 2011.

Houston - rule of halfes

The last pillar is estimated based on the general Rule of Halves due to lack of data.


The research was performed by University of Texas, School of Public Health led by professor Stephen Linder.

Read more about the research and results in Houston in Urban Diabetes – Understanding the challenges and opportunities.


The Rule of Halves for Houston is based on existing published research and covers type 2 diabetes among adults over the age of 20. Cluster research of existing characteristics of people with diagnosed type 2 diabetes made it possible to identify and geographically locate people who are vulnerable to developing type 2 diabetes.

The three locations served as a basis for recruiting participants for the qualitative vulnerability assessment, which was based on 125 individual interviews performed by trained fieldworkers in people’s homes. Results qualify the findings from the quantitative research and provide insights into the characteristics of people who are vulnerable to developing type 2 diabetes and the associated social factors and cultural determinants.


Explore challenges and key insights for each city