Targeting Diabetes Care in Underserved, Underresourced Areas

Lisa Mulcahy

December 21, 2022

Sherry Phillips lives in a food desert. The 63-year-old resident of Chicago's Englewood neighborhood is one of approximately 13.5 million Americans who live in urban areas with few grocers. Because of this, residents are forced to buy highly processed, expensive food from convenience stores, or to rely on fast-food restaurants. The inability to buy items like fresh produce puts residents at higher risk for diseases like diabetes.

Phillips, however, has been able to reduce her health risk, thanks to Dion's Chicago Dream, an organization that delivers healthy food to residents of underresourced areas in the city. "I don't have to go from store to store trying to find fruits and vegetables that don't cost an arm and a leg," she says. "I like the quality and taste. My grandchildren love it too, so they will eat healthier."

Access to healthcare and other resources is a continuing problem for those living in underresourced areas. The updated American Diabetes Association (ADA) Standard of Care in Diabetes for 2023 includes guidance to support diabetes management, as reported on Medscape. A growing number of initiatives, like Dion's Chicago Dream, are bringing essential care and prevention strategies to these areas.

The Problem as a Whole

Physicians continue to evaluate why patients in underserved communities are at higher risk for diabetes. "While we used to blame most of the discrepancy on genetics, we've learned that it's really epigenetics: the environment we expose our genes to, and what that does to affect our health." says Francisco Prieto, MD, a family physician in Sacramento, California, and the ADA's national advocacy chair. "Research has shown us that many, if not most, of the health discrepancies we see in minority communities are due to the social determinants of health. Poverty, discrimination, and poor access to healthcare contribute to chronic stress, which leads to poor glucose control as well as hypertension and heart disease."

Having little or no insurance coverage is another huge detriment. "The ER will not help you manage your blood sugar or refill the meds you need for your chronic disease," Pietro continues. "Even after the Affordable Care Act, millions of Americans are uninsured or underinsured, and 1 in 7 people with diabetes report rationing their medications, while for people who use insulin it's almost 1 in 4. This is especially dangerous if their blood sugar spirals out of control. The cost of insulin in particular has more than tripled in the last couple of decades."

The ADA began to take action regarding this affordability crisis 7 years ago in launching its Make Insulin Affordable campaign. "We won a major victory when a cap on the Medicare copayment for insulin was included in the Inflation Reduction Act, recently signed by President Biden," Prieto adds. "Twenty-two states and the District of Columbia have also put caps on the copayment for insulin for all types of health insurance."

Caps are not yet federally mandated, however. To help bridge the gap, the ADA Health Equity Now Initiative allows users to search by their zip code to find available area resources that may provide financial assistance or discounted health insurance.

A Racial Divide

Over 50% of Latinx persons are at risk of developing type 2 diabetes, according to the Centers for Disease Control and Prevention.

"Despite the exponential growth of the Latino population in the US over the last several years, our country has done a poor job of serving their unique needs," says Ana Fuentevilla, MD, MHCDS, co-founder and national chief medical officer of Suvida Healthcare in Houston, Texas. "This has led to worse healthcare outcomes and a higher prevalence of several chronic conditions, including diabetes, among this ethnic group."

Fuentevilla notes that Hispanic persons in the United States are two times more likely to live in poverty and four times more likely to not graduate from high school than their White counterparts, as well as to be uninsured. "Given the socioeconomic circumstances many Latinos in the US face, it is more challenging for these families to make healthy choices, such as being physically active and eating nutritious foods, as well as access high-quality healthcare," she says. "Further, when coupled with the fact that a third of Hispanics in our country are not fluent in English, it's easy to understand why this population is more likely to fail to understand and internalize necessary health information, perpetuating higher rates of diabetes and obesity and worse outcomes overall."

In Black populations, this problem has hit similarly critical levels. A recent report issued by Chicago's Department of Public Health found that the diabetes-related death rate for Black residents is 70% higher than for their non-Black counterparts. The lack of consistent, high-quality nourishment for these residents heightens that risk. "In Chicago, this is more than just an urgent need; it is literally an existential crisis," says Dion Dawson, founder of Dion's Chicago Dream. "We know this by looking at data on something as basic as life expectancy."

A 2019 New York University study found that the average life expectancy difference between residents in Chicago's upscale Streeterville neighborhood and the largely Black Englewood area was three decades. "Multiply 30 years by Englewood's population, and you get over 700,000 years of life lost," Dawson added.

Suvida focuses on Latinx persons aged 65 or over by offering a new team-based, neighborhood-centric diabetes care model in cities across the United States. Bilingual healthcare providers offer in-person visits, at-home care, and virtual patient communication.

The Importance of Physician Outreach

Facilitating doctors' ability to provide targeted diabetes care to their local patient population is a vital step in helping the underserved. In rural Nebraska, a program called Diabetes OnTrack: Transforming Rural Diabetes Care and Education has been funded by the University of Nebraska Foundation. This pilot program focuses on bringing healthcare and community leaders together to discuss prevention and education opportunities based on local data.

Patient communication is key in working with individuals in underserved communities. During care appointments, doctors should "truly listen and seek to understand," says Fuentevilla. "When patients don't feel seen or heard by their provider, they often avoid seeking care, resulting in preventable adverse health outcomes. Establishing trust and respect is critical to identifying social needs and building a meaningful patient-provider relationship that drives better outcomes. When developing care plans and recommendations, it's important to suggest realistic lifestyle modifications, such as learning to cook culturally important foods in a healthier way."

Clearly informing patients of diabetes complications is vital. Black Americans are at four times the risk for a diabetes-related foot amputation vs the non-Hispanic White population. Latinx persons are at two times the risk. As many as 85% of amputations may be preventable, according to a recent commentary on Medscape.

"Without a consistent provider who can identify foot problems before they're out of control, treating blood sugar, blood pressure, and vascular disease, too many people in these communities will arrive at the ER when their foot can no longer be saved, or at a hospital without the facilities and vascular expertise to save an endangered foot," says Prieto. "Between 35% and 65% of those people suffering amputations will be dead within 3 years, a rate worse than most cancers."

In addition to stressing the importance of regular medical appointments, physicians can direct their patients to resources such as the ADA Amputation Prevention Alliance , which seeks to curb severe complications from diabetes. A limb is amputated every 3-4 minutes in the United States due to diabetes, and, as noted above, 85% of these amputations are preventable. The Alliance provides information to underserved populations about related conditions like peripheral artery disease, and offers instructions on how patients can check their feet, wear proper footwear, and seek regular medical treatment.

Finally, physicians can volunteer clinical care time, advocate in their community, and donate financially. As Dawson sums it up, "No amount is too small."

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