Deeply Rooted

An Endocrine Web Special Report on Race and Diabetes

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We are a nation founded on the idea of equality, freedom, self-determination, and individualism. That ideology informs the way we talk about (and care for) diabetes. “Make the right food and lifestyle choices. Take your medication. Be the hero of your own health.” The message is seductive in its simplicity. But it’s also a half-truth. And the deception lies in one reality: Black, Indigenous, and Latinx people are more likely to get the disease, suffer from its many complications, and ultimately die from it, compared to whites. If race is one of the biggest risk factors for diabetes, why is there such deep inequality in medicine? And what can be done to right that gross disparity? In search of answers, Endocrine Web reports from the cities and towns in the crosshairs of the Type 2 epidemic.

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Diabetes has snarled and knotted its way through Felix Gonzalez’s family tree. Both grandmothers had the disease. As did his mother. The same fate extended to six of his nine sisters and brothers, one of whom died from Type 2 complications. Felix himself was diagnosed two decades ago, after his physician repeatedly failed to warn him of his prediabetic state. Over the years, the Dominican-American was shuffled from one doctor to another and developed high blood pressure, which was not successfully monitored. A year ago, vomiting and dizziness landed him in the ER, and a cardiologist referred him to a new primary care physician. Gonzalez also began seeing a registered dietitian and nutritionist, Madalyn Vasquez, whose dietary advice helped stabilize his BP and lower his blood sugar.

You could say that Vasquez treats Gonzalez like family, because she is—his niece, to be exact. Vasquez was drawn to a career in nutrition after seeing what Type 2 did to her loved ones, specifically her grandmother. Her doctor didn’t help her connect the dots between food choices, nutrition, and diabetes. “I don’t think she ever saw a dietitian,” says Vasquez. That education could have the made the difference between life and death. 

Vasquez may have helped save her uncle, but millions of Americans have no lifeline. And those Americans are more likely to be people of color. Per the latest 2020 National Diabetes Statistics Report from the Centers for Disease Control and Prevention (CDC), the rate of diagnosed diabetes in white adults is 7.5%. For Asian Americans it’s 9.2%. The numbers tick upward for Black people at 11.7% and 12.5% for Latinx Americans. By the time we reach Indigenous people, the rate has nearly doubled from white adults at 14.7%. Zero in on specific groups and more dramatic differences emerge. Among Latinx adults in the US, Mexican Americans have the highest rates of diagnosed diabetes, at 14.4%. Rates among Asian Americans overall look relatively low at 9.2%, but 12.6% of Indian and Pakistani Americans have diabetes. 

We tend to tell two narratives about these disparities, and they both revolve around food. One blames Black people, Indigenous people, and people of color (BIPOC) for poor diets that put them in Type 2’s grip. The other points the finger at food deserts, suggesting that people would make healthier choices if they had better supermarkets. There’s no denying the power nutrition has to minimize the adverse effects of diabetes. But both of these narratives misunderstand cultural history and traditions, have the built-in assumption that the healthiest choices are equally obvious and accessible to everyone, and suggest food can fix everything. It can’t.

What will? Addressing the many gnarly branches of systemic racism. The kind of systemic racism that means predominantly BIPOC-populated neighborhoods are not walkable (consistent exercise helps control blood sugar), have fewer community centers (needed to guide/counsel on health education), and are more likely to be polluted (studies have shown that environmental air pollution—auto exhaust, nearby factories—raises the risk for Type 2 diabetes along with other illnesses that often accompany it such as cardiovascular disease).

And we can’t talk about systemic racism without addressing doctors and the medical industrial complex: the bias that exists in the predominately white clinicians who are practicing today…and the challenge of recruiting more people of color into careers in medicine tomorrow. 

Given the racial tensions in the US, it’s not surprising that a trust gap exists between people of color and doctors. According to the latest report from the US Department of Health and Human Services, two thirds of all medical professionals are white, 16% are Latinx, and 12% are Black. Studies have shown that medical professionals tend to have a more negative opinion of their patients of color than their white patients. The reverse also applies. In a 2018 review of literature, researchers found that Black patients with diabetes reported poorer patient-physician communication than white patients. 

“We need more representation in the health care system,” says Dr. Lorena Alarcon-Casas Wright, an endocrinologist at the University of Washington who serves as director of the Latinx Diabetes Clinic at the SLU Diabetes Institute. For Wright, that takes on a few meanings. It means more Black and Latinx doctors, and also more bilingual doctors, “because that can make a big difference for patients to feel more comfortable,” she says.

Ethnic and racial diversity among doctors has also been shown to help build cultural awareness of their white colleagues. “We fear things that are different,” says Wright. “When we have colleagues from different cultures, and different backgrounds, we understand their cultures and their points of view. This diversity increases creativity and helps achieve better outcomes.” That's why it's so important to have a diverse population of health care practitioners.

Another benefit? When young BIPOC patients see doctors who look like them, they're more likely to go into sciences and medical school themselves. “Our current lack of diversity, systemic racism, and implicit bias in medicine have a detrimental impact in all areas of our society, not just healthcare,” she says. 

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Baltimore Maryland skyline

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Cherry Hill, Baltimore

Baltimore’s last undeveloped waterfront community, Cherry Hill, sits to the south of the city, between the Patapsco River and railroad tracks. It was founded by Black American soldiers returning from World War II before the city built its largest housing projects there. The town center used to feature Black-owned hair salons, a hardware store, and clothing shops, which in the past generation have been replaced with fast food take-out businesses, a laundromat, and a nail salon, all owned by non-Black people from outside the neighborhood. Only the barber shop is Black-owned, and only that and a daycare center employ people from the community. The rest are employed by non-Black people from outside.

But there are also parks with bike paths, indoor and outdoor public pools, and the Cherry Hill Urban Garden, a 1.5-acre farm founded by 73-year-old Juanita Ewell in 2010. It grows produce the community can purchase using Electronic Benefit Transfer (EBT) and the Special Supplemental Nutrition Program for Women, Infants and Children (WIC). Spend some time there, and you may come across Eric Jackson, the founder and director of the Black Yield Institute (BYI).

Black Yield teaches farming and land stewardship through the community garden, organizes educational and leadership workshops, connects with other organizations to advocate for change, and is working on establishing a food cooperative. 

Cherry Hill raised Jackson. His grandmother came to the community in 1968 with her six children, including Jackson’s then-infant mother. The daughter of sharecroppers, Jackson’s grandmother developed diabetes. As far back as he can remember, it was a huge part of her life, with multiple hospital stays, an amputation, and her premature death at the age of 69 from complications. 

