If we reduce obesity by 25.0% by 2045, 300,000 cases of type 2 diabetes can be avoided and 149 million dollars in healthcare expenditure saved


In Tianjin, the vulnerability assessment reveals new insights into how vulnerability impacts people’s ability to manage their diabetes. It also reveals misconceptions about the causes of diabetes.

Various insights into vulnerability to type 2 diabetes and diabetes-related complications have emerged from the research and some of the most important are highlighted below.

Diabetes is a burden not just physically and emotionally, but also financially. Even among participants who have health insurance plans, the treatment of diabetes can be challenging in the face of financial constraints.

In Tianjin, the cost of healthcare and pharmaceutical medicines often drives people with diabetes to seek alternative, less expensive treatment options. Some participants have to ‘budget’ their medication or make a choice about which resources they will have to do without. This seems to allow for a viable market of counterfeit medicines that are informally advertised as ‘miracle cures’. Though participants acknowledge that these are not real alternatives and may lead to even greater expenses in the long run, many participants do not know how else to manage a situation of financial limitations.

Many participants in Tianjin feel that diabetes is not a ‘serious’ disease, and therefore do not pay much attention to everyday diabetes care. However, once diabetes-related complications occur, they dramatically impact beliefs and attitude towards the illness: suddenly, it is taken much more seriously.

Furthermore, diabetes diagnosis can be experienced as a traumatic event and some report feeling that diabetes was an early death sentence, either literally or in that it takes away the pleasures and spontaneity of life.

Beliefs about what causes diabetes are equally important, as they determine the behaviours people will engage to avoid developing the disease. Participants mentioned causes like: poor food, lack of exercise, lack of diabetes education, overworking, poor mental health or escesive stress/anxiety, water and air quality, food quality, low-grade oil, pesticies, genetically modified food, hormones and chemical additives to food.

Whether having diabetes or not, the consensus among our participants is that there cannot be enough information on diabetes treatment and prevention. Poor diabetes literacy was identified as a cause of its increasing prevalence in China.

Some participants mentioned how insufficient education ultimately also endangers the health of people with diabetes, who are vulnerable to misleading advice, advertisements or compromised treatment avenues. Misconceptions about what causes diabetes need to be tackled in order to reduce its occurrence. Some participants expressed that had they known about diabetes beforehand, they would have taken the necessary measures to avoid developing it in the first place.

Doctors’ comprehensive understanding of the disease was also seen as being of significant importance. This gave the participants the confidence to manage their condition and to ask questions when their confidence was lacking.

Diabetes can be a weighty emotional burden. Feelings of guilt and regret over the state of their health were common among participants in Tianjin. Many also experience anxiety about the genetic risk factors of diabetes, and express great worries that their children will inherit the disease. Depression is a frequent comorbidity in Tianjin.

While some people take a nonchalant attitude towards the care of their diabetes, for others this responsibility is very serious. When their health outcomes do not meet their expectations or match their efforts, they are extremely disappointed. In addition, seeing or feeling the effects of diabetes on their physical state causes many people a significant amount of grief over their deteriorating health.

Diagnosis was, in many cases, experienced as an end to life as they had known it before, and was thus accompanied by much sadness and anxiety.


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

Three cases from Tianjin

Meet Xia

Meet Xia

• 55 years old
• Works as a full-time labourer
• Slightly overweight
• Type 2 diabetes

About Xia

Xia is a 55-year-old woman from Tianjin, where she lives with her husband in an apartment. Her children live in the same building on another floor. The area surrounding the apartment building is open and spacious, and there is a playground nearby with exercise equipment, where people dance and play ball games.

Xia is fond of exercise, but rarely has the time for it. She is kept very busy by her farm work and housework, such as preparing meals. She also has health issues that make it difficult for her to participate.

Each day, Xia spends many hours doing farm work. However, she believes she is in good physical condition as she spends many hours each day doing this. Each day, she also cycles the half-hour distance to cultivate her furthest away vegetable field.

Often during the day, Xia does not eat regularly and, at times, even skips meals. She believes that a poor and irregular diet most probably causes diabetes, but knows nothing more: “I think I get the diabetes because I eat too much this time and too little next [time]”.

Xia is very concerned about the complications of diabetes, which could hinder her ability to farm and take care of her family. Though she, in principle, trusts doctors, she is very unsure as to what help doctors can give her, which means that she avoids seeking medical attention, even when necessary. She also mistrusts any advice or information from her family, neighbours and friends because she feels it is unreliable: “I just believe the hospital and I don’t believe the information from other place. I pay all my attention on the doctors and I don’t believe other people”. Recently, however, her children did successfully manage to persuade her to pay a visit to the hospital because her hands were so numb and swollen that she could not hold a broom.

Xia and diabetes

Xia has a very limited knowledge of diabetes, though she knows that she can get information at the local hospital. To her, diabetes seems troublesome, since people with diabetes need to be quite careful in every way – they need to avoid overexhaustion and always watch their diet, but she is unsure as to what is specifically suitable to eat. She also feels that those with diabetes have a quick temper.

Why is Xia’s case interesting?

Xia’s case is interesting because Xia is representative of a group of people engaging in small-scale agriculture in the suburbs of Tianjin. They typically have a low level of income and education, and have worked as physical labourers all their lives. The practice of growing your own food is not common in Tianjin anymore.

