So, welcome today to today's webinar, Addressing Diabetes, Disparities, and Inequities in Diabetes Care. This is the first of a four-part webinar series exploring diabetes disparities in various aspects, including prevention, management, and outcomes. Today's webinar, we will discuss the root of the problem and tangible solutions. We have two wonderful speakers, Dr. Enrique Caballero and Dr. Rocio Pereira. My name is Estelle Everett. I am an endocrinologist and health services researcher at UCLA, and I am one of the moderators for today's webinar, alongside with Dr. Obong Aida, who I will let introduce herself and our first speaker. Hello, everyone. My name is Oto. I'm a human physiologist from the University of Just Nigeria, and this webinar series is very precious to me. We had the first series on obesity last year, and this year, we're focusing on diabetes. And so, I'm going to introduce our first speaker, but before then, I just want us to know that the live Q&A will occur at the end of the session, so please be sure to submit your questions or upvote any questions you like throughout the session so that our speakers can attend to the questions. And so, I want to introduce our first speaker. She's Dr. Ro Pereira. Dr. Ro Pereira is the Director of the Office of Health Equity and Chief of Endocrinology at Denver Health. She's an Associate Professor of Medicine at the University of Colorado, Division of Endocrinology, Metabolism, and Diabetes, and she's the founder and director of the Vuela for Health Lifestyle Intervention Program for Latinos. The primary focus of Dr. Pereira's work is advancing health equity. Dr. Pereira has been a member of the Endocrine Society since 2001. She served as Chair of the Society's Minority Affairs Committee, now called Committee on Diversity and Inclusion, CODI. She has contributed to a number of other society efforts. Dr. Pereira is currently a member of the Board of Directors. She's a Board Representative to CODI and the Program Director for the EXCEL, that is Excellence in Clinical Endocrinology and Leadership Program. Dr. Ro Pereira will be addressing disparities and inequalities in diabetes. She's going to be talking about key drivers in diabetes care, disparities, and general strategies to eliminate disparities. She'll also be leading us through the prevalence and trends and disparities in diabetes the world over. She'll also be talking about primary determinants of health. At this point, I just want to introduce to us Dr. Ro Pereira. Over to you, Dr. Pereira. Thank you so much, and welcome, everybody. Thank you for joining us. Let me share my screen here. Okay. I will be presenting the first part of this lecture. Dr. Caballero will present the second part. I will just start talking about the disparities that exist in diabetes and just a bit on what we can do about them. I have no financial relationships to disclose. I'll start with the prevalences and trends. Most of my talk will be focused on diabetes in the United States, but as we know, this is a worldwide problem. And in the world, we have over 500 million adults affected by diabetes. Most three out of four of individuals with diabetes live in low- and middle-income countries. And diabetes is responsible for almost 7 million deaths, so one every five seconds, from diabetes and diabetes complications in the world. We know here in the United States that diabetes prevalence has been increasing since the early 1900s. I'm sorry, early 2000s, late 1900s. And as of 2019, there were 34 million individuals, that's 10% of the population, one in five who remain undiagnosed. And we know that there are disparities in the prevalence of diabetes by race, ethnicity. And so here you can see for adults, the prevalence of diabetes is highest for American Indians, Alaskan Natives, and lowest for non-Hispanic white populations. And this disparity is seen also among the youth. So we see that minority youth, the incidence rate of diabetes for minority youth is highest for Black and American Indian populations, and lowest for white youth. And the incidence of type 2 diabetes in minority youth has continued to increase. So here on the right side, you see the incidence of type 2 diabetes over time. And we can see that as of the last reported year here in this graph, the incidence of diabetes for Asian and Hispanic and Black youth has continued to rise. And we know that diabetes is associated with diabetes complications. We see these same disparities in diabetes complications affecting non-white populations non-white populations. So our Black and Hispanic patients are more likely to have diabetic retinopathy, lower limb amputations, end-stage renal disease, and all the other complications of diabetes. In particular, the disparity of end-stage renal disease for Black adults is very large. The incidence of end-stage renal disease in Black adults has been decreasing over time. But as of the last measurement year here, 2017, we see that the incidence of end-stage renal disease for Black adults was twice as high as for Latinos, and three times as high as that of white adults. Diabetes mortality is also a higher problem for Black individuals, Black communities, compared to white adults. So this is a study that looked at mortality, diabetes-specific mortality in large cities throughout the US. And it found that on average, mortality for Black adults was twice as high as for white adults. And from the years that they looked at, from 2013 to 2017, there were more than 7,000 excess Black deaths each year due to racial inequities in diabetes mortality. This is a chart looking at trends of diabetes mortality over time. And we can see that diabetes mortality has been decreasing for all groups. But the top points there are for American Indian, Alaskan Native. The next one in green is for the Black population. And the one below that is for Hispanic population. And we can see that diabetes mortality for all those groups is much higher than for the white population, which is the lower line there. So these disparities are clearly of moral impact. And Dr. Martin Luther King, Jr., who, as it happens, was assassinated 55 years ago today, was quoted to say, of all the forms of inequality, injustice in health care is the most shocking and inhumane. Injustice in health care is the most shocking and inhumane. But also, this is a big problem in terms of cost. So the cost for