Type 2 diabetes rarely shows up on its own. It’s almost always accompanied by at least one other condition. In fact, 88.5% of people with diabetes have two or more comorbidities. The most common comorbidities are, in order of prevalence:

  • Hypertension 82.1%
  • Hyperlipidemia 77.2%
  • Chronic kidney disease 24.1%
  • Cardiovascular disease 21.6%

Complications from diabetes hit Black Americans harder than any other group. According to the most recent CDC figures, Black people with diabetes are 2.3% times more likely to be hospitalized for lower-limb amputations than white people, and are 3.2% more likely to be diagnosed with end-stage renal disease. These complications come with costly treatments, equipment, and rehab, and they significantly impact quality of life. Even more alarming, Black Americans with diabetes are twice as likely to die from it than white Americans. Every death disrupts a network of family and community.

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Common comorbidities

Black Americans with diabetes are twice as likely to die from it than white Americans. Every death disrupts a network of family and community.

Jackson was 14 years old when his grandmother died. Rather than dwell on her loss, he has elevated his relationship with her to a deeper, spiritual level. Her story helped inform the founding of the Black Yield Institute. “It’s interesting,” Jackson adds, “that 69 is also the average life expectancy for Cherry Hill residents.” His grandmother’s experience and eventual death from diabetes shaped his understanding of food, health, and nutrition, from his personal choices to his college studies in social work, community organizing, food, and economic justice. Both of his parents also struggled with diabetes, and his father passed at 47 of complications from the disease. “That threat became a driving force in me. It wasn’t simply about just being alive. It was being and living well.”

Jackson refuses to accept inhumane living conditions for anyone on account of their socioeconomic status or race. "When we talk about food apartheid," he says, "we are talking about systemic racism." For him, his work is about asserting the humanity of Black people. He intentionally says “food apartheid” rather than “food deserts,” a phrase more commonly used to describe neighborhoods with scant access to fresh produce and meat. In government reports, food deserts are defined as areas where residents live more than a mile away from a grocery store if they’re in a city, or more than 10 miles away if they’re in a rural area. But many of the people who live in these communities feel that doesn’t tell the real story of what they’re experiencing.

“Food apartheid” describes a lack of agency over the food in your own community. It takes into account everything from economics to systemic racism, and can manifest through predatory marketing, corporate-owned fast food and dollar stores filling storefronts, and lack of financing for businesses started by community members.

The mushrooming of dollar stores has been especially toxic to predominantly Black communities, according to a 2018 report by the Institute for Local Self Reliance.

Historically, banks have been reluctant to lend to Black entrepreneurs and even big chain supermarkets have avoided lower-income neighborhoods for fear of low profits. Seizing an opportunity, dollar stores have filled the gap. Why? Our national economic infrastructure makes it relatively easy for a corporation to set up a business wherever it wants, while a community-run food coop requires largely volunteer organizing, lobbying for support from local government, grant-writing, and more.

Black people are fighting back for food sovereignty all over the country. In Tulsa, Oklahoma, a combination of community protests, a dollar store moratorium, and ordinances led by city council member Vanessa Hall-Harper has stemmed the proliferation. It takes research, community engagement, and persistence, but organizers are slowly taking back control of their food sources. As part of their work, BYI works with public agencies to help them rethink how they allocate public funds and advocates for those dollars to go towards local Black institutions, companies, and individuals instead.

For example, the Baltimore Food Policy Initiative, part of the Department of City Planning, was working on what they called a food retail strategy. This would involve recruiting grocery stores to Cherry Hill, where residents could spend their CHIPS and WIC funds. While that would conceivably bring more fresh fruit and vegetables into the neighborhood, it would also divert public funds out of the community and into the pockets of the corporation that owns the supermarkets and toward workers who live outside Cherry Hill.

What if the initiative worked with the Cherry Hill community to build community-owned institutions like food co-ops instead? What if the initiative centered self-determination in the projects it helps fund, rather than bringing outside companies and organizations to control the food system there? This is the kind of reframing that BYI and other groups like it in Black communities nationwide are working toward.

BYI gathers qualitative and quantitative research, recording traditions of everything from foraging medicinal plants like dandelion to home-canning. Keeping these local traditions alive strengthens relationships among neighbors as everyone works together toward greater self-determination.

While the Black Yield Institute addresses health through food sovereignty in Baltimore, there is a promising, growing movement toward using a community organizing model for addressing health disparities nationwide. Facilitated by community health workers, this model positions community members as the decision makers, helping them to actively engage and identify their own key health issues and best address them, rather than being told what they are by white do-gooders and other outsiders.

The Seeds of Fast-Food Franchises in Black Communities

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There are 2.4 fast food restaurants per square mile in predominantly Black communities compared with 1.5 in white neighborhoods. But why? To answer that question, we could look at the history of McDonald’s. You've probably heard the success story of its founder Ray Kroc, who proliferated his quick-serve, assembly-line burger restaurants and his real estate holdings all over America. Less known is the way white McDonald’s franchise operators began selling off their restaurants in Black neighborhoods to Black owners following the upheaval of the civil rights movement and the assassination of Martin Luther King Jr. This is how “fast food became Black,” says Dr. Marcia Chatelain, author of the book Franchise: The Golden Arches in Black America.

“Essentially the fast-food franchise is a model that pushes liability onto the franchise owner, and depending on the community that person is in, that franchise can start to serve a lot of different purposes and needs," Chatelain explains. This includes jobs, a safe gathering place, and opportunities for management and ownership that are otherwise elusive. As McDonald’s began using Black celebrities in their advertising, there developed a new kind of relationship with the idea of fast food in the Black community, due to the public recognition of Black consumers and therefore Black culture as significant to mainstream America.

"I think that increasingly people who are interested in health and nutrition have to ask more sophisticated questions, not only about consumer brands and brand loyalty, but the ways that people are consuming food in an ecosystem in which there's many demands on their time and their resources," she says. When we talk about communities of color not having access to fresh foods, the larger issue may be more about having reliable refrigeration, or a steady supply of electricity or gas, or even time for cooking while working multiple jobs that do not provide a living wage. “It’s not just about the food,” Chatelain says. “It's about the cultural and social context in which the food emerges and sustains itself.”

The Cultural Roots of Nutritional Decision Making

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Madalyn Vasquez, the nutritionist we met earlier, doesn’t just understand the cultural connection to food for her uncle, Felix. That shared background helps her connect with all of her clients.

