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Social Determinants of Health

The Case of the Diabetic Commuter

Bui, Simonetti, Benson, Malek and Anderson
Published 01/04/2015

A 38-year-old woman who works as an office manager for a company in an urban center, presents for routine follow up of fibromyalgia, migraine headache and diabetes.  She has made several attempts to lose weight but found it difficult to exercise due to limited time in her day for health-related activities.  Two years ago, she moved to the suburbs and currently commutes 70 minutes to work each way. On physical examination, her BP is 150/94 and her BMI is 38. You observe normal sensation on foot exam.  Labs include: A1C 9.4, creatinine 1.1, and no albuminuria.  She has repeatedly deferred eye exam, pap smear and specialist referral due to difficulty in taking time off from her work schedule.  She is currently on metformin 1000 mg bid.  You plan to add lisinopril and refer her to the diabetes educator to discuss insulin therapy and lifestyle modification. 

What other recommendation could play a significant role in her health outcomes?

  1. Refer her to an ophthalmologist close to work and schedule a pap smear at her next visit
  2. Refer her to a health coach for behavioral counseling
  3. Advise her on strategies to minimize her daily commuting time and its impacts
  4. Refer her to a multidisciplinary fibromyalgia program to address her pain

Fast Fact:

A number of studies have documented the association between increased commuting time (by both public transportation and private car, especially greater than 60 min daily) and less time spent on health-related activities such as exercise and food preparation, as well as worse health outcomes, including higher cardiovascular mortality.  Men who reported >10 hours per week riding in a car had 82% greater risk of dying from cardiovascular disease than those who reported <4 hours per week.