Debate: Race-based medicine promotes stereotypes, harms health equity in diabetes
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Key takeaways:
- Race-based medicine may identify individuals at higher risk for prediabetes and diabetes.
- Conversely, race-based medicine can further impede health equity for racially discriminated individuals with diabetes.
ORLANDO — Race-conscious medicine can help to identify those at higher risk for prediabetes and diabetes; however, this method can exacerbate racism and impede health equity, according to two speakers.
During a debate at the American Diabetes Association Scientific Sessions, Quyen Ngo-Metzger, MD, MPH, professor of medicine at Kaiser Permanente and former scientific director at the U.S. Preventive Services Task Force, argued that using race and ethnicity-based BMI cut points helps to identify individuals of certain racial and ethnic groups at higher risk for developing prediabetes and diabetes, such as Asian and Asian Americans. About 60% of the global population self-identifies as Asian, Ngo-Metzger said, and diabetes prevalence is high in India, Pakistan and Bangladesh with more than 77 million individuals with diabetes.
“In clinical practice, you need to be aware that Asians and Asian Americans have a higher risk for diabetes and other metabolic diseases at a lower BMI level and perhaps use the cut point of 23 [kg/m2] as recommended by WHO, the International Diabetes Federation, the American Diabetes Association, and the U.S. Preventive Services Task Force,” Ngo-Metzger said during the debate. “But even then, be aware of the heterogeneity among Asian American populations regarding diabetes risk, because we really know that BMI is just a proxy variable for the ratio of abdominal fat vs. lean body weight. So if we can measure that, that will be better, but we were stuck with the BMI in clinical practice.”
Conversely, Jessica P. Cerdeña, MD, PhD, a family physician and medical anthropologist at the Yale School of Medicine, argued that race-based medicine might increase racial and ethnic disparities in the realm of diabetes and other areas of medicine. She said the concept of race-conscious medicine is more beneficial.
“You may think that when we talk about race, we are just describing existing natural divisions among humans. I am here to tell you that that is false,” Cerdeña said. “And, in fact, using racial categories in medicine and science without discussing their political nature is racist.”
Benefits of race-based medicine
Twenty-four million people self-identified as Asian Americans in the 2020 U.S. census, which is a 35% increase from the 2010 census. This makes Asian Americans the fastest growing subgroup in the U.S., according to Ngo-Metzger.
Prediabetes prevalence is 37% and diabetes prevalence is 17% for Asian Americans. After moving to the U.S., those from India, Pakistan, Bangladesh, the Philippines, China, Korea and Vietnam have a higher diabetes prevalence compared with residence in their country of origin, Ngo-Metzger said.
“There are some genetic predispositions that Asian Americans may have toward diabetes, but there are also changes in lifestyle and diet, and, with urbanization, there’s decreased physical exercise and a culturation to the American diet,” Ngo-Metzger said. “Therefore, there are higher rates of diabetes for Asian Americans compared to Asians who live in their own country of origin.”
Asian and Asian American individuals develop diabetes at lower BMI compared with other racial/ethnic groups, partly due to body fat distribution, Ngo-Metzger said. Epidemiologic studies showed that Asian and Asian Americans have a higher distribution of abdominal or central adiposity at any BMI and higher diabetes risk at the same BMI compared with those of European descent, according to Ngo-Metzger.
“The cut points that we use to define what’s normal weight, what’s overweight and what’s obese were based out of populations of European descent,” Ngo-Metzger said.
With this, risk for metabolic diseases, including diabetes, were calculated based on BMI definitions for overweight and obesity based on individuals of European descent.
Currently, WHO recommends BMI cut points for Asians and Asian Americans with normal weight as 18.5 kg/m2 to 22.9 kg/m2, overweight as 23 kg/m2 to 24.9 kg/m2 and obesity as 25 kg/m2 or greater. The International Diabetes Federation (IDF) and the ADA define increased diabetes risk for Asians and Asian Americans with BMI greater than 23 kg/m2, and the IDF defines the highest diabetes risk for Asians and Asian Americans with BMI greater than 27.5 kg/m2.
A study from Annals of Internal Medicine used the Behavioral Risk Factor Surveillance System (BRFSS) and BMI thresholds of greater than 30 kg/m2. With this, researchers identified a 30% obesity prevalence for white individuals and a 32% to 35% prevalence for Black individuals. However, researchers observed a much lower obesity prevalence for Asian Americans when using the standard BMI cutoff compared with the higher threshold of greater than 27.5 kg/m2.
Another study, published in BMC Public Health, of 400,000 people from the Kaiser Permanente Group in Northern California, found that, within weight categories, Filipino (31% and 25%, respectively) and South Asian (29% and 28%, respectively) Americans with healthy weight had a doubled prediabetes and diabetes prevalence compared with white counterparts (18% and 5%, respectively). Similar results were observed in the overweight group with Filipino (35% and 29%, respectively) and South Asian (33% and 30%, respectively) Americans having doubled prediabetes and diabetes prevalence compared with white counterparts (23% and 9%, respectively).
