Issue: November 2020
Disclosures: Disclosures: Stanford reports she is a consultant for Calibrate, Doximity, GoodRX and Novo Nordisk. Blackstock, Hill Golden, Joseph and LeRoy report no relevant financial disclosures.
November 20, 2020
11 min read

Inequities in health outcomes prompt renewed calls for change

Issue: November 2020
Disclosures: Disclosures: Stanford reports she is a consultant for Calibrate, Doximity, GoodRX and Novo Nordisk. Blackstock, Hill Golden, Joseph and LeRoy report no relevant financial disclosures.
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Racial discrimination across generations — both overt and subtle — has had profound consequences for the health of Black Americans and other underrepresented populations.

Issues such as environmental exposures and stress, diet and lifestyle can all induce changes even at the epigenetic level, according to experts, determining which genes are turned “on” or “off” and influencing health outcomes.

Black patients often seek but have a difficult time finding Black physicians, according to Fatima Cody Stanford, MD, MPH, MPA, FAAP, FACP, FAHA, FTOS.

Photo by Jeff Schear. Printed with permission.

The results can be clearly seen on maps showing high rates of obesity and type 2 diabetes that overlap with areas of marginalized communities.

“The people most likely to benefit from chronic treatment of obesity — those from Black and minority communities — do not receive a diagnosis of obesity,” Fatima Cody Stanford, MD, MPH, MPA, FAAP, FACP, FAHA, FTOS, an obesity medicine physician scientist at Massachusetts General Hospital and Harvard Medical School, told Endocrine Today. “Studies demonstrate that communities of color are less likely to receive a diagnosis of obesity despite the higher prevalence.”

Obesity is the strongest risk factor for development of type 2 diabetes, in particular, and the prevalence of type 2 diabetes is substantially higher among Black and other historically underrepresented groups compared with white adults. According to 2020 diabetes statistics from the CDC, the prevalence of diagnosed diabetes among U.S. residents is 14.7% for American Indians and Alaska Natives, 12.5% for people of Hispanic origin, 11.7% for Black adults and 7.5% for non-Hispanic whites.

“Diabetes preferentially disadvantages American Indians, Alaskan Natives, non-Hispanic Blacks and Hispanics, but end-stage renal disease is three times higher in non-Hispanic Blacks and is almost one and a half times higher in Hispanics vs. whites,” Griffin Rodgers, MD, MACP, director of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), said during an October congressional briefing on addressing racial and ethnic disparities in research. “These disparities are further exacerbated by the ongoing and novel coronavirus pandemic [and] are associated with increased rates of infection and disproportionately poor outcomes from COVID-19 in individuals with these same [cardiometabolic] conditions.”

Uché Blackstock

The disproportionate rate of diabetes, particularly in Black communities, now coupled with the ongoing COVID-19 pandemic, has demonstrated structural inequities that endocrinologists, obesity medicine specialists and diabetes care and education specialists have an opportunity to change, according to experts.

“We are in the midst of an unprecedented time — a horrible pandemic that has exposed racial health inequities, and then the killing of Black Americans that have been very public,” Uché Blackstock, MD, founder and CEO of Advancing Health Equity and former associate professor of emergency medicine at the New York University School of Medicine, told Endocrine Today. “People feel paralyzed. These are conversations we need to have, but people wonder: ‘What do I do? How can I make a difference?’”

Structural racism and diabetes risk

It is crucial to recognize that environment influences a person’s “individual choices” that can lead to metabolic diseases, such as obesity, prediabetes and overt type 2 diabetes, according to Sherita Hill Golden, MD, MHS, the Hugh P. McCormick Family Professor of Endocrinology and Metabolism and vice president and chief diversity officer of the office of diversity, inclusion and health equity at Johns Hopkins Medicine. Many populations at high risk for development of type 2 diabetes live in environments — and seek health care in systems — that have been shaped by structural racism, she said.

“These important social determinants of health contribute to poor health for Black Americans and other marginalized communities who live in these neighborhoods,” Golden told Endocrine Today. “Therefore, many of our patients have limited choices, in reality.”

These factors fall into two categories, Golden said. The first is medical and scientific contributors. Eugenics theory, defining certain races and ethnicities as biologically inferior, and experimentation on enslaved and other vulnerable groups without their consent, led many Black Americans to distrust the medical establishment and resulted in health care provider bias toward Black patients, Golden said.

“This leads to poor quality of care and decreased participatory decision-making in the patient-provider relationship, as well as poor access to health care,” she said.

Historically, a lack of Black physicians due to the closure of medical schools that trained Black students in 1910, following publication of the Flexner Report on medical education in the U.S., left only two institutions training Black physicians at a time when they could not gain access to predominantly white medical schools due to discrimination.