diabetes care is very high. The United States, we spend $380 billion. This is in 2021. $380 billion in diabetes care. That's both direct and indirect care for diabetes. And that's $1 in $4 that the US spends in the treatment of diabetes and diabetes complications. And our patients with diabetes spend more than twice the amount of money the rest of us spend on health care. And globally, we know this is a huge financial expenditure as well. All right. So why do we have diabetes disparities? And what can we do about it? We used to think about diabetes disparities in terms of genetic risk and thought that minority populations perhaps had a higher genetic risk and were more likely to follow lifestyle habits that were not healthy and that this resulted in the disparities that we see. And we know that this is clearly not true. We know that genetic disposition doesn't explain these ethnic racial disparities that we see. Genes are obviously associated with diabetes risk, but differences in genetics explain a very small fraction of the variability that we see across populations. The other thing to keep in mind is that race is a social construct. We identify people's races or people self-identify races, but these races are not biological groups. So the genetics of one group versus another are not different. And really, there's more genetic variation within these racial groups than between them. And so sociologists, Dr. Goodman wrote a publication 20 years ago, more than 20 years ago, Why Genes Don't Count for Racial Differences in Health. And he said, just as we have moved beyond thinking that the sun revolves around the moon and that a fully formed tiny human lives in sperm, so too, it is time to move beyond believing that race is a valid method for classifying human biological differences. And so we know also that individual behaviors do not explain ethnic racial differences. Diabetes disparities are often attributed to our patients not eating a healthy diet, not exercising, et cetera. But we know these behaviors are not determined by skin color. And in fact, eating and physical activity behaviors are learned social behaviors. They're influenced by a number of different factors, many of them environmental and economic. And we can see, for instance, this map of places where households have lived with no supermarket within a mile and have no car. And you can see that areas where there's more individuals or households living with low food access or healthy food access are the same areas where there's more diabetes, if you remember those maps that I showed you earlier. And in fact, we can look at diabetes rates by education and by income and see that there are very strong relationships there with people who have more than a high school degree being less likely to have diabetes and individuals who have a higher income or families with higher incomes have lower diabetes. So these are what we know as the social determinants of health. There was a very nice review article published by Dr. Hill Briggs in 2020 showing that all of these social determinants of health are associated with diabetes and diabetes control. So individuals who live in poverty, have low educational attainment, have no insurance, live in polluted neighborhoods, or have low social support are more likely to have diabetes, to have high A1Cs, to have higher mortality, et cetera. And we know that the reason that minority individuals or minority groups are more likely to have social determinants of health that are associated with disease is because of unequal access to education, to economic opportunities, et cetera. And this is true for healthcare and unequal access to healthcare does contribute to health disparities. This was documented in a report 20 years ago by the Institute of Medicine, which found that racial and ethnic disparities in care exist even when insurance and when insurance status, income, et cetera are the same. And we continue to see this. This is data from 2019. Individuals who are Black or Hispanic, regardless of income, are less likely to have health insurance and more likely to face delayed care. And we see disparities also in the care that we provide to our patients. So this is a study showing young adults with type 1 diabetes, Black young adults are more likely to have uncontrolled diabetes or higher A1C. And if you control for different factors, we see that a large amount of this difference is due to differences in the treatment regimen that we provide. So Black youth are less likely to be on insulin pumps. They're more likely to be on multiple daily injections, and they're less likely to be using a continuous glucose monitor, for instance. We also see disparities in care for our newer medications, so SGLT2 inhibitors. This is a study that looked at commercially insured patients, lower rates of prescriptions for SGLT2 inhibitors. And this was seen despite even when looking at subgroups of patients who had cardiovascular disease or CKD and would most benefit from these agents, and was still seen when controlling for whether patients were managed by the cardiology specialists or endocrinology specialists. Similarly, the study looked at SGLT2 and GLP1 prescriptions, and Black patients were less likely to have to be given these prescriptions, despite all having the same coverage for insurance. There are clearly also cost considerations. Up to 25% of patients on insulin report that they have not been injecting the amount of insulin prescribed because of costs for insulin. Medication costs very much influence our patients' practices. So what do we do about this? So a couple of things we can do, and I'll talk about actions that we can take at different levels. So on a personal, individual level, treating everyone the same as much as we can and following our guidelines and decision-making tools, being aware of our own subconscious associations, not assuming that a patient is not able to afford a medication that we know we should provide for them, practicing shared decision-making. So really making that effort to understand what the barriers are for your patients and address any health-related social needs that they may have, understand what support and resources are available for your patients, and connecting them to those resources. On an interpersonal level, it's important for us as clinical teams to really learn about the culture and the beliefs of our