November/December 2022

It’s Not You, It’s Us
By Jamie Santa Cruz
Today’s Geriatric Medicine
Vol. 15 No. 6 P. 10

Toward a Community Approach to Managing Diabetes

Diabetes prevention and management have long been seen as a matter of individual responsibility. It’s important to recognize the collective role of entire communities in addressing the disease. Consider this scenario: Claudette, a 66-year-old Black woman, presents in your clinic with symptoms of increased thirst and frequent urination. She reports a family history of diabetes on her father’s side, and her HbA1c level is confirmed in a lab test to be 7.5%, sufficient to diagnose diabetes.

In addition to prescribing metformin, you advise Claudette to shift toward a Mediterranean diet high in fruits and vegetables. You also encourage her to start exercising for 150 minutes per week and refer her to a diabetes self-management education program in her neighborhood.

The Problem?
Claudette lives in a historically underresourced neighborhood where the nearest grocery store is more than a mile away—and she doesn’t have a car. She buys much of her food at the corner store, which carries only a few produce items. Even when she can get to a full grocery store, Claudette has a hard time buying the produce, nuts, and whole grains characteristic of a Mediterranean diet because these foods are too pricey for her to afford on her low fixed income. She hears your dietary recommendation, but it’s unrealistic in her context.

The same is true for physical activity. There are no parks or greenspaces near Claudette’s home. And because of the elevated crime rate in her neighborhood, she doesn’t feel safe walking the streets alone. She doesn’t have access to a safe place to get regular exercise.

Though fictional, this scenario nevertheless illustrates a truth: even when individuals with diabetes want to live healthy lives and manage their condition well, those who are at the highest risk of diabetes complications often live in contexts that make it very difficult to do so.

Traditionally, the emphasis in the medical community has been on teaching patients with diabetes to self-manage their condition. But if social, cultural, and environmental contexts influence a person’s ability to prevent and manage diabetes, that suggests the need for a community—not just individual—approach to addressing diabetes.

“We say, ‘Physical activity is really important, eating healthy vegetables and fruits is really important, getting sleep is really important, and managing stress is really important,’” says Joshua J. Joseph, MD, an assistant professor of endocrinology, diabetes, and metabolism at The Ohio State University College of Medicine. “Well, if someone lives in an environment where they don’t have a supermarket with fresh fruits and vegetables, that’s going to be really difficult. We’re engaged in this conversation, and they’re thinking in their mind, ‘Where am I going to get these fruits and vegetables?’”

“We tend to emphasize individual responsibility because we think it’s empowering, but there are limits to how much autonomy patients have,” says Lindsay Wiley, JD, MPH, a professor of law and faculty director of the health law and policy program at the University of California, Los Angeles School of Law. Instead of placing the responsibility on individuals alone to make healthy decisions, she says, it’s equally important to make investments at the neighborhood, city, or county level that facilitate healthier lifestyles for everyone.

Physicians can’t transform community contexts alone. However, they have a key role to play in changing the narrative around diabetes from an individualistic to a collective story—and in advocating for changes at the community level that can bring about better health for all.

Social and Environmental Factors Associated With Diabetes Risk and Outcomes
It’s well known that diabetes risk varies dramatically across geographic, social, and cultural contexts. Black, Asian, and Hispanic Americans, as well as American Indians, are at substantially higher risk than are white Americans.1 People living in the “diabetes belt,” which covers much of the southeastern United States, are at higher risk than are those in other geographic regions.2,3

But what factors underlie these disparities? Five social determinants of diabetes help explain the difference in risk:

1. Socioeconomic status: Those at the highest levels of income have the lowest risk of diabetes, whereas those at lower income levels have a dramatically higher risk.4 High job insecurity, shift work, and lower educational attainment have also been associated with higher diabetes risk.5-7

