The role of structural racism and geographical inequity in diabetes outcomes

Agarwal, Shivani; Wade, Alisha N.; Mbanya, Jean Claude; Yajnik, Chittaranjan S.; Nicolaï, Thomas; Egede, Leonard E.; Campbell, Jennifer A.; Walker, Rebekah J.; Maple-Brown, Louise; Graham, Sian

doi:10.1016/s0140-6736(23)00909-1

Cited by 34 publications

(8 citation statements)

References 144 publications

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“…The underpinnings of such associations likely stem from other related upstream characteristics, such as food insecurity, 37 local environments not conducive to physical activity, 38,39 and structural inequity. 40 Partner diabetes was another risk indicator for maternal type 2 diabetes development in our analyses, with a 43% increase in hazards. This is consistent with our prior studies 41,42 demonstrating increases in hazards for the development of diabetes in fathers whose partners had GD compared with those whose partners did not.…”

Section: Jama Network Open | Diabetes and Endocrinologymentioning

confidence: 65%

“…Alongside health behaviors and physiological changes, our analyses reinforce the importance of social factors, including material and social deprivation and non-European background. The underpinnings of such associations likely stem from other related upstream characteristics, such as food insecurity, local environments not conducive to physical activity, and structural inequity . Partner diabetes was another risk indicator for maternal type 2 diabetes development in our analyses, with a 43% increase in hazards.…”

Section: Discussionmentioning

confidence: 82%

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Incident Diabetes in Women With Patterns of Gestational Diabetes Occurrences Across 2 Pregnancies

Mussa,

Rahme,

Dahhou

et al. 2024

JAMA Netw Open

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ImportanceGestational diabetes is a type 2 diabetes risk indicator, and recurrence further augments risk. In women with a single occurrence across 2 pregnancies, it is unclear whether first- vs second-pregnancy gestational diabetes differ in terms of risk.ObjectiveTo compare the hazards of incident diabetes among those with gestational diabetes in the first, in the second, and in both pregnancies with women without gestational diabetes in either.Design, Setting, and ParticipantsThis was a retrospective cohort study with cohort inception from April 1, 1990, to December 31, 2012. Follow-up was April 1, 1990, to April 1, 2019. Participants were mothers with 2 singleton deliveries between April 1, 1990, and December 31, 2012, without diabetes before or between pregnancies, who were listed in public health care insurance administrative databases and birth, stillbirth, and death registries in Quebec, Canada. Data were analyzed from July to December 2023.ExposureGestational diabetes occurrence(s) across 2 pregnancies.Main outcomes and measuresIncident diabetes from the second delivery until a third pregnancy, death, or the end of the follow-up period, whichever occurred first.ResultsThe 431 980 women with 2 singleton deliveries studied had a mean (SD) age of 30.1 (4.5) years at second delivery, with a mean (SD) of 2.8 (1.5) years elapsed between deliveries; 373 415 (86.4%) were of European background, and 78 770 (18.2%) were at the highest quintile of material deprivation. Overall, 10 920 women (2.5%) had gestational diabetes in their first pregnancy, 16 145 (3.7%) in their second, and 8255 (1.9%) in both (12 205 incident diabetes events; median [IQR] follow-up 11.5 [5.3-19.4] years). First pregnancy–only gestational diabetes increased hazards 4.35-fold (95% CI, 4.06-4.67), second pregnancy–only increased hazards 7.68-fold (95% CI, 7.31-8.07), and gestational diabetes in both pregnancies increased hazards 15.8-fold (95% CI, 15.0-16.6). Compared with first pregnancy–only gestational diabetes, second pregnancy–only gestational diabetes increased hazards by 76% (95% CI, 1.63-1.91), while gestational diabetes in both pregnancies increased it 3.63-fold (95% CI, 3.36-3.93).Conclusions and relevanceIn this retrospective cohort study of nearly half a million women with 2 singleton pregnancies, both the number and ordinal pregnancy of any gestational diabetes occurrence increased diabetes risk. These considerations offer greater nuance than an ever or never gestational diabetes dichotomy.

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Section: Jama Network Open | Diabetes and Endocrinologymentioning

confidence: 65%

Section: Discussionmentioning

confidence: 82%

Incident Diabetes in Women With Patterns of Gestational Diabetes Occurrences Across 2 Pregnancies

Mussa,

Rahme,

Dahhou

et al. 2024

JAMA Netw Open

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“…Note that, for simulation, we streamlined our modeling approach, with simplified health goals and demographic groups based on age. Therefore, our quantitative results are merely illustrative, but the principles of this approach could be applied and enriched with more sophisticated modeling and other criteria, such as race or ethnicity, geographic location, or other salient sources of existing inequity (as documented in diabetes care [19]), when information about those factors is available.…”

Section: Principal Findingsmentioning

confidence: 99%

“…In this work, we aimed to develop a resource allocation strategy for a digital health app to support patients with T2D applying an RMAB framework. We intentionally sought to incorporate equity as a desirable feature of our approach, aiming to leverage recent innovations in health care, such as the emergence of digital health, without perpetuating systemic flaws in care delivery, such as societal inequities [15]; moreover, T2D represents an unfortunate example where the presence of systemic inequities continues to have a negative impact in care [19]. We introduce a new solution, equitable RMAB (ERMAB), which requires that allocation policies take affirmative steps to distribute resources in a way that equalizes outcomes across prespecified groups.…”

