Being a minority person with diabetes doubles down on the health care disparities that vulnerable minority populations already face.
That’s according to the five researchers who presented the Scientific Sessions symposium Disparities in Diabetes and Diabetes Care—What Can We Do about It? The session can be viewed by registered meeting attendees at ADA2020.org through September 10, 2020. If you haven’t registered for the Virtual 80th Scientific Sessions, register today to access all of the valuable meeting content.
Ashley M. Butler, PhD, Associate Professor of Pediatrics at Baylor College of Medicine, reviewed community- and family-based strategies to improve type 1 diabetes management among African American and Latino school-aged children. African American and Latino families face serious roadblocks to diabetes management, she said, noting they are more likely to have food insecurity, financial insecurity, employment challenges, school challenges, and less social integration.
“Research shows minority children are less likely to have a written plan in the school setting around diabetes, less likely to have a school nurse, and parents are less likely to be aware of the laws in place that place them at an advantage to have access to resources,” she added.
Dr. Butler emphasized the importance of intervening early in the diabetes disease course with less intense, universal interventions to mitigate disparities. She recommended using community outreach with more inclusive language and images, making sure families are linked to personalized written community resources, and also providing lay worker navigation, computer interventions, and in-home videoconferencing.
“Universal interventions really need to integrate a focus on both social contributors to diabetes outcomes as well as behavioral, with the goal of mitigating disparities early in the disease course,” she said. “There’s a need to develop and implement low-intensity strategies for minority youth, particularly those who are newly diagnosed and those with younger children. Multidisciplinary teams can use their expertise and innovation to implement those strategies.”
Young adults are developmentally unique and particularly vulnerable as they navigate life transitions. When you add minority status to this equation, it increases vulnerability exponentially, said Shivani Agarwal, MD, MPH, Assistant Professor of Medicine–Endocrinology and Director of the Supporting Emerging Adults with Diabetes Program at the Fleischer Institute for Diabetes and Metabolism.
Dr. Agarwal reviewed data from the Young Adult Racial Disparities in Type 1 Diabetes Study (YARDD), a study she developed and conducted as the principal investigator that examined how social determinants of health contribute to A1C disparities. YARDD results indicated that non-Hispanic Blacks and Hispanics had lower socioeconomic status and higher A1C than their white peers, and much less frequent use of diabetes technology. However, Black young adults differed from Hispanic young adults, reporting higher diabetes distress and lower self-management. Dr. Agarwal offered some suggestions for mitigating diabetes in these populations.
“We need to tailor our care for young adults in general, but also for these underserved young adults, understanding these cultural and historical contexts they live in,” she said. “For patient-provider relationships, we need to think about how we can change our care approaches and communication strategies, understanding what motivational interviewing is, getting training on it, and becoming more culturally appropriate in delivering care. That’s really important. Lastly, shared decision-making. I think this is for anyone with diabetes, especially for these young adults and especially for these underserved young adults who don’t really have a voice otherwise. Giving them the floor, making sure they’re involved in decision-making, especially with regard to technology, and using low health literacy materials and show-and-tell techniques as opposed to written materials is going to be really important for mitigating disparities.”
Elizabeth Lynch, PhD, Associate Professor at Rush Medical College, discussed how diets and social networks affect diabetes disparities. Higher socioeconomic status (SES) typically translates to a higher quality diet, while lower socioeconomic status is associated with poorer diet quality, which leads to an increased risk of diabetes, she explained.
The social network effect is when an individual is more likely to engage in a behavior based on the number of people in their social network who are engaged in that behavior. In the Lifestyle Improvement through Food and Exercise Study, a lifestyle intervention study to promote diabetes self-management among low-income African Americans with uncontrolled type 2 diabetes, Dr. Lynch and her team found that violating the eating norms of a social network was a significant and often upsetting barrier to participants as they tried to change their diets.
“These conditions are consistent with sociological data that shows network effects increase inequality across a bunch of domains—labor, migration, education. Dietary behavior is one of those,” she said. “We can see this systematic effect of social networks on dietary behavior that then may result in health inequities as well. Dietary behavior is vulnerable to network effects, which exacerbate social inequalities. Social networks make it difficult for low SES individuals to adopt a high-quality diet. We need to better understand social network phenomena in diet and other health behaviors in order to understand health disparities.”
Latinos currently make up about 15% of the U.S. population and that number is projected to grow to 30% by 2050, said Arshiya A. Baig, MD, MPH, FACP, Associate Professor of Medicine in the Section of General Internal Medicine and Associate Director of the Chicago Center for Diabetes Translation Research at the University of Chicago. The majority of U.S. Hispanics are of Mexican origin and the diabetes prevalence is very high in this population, she said. About 19% of Mexican American adults have diabetes, according to the Centers for Disease Prevention and Control.
“We need multi-pronged interventions to tackle Latino diabetes disparities,” Dr. Baig said. “We need to integrate patient input and community partnerships to gain trust and utilize local resources. Ultimately, we want results that are practical and relevant to patients and policymakers. I think the disparities we see are being translated to what we’re seeing with the COVID pandemic. It’s just amplifying what is already there.”
At the time of her presentation, Hispanic COVID-19 cases in Illinois comprised 44.6% of all cases in the state, and more than 50% of Latinos tested for COVID-19 were positive. To address these underlying health disparities, Dr. Baig called for more testing and contact tracing, culturally and linguistically tailored messaging, more support for local nonprofits and health care systems, and improved workplace protections.
Jeffrey S. Gonzalez, PhD, Professor of Psychology and Medicine and Director of the New York Regional Center for Diabetes Translation Research at Yeshiva University and Albert Einstein College of Medicine, reviewed various interventions designed to reach socioeconomically disadvantaged adults with type 2 diabetes.
Dr. Gonzalez shared results from the Bronx A1C study spearheaded by Elizabeth Walker, PhD, RN. The randomized controlled trial examined how telephonic interventions could be used to improve metabolic control in a low-income, multi-ethnic sample of 941 English- and Spanish-speaking adults with type 2 diabetes and A1C greater than 7% from the New York City Department of Health and Mental Hygiene’s A1C Registry.
“Telephonic self-management support is feasible, acceptable, and effective at improving A1C and hospitalization outcomes,” Dr. Gonzalez said. “It has a wide reach to underserved populations. Prior studies that have involved in-person visits would have had a harder time reaching these people.”