Eliminating Bias in Diabetes Care

This article by Agarwal et al. (2020) provides an important scientific contribution by examining how a broad array of social determinants of health (SDOH) and disease-specific variables collectively influence glycemic outcomes in a national sample of emerging adults. This was a cross-sectional study leveraging the Type 1 Diabetes Exchange clinic network for participant recruitment. A major strength of this study lies in the thoughtful and intentional construction of its sample. The researchers recruited 300 emerging adults (ages 18-25) with T1D across six geographically diverse diabetes centers, ensuring near equal representation of non-Hispanic Black (n=97), Hispanic (n=103), and non-Hispanic White (n=100) participants. This level of demographic balance is rare in T1D research, where racial and ethnic minority groups are often severely underrepresented, especially among emerging adults. This intentional equal representation enhanced the authors’ ability to make balanced racial and ethnic comparisons. Furthermore, the sample was also economically and clinically diverse, with variation in insurance coverage (private, public, none), income level, diabetes technology use, and diabetes care setting. 

The results of this study show substantial racial and ethnic disparities in meeting glycemic targets, diabetes technology use, psychosocial burden, and self-management. Importantly, non-Hispanic Black emerging adults consistently had the highest A1C levels, the lowest technology use, and the greatest levels of diabetes distress, even after accounting for socioeconomic status. However, Hispanic emerging adults had similar A1C levels to non-Hispanic White emerging adults, after accounting for socioeconomic status. Diabetes technology use, diabetes distress, and diabetes self-management contributed most to the disparity in A1C between non-Hispanic Black and non-Hispanic White emerging adults, out of all of the considerations captured. This illustrates that racial and ethnic differences in diabetes outcomes arise from social and contextual factors, and should not be considered inherent biological differences. Importantly, the authors of this article point out that in addition to cost, other factors such as personal and cultural preferences, clinician bias, literacy, and social support may drive disparities in diabetes technology use and diabetes outcomes.  

Jorden Rieke, BSN, RN, CCRN and Quiana Howard MSN, RN-BC 

Link to the paper

Citation: 

Shivani Agarwal, Lauren G Kanapka, Jennifer K Raymond, Ashby Walker, Andrea Gerard-Gonzalez, Davida Kruger, Maria J Redondo, Michael R Rickels, Viral N Shah, Ashley Butler, Jeffrey Gonzalez, Alandra S Verdejo, Robin L Gal, Steven Willi, Judith A Long, Racial-Ethnic Inequity in Young Adults With Type 1 Diabetes, The Journal of Clinical Endocrinology & Metabolism, Volume 105, Issue 8, August 2020, Pages e2960–e2969, https://doi.org/10.1210/clinem/dgaa236 

Vela and colleagues conducted a systematic review to assess the efficacy of 25 studies with interventions designed to increase awareness of the harmful effects of bias. Most of the interventions increased the awareness of bias and interest in mitigating bias among participants. However, no study showed sustained decrease in implicit bias among health care providers and trainees. 

Vela and colleagues suggest that the beneficial effects of provider level bias interventions are waned by structural biases in the work and learning environment of health care providers (e.g., racialized medicine) and structural inequalities outside the health care system (e.g., poverty, limited education, poor housing, healthy food scarcity). The authors present a conceptual model of implicit bias that illustrates how structural factors inside and outside of the HCS reinforce implicit bias. Work and learning environments with discriminatory practices send covert messaging to health care providers and trainees that reinforce biases. When caring for a patient with diabetes from a marginalized group, a provider’s bias may thwart communication resulting in suboptimal decision making. The patient, sensing the bias, distrusts the provider and does not disclose that he/she lacks the resources (e.g., money to purchase medications or healthy foods) to follow the provider’s instructions for self-care. This results in a poor health outcome that reinforces the provider’s bias. This vicious cycle promotes suboptimal health outcomes for marginalized groups, thus widening the health disparity gap. Provider level bias training should be accompanied by interventions that systematically change structures inside the healthcare system and increase awareness of structural inequalities within our society.  

Eva Vivian, PharmD, PhD, MS, CDCES, BC-ADM, FADCES 

Link to the paper

Citation: 

Vela MB, Erondu AI, Smith NA, Peek ME, Woodruff JN, Chin MH. Eliminating Explicit and Implicit Biases in Health Care: Evidence and Research Needs. Annu Rev Public Health. 2022 Apr 5;43:477-501. doi: 10.1146/annurev-publhealth-052620-103528.  

