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Social Determinants Of Health & Health Equity

The prevention and improved management of diabetes and its comorbidities and complexities are influenced greatly by lifestyle and its relationship with the social determinants of health (SDOH) and health inequities.  SDOH, the non-medical factors that influence health outcomes, are defined by the WHO, the CDC and other government organizations.  Their definition is recognized by the American Diabetes Association and the International Diabetes Federation.  SDOH are “the conditions in which people are born, grow, work, live and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include social norms and economic and social policies and systems.” 

SDOH have an important influence on health inequities.  They are defined by the WHO as the unfair and avoidable differences in health status among population groups described socially, economically, demographically or geographically.  

Research shows that SDOH can be more important than health care or lifestyle choices in influencing health.  

Accordingly, the design and management of diabetes management and support therapies tailored to a patient and governed by outcome measures are fundamental to the successful prevention of diabetes and its improved management.  

Society & Culture

Diabetes stigma
Diabetes stigma describes the negative attitudes, judgment, discrimination or prejudice against people with diabetes.  Often, the stigma stems from the idea that diabetes (particularly Type 2 diabetes) resulted from poor lifestyle and unhealthy food choices rather than other causal factors like genetics and social determinants of health.  Manifestation of stigma can be seen throughout different cultures and contexts.  Scenarios include diabetes statuses affecting marriage proposals, workplace-employment and social standing in communities.  

Stigma is also seen internally, as people with diabetes also can have negative beliefs about themselves.  Often these cases of self-stigma are associated with higher diabetes-specific distress, lower self-efficacy and poorer provider-patient interactions during diabetes care.  

Racial and economic inequalities
Racial and ethnic minorities are disproportionately affected with higher prevalence of diabetes compared to non-minority individuals.  While US adults overall have a 40% chance of developing type 2 diabetes, Hispanic/Latino adults’ chance is more than 50%.  African Americans also are much more likely to be diagnosed with diabetes compared to White Americans.  Asians have increased risk of diabetes, as diabetes can develop at lower BMI due to differences in visceral fat compared to other races.  As a result, for Asians, diabetes can develop at a younger age and lower body fat compared to other groups.  Additionally, diabetes is highly underreported in Asian Americans, as 1 in 3 cases are undiagnosed compared to the average 1 in 5 for the US.  

People with diabetes who have neuropathic symptoms, such as numbness or tingling in feet or hands, are more likely to be unemployed as those without the symptoms.  

In 2010, diabetes-related emergency room visit rates in the US were higher among people from the lowest income communities than from the highest income communities.  Approximately 9.4% of diabetes-related ER visits were for the uninsured.

Key Diabetes Facts

  • There is a global epidemic of diabetes.
  • The number of people living with diabetes rose from 200 million in 1990 to 830 million in 2022, and continue to rise at an increasingly accelerated rate.  
  • By 2045, it is projected that 1 in 8 adults, approximately 783 million, will be living with diabetes, an increase of 46% from 2021.  
  • 10.5% of the global adult population (20-79 years) has diabetes, and almost half are unaware that they are living with the condition.  
  • Diabetes causes blindness, kidney failure, heart attacks, stroke and lower limb amputation.
  • A healthy diet, regular physical activity, maintaining a normal body weight and avoiding tobacco use are ways to prevent or delay the onset of type 2 diabetes.
  • It is possible to reduce the impact of diabetes by taking preventive measures for type 2 diabetes and providing early diagnosis and proper care for all types of diabetes.  
  • Diabetes can be treated and its consequences avoided or delayed with lifestyle modification, medication and regular screening and treatment for complications.

Diabetes Overview

Diabetes mellitus, often known simply as diabetes, is a chronic disease that occurs either when the body does not produce enough insulin (a hormone that regulates blood glucose), or when the body cannot effectively use the insulin it produces.  If left untreated, the disease can lead to various health complications, including disorders of the cardiovascular system, eye, kidney and nerves.  Diabetes accounts for approximately 4.2 million deaths every year, with an estimated 1.5 million caused by either untreated or poorly treated diabetes.  