patients and the barriers that they face, and to address bias when we see it. So be an upstander and a person who acts when they witness unfair treatment for our patients. Prioritize equitable care, so have those difficult conversations within your teams about bias, racism, and the differences that we face, and then to measure the performance of the team in terms of equity. On an organizational level, it's important for hospitals and clinics to be measuring that performance in terms of equity and to make sure that we are using those decision support tools, standardizing care. So this is a lot of the work that we do in quality improvement. Avoid the use of clinical algorithms that perpetuate disparities. So there was an article a couple of years ago in the New England Journal that identified a number of clinical algorithms that we continue to use where there's an adjustment for individuals of minority race, and these tools can perpetuate disparities because they can lead to less access to services for our patients. Utilizing community resources, there are a number of community organizations that provide services to our patients, and as clinics, as clinicians, providers, we need to be aware of what's available in the community in terms of resources for our patients, and then working towards equal access to services and medications. On a community level, prioritizing health equity and racial justice is important, and we do that as an endocrinology society to avoid using race as a surrogate for biology. Avoid the use of race-adjusted clinical algorithms to really understand those payment models and reimbursement structures to increase the reimbursement that we get for the services we provide so we can continue to provide services to everyone and engage in healthcare advocacy. And then on a societal level, so talking about local, state, federal laws and policies, again, fair reimbursement for healthcare services. We need to ensure that we support the clinics and the providers who are providing care for all our patients. And then health-related social needs. We need to figure out as a society how we help our patients address those health-related social needs and how we can do that better. Cost regulation for medications is an area where the Endocrine Society has put a lot of focus in making sure that our patients are able to afford their medications. And then figuring out how to get reimbursement for our community health workers who provide services to support the medical care of our patients is really important. So I will stop there. I know Dr. Caballero has a number of more specific practical recommendations for all of you. So I'll stop there and we'll turn it back to our, to, I believe, Dr. Everett. Yes. So thank you, Dr. Perea, for that great presentation that nicely summarizes the disparity seen in the prevalence management outcomes of diabetes and for that great discussion about some of the drivers of those findings. So I know many of you have many questions for Dr. Perea, but I wanted to remind you that we will have a live Q&A session at the end of the webinar. So please be sure to submit your questions or upvote existing questions in the Q&A chat. So I would now like to introduce our second speaker, Dr. Enrique Caballero. Dr. Caballero is an endocrinologist, investigator, and educator. He is a director of the International Innovations Program in the Office of External Education and a director of diabetes education in the postgraduate medical education department at Harvard Medical School, where he leads his development of education programs that benefit healthcare professionals and patients around the world. Dr. Caballero has a strong and long commitment to help underserved populations. He founded the Latino Diabetes Initiative at Jocelyn Diabetes Center and is currently the director of the Latino Diabetes Health at the Brigham and Women's Hospital in Boston. He is the immediate past chair for the Healthcare Disparities Committee at the American Diabetes Association and is currently a member of the Diversity, Equity, and Inclusion Committee at the Endocrine Society. His work has been recognized nationally and internationally. He is a recipient of the 2023 American Diabetes Association's Outstanding Educator Award in Diabetes. Today, he will be speaking to us about comprehensive culturally-oriented diabetes care. Great, thank you, Estelle. Hi, everyone. It's really wonderful to be here in this activity. I want to thank the Endocrine Society for the opportunity. It's particularly nice to be with my good friends and colleagues in this panel as well. And thank you all for taking the time to be with us. I want to expand on what Dr. Pereda already mentioned, which I think she clearly demonstrated with a lot of very compelling information, the disparities that exist in the field of diabetes. And she already alluded to some areas that we need to consider as we move forward in this field for all of us in the endocrinology field. I don't have any conflicts of interest related to this presentation either. And I want to go back to something that she said as well in terms of how the problems with disparities really emerge from different elements in what I call the common triad in healthcare. We as healthcare providers, the patients and the healthcare system, and there's opportunities to improve a lot of things in these three domains. Now, if you think about what we usually do, and again, this isn't diabetes care, but that could apply to any endocrine condition really, is that we interact with patients and we want to help them improve their self-care behaviors. In the field of diabetes, you can read there all the different things that we always ask them to do better, improving their lifestyle and testing their medication, testing their blood sugars, taking their medications and so forth. But the reality is that we're helping only a very small fraction of patients. And the question is, why are we not having the impact that we should? And why do these disparities exist? And I believe that it's obviously a complex situation, but some of the things that we're leaving on the side, I think is that we are not very good. And I say that always very respectfully because I include myself as a clinician in this statement is that we're not very good at addressing psychosocial issues. We don't know what to do with that information. We don't know how