Vasquez is well aware of how starch-centered a typical Dominican diet can be, with its rice, beans, and plantains, so she never starts a relationship with a client by forbidding those central staples. “When you're trying to help someone shift their mindset, you can't tell them to completely stop eating the foods they grew up with,” she says. “That's the foundation of culture!”

When you're trying to help someone shift their mindset, you can't tell them to completely stop eating the foods they grew up with. That's the foundation of culture!

Instead, Vasquez meets her clients where they are, with respect and understanding of their culture (because she shares it with them), consideration for their resources, and the mantra that “every food fits” into a diabetic-friendly diet. In other words, no one should have to abandon their heritage for their health. Rather, adjustments can gradually be incorporated with the help of professionals like her to eat more of some foods and less of others. Vasquez educates her patients on the differences between starchy and non-starchy vegetables early on, which naturally leads to small, incremental changes they can make within their diets over time. She reminds them that their blood sugar does not define them, but that it's an opportunity for sustainable, positive change.

Increasing research supports this shift in diabetes treatment in communities of color. Nutritional programs that take a “culturally competent” approach are more successful. This is health care that respects a patient’s culture and recognizes related factors that can affect their health, such as language, communication style, behaviors, and beliefs.

Vasquez sees the difference her empathy makes with her patients every day. “They feel comfortable with me and understood,” she says. “The biggest thing is, ‘I know your struggle because I came from that struggle,’ you know, because I grew up in a household where we didn't eat vegetables.” Like her patients, she had to learn about the connections between nutrition and health as an adult.  Showing up with that shared experience, respect, and compassion helps her patients trust her. From there, she is able to show them how the small changes they make translate into better blood glucose numbers and longer, healthier lives.

Washington Heights Manhattan

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Washington Heights, Manhattan

There were some barriers Vasquez could not lift for her patients, particularly the high cost of medical devices. Once she changed jobs and started working with a middle-income population at a diabetes clinic, she saw the difference having health insurance and financial resources could make. Where most of her Washington Heights patients who used insulin relied on a complicated combination of syringes and meds, her better-resourced patients mostly used insulin pumps. Paying for insulin and medication can pose a financial burden that is too large for many people of color to bear without adequate health coverage. Vasquez has seen patients stop taking their meds and insulin because they can’t afford them, which exacerbates their conditions. Monitoring blood sugar also gets easier when health insurance covers your equipment.

“One thing that has been a complete eye opener for me is continuous glucose monitors (CGM),” she says. They were never used at the Washington Heights clinic. CGM helps people better manage their blood sugar levels to avoid emergencies and complications. But without insurance, monitoring can cost $2,500-4,000 a year (including the cost of the transmitter and sensor). Medicare started covering continuous glucose monitors in 2017, but Medicaid coverage varies by state. Only 14 states cover it for both Type 1 and Type 2 diabetes. Several others cover it solely for Type 1, or for children, or not at all.

When managing your health includes literal physical pain in the form of pin pricks daily because you can’t afford continuous glucose monitoring or an insulin pump, that’s a high barrier to overcome, without even factoring in the sky-rocketing cost of insulin.

Having a chronic disease is stressful enough on its own. When managing your health includes literal physical pain in the form of pin pricks daily because you can’t afford continuous glucose monitoring or an insulin pump, that’s a high barrier to overcome, without even factoring in the sky-rocketing cost of insulin. It’s no wonder many less-resourced patients are flying blindly.

“Continuous glucose monitors are a great tool to help patients manage their blood sugar, and to understand the effects of food and activity,” says Dr. Wright. Sometimes, it's just enough for patients to change their behavior because they see how certain foods or going for a walk can affect their blood sugar. But the expense is a major barrier. Dr. Wright says even for people with private health insurance, the co-pay can still be prohibitive. Not to mention that the time-consuming process of getting authorization for coverage and the sheer volume of paperwork involved may discourage providers from recommending CGM.

Another deterrent specifically for Latinx and other patients who speak English as a second language is the education needed to use the technology. Hospitals and clinics often have translators, but that takes up extra time during already short office visits. Additionally, Dr. Wright adds, unconscious bias among doctors may cause them to assume that these patients can’t manage the technology. “There are other reasons why I think we see these disparities in using continuous glucose monitors, insulin pumps, or any technology, other than just the obvious, like not having insurance,” she says.

Lack of health coverage is still the number one risk factor for diabetic complications, coma, and death because of inability to afford insulin.

Insulin itself is notoriously expensive. Over the past decade, the four most popular insulins have tripled their prices. As of 2020, eight states have enacted insulin price caps at or under $100 per month for co-pay: Colorado, Illinois, Maine, New Mexico, New York, Utah, Washington, and West Virginia. Five states have pending legislation, including Connecticut, Florida, Kentucky, Tennessee, and Virginia. In May 2020, Medicare announced that some of its programs would temporarily limit insulin costs to $35 for seniors, which helps fewer than half of the people who need it. Lack of health coverage is still the number one risk factor for diabetic complications, coma, and death because of being unable to afford insulin.

Colonias of the Rio Grande Valley

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The Colonias of the Rio Grande Valley

Outside the cities and towns of the Rio Grande Valley in Texas are dozens of unincorporated, makeshift communities called colonias running parallel to the border with Mexico. These neighborhoods typically lack basic infrastructure such as sewage, potable water, and garbage collection, even though the estimated 500,000 people who live in them are Americans who pay taxes. The land is inexpensive, so people buy or rent a small plot first, and then gradually add housing. There are no public hospitals in the Rio Grande Valley. Nearly a third of colonia residents have diabetes, and 60% are either diabetic or prediabetic.

Vanessa Alvarado is a health outreach coordinator for LUPE (La Union del Pueblo Entero) a community union founded by Cesar Chavez and Dolores Huerta, and a sister organization to the United Farmworkers Association. She works to connect residents of colonias with health resources. “We have people fill out this screening questionnaire, and if they are at risk of diabetes, or it looks like they may be diabetic, it’s a way of getting a wake-up call, and of getting their attention.”

From there Alvarado will bring the patient to a local endocrinologist who can give them a screening and subsequent treatment. Next, she’ll lead her new patients through LUPE’s nutrition program and connect them with a local nutrition club, where they can learn more about the link between food and their health. Diabetes patients are also connected with promotoras, trained health workers who live within the community and are best suited to bringing a culturally relevant message. A promotora is a key player in the tenuous system of support for people with chronic illnesses.

They don't want to go to the doctor – they don't want to hear it, because hearing it means that they have to do something about it. That means make regular visits, take medication, and monitor their blood sugar, all of which costs money that they don’t have to spend on their health.