Type 1 Diabetes 

Type 1 diabetes (previously known as insulin-dependent, juvenile or childhood-onset) is characterized by deficient insulin production and requires daily administration of insulin.  In 2017 there were 9 million people with type 1 diabetes; the majority of them live in high-income countries.  Neither its cause, nor the means to prevent it,  are known.

Type 2 Diabetes

Type 2 diabetes affects how your body uses sugar (glucose) for energy.  It stops the body from using insulin properly, which can lead to high levels of blood sugar if not treated.  Over time, type 2 diabetes can cause serious damage to the body, especially nerves and blood vessels.  Type 2 diabetes is often preventable.  Factors that contribute to developing type 2 diabetes include being overweight, not getting enough exercise and genetics.  

Early diagnosis is important to prevent the worst effects of type 2 diabetes.  The best way to detect diabetes early is to get regular check-ups and blood tests with a healthcare provider.  

Symptoms of type 2 diabetes can be mild.  They may take several years to be noticed.  As a result, the disease may be diagnosed several years after onset, after complications have already arisen.

More than 95% of people with diabetes have type 2 diabetes.  Until recently, this type of diabetes was seen only in adults but it is now also occurring with increased frequently in children.

Gestational diabetes

Gestational diabetes occurs during pregnancy.  Women with gestational diabetes are at an increased risk of complications during pregnancy and at delivery.  These women and possibly their children are also at increased risk of type 2 diabetes in the future.  Gestational diabetes normally resolves itself shortly after delivery.  

Prediabetes

Prediabetes is an early stage of diabetes.  The Centers for Disease Control and Prevention (CDC) estimates that more than 30 million Americans have diabetes — but one-fourth of them don’t realize it.  As of 2020, 38% of all US adults had prediabetes.  A landmark study conducted by UCLA reported that almost 50% of youth in California are prediabetic.  

Diabetes And Youth

Youth dealing with diabetes face unique challenges.  These can include the emotional, psychological and social implications as a result of managing a chronic condition at such a young age.  As a result, early intervention and impactful management are important to improving long-term health.  

Physical activity plays a vital role in managing diabetes, improving glycemic control and enhancing the overall quality of life for children and adolescents.  Increased physical activity in youth with T1D can be associated with improved health, such as healthier body composition (reduced waist circumference and BMI) and improved overall physical health.  These benefits are especially important during childhood and adolescence, because this is when proper growth and development are occurring.  However, as diabetes progresses, younger children and adolescents may face more barriers to engaging in physical activity.  There may be anxiety about experiencing hypoglycemic events during exercise or the physical challenges posed by the long-term complications caused by diabetes.  

Prevelance

In 2022, 14% of adults aged 18 years and older were living with diabetes, an increase from 7% in 1990.  More than half (59%) of adults aged 30 years and over living with diabetes were not taking medication for their diabetes in 2022.

  As of 2021, an estimated 537 million people worldwide had diabetes accounting for 10.5% of the adult population, with type 2 making up about 90% of all cases.  The World Health Organization (WHO) reported that diabetes was “among the top 10 causes of death in 2021, following a significant percentage increase of 95% since 2000.”  It is estimated that by 2045, approximately 783 million adults — 1 in 8 — will be living with diabetes, representing a 46% increase from the current figures.  Rates are similar in women and men. 

The chart below presents the Worldwide Diabetes Prevalence And Projected Growth from 2021 – 2045 for people 20-79 Years of Age. 

Worldwide Diabetes Prevalence And Projected Growth
(20-79 Years of Age); 2021-2045
Source: International Diabetes Federation; IDF Atlas 2021 

Prevention and Treatment

Type 1 diabetes currently cannot be prevented.  

Lifestyle changes (achieving a healthy body weight and moderate physical activity) generally are seen as the best way to prevent or delay the onset of type 2 diabetes.  Lifestyle changes include the design and management of diabetes self-management and support therapies tailored to the patient and governed by outcome measures.    