to engage in conversations and we don't know how to really help patients in this space. So it's honestly easier to stay in our comfort zone of addressing the biological aspects of diseases and we don't pay too much attention to this area. And that's why here on the left-hand side, I always emphasize a need to enhance our cultural humility. And that's really our ability to interact with patients to better understand their needs, where they come from, their health behaviors, their thoughts. And I think that that would really help us in formulating better treatment plans and engage in more productive conversations with them. So it's obviously a complicated issue. And I'll talk about the healthcare system in a couple of minutes because I think that's also very important. Now, from the very clinical perspective, I created a few years ago, this list that I call the A to Z list for diabetes management. And again, this is not just for racial ethnic minorities. What I have been reflecting over the years is that there are so many factors that we don't usually pay attention to in clinical practice. Now, if you go through this list, I am sure that you can identify many things that you do routinely discuss with patients, but many others that probably are not in your radar all the time. And this list just helps me, for example, identify different factors. Of course, I can't discuss all these things in one single visit with patients. That's not the goal. But if you create a map of, a roadmap of different things that you want to eventually discuss with your patients, you know, that could be a helpful list of different factors. Now, what I did for this review was to really try to find information that supports the relevance of all these different factors in routine diabetes care. And there's data that support how each one of these elements is actually important for patients and for diabetes care. And some of them are actually related to diabetes-related outcomes. And let me just give you some examples about this. So for example, in the field of acculturation, which is usually, of course, reflective to what extent people that come to this country have sort of integrated themselves into the mainstream culture in the United States, you wouldn't be surprised to see that, for example, in this study, in the Latino community, the SALT study, it was identified that the risk for cardiovascular disease was higher in individuals that were born in the U.S., that have been here the longest, which reflects that perhaps healthier individuals are coming to work here in this country. And as they adapt to the lifestyle in the U.S., they may actually develop more disease. Later on, there are studies that show that people may obviously have different choices, but that's sort of the trend that we see. I actually saw that if people prefer to speak Spanish, the risk for cardiovascular disease is lower than if Latinos prefer to speak English. I try to speak Spanish most of the time to see if that can lower my cardiovascular risk. All right, another example is, for example, in terms of biology, and Dr. Pereira already mentioned that this is not related to race and ethnicity as a way to explain the disparities, but I think it's important to also recognize that there's different phenotypes. And all these abnormalities that we always encounter in diabetes, in patients with diabetes, may present differently. And there's some very nice studies. I don't have a slide to show you, but some studies, for example, in Mexico that I have been working on with a group there, it's been found that the poorer the socioeconomic status, probably the less insulin resistance and obesity, as we traditionally consider it, people may have. And that may influence some of the decisions that we make in terms of some of the medications and approaches, et cetera. So I think that we also need to do more studies to identify these different types of phenotypes in the different populations that we see. Again, that may be more driven by socioeconomic characteristics than biology. Now, I have also learned over the years that diabetes-related emotional distress and depression are very common. I think this could affect anyone in any racial ethnic group, but it is also likely to be more present in people that come from other countries, in people from different racial ethnic minorities, for obvious reasons. There's obviously stress and there's so many struggles that are taking place that it's important to pay attention to that. Now, depression is probably the most frequently missed diagnosis in clinical practice. And I have to admit that I was not routinely assessing this with my patients, but I learned that that's really important. And I am sure that you're familiar with the PHQ-2 items. And I now routinely ask my patients these questions because if they answer yes to any of these statements, then forget about asking them to follow a better meal plan and take more insulin and add another medication and test their blood sugars more frequently. That doesn't really make any sense. This is the main thing in their lives right now. So referring patients to the proper specialists and providers and teams. And I think that obviously that also speaks to the need to have other professionals that can help us with the day-to-day activities with our patients is absolutely important. So don't forget to always incorporate that into your assessments with your patients. Now, another thing is about fears. And again, this is probably culturally driven. And I think it's important to recognize that we all have personal, but also perhaps some cultural issues that make us be more fearful about some medications or strategies, et cetera. So it's obviously very important to engage in conversations with patients and respectfully ask them about this. For example, in the Hispanic Latino community, and again, it's not just in this community, but I know that very well, there's the concept that once you start insulin therapy, it's like a death sentence and people are not gonna live that long after they start insulin. And that's obviously because we start the treatment late, but people hear that once you start with insulin, then other complications will be identified, et cetera. And I always relate to a case of a patient that was referred to me by a primary care physician with very high blood sugars. And in theory, he was taking insulin