That shift led to effects felt today, Stanford said.

“People like to go to places where they see people that look like them and they feel comfortable engaging,” Stanford said. “My Black patients tend to do very well with me, but maybe not so well with other, white providers, because they see me as someone they can identify with. They think I will have their best interests at heart, and that is in part because of historical issues that have happened in this country with respect to health care, and there is validity to that. As a Black physician, I have found myself trying to find someone who looks like me to deliver care, thinking they might be more understanding of what my daily thoughts are regarding systemic disease.”

Sherita Hill Golden

The second of Golden’s categories refers to social conditions and policies resulting in structural and institutional racism — redlining and predatory lending practices that persisted for years, leading to racial residential segregation; inadequate investment to maintain public works and school systems in redlined neighborhoods; and discrimination in access to high-quality jobs with adequate health insurance.

The present-day result has been decreased neighborhood stability, cleanliness, open spaces, parks, healthy food and affordable housing in those communities.

“Too often, for chronic medical problems like diabetes, we’re taught as educators and clinicians that it is due to individual choices,” Blackstock said. “But we have the data to show that there are larger social structures at play that influence the diabetes rates we see in Black communities. We know that structural racism is a key driving force of social determinants of health. Where you have poverty and inequality, you see higher rates of diabetes. That is because of lack of access to health care and healthy foods.”

Reaching disadvantaged communities

Access problems are compounded for individuals who lack things many take for granted: a car, broadband internet, a stable job with health insurance. Clinicians are obligated to try to reach those individuals, according to Gary L. LeRoy, MD, FAAFP, president of the American Academy of Family Physicians.

“That is a giant hill we have to climb,” LeRoy, also associate dean for student affairs and admission at Wright State University Boonshoft School of Medicine in Dayton, Ohio, told Endocrine Today. “Be out in your community that you serve. Shop in the community where you serve. I’ll run into patients in the local shops. It is an interesting social intervention to actually shop where your patients shop. It gives you a better sense of what they are dealing with. Don’t just drive in, do you job and drive home. Be involved. Go to some of the PTA meetings, ask to be invited and speak. Find opportunities where a physician can come out and talk about the importance of things like getting your flu vaccine.”

LeRoy, too, said a lack of diversity in medicine can serve as yet another barrier to care.

“I don’t know an endocrinologist of color in our entire county that I refer to,” LeRoy said. “Sometimes, I ask patients how was that discussion with, say, the endocrinologist. And that patient will say, ‘Well, he or she didn’t listen to me,’ or ‘Well, I didn’t really understand what he or she was saying.’ Or they said, ‘Well, they told me I have to lose 25 pounds.’ We must educate on the importance of social determinants of health. These clinicians are not bad people. They are just not aware of the social challenges some people who are not within their social bubble have.”

Joshua J. Joseph, MD, MPH, FAHA, assistant professor of medicine in the division of endocrinology, diabetes and metabolism at The Ohio State University Wexner Medical Center, said clinicians should keep three key goals in mind to reach patients.

“I like to say investigate, educate and motivate,” Joseph told Endocrine Today. “Really talk to your patient. Investigate what are the barriers in their lives leading to poor control. Use person-first language — not saying someone is ‘diabetic,’ but that they are a person with diabetes. A person is not ‘non-adherent.’ Instead, ask, ‘Are you taking the medications you’re prescribed?’ If not, what are the barriers that limit your ability to take medications consistently? If you don’t take that additional step and simply say the person is non-adherent, you’re never going to get there.”

Community engagement is also key, Golden said.

“Endocrinologists and obesity medicine specialists can also engage in and promote academic-community partnerships to deliver health care needs to communities where trust with the medical establishment has been compromised,” Golden said. “For example, during the COVID-19 pandemic, Johns Hopkins Medicine partnered with community organizations to deliver culturally appropriate public health preventive measures and to start up a mobile COVID-19 testing site in the local community, away from the hospital.”

At the October congressional briefing, Rodgers said taking social determinants of health “out of context” will not yield the same benefits that could be derived from working together with groups outside of NIDDK.

“Understanding the role of social determinants of health, beyond race and ethnicity, is pivotal to moving the needle effectively,” Rodgers said after the briefing. “As an example, we are trying to work with the U.S. Department of Transportation, the Department of Education, and people in the Department of Housing and Urban Development. Because one can imagine the roots of certain problems may exist in areas of where people live, for example. If we can address those issues, we would have, in the longer term, a better way of attacking not only obesity and potentially diabetes, but the underlying risk factors for liver disease and certain types of cancer. That is something we are actively engaged in at the moment.”