Effective approaches to preventing type 2 diabetes and to preventing the complications and premature death that can result from all types of diabetes include policies and practices across whole populations and within specific settings (home, school, workplace, etc.) that contribute to good health for everyone.  Such practices include:

  • Blood glucose control through a combination of diet, physical activity and, if necessary, medication
  • Control of blood pressure and lipids to reduce cardiovascular risk and other complications
  • Regular screening for damage to the eyes, kidneys and feet to facilitate early treatment 
  • Reaching and keeping a health body weight
  • Eating a healthy diet and avoiding sugar and saturated fat
  • Not smoking tobacco 
  • Regular screenings and check-ups, especially for people at risk

The starting point for living well with diabetes is an early diagnosis – the longer a person lives with undiagnosed and untreated diabetes, the worse their health outcomes are likely to be.  In the US, easy access to basic diagnostics should be available in primary healthcare settings with general practitioners and specialists sharing care in a team approach.   Patients will need periodic specialist assessment or treatment for complications.  In countries using a general practitioner system, such as the United Kingdom, care may take place mainly outside hospitals, with hospital-based specialist care used only in case of complications, difficult blood sugar control or research projects.

Complications

Promising research indicates that cardiometabolic syndrome (CMS) may be the new paradigm in addressing complications from diabetes.  CMS is a complex interplay of diabetes risk factors, cardiovascular disease and metabolic dysregulation.  Encompassed with CMS are obesity, insulin resistance, dyslipidemia, hyperuricemia and hypertension, with obesity triggering metabolic disturbances. The global prevalence of CMS is driven by rising obesity rates and sedentary lifestyles.  Underlying CMS mechanisms intertwine with and interact among genetics, sedentary behaviors, poor diets and hormonal imbalances.  Innovative CMS approaches appear to revolve around lifestyle interventions, personalized medicine, biomarkers, and pharmacological breakthroughs.  (See Khan AR, Salama AH, Aleem Z, Alfakeer H, Alnemr L, Shareef AMM. The Promising Frontier of Cardiometabolic Syndrome: A New Paradigm in Cardiology. Cureus. 2023 Sep 19;15(9):e45542. doi: 10.7759/cureus.45542. PMID: 37868505; PMCID: PMC10586230.)  

Comorbidity: Multiple Chronic Conditions; Unmet Medical Needs; Expenditures

Diabetes patients often have comorbidities that, together, have a significant impact on medical expenses and related costs.  It has been demonstrated that patients with diabetes are more likely to experience respiratory, urinary tract and skin infections, develop atherosclerosis, hypertension and chronic kidney disease, putting such patients at increased risk of infection and complications that require medical attention.  

  • Multiple Chronic Conditions (MCCs)
  • The most common chronic condition experienced by adults is the coexistence of multiple chronic conditions or diseases. 
  • There is an unmet medical need for outcome measures for persons with MCCs.
  • Cost Burden From MCCs
  • There is an unmet medical need for actionable information (a) that informs the impact that MCC clusters and their associated complex care have on the burden of healthcare cost and (b) that informs the impact of MCC clusters on operationalizing complex care.  
  • MCCs & Disease Management Programs
  • There is an unmet medical need for disease management programs designed towards a multiple-condition approach to MCC clusters.  Disease management programs focus on single diseases.  Single-disease programs do not address the actual, person-centered, complex care needs of high-need high-cost patients with MCCs   
  • Certain chronic conditions cluster together frequently.  Medicare reports 81 diabetes clusters of MCC triads.  Each diabetes MCC triad represents an average annual expenditure of $65,000+ per Medicare beneficiary.

Source: CMS Chartbook 2012; 2017 update; adjusted to 2022 dollars); Adjustment for Multiple Chronic Conditions (MCCs) Economic Costs of Diabetes in the U.S. in 2017, Diabetes Care 2018;41:917–928 | https://doi.org/10.2337/dci18-0007

  • Medicaid typically pays providers 50%+ less than Medicare.
  • The global expenditure on diabetes-related healthcare is an estimated US$760 billion a year.

