Even with all the advances in therapeutic options in diabetes management, our focus has only recently turned to a more difficult and perhaps more pertinent aspect of patient care: the physical environment in which people with diabetes reside.
The Centers for Disease Control and Prevention defines social determinants of health (SDOH) as conditions in the places where people live, learn, work, and play that affect a wide range of health and quality-of-life risks and outcomes (1). SDOH are further defined by the World Health Organization as the conditions in which people are born, grow, live, work, and age (2). These circumstances are shaped by the distribution of money, power, and resources at global, national, and local levels. Both organizations endorse the view that SDOH bear most of the responsibility for health inequities (i.e., the unfair and avoidable differences in health status seen within and between countries ).
The American Diabetes Association (ADA) recently undertook a major review of the impact of SDOH and diabetes (3). Among the many revelations included in this report was a doubling of risk of diabetes-related mortality that occurs in poorer versus wealthier adults with type 2 diabetes in the United States (4). Additionally, as many as one in five households that include a person with diabetes report food insecurity (5), which is major risk factor for poor diabetes management (6).
Of course, significant compounding issues exist relative to poverty, education, and access to nutritious foods and health services. However, lack of awareness of these issues by clinicians, let alone the ability to address them, can have deleterious effects on patient outcomes.
Several health care organizations and associations have developed guidelines and resources to help clinicians assess and address these issues. The ADA’s Standards of Medical Care in Diabetes—2022 includes recommendations based on level-A evidence that clinicians should assess food insecurity, housing insecurity/homelessness, financial barriers, and social capital/social community support to inform treatment decisions, making referrals to appropriate local community resources. These guidelines also recommend the provision to patients of diabetes self-management support from lay health coaches, navigators, or community health workers, when available (7). The American Academy of Family Physicians’ EveryONE Project has developed a toolkit for practitioners offering helpful resources on this matter (8). Among these resources are a guide to social needs screening and a validated social needs screening tool assessing five core health-related social needs, including housing, food, transportation, utilities, and personal safety, as well as additional needs, including employment, education, child care, and financial strain. Another useful tool is a social needs questionnaire developed by the University of Colorado A.F. Williams Family Medicine Center that can be easily incorporated into medical clinic visits (9). Additionally, a Robert Wood Johnson Foundation–funded report offers considerations for implementation of SDOH screening in populations with complex needs (10).
It is critical for us to be cognizant of all aspects of our patients’ social situations to appropriately understand and address the circumstances affecting their diabetes management. In so doing, we will genuinely put patients at the center of the care we provide.
Duality of Interest
No potential conflicts of interest relevant to this article were reported.