Diabetes has been a model disease for illustrating the impact of social determinants of health (SDOH), and presenters in ADA Diabetes Care Symposium—Social Determinants of Health—Impact on Diabetes Development and Care explored the issues of food insecurity, physical environment, and economic adversity in relation to diabetes.

The session can be viewed by registered meeting participants at ADA2023.org. If you haven’t registered for the 83rd Scientific Sessions, register today to access the valuable meeting content through August 28.

Felicia Hill-Briggs, PhD, ABPP, Professor at the Feinstein Institutes for Medical Research at Northwell Health, provided an overview of SDOH in the development of diabetes in a pre-recorded presentation.

Dr. Hill-Briggs was the chair of the committee that wrote the scientific review of SDOH for the ADA journal Diabetes Care in January 2021. The group reviewed five SDOH and their component factors: socioeconomic status, neighborhood and physical environment, food environment, health care, and social context. She kept her focus on socioeconomic factors.

“We know there are longstanding patterns of lower socioeconomic status and higher development of diabetes,” she said.

SDOH are cyclical, intergenerational, population-based, and systemic, she continued. The U.S. government uses the five determinants identified in the scientific review. These can be conceptualized as individual-level needs and shape how interventions and mandates are often defined.

The World Health Organization (WHO), however, does not start there; rather, it includes SDOH before all the others that encompass governance, social and public policy, and cultural values.

“The implication here is that the WHO is recommending policy interventions in order to address these upstream, contextual factors that set the stage for the adverse SDOH,” Dr. Hill-Briggs said. “And they recommend population-level intervention, rather than at an individual level.”

Historical context and racism are also factors in the root causes of SDOH in diabetes, she explained. Anti-literacy laws and segregation affected educational opportunities for Black and African-American students, and educational disparities exist to this day. Income disparities are gross and persistent, as are neighborhood and housing disparities.

There are emerging actions: The Centers for Disease Control and Prevention (CDC) has developed the Health in All Policies approach that integrates and articulates health considerations into policymaking across sectors to improve the health of all communities and people.

“Adding socioeconomic and political context and racism into U.S. governmental SDOH frameworks as root causes can expand the range of interventions—especially policy—that are investigated and pursued,” Dr. Hill-Briggs concluded. “Such interventions will require a Health in All Policies approach and multi sector collaboration.”

Seth A. Berkowitz, MD, MPH, Associate Professor of Medicine at the University of North Carolina School of Medicine, discussed food insecurity and diabetes and the social context in which food insecurity occurs.

A lack of consistent access to food needed for a healthy life affects about 10% of the U.S. population. Of those, about 20% are people with diabetes.

Food insecurity is principally a problem of distributive institutions, he said, and distribution happens in one of three ways: “factor payment,” as from a job or business; pooled money in a household; and income-support or state-transfer programs. But about half of the population is not employed for reasons such as age, disability, or student status.

“Even if you are working, the factor payment system might result in income that is insufficient to avoid food insecurity,” Dr. Berkowitz said.

Employer bargaining power and discrimination in the education system and labor market are among factors that affect income.

State transfers can have administrative burdens and phase-out requirements that make it difficult to get benefits.

“A lot of people are not getting the benefits that they could,” he said.

He outlined three evidence-supported mechanisms between food insecurity and poor type 2 diabetes outcomes: nutritional, compensatory, and psychological mechanisms. Nutritional concerns limit food options, while compensatory issues could mean choosing food over medication. And food insecurity can create psychological issues such as depression.

Food insecurity, and its effects on diabetes, can be addressed outside and inside of health care, Dr. Berkowitz said. Outside support happens at the law and policy level by reforming income-support programs, and inside support happens with clinical management programs and material resources.

“It’s important to recognize these are not mutually exclusive; they can and should be more effective if worked on in parallel,” he said.

Mahasin Mujahid, PhD, MS, FAHA, Associate Professor of Epidemiology at the University of California, Berkeley School of Public Health, covered the neighborhood physical environment and social cohesion as they relate to diabetes prevalence and care. The presentation was linked to a scientific review Dr. Mujahid and her colleagues published in Diabetes Care that showed neighborhood environments significantly influence the development of diabetes risk factors, morbidity, and mortality.

Michelle Albert, MD, MPH, Professor of Medicine at the University of California San Francisco, addressed the topic of economic adversity as a driver of outcomes for individuals with diabetes.

The June 23 death of Dr. Hill-Briggs was announced at the end of the session. An upcoming issue of Diabetes Care will be dedicated to her memory.