Awareness of implicit bias continues to grow, though there is significant room for improvement. Implicit bias is, by nature, unconscious. Since it's not something that can be directly observed, it is difficult to address implicit bias without purposeful, intentional effort.  But what are we to do about this problem?   

This publication reviews practical ways we can recognize and address our unconscious biases in the context of diabetes care.  The authors highlight how racial, ethnic, and obesity related biases can affect and shape clinical decisions and patient experiences.  Not only do they raise awareness in this context, but the authors provide evidence-based recommendations to help reduce negative effects of implicit bias and improve overall care for people with diabetes.  The authors provide guidance at both individual and systemic levels, and stakeholders across different roles can benefit.  Readers will find that the review and implementation of available tools, recommendations, and data-collection strategies support providers, administrators, and anyone else involved in caring for people with diabetes. 

Victor Phan, PharmD, MPH, CDCES, BCACP, APh 

Link to paper

Citation: 

Enrique Caballero, Nuha A. ElSayed, Sherita Hill Golden, Raveendhara R. Bannuru, Brigid Gregg; Implicit or Unconscious Bias in Diabetes Care. Clin Diabetes 15 April 2024; 42 (2): 308–313. https://doi.org/10.2337/cd23-0048 

Research shows that physicians treating type 2 diabetes (T2D) consistently harbor moderate levels of bias and negative stereotypes toward their patients, despite generally feeling professionally prepared and confident in their ability to provide quality care (85%–86%). Among 205 surveyed physicians specializing in internal medicine or endocrinology, approximately one-third reported being repulsed by people with T2D, and substantial percentages endorsed negative stereotypes, viewing people with T2D as lazy (39%), lacking motivation (44%), and often “non-compliant” with treatment recommendations (44%). More than two-thirds believed individuals are personally responsible for developing T2D or that the condition is at least partially controllable. While weight stigma was slightly higher than diabetes stigma, the differences were small, suggesting the intersectionality of weight-based and diabetes-based stereotypes due to the frequent co-occurrence of obesity and T2D. These findings collectively demonstrate a pervasive level of stigma that requires urgent attention through targeted stigma reduction interventions for medical providers. 

Researchers, Bennett and Puhl, used online questionnaires completed by physicians practicing in the U.S. who were predominantly male (72%) and White (79%), which limits generalizability to the broader physician population. Bias was significantly worse among younger physicians and those with fewer years in practice, and a higher percentage of people with T2D in a physician’s caseload was linked to greater lack of empathy and stronger beliefs about personal controllability. As this research was cross-sectional, future studies are needed to examine how physician bias impacts care quality, health outcomes, and healthcare avoidance. Meanwhile, integrating stigma-reduction strategies into medical education, continuing professional development, and clinical practice, such as using person-first language, addressing implicit bias in team training, and fostering compassionate communication, can help improve patient trust and outcomes. 

Jennifer Rosselli, PharmD, BCACP, BC-ADM, CDCES 

Link to the paper

Citation: 

Bennett BL, Puhl RM. Diabetes stigma and weight stigma among physicians treating type 2 diabetes: Overlapping patterns of bias. Diabetes Res Clin Pract. 2023 Aug;202:110827. doi: 10.1016/j.diabres.2023.110827. Epub 2023 Jul 13. PMID: 37451627. 

Clinical decision-making is central to effective diabetes management, and a well-documented barrier to optimal decision-making is implicit bias. This innovative study was the first to investigate the influence of gender bias on clinical decision-making related specifically to type 2 diabetes. Participants were Dutch general practitioners. The study employed vignette-based scenarios (carefully constructed hypothetical clinical encounters that varied only by gender) depicting interactions between a person with type 2 diabetes and a healthcare professional. After reviewing the vignettes, participants rated the likelihood of various medical diagnoses, including the likelihood of a type 2 diabetes diagnosis. Participants also selected treatment recommendations and reported their confidence in the vignette character following their recommendations. Male general practitioners were more likely to diagnose male patients with type 2 diabetes, whereas female general practitioners were more likely to recommend motivational interviewing. Female participants were also more likely to diagnose with type 2 diabetes. Female vignette characters were much more likely to be referred to a dietician. Gender bias influenced not only diagnostic decisions but also treatment approaches. These results highlight the significant role of gender implicit bias in shaping the healthcare experiences and outcomes of people living with diabetes. Further, these findings provided clear evidence that general practitioners demonstrated gender-based implicit biases that affected their clinical decision making. 