regularly, but he wasn't. And I asked him and he said, I don't take it because I don't wanna get blind from taking insulin. So somehow this is a very common fear in our community. So openly discussing the benefits, the pros, and the myths about medications, I think it's an important consideration to add to clinical activities. And again, you can incorporate that into education programs. We do have a class in which we dispel all the myths about diabetes management, et cetera, which I think is particularly helpful. Now, the other aspect is about the group engagement and community support. In some communities or in some groups, I think this is very, very strong. Again, most of my work has been with a Latino Hispanic community, but I think this applies to other groups as well. And the reality is that we emphasize the work with individuals and in some communities, and in some cases that may be fine. But I do believe that the more we incorporate relatives and friends and people around patients, it is more likely that we will get their attention and their engagement into improving their diabetes self-care behaviors. So one thing that I have tried for many years now are the shared medical appointments or group medical visits. And here you see a picture in which I have several patients that come to an appointment. All of them come at the same time. What I do is that I go with each one as if I were doing an individual appointment, but we do that in a group setting. So everybody's learning from each other about what's happening with the other patients. Obviously, you need to create a good environment for this. You have to select patients properly. There's confidentiality issues. Everybody signs a confidentiality form and you need to also manage time, et cetera. I usually have the educator with me that may also provide some very important information to the patient. So if you can handle the pressure of organizing this and time, it may be actually a very productive way of providing care to patients. This is actually not just exclusive to diabetes. There's many different groups trying this and many other diseases. So I think that's something also that you could consider and you can actually bill for the services as well. What I do in these visits is, for example, that I create this table in which we have the patient names and I have the most recent information, as you can see here on the left, of different parameters. And then we discuss them in front of the group. Again, the idea is not to make anyone feel bad about their results, but it's really more to motivate each other to try to accomplish goals. And this allows us to discuss a lot of targets and very practical information about how to improve their diabetes care. Now, Dr. Pereira already talked about community health workers and other people that I think are crucial in diabetes care. This is a study that I think was really challenging because we worked in a remote area in Mexico. This is in the Yucatan Peninsula, and these are people that are in the Mayan community. Most of them actually don't even speak Spanish. They speak Mayan, but they do have diabetes. It's interesting that that has reached every single population around the world, mostly. And what we did is to train some of them, to educate them so that they could provide peer support, help others in improving their diabetes care, et cetera. And what we were able to find is that even though everybody improved, including those in the control group, those that were exposed to the peer support system did actually even better in their A1C reduction. Now, as Dr. Pereira already pointed out, this is not part of the system. We don't have good support for community health workers. I think that's something that needs to be really emphasized. And hopefully, perhaps in your institution, you could advocate for the introduction of many of these other professionals in healthcare teams. Now, language. I think that's important. That goes without saying. Obviously, communicating with patients properly, I think is important. And I'll just show you two quick examples of how this could go wrong. So this is a case of a woman, 64 years old, who didn't speak any English. She was treated for hypertension, and she received a prescription for like Sinopril 10 milligrams, and it was signed as ONCE slash D. And the patient was rushed to the ER due to severe hypertension. And for those of you that speak Spanish, I am sure you know that you can identify what happened. ONCE is ONCE, and in Spanish, ONCE is 11. So she took 11 tablets of the medication. She could have, of course, died from this mistake. I don't think that we can blame the patient by following the instructions. I think this was really a big mistake in how the prescription was written, and the fact that no one really checked about whether the patient was able to understand the language. And this actually happened here in Boston many years ago. That's why I always keep that as an example in my mind. Now, many of you may also be interested in developing culturally-oriented materials and translating materials in your organization, either in Spanish or in any other language, and I think that's great. Now, remember that it's not just language, but it's also culture. An example that I always present is this, that we all are familiar with Friday the 13th. Now, if you were to translate that into Spanish, well, maybe you could translate Friday to Viernes and 13, Trece, and that's it. But the reality is that from the cultural perspective, the equivalent to Friday the 13th is Tuesday the 13th, so the correct translation would be Martes, not Viernes, so Tuesday, not Friday. So again, probably you can find people that may translate materials, but not everybody may be familiar with the culture, and I think that's an important message in terms of always trying to find that whatever you develop is not only linguistically, but also culturally appropriate. Now, just to finish up with some other quick examples, in terms of nutrition, I can't tell you enough how important it is, obviously, to understand people's preferences, not to impose any particular diet that we may think is good for patients. I think it's important to hear what they do, what they would like to improve, because they know better than us, to be honest, in what may work for them. We obviously can guide them in terms of food preparation and