Reimagining Type 2 Diabetes Prevention and Management: From Lived Experience to Digital Equity

The challenge

Asha is 29 years old and has just been diagnosed with type 2 diabetes (T2DM) with a very high HbA1c (90 mmol/mol). She works full-time in retail while caring for her mother, who is dying from cancer. Her mother developed diabetes following gestational diabetes in her twenties, and her older brother died from T2DM complications in his thirties.

For Asha, the diagnosis felt less like a shock and more like confirmation of an inherited inevitability. She had tried to make changes to improve her weight, but the daily strain of juggling work, grief, and caring left little room for self-care.

Asha’s story is not unusual. It captures how social and emotional pressures, genetic vulnerability, and structural inequality intertwine to shape risk and response. Why does our system continue to fail people like her, despite decades of prevention research, policy and innovation?

Understanding why prevention is failing some communities

T2DM is one of the most pressing public health challenges of our time, with rates rising fastest among younger adults and communities experiencing multiple forms of disadvantage(1,2). Despite substantial investment in prevention programmes and pharmacological advances, inequities in who develops T2DM, who experiences complications, and who benefits from care continue to widen(3).

During my DPhil, I set out to understand why these inequities persist. My research examined how people experience a pre-diabetes diagnosis and how this label shapes behaviour, motivation, and identity. Through interviews and focus groups with patients, clinicians, and policymakers, I found that while the diagnosis was often framed as a “wake-up call”, for many it produced frustration, guilt, and stigma rather than empowerment(4).

Those most affected by disadvantage were navigating intersecting structural constraints— insecure employment, financial strain, structural racism, and gendered caring responsibilities. For them, lifestyle change was often unattainable, and prevention advice felt detached from their lived reality.

These findings, published in the BMJ and the British Journal of General Practice, showed how prevention strategies built on individual responsibility fail to engage with the social and economic conditions that shape health (5,6). Health behaviours are not simply a matter of willpower; they reflect opportunity, resources, and the pressures of daily life amidst a cost-of-living crisis.

Lessons from the consulting room

As a GP Clinical Lead for Diabetes in a practice serving a diverse community in a deprived area, these insights resonate daily. Many of my patients are young people balancing low-paid work, family responsibilities, and financial insecurity. Advice to “eat more healthily” or “be more active” often collides with the realities of time scarcity and food insecurity.

For those already living with T2DM, these same pressures undermine management. Attending reviews, accessing specialist advice, or adhering to medication plans can be impossible when life is unpredictable. Many experience shame, stigma, and diabetes distress; others face digital exclusion or mistrust remote services (7,8).

Clinicians recognise these challenges yet face systemic constraints of their own. Consultations are brief, pathways fragmented, and much of the burden of self-management falls on those least able to carry it (9).

Policy perspectives and structural barriers

My research with local and national policymakers revealed similar tensions (10). Policymakers were acutely aware that social determinants such as housing, employment, and poverty drive outcomes, but short funding cycles and political imperatives often push focus towards individualised interventions that show quick results.

The result is a “high-risk” model that targets individuals already on the path to diabetes rather than addressing the environments that produce risk. This approach inadvertently widens inequality: those with time, education, and stability can act on prevention advice or access emerging treatments such as GLP-1 agonists, while those facing intersecting disadvantages are left behind.

Building on this work

Through my current NIHR Development and Skills Enhancement Award, I am extending this work to examine how primary care, public health, and community systems interact to shape T2DM prevention and management. My ongoing scoping and narrative synthesis have revealed two major evidence gaps.

First, there is limited understanding of how community, clinical, and policy systems intersect to form real-world care pathways. Second, while digital and artificial intelligence (AI) tools are increasingly developed to support diabetes care, they rarely include input from the people expected to use them. Tools are often designed for efficiency and scale, not inclusion. Few studies consider how digital literacy, trust, or access shape engagement and outcomes.

Digital promise, digital peril

Digital health technologies offer extraordinary potential to enhance T2DM prevention and management by providing personalised, continuous support. AI-driven platforms can help people interpret results, track patterns, and receive tailored guidance. Yet, as colleagues and I argued in a BMJ editorial, digital innovation without inclusion risks reinforcing the inequalities it seeks to address (11).

The people most at risk of poor diabetes outcomes are often least likely to benefit from these technologies— hindered by language barriers, digital illiteracy, or limited trust in online systems. The challenge is therefore not only technical but ethical: how do we ensure that digital transformation serves everyone, not just those already digitally privileged?

From insight to innovation

My future research will address this question directly. Using mixed methods, narrative inquiry, epidemiological analysis, and participatory systems mapping, I aim to explore how AI and digital tools can be integrated into primary care in ways that are ethical, equitable, and grounded in lived experience.