Meet Liu

Meet Liu

• 70 years old
• Diabetes-related complications
• Type 2 diabetes

About Liu

Liu is a well-groomed 70-year-old man. He is retired and lives together with his wife and son, who has returned from studying abroad.

Diabetes has cost Liu his left foot. His foot was amputated 30 years ago after a small wound on his toe developed into a large ulcer – this is a common complication of diabetes. He is now confined to a wheelchair as a result of his disability. This experience has left him disappointed with the medical system available to people like himself. He has suffered a lot as a consequence of diabetes, but this does not stop him from engaging in medical care and looking after his health.

Consequently, Liu is keen to prevent and control any diabetes-related complications, and keeps himself informed about what challenges can arise as well as how he can treat or avoid them. He believes that diabetes is caused by lack of exercise or by dietary habits such as eating fried foods or consuming excessive sugar. Furthermore, he holds the view that a big risk factor for developing diabetes is genetic predisposition.

Although he and his wife each receive 2,500 Chinese yuan (about 393 dollars) a month from their pensions, this is not enough to meet their needs. So to support his family’s needs, Liu sells newspapers, cigarettes and soft drinks on the streets in his neighbourhood. Fortunately for Liu, he has the support of many of his neighbours, who keep in regular contact with him and help Liu carry things up and down the stairs at his home. “My son has returned from studying abroad and doesn’t have a job as yet, so I have to earn money”.

Liu and diabetes

Liu pays careful attention to his diet, regulating his blood sugar levels by eating balanced meals at regular intervals, and he is diligent about going to the hospital regularly for examinations and seeking appropriate therapies.

However, due to his financial situation, he has to compromise on his medication. The high costs of treatment represent a significant burden for Liu. He feels his treatment is compromised because he cannot afford better healthcare. Financial limitations are a great source of stress for Liu and represent a significant burden to his overall wellbeing.

Why is Liu’s case interesting?

Liu’s case is of interest as it illustrates how financial disadvantage can compromise a person’s ability to self-manage their diabetes despite their personal determination to manage the condition. Liu is representative of many people who suffer from diabetes-related complications but, due to economic hardship, have to compromise their treatment.

Meet Shi

Meet Shi

• 75 years old
• Pensioner
• Family history of diabetes
• Type 2 diabetes

About Shi

Shi is a 75-year-old retired man who lives with his wife in the Hexi district of Tianjin, a densely populated residential area. The area has good public transport links, schools, grocery shops and some restaurants, making it convenient and pleasant,and a small park, where Shi goes every day to chat with his many neighbours and to do some exercise.

Shi has an optimistic attitude and a strong sense of self-discipline. “No matter what happens, I can do things by myself. First of all, I rarely eat out. Second, I take my medicine on time”. Shi has lived with type 2 diabetes since 1988 and keeps copies of all his case histories, hospital records and receipts, carefully keeping track of his healthcare expenses.

He trusts doctors and has spent quite a bit of time in hospitals: “The number of doctors whom I know is large enough to set up a hospital by themselves”. As advised by his doctor, he always takes his medicine on time: “I punctually take medicine and injection and rarely miss this practice”.

Shi likes to share his doctor’s advice with his friends and former colleagues. They often seek advice from him about how to take medicine, and he always likes to help because he feels that “they lack the knowledge about diabetes”. Shi used to love being physically active from an early age, and he was a well-known football player in his youth. However, considering his physical condition, he now works out much less frequently, regarding the practice of doing housework as his primary form of exercise. In his opinion, physical exercise is good for the health and should be promoted.

Shi also feels that misleading information is often released to those who have diabetes via the media, including newspapers and commercials. “I wish the government would crack down on some false advertising, even stop them”. He also feels that those with less knowledge about diabetes than he has might be particularly vulnerable to the disease. He knows of worrying incidents where particular individuals sell counterfeit diabetes drugs to the public.

Shi and diabetes

As someone who is health-conscious, Shi is very concerned about diabetes in his community. He knows a lot of people and has voluntarily taken on the task of being a diabetes advocate among friends, former colleagues and classmates.

He feels strongly that it is necessary to intensify efforts to create public awareness of diabetes. He feels that misleading information has often been released to those who are less knowledgeable about diabetes, and this makes them vulnerable.

Why is Shi’s case interesting?

Shi’s case is interesting as it gives an example of a participant who, despite his diabetes and multiple diabetes-related complications, still has the ability to act as a diabetes advocate among friends and in the community.


Rule of Halves

The Rule of Halves reveals that 9.5% of adults in Tianjin have type 2 diabetes. Only about half of the people with type 2 diabetes are diagnosed and thereby aware of the disease. It has not been possible to calculate the remaining three pillars.

Rule of halves Tianjin

The last three pillars are estimated based on the general Rule of Halves due to lack of data.


The research in Tianjin was performed by School of Public Health, Tianjin Medical University led by Professor Ma Jun.

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


The Rule of Halves research is based on previously published quantitative data for Tianjin.

The research in Tianjin was performed by School of Public Health, Tianjin Medical University led by Professor Jun Ma.

The insights presented here are based on 229 individual interviews with people with type 2 diabetes performed by medical doctors from local hospitals trained in the Vulnerability Assessment interview guide.


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