1. Martyn-Nemeth, Pamela PhD, RN
  2. Hayman, Laura L. MSN, PhD

Article Content

Type 1 diabetes (T1D) is an autoimmune disorder leading to progressive destruction of the pancreatic [beta] cells, resulting in dependence on exogenous insulin to maintain near-normal blood glucose levels.1 Type 1 diabetes is a significant public health burden with 1.6 million people affected in the United States, and it is increasing with a relative increase of 1.9% per year among youth in the United States (2002-2015).2 Although the overall prevalence of T1D is greater among non-Hispanic Whites, larger increases in T1D diagnosis were observed among Blacks (2.7%/year) and Hispanics (4.0%/year) compared with non-Hispanic White counterparts (0.7%/year) during this same period.2 These data represent a shift in previous prevalence patterns.


Across the life course, underrepresented racial and ethnic minorities bear a greater burden of T1D, with poorer glycemic control than non-Hispanic Whites,3 and more hospital admissions for acute diabetes complications such as hyperglycemia and hypoglycemia.3-5 Poor glycemic control is linked to long-term complications including cardiovascular disease, the major cause of morbidity and mortality in individuals with T1D.6 Advancements in technology, such as insulin analogs, continuous glucose monitors, insulin pumps, and closed loop systems, have reduced the burden of diabetes self-management and have helped patients achieve improved glycemic targets.7 Of concern, not all patients have access to and/or use these technological advances. Access to these technological advances is less than optimal in patients with T1D from racial-ethnic minority populations.7-9 Many study authors report socioeconomic status and insurance as reasons for low use,7 yet racial-ethnic inequities have been identified when controlling for income and insurance status.3,9,10 This suggests that additional factors besides socioeconomic status and insurance contribute to the problem.


Patient-provider system level factors have been identified that contribute to access and information about treatment options. In a qualitative study, 40 young adults with T1D (72% Hispanic, 28% non-Hispanic Black) described that most of the information they received about technology came from their healthcare providers. Many reported that, although they heard about diabetes technologies, they were not offered these technologies and were not involved in shared decision making regarding the therapeutic options available to them.11 Negative previous experiences with technology such as body image concerns, stigma, and attachment issues of wearing devices were identified as barriers; however, optimistic, supportive, and tailored communication from providers was helpful and facilitated making technology decisions.11


Person-level factors have also been identified and may contribute to inequities in diabetes care. Self-management practices are the most explored person-level factors. Butler et al12 evaluated self-management behaviors among 3456 emerging adults (18-25 years old). Compared with White counterparts, frequency of blood glucose monitoring, insulin administration, and monitoring for ketoacidosis was lower among African American and Hispanic emerging adults compared with their White counterparts.12 Feeling different from peers and not having peers with T1D was identified as a major barrier.13


Psychological factors such as diabetes distress contributes to self-management behaviors. Diabetes distress is conceptually distinct from depression and refers to the emotional response to managing a complex chronic condition such as T1D.14 High levels of diabetes distress are known to be a barrier to self-management behavior.15,16 Studies comparing diabetes distress among various racial/ethnic groups have found diabetes distress to be higher in youth with a lower socioeconomic status and in those from racial/ethnic minority backgrounds.17 Coupled with a need for more inclusive recruitment in research studies,18 a better understanding of the sources of distress among underrepresented racial and ethnic minorities is greatly needed.


Taken together, diabetes technology use, self-management behaviors, and diabetes distress have been found to contribute to the racial/ethnic gap in glycemic control.19 Innovative approaches designed to provide and increase the uptake of evidence-based information regarding diabetes technologies and enhance shared decision making are needed. Development and implementation of strategies to improve self-management behaviors and address sources of diabetes distress are also indicated. Disparities in technology use and diabetes outcomes in T1D are critical problems that need to be addressed to reduce health inequities. Nurse scientists and clinicians have a central and essential role in contributing to the evidence base designed to reduce disparities in treatment and outcomes for T1D and in providing optimal care for all individuals with T1D.