There are a few diabetes clinics in the region, but even with a sliding scale fee structure they still cost something, and at least half of people from the colonias don’t have private health insurance. “They don't want to go to the doctor – they don't want to hear it, because hearing it means that they have to do something about it,” by which Alvarado means they’ll have to make regular visits, take medication, and monitor their blood sugar, all of which cost money that they don’t have. Many of them are also undocumented, so they don’t have ID, which means clinics will not accept them. (The Migration Policy Institute estimates 100,000 people in the Rio Grande Valley are undocumented.) If they join LUPE, however, they can receive an ID that clinics will accept. Still, Alvarado adds, “Not everyone knows that’s an option. If they don’t, they’ll miss out on those services, and the waiting lists for the clinics are long.”

Getting a diabetes diagnosis means a massive lifestyle change, which can feel difficult or almost impossible for people who are already barely making ends meet.

Another roadblock: Most of the people living in colonias do not have their own cars. They depend on ride shares or the bus, if one comes anywhere near their neighborhood. From time to time mobile clinics have brought the care to them (currently these have been either limited or eliminated because of the COVID-19 pandemic). Getting a diabetes diagnosis means a massive lifestyle change, which can feel difficult or almost impossible for people who are already barely making ends meet. “Unfortunately, what's affordable is not necessarily the best option,” she says. “It’s often fast food, which is ubiquitous. People need a lot of support in letting go of that option. It’s a shift that’s hard to make if you’re already struggling to feed your family, even when you’re sick.”

“But there is a will,” Alvarado says. Nutrition clubs provide that needed support, and help educate people about how to manage diabetes, which is another acute need in communities like the colonias where most people are uninsured. Fortunately, she notes, there are several other organizations that offer nutrition programs in the region. Texas A&M professor and research scientist Ninfa Peña-Purcell PhD created two culturally competent diabetes self-management programs, ¡Si, Yo Puedo Controlar Mis Diabetes! for the Latinx community and Wisdom, Power, Control, for the Black community. The programs, jointly, have been recognized by the American Diabetes Association for “offering needed programming to help people with diabetes thrive.” Both programs, says Peña-Purcell, are about promoting health equity and reducing health disparities.

We can’t just make diabetes education a one-size-fits-all thing. We have to look through the lens of their cultural worldview.

She points to the cultural competency piece as the key to the programs’ success. “We can’t just make diabetes education a one-size-fits-all thing. We have to look through the lens of their cultural worldview.” Partnerships with county agents are also key. These are educators employed by Texas A&M AgriLife Extension Service who work directly with communities through programs for specific audiences, such as nutrition education for low-income families with children. “Agents are basically our boots on the ground,” Peña-Purcell explains. “They also collaborate with the promotoras.”

Peña-Purcell implemented Si Yo Puedo among the border-region colonias of South Texas as well as the urban areas where migrants work. Engaging directly with the community and asking members what they need revealed a prevalence of prediabetes and undiagnosed diabetes. Education, awareness, and early detection are important, especially as there’s a powerful opportunity to reverse health outcomes in the prediabetes stage. “My work has continually been about, how do we get this program out? This is an evidence-based program that has been tested, that can reach Latinos.” But Peña-Purcell’s work is also largely about collaborating with other organizations and bringing more resources to the communities her program serves.

Resources are important because education on its own is not enough to change behaviors.

Resources are important because education on its own is not enough to change behaviors. For example, when you go to the doctor, does the clinic have a social worker who can help you with the emotional aspects of the disease? “When we look at any illness and chronic illness, you can't ignore the whole environment, and all the determinants of health. They're all interrelated.” To address the transportation issue, Peña-Purcell envisions a bus system that collaborates with a health care system, so that routes are created that can bring isolated people to their treatments. “If we can work more collectively, then we start seeing how we can address these issues that are impacting ethnic and racial groups with disparities to enhance their health outcomes.”

Building In-Roads for Better Access to Care in Rural America

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Transportation is a challenge for people with diabetes throughout rural America, as explained in a recent AARP report Focusing on Rural Livability. People there tend to be older, poorer, and are more likely to be disabled, so they’re less likely to drive or own cars. Yet public transportation is not reliable and often not even available. Rural residents have fewer options for specialized health care and must travel farther for it than people living in cities. That’s not to say it’s easy for city-dwelling people too ill to drive or travel by bus, but in urban areas there are sometimes ride-sharing programs such as LyftUp and Uber Health.

Many people fear that “eating healthier” is going to mean giving up the foods that make them feel connected to their culture.

Cultural relevance is another piece of the puzzle. Many people fear that “eating healthier” is going to mean giving up the foods that make them feel connected to their culture. “When I work with these communities, it's a struggle because they make their frijoles (Spanish for beans), but their hearty servings still have a lot of lard and calories, you know, so how do you modify those traditional foods?” says Peña-Purcell. Refried beans are traditionally made with lard, but they can also be made with monounsaturated oils, such as sunflower oil. The program teaches people how to plan meals with appropriate portion sizes, altering recipes so they’re more in line with their health goals without sacrificing taste or tradition. “It's adapting their traditional diet in a way that's healthier as opposed to insisting on a whole new diet, and that's part of the education that needs to happen in this process as well,” she says.

It's adapting their traditional diet in a way that's healthier as opposed to insisting on a new diet, and that's part of the education that needs to happen in this process as well.

As important as education is, information alone does not lead to behavior change. “There's an emotional component that's so important,” according to Peña-Purcell. The program has begun to take into account the mental health issues that accompany the disease. Feelings of denial and that diabetes is an incurable condition are extremely common. Peña-Purcell teaches her facilitators that part of their work is to give people hope and a sense of empowerment. “So much of our diabetes education is coaching and being the cheerleader,” she says.

Churches in Latinx communities can provide a high level of support as well. “When you come to a life crisis, you dig deep into your spirituality. They look at their pastor or their priest as a person of authority and guidance,” says Peña-Purcell. That’s what makes getting “pulpit support” where spiritual leaders promote wellness and recommend diabetes programs a critical piece of the puzzle.

It takes an entire network of efforts to make a difference, all coordinating, communicating, and working in concert with each other. That’s the lens Peña-Purcell wants more people to use when thinking about health care, instead of seeing an isolated patient with an illness who gets a prescription from their doctor and goes home struggling to figure out how to lose weight and regulate their blood sugar alone.

While the US has long valued individualism, and an ethic of ‘pull yourself up by your bootstraps,’ when it comes to health, it’s more effective to think in terms of collective efforts.

