Diabetes Is Not Just An Outcome

Health and Well-Being Matter is the monthly blog of the Director of the Office of Disease Prevention and Health Promotion.

In teaching an Officer Basic Course for newly commissioned officers of the United States Public Health Service, I share with my students that discussing public health can often be a very data-driven exercise.

For example, by the numbers, CDC diabetes data shows that diabetes is now the seventh-leading cause of death in the United States. More than 34 million people — including 13 percent of all adults — in the United States have diabetes, with 90 to 95 percent of those cases being type 2. The number of adults diagnosed with diabetes has more than doubled over the past 20 years, while 1 in 5 people with diabetes remain unaware that they have it. About a third of the entire U.S. adult population (approximately 88 million people) have prediabetes, and 84 percent of them don’t know about their own condition. CDC data on youth with diabetes show that from 2001 to 2017, the number of youth younger than 20 living with type 2 diabetes grew by 95 percent. The greatest increases in type 2 diabetes were in Black or Hispanic youth, and the highest number of youth per 1,000 living with type 2 diabetes was in Black or American Indian youth.

I also instruct my students that by only focusing on certain aspects of data, we miss the larger impact a disease can have on an individual and a society, and how such chronic disease is influenced by an individual’s life circumstances. We may make the mistake of reducing a disease to just an outcome.

While these numbers show the apparent grave scope of the diabetes epidemic, they don’t fully account for the share of morbidity and premature mortality in this country that is linked to a handful of conditions such as diabetes. Along with obesity, hypertension, and other common chronic conditions, diabetes greatly increases risk for negative health outcomes when other comorbidities are present. Complications often feedback on one another in ways that compound health problems and lead to increasingly poor consequences. For these reasons and more, I would argue that diabetes is not just an outcome. Rather, it is a condition that also contributes to, and is impacted by, myriad other conditions — physical, mental, emotional, spiritual, social, and economic.

The current pandemic clearly illustrates the vulnerability a person with diabetes has to acquired infection. Those with pre-existing diabetes who are infected with the SARS-CoV-2 virus are more likely to experience worse complications. Although the complete picture remains to be fully understood, an array of studies has revealed that patients with diabetes suffer more severe COVID-19 illness, are more likely to be hospitalized, and are subject to higher rates of mortality. One in 5 hospitalizations for COVID-19-related complications are attributable to a patient having underlying diabetes alone. Nearly 60 percent of all COVID-19 hospitalizations are attributable to a patient having diabetes, hypertension, and obesity combined.

I also teach my students that numbers only tell part of the story. The experiences and challenges people face beyond the hard data are equally or more important to understand.

We know that social determinants of health — the conditions in which we are born, live, learn, work, play, worship, and age — are significant drivers in the development and course of diabetes and other chronic illnesses. Additionally, these factors are linked to a disproportionately increased risk for people who are African American, Hispanic/Latino American, American Indian, or Alaska Native and some people who are Pacific Islander or Asian American. Diabetes prevention and treatment efforts, including large and small systems of care, that fail to address inequities in social determinants of health — such as food insecurity, poor access to preventive health services, and lack of health-promoting school environments, to name just a few — are likely to be unsuccessful.

Despite being a primary care clinician by training and in more than half my professional life, I have come to realize that meaningful change in the numbers and in the lives of people with diabetes hinges on improving upon the social determinants of health — which has historically been mostly outside the influence of clinical providers and the traditional health care system. In the simplest terms, that means ensuring vital conditions are met such that individuals are able to live the healthiest lives they can.

Concretely and with particular relevance to diabetes prevention and care, the process for establishing such vital conditions is largely threefold: first, rigorously employ local community-based assessments to understand inequities across social determinants of health domains at the smallest level of community; second, improve health literacy in culturally sensitive ways; third, support communities with programs relative to their local needs such that individuals are best able to maintain healthy lifestyles

We must remediate systemic barriers that negatively affect our health and well-being. Healthy eating is an imperative in preventing and treating diabetes. However, a healthy diet cannot readily be realized without access to affordable, nutritious foods. An appropriate level of physical activity — a key underpinning of health and well-being — becomes more difficult to achieve when one is limited by a lack of safe and accessible spaces for recreation or simply being able to walk as part of activities of daily life.

If we are to make truly meaningful, sustainable progress in preventing and treating diabetes, as well as other chronic conditions, we can no longer passively accept the social inequities that exist across this country and that have been shown to increase the prevalence of chronic disease.

The scale of the problem and the pace with which diabetes is becoming more prevalent across the United States means that everyone, in all sectors of society, must take note and act with greater urgency. Especially now, when our collective awareness of well-being is foremost on our minds, we should be doing the hard work of tackling issues such as diabetes as the complex, socially determined conditions that they represent.

For ODPHP’s part, nearly everything we do within our mandate can directly or indirectly help address diabetes. With resources such as the Physical Activity Guidelines for Americans and Dietary Guidelines for Americans, we’re committed to helping prevent type 2 diabetes and related comorbidities. We have developed Healthy People 2030 diabetes objectives focused on reducing diabetes cases, complications, and deaths. In addition, Healthy People 2030 features 10-year targets for objectives that address factors related to social determinants of health that will help focus our country toward achieving health equity.

By incorporating a more comprehensive approach to understanding, charting, and acting on issues of public health, ODPHP is striving to achieve better individual health and well-being, and ultimately, enhanced resilience for every individual and the nation as a whole.

Yours in health,

Paul Reed, MD
Rear Admiral, U.S. Public Health Service
Deputy Assistant Secretary for Health
Director, Office of Disease Prevention and Health Promotion

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