Type 2 diabetes afflicts nearly 37 million Americans, yet incidence of type 2 diabetes is not evenly distributed across demographics. As cases of type 2 diabetes trend downward in middle-class communities, Black/African American and immigrant communities continue to bear the brunt of this epidemic. Studies have proven type 2 diabetes to be largely preventable, making it a disease of disadvantaged communities who lack the systemic resources of their more advantaged counterparts. Dr. Felicia Hill-Briggs, vice president for prevention at Northwell Health and a nationally recognized expert in diabetes prevention, is leading the charge to reverse this trend.
“Type 2 diabetes is heavily influenced by lifestyle factors,” says Dr. Hill-Briggs, who is also a Professor in the Institute of Health System Science at the Feinstein Institutes for Medical Research, the home of research at Northwell. “Research shows that what the person eats, lack of physical activity, obesity, sedentary lifestyle ― all these factors put one at very high risk for type 2 diabetes.”
According to Dr. Hill-Briggs and other diabetes experts, there’s a strong connection between the social determinants of health – the conditions in which people are born, grow, work, live and age – and who develops type 2 diabetes, as strong as a person’s biological factors.
“When we move beyond thinking of health as just biological disease, then we’re able to see that the social determinants of health play a very, very key role in influencing who gets disease and what the outcomes of the disease are,” Dr. Hill-Briggs says.
This new understanding is based on research conducted by the American Diabetes Association and chaired by Dr. Hill-Briggs. They found that type 2 diabetes is a disease disproportionately affecting underserved, marginalized and socio-economically depressed communities, communities that lack access to green space for exercise, healthy food and adequate education. To combat this problem, Dr. Hill-Briggs developed the DECIDE Self-Management Support Program, a problem-solving approach to chronic disease self-management for high-risk patients. DECIDE is an American Diabetes Association recognized, research-tested diabetes support program that can be used in clinical, community and public health settings. In a series of clinical trials, research groups adapted DECIDE for use with multiple high-risk populations and diseases, including hypertension, chronic kidney disease and mental health.
DIABETES RESEARCH
Addressing the Social Determinants of Health Is Key in the Fight Against Type 2 Diabetes
“When we move beyond thinking of health as just biological disease, then we’re able to see that the social determinants of health play a very key role in influencing who gets disease and what the outcomes are”
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This disparity stems from both current and historical material conditions. For recent immigrants to the United States, finding the healthy, non-processed ingredients to make the food traditional to their culture is difficult, especially in lower socioeconomic communities where immigrants often reside. This lack of access often forces ethnic minorities to substitute inexpensive, processed ingredients to create the same cuisine they’re used to enjoying in their native country. These processed ingredients are high in sodium, sugar and fat, three factors that greatly contribute to the development of type 2 diabetes.
“It’s very difficult to get natural food in the ultra-processed food environment we have in the U.S.,” says Dr. Hill-Briggs. “Food is of course meant to nourish the body, but once you’re in an ultra-processed, high sodium, fat and sugar food environment, food is causing disease rather than providing nutrition.”
For Black/African Americans and Native Americans, the historical conditions are more insidious. Both Black/African Americans and Native Americans have been subjected to laws and policies that restricted their access to healthy, nutritious food. Slavery forced Black/African Americans to depend on foods high in salt and fat to survive. Denied regular water or nourishment, Black/African Americans built their cuisine on discarded animal parts and formerly inedible vegetables soaked in salt and fat, just so that they wouldn’t dehydrate and die while performing slave labor. For Dr. Hill-Briggs, herself a descendent of enslaved Black/African Americans, the history is instructive, as it provides a perspective shift to encourage a new way of eating for Black/African Americans today.
“In the same way that our ancestors from Africa would never have eaten what they were forced to eat under American slavery, they adapted brilliantly to stay alive,” says Dr. Hill-Briggs. “Now it’s time for us to adapt again. In the same way we ate what we could to live in that era, now it’s time for us to eat in a way that will allow us to live in this era.”