2. Neighborhood and physical environment: The walkability of an individual’s neighborhood and the availability of green space have been linked in multiple studies with diabetes prevalence and outcomes.8-10 Toxic environmental exposures—including to air pollution and hazardous chemicals such as arsenic and phthalates—are also associated with elevated risk of diabetes.11 Incidentally, exposure to environmental toxins is higher in lower-income and minority neighborhoods.12,13 In part, this is because zoning regulations have historically located polluting industries in poorer racial/ethnic minority and rural neighborhoods, away from wealthier and whiter areas;14 another factor is that certain personal care and cosmetic products with higher levels of toxic chemicals tend to be marketed more heavily to people of color.15

3. Food environment: The prevalence of both fast-food restaurants and convenience stores in a given neighborhood has been linked to higher rates of diabetes, while other studies indicate that easier access to grocery stores is associated with lower risk.16-20 Meanwhile, food insecurity—which affects 20% of people living with diabetes21—has been linked to poor outcomes in diabetes, including severe hypoglycemia and worse glycemic control.11 Some evidence suggests that improving the food environment—increasing access to healthy foods through food pantry interventions or bringing additional grocery stores into areas where they are scarce—can reduce diabetes risk and improve outcomes in those who already have the condition.11 In addition, diabetes culinary education, a combination of diabetes self-management education and cooking classes, has been shown to improve diabetes self-management.22

4. Access to health care: This includes access to health insurance and affordable quality care. Poor access to health care has been linked to poorer outcomes in diabetes.11 On the flip side, deploying trained lay people to implement community health worker interventions has been shown to improve diabetes outcomes.11 Similarly, health-system interventions that provide self-management education in a way designed to overcome barriers for underserved patients (such as transportation, childcare, low vision, and low-literacy barriers) have also been shown to improve self-care behaviors and clinical outcomes.11

5. Social context: High levels of social cohesion, which includes such factors as trust in neighbors and shared values with neighbors, are associated with a significantly lower risk of type 2 diabetes.19 Similarly, multiple studies have shown that stronger social support is linked with better glycemic control and improved quality of life.11

Together, these factors suggest that the traditional individualistic narrative around diabetes is inadequate.

“We have tended to think of individual risk factors” such as blood pressure and obesity, says Tiffany Gary-Webb, PhD, MHS, a professor of epidemiology and associate director of the Center for Health Equity at the University of Pittsburgh School of Public Health. “But the ability to prevent and manage those risk factors lies in their ability to afford food, get physical activity, get health care. These are things that are not controlled by the individual.”

Toward Solutions
If diabetes prevalence and outcomes are significantly influenced by geographic, social, and environmental context, effective prevention and management can’t occur on an individual level alone; collective action is essential.

Many of the interventions necessary to address social determinants of diabetes require action at the state and national levels. This includes initiatives to promote health care access, increase affordable housing, cap insulin costs, and develop a living wage. However, there is also a range of interventions on the local community level that can address the social determinants of diabetes—or at least help mitigate their effects.

Clinical-Community Linkages
Clinical-community linkages are collaborations between physicians or medical centers and various nonclinical partners in the community who work together to improve the health of their communities. One example of a clinical-community linkage helping address social determinants of health is Health Forward, a medical-legal partnership in the Chicago area between Legal Aid Chicago, the Cook County Health & Hospitals System, and the Chicago Department of Public Health.23 Through this partnership, medical providers are trained to identify situations their patients are experiencing that could have a legal solution—such as threat of eviction, denial or reduction of public benefits, or disability rights issues. When they identify such a situation, providers can then refer patients to Legal Aid Chicago for free legal support.