While the US has long valued individualism, and an ethic of 'pull yourself up by your bootstraps,' when it comes to health, it’s more effective to think in terms of collective efforts. Peña-Purcell acknowledges the role individual responsibility and accountability play, but emphasizes that it can't always happen single-handedly. She’s seen how powerful support from institutions and trusted community members can be in helping patients make lifestyle changes they need to nurture their health.

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Championing Local Grocers Over Cheap Chains

According to a 2015 AP Federal Food Stamp Data analysis, the top 75 food retailers opened 2,434 grocery stores between 2011-2015. Fewer than 250 of those were in the kinds of low-income neighborhoods that need access to fresh fruit and vegetables the most. Even when grocery stores open in low-income neighborhoods, they’re less likely to stock vegetables in the freezer. Instead, there’s more ice cream and processed foods. Meanwhile, two thirds of the stores that have opened in low-income neighborhoods have been from Dollar General, Family Dollar, and Dollar Tree chains (the latter two merged in 2015). And this is after grocery retailers participating in Michelle Obama’s Partnership for a Healthier America pledged to build more outposts in so-called food deserts. So far, they have opened or renovated only 602 grocery stores nationwide – well under half of the pledged amount. Dollar stores tend to charge more for staples like bread and milk than grocery stores in other neighborhoods. Dollar General recently began opening Dollar General Markets that sell fresh produce, but these comprise only 1% of their total stores.

None of us are making food or lifestyle choices in a vacuum. It’s not the choices you make, it’s the system of choices that matters, and we need to think about that. Who created it? Who benefits from it? Who decides what options we have?

Anthony Hatch, Wesleyan University professor and author of the book Blood Sugar: Racial Pharmacology and Food Justice in Black America, thinks we should reconsider market solutions to complex systemic problems like diabetes. “By virtue of structural racism, by virtue of the structure of the food system and how the food system has emerged in neighborhood contexts, you have a situation where African Americans consume more sugar than any other racial ethnic group in the country today,” he says. Type 2 diabetes is often called a lifestyle disease, one we bring upon ourselves through our food choices. But Hatch wants to squash that notion, because our so-called lifestyle exists within the context of our culture, which in turn is connected to the political and economic system of our time. None of us are making food or lifestyle choices in a vacuum. In fact, Hatch has often said, “It’s not the choices you make, it’s the system of choices that matters, and we need to think about that system. Who created it? Who benefits from it? Who decides what options we have?"

By neglecting to investigate these conditions, namely systemic racism, those who don’t want to look too closely end up unintentionally upholding them.

Unfortunately, health researchers are only beginning to ask these questions. In a recent op-ed in the Journal of Health Affairs, On Racism: A New Standard for Publishing on Racial Health Inequities, a group of researchers called out the journal for not sufficiently interrogating the racial disparities they publish research about. The journal allows researchers to say variations of, “There are many possible explanations for these racial disparities, maybe they’re genetic, who knows?” as Hatch paraphrases the gist of such equivocations. But the problem is that there should be more investigation into the cultural and systemic conditions in the first place. By neglecting to investigate these conditions, namely systemic racism, those who don’t want to look too closely often end up unintentionally upholding them.

The more stress we experience, the more likely we are to develop a chronic illness like diabetes that will become severe and have lasting health impacts such as disability and premature death.

For example, stress has long been linked with other chronic illnesses. It shortens cellular life, triggers hormonal responses that wear on the body and brain, and makes us less resilient. The more stress we experience, the more likely we are to develop a chronic illness like diabetes that will become severe and have lasting health impacts such as disability and premature death. Well, stress is directly related to our social and economic position. “We now know that racism, both as an institutional system and as an experience, is extraordinarily stressful,” Hatch says. Meaning systemic racism creates the conditions for Black people to be more impacted by stress and therefore to be more vulnerable to chronic illnesses. “Any conversation around racial health equality has to really come to the question of the unequal distribution of resources that's at the heart of it,” he says.

Hatch points to the UK as an example. Their National Health Service supposedly provides everyone with the same level of health care. And yet, disparities persist. People with higher socio-economic standing live longer and have less illness than people with less. Providing health care for all helps, but it’s not enough on its own.

Layered over this history of inequality is the narrative of genetic heritability – the notion that because your parents and grandparents had diabetes, you will too. It’s a very powerful narrative in Black American families, and it creates a sense of fatalism. People feel like there’s not much they can do about their genes, so they figure they might as well keep doing what they’ve been doing if they’re going to get diabetes no matter what.

In reality, the heritability of Type 2 diabetes is not nearly as strong as the social influences. “That biology is always unfolding in a social environment, and it's that environment that's driving the diabetes. The biological system is a medium for the expression of the social,” Hatch says. In a way, diabetes is the social imprinting itself on the body. This is why it’s so important to go beyond the data, beyond a medical concept of health, and include a social view as well. “It's important for medical researchers to expand their thinking,” says Hatch. “It's not just about what the biological data is saying, but what people are experiencing, how we make sense of it, and how we interpret it.”

Hatch has had Type 1 diabetes for nearly 30 years. Even after all this research on the social issues contributing to health disparities, he says, “I would never tell you that, as a Type 1 diabetic who wears an insulin pump and very closely monitors his food intake, exercise, and insulin, that my family history and the choices I make don't matter. I would never say that.”

But medicine does need to find ways to empower patients without blaming them for their own ailments. Clinics shouldn’t feel like moral courts, where patients are judged by their weight or blood sugar data and scolded rather than connected to the resources they need to improve their blood sugar management. Health providers must gain a complete understanding of how their patients get sick, as well as how those patients understand their disease.

There needs to be conversation about the patient’s neighborhood, their home life, their finances, and whatever else might be shaping the choices they make that affect their health. Beyond patient agency, we need to make room for collective work that changes the conditions that shape people’s exposure to a disease.

"The central reason why we have to challenge the narrative of personal responsibility and choice," Hatch says, is because it directly informs health disparities research, which then "makes it impossible to think about collective action and change." In other words, even health researchers are biased toward seeing health disparities as the outcome of individual decisions, rather than a symptom of larger systemic forces. This influences everything from the questions that shape their studies to the possible solutions that present themselves as a result of those investigations.

Instead of asking what choices people in a marginalized group should be making, or how we can help them make better choices, we could be asking how their environment could be improved, or what larger mechanisms could be in place to support an entire community's health.

