Lowering the higher rates of diabetes seen among racial and ethnic minorities requires solutions to address all of the major factors that contribute to diabetes prevalence.
Multidimensional solutions are needed to address the social determinants of health associated with the racial, ethnic, and socioeconomic disparities in diabetes prevalence and outcomes, according to a scientific review published in Diabetes Care.
In the review, those with a lower socioeconomic status (SES) were shown to be more likely to develop type 2 diabetes (T2D), experience more complications, and die sooner than those with a higher SES. SES—which in this study encompasses educational, economic, and occupational statuses—was noted to be a strong predictor of diabetes onset and progression.
“[SES] is associated with the extent to which individuals and communities can access material resources including health care, housing, transportation, and nutritious food and social resources such as political power, social engagement, and control,” said the authors.
They recommended possibly combining literacy-sensitive interventions, which research has shown can result in a small but statistically significant decrease in hemoglobin A1c with evidence-bases behavioral self-management interventions to improve outcomes for minority populations with T2D.
Diabetes, as affected by neighborhood and physical environment, entails how stable housing, infrastructure, walkability, pollution, and green spaces influence diabetes incidence and prevalence. Many of these factors are also related to SES.
The authors found that people with stable housing were more likely to receive evaluation and management services for diabetes than those who were homeless. In addition, the ability to walk to places and having access to green spaces was associated with lower incidence of T2D.
Toxic environmental exposures, such as air and water pollution and ambient nose, have been linked to diabetes in the past, disproportionally affecting racial and ethnic minorities from possible systemic racism in environmental regulation. Additionally, endocrine disrupters (ie, chemicals) can be found in food packaging and fast food, which individuals in low-income neighborhoods are more likely to use.
The researchers noted that addressing environmental issues will take policy changes such as adding green spaces, developing better infrastructure, and mitigating homelessness issues. Additionally, they recommended that research investigate if such actions as testing air and water for toxins, reducing food packaging and heating of plastic containers, minimizing the use of certain cosmetic products, and installing air and water filters, can make a difference on diabetes.
Food environment is determined by the accessibility, availability, affordability, and quality of food. Differences in food environments can be the result of government policies and incentives that limit the availability of nutritious food, including red-lining policies and segregation.
The researchers found that people who lived in areas with a high ratio of healthy to unhealthy food outlets had better glycemic control, took less time to achieve glycemic control compared with individuals who lived in less advantaged areas, and had a lower risk for hypoglycemia. Additionally, food insecurity can undermine a person’s ability to care for themselves and increases depressive symptoms and diabetes distress.
They also said that interventions can help lower the risks of developing diabetes and improve clinical and psychological outcomes by increasing diabetes-targeted foods and self-management care at food banks and increasing the number of grocery stores in low-income neighborhoods.
The authors stated that health insurance access and affordability is the strongest predictor of whether diabetes screening and care are accessible to adults.
“Compared with insured adults with diabetes, the uninsured have 60% fewer office visits with a physician, are prescribed 52% fewer medications, and have 168% more emergency department visits,” they said.
Specialists, such as endocrinologists, may not be accessible in many geographic regions with high diabetes prevalence, according to the authors. Therefore, addressing health care problems will take major policy change, such as expanding Medicaid services to include more diabetes care provisions. For example, the Affordable Care Act is responsible for increasing the number of insured adults with diabetes by 777,000 between 2009 and 2016. They also recommended increasing community health worker interventions in African American and Hispanic communities with T2D and comorbid conditions.
Lastly, the review stated that lack of social cohesion and social support impact diabetes incidence and are associated with increased mortality and diabetes-related complications. Although there is no current research on how interventions on social cohesion and support impact diabetes outcomes, the researchers found that Hispanic and African American communities have benefitted from telephone, group, and internet support.
Future research should be conducted to determine whether change in SES has an impact on diabetes.
Hill-Briggs F, Adler NE, Berkoqitz SA, et al. Social determinants of health and diabetes: a scientific review. Diabetes Care. Published online November 2, 2020. doi:10.2337/dci20-0053