Another example of a clinical-community linkage is the Healthy Corner Initiative in Philadelphia. This project is a partnership between The Food Trust (a nonprofit organization promoting access to healthy food), the City of Philadelphia, the Philadelphia Department of Health, and two different local hospital systems. In this partnership, the Food Trust works with corner stores in underserved parts of Philadelphia to offer and promote more healthful food items in their stores, and they also provide nutrition education sessions in the corner stores. The role of the hospitals, meanwhile, is to send staff once a month to conduct health screenings in corner stores that are participating in the program. People who receive screenings but who don’t have a primary care provider are referred to one of the medical centers for care; meanwhile, nurses and physicians working in the medical centers refer their patients to the resources available at the corner stores participating in the program.24

Food “farmacies,” which have begun to pop up around the country,25 offer yet a third possibility for linkages between health systems and other community organizations. These farmacies, which are typically partnerships between a health system and another community organization such as a food bank, offer no-cost fresh produce and other healthful food items to food-insecure patients at risk of complications from chronic conditions such as diabetes. Farmacy programs typically also offer nutrition education with the goal of improving patients’ management of their condition. Investigators at The Ohio State University, including Joshua J. Joseph, are taking the farmacy concept a step further: They are testing an intervention that combines produce provision through the Mid-Ohio Farmacy26 with diabetes education through cooking.27 But the project also addresses other social needs, including transportation barriers, housing instability, and job insecurity, through partnerships with other community-based organizations through the Ohio Pathways Community Hubs (ClinicalTrials.gov identifier: NCT05472441).27,28

Each of the above illustrations of clinical-community linkages involves well-developed partnerships between two or more organizations. However, a simpler version of clinical-community linkages might simply involve a health system or physician’s office merely maintaining a list of community services, such as food pantries, housing assistance, transportation support, mental health services, or substance abuse programs to which providers can refer patients as needed. (Providers who want to find out what community resources are available in their areas can contact their local chamber of commerce or visit www.211.org as a starting point.)

Such linkages are becoming more popular, but they are still weak or nonexistent in many communities, according to Gary-Webb. “In big health systems, there are a lot of linkages. But even those types of things are not systemic in most systems.” In settings where these linkages don’t already exist, however, physicians can at least begin to advocate for them.

Local Policy Initiatives
In many cases, clinical-community linkages will only be able to mitigate the effects of social determinants driving disparities in diabetes, not actually resolve the root causes driving those social conditions. However, legislative policy can begin to affect those root causes. And according to Wiley, many of the policies that can make the biggest difference are local-level policies, where physician advocacy can carry significant weight.

“Physicians are community members, and they are often well respected,” Wiley says, “and have potentially powerful voices in local policy decision making. Policy advocacy can absolutely be something that physicians can engage in in local government, [such as in] testifying before local council about the kinds of challenges their patients are facing in managing their diabetes.”

Some policies designed to combat diabetes or other chronic conditions can be highly controversial, for example, soda taxes or caps on soda sizes. But policy advocacy doesn’t have to involve polarizing political issues. Some examples of local policy areas that aren’t highly polarized but that can meaningfully influence social determinants of diabetes include the following:

• Tax incentives to encourage desirable businesses to move into a given area. These can be a useful way to encourage, say, quality grocery stores to open in previously underresourced neighborhoods, Wiley says.

• Zoning restrictions. Legal barriers sometimes prevent full-service grocery stores from opening in low-income areas or communities of color. A key, then, is simply “making sure the government isn’t making it harder for those full-service grocery stores to operate,” Wiley says.

• Policies around active transit. By improving bicycle and pedestrian facilities and funding local trails, communities can create more opportunities for people to walk or bicycle, either to work or for recreation.

• Policies governing shared use agreements. In many communities, key recreational spaces are privately owned or else designated for schools. These spaces could be opened up to the public, increasing community access to amenities like basketball courts or playgrounds, which would facilitate more community recreation. However, “one of the barriers to opening that space up for community use might be liability concerns. They worry that if they allow community members to come walk for exercise on the high school track outside of school hours, they might get sued as the property owner,” Wiley says. Shared-use agreements have tried to remove some of those concerns by clarifying liability—and they are working. “Those shared-use arrangements have had a lot of success in opening up more recreational space in communities that lack it.”