Bridging the Gap

Plant growing from seed in hand

Many BIPOC and ally doctors are organizing themselves to build cultural competence among their colleagues. For example, a team of four physicians from around the country created the Cultural Complications Curriculum, 12 modules of data-driven education on medical bias for health care workers.

The US Department of Health and Human Services (HHS) has begun coordinating with various federal, state, and local agencies on initiatives that address health disparities in comprehensive, integrative ways. For example, The Healthy People 2030 initiative has nine objectives which specifically address diabetes, from increasing the proportion of adults with diabetes and chronic kidney disease who get ACE inhibitors or ARBs to increasing the proportion of people with diabetes who get formal diabetes education, to reducing the rate of foot and leg amputations.

Dig a little deeper, and there is a labyrinth of government agencies coordinating with each other in attempt to tackle the problem. The HHS Office of Minority Health reports to congress and “works to raise awareness on efforts aimed at reducing health and health care disparities and advancing health equity” through several initiatives. They also award grants to programs addressing health inequities around the country. On the research end, the Office of Minority Health Research Coordination (via the National Institute of Diabetes and Digestive and Kidney Diseases) partners with the National Institute on Minority Health and Health Disparities (NIDDK) to train new investigators from underrepresented groups in biomedical research. They also recently established a network of researchers interested in minority health.

“The ongoing impact of diabetes in the era of COVID-19 has highlighted the importance of treating this costly, chronic, and consequential disease that continues to impact communities of color at disproportionately high rates,” says Dr. Lawrence Agodoa, director of the Office of Minority Health Research Coordination. “In order to address diabetes and a number of other health disparities, it is of critical importance that the team of researchers addressing these diseases also reflect the communities that are most impacted. In order to increase representation, NIDDK funds a number of training opportunities for individuals ranging in experience from high schooler to early-stage investigator. However, there is still much work to be done to ensure greater representation and further address racial and ethnic disparities in who gets diabetes and what treatment they receive.”

In order to address diabetes and a number of other health disparities, it is of critical importance that the team of researchers addressing these diseases also reflect the communities that are most impacted.

The National Institute on Minority Health and Health Disparities at the National Institutes of Health is also committed to promoting and supporting research that reduces or eliminates health disparities, says Dr. Larissa Avilés-Santa, Director of Clinical and Health Services Research.

At the FDA, the Office of Minority Health and Health Equity is working to increase the amount of health research on racial and ethnic minorities and to get more health information to minorities, including those speak who English as a second language. In 2010, the Centers for Disease Control and Prevention (CDC) partnered with public and private organizations like the ADA to develop the National Diabetes Prevention Program (National DPP), which is an evidence-based lifestyle change program to help people with prediabetes prevent or delay Type 2 diabetes. Through this program, the CDC funds national organizations that start new, in-person programs in underserved areas. They created the Native Diabetes Wellness Program specifically for Indigenous Americans, and in 2019 they published an update to their study on racial and ethnic differences in diabetes screening for hypoglycemia for women. And, in January, Biden appointed Marcella Nunez-Smith as the chair of the first ever White House equity task force.

So you may be wondering: Is any of this working? We need more information to say. It’s hard to believe, but the CDC’s latest report was the first time the agency published national estimates on diabetes within adult Latinx and Asian populations, using data from 2011 to 2016. This is just one example of the glaring research gap that has historically excluded entire groups from diabetes studies. That said, according to the ADA, the National DPP has been shown to reduce the risk of development of Type 2 diabetes by 58% (71% for people over the age of 60) for the general population, according to Lisa Murdock, Vice President of State Government Affairs and Advocacy at the ADA. Led by trained lifestyle coaches, participants learn about healthier eating, working physical activity into their everyday lives, and effective coping mechanisms. Programs are offered in communities all over the US.

As the most visible diabetes nonprofit organization in the country, the American Diabetes Association works to educate the public about diabetes and helps fund programs. But they also engage in advocacy to make education programs more accessible to underserved communities. The ADA helped advocate for the National DPP to be covered by Medicare, and they are currently fighting for Medicaid programs to cover it as well.

The ADA is also working at the state level to expand Medicaid and to support policies that reduce food insecurity. In terms of focusing on communities of color, the ADA has most recently endorsed H.R. 8200, the Ending Health Disparities during COVID-19 Act, introduced by representative Robin Kelly of Illinois. Their newly updated 2021 Standards of Care include updated recommendations addressing social determinants of health, which they define as "the economic, environmental, political, and social conditions in which people live and are responsible for a major part of health inequality worldwide," reflecting the findings of a new scientific review published in November 2020. These recommendations address food insecurity, housing insecurity, migrant and seasonal agricultural workers, language barriers, and community support.

This past summer, the ADA launched its campaign Health Equity Now, a platform which you can use to contact your elected officials about the health inequities experienced while living with diabetes. It aims to ensure that “all people with diabetes have the right to health, quality care, and medical resources,” and includes a newly created Health Equity Bill of Rights, composed of these ten basic rights for people with diabetes or prediabetes:

  • The right to access insulin and other drugs affordably.
  • The right to healthy food.
  • The right to insurance that covers diabetes management and future cures.
  • The right not to face stigma or discrimination.
  • The right to avoid preventable amputations.
  • The right to participate in clinical trials without fear.
  • The right to stop prediabetes from becoming diabetes.
  • The right to a built environment that does not put you at greater risk for getting diabetes.
  • The right to the latest medical advances.
  • The right to have your voice heard.

Facing Discrimination at the Doctor’s Office

Plant growing from seed soil

Racial and ethnic-based microaggressions and biases are ubiquitous in doctors’ offices around the country. They come in the forms of stereotyping, lack of respect, misdiagnosis, shaming, and minimization of symptoms. A 2016 study revealed that many white health care workers, medical students, and residents “hold false beliefs about biological differences between blacks and whites and demonstrate that these beliefs predict racial bias in pain perception and treatment recommendation accuracy.” The repercussions of these microaggressions in health care are so significant, that researchers are working on new ways to measure them – and also how to prevent them from occurring in the first place.

This discrimination extends even into the waiting room, where BIPOC patients spend 25% more time waiting to see a doctor than white patients.

  • White Americans spend 80 minutes 
  • Black Americans spend 99 minutes
  • Latinx Americans spend 105 minutes
Minutes spent waiting for care graphic

Black and Latinx people spend 10 more minutes traveling to a doctor’s office or medical center. They are also asked about insurance more frequently and scheduled further in advance than white patients (meaning they wait longer for appointments with their doctors as well).

