From Diagnosis Through Complications: Disparities in Diabetes Care
There is no question that disparities exist in diabetes care, particularly among African Americans and Hispanics living with the disease.
Recent research has confirmed that ethnic and racial disparities occur in diabetes care, and that the issue is consistent throughout a patient’s life with diabetes, beginning at diagnosis and ending in consistently higher rates of complications[1] among ethnic minorities in the US.
The causes of disparities in diabetes care are complex: social determinants of health, a gap in technology use and implicit bias all play a role in a problem that absolutely must be addressed.
Indicators
Disparities in diabetes across ethnic and racial lines exist not just during treatment, but at the time of diagnosis. A recent study found that African American youth were more likely to present in diabetes ketoacidosis (DKA) at the time of their diagnosis than their Non-Hispanic White counterparts.[2] The same study found that both African Americans and Hispanics were in a higher body mass index (BMI) percentile at the time of their diagnosis.
Throughout the first three years of their type 1 diabetes (T1D) care, African American youth had more severe hypoglycemic events and trajectories with higher HbA1Cs percentages, leading the study authors to the overall conclusion that “youth of minority race/ethnicity have increased markers of poor prognosis of type 1 diabetes at diagnosis and three years postdiagnosis.”
Disparities go beyond A1C measurements, too. A 2020 paper showed a large racial divide in youth with T1D that participated in summer camps through the American Diabetes Association (ADA). In comparison with the general population of children with T1D, minority youth were “more likely to attend day camp, be first-time campers and request financial aid, and they were less likely to be on insulin pump therapy or use continuous glucose monitors.”[3]
A complex problem
As research continues, analysts continue to question what is creating these disparities. Several studies point towards social determinants of health, such as income and access to insurance, as the leading cause for disparities amongst ethnic minorities in the US.
While studying immigrants’ diabetes management and care, one study concluded that “housing precarity, food insecurity, poverty, uninsured and underinsured, and limited support for immigrants in healthcare systems are consistently shown to deter diabetes management and care.”[4]
Another study that was focused on Mexican-Americans with diabetes suggested that concerns regarding negative impacts of medication and concerns regarding a medication’s effectiveness were the largest barriers to their diabetes management.[5]
In a recent publication from the ADA, research reiterated that an individual’s social determinants of health are often a vital indication for what their diabetes management and care levels will be.[6] Researchers suggested community health workers and organizational interventions as some of the best ways to quickly improve prevalent disparities in minority communities.
However, social determinants of health are not the only issue at play.
Technology gap
Research has also shown that even when social economic factors are adjusted for, there is still a major disparity regarding access to diabetes technology.
Despite studies illustrating a direct correlation between pump use and improved health outcomes as well as quality of life[7], Latinx and African American youth are less likely to be offered an insulin pump. Specifically, 61 percent of white participants used a pump, whereas only 29 percent of African American and 39 percent of Latinx were using insulin pumps. [8]
Additional studies have found similar results. One concluded that lower diabetes technology use, diabetes distress and disease self-management are the leading factors behind higher A1Cs for Black, indigenous and people of color (BIPOC) youth with T1D.[9]
Implicit Bias
Many researchers and patients alike have wondered how implicit bias impacts their healthcare. Implicit bias refers to stereotypes or attitudes someone has that impacts their understanding, actions and decisions in an unconscious manner. Although medical students now have to go through implicit bias training, racial bias and racism are still prevalent within the healthcare field.
Many patients with diabetes have reported racial discrimination practices during their healthcare visits, such as a lower number of provider foot examinations being offered to BIPOC patients than offered to non-Hispanic white patients. Overall, this study found that discrimination in healthcare “was associated with worse diabetes care and more diabetes complications” and that “factors beyond patients’ own behaviors may be the main source of differential outcomes.”[10]
Implementing change
Recent research continues to demonstrate the systemic issues BIPOC living with diabetes have at all levels of life, including within healthcare. And although we are a long way away from true health equity, it is worth highlighting some of the ongoing efforts by advocates and scientists to improve these disparities.
One such trial attempted to fix some of these disparities by using photovoice to promote diabetes self-management in Latinx patients. Photovoice is a method in which patients take photographs of their success and challenges in their diabetes management, participants then discuss their photographs in group classes.
In this study, the majority of participants agreed that social support is a necessary, but often lacking, piece of diabetes care. 86 percent of the group later reported that they learned how to better manage their diabetes from other’s photos, and another 93 percent said that sharing photos made them feel more connected to the group. Overall, the researchers concluded that photovoice was “well received by Latinx adults and provided a vehicle to receive and provide social support in self-care.”[11]
There is still a long way to go to bridge the gap between quality of care and outcomes for ethnic and racial minorities living with diabetes, and research alone cannot solve the systemic issues that need addressing.
