Disparities in pediatric diabetes outcomes: An approach to addressing the gaps

A diagnosis of type 1 or type 2 diabetes changes a child’s day-to-day life dramatically, but research has repeatedly shown that those changes come sooner and are more dramatic in racial and ethnic minority families. Providers at Texas Children’s Hospital have been following these disparities and are committed to improving the health of all children with diabetes while ensuring that those who are at greatest risk of complications get the care they need. By contributing to the national body of research on disparities in diabetes healthcare and implementing novel programs in their clinics, Texas Children’s Hospital is working towards total equity in their approach to diabetes. 

Recent research 

Mustafa Tosur, MD, Assistant Professor of Pediatrics in the Division of Diabetes and Endocrinology at Baylor College of Medicine, has a special research interest in racial and ethnic disparities in pediatric diabetes. He has published data that focuses on racial and ethnic differences prior to and after diabetes development. For example, in children younger than 12 years of age, Dr. Tosur finds that although progression to type 1 diabetes in relatives of patients with type 1 diabetes is slower in Hispanics, obesity increases type 1 diabetes risk disproportionately in Hispanics (quadrupled risk in Hispanics vs. only 36% increase in non-Hispanic whites) (1). Across racial and ethnic minority groups, the incidences of obesity, diabetic ketoacidosis, and, in Hispanics, dyslipidemia is higher at the time of diagnosis than in caucasians. (2-3). Dr. Tosur also finds that children in minority groups are diagnosed with type 2 diabetes younger than their non-Hispanic white counterparts (4). 

Ashley Butler, PhD, Associate Professor of Pediatrics in the Psychology Division, looks at the psychosocial effects of diabetes and sees similar trends. When counseling children with diabetes and their families, she has found that “the emotional burden of caring for diabetes tends to be higher among minority groups.” She notes that recent research has determined that children in racial and ethnic minority groups have higher rates of diabetes burnout (4). 

Reasons for disparities in health outcomes 

While the evidence clearly shows the medical and psychosocial burdens that racial and ethnic minority families face when caring for children with diabetes, determining the root cause is more difficult. Dr. Butler is quick to point out that while socioeconomic status is an important factor, it is important to be thinking “not just at the individual family level but thinking of larger societal and community influences on an individual’s health.” Food insecurity, transportation needs and unreliable access to telehealth are all of concern. However, meager community support or lack of skilled nursing help in low-income schools are societal issues that also make it harder to manage diabetes. Dr. Tosur notes that even after adjusting for socioeconomic status, there are some differences in markers of diabetes health between racial and ethnic minority groups and non-Hispanic whites, indicating that there may be some biological or genetic factors at play. Both Dr. Butler and Dr. Tosur acknowledge that implicit bias on the part of a child’s healthcare team, and a resulting lack of trust by minority patients and families are important to consider as well. 

COVID-19 

During the COVID-19 pandemic, rates of new diabetes diagnosis have increased, as have cases of diabetic ketoacidosis. Dr. Tosur notes that “if a patient has diabetes, they are at risk for contracting a severe COVID-19 infection, but also that COVID-19, based on CDC and other emerging data, increases risk of new diabetes diagnosis.” Dr. Butler notes that despite these trends, she has not noticed increases in rates of diabetes distress but has noticed increases in symptoms of depression and anxiety across her patients during the COVID-19 pandemic. 

Moving forward 

Dr. Butler and Dr. Tosur have recommendations for primary care clinics and mental health facilities to address these disparities, but they have also been working hard within their own organizations to foster equity in care. 

Recognizing that social determinants of health can vary significantly between families, Dr. Butler recommends that providers ask detailed questions about access to food and medicine in all patients, regardless of race or ethnicity, especially during the pandemic. Dr. Tosur emphasizes the need for vaccination while celebrating recent data from the CDC showing that vaccination rates are now very similar between non-Hispanic white, African American and Hispanic populations. He also encourages providers to be aware that children with diabetes are at increased risk for complications from COVID-19 and to refer them for advanced care in a timely manner. 

Programs at Texas Children’s Hospital that work to address inequities 

Texas Children’s Hospital has been working hard to eliminate health care disparities in their patients. In the Division of Psychology, Dr. Butler and her team recently set up a network of families managing diabetes that allows those newer to the diagnosis to meet peers who have more experience. She says that the program has “the overall goal of helping African American and Hispanic families to not feel alone with diabetes and to get the emotional and informational support that they feel like they might benefit from.” Her team is also looking at ways of screening families at the time of diagnosis for social needs that can be met through community or hospital programs. 

Dr. Tosur reports that in the Division of Diabetes and Endocrinology, their team has been working to recognize and, if possible, remove implicit human bias. Seeing that there is a racial and ethnic gap in adoption of impactful diabetes technologies such as insulin pumps and continuous glucose monitors, Dr. Tosur states that, “there is work around developing a standard pathway for insulin pump initiation for our clinic patients so that treatment decisions are not affected by implicit bias.” They have also instituted objective scoring measures to assess the risk of diabetic ketoacidosis and act proactively in its prevention. 

By facing the disparities that exist in diabetes outcomes, the teams at Texas Children’s Hospital can align diabetes care with values of equality and excellence. Novel programs are suggested and tested frequently to best address this ever-changing landscape. If you have patients who would benefit from these programs, Texas Children’s Hospital accepts referrals through their provider portal. More information about the Department of Pediatric Psychology can be found here, and the Department of Diabetes and Endocrinology can be found here. 

(1) Tosur et al. Ethnic differences in progression of islet autoimmunity and type 1 diabetes in relatives at risk. Diabetologia. 2018 Sep; 61 (9):2043-2053. doi: 10.1007/s00125-018-4660-9. 

(2) Tosur et al. The Effect of Ethnicity in the Rate of Beta-Cell Functional Loss in the First 3 Years After Type 1 Diabetes Diagnosis. JCEM. (2020) 105(12):e4393-e4406. doi: 10.1210/clinem/dgaa348 

(3) Redondo & Tosur et al. Racial/Ethnic Minority Youth With Recent-Onset Type 1 Diabetes Have Poor Prognostic Factors. 2018 May; 41(5) :1017-1024. doi: 10.2337/dc17-2335. 

(4) Astudillo & Tosur et al. Type 2 diabetes in prepubertal children. Pediatric Diabetes. (2021) Nov;22(7):946-950. doi: 10.1111/pedi.13254 

(5)Fegan-Bohm et al. (2020). Diabetes distress and HbA1c in racially/ethnically and socioeconomically diverse youth with type 1 diabetes. Pediatric Diabetes. Available at: https://pubmed.ncbi.nlm.nih.gov/32893939/. Accessed on February 7, 2022.