Waiting for change graphic

A survey published in 2019 found that three out of four diabetes patients fail to adequately control their blood glucose, blood pressure, blood cholesterol, and smoking. One of the reasons why is because some patients simply aren’t prescribed the medications and treatments they need. The groups most likely to go undertreated are young people, those without health insurance, and BIPOC. As you can imagine, these groups overlap.

Diabetes patients graphic
Undertreated groups graphic
A 2015 study found that white children from low-income families without private insurance are more likely to have insulin pumps than Black children from higher-income families with private insurance.

There are also indications that doctors are making assumptions about what kinds of treatment people can afford based on their race or ethnicity. A 2015 study found that white children from low-income families who don’t have private insurance are still more likely to have insulin pumps than Black children from higher-income families with private insurance. Researchers at the 2020 virtual annual scientific sessions for the American Diabetes Association reported that racial and ethnic minorities and Medicare beneficiaries were less likely to be prescribed the newer diabetes medications they need. Dr. Wright notes that language barriers may subconsciously and inaccurately influence doctors’ assumptions about whether a patient can handle technology.

The Truth About Genetic Risk

Plant growing from seed soil

Genetics play a major role in the way we talk about diabetes in American Indians and Native Alaskans—both of which have the highest rates of Type 2 diabetes among all ethnic groups in the US. The federal government started tracking the disease among them after World War II. It wasn’t one of the top 10 causes for death until 2009, when it jumped to number four. Indigenous people experience a higher incidence of long-term complications due to diabetes, and from a younger age. The effect on youth is especially alarming. Between 1990 and 2004, there was a 77% increase in diagnosed diabetes among children under 15, and a 128% increase among teens from 15 to 19.

Among the Pima Indians in Arizona, prevalence has been especially high. By 1970, 40% were diagnosed with Type 2 diabetes, and the rates continued growing after that. This has been attributed to a combination of the so-called “thrifty gene” hypothesis, in which a tendency to conserve calories is selected over time in populations that deal with periods of limited resources, and the total decimation of their way of life, from a labor-intensive agrarian lifestyle with a high-carbohydrate, low-fat diet, to a life of labor scarcity with high-fat diet. (At the turn of the 20th century, white settlers north of the Pima diverted their water source, making farming impossible.)

A 1991 study compared the Arizona Pimas with another Pima community in a remote location in Mexico and found the Mexican community, with its original lifestyle intact, had significantly lower rates of diabetes. A larger 1994 study bore out the same results, showing that environmental factors such as diet and physical activity have a much more significant effect on rates of diabetes than genetics.

This isn’t to say genetics do not play any role at all. There is a strong genetic component to type 1 diabetes, which is an autoimmune disease. And there is still a link from a family history of diabetes to an increased risk for Type 2 diabetes. Recent research has unearthed possible clues to the role genetics might play in some groups. For example, in Mexican Americans with Type 2 diabetes, there is a connection to chromosome 2q37, suggesting an ethnicity-based genetic susceptibility.

Out of all ethnic groups, Asian Indians in the US have the highest risk for developing diabetes at a younger age, as well as when not overweight or eating a diet that is high in sugar. Possible causes for this tendency include a predisposition to be more insulin resistant and hyper insulinemic, as well as an increased likelihood of developing more visceral fat (hidden behind the abdominal wall and around the organs) which puts you at greater risk for diabetes.

It’s not just Indians. Asians tend to develop diabetes at a lower BMI than other groups.

One in four people with diabetes goes undiagnosed. But 51% of Asian Americans with diabetes are undiagnosed. They don’t look at risk, so they fly under doctors’ radars.

One in four people with diabetes goes undiagnosed. But 51% of Asian Americans with diabetes go undiagnosed. They don’t look at risk, so they fly under doctors’ radars. In other racial and ethnic groups, however, genetic predispositions are increasingly being found to be a smaller piece of the puzzle than previously believed.

In addition to having a greater proportion of visceral fat, Asian Americans tend to have a lower proportion of muscle mass relative to body fat. Researchers believe it may be due to a combination of environment and genetics. Rates of diabetes for people of Chinese or Japanese descent living in the US are higher than for people living in China and Japan. But second and third generation Asian Americans, who are likely acclimated to a western diet, have higher rates of diabetes than white Americans. In response, the ADA recently changed its recommendation for testing Asian Americans. For the overall population, doctors are advised to test people with a BMI of 25 or higher or who are over the age of 45. For Asian Americans, the ADA recommends testing those with a BMI of 23 or higher.

But environment, from socioeconomic to lifestyle factors, seems to play a much larger role in determining how any genetic susceptibility will play out. For this and many other complex reasons, it’s extremely difficult to tease out exactly what role genetics may play in a person’s susceptibility to Type 2 diabetes.

To further complicate matters, the majority of large-scale genomic studies have been conducted on people of European and Asian ancestry. Researchers have begun investigating possible genetic factors among Black and Latinx people only recently, for example at the South Texas Diabetes and Obesity Institute in the Rio Grande Valley, so we still have a lot to learn.

The story may be most dramatic among the Pima, but the same themes emerge among all the Indigenous people of North America. What was once a nation of some 500 tribes was irrevocably disrupted by European settlers who dispossessed these communities of their lands and their way of life. Children were sent to boarding schools and divorced from their family traditions. Enter diabetes, within a tangled web of related deleterious social and health outcomes. But the story doesn’t end there. Awakened to the crisis, Indian Health Services created the Special Diabetes Program for Indians (SDPI) in 1997, and diabetes rates have been steadily declining ever since.

The key factor to its success is partnering with the community to care for everyone’s health, not just those with diabetes. First of all, it’s the community who decides how resources will be spent, not an outside expert. Two-thirds of the grantees spend their funding on things that benefit the tribe as a whole, like afterschool physical activities for children, community gardens, seed-saving programs, and elders teaching youth about traditional foods. It’s an approach that recognizes that diabetes shows up alongside other conditions such as chronic stress, heart disease, and depression, and that these conditions arise from risk factors like poverty, trauma, and food insecurity.

Holding the Medical Community Accountable

Clearly there is an urgent need for more BIPOC health professionals. Addressing racial health disparities requires us to also address inequality in education. According to the Association of American Medical Colleges, as of 2015, 51.2% of medical school graduates were white, 6% were Black, and 5% were Latinx.

On November 16, 2020, the American Medical Association (AMA) issued a statement, saying it had taken action to “explicitly recognize racism as a public health threat” and detailed a plan to mitigate its effects. They made a point to recognize race as a social construct, “distinct from ethnicity, genetic ancestry or biology” and will “recommend that clinicians and researchers focus on genetics and biology, the experience of racism, and social determinants of health – and not race – when describing risk factors for disease.”