Multiple Chronic Conditions

  • There is a dearth of measures for persons with MCCs and a great need for these measures.
  • The most common chronic condition experienced by adults is the coexistence of multiple chronic conditions or diseases.
  • Our approach integrates and manages Enhanced Care Management (ECM), Complex Care Management (CCM) and Population Health.  While both ECM and CCM focus on managing complex patient needs, ECM is a specific tier within the broader CCM and Population Health frameworks.  ECM is a more intensive and personalized approach specifically designed for the highest-need individuals within a population.  CCM is a broader term encompassing care coordination for patients with multiple chronic conditions.  Population Health looks at the overall health of a larger group and aims to implement preventative measures across the entire population, not just high-risk individuals.
  • Key Differences: 
    • Focus Population: ECM targets the most complex patients within a population, often including those with multiple chronic conditions, social determinants of health issues and high healthcare utilization, while CCM may include a wider range of patients with complex needs, but not necessarily the absolute highest need individuals.  
    • Care Coordination Level: ECM typically involves a dedicated Lead Care Manager who actively coordinates all aspects of a patient’s care across different healthcare providers and social services, providing a more hands-on approach.  CCM may involve a similar care coordination function, but with potentially less intensive oversight depending on the patient’s needs.  
    • Population Health Perspective: While both ECM and CCM can contribute to population health management, the primary focus of Population Health is on identifying and addressing health risks across an entire population through preventative measures and targeted interventions, whereas ECM is specifically focused on managing the most complex individuals within that population.  

Cost Burden From MCCs

  • There is an unmet medical need for actionable information (a) that informs the impact that MCC clusters and their associated complex care have on the burden of healthcare cost and (b) that informs the impact of MCC clusters on operationalizing complex care.  

Medicaid Unmet Medical Needs

  • In some States, over half of Medicaid spending is attributable to the 5% of Enrollees with the highest-cost needs
  • Enrollees typically have several complex health conditions involving clinical, physical, behavioral and social needs
  • Enrollees often must engage several delivery systems to access care, including primary and specialty care, dental, mental health, substance use disorder and long-term services and supports 
  • Enrollees are at high risk of hospitalization, institutionalization and other higher cost services, with higher rates of diabetes, hypertension, HIV and mortality resulting in longer hospital stays and higher readmission rates
  • In some communities, the prevalence rate exceeds 18% and comprise more than 65% of such Enrollees 

Self-Management & Support

Diabetes management concentrates on keeping blood sugar levels close to normal, without causing low blood sugar.  This often is accomplished with lifestyle changes, including dietary changes, exercise and weight loss, together with the use of appropriate medications.  Lifestyle changes must include the design and management of diabetes self-management and support therapies tailored to the patient and governed by outcome measures.   

In the US, the major disease management programs for diabetes are Diabetes Self-Management Education And Support; CDC-Approved Diabetes Management Program; Team-Based Complex Care Management; Enhanced Care Management And Community Supports; Care Coordination / Transition; Community Partner Collaborations; nurse-specific measures; and culturally tailored interventions. 

Self-management and support programs must recognize and accommodate the evidence-base that the underlying determinants of diabetes are a reflection of the major forces driving social, economic and cultural change:  globalization, urbanization, an aging population aging and related demographics, decreasing levels of physical activity, the global nutrition transition with its increasing prevalence of overweight and obesity marked by increased intake of foods that are high energy-dense but nutrient-poor (often high in sugar and saturated fats, sometimes referred to as the “Western-style” diet), genetic factors and the general health policy environment.

Lifestyle

People with diabetes can benefit from education about the disease and treatment, dietary changes and exercise, with the goal of keeping both short-term and long-term blood glucose levels within acceptable bounds.  In addition, given the associated higher risks of cardiovascular disease, lifestyle modifications are recommended to control blood pressure.  

Weight loss can prevent progression from prediabetes to diabetes type 2, decrease the risk of cardiovascular disease or result in a partial remission in people with diabetes.  However, no single dietary pattern is best for all people with diabetes.