nutrients and quantities, quality of food, et cetera. But my sense is that when we provide these recommendations to patients, they leave the office, and honestly, they don't know very well what to do. So we did a study a few years ago in which we said, what if we actually go to the supermarket with patients to guide them on how to identify better foods to bring home? So we did this particular study in which we identified 25 families with diabetes and struggling with their diabetes control. And to make a long story short, we provided some education, but our educator went to the supermarket in helping patients identify better foods to bring home. And to make a long story short, after some of these educational activities, people were able to bring healthier foods home and, of course, that translated into better behaviors. And I think that's really great. Now, I'm not saying by any means you now go to the supermarket with your patients because obviously no one has the time to do that. But what about trying to connect with patients where they're not in the office or in the clinic? I think that's the future in terms of trying to provide perhaps virtual education. We have a program now in which people can actually show us what they have in their refrigerator so that we can guide them a little bit better in terms of selecting what they are going to bring home or what they're going to eat, rather. One word about the body image, because, again, this is a cultural issue. We did a study a few years ago in which we asked our Latino patients with type 2 diabetes, which of these silhouettes represents the healthiest person or the one that you would identify with, that you would like to be? Now, in the white community, most women may identify people who have a normal body mass index as the healthiest ones, not in our Latino culture, that people may identify that if you have a few extra pounds, that's actually a sign of good health. Now, I'm not saying that people intentionally want to gain weight, but when you discuss goals and treatments, I think it's important to get their sense as to how they perceive their weight. I think that's the key message here. And the last piece here is about technology. I think that we all are learning more about this, and I think that telemedicine, I think, could be expanded. Now, unfortunately, not everybody has access to Internet. Not everybody has the skills to get engaged into these conversations. So I think that there's also an opportunity here to improve diabetes care for everybody. But obviously, as Dr. Pereira said already, there are populations who need an extra hand, and I think that's what we need to consider as well. And the last point here is to zip it, which also reminds me that I need to finish my presentation soon. But my point here to remind everybody is that in clinical practice, we are the ones that speak the most. We don't allow patients to talk and express all the things and concerns that they have. There's actually a study, I don't have the slide, that shows that it takes an average of 23 seconds for a health care provider to interrupt the patient once the patient started to present a complaint or something. Why? Because we're busy. We need to move fast. We need so much information to cover, and I don't think that that's really a very productive communication. Now, the last piece here is in terms of the system, because I think that everything that we have discussed today is something that you may say, great, I want to explore some of these things, but I'm busy. I have so many things to do. Well, addressing the social, the terms of health, I would say is particularly important. At the Brigham, the maternal Brigham system where I work, we do have this screen that reminds us about assessing all these social determinants of health, and this is very helpful. That's not something that we need to do as health care providers directly, but our team gets all this information. And that's very helpful for me because I can then discuss some of these aspects with patients. So I have a better sense of some of the struggles that they may have. And the last two slides that I have for you here is that I think we also have learned and during the COVID-19 pandemic that there's opportunities to improve the way we are providing care. So here on the upper left hand corner, you see the prior diabetes care approach was just to wait for patients to come and see us in the clinic. Obviously, during the pandemic here, the lower left, we couldn't do that. So we had to communicate with patients remotely, telemedicine, cell phone conversations, video conversations, whatever it was. Now that we are going back to normal, I hope that actually we don't go back to what we were doing before because, again, that was not working for the vast majority of individuals. I think that trying to establish communication with patients when they're not in the clinic, community based activities, trying to do something that is more proactive, prevention strategies, education and addressing the social determinants of health. I think that's absolutely important. So I think those are all the elements that I wanted to discuss with you. And one final point about the health care system, which I think it's important for all of us to remember, is that in your own institutions, maybe there is this idea of trying to identify disparities. I just want to share with you, and I'm very proud of what the Brigham did, the hospital where I work, and they published this, that when people come to the hospital, they go to the emergency department. If people are Black or Latino or Latinx, they're more likely to be admitted to the general medicine department when they come with heart failure. If people are white, they're more likely to go to the cardiology department. Now, this is equal access, equal opportunity for people to be treated differently, and that's not happening. Now, who's making all these decisions? I would just leave that for you to reflect on how all these things are happening and perhaps, you know, an opportunity to improve the way we provide care to individuals. Ultimately, I think that we have an area of inequality in our system, and the solution is not to provide the same to everybody. I think it's provide everybody with what's needed in order to get to the same place. But perhaps, hopefully, at some point, everybody would have equal