Section: Introductionmentioning

confidence: 99%

New Approach to Equitable Intervention Planning to Improve Engagement and Outcomes in a Digital Health Program: Simulation Study

Killian,

Jain,

Jia

et al. 2024

JMIR Diabetes

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Background Digital health programs provide individualized support to patients with chronic diseases and their effectiveness is measured by the extent to which patients achieve target individual clinical outcomes and the program’s ability to sustain patient engagement. However, patient dropout and inequitable intervention delivery strategies, which may unintentionally penalize certain patient subgroups, represent challenges to maximizing effectiveness. Therefore, methodologies that optimize the balance between success factors (achievement of target clinical outcomes and sustained engagement) equitably would be desirable, particularly when there are resource constraints. Objective Our objectives were to propose a model for digital health program resource management that accounts jointly for the interaction between individual clinical outcomes and patient engagement, ensures equitable allocation as well as allows for capacity planning, and conducts extensive simulations using publicly available data on type 2 diabetes, a chronic disease. Methods We propose a restless multiarmed bandit (RMAB) model to plan interventions that jointly optimize long-term engagement and individual clinical outcomes (in this case measured as the achievement of target healthy glucose levels). To mitigate the tendency of RMAB to achieve good aggregate performance by exacerbating disparities between groups, we propose new equitable objectives for RMAB and apply bilevel optimization algorithms to solve them. We formulated a model for the joint evolution of patient engagement and individual clinical outcome trajectory to capture the key dynamics of interest in digital chronic disease management programs. Results In simulation exercises, our optimized intervention policies lead to up to 10% more patients reaching healthy glucose levels after 12 months, with a 10% reduction in dropout compared to standard-of-care baselines. Further, our new equitable policies reduce the mean absolute difference of engagement and health outcomes across 6 demographic groups by up to 85% compared to the state-of-the-art. Conclusions Planning digital health interventions with individual clinical outcome objectives and long-term engagement dynamics as considerations can be both feasible and effective. We propose using an RMAB sequential decision-making framework, which may offer additional capabilities in capacity planning as well. The integration of an equitable RMAB algorithm further enhances the potential for reaching equitable solutions. This approach provides program designers with the flexibility to switch between different priorities and balance trade-offs across various objectives according to their preferences.

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“…There is a critical need for the development of systems and supports for the management of youth-onset type 2 diabetes (defined as that diagnosed in people aged [12][13][14][15][16][17][18][19][20][21][22][23][24][25]. While the high prevalence of type 2 diabetes among older adults has received considerable attention, 1 youth-onset type 2 diabetes is an emerging condition worldwide, particularly in STRENGTHS AND LIMITATIONS OF THIS STUDY ⇒ Our study design, which encompasses four regional sites spanning Northern Australia and partnerships with key stakeholders from each jurisdiction, will advance the implementation of enhanced models of care.…”

Section: Introductionmentioning

confidence: 99%

Codesigning enhanced models of care for Northern Australian Aboriginal and Torres Strait Islander youth with type 2 diabetes: study protocol

Kirkham,

Puszka,

Titmuss

et al. 2024

BMJ Open

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IntroductionPremature onset of type 2 diabetes and excess mortality are critical issues internationally, particularly in Indigenous populations. There is an urgent need for developmentally appropriate and culturally safe models of care. We describe the methods for the codesign, implementation and evaluation of enhanced models of care with Aboriginal and Torres Strait Islander youth living with type 2 diabetes across Northern Australia.Methods and analysisOur mixed-methods approach is informed by the principles of codesign. Across eight sites in four regions, the project brings together the lived experience of Aboriginal and Torres Strait Islander young people (aged 10–25) with type 2 diabetes, their families and communities, and health professionals providing diabetes care through a structured yet flexible codesign process. Participants will help identify and collaborate in the development of a range of multifaceted improvements to current models of care. These may include addressing needs identified in our formative work such as the development of screening and management guidelines, referral pathways, peer support networks, diabetes information resources and training for health professionals in youth type 2 diabetes management. The codesign process will adopt a range of methods including qualitative interviews, focus group discussions, art-based methods and healthcare systems assessments. A developmental evaluation approach will be used to create and refine the components and principles of enhanced models of care. We anticipate that this codesign study will produce new theoretical insights and practice frameworks, resources and approaches for age-appropriate, culturally safe models of care.Ethics and disseminationThe study design was developed in collaboration with Aboriginal and Torres Strait Islander and non-Indigenous researchers, health professionals and health service managers and has received ethical approval across all sites. A range of outputs will be produced to disseminate findings to participants, other stakeholders and the scholarly community using creative and traditional formats.

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The role of structural racism and geographical inequity in diabetes outcomes

Cited by 34 publications

References 144 publications

Incident Diabetes in Women With Patterns of Gestational Diabetes Occurrences Across 2 Pregnancies

Incident Diabetes in Women With Patterns of Gestational Diabetes Occurrences Across 2 Pregnancies

New Approach to Equitable Intervention Planning to Improve Engagement and Outcomes in a Digital Health Program: Simulation Study

Codesigning enhanced models of care for Northern Australian Aboriginal and Torres Strait Islander youth with type 2 diabetes: study protocol

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