The Role of Physicians in the Clinical Setting If diabetes is a social condition to be managed largely at the community level, the implication is that there’s only so much individual clinicians can do one-on-one with patients to effect change. However, there are a few key steps physicians can take in clinic to promote equity:

• Cultivate awareness of the obstacles patients face in preventing and managing diabetes. Out of this awareness, exercise sensitivity in how you counsel them regarding their diabetes. “There’s a line between equipping patients with the knowledge they need to take care of their diabetes and, on the other hand, making patients feel judged and shamed by their clinicians, which might actually make them less likely to come for their routine care that they really do need,” Wiley says.

• Screen patients for social determinants of health that might affect their diabetes risk or outcomes. This screening should cover such topics as the patient’s housing stability, food security, transportation needs, utility needs, and interpersonal safety. A screening in itself can’t address the social needs that it may uncover. However, “If you’re screening for food insecurity, and you know the patient is having problems accessing food, that’s when they can be referred to other resources,” Gary-Webb says.

• One screening tool for identifying social needs is the CMS questionnaire available at https://innovation.cms.gov/files/worksheets/ahcm-screeningtool.pdf.

• Collaborate with other professionals to help address patients’ unmet social needs. Involve social workers, take advantage of any clinical-community linkages that exist within your health system, and refer patients whenever possible to community organizations that can help address food insecurity, housing instability, and the like.

Ultimately, it’s a matter of physicians working to shift the narrative around diabetes from an individual to a communal story. Individual patients must always hold some level of responsibility for their choices. But physicians can help bring to light the constraints many patients are under and emphasize the role of the entire community in rectifying inequities.

— Jamie Santa Cruz is a freelance writer in Parker, Colorado.

References
1. By the numbers: diabetes in America. Centers for Disease Control and Prevention website. https://www.cdc.gov/diabetes/health-equity/diabetes-by-the-numbers.html. Updated March 28, 2022. Accessed August 12, 2022.

2. CDC identifies diabetes belt. Centers for Disease Control and Prevention website. https://stacks.cdc.gov/view/cdc/46013. Published March 7, 2015. Accessed August 12, 2022.

3. Voeks JH, McClure LA, Go RC, et al. Regional differences in diabetes as a possible contributor to the geographic disparity in stroke mortality: the reasons for Geographic and Racial Differences in Stroke Study. Stroke. 2008;39(6):1675-1680.

4. Beckles GL, Chou C. Disparities in the prevalence of diagnosed diabetes – United States, 1999–2002 and 2011–2014. MMWR Morb Mortal Wkly Rep. 2016;65(45):1265-1269.

5. Ferrie JE, Virtanen M, Jokela M, et al. Job insecurity and risk of diabetes: a meta-analysis of individual participant data. CMAJ. 2016;188(17-18):E447-E455.

6. Gan Y, Yang C, Tong X, et al. Shift work and diabetes mellitus: a meta-analysis of observational studies. Occup Environ Med. 2015;72(1):72-78.

7. Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2017. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Dept of Health and Human Services; 2017.

8. Chandrabose M, Rachele JN, Gunn L, et al. Built environment and cardio-metabolic health: systematic review and meta-analysis of longitudinal studies. Obes Rev. 2019;20(1):41-54.

9. Twohig-Bennett C, Jones A. The health benefits of the great outdoors: a systematic review and meta-analysis of greenspace exposure and health outcomes. Environ Res. 2018;166:628-637.

10. Bilal U, Auchincloss AH, Diez-Roux AV. Neighborhood environments and diabetes risk and control. Curr Diab Rep. 2018;18(9):62.

11. Hill-Briggs F, Adler NE, Berkowitz SA, et al. Social determinants of health and diabetes: a scientific review. Diabetes Care. 2020;44(1):258-279.