[1]Loes C. Lanting, MSC, Inez M.A. Joung, PHD, Johan P. Mackenbach, PHD, MD, Steven W.J. Lamberts, PHD, MD, and Aart H. Bootsma, PHD, MD. Ethnic Differences in Mortality, End-Stage Complications, and Quality of Care Among Diabetic Patients. Diabetes Care 2005 Sep; 28(9): 2280-2288. https://doi.org/10.2337/diacare.28.9.2280
[2]Maria Jose Redondo, Ingrid Libman, Peiyao Cheng, Craig Kollman, Mustafa Tosur1, Robin L. Gal, Fida Bacha, Georgeanna J. Klingensmith and Mark Clements. Racial/Ethnic Minority Youth With Recent-Onset Type 1 Diabetes Have Poor Prognostic Factors. Diabetes Care 2018 May; 41(5): 1017-1024. https://doi.org/10.2337/dc17-2335
[3]Jessica M. Valenzuela, Sam E. Records, Kelly A. Mueller, Megan T. Martin and Risa M. Wolf. Racial Ethnic Disparities in Youth With Type 1 Diabetes Participating in Diabetes Summer Camps. Diabetes Care 2020 Apr; 43(4): 903-905. https://doi.org/10.2337/dc19-1502
[4]Martinez-Cardoso, A., Jang, W. & Baig, A.A. Moving Diabetes Upstream: the Social Determinants of Diabetes Management and Control Among Immigrants in the US. Curr Diab Rep 20, 48 (2020). https://doi.org/10.1007/s11892-020-01332-w
[5] Baghikar, S., Benitez, A., Fernandez Piñeros, P. et al. Factors Impacting Adherence to Diabetes Medication Among Urban, Low Income Mexican-Americans with Diabetes. J Immigrant Minority Health 21, 1334–1341 (2019). https://doi.org/10.1007/s10903-019-00867-9
[6] Felicia Hill-Briggs, Nancy E. Adler, Seth A. Berkowitz, Marshall H. Chin, Tiffany L. Gary-Webb, Ana Navas-Acien, Pamela L. Thornton, Debra Haire-Joshu. Social Determinants of Health and Diabetes: A Scientific Review Diabetes Care 2020 Nov; dci200053. https://doi.org/10.2337/dci20-0053
[7] Ghazanfar H, Rizvi S, Khurram A, Orooj F, Qaiser I. Impact of insulin pump on quality of life of diabetic patients. Indian J Endocrinol Metab 2016; 20:506–11.
[8] Willi, S. M., Miller, K. M., DiMeglio, L. A., Klingensmith, G. J., Simmons, J. H., Tamborlane, W. V., Nadeau, K. J., Kittelsrud, J. M., Huckfeldt, P., Beck, R. W., Lipman, T. H., & T1D Exchange Clinic Network (2015). Racial-ethnic disparities in management and outcomes among children with type 1 diabetes. Pediatrics, 135(3), 424–434. https://doi.org/10.1542/peds.2014-1774
[9] Shivani Agarwal, Lauren G Kanapka, Jennifer K Raymond, Ashby Walker, Andrea Gerard-Gonzalez, Davida Kruger, Maria J Redondo, Michael R Rickels, Viral N Shah, Ashley Butler, Jeffrey Gonzalez, Alandra S Verdejo, Robin L Gal, Steven Willi, Judith A Long, Racial-Ethnic Inequity in Young Adults With Type 1 Diabetes, The Journal of Clinical Endocrinology & Metabolism, Volume 105, Issue 8, August 2020, Pages e2960–e2969, https://doi.org/10.1210/clinem/dgaa236
[10] Peek, M. E., Wagner, J., Tang, H., Baker, D. C., & Chin, M. H. (2011). Self-reported racial discrimination in health care and diabetes outcomes. Medical care, 49(7), 618–625. https://doi.org/10.1097/MLR.0b013e318215d925
[11]Arshiya A Baig, Matthew R Stutz, Patricia Fernandez Piñeros, Amanda Benitez, Yue Gao, Michael T Quinn, Marla C Solomon, Lisa Sanchez-Johnsen, Deborah L Burnet, Marshall H Chin, Little Village Community Advisory Board, Using photovoice to promote diabetes self-management in Latino patients, Translational Behavioral Medicine, Volume 9, Issue 6, December 2019, Pages 1151–1156, https://doi.org/10.1093/tbm/ibz082
This content was made possible with support from Medtronic Diabetes, an active partner of Beyond Type 1 at the time of publication, who recognize that a major racial disparity exists in technology use and access in the diabetes community. Did you know that ethnic minorities are 3x less likely to use technology like a CGM or pump? The Medtronic ASK (“Acquire Some Knowledge”) campaign is all about education and raising awareness around this issue.
Learn more on Medtronic’s ASK campaign here.