It makes a difference that a doctor understands the various ways a person of African ancestry, who has experienced a lifetime of racism while living as a Black person in America, may be at risk for diseases like diabetes – versus oversimplifying that a person is at risk for diabetes simply because they are Black.

This may sound like semantics, but it could have profound and long-lasting effects if it’s thoughtfully carried out. It makes a difference that a doctor understands the various ways a person of African ancestry, who has experienced a lifetime of racism while living as a Black person in America, may be at risk for diseases like diabetes – versus oversimplifying that a person is at risk for diabetes simply because they are Black. This is a paradigmatic structure that could help doctors see patients as multidimensional, rather than reducing them to simplistic categories. It’s treating a patient as a human being with a set of genetic factors, a particular biology, and a specific life experience, all of which have implications for their health.

Such changes are going to take years. But you’re not powerless. There are things you can do right now to get the care you need and deserve.

Indigenous people graphic
American med school graduates graphic

How to Navigate a Doctor’s Appointment

Our 8-step guide will help you troubleshoot inferior care.

1) If you’re having your annual exam, and believe you’re at risk for diabetes: Ask for a blood glucose lab test, and insist on reviewing the results with your doctor.

2) If you’re not diabetic, ask if you’re prediabetic: If yes, ask for next steps for prevention and programs offering support.

3) If your doctor prescribes medication or equipment: Tell your doctor what kind of insurance you have. Ask if this is the most appropriate medication your insurance will cover.

4) If your doctor gives you vague guidance like to just cut sugar: Find a diabetes educator, local classes, and/or a diabetes dietitian. See the list of resources below.

5) If your doctor shames you: This can be highly subjective, but you know how someone makes you feel. You could write a letter of complaint to the doctor, or to the manager of their practice, or to your insurance company. First, document exactly what the doctor said, word for word. Say how those words made you feel. Even if you never send the letter, writing can help you process the experience. Next: find a new doctor.

6) If your doctor refuses a treatment: Tell them, "I will need you to document, on record, that you are refusing the treatment I requested, and the reason you are refusing to do so." You are asking the doctor to put it in writing. You will want one copy of this document to keep, and another copy (or at least a note) in your medical records at the doctor's office. The nonprofit organization Patients Rising works with people with chronic illnesses to advocate for access to the treatments and care they need. They have a support line for questions.

7) If you feel your health has been affected by inadequate care: File a complaint with your state medical board; this could help prevent other people from receiving the same bad treatment, or at least alert a doctor that they need to do better. If you’re covered by Medicare: Here is a list of resources.

8) Find a patient advocate: The Patient Advocate Foundation can connect you with a case manager.

How to Find a Better Doctor

It takes work…but there are resources. If you’re looking for a doctor who…

Questions to Ask at Your Appointment

  • Can you connect me with resources, including diabetes educators, dietitians, and support groups?
  • What if I have questions after our visit?
  • Can I communicate with you through an online portal?
  • What if I need care after business hours?
  • Which hospitals are you affiliated with? (Make sure at least one is near you.)
  • How do you handle lab tests? How long do they take, and how soon will we talk about the results? In person or over the phone?

Questions to Ask Yourself Post-Appointment

  • Did you feel like you were being treated with compassion?
  • Did the doctor answer all of your questions? 
  • Did the doctor use familiar words or a lot of medical jargon?
  • Was the doctor respectful of your culture and beliefs?
  • Do you feel safe talking about difficulties you’re having, or asking awkward questions?
  • Do you feel like you can be totally honest with your doctor, or can you tell you’re going to want to hold things back?
  • How long did it take to schedule an appointment?
  • How long were you in the waiting room?
  • How did the office staff treat you?
  • Medicare has a physician compare tool that lets you see what kind of care physicians have provided and recommended to their patients.
Doctor

Money Matters

The four-letter word in diabetes care: COST. Finding a diabetes educator or dietitian who understands where you’re coming from culturally is challenging. But at least there are programs and services that are free, low-cost, or covered by insurance: 

  • Find a diabetes education program via the Association of Diabetes Care & Education or the American Diabetes Association
  • Find a dietitian and Certified Diabetes Educator (CDE) via the Academy of Nutrition and Dietetics 
  • Steady Health combines continuous glucose monitoring with a food and exercise-tracking app and care from doctors and health coaches starting at $85/month.
  • Eli Lily, Novo Nordisk, Sanofi, and MannKind Support Programs offer assistance for low-income individuals with diabetes, including donated insulin. (See the ADA’s resource page for more information.)
  • The Lily Insulin Value Program enables people to purchase a month’s prescription for $35, whether or not they have insurance (you can get the co-pay card online). There are limitations. Seniors using Medicare Part D, for example, are ineligible. Novo Nordisk’s Novolin ReliOn Insulin is available at Walmart for $25, but it has different peak times and duration action times than analog insulin, so it's important to closely follow a well-informed doctor's instructions for using it.

    For Access to Insulin and Medical Services
  • Nick Jonas founded GetInsulin.org, an online tool to help people get stable, long-term access to insulin. People with Type 2 diabetes don’t necessarily need insulin. You may be more likely to take Alpha-glucosidase inhibitors, Biguanides, Bile Acid Sequestrants, Dopamine-2 Agonists, DPP-4 inhibitors, or TZDs, to name just a few. It could add up to $200-600 a month. For these medications, there are a handful of resources:
  • Financial help for medication, supplies, and more
  • The Good Rx app lets you compare prices at different pharmacies in your area. 
  • Dr. Barbara Onumah of Anne Arundel Medical Center in Annapolis, Maryland has compiled a list of low-cost medication options (though this is guidance created for health care providers). Newer drugs tend to be considerably more expensive than older versions without necessarily delivering more quality.
  • Testing and lab work are also becoming more accessible. You can get a free diabetes screening at many drug stores and some hospitals, though it’s usually just a simple blood sugar test. For a more accurate measure there are a number of companies, like Walk-In Lab and Health Testing Centers, that enable you to order lab work and blood tests online without a doctor or insurance. Most of these companies partner with labs like Quest Diagnostics and LabCorp. Labwork365 offers a diabetes and kidney package for $59.
  • The Bridge provides home visits and other outreach for patients with chronic disease in Appalachia. The Northern Dental Access Center Medical-Legal Partnership offers support to patients in rural Minnesota in identifying legal and other barriers to oral health. The Trust for America’s Health has a list of successful community-based public health interventions (listed by state).

Organizations and Resources

Find Community Online

Sources