Regarding screening, in another study using BRFSS published in Journal of General Internal Medicine, researchers observed 34% decreased odds of undergoing diabetes screening for Asian Americans compared with white counterparts.
“Race is a social construct, but it does have health implications,” Ngo-Metzger said. “Racism being a systemic oppression of one racial group to the social, economic and political advantage of another and there’s even scientific racism, where we conflate race with genetic differences.”
According to the NIH, scientific racism persists in science and research today. To combat this, according to Ngo-Metzger, The Lancet released guidance encouraging researchers to include minoritized racial/ethnic populations in research, prioritize community engagement and self-determination in research, discuss potential limitations and possible roles of unmeasured confounders and wider contexts of socioeconomic or other structural drivers of racial/ethnic disparities. In addition, JAMA updated guidance to reduce biases by advising authors to explain who identified race/ethnicity, clearly define other races/ethnicities, avoid using the term “minorities” and instead use “underserved” or “underrepresented” and avoid using the term “Caucasian.”
In research and policy, according to Ngo-Metzger, diverse populations should be included in research, and race should be treated as a social construct. In addition, Ngo-Metzger said to use other variables to measure biological, genetic, social, economic or environmental factors besides race, and use terms such as “ancestry” if discussing geography or ethnicity.
“Hopefully, at some point, we’ll be able to measure and look at the difference between lean body mass and central adiposity,” Ngo-Metzger said. “But, in the meantime, I think it’s necessary that we realize that there are some people at increased risks at a lower body mass index and we need to address these disparities today.”
Race-based vs. race-conscious medicine
Racism preceded the concept of race, so treating race/ethnicity as a clinical category or research variable is engaging in racism, according to Cerdeña. Many believe using race-based cut points or risk assessments can counteract racial disparities, but this is false, she said. Racial disparities in diabetes prevalence exist, Cerdeña said, but this is due to the social and political consequences of racism and white supremacy.
“We need to push policy reforms that gave our racially oppressed patients the best chance at healthy futures,” Cerdeña said. “Race-based medicine robs patients of autonomy, promotes stereotyping and compromises biological ideas of race, harming patients. By contrast, race-conscious medicine encourages interrogation of the political dimensions of race and encourages policy advocacy to eliminate racial health disparities.”
Because diabetes occurs from the interaction of multiple genes in the genome and is influenced by environmental factors, it is important to consider how racism impedes the ability to prevent and treat diabetes, according to Cerdeña.
For example, racial discrimination is associated with lower diet quality, poor glycemic control and more diabetes distress; mass incarceration, which is associated with worse self-care and health for those with diabetes; and social deprivation, which is associated with poor glycemic control.
Comparing different races/ethnicities with white individuals as the default is a racist practice that treats race as the “biological titan” in which white bodies are the “gold standard,” according to Cerdeña. Instead of using these measures, it is more beneficial to consider indicators of adiposity and metabolic syndrome as a comorbidity and measure of racism.
“We can counteract racial disparities in diabetes diagnosis, prevalence, morbidity and mortality by optimizing precision in our risk assessments, partnering with our patients, and advocating for policies that dismantle racist and white supremacist structures,” Cerdeña said.
An alternative to race-based medicine is race-conscious medicine, Cerdeña noted.
Race-based medicine considers race itself biologically meaningful, studies race as a driver of physiologic and epidemiologic difference, teaches race as a biological determinant of health disparities and promotes racial stereotypes, which ultimately exacerbates health outcomes, according to Cerdeña.
Conversely, Cerdeña said, race-conscious medicine emphasizes that race is political, studies racism as a political organizing system that impacts health outcomes and encourages political reforms to reduce health inequities.
Instead of race-based adjustments, Cerdeña said, policy reforms to promote health justice should be enacted, such as universal basic income, Medicaid expansion, food pharmacies, criminalization of predatory pricing in segregated areas and subsidization of rural grocers.
“All of us as clinicians, scholars and advocates can use our power, our education, our titles, our knowledge and our expertise to move toward racial justice for our patients and loved ones,” Cerdeña said.
References:
- Shah NS, et al. Ann Intern Med. 2022;doi:10.7326/M22-0609.
- Tung EL, et al. J Gen Intern Med. 2016;doi:10.1007/s11606-016-3913-x.
- Vicks WS, et al. BMC Pub Health. 2022;doi:10.1186/s12889-022-14362-8.
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Ngo-Metzger Q, et al. Race and ethnicity-based cut points in diabetes screening and diagnosis — Benefit or harm for reducing disparities. Presented at: American Diabetes Association Scientific Sessions; June 21-24, 2024; Orlando.
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