Assess social determinants of health to limit disparities for people with diabetes
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Social conditions caused by systemic racism contribute to health disparities for people with diabetes and other endocrine conditions, and endocrinologists can take concrete steps to assess patient nonmedical needs and advocate for change.
In a paper published Jan. 18 in The Journal of Clinical Endocrinology & Metabolism, 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, Felicia Hill-Briggs, PhD, ABPP, professor of medicine and senior director of population health research and development at Johns Hopkins University School of Medicine, and 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, outlined the social determinants of health that contribute to negative health outcomes, particularly for Black adults with diabetes, such as poverty, unsafe housing, lack of access to healthy food and safe physical activity, and inadequate employment and educational opportunities.
“As a specialty, our focus has been on the biology of metabolic disease risk —pathophysiological pathways and responses that lead to obesity, diabetes, metabolic bone disease and thyroid disease,” the researchers wrote. “But what if our call is even broader — to take a step back and ask the question: ‘Why are we seeing these biological responses leading to higher metabolic disease risk and poorer outcomes in minority populations?’”
Healio spoke with Joseph about the structural issues that drive health inequity in diabetes, health system approaches to reduce endocrine disparities and the importance of measuring racism in the clinic to reduce implicit bias and promote equitable treatment.
What led you and your colleagues to write this paper?
Joseph: We know that health equity is our north star. It is where we need to go. We have great disparities in many endocrine diseases, including diabetes and obesity. Understanding what underpins those challenges and moving forward to advance and promote equity around those challenges is something that we all value.
You and your colleagues write that diabetes is an “exemplar health disparity condition.” What does that mean?
Joseph: What is unacceptable in diabetes is there are disparities at every level of the disease course. There are health disparities among individuals at risk for diabetes, disparities among those who develop diabetes, disparities in the prevalence of the disease, disparities in the control of diabetes, and disparities in the macrovascular and microvascular outcomes of diabetes, including cardiovascular disease, nephropathy, and the list goes on. Then there are disparities in mortality, with ethnic minorities developing diabetes earlier in their lives and also dying earlier. All of that is framed around social determinants of health. For some conditions, it may be there is a disparity in screening or a disparity in treatment or in outcomes. In diabetes, we see disparities throughout the spectrum of disease. That is why diabetes is an exemplar health disparity condition.
Can you outline some of the structural issues that underpin these disparities?
Joseph: If you think of these problems as a river, with the upstream determinants coming down from the top, farthest upstream are poverty, racism and discrimination. We have to address those, but those are the most difficult pieces to address because they require policy and cultural changes, as well as investment. Policy and cultural change can be arduous.
From there we have the midstream determinants: housing, the built environment, economic inequality, food insecurity. All those things in the “middle” — nonmedical health-related social needs — influence downstream health outcomes. That is where our disparities come from in diabetes and obesity and other endocrine disorders. There is opportunity for our entire health care system to more adequately address nonmedical health-related social needs, but we have to ultimately move upstream and address policy. That is what will end these inequities.
What are some concrete steps endocrinologists and diabetes care and education specialists can take today to make change in these areas?
Joseph: Providers can advocate for measuring nonmedical health-related social needs in their clinics. For instance, screening for food insecurity in clinics. Not only screening for it, but developing programs where providers can refer people to get the problem addressed. At Ohio State University, we offer a “food farmacy” program. We ask two validated screening questions to identify food insecurity. If a person has an affirmative response to either question, we refer them to our food farmacy where they receive produce on a weekly basis. We not only identify a significant barrier to health, we address it with a solution. Thus, endocrinologists have the opportunity to understand and measure the challenges patients are facing, and then develop solutions for those challenges.
In Ohio, we also have a community hub model, with nine hubs through the state, where we can refer people into pathways to address specific social determinants of health. The state-managed Medicaid programs pay community care agencies to address social determinants. If food insecurity is the challenge, people are referred to a local food bank, and then that is reported to the state and the community care agency receives a payment from the state. This system was born out of policy advocacy at the state level, to make it germane to address social determinants of health.
The other piece of this is to actively engage in antiracism efforts. What does that mean? Many universities are actively engaging in conversations around antiracism, which has moved from dialogue to plans to structures and policies. On the front end of that, you have to measure racism and bias in health care systems. There are opportunities to assess this from multiple perspectives, including patients and staff. Then, we have to ensure that, in clinics and hospitals, we have practices that are equitable and antiracist and that implicit biases are not impacting care. We need to make sure our clinic space is welcoming and is a “safe space” for all. That is the responsibility of us as providers. We’re getting there, but we are not quite there.
What are some policies that should be championed, both at the state and federal level, to reduce health disparities?
Joseph: I’m not going to answer this the way one might expect.
If, as organizations and as providers, we are measuring the social determinants of health within our organizations and understanding the challenges our patients are facing, we can use that data to make change. Many colleges and universities are stakeholders in their communities — large employers, large government affairs departments, etc. — we could use the data we gather as providers and health systems to better understand the specific social determinants of health impacting the populations we serve. Given that social determinants of health impact populations differently, we should use the collected data to advocate for policies that will impact our patients in the communities where they live. We have data analytics to do this here in Ohio, to drill down to the neighborhood level and see, for example, what are the top three social determinants of health are impacting disease processes, like diabetes at the census tract level.
All of this takes teamwork. From a provider level and an organization level, we have to come together and partner across organizations to address the social determinants of health. An emphasis on collaboration, partnership and teamwork are key to solving the challenges we are facing.
Reference:
Golden SH, et al. J Clin Endocrinol Metab. 2021;doi:10.1210/clinem/dgaa938.
For more information:
Joshua J. Joseph, MD, MPH, FAHA, can be reached at joseph.117@osu.edu; Twitter: @joshuajosephmd.
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