opportunity to start in our society. Thank you very much for your attention. I'll turn it over to our moderators for the discussion. Thanks. All right. Thank you, Dr. Caballero, for that excellent presentation and for giving us a practical framework that we can use to address disparities in our own clinical practice. So now we will move on to the Q&A section of the webinar. So if anyone has any questions for our speakers, I encourage you that you write it in our chat. So while we wait for questions to come in, I can go ahead and ask a question that I have for Dr. Caballero. So you discussed evaluating mental health, so depression. And we know that there is a, you know, patients with depression have a higher rates of diabetes and those with diabetes have higher rates of depression. So that's something that's often comorbid with each other. And we also know that in certain cultures, certain cultures are more receptive to discussing mental health issues and some are not. And similarly with some are more receptive to receiving like treatment. So in your practice, how do you navigate my differences in cultures when bringing up the discussion of mental health and depression and how that affects diabetes? Yeah, yeah, that's that's a good a good question. A few things. One is that we need to eliminate the stigma, you know, that because people are referred perhaps to one of these departments is because there's something wrong in their head and they're crazy and that's not the issue. In fact, we don't actually call it mental health. I don't know what people do in other departments, but it's more behavioral health because that eliminates the bad connotation that I'm referring you to someone because there's something wrong in your head. But the other important thing is to just try to normalize the situation, because what I tell my patients is you have diabetes every single day of your life. It's perfectly understandable and expected that you're not going to feel well about this and that you may struggle with coping with the disease. So I would like to explore to what extent this is affecting you. If there's other things in your life that may be affecting your ability to improve your self-care behaviors. And that's how we start the conversations. I think it's eliminating guilt, eliminating stigma and understanding that people with diabetes are very likely to go through some of these issues and then start the conversation. And then, of course, refer them to the proper teams. But what I want to emphasize is if we are not the ones identifying these issues, who is going to do it? Because sometimes other people may not actually then ask the questions. And I also know that patients may not volunteer this information because it's very private. So unless you really engage in this communication and then you respectfully ask patients and explain why you want to explore this, you may not identify. Now, just to clarify, the questions that I mentioned in the presentation are mostly to identify severe depression. But there may be people who don't have severe depression who are also struggling. So I think this should be just part of the regular conversations with patients. OK, great. That was very helpful. We have one question from Dr. Gosein. He says, many of the disparities are due to limited resources and minority groups. If we take into the account, if we take into account the income, do these racial disparities still persist? Maybe Dr. Yeah, yeah, I can take that question. Yes. In fact, those disparities, even though they are affected by limited resources, even when we control for financial for income, we do see those disparities. So race, ethnicity is an independent determinant also of of health disparities. Doesn't mean that we see it for everybody, but people who are of minority in minority populations are more likely to face disparities. And we think this is because it's not just the socioeconomic status that makes a difference. It's also the way people are treated. The the resources that they have available to them or not also cause stress. Right. If you're living in a situation where you have lower resources or there is more violence in the against the groups that you are a part of, then that's going to cause also a stress. And so there's there's a number of different things that that minority populations face just from being minority members. OK, great. Thank you for that. We now have a question from Gabriela Sanchez. She says, for both speakers, do you think that genetic studies that identify strictly racial slash ethnic based genome differences are strictly valid when accounting for metabolic or age related diseases like type two diabetes? If not, how do you circumvent this? Well, I can give my opinion and I know that Dr. Breyer can also expand on that. I think there's no question that there have been genes that have been identified that have been linked to different abnormalities in type two diabetes. For example, there's genes that have been associated with more insulin resistance in some populations. And again, I'm not talking just about the Hispanic community, but, you know, in in the black community, in the American Indian community, in other communities and actually international studies in different populations, some that are related to some that are related to decreased insulin production in the beta cells, et cetera. But the reality is that the vast majority of patients that we see are probably not going to be linked to any of these abnormalities that have been described. You know, talking to people that work in the field of genetics, they always say the truth is that probably we can only explain 10 percent, 15 percent of all the cases with diabetes, which means the vast majority, we don't know what the genetic component is. Now, that doesn't mean that there may not be genetic factors playing a role here. But I think that what that means is that probably that's not the most important thing that is driving the issue about type two diabetes in the general population or in any of these groups. I think that the social determinants of health are probably contributing to the development of type two diabetes at a much higher level than whatever genetic predisposition may be. I can also say, for example, that in the diabetes prevention program that I've been fortunate to participate in as a co-investigator, we found that even if people have