Across the US, those living with type 2 diabetes regularly face obstacles to care. Perhaps they can’t afford treatment and have to choose between rent and diabetes medications. Perhaps they can’t understand their doctor’s instructions because they don’t speak the same language or are hard of hearing. Or perhaps their doctor’s instructions run counter to cultural beliefs or norms.
“These are just a few of the challenges facing patients,” says Michelle Litchman, a Researcher and Medical Director of the Intensive Diabetes Education and Support Program at the Utah Diabetes and Endocrinology Center. Litchman investigates real-world management of diabetes and other chronic diseases.
“We see that [people] want to take care of themselves,” she says, but they often have to choose between care and say, cost or stigma or taking time from work. Opting out of care only worsens diabetes and can heighten the risk of cardiovascular disease (CVD), which is already the leading cause of death for those living with type 2 diabetes.
An estimated 34.1 million adults in the U.S. have diabetes, according to the US Centers for Disease Control and Prevention, and between 90 and 95 percent of them have type 2 diabetes.1 That is about 13 percent of the 18+ population. The figure doubles to 26 percent when looking at populations of 65 and older.1
Higher still is the incidence of type 2 diabetes among minority and economically disadvantaged populations, when compared with non-Hispanic white people or the wealthy. Deaths from CVD among type 2 diabetes patients within those communities can be up to seven times greater than wealthier ones.1,2
Such inequities have been studied for decades, and it’s clear that addressing them will relieve suffering and prolong life for those living with type 2 diabetes. The question is how best to do so.
In October, Scientific American’s Custom Media division hosted a virtual event to examine disparities in care and outcomes among those living with type 2 diabetes. It was part of a series supported by Know Diabetes by Heart, a joint initiative of the American Heart Association and the American Diabetes Association.
Three experts took to the virtual stage: Michelle Litchman; Dr. K.M. Venkat Narayan, the Ruth and O.C. Hubert Chair of Global Health and Director the Global Diabetes Research Center at Emory University; and Dr. Enrique Caballero, Faculty Director of International Innovation Programs at Harvard Medical School.
At the event, the panelists explored ways to reverse the compound threats that certain demographics face from diabetes and heart disease. They examined bias in diagnosis and treatment; genetic, cultural and sociological risk factors; and they outlined ways that health care providers can better meet the needs of patients who have faced discrimination or exclusion.
As comprehensive as the U.S. health care system is, type 2 diabetes patients regularly encounter gaps or obstacles that can derail care. “We know that referrals to diabetes care and education specialists differ based on race and ethnicity,” Litchman said at the event. That heavily impacts patients’ abilities to manage their health. Data show that minority populations are also less likely to be prescribed – or get – necessary follow-up testing.
With better communication, patients’ conditions can improve. Caballero highlighted a successful program instituted by the Kaiser Permanent group, in California, that paired Spanish-speaking patients and doctors. Medically-trained interpreters can also help.
But not enough interpreters or multilingual health care providers exist to meet demand. Caballero emphasized the need for medical educators to actively recruit minorities. But he also called clinicians to account. “I think that every health care professional should embrace the need to communicate better and understand the culture of our patients,” he said.
The deaf and hearing impaired, who have higher rates of diabetes and cardiovascular disease than others in the same age bracket, also need special consideration, often in the form of online resources.
Caballero noted that society is quick to blame patients for not taking good care of themselves or ignoring medical recommendations. He places significant responsibility on the health care system, noting that “even if people have access to health care, the quality of care that is provided to underserved communities is much lower than what is provided to the white population.”
A large, inclusive study by the US National Institutes of Health revealed that with equitable care, everyone benefited regardless of age, ethnicity, race or gender.3 “That should take away the myth that it is the patient’s fault,” Narayan added. “It really is the system’s fault.”
The panelists expressed concern about bias, both conscious and unconscious, among doctors and those in the health care system. While pervasive, they said, it was clearly evident in U.S. clinical research. Historically, most studies and clinical trials have been heavily weighted toward white, male populations, leaving minorities, women, and other underrepresented groups unaccounted for.
Diabetes is a complex disease, with genetic and lifestyle underpinnings and such racial and ethnic disparities in research, and can blind caregivers to potential issues. For example, Narayan noted, there seems to be greater insulin resistance among Hispanic, African American, and South Asian communities4, and up to 60 percent of some Native American and Alaska Native communities may have diabetes.5 Asian Americans may develop both diabetes risk and cardiovascular disease at a far lower body mass index than other groups. Without such groups accounted for in clinical research and trials, doctors and patients are at a disadvantage.
The way forward
While addressing disparities among type 2 diabetes patients is complex, every panelist stressed that it is also feasible. More equitable research and clinical trials along with greater access to interpreters and translated information are good steps, but the panelists had a number of others.
Since there is sometimes mistrust towards health care professionals, Litchman emphasized the important role that community health workers play in facilitating successful treatment. They can see patients at home or in the neighborhood; explain doctors’ recommendations; offer healthy, culturally appropriate recipes; and coach patients as they adopt a healthier lifestyle and control their blood glucose.
She also noted that the vast expansion of telehealth, sparked by the COVID-19 pandemic, has greatly expanded access to care. It has allowed health care providers to communicate with patients in their homes via cell phone, virtual appointments and text messaging. The key is to make these resources accessible to all.
Caballero urged health care providers to include social and cultural considerations in their clinical practices. “Think about transportation, housing, financial challenges, safety in [patients’] neighborhoods, availability of foods and where people are going to be able to implement your recommendations,” he said.
Perhaps most importantly, Lichtman said, providers need to acknowledge that disparities exist. With increased awareness, “We need to move into action,” she said, to improve diagnosis, testing, referrals, treatment, research and patient education. “Every patient that comes to the door has unique needs. We need to address them on a case-by-case basis.”
For information and tools to manage type 2 diabetes and heart disease, visit KnowDiabetesByHeart.org.
- Centers for Disease Control and Prevention. National Diabetes Statistics report 2020. Accessed November 5, 202 https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf
- Zuma B Z, Parizo J T, Valencia A, et al. County‐Level Factors Associated With Cardiovascular Mortality by Race/Ethnicity. J Am Heart Assoc. 2021; Vol 10(6). doi.org/10.1161/JAHA.120.018835
- Rust G, Levine RS, Fry-Johnson Y, Baltrus P, Ye J, Mack D. Paths to success: optimal and equitable health outcomes for all. J Health Care Poor Underserved. 2012;23(2 Suppl):7-19. doi:10.1353/hpu.2012.0084
- Raygor V, Abbasi F, Lazzeroni L C, et al. Impact of race/ethnicity on insulin resistance and hypertriglyceridaemia. Diabetes & Vascular Disease Research. 2019; Vol 16(2) 153-159.
- McLaughlin Sue. Traditions and Diabetes Prevention: A Healthy Path for Native Americans. Diabetes Spectrum. Oct 2010, 23 (4) 272-277.