1. Kaufman FRAmerican Diabetes Association. Medical Management of Type 1 Diabetes. 5th ed. Alexandria, VA: American Diabetes Association; 2008. [Context Link]


2. Divers J, Mayer-Davis EJ, Lawrence JM, et al. Trends in Incidence of type 1 and type 2 diabetes among youths-selected counties and Indian reservations, United States, 2002-2015. MMWR Morb Mortal Wkly Rep. 2020;69(6):161-165. [Context Link]


3. Willi SM, Miller KM, DiMeglio LA, et al. Racial-ethnic disparities in management and outcomes among children with type 1 diabetes. Pediatrics. 2015;135(3):424-434. [Context Link]


4. Glantz NM, Duncan I, Ahmed T, et al. Racial and ethnic disparities in the burden and cost of diabetes for US Medicare beneficiaries. Health Equity. 2019;3(1):211-218. [Context Link]


5. Lipman TH, Smith JA, Patil O, Willi SM, Hawkes CP. Racial disparities in treatment and outcomes of children with type 1 diabetes. Pediatr Diabetes. 2021;22(2):241-248. [Context Link]


6. Htay T, Soe K, Lopez-Perez A, Doan AH, Romagosa MA, Aung K. Mortality and cardiovascular disease in type 1 and type 2 diabetes. Curr Cardiol Rep. 2019;21(6):45. [Context Link]


7. Foster NC, Beck RW, Miller KM, et al. State of type 1 diabetes management and outcomes from the T1D exchange in 2016-2018. Diabetes Technol Ther. 2019;21(2):66-72. [Context Link]


8. Agarwal S, Schechter C, Gonzalez J, Long JA. Racial-ethnic disparities in diabetes technology use among young adults with type 1 diabetes. Diabetes Technol Ther. 2021;23(4):306-313. [Context Link]


9. Fantasia KL, Wirunsawanya K, Lee C, Rizo I. Racial disparities in diabetes technology use and outcomes in type 1 diabetes in a safety-net hospital. J Diabetes Sci Technol. 2021;15(5):1010-1017. [Context Link]


10. McKergow E, Parkin L, Barson DJ, Sharples KJ, Wheeler BJ. Demographic and regional disparities in insulin pump utilization in a setting of universal funding: a New Zealand nationwide study. Acta Diabetol. 2017;54(1):63-71. [Context Link]


11. Agarwal S, Crespo-Ramos G, Long JA, Miller VA. 'I Didn't Really Have a Choice': qualitative analysis of racial-ethnic disparities in diabetes technology use among young adults with type 1 diabetes. Diabetes Technol Ther. 2021;23(9):616-622. [Context Link]


12. Butler AM, Weller BE, Rodgers CRR, Teasdale AE. Type 1 diabetes self-management behaviors among emerging adults: racial/ethnic differences. Pediatr Diabetes. 2020;21(6):979-986. [Context Link]


13. Mencher SR, Weinzimer SA, Nally LM, Van Name M, Nunez-Smith M, Sadler LS. Technology utilization in Black adolescents with type 1 diabetes: exploring the decision-making process. Diabetes Technol Ther. 2022;24(4):249-257. [Context Link]


14. Fisher L, Gonzalez JS, Polonsky WH. The confusing tale of depression and distress in patients with diabetes: a call for greater clarity and precision. Diabetic Med. 2014;31(7):764-772. [Context Link]


15. Hagger V, Hendrieckx C, Sturt J, Skinner TC, Speight J. Diabetes distress among adolescents with type 1 diabetes: a systematic review. Curr Diab Rep. 2016;16(1):9. [Context Link]


16. Hessler DM, Fisher L, Polonsky WH, Masharani U, Strycker LA, P. Diabetes distress is linked with worsening diabetes management over time in adults with type 1 diabetes. Diabetic Med. 2017;34(9):1228-1234. [Context Link]


17. Fegan-Bohm K, Minard CG, Anderson BJ, et al. Diabetes distress and HbA1c in racially/ethnically and socioeconomically diverse youth with type 1 diabetes. Pediatr Diabetes. 2020;21(7):1362-1369. [Context Link]


18. Akturk HK, Agarwal S, Hoffecker L, Shah VN. Inequity in racial-ethnic representation in randomized controlled trials of diabetes technologies in type 1 diabetes: critical need for new standards. Diabetes Care. 2021;44(6):e121-e123. [Context Link]


19. Agarwal S, Kanapka LG, Raymond JK, et al. Racial-ethnic inequity in young adults with type 1 diabetes. J Clin Endocrinol Metabol. 2020;105(8):e2960-e2969. [Context Link]