12. Mohai P, Lantz PM, Morenoff J, House JS, Mero RP. Racial and socioeconomic disparities in residential proximity to polluting industrial facilities: evidence from the Americans’ Changing Lives Study. Am J Public Health. 2009;99(Suppl 3):S649-S656.

13. Jones MR, Diez-Roux AV, Hajat A, et al. Race/ethnicity, residential segregation, and exposure to ambient air pollution: the Multi-Ethnic Study of Atherosclerosis (MESA). Am J Public Health. 2014;104(11):2130-2137.

14. Rothstein R. Racial Zoning. In: Rothstein R. The Color of Law. New York City, NY: Liveright Publishing Corporation; 2017:39-58.

15. Zota AR, Shamasunder B. The environmental injustice of beauty: framing chemical exposures from beauty products as a health disparities concern. Am J Obstet Gynecol. 2017;217(4):418.e1-418.e6.

16. Ahern M, Brown C, Dukas S. A national study of the association between food environments and county-level health outcomes. J Rural Health. 2011;27(4):367-379.

17. Haynes-Maslow L, Leone LA. Examining the relationship between the food environment and adult diabetes prevalence by county economic and racial composition: an ecological study. BMC Public Health. 2017;17(1):648.

18. den Braver NR, Lakerveld J, Rutters F, Schoonmade LJ, Brug J, Beulens JWJ. Built environmental characteristics and diabetes: a systematic review and meta-analysis. BMC Med. 2018;16(1):12.

19. Gebreab SY, Hickson DA, Sims M, et al. Neighborhood social and physical environments and type 2 diabetes mellitus in African Americans: the Jackson Heart Study. Health Place. 2017;43:128-137.

20. Herrick CJ, Yount BW, Eyler AA. Implications of supermarket access, neighbourhood walkability and poverty rates for diabetes risk in an employee population. Public Health Nutr. 2016;19(11):2040-2048.

21. Berkowitz SA, Seligman HK, Choudhry NK. Treat or eat: food insecurity, cost-related medication underuse, and unmet needs. Am J Med. 2014;127(4):303-310.e3.

22. Williams A, Shrodes JC, Radabaugh JN, et al. Outcomes of cooking matters for diabetes: a 6-week randomized, controlled cooking and diabetes self-management education intervention [published online August 9, 2022]. J Acad Nutr Diet. doi: 10.1016/j.jand.2022.07.021..

23. Medical-Legal Partnership helps align diverse partners to achieve common goals. Practical Playbook website. https://www.practicalplaybook.org/success/story/medical-legal-partnership-helps-align-diverse-partners-achieve-common-goals. Accessed August 13, 2022.

24. Healthy corner stores: Philadelphia’s model for improving food access. Practical Playbook website. https://www.practicalplaybook.org/success/story/healthy-corner-stores-philadelphias-model-improving-food-access. Accessed August 13, 2022.

25. Geisinger brings fresh food farmacy to Lewistown community. Geisinger website. https://www.geisinger.org/about-geisinger/news-and-media/news-releases/2019/10/18/15/18/geisinger-brings-fresh-food-farmacy-to-lewistown-community. Published October 10, 2019. Accessed August 13, 2022.

26. Walker DM, DePuccio MJ, Hefner JL, et al. Utilization patterns of a food referral program: findings from the Mid-Ohio Farmacy. J Am Board Fam Med. 2021;34(6):1174-1182.

27. Ohio State, Mid-Ohio food collective and health impact Ohio receive grant to address type 2 diabetes and food insecurity. The Ohio State University College of Medicine website. https://medicine.osu.edu/news/diabetes-and-food-insecurity-grant. Published June 10, 2022.

28. CARDI-OH. Ohio Pathways Community HUBs: understanding the benefits for patients with diabetes. https://www.cardi-oh.org/assets/best-practices/social-determinants/Cardi-OH-Ohio-Pathways-Community-HUBs-Understanding-the-Benefits-for-Patients-with-Diabetes.pdf. Published November 2021. Accessed August 13, 2022.

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