Diabetes and health inequalities: the view from America

Under-resourced populations bear the biggest burden of diabetes – and are set to bear the brunt of the alarming rise in diabetes prevalence. In the first of a two-part series posting on Horizons this week, Dr Susan Aldridge reports on presentations from three speakers at the EASD 2022 meeting who discussed the challenges faced in their own part of the world – and some of the solutions. First up: a view from the USA.

According to the International Diabetes Federation (IDF), the prevalence of diabetes is rising at an alarming rate, from 4.6% of the world’s population in 2000 to 10.0% in 2021 and is estimated to reach 12.5% (more than 780 million people) in 2045, if no action is taken.

Health inequality and under-resourcing are challenges for diabetes care everywhere, and the USA – despite its wealth and influence – is no exception. Dr Shivani Agarwal, Assistant Professor of Medicine at Albert Einstein College of Medicine, New York, looked at some of the challenges faced here. (Her talk was given by Dr Anne Peters, Professor of Clinical Medicine at the University of Southern California).

In the USA, 11.3 % of the population has diabetes. “Diabetes is a societal disease,” Professor Peters said. “We know there are three key features that interact – income, education and race or ethnicity – and influence having and doing poorly with diabetes.” So, rates are highest in Amerindians and Alaskan natives at 14.5%, compared with 7.4% in White non-Hispanic people. Those with less than a high school education and those with the lowest incomes are also the most likely to develop diabetes. Diabetes is also on the increase among the young in the USA, with type 2 increasing faster than type 1, especially in the Black non-Hispanic population. 

Many factors influence diabetes care and outcomes. It starts at the top with public policy, including research funding and health insurance, then there is the societal level, with factors like structural racism and market forces. Below that is the community, with the social determinants of health like education, neighbourhood and built environment, and economic stability. Finally, there are individual factors like genetics, duration, family history and diabetes care, including monitoring, clinic visits, technology, insulin and nutrition.

Racial and ethnic disparities in the USA

Professor Peters pointed to three trajectories in studies of HbA1c over time with ethnicity. In one, levels stayed the same from diagnosis (though still higher than 7%), the second did less well and the third much worse. Those in the second two groups were more likely to be Black or Hispanic. The same trend is seen in deaths from diabetes. Although these are coming down, there is a long way to go before they are equal to levels in white people.

When it comes to tackling health inequality, how much is wishful thinking and how much is possible? Healthcare professionals are increasingly aware of what needs to be done in education and screening for risk – but is this enough?

“Education is a start, but certainly not an end in itself,” Professor Peters said. “How will theoretical knowledge translate to practical care situations and will dissemination of knowledge be evenly distributed among those who need to know?”  

And how will identification through screening solve the problem of health inequality, without the tools and strategies to address social needs? “I think it is really important that healthcare providers know how to access community resources,” Professor Peters said. “It can be really hard when you’re busy in clinic to know how to get patients connected to the right resources. We need a team of people working with our patients. I really value the social workers and community health workers I work with. And I think it’d be a good idea to pay for all this, because it cuts costs downstream. At present, we don’t necessarily have funding for the kind of care our patients need.”

There is a great need for research in this area – pragmatic studies with stakeholder involvement, looking into the impact of psychosocial stress and resilience, cultural relevance and focusing on implementation and sustainability. “Often these projects are not sustained, and we leave these communities no better off.” Professor Peters said.  “So Shivani says – and I agree with her – that we can focus on individual and relationship issues but often we don’t deal with community issues or society at large.”

Lessons from Los Angeles

Professor Peters went on to show what she and others have been able to do in Los Angeles to change things for their under-resourced patients. “I’m a real believer that if we’re champions we can make a big difference. So we need to unite public health and diabetes care with more collaboration with public health and community organisations.”

Leaders in this kind of work need to be engaged and knowledgeable on the impact of area initiatives on diabetes health, such as housing, encouraging social cohesion, infrastructure (avoid food deserts), food banks and empowering patient advocates and faith organisations to give the underserved a voice.   

“Big problems need big solutions and big players. Everyone in this room needs to make a lot of noise in their own countries to make a difference – get the politicians involved to change government policies.”

Speaking more personally, Professor Peters committed to staying in same place – Los Angeles county – for 30 years, so people could get to know her. She started community participatory research in two under-resourced areas in Los Angeles to try to address people’s needs when it came to healthy lifestyle and, as a result, set up both a ‘safe’ walking group and a farmers market. ­ 

She also created a diabetes working group within the local health department and this created a formulary with GLP-1 receptor agonists, SLGT-2 inhibitors and long and rapid-acting insulins, to provide ‘great care’ to people with diabetes. She also campaigned to get continuous glucose monitoring (CGM) for all patients with type 1 diabetes and their outcomes have improved. “This is a form of health equity and, thanks to a donation, people with type 2 diabetes now also have CGM and we are doing a study on this.”

And finally, she has been mentoring Skyla, a young person at risk due to endemic racism, since the girl – now in college – was eight years old. Working in this way, Professor Peters and colleagues were able to give Skyla an opportunity.

So, big gaps continue to exist in the USA in terms of health equality. The issue is real and multifactorial. “Remember to work with your patients and communities to find out what is needed,” she concluded. “We only know our own solutions, not theirs. We all have to be champions.”

To learn about the Asian and European perspectives on this topic, read part two of this series, tomorrow on Horizons.

Any opinions expressed in this article are the responsibility of the EASD e-Learning Programme Director, Dr Eleanor D Kennedy.