Racial disparities in type 1 diabetes (T1D) treatment and outcomes have been extensively described. In the United States, non-Hispanic Black children have higher rates of ketoacidosis at diagnosis, higher rates of subsequent hospital admissions, and lower rates of technology use in managing their disease.1 Rates of poor glycemic control, diabetes complications, depression, and diabetes-related mortality2 are all higher in this population.3,4 As technology has evolved to play a more central role in the management of this disease, these devices have not been used equitably.5 In this issue of Pediatrics, Sherr et al6 add a new international perspective to these disparities in diabetes outcomes. They describe disparities emerging soon after diagnosis that can be identified by the trajectory of glycemic control. In 3 large international registries, children and adults with T1D from minority groups were 1.3 (Austria and Germany), 3 (Australasia), and 3.5 (North America) times more likely to have an early precipitous rise in HbA1c level into the suboptimal range. Although minority status is defined differently in each cohort, the recurring message emerges that children within these registries who are people of color do particularly poorly.7 These disparities are widest in the United States. Although there are many potential proximal mediators of these outcomes in this country, we must address the role of structural racism.
Sherr et al6 suggest that the disparities might be addressed by improving patient knowledge and behaviors, better targeting of precision medicine, and considering the potential that there is a racial biological predisposition to worse outcomes. To meaningfully address health disparities, however, we need to be unafraid to identify, name, and address structural racism and reflect on the roles that we as individuals, the health care team, and society play in perpetuating the effect of structural racism on health outcomes. The authors acknowledge the potential of implicit bias in determining technology use in children with T1D, but the challenge of structural racism extends far beyond the narrow window of traditional diabetes care.8,9 The social determinants of health are not equitably distributed in the United States yet present real barriers to optimal health outcomes in children with diabetes.10,11 Sherr et al6 have shown us that this is evident from the time of diagnosis.
Patient and family education is often proposed but is rarely the solution when disparities are identified. Disparate outcomes are not the fault of the patients and their families. We need to recognize that inequity is due to deficiencies in our knowledge and approach, not to the patients’ lack of ability or desire to learn the components of T1D management. Moreover, it has been shown that interventions focused on education and intensive support improve the outcomes for well-resourced children, while actually widening socioeconomic disparities.12 If we are to narrow the gap in outcomes, we need to address the barriers that are disproportionately affecting marginalized populations.
There is a long, problematic history of attributing disparities to genetic predisposition or biology.13 Sherr et al6 posit that a “deterioration in glycemia despite intensification of therapy may have an underlying biological predisposition,” citing data revealing that racial differences of 0.4% (95% CI 0.2–0.6) exist with the mean glucose-HbA1c relationship.14 Large scale studies have revealed that HbA1c concentrations in non-Hispanic Black children are significantly higher than in non-Hispanic white children, far greater than can be accounted by differences in red cell kinetics.1,7 Proposing a biological or genetic basis for racial differences in health outcomes is inaccurate and has detrimental consequences. Implying an innate propensity for disease and biological inferiority obviates the need for an in-depth exploration of the role of the health care system in perpetuating racism and inequitable care.8,9
A precision medicine approach is often proposed as a solution to improving outcomes. However, precision medicine is not unaffected by inherent scientific biases and has the potential to exacerbate health disparities. Structural racism can influence this approach through the underrepresentation of minority groups in the clinical and research data used to develop precision medicine algorithms. Furthermore, systematically applying an approach that is based on data in which minority populations have disparate outcomes is unlikely to reduce disparities.15,16
In describing trajectories and early warning signs, Sherr et al6 have provided data to identify the children who are at high risk for adverse outcomes. So where do we go from here? We propose shifting the solution from the patient to the system. Structural racism, in society and health care, has biological consequences.8,9,17 A lack of diversity of health care teams, unequal access to care,18,19 and microaggressions in provider and patient relationships20 are just a few examples of how racism leads to disparities. It is time for us to take responsibility for the major public health issue of racial disparities. How can we be guided by our patients? As a first step, we must be prepared to be the educated and not the educators. We could work together to develop community-based interventions to address systematic racism, including the persistent adverse social determinants of health.21 We must be prepared to fight the entrenched systems that are structured to disadvantage populations of color. None of this can be accomplished without identifying, confronting, and abolishing structural racism as the root of inequity.22
Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.
FUNDING: No external funding.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2020-048942.
type 1 diabetes
POTENTIAL CONLIFCT OF INTEREST: The authors have indicated they no conflicts of interest to disclose.
FINANCIAL DISCLOSURES: The authors have indicated they have no financial relationships relevant to this article to disclose.