Diabetes Awareness Month: Understanding the link between racial inequalities and diabetes

Think diet alone causes diabetes? Think again. Health equity researcher breaks down commonly overlooked risk factors for diabetes and offers actionable advice for prevention.

By Thalia Plata

Photo by Towfiqu barbhuiya on Unsplash

According to the Centers for Disease Control and Prevention, 37 million Americans are living with diabetes, a chronic health condition that occurs when your blood sugar is too high. Over time, diabetes can lead to other health complications such as heart disease, nerve damage, eye problems, and kidney disease.

Despite accounting for a smaller percentage of the population, Black, Latinx/e, American Indian or Alaskan Native people are more likely to develop diabetes than their white counterparts. To better understand why this is, we turned to Dr. Monica Wang, an associate professor of community health sciences at the Boston University School of Public Health and chair of the narrative office at the BU Center for Antiracist Research.

Dr. Wang is nationally recognized as a leading health equity researcher in obesity and chronic disease prevention. She directs community-engaged research to target racial inequities in health and pursues cross-sector collaborations to promote health and health equity through public health interventions and policies. In this Q&A, Wang explains why diet and genetics are not the only factors contributing to the health disparities in diabetes.

Why do racial inequities in type 2 diabetes exist among Black Americans, Latinx/es, American Indian, or Alaskan native populations?

First, it is important to clarify that race itself does not necessarily cause higher risk of disease. Race is a social construct, and its definition and measurement have varied over time and place. The higher rates of type 2 diabetes among Black Americans, Latine, and American Indian or Alaskan Native populations arise from numerous factors, including the built environment, policy, interpersonal influences, lifestyle, and genetics.

The most pressing factors to highlight are the ones that are commonly overlooked — the impact of social determinants of health such as systemic racism and structural conditions that have created unhealthier environments for communities of color compared to white communities, particularly in places like the U.S.

One JAMA study of adults found that after adjusting for biological, psychosocial, socioeconomic, and lifestyle behaviors, the racial disparity between Black and white participants in developing type 2 diabetes disappeared. Research such as this and others indicate that race itself does not drive higher risk of diabetes but may be a proxy for other factors. Which include unequal access to health care, healthy food, parks, pharmacies and other services and resources that arose from racial residential segregation; chronic exposure to stress from discrimination; and unequal treatment in the health care setting. All these factors have created these inequities.

The rate of childhood diabetes is on the rise, especially among Latinx/e children. Can you provide some insight into what’s causing the rise of childhood diabetes and what you’ve learned in your research?

Childhood obesity rates in the U.S. have more than tripled between 1970–2000 among children ages 6–11, and this rapid increase cannot be due to genetics alone. A variety of individual, interpersonal, community, environmental, and policy factors contribute to rising rates of childhood obesity in the U.S. and globally.

Our daily lives and the environments in which we live have increasingly shifted towards unhealthy behaviors (e.g., massive exposure to screen time, limited opportunities and resources to be active, increased exposure to fast foods) as the default or more convenient option. Engaging in healthy behaviors routinely requires financial, time, and social support resources that many families may not have. The most recent State of Childhood Obesity Report: From Crisis to Opportunity identifies food insecurity, structural racism, and COVID-19 as key factors that have contributed to rising obesity among youth.

With respect to the link between obesity and diabetes, the consumption of sugary drinks is a key behavioral factor that increases the risk for both conditions. And, as with tobacco and other products, we’ve seen sugary drinks and other “Big Food” products disproportionately marketed to children and specifically to children and families of color. Given the relationship between sugary drinks, obesity and diabetes, placing guidelines on the marketing of such products and promoting the consumption of healthier alternatives, such as water or milk, through environmental, policy, and community approaches are needed.

In my own research, we have found that by reducing the number of sugary drinks consumed and increasing their water consumption as an alternative, children, including those who are low-income and identify as youth of color, are able to better maintain a healthy weight trajectory and thus decrease their future risk of developing diabetes.

What steps can families take to better understand and reduce their risk of developing diabetes?

Parents and caregivers can make small changes at home to help their children to engage in healthy behaviors that prevent diabetes, and it is important to understand that type 2 diabetes is preventable and can be managed. As shown in our research, one small change is to make sugary drinks and processed foods high in sugar less readily available and accessible at home. Purchase fewer of these options and place them out of reach and sight of children. Another is to model the health behaviors you want them to engage in. Exercise together, drink water, limit screen time and remind your children to do the same. Children look to adult caregivers as role models, and it is much easier to shift behavior changes as a family.

Are there public health interventions and policies that could address this issue that you’d like to see in the future or are currently advocating for?

In terms of programs, the Diabetes Prevention Program (DPP) is a globally recognized lifestyle change program that has demonstrated success in reducing the risk of developing diabetes, including among participants of color. A randomized controlled trial found that participating in this program led to a 58% reduction in diabetes incidence; since then, the DPP has been scaled globally and translated into multiple languages.

With respect to policies, given the known link between added sugar intake and diabetes, several U.S. cities and countries around the world have passed legislation on sugar-sweetened beverage taxation as a food environment policy approach to curb the obesity and related diabetes epidemics. This shift in legislation alongside growing consumer demand for healthier alternatives has also encouraged the beverage industry to reformulate their products. And, in cities and countries that are collecting data, emerging research shows that the taxation is having intended results — reduced sugary drink purchase and consumption, and increased purchase of water.

I’d like to see us move in the direction of improving the built food and physical activity environment locally, nationally, and globally and have that be central to urban planning and design. Doing so successfully requires a commitment to health equity and cultivating interdisciplinary collaborations that span multiple sectors and levels of influence.

For additional commentary by Boston University experts, follow us on Twitter at @BUexperts. Follow Dr. Monica Wang on Twitter at @DrMonicaWang. For research updates from BU’s School of Public Health and the Center for Antiracist Research, follow @BUSPH and @AntiracismCtr.

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