Allyson S. Hughes, PhD 

Link to the paper

Citation:  

Skvortsova A, Meeuwis SH, Vos RC, Vos HMM, van Middendorp H, Veldhuijzen DS, Evers AWM. Implicit gender bias in the diagnosis and treatment of type 2 diabetes: A randomized online study. Diabet Med. 2023 Aug;40(8):e15087. doi: 10.1111/dme.15087. Epub 2023 Mar 23. PMID: 36919798. 

This article demonstrated concrete evidence of bias in providers’ recommendations for technology in children and youth diagnosed with type 1 diabetes. What was surprising was that the bias was not race/ethnicity based but was insurance based. Thirty-nine providers from California, Colorado, Connecticut, District of Columbia, Massachusetts, North Carolina, Ohio and Texas participated. The majority (twenty-one) were from California, female and white. The group was comprised of physicians, nurse practitioners, and CDCESs, and eleven (28.2%) had a diagnosis of type 1 diabetes themselves. Thirty-three out of thirty-nine providers demonstrated bias against recommending technology for patients on public health insurance. This bias was not affected by age but was affected by years in practice. The longer someone was in practice the more likely they were to show bias in not recommending continuous glucose monitors for patients on public insurance; it was the second factor in order of importance for many providers. 

When it came to recommending insulin pumps there was less bias, it was the fourth factor out of seven ranked. In both cases race/ethnicity came last. It was encouraging to see that family preference was the first thing considered by providers for both CGM and insulin pumps and that in both cases race/ethnicity came last. The authors theorized that providers, having practiced for longer, had previously had trouble getting diabetes technology covered through public insurance. So, a potential solution would be to provide updates on how to get technology covered through public insurance as well as updates on American Diabetes Association (ADA) guidance changes. The ADA now recommends diabetes technology for all patients with type 1 diabetes based on shared decision-making and patient/family preference. This is heartening news since a bias rooted in practical insurance and knowledge barriers can be more easily fixed. Some limitations of this research intervention are the small sample size (thirty-nine) and the lack of racial and gender diversity (predominantly white and female). 

Liseli Mulala, RPh, MPH, PhD, CDCES, BCMTMS  

Link to the Paper 

Citation: 

Addala A, Hanes S, Naranjo D, Maahs DM, Hood KK. Provider Implicit Bias Impacts Pediatric Type 1 Diabetes Technology Recommendations in the United States: Findings from The Gatekeeper Study. Journal of Diabetes Science and Technology. 2021;15(5):1027-1033. doi:10.1177/19322968211006476

Recent advances like automated insulin pumps and continuous glucose monitors have reduced the daily burden of diabetes management and lowered risks such as hypoglycemia and diabetic ketoacidosis. However, access to these technologies is not equal—race, ethnicity, and socioeconomic status strongly influence who receives education and uses these devices. To address these disparities, Singh and colleagues (2025) examined what factors drive technology use and how provider practices affect recommendations. A large chart review was conducted to see if socioeconomic factors like insurance type explained differences in diabetes technology use. The study also surveyed children with diabetes and their caregivers during clinic visits to learn their views on the benefits and challenges of using devices. Finally, clinic providers were surveyed about their prescribing practices for diabetes technology.  

Black and Hispanic youth were far less likely to use insulin pumps or continuous glucose monitors than White youth, even when insurance and HbA1c were similar. These families often learned about technology later, while most White families were introduced at diagnosis. Caregivers with limited English perceived more barriers to technology use.  Overall, Black and Hispanic families had positive attitudes toward these devices, showing that low use is not due to lack of interest. Providers often based decisions on subjective factors like family stability and health literacy instead of clear clinical criteria; this suggests access to technology depends more on provider perceptions than medical need. This study underscores the need for increased provider awareness of personal bias when providing diabetes care and education; additionally, standardized clinical guidelines are essential to ensure all families receive timely education and equal access to diabetes technology. Clear, consistent communication between providers and patients—paired with structured clinical practices—can reduce barriers and improve outcomes for everyone managing diabetes. 

Synneva Hagen-Lillevik, PhD, MS, RD 
Note: The content of is solely the responsibility of the author and does not necessarily represent the official views of the National Institutes of Health.

Link to the paper

Citation: 

Singh, P., Garcia, A., Grishman, E. K., Naranjo, D., Hynan, L. S., Lau, M., White, P., & Gupta, O. T. (2025). Disparities in diabetes technology utilization in youth with diabetes. BMJ Open Diabetes Research & Care, 13(6), e005067. https://doi.org/10.1136/bmjdrc-2025-005067