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June 23, 2023

Series in The Lancet and The Lancet Diabetes & Endocrinology Identifies Structural Racism and Geographic Inequity as Key Drivers of Disparities

June 22, 2023—(BRONX, NY)—Despite increased awareness and ongoing multinational efforts, diabetes is pervasive, exponentially growing in prevalence, and outpacing most diseases globally, according to a new series published in   journals. Worse still, structural racism experienced by minority ethnic groups and geographic inequity experienced by low-and middle-income countries (LMICs) are accelerating soaring rates of diabetes disease, illness, and death around the world.

“Diabetes remains one of the biggest public health threats of our time and is set to grow aggressively over the coming three decades in every country, age group, and sex, posing a serious challenge to health-care systems worldwide,” says Shivani Agarwal, M.D., M.P.H., leader of The Lancet series, associate professor of medicine and associate director of the Fleischer Institute for Diabetes and Metabolism at Albert Einstein College of Medicine and an endocrinologist at Montefiore Health System. “This series offers an important opportunity for concerted, pragmatic action to transform approaches to diabetes care and outcomes for marginalised populations around the world.”

Structural Inequities and Racism

New estimates published in the series highlights how the ever-growing global burden of diabetes—expected to top one billion people by 2050—is further exacerbated by large-scale inequity in diabetes prevalence, illness, and death. Estimates indicate that more than three-quarters of adults with diabetes will live in LMICs by 2045, of whom fewer than 1 in 10 will receive guideline-based comprehensive diabetes care. In high-income countries (HICs) like the U.S., rates of diabetes are almost 1.5 times higher among minority ethnic groups (i.e., American Indians and Alaska Natives, Black, Hispanic, Asian) compared to white populations, fuelled by structural racism. The series found that people from marginalized communities around the world are less likely to get access to essential medicines like insulin and new treatments, have worse blood sugar control, and have a lower quality of life and reduced life expectancy.

The series outlines how the large-scale and deeply rooted effects of structural racism and geographic inequity lead to unequal impacts of social determinants of health (the social and economic conditions in which people live and work) on global diabetes prevalence, care, and outcomes over the life course. Negative impacts of public awareness and policy, economic development, access to high-quality care, innovations in management, and sociocultural norms are felt widely by marginalised populations and for generations to come.

Structural racism and structural conditions in the places people live and work have far-reaching, trans-generational negative effects on diabetes outcomes across the world. “It is vital that the impact of social and economic factors on diabetes is acknowledged, understood, and incorporated into efforts to curb the global diabetes crisis,” said Dr. Agarwal.

A series article published in The Lancet Diabetes & Endocrinology adds further weight to these findings, highlighting the large disparities in diabetes burden and management that exist between and within race and ethnic groupings in the USA. For example, Black people born in Africa or the Caribbean are 25% less likely to develop diabetes than U.S.-born Black individuals; and Asian, Black, and Hispanic individuals and those on low incomes are less likely to receive diabetes treatment with GLP1 receptor agonists than their white or wealthier counterparts.

Opportunities to Improve

Building on recommendations from the 2020 Lancet Diabetes Commission, together with WHO’s 2021 Global Diabetes Compact and the UN Sustainable Development Goals, the series outlines action plans to tackle racial inequities in diabetes care and improve outcomes by including the most affected communities in the development and implementation of interventions, and incorporating multi-layered strategies to address structural and social determinants of health that are the root causes of inequity globally.

The authors highlight international examples of how to address diabetes inequity in the real world by changing the ecosystem (societal and policy-level factors), building capacity, and improving the clinical practice environment.

Insulin access is an important part of the ecosystem for millions of people with diabetes who cannot obtain or afford the necessary supplies to self-manage their diabetes. One intervention in sub-Saharan Africa, developed in partnership with governments, industry, and patient groups, is the Diabetes CarePak “co-packaging” solution to increase access to safe insulin and supplies. The month’s supply of test strips, alcohol swabs, needles and syringes and a glucose meter has resulted in more frequent blood glucose monitoring as well as an average haemoglobin A1C decrease of 2.8% over two months—a reduction which compares favourably to medication use.


Ultimately, the series solidifies the need for more high impact, high-quality, real-world research to ensure that all people with diabetes receive the care they need where and when they need it. “While research has focused on describing these inequities, it is critical to develop and test interventions to address them,” said Dr. Agarwal. “There is a dearth of on-the-ground approaches published in high-impact journals. We must stop admiring the problem and start fixing it.”



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