Collaboration is central to identify where technology adds value, where it creates risk, and what conditions allow innovation to thrive without deepening inequity. The aim is not to produce more tools but to deploy them responsibly within complex systems. By embedding digital design within the realities of daily life and care delivery, interventions can become not only effective but socially attuned and trusted.

A systems lens for care and innovation

In clinical practice, I see both sides of this reality. Some patients find digital tools empowering with apps that monitor their glucose levels, inform patients of their results, portals that simplify communication, online groups that provide peer support. For others, these same tools are alienating or inaccessible. True innovation lies not in technology itself but in how health systems adapt to use it fairly.

By adopting a systems perspective, recognising the interdependence of social structures, clinical pathways, and digital ecosystems, my research seeks to identify leverage points where small, evidence-informed changes could deliver large-scale benefit for people living with, or at risk of, T2DM.

A call to action

As we mark World Diabetes Day, the future of T2DM prevention and management depends on recognising lived experience as a vital form of knowledge and evidence. To make meaningful progress, we must move away from uncritical technological optimism, towards approaches grounded in the realities of people’s lives, with equity-driven, context-aware systems.

Health systems must be designed with equity in mind, building pathways that reflect the complexity of people’s lives and evaluating not only whether interventions work, but for whom, in what contexts, and at what cost (12).

Only by uniting structural understanding with digital imagination can we create a future in which type 2 diabetes prevention and management are effective, inclusive, and just.

Eleanor completed this research as part of her DPhil in Primary Health Care. Click here to learn more about our DPhil programmes.

References

1. Misra S, Ke C, Srinivasan S, Goyal A, Nyriyenda MJ, Florez JC, et al. Current insights and emerging trends in early-onset type 2 diabetes. Lancet Diabetes Endocrinol. 2023 Oct 1;11(10):768–82.
2. Lim LL, Jones S, Cikomola JC, Hivert MF, Misra S. Understanding the drivers and consequences of early-onset type 2 diabetes. The Lancet. 2025 Jun 28;405(10497):2327–40.
3. Health inequalities in 2040 | The Health Foundation [Internet]. 2024 [cited 2025 Mar 27]. Available from: https://www.health.org.uk/reports-and-analysis/reports/health-inequalities-in-2040
4. Barry E. Type 2 diabetes prevention policy and practice: a multimethod qualitative study exploring the perspectives of patients, clinicians, and policy makers [Internet] [http://purl.org/dc/dcmitype/Text]. University of Oxford; 2024 [cited 2025 Sep 27]. Available from: https://ora.ox.ac.uk/objects/uuid:a61c0220-85dd-4a03-95f2-3da468339e83
5. Barry E, Greenhalgh T, Papoutsi C, Shaw SE, Ferrey A, Rutter H. Preventing type 2 diabetes: A qualitative study exploring the complexity of health-related practices in people with pre-diabetes. Br J Gen Pract [Internet]. 2025 Sep 10 [cited 2025 Sep 27]; Available from: https://bjgp.org/content/early/2025/09/12/BJGP.2025.0208
6. Barry E, Roberts S, Oke J, Vijayaraghavan S, Normansell R, Greenhalgh T. Efficacy and effectiveness of screen and treat policies in prevention of type 2 diabetes: systematic review and meta-analysis of screening tests and interventions. BMJ. 2017 Jan 4;356:i6538.
7. Hadjiconstantinou M, Dunkley AJ, Eborall H, Robertson N, Khunti K, Davies M. Perceptions of healthcare professionals and people with type 2 diabetes on emotional support: a qualitative study. BJGP Open [Internet]. 2020 Apr 1 [cited 2025 Nov 5];4(1). Available from: https://bjgpopen.org/content/4/1/bjgpopen20X101018
8. Diabetes UK [Internet]. [cited 2025 Nov 5]. Chapter 3 - Diabetes distress. Available from: https://www.diabetes.org.uk/for-professionals/improving-care/good-practice/psychological-care/emotional-health-professionals-guide/chapter-3-diabetes-distress
9. Barry E, Blane D, Ross J, Freeman J. Conversations matter: improving the diagnosis experience for people with type 2 diabetes. Br J Gen Pract. 2024 Nov 1;74(748):489–90.
10. Barry E, Greenhalgh T, Shaw S, Papoutsi C. Explaining the UK’s ‘high-risk’ approach to type 2 diabetes prevention: findings from a qualitative interview study with policy-makers in England. BMJ Open. 2023 Feb 1;13(2):e066301.
11. Morley J, Cowls J, Taddeo M, Floridi L. Public Health in the Information Age: Recognizing the Infosphere as a Social Determinant of Health. J Med Internet Res. 2020 Aug 3;22(8):e19311.
12. Bolton KA, Whelan J, Fraser P, Bell C, Allender S, Brown AD. The Public Health 12 framework: interpreting the ‘Meadows 12 places to act in a system’ for use in public health. Arch Public Health. 2022 Mar 7;80(1):72.