Youth-Onset of Prediabetes Linked with Social Determinants of Health

Social determinants of health such as food insecurity, low household income and a lack of health insurance has been linked to youth-onset of prediabetes—higher-than-normal blood sugar—in adolescents, independent of race and ethnicity according to a new study published today in JAMA Open Network. The research, by investigators at the University of Pittsburgh and the University of Pittsburgh Medical Center (UPMC), suggests that these findings can help identify youth at risk and could eventually lead to early medical intervention to help prevent the conditions from progressing to type 2 diabetes.

“This study underscores the importance of using social factors, which are modifiable— meaning that we can address them—to understand and reduce diabetes risk in adolescents as opposed to personal, non-modifiable characteristics like race and ethnicity,” said senior author Mary Ellen Vajravelu, MD, an assistant professor of pediatrics at Pitt and pediatric endocrinologist at UPMC Children’s Hospital of Pittsburgh. “Many medical guidelines are moving away from the use of race and ethnicity to determine care and screening practices because it can exacerbate disparities instead of reducing them.”

Vajravelu noted that type 2 diabetes and prediabetes are more prevalent in Native American, Asian, Black, and Hispanic youth than it is in white adolescents. But the new research highlights that prediabetes may be more prevalent in these groups exactly because they are also more likely to experience adverse social determinants of health. This makes it likely that these factors, and not race itself, that influence the risk of developing these health conditions.

“In our clinic we see a lot of adolescents with type 2 diabetes, which is a very serious condition when it starts in childhood,” Vajravelu noted. “Current guidelines for identifying children at high risk for type 2 diabetes and prediabetes use characteristics such as body size, race, ethnicity and family history, but those risk factors still don’t fully explain who presents with type 2 diabetes in childhood.”

For this study, the Pitt and UPMC researchers tapped a large national health database to identify 1,563 people, aged 12 to 18 with obesity, with 8.5% of them having higher-than-normal blood glucose, or A1c, which indicates prediabetes. The researchers then examined the social determinants of health that could affect the management of diabetes including food security, household income, and whether they had health insurance.

They found that all three determinants were linked with prediabetes risk. Prevalence of prediabetes was:

• 1% higher among participants from households with food insecurity compared to those with food security;
• 3% higher in youths with public compared to private insurance; and
• 7% higher in youths with household income at less than 130% of the federal poverty level compared to those with higher incomes.

The link of the risk factors to prediabetes also differed within racial groups, which the researchers say highlight the need to consider a child’s social determinants of health to better understand their risk of developing type 2 diabetes. As an example, they point to their data which showed white children—who are normally considered at lower risk of developing prediabetes—going from one to two to three adverse social determinants of health had four times the rates of prediabetes in adolescents.

“If we use race and ethnicity to guide us in identifying children at risk of prediabetes, it could steer us away from screening children who do not fall into a higher risk race or ethnicity category,” said Vajravelu. “Instead, if we tailor our screenings based on exposure to risk factors, not race, we might be able to pick up additional children who are at risk for diabetes.”

Vajravelu noted that other social factors that could play into the risk of type 2 diabetes development. With this in mind, she and coauthor Maya Ragavan, MD, an assistant professor of pediatrics at Pitt, plan a follow up study to see how housing instability and other health-related social needs could improve clinical outcomes for patients with diabetes.