Assess social determinants of well being to restrict disparities for folks with diabetes


February 01, 2021

5 min read

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Healio interview

Joseph does not report any relevant financial information.


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Social conditions caused by systemic racism contribute to health inequalities among people with diabetes and other endocrine disorders, and endocrinologists can take concrete steps to assess patients’ non-medical needs and advocate for change.

In an article published January 18 in the Journal of Clinical Endocrinology & Metabolism, Sherita Hill Golden, MD, MHS, the Hugh P. McCormick Family Professor of Endocrinology and Metabolism and Vice President and Chief Diversity Officer of the Bureau of Diversity, Inclusion and Health Justice at Johns Hopkins Medicine, Felicia Hill-Briggs, PhD, ABPP, Professor of Medicine and Senior Director of Public Health Research and Development at the Johns Hopkins University School of Medicine, and Joshua J. Joseph, MD, MPH, FAHA, Assistant Professor of Medicine in the Department of Endocrinology, Diabetes, and Metabolism at Ohio State University’s Wexner Medical Center, explained the social determinants of health that contribute to negative health outcomes, especially for black adults with diabetes, such as poverty, insecure housing, lack of Access to healthy food and safe physical activity, and inadequate employment and educational opportunities.

Joseph is a Assistant Professor of Medicine in the Department of Endocrinology, Diabetes, and Metabolism at Ohio State University’s Wexner Medical Center.

“As a specialty, our focus was on the biology of metabolic disease risk – pathophysiological pathways and responses that lead to obesity, diabetes, metabolic bone disease, and thyroid disease,” the researchers wrote. “But what if our appeal is even broader – to take a step back and ask the question, ‘Why do we see these biological responses that lead to higher risk of metabolic disease and poorer outcomes in minorities?'”

Healio spoke with Joseph about the structural problems that lead to health inequalities in diabetes, health system approaches to reducing endocrine disparities, and the importance of measuring racism in the clinic to reduce implicit bias and promote equitable treatment.

What made you and your colleagues write this paper?

Joseph: We know that health justice is our north star. We have to go here. We have great differences in many endocrine diseases, including diabetes and obesity. We all appreciate understanding what underpins these challenges and moving forward to advance and promote justice related to these challenges.

You and your colleagues write that diabetes is “an exemplary health inequality”. What does that mean?

Joseph: What is unacceptable about diabetes is that there are differences at every level of the disease process. There are health differences among people at risk of diabetes, differences between people who develop diabetes, differences in the prevalence of the disease, differences in the control of diabetes, and differences in the macrovascular and microvascular outcomes of diabetes, including cardiovascular disease -Diseases, Nephropathy, and the list goes on. Then there are differences in mortality, with ethnic minorities developing diabetes earlier in life and dying earlier too. All of this revolves around social determinants of health. In certain circumstances the screening or treatment or results may be different. In diabetes, we see differences across the spectrum of diseases. For this reason, diabetes is an exemplary health condition.

Can you outline some of the structural problems that explain these differences?

Joseph: If you think of these problems as a river with the upstream determinants coming down from above, then poverty, racism and discrimination are furthest upstream. We have to deal with these, but these are the most difficult to deal with as they require political and cultural change and investment. Politics and cultural change can be arduous.

From there we have the midstream determinants: housing, built environment, economic inequality, food insecurity. All of these “middle” things – non-medical health-related social needs – affect downstream health outcomes. This is where our differences in diabetes, obesity, and other endocrine disorders come from. Our entire health system has the ability to more adequately address non-medical health-related social needs, but we ultimately need to go upstream and address politics. This is what will end these inequalities.

What concrete steps can endocrinologists and diabetes care and education specialists take today to make changes in these areas?

Joseph: Providers can advocate measuring non-medical health-related social needs in their clinics. For example, screening for food insecurity in hospitals. Not just screening, but developing programs where providers can refer people to solve the problem. We have a Food Farmacy program at Ohio State University. We ask two validated screening questions to identify food insecurity. If a person has a positive answer to either question, we refer them to our food farm where they receive products on a weekly basis. Not only do we identify a significant obstacle to health, we also address it with a solution. This gives endocrinologists the ability to understand and measure the challenges patients face and then develop solutions to those challenges.

In Ohio, we also have a community hub model with nine hubs across the state where we can direct people to ways to address certain social determinants of health. The government-administered Medicaid programs pay community care facilities to address social determinants. When food insecurity is the challenge, people are referred to a local food bank. This is reported to the state, and the community maintenance department receives a payment from the state. This system arose out of the advocacy of policies at the state level to allow social determinants of health to be taken into account.

The other piece of it is to actively participate in anti-racism efforts. What does that mean? Many universities are actively engaged in discussions about anti-racism, which has moved from dialogue about plans to structures and policies. To begin with, you have to measure racism and bias in health systems. There are ways to evaluate this from different perspectives, including patients and staff. Then we need to make sure that we have practices in clinics and hospitals that are fair, anti-racist, and that implicit biases do not affect care. We need to make sure our clinic space is welcoming and a “safe space” for everyone. That is our responsibility as a provider. We’re getting there, but we’re not quite there.

Which measures should be supported at both state and federal level in order to reduce the health differences?

Joseph: I’m not going to answer that as one might expect.

When we, as organizations and as providers, measure the social determinants of health in our organizations and understand the challenges our patients face, we can use that data to make changes. Many colleges and universities are stakeholders in their communities – large employers, large government affairs departments, etc. – we could use the data we collect as providers and health systems to determine the specific social determinants of health that affect those we care for Impact population groups to better understand. Given the diverse social determinants of health effects, we should use the data we collect to advocate policies that affect our patients in the communities in which they live. We have data analytics to do this here in Ohio to drill down to the neighborhood level and see, for example, which of the three main social determinants of health affect disease processes like diabetes at the census tract level.

All of this requires teamwork. At the provider and organizational levels, we need to come together and work together across organizations to address the social determinants of health. An emphasis on collaboration, partnership and teamwork is key to solving the challenges we face.


Golden SH et al. J Clin Endocrinol Metab. 2021; doi: 10.1210 / clinem / dgaa938.

For more informations:

Joshua J. Joseph, MD, MPH, FAHA, can be reached at; Twitter: @joshuajosephmd.


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Race and medicine

Race and medicine