A widening racial and social gap in diabetes

Abstract

On June 10, the 17th annual National Paediatric Diabetes Audit (NPDA) was published by the Royal College of Paediatrics and Child Health (London, UK). This latest iteration of the NPDA captured information on the care and outcomes of almost 30 000 children and young people (aged 0–24 years) with all forms of diabetes (95% with type 1 diabetes; 3% type 2 diabetes; 2% other forms) who attended a paediatric diabetes unit in England and Wales between April 1, 2019, and March 31, 2020. Concerningly, the audit found not just continuing but widening racial and social inequalities in type 1 diabetes care and outcomes. Specifically, the NPDA found that access to vital diabetes technology varied considerably by both race and ethnicity, and social deprivation status. Insulin pumps were used by only 27% of Black children and young people compared with 40% of White children and young people, and by only 32% in the most deprived areas compared with 44% in the least deprived areas—a gap that has almost doubled since 2014–15. Similarly, use of real-time continuous glucose monitoring was lower among Black children and young people (12%) than among White children and young people (20%), and in those from the most deprived areas (14%) compared with the least deprived areas (25%). A knock-on effect of reduced access to technology, Black children and young people and those from the most deprived areas had higher average HbA1c levels than their White, less deprived counterparts; a pattern also observed for those with type 2 diabetes. Worrying though the widening diabetes inequity revealed by the NPDA is, it is by no means surprising or even unique to children and young people with type 1 diabetes, or indeed to the UK. A 2019 Editorial in The Lancet Diabetes & Endocrinology highlighted how Black and minority ethnic adults in the USA and UK with type 1 and type 2 diabetes were less likely to be prescribed newer diabetes drugs and to have annual testing for HbA1c and retinopathy, and had higher risk of hospital readmission (suggestive of poorer initial care) than White people. Minority ethnic groups and low-income populations have long been known to shoulder a disproportionate burden of diabetes, having both higher disease risk and rates of diabetes complications and mortality. Data from the Centers for Disease Control and Prevention show that some racial and ethnic groups in the USA are twice as likely to be diagnosed with diabetes as White people (American Indian or Alaska Native [14·7%], Asian [9·2%], Hispanic [12·5%], Black, non-Hispanic [11·7%], White, non-Hispanic [7·5%]). The increased risk of diabetes and worse outcomes in Black and minority ethnic groups is further compounded and inextricably linked to higher levels of socioeconomic deprivation, in terms of income, education, occupation, housing, food security, social support, and access to quality health care. The COVID-19 pandemic has further widened diabetes inequalities, with people with diabetes being at increased risk of COVID-19 morbidity and mortality; consequently, Black and minority ethnic groups have been particularly hard hit. The acceleration of virtual health care during the pandemic might further contribute to widening diabetes inequity, favouring the least socially disadvantaged. In this issue of The Lancet Diabetes & Endocrinology, Sherita Hill Golden (Johns Hopkins University, Baltimore, MD, USA) charts how diabetes has evolved as a racialised disease in the USA over the past 130 years—transitioning from being perceived as a disease of White people to one of non-White people—and discusses how structural racism has led to current diabetes inequity. The ‘Black Lives Matter’ protests in 2020 following the death of George Floyd marked a sea change around the world, putting racism firmly at the top of the agenda for change. Now is the time to capitalise on this momentum to drive change at individual, organisational, and policy levels to eliminate the root causes of racial and social inequalities in diabetes and wider health—society can no longer ignore racism, whether individual or structural, conscious or unconscious, current or historic. Signs of change are already evident, with institutions and organisations implementing unconscious bias and anti-racism training, and diversifying their workforce; a start, but much, much more needs to be done. Equity in diabetes can be achieved for Black and minority ethnic groups, but not without recognising and counteracting the role of racism (current and historic) in creating and perpetuating diabetes inequalities. We can move forward—we must move forward—but first, we must look back.