Diabetes pillars of care must include health equity
Equity should be at the forefront of diabetes care, and health care professionals must close existing diabetes inequities, according to a speaker.
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 it is crucial for health care professionals not only to focus the power of their organizations on improving equity, but also to address nonmedical social needs within the communities they serve.
“We are all on this yellow brick road together where equity is our North Star,” Joseph said during a presentation at the Association of Diabetes Care & Education Specialists virtual conference. “Unfortunately, oftentimes individuals do not think of equity at the beginning of their projects. ... We should think and act on equity at the beginning of any intervention for treatment and care that we do.”
A history of diabetes inequities
Disparities exist in many areas of health care, including diabetes. From 1998 to 2018, non-Hispanic white and Asian adults had declining incidences of diabetes, whereas diabetes incidences among Black and Hispanic people were flat or increased during the same period. However, the prevalence of diabetes decreased from 2014 to 2018.
“If we have decreases in the number of people with diabetes, but more individuals in ethnic minority groups developing diabetes, what does that mean? Unfortunately, this means that there are gaps in diabetes mortality,” Joseph said. “In the U.S., there’s a ratio of about 2.2 higher-fold risk of death among Blacks compared to whites.”
The disparities are not just limited to race. Both Black and white people living in rural areas have higher diabetes mortality rates compared with those living in urban areas. Black adults and those living in lower socioeconomic communities also have declining rates of glycemic control.
Joseph said these disparities are alarming, especially during the COVID-19 pandemic in which people with diabetes, especially those with worse glycemic profiles, have a higher risk for COVID-19 hospitalization or mortality.
In addition, social inequities stemming from structural racism — including income inequality, a low rate of homeownership and neighborhoods with high population density — can influence a person’s ability to access safe housing, healthy food, high-quality health care and other goods. These determinants ultimately lead to poor health outcomes, including diabetes.
Creating equitable interventions
To address social needs, organizations can refer to a hub that is connected to community care agencies. These agencies have community health workers who can meet with people and go through a social needs screening before addressing those needs. The workers gather data on the needs most affecting their community and use that information, along with community engagement, to advocate for policy changes.
“We firmly believe that we have to search for equity in all policies, including a living wage, access to adequate and affordable health care, access to nutritious food, excellent education throughout the life span and increase the number of licensed early childcare providers that have adopted healthy eating policies,” Joseph said.
Provider communication is also important when treating Black adults. Health care professionals who communicate better and participate in shared decision-making improve medication adherence in Black adults.
Joseph said people can connect with others by practicing cultural humility rather than cultural competency. Language should be a focus for diabetes care and education specialists, with an emphasis on person-first and strength-based speaking to build trust with patients.
“Within anti-racist practices, we want to elevate the cause; engage stakeholders; equip communities, employees and learners; empower those who are marginalized or oppressed; and evaluation and accountability are really key to any of those efforts,” Joseph said.
Building strong patient-centered diabetes teams
Engagement, empowerment and ongoing support are key contributors to successful diabetes self-management, Joseph said. However, he detailed a few ways diabetes care and education specialists can further improve health outcomes.
Joseph said diabetes care teams should participate in community engagement long term. Community engagement could include classes for adults with diabetes centered on cooking, community gardens in low socioeconomic status communities to improve access to healthy food, or a referral program with local parks and recreational organizations to increase access to physical activity opportunities.
Access to technology also should be improved. Joseph noted that Black and Hispanic adults are less likely to be prescribed continuous glucose monitors compared with white adults, and many low socioeconomic status communities lack access to broadband internet.
“When we think about technology, we can use it to connect with patients,” Joseph said. “We have to think about the strategies that we’re going to use, particularly among patients that are vulnerable.”
Joseph said organizations should also build diabetes care teams that better represent the communities they serve. Although Hispanic people make up 19% of the U.S. population Black people 13%, only 6% of health care professionals identify as Hispanic and only 3% as Black.
“We want to represent those communities we serve, so we can have better conversations about moving forward treatment and care,” Joseph said.