Race inequities in clinical trials

Joshua J. Joseph

Data from clinical trials show that findings often do not apply to historically underrepresented populations, and trialists must adopt cultural competency practices to recruit and retain Black and Hispanic participants.

Often clinical trial data are confounded by the fact that global trials do not emphasize the recruitment of Black and Hispanic adults as priority populations, Joseph said. This means that health care providers are limited in what they can say with confidence to high-risk populations about particular study interventions.

In a systematic review and meta-analysis published in February 2019 in Diabetes Obesity and Metabolism, Basem M. Mishriky, MD, assistant professor in the department of internal medicine at the Brody School of Medicine at East Carolina University, and colleagues, compared SGLT2 inhibitors, GLP-1 receptor agonists and DPP-IV inhibitors with placebo for adults with type 2 diabetes across 11 cardiovascular outcomes trials assessing three- or four-point major adverse cardiac events. Of the 102,416 participants enrolled in the trials, only 4,601 participants, or 4.5%, were Black.

Pooled results showed no significant difference in the incidence of major adverse CV events among the three classes of diabetes medications vs. placebo among Black participants with type 2 diabetes, with an overall RR of 0.94 (95% CI, 0.77-1.16). Results persisted in analyses stratified by medication class.

The researchers noted that the available data were underpowered, and that it is possible that different medications within the same drug class may have different effects on CV risk among Black adults, and “additional studies targeting Black patients are needed to evaluate cardiovascular benefit.”

“This paper showed that there is a huge question around the impact of medications like SGLT2 inhibitors on CV health in Black adults,” Joseph said. “This demonstrates the point that we need greater participation in these trials, not only in the U.S., but throughout the world.”

Gary L. LeRoy

Results can also differ for Hispanic adults. According to the NIH’s National Institute on Minority Health and Health Disparities, less than 8% of clinical trial enrollees are Hispanic, despite Hispanic adults comprising 17% of the U.S. population.

Joseph pointed to five common barriers that are associated with a lack of participation among underrepresented adults in clinical trials: mistrust, lack of comfort, lack of information, lack of awareness, and time and resource constraints.

“The one that is not talked about as a barrier — but it is one — is the lack of clinical trial workforce diversity,” Joseph said. “When we think about these things, the biggest solution to this is building relationships with communities of individuals appropriate for clinical trials. How do you build trust? It is about community engagement.”

The Ohio State University Wexner Medical Center now holds a regular “community scientist academy,” where individuals go through an 8-week program to learn about clinical trials and how they can participate. The program has brought results, Joseph said.

“In that 8 weeks, we are training people to participate in clinical trials,” Joseph said. “One of the individuals is on our institutional review board now, but we are also training people to be research ambassadors in their communities. Can you go now to your community church? To a local health fair?”

Additionally, national databases, such as Research Match, can be leveraged to help recruit people from underserved and underrepresented communities for trials, Joseph said. “They will get an email when relevant trials are taking place,” he said.

A moment to seize

Institutions and professional associations are taking steps to address racial inequality. In August, the American Diabetes Association launched #HealthEquityNow, a national platform that calls on businesses, policymakers, philanthropic organizations and other leaders to take steps to address systemic inequities faced by people of color. The ADA also recently compiled survey data to help push for continuity of health care coverage at the federal level and a $0 copay for insulin.

Under a recently renewed grant from the NIH, the Endocrine Society is expanding its Future Leaders Advancing Research in Endocrinology (FLARE) program, a professional development initiative supporting 150 underrepresented endocrine fellows. FLARE is designed to enhance preparation for leadership positions, connect trainees with mentors and expand professional networks, with the goal of increasing diversity throughout the specialty.

Golden said building and expanding academic-community partnerships and advocating for health equity-focused legislation are essential at this moment and beyond.

“We need to continue the conversation and the advocacy work even when the acute outrage has quieted, because the challenges will still be present,” Golden said.

Stanford said clinicians must have a “deep level of empathy” that extends beyond the trendiness of this topic at the moment.

“If you have a Black Lives Matter poster up in front of your home, you’re seen as cool,” Stanford said. “I don’t care about demonstrations. I care about action. How will you use this moment in history to change the narrative of what we are seeing in 1 year, 5 years, 20 years down the road? Is this going to propel sustainable change? It is similar to weight loss. I don’t want to get you to lose weight so you look good in a certain dress for your next special event. It is about sustainability.“In our neuroendocrine unit, I’m the director of our antiracism initiatives, and people are sometimes taken aback when they are asked to look at themselves,” Stanford said. “It’s uncomfortable. Anything that leads to measurable change is going to be uncomfortable. We have to be OK with that discomfort if it improves patient outcomes. Anything that is going to come easy is probably not worth it.