Because we now understand type 2 diabetes is a disease largely born of social and lifestyle conditions, prevention is not only possible but highly prescriptive. Northwell is focusing on two major directions of prevention. First, Northwell is intervening on the social determinants of health as recommended in the report to Congress. Black/African American and Immigrant communities often live in food deserts where healthy food is hard to get or have trouble obtaining food altogether. Advocating for access to better food in these communities, plus access to green spaces for safe exercise, will help. In the meantime, Northwell’s mobile nutrition education program, Wellness
on Wheels, is already addressing food insecurity in underserved communities.
Secondly, Northwell aims to widely disseminate the National Diabetes Prevention Program across the population Northwell serves. Dr. Hill-Briggs hopes that Northwell’s example, where the NDPP is spreading throughout Northwell communities and specifically seeking to reach populations most at-risk in the State, will be followed by health care systems nationwide and we’ll see a more equitable decline in new cases of type 2 diabetes nationally.
Dr. Hill-Briggs sees a future in which type 2 diabetes no longer decimates minority communities, but it will take the combined efforts of individuals taking agency in their own health, trusted community leaders educating their community members, health care leaders like Northwell establishing education and prevention programs, and, finally, federal agencies taking Dr. Hill-Briggs’ recommendations on addressing the social determinants of health.
“If we change how our federal agencies approach health and equity, making healthy food sources available, making neighborhoods walkable irrespective of the income of the people who live there, amazing things can happen ― not just for diabetes, but for all other health conditions as well.”
“I’ve studied medical history,” Dr. Tracey recalls, “and you can sum up the story of what kills human beings in two words: infection and inflammation.”
These crucial findings led the National Clinical Care Commission, a panel of over two dozen experts, to present Congress with a first-of-its-kind report recommending action on social and environmental conditions as the key to our success in the fight against type 2 diabetes.
“The report was groundbreaking,” recalls Dr. Hill-Briggs. “We’ll never be able to have any impact on diabetes if we don’t start addressing the social determinants of health, our food, our environment, our housing. The report recommended to Congress what each federal agency can and should be doing, what HUD should be doing, what the FTA should be doing.”
As a leader in health care, Northwell aims to take this new understanding that type 2 diabetes is a disease of health inequity and work to resolve the systemic barriers so that all New Yorkers and, by extension, all Americans, can live healthy lives. Under Dr. Hill-Briggs’ leadership, Northwell has partnered with the CDC to implement the National
Diabetes Prevention Program (NDPP), a prevention plan with proven results in preventing type 2 diabetes. By educating communities on the risk factors of type 2 diabetes, the NDPP makes it easier for those at risk to participate in evidence-based lifestyle change programs to reduce their risk of later developing the disease.
The randomized study on which the NDPP is based showed that moderate physical activity ― done mostly by walking ― plus healthier eating leading to a 5%-7% weight loss, stopped most participants from developing diabetes or significantly delayed the onset to much later in life, when compared to taking medication. The study has been repeated with the same conclusion: lifestyle changes are highly effective at preventing diabetes.
Yet, still, rates of diabetes are increasing in Black/African American, immigrant and lower socioeconomic communities. That’s because lifestyle alone isn’t responsible for type 2 diabetes; it’s also a disease of social inequity, says Dr. Hill-Briggs. “In the U.S., racial and ethnic minorities and lower socioeconomic groups have always had higher prevalence of diabetes.”
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Secondly, Northwell aims to widely disseminate the National Diabetes Prevention Program across the population Northwell serves. Dr. Hill-Briggs hopes that Northwell’s example, where the NDPP is spreading throughout Northwell communities and specifically seeking to reach populations most at-risk in the State, will be followed by health care systems nationwide and we’ll see a more equitable decline in new cases of type 2 diabetes nationally.
Dr. Hill-Briggs sees a future in which type 2 diabetes no longer decimates minority communities, but it will take the combined efforts of individuals taking agency in their own health, trusted community leaders educating their community members, health care leaders like Northwell establishing education and prevention programs, and, finally, federal agencies taking Dr. Hill-Briggs’ recommendations on addressing the social determinants of health.
“If we change how our federal agencies approach health and equity, making healthy food sources available, making neighborhoods walkable irrespective of the income of the people who live there, amazing things can happen ― not just for diabetes, but for all other health conditions as well.”