Research Profile

More than 1.6 million people in the United States have type 1 diabetes, an autoimmune disease that requires lifelong treatment with insulin. At least 450,000 of these people belong to racial and ethnic minority groups. Management of type 1 diabetes is complex, and much of the burden for managing the disease falls directly on the patient. Newer insulin delivery and glucose monitoring technologies have led to significant improvements in diabetes care over the past several decades, and are shown to improve glycemic control, reduce complications and increase quality of life (QOL). However, these benefits have not been equally shared among racial/ethnic groups. Disparities in self-management behaviors, glycemic control and outcomes have been reported among children and young adults who belong to minority race/ethnicity groups. Further, adoption of diabetes management technologies such as continuous glucose monitoring (CGM) systems, insulin pumps providing continuous subcutaneous insulin infusion and hybrid closed loop (HCL) systems is lower among Hispanic and African American (AA) people with type 1 diabetes. This lower technology use could explain why Hispanic and AA people with type 1 diabetes have worse glycemic control and more complications. We propose to examine individual and systemic/provider barriers to adoption and optimal use of diabetes technologies among minority youth and young adults with T1D treated at the Barbara Davis Center (BDC) and Denver Health, to inform development of an intervention to improve technology use. We propose to develop a diabetes self-management support (SMS) toolkit, in conjunction with system/provider changes as informed by this project.

Diabetes technologies, including continuous glucose monitoring (CGM) systems, insulin pumps and hybrid closed-loop (HCL) system, improve glycemic control and quality of life for many people with diabetes. In addition, the use of these technologies may reduce diabetes complications, including diabetic ketoacidosis (DKA), kidney and eye disease, and heart disease. However, there are stark disparities in diabetes technology use among minorities (African Americans [AA], Hispanics and other US minority groups) when compared to non-Hispanic white (NHW) people. These disparities may be linked to not only fewer people starting diabetes technologies, but also increased discontinuation of these technologies. While income of other disparities account for some of the reduced adoption of diabetes technologies by racial and ethnic minorities, disparities are independent of insurance coverage and other socioeconomic factors. Minority groups have been under-represented in clinical trials of diabetes technologies, perhaps leading to disparities in human factors and perceived benefit. Therefore, the advances made in diabetes care over the past several decades have not improved care equally among all patients, leading to widening disparities in diabetes related outcomes by race/ethnicity. Racial and ethnic minority patients have consistently been shown to have worse glycemic control and higher complication rates, and this is at least partially explained by lower rates of adoption of technologies. However, disparities in glycemic control persist even among minority patients using diabetes technologies, suggesting suboptimal use. The reasons underlying these disparities are likely complex, and remain poorly understood. In this study, we propose to examine barriers to technology adoption and optimal use among minority patients followed in an academic-based specialty diabetes center and a community diabetes clinic, in order to inform development of a diabetes self-management support (SMS) toolkit and provider/system interventions that will address these barriers. We hope that by talking to patients, health care providers and diabetes technology device companies, we can improve the factors that prevent some patients from effectively using technology. In turn, we expect that improving use of technology will reduce diabetes complications.

My research has focused on complications of diabetes, because these outcomes can be devastating to people's lives, causing worse health, greater health care expenses, and loss of years of life. Like most people in the United States, I have family members affected by diabetes and have seen how much effort the management of this disease takes, for patients and their families. It has been gratifying to see the introduction of so many new technologies that allow better control of blood glucose, and which sometimes reduce the burden of diabetes management. However, I've seen in my research that the benefits of improved care and new technologies has not been equal among all patients. In particular, people without access to knowledgeable health care providers, insurance coverage for these technologies, and education and training that is culturally appropriate and available in their language have not been able to take advantage of these tools. It is important to me to improve the care that we can offer to ALL people who have diabetes, which is why I was motivated to apply for this award.

Diabetes research has focused a lot on devices and monitoring of blood glucose, which has led to a lot of improvements. However, I think the future of diabetes research is going in the direction of personalizing care for the individual, taking into account what is important to them and determining how to overcome barriers to optimal care in that individual. Factors outside of the individual, including health care policy, insurance coverage, device manufacturer decisions, family factors and community level resources all impact an individual's ability to care for their diabetes. With growing incidence of both type 1 and type 2 diabetes, it will be more important than ever to take a holistic approach to improving care and treatment of diabetes.