A link between urbanisation and diabetes exists

Cities provide tremendous opportunity for studying and understanding the drivers behind type 2 diabetes. Cities are highly complex and dynamic and differ considerably in relation to urbanisation rate, and population size and density. Furthermore, most cities consist of both wealthy and poor and deprived areas. These vital differences between and within cities make it challenging to generalise on how city life implement health. Specific city characteristics may affect certain diseases adversely, while other characteristics may offer protection and a complex interrelationship between the characteristics makes it extremely difficult to predict the exact impact and generalise on how city life implement health.

Extensive research has been performed in five cities from 2014 to 2016: Mexico City, Copenhagen, Houston, Tianjin and Shanghai. Research has also been initiated in Johannesburg, Vancouver and Rome - and more cities are expected to conduct research as they join the programme.

These are cities with a combined population of almost 70 million people. They represent the characteristics of rapidly growing cities of emerging economies and more mature cities of the developed world: all of them faced with the challenge of a growing number of people with diabetes resulting in a growing economic burden for society.  




The aim of the quantitative research is to estimate the extent of the diabetes burden in each city and define where the greatest challenges are in relation to diagnosis and/or treatment. We use the so-called “Rule of Halves” (RoH). 1 2

RoH is a framework used in various chronic diseases and it originally states  that half the people with a chronic disease are not diagnosed, half of those diagnosed are not receiving care, half of those receiving care are not controlled.1 The first term of the rule of halves was suggested in the USA in 1947 for non-insulin dependent diabetes3 and in 1964 confirmed in the UK.4 The second term of the rule of halves for diabetes was added in 19765 and in 1980, the third term was established.6

The rule of halves still largely holds true for most chronic diseases.7 For this programme the RoH is adapted and two additional terms are included: half the people with diabetes are not diagnosed, half of those diagnosed are not receiving care, half of those receiving care are not achieving treatment targets, and half of those achieving treatment targets are not achieving the desired outcome (no complications).

  1. Hart JT. Rule of halves: implications of increasing diagnosis and reducing dropout for future workload and prescribing costs in primary care. The British journal of general practice : the journal of the Royal College of General Practitioners 1992;42:116-9.

  2. Smith WC, Lee AJ, Crombie IK, et al. Control of blood pressure in Scotland: the rule of halves. BMJ (Clinical research ed) 1990;300:981-3.

  3. Wilkerson HL, Krall LP. Diabetes in a New England town: a study of 3,516 persons in Oxford, Mass. Journal of the American Medical Association 1947;135:209-16.

  4. Sharp C. Diabetes survey in Bedford 1962. Proceedings of the Royal Society of Medicine 1964;57:193.

  5. Doney BJ. An audit of the care of diabetics in a group practice. The Journal of the Royal College of General Practitioners 1976;26:734.

  6. Wilkes E, Lawton EE. The diabetic, the hospital and primary care. The Journal of the Royal College of General Practitioners 1980;30:199.

  7. Mufunda J, Ghebrat Y, Usman A, et al. Underestimation of prevalence of raised blood sugar from history compared to biochemical estimation: support for the WHO rule of halves in a population based survey in Eritrea of 2009. SpringerPlus 2015;4:723.


The aim of the qualitative research is to understand what makes certain people vulnerable to type 2 diabetes and its complications. This makes it possible to go beyond the Rule of Halves results by exploring the socio-cultural drivers of type 2 diabetes in cities.

To serve this aim a Diabetes Vulnerability Assessment (D-VA) was designed based on an established Vulnerability Assessment (VA) tool developed previously by the academic lead at University College London in collaboration with the Unites Nations.1

The D-VA is tailored to each city to accommodate local circumstances and local language. Each local academic partner carries out data collection and performs analyses to identify relevant local factors that impact how health and wellbeing are experienced amongst individuals at local levels. Global analyses are conducted by the global academic lead at UCL to identify globally salient themes and develop a global set of social factors and cultural determinants based on the locally conducted D-VA.

In total, 740 interviews have been conducted in the first five cities.

To expand and further strengthen the global research platform, the Cities Changing Diabetes (CCD) programme is in the process of developing a new research tool. The Diabetes Q-Study Tool (D-Q) will enable new cities to better understand local specific social and cultural factors related to health, well-being and diabetes.

The D-Q tool utilizes Q-methodology2 3 and builds on the findings of the Diabetes Vulnerability Assessment (D-VA).

The D-Q tool principally answers two overall questions:

  • Which social factors and cultural determinants matter most among the respondents in regards to their health, wellbeing, and diabetes experience.

  •  Why these social factors and cultural determinants are important and how they shape health and diabetes among subgroups of a city’s citizens.

The D-Q tool enables cities to establish local research platform that can inform interventions and policies, at the same time contributing to further strengthen the global research platform.  

The D-Q tool will be pilot-tested in Vancouver in the beginning of 2017.

  1. The Tripartite Core Group. Post-Nargis Periodic Review I: the Association of Southeast Asian Nations (ASEAN), the Government of the Union of Myanmar and the United Nations, 2008.

  2. Stephenson, W. The Study of Behavior: Q Technique and its Methodology. Chicago: University of Chicago Press. 1953.

  3. Watts, S and Stenner, P. Doing Q Methodological Research. Sage Publications. 2012

Explore challenges and key insights for each city