Barriers and Solutions to Trends and Disparities in Glycemic Control and Severe Hyperglycemia Among US Adults With Diabetes Using Insulin From 1988 to 2020

Venkatraman et al ¹ recently reported that among US adults with diabetes using insulin, glycemic control stagnated between 1988 and 2020. They compared Mexican Americans, Non-Hispanic blacks, and Non-Hispanic whites. Among these groups, Mexican Americans were the likeliest to trend away from target glycemic control (A1C <7%) and toward severe hyperglycemia (A1C >10%). The authors proposed three potential contributing factors to lack of improved outcomes, including the cost of insulin, therapeutic inertia in intensifying insulin therapy, and low acceptability of insulin. ¹ We agree that these three factors likely contributed to lack of improved glycemic control and propose three additional contributing factors.

Digital Connectivity

Digital health sensors, mobile applications, and telehealth connectivity have become important components in caring for diabetes. Connectivity of digital health tools, telehealth, and the electronic health record are key components of modern virtual health care. Digital connectivity has been referred to as the sixth vital sign. ² Digital health interventions can potentially increase adherence to treatment recommendations which can reduce morbidity and mortality and advance health equity. Among adults with diabetes, Hispanic/Latinos, compared with whites, have higher odds of never having logged onto a patient portal and lower health literacy. ³ The promotion of digital health literacy and development of culturally appropriate tools are needed by the Mexican American population to improve effective adherence initiatives.

Food Choices

In the United States, communities facing a disproportionate burden of type 2 diabetes (T2D) are also living within diabetogenic environments based on their social gradient. This gradient includes barriers in accessing affordable, healthy foods. An individual’s position on a social gradient begins early in life, and ascending the social gradient can be a major challenge. A microsimulation study suggested that implementing healthy food prescriptions within government health care programs could generate substantial and cost-effective health gains. ⁴ Food prescription programs are associated with measurable improvements in health outcomes, including food security, sleep, and mood for Hispanic/Latino adults with or at-risk of non-insulin-treated T2D. ⁵ Furthermore, combining food prescriptions with wearable technologies such as continuous glucose monitoring may provide insights into progression of dysglycemia leading to more personalized lifestyle interventions.

Social determinants of health

The Social Determinants of Health (SDoH) have an important effect on the results of diabetes management programs, both at the individual and community levels. The risk of developing diabetes, adherence to treatment, and health outcomes are all linked to SDoH. ⁶ Among Mexican Americans, a higher socioeconomic advantage index, reflecting better access to health care professionals and other social support resources, have been associated with improved diabetes outcomes. At the community level, factors that influence lifestyle, such as access to safe places to walk and play as well as exposure to environmental toxins have been shown to contribute to poor health care outcomes. Ultimately, additional study, and the use of a culturally responsive evaluation framework may be needed to understand disparities in diabetes control among different populations.

Conclusions

The three factors presented by Venkatraman et al regarding insulin therapy and the three additional factors regarding diabetes therapy in this letter all contributed to trends and disparities in glycemic control and severe hyperglycemia.