the strongest genetic risk for type two diabetes, lifestyle modification can reduce the progression equally, whether you have the genetic risk or not, which means lifestyle on the one hand can influence the development of diabetes is not adequate, but it also could reduce the risk for type two diabetes if you improve it, which speaks to the point that in the end, I think it's behaviors that are driving most of these problems and behaviors are linked, of course, to socioeconomic, cultural conditions, opportunities, et cetera. Yeah, I agree with all of that, and I guess the only thing I would add is, you know, I think it's really important for us to continue to learn about genetics of diabetes and to move towards this personalized medicine approach. But we are just not there right now. Eventually, if we're able to look at somebody's genes on an individual level and decide what medicine is going to work for them best, at the same time that we're also working towards addressing the health related social needs, I think we're going to be in a better place. But right now, what we do is we use race and ethnicity as a surrogate, and that is just not a valid way to identify a genetic risk. And so that's what I would say. I think we need more information to develop those tools. OK, our next question, what are some of the decision support tools that we should do away with, and are there any that we should incorporate in order to provide better and equitable care? Are there one or two interventions that the experts here could recommend our institution implement in our outpatient or inpatient diabetes management care? Well, Rob, maybe you can you can also expand on that, but the quick thing for me would be first, establish the diagnosis. You know, I'm thinking as a clinician, if you want to give a treatment, identify the problem. And I would encourage everyone to look in your own institutions and see how significant the problem is. We may not want to get that information, but I think it's absolutely crucial. Are you treating all patients fairly? Are the outcomes in your institution different when you look at race and ethnicity? I think that would be the very first thing to do. If you don't have that information, I would say that's the place to start, because that would be an eye opening experience. If you identify that outcomes are different, that let's say in diabetes, if the A1c levels for all your patients from racial ethnic minorities are much higher than the non-Hispanic white community, well, that's telling you something. And I think the mistake would be to say, well, it's because they just don't follow the recommendations. That's not the answer. The answer is, is it us? Is it the system? Is it that we are not providing equal opportunities and treatments to patients? What's really going on there? So the diagnosis. And then I would just refer to what Rob mentioned already. I think it's a multilevel approach, trying to organize many different things, but make the diagnosis first and then establish activities that would help you, obviously, improve some of those outcomes. I don't know, Ro, if you want to expand. Yeah, I would just add the race-adjusted algorithm question. So there are a number of calculations that we use that we race-adjust, the medicine providers, clinical providers. And so the most common is the EGFR calculation, which is adjusted to look like the kidney function is better for somebody who's Black compared to somebody who's white, regardless with everything else being equal. So we just add points to make it look better. The doing that leads to less care and delayed care for patients for kidney disease. And so doing away with that one, I would say, is the first step. If you're wanting to look at biased calculations or biased practices, looking at EGFR would be the first step. And then our last question, it's for Enrique. Thank you so much for good guidance and advice. CGM being cloud-based seems like a good tool to reach minorities, but what do we have to do to make it really affordable and available? CGM? Correct. Oh, well, I think it's a fantastic tool. And unfortunately, access is not there yet for everybody. I know it's moving in the right direction, and I think there's been some good progress. But the reality is that there are still challenges for some of these populations. And I think insurance companies and programs should really embrace the use of technology. I, for example, I'm linking now CGM to the group medical visits that I mentioned before because it's such a wonderful opportunity to educate patients on their glucose patterns and understand what they need to do better in terms of nutrition and exercise and medications. So I don't know what the answer is in terms of what we need to do now. But I think that collectively, as endocrinologists and in the society, to put pressure on some of these great advances in technology, medications to be really affordable and that people could have access to all of them. I think that would be that would be really great, Ro. I think you briefly mentioned that in your lecture as well. Yeah, we need to continue to advocate for CGM access to our patients. The Denver Health also has a Denver Health medical plan. It's an insurance. It's a Medicaid plan for our patients. And that Medicaid plan has made available CGM to our patients with diabetes. No questions asked. And I just published a paper recently showing that using CGM for our patients and we are we are an FQHC, so we serve the underserved. We saw a decrease in A1C for all our patients. So clearly, we need to do better to increase access to CGM and other tools. All right, great. So we are out of time. We will try to answer any other questions maybe directly through the chat and kind of following up that question and a plug for our health disparities webinar. Our next webinar is scheduled to be on the topic of disparities in diabetes technology. So we can continue this great discussion at that webinar. So I wanted to thank everybody for attending today's webinar. This concludes our session. So thank you for joining us. And please keep an eye on for our next health disparities webinar.

Diabetes disparities

Root causes

Social determinants of health

Culturally-oriented approach

Disparities in diabetes outcomes

Support and resources

Racial and ethnic disparities

Improving diabetes care

Healthcare bias and racism