How low socioeconomic status influences disparities in diabetes care

A variety of sociodemographic characteristics contribute to the differences found in pediatric diabetes care. At the 81st virtual science sessions for the American Diabetes Association, Ananta Addala, DO, MPH, a pediatric endocrinologist and physician-scientist at Stanford University in Palo Alto, California, spoke about the role socioeconomic status plays in those inequalities.

Addala noted that previous research has shown that patients from minority groups often receive a lower quality of health care than their peers. Reasons for the differences in care include environmental factors and discrimination. Clinical judgment on the appropriateness of care and patient preference are also considered to contribute to the difference in quality of care, but it has long been noted that it does not contribute to differences, but Addala believes that both do. In diabetes management, one of the key places where differences are seen is access to diabetes technology such as insulin pumps and continuous glucose monitors. Diabetes technology has been shown to improve hemoglobin A1c levels, especially in pediatric cases. Children with low family incomes and public or no insurance have higher hemoglobin A1c levels, indicating lower access to diabetes technology.

She then discusses the results of a study comparing insulin pump use and continuous glucose monitoring with socioeconomic status in 2 cohorts: 1 in the United States and Germany, at 2 different time points, 2010-2012 and 2016-2018. The German cohort was selected because it represented an economy comparable to that of the United States. In both cohorts, the researchers found an increased use of insulin pumps between the 2 time periods. However, the US cohort showed that far fewer patients in the lowest socioeconomic group used pumps than those in the highest economic group, while in the German cohort negligible differences were noted between socioeconomic groups. Continuous glucose monitoring saw a significant increase in use for both cohorts, but as with insulin pumps, the US cohort showed significant differences in use across socioeconomic status. In Germany there was little difference between them. As a result, hemoglobin A1c levels are significantly higher in the lowest socioeconomic status level in the United States. Children with the lowest socioeconomic status in Germany also had higher hemoglobin A1c levels than their more affluent peers, but the difference was much less significant.

Insurance can cause these inequalities that Addala has noted. She discussed a recent commentary showing the variability of requirements for a child in a Medicaid program to receive continuous glucose monitoring. Some states such as Ohio and Wisconsin do not offer specific requirements for the technology. Others, such as Utah and New York, will only cover the technology for patients with type 1 diabetes who also take self-managed blood glucose readings via fingersticks at least 4 times a day. A final cause of differences is the prejudices that some healthcare providers may have towards patients with a lower socioeconomic status. A meta-analysis found that health care providers often had less empathy for patients from low socioeconomic groups.


1. Addala A. The state of disparity in pediatric diabetes care: the role of socioeconomic status. American Diabetes Association Scientific Sessions 2021; June 26, 2021; virtual. Access until June 26, 2021.

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