“Black Americans with diabetes are more likely to die than white Americans with diabetes across the country and across every single one of the largest 30 cities in the country.”
In this episode, Dr. Buscemi talks about her research in diabetes mortality by race. We talk about the United States cities with the worst health disparities, how inequality affects diabetes mortality, and how health policy can be changed to fix this.
Dr. Joanna Buscemi is a Clinical Health Psychologist and Assistant Professor at DePaul University specializing in health inequities. She also serves as the Health Policy Council Chair at the Society of Behavioral Medicine.
Shireen: Dr. Buscemi talks about her research in diabetes mortality by race. We talk about the United States cities with the worst health disparities, how inequality affects diabetes mortality, and how health policy can be changed to fix this.
Podcasting from Dallas, Texas. I am Shireen, and this is the Yumlish Podcast.
Yumlish is working to empower you to take charge of your health through diet and exercise and reduce the risk of chronic conditions like type two diabetes and heart disease. We hope to share a unique perspective and a culturally relevant approach to managing these chronic conditions with you each week.
Dr. Joanna Buscemi is a clinical health psychologist and assistant professor at DePaul University specializing in health inequities. She also serves as a Health Policy Council Chair at the Society of Behavioral Medicine.
Welcome Dr. Buscemi.
Joanna: Thanks so much for having me today.
Shireen: An absolute pleasure. So, can you talk a little bit about your background as a clinical psychologist in really your role as the chair of the Health Policy Council for the Society of Behavioral Medicine?
Joanna: Sure. As you mentioned, I'm a health psychologist. And how psychologists really work at the intersection of health and behavior, and my work in health psychology specifically has focused on health inequities. And while most of my work has focused on obesity prevention and treatment in minoritized populations, I've also worked across health behaviors and across disease presentations.
And I found that they really share a lot of the same risk factors like social determinants of health and experiences with racism and oppression. And so, I've also worked in the areas of cancer and diabetes, which is what we're going to talk about today. In addition to the academic role that I have at DePaul and my research program, I also serve as the chair of the Health Policy Council for the Society of Behavioral Medicine.
And in this role, I oversee our advocacy program and I train our members to build relationships with legislative staffers across the country. Um, and the main goal of this program is to educate policy makers about our science. Most health psychologists are really trained to work at individual levels and to look at individual factors that are associated with health and health behaviors.
But through this work, I realized that when we focus only on individuals, we really largely ignore systemic factors that perpetuate inequities in disease and quality of life as well. So, I really wanted to focus my professional service efforts in this space, in the health policy advocacy space. And my role at the Society of Behavioral Medicine has allowed me to do that.
Shireen: That's lovely. So, speaking of diabetes, um, you, in your recent study on diabetes mortality and racial inequalities published last January, you and your team really focused on the biggest cities in the United States. Why did you choose to structure the study in this way? And what insight did you really gain from this choice?
Joanna: In terms of diabetes mortality inequities, as we know at the national level that Black Americans die of diabetes at a higher rate than white Americans with diabetes, but the problem with national data is that it conceals potential local variations in diabetes mortality inequities.
And finding out what those local variations are, could be really helpful in terms of policy development and developing policies that can address these inequities in specific areas. So, we wanted to see where these local variations exist across the country, and this will allow us to think more deeply about what might be causing some of these issues in these areas and how we can then go about addressing them. So, that's why we took this strategy.
Shireen: What are some of the biggest takeaways from this study about diabetes in the United States?
Joanna: I would say there are three main takeaways to our study. One is that Black Americans with diabetes are more likely to die than white Americans with diabetes across the country and across every single one of the largest 30 cities in the country.
That's number one, number two, we found that the highest diabetes mortality inequities exist in Washington, DC. And it was really surprising what we found. So, in DC, Black Americans are almost seven times more likely to die of diabetes than White Americans with diabetes. So, the inequity in DC was much larger than all of the other largest 30 cities in the country.
And the third main takeaway is that some of the cities have seen a decrease in inequities over time, including Louisville and Phoenix. And I think the reason this is important is because we were able to see changes over two five-year periods. And it's interesting to see where things have gotten better rather than worse, and then we can take a look at those cities and figure out what they might be doing well to address inequities and diabetes, mortality over time.
Shireen: Interesting. What needs to really be done to alleviate this problem on both a city level and also on a national level?
Joanna: Our findings really point to a need to address root causes of these inequities.
They're largely systemic in nature. Our study didn't really look at why the inequities exist. We just looked at the actual numbers. But we know from other bodies of literature, that these issues are largely systemic. They're largely linked to racism and oppression. And while there's likely many paths we could take to resolve some of these inequities, I focused my writing on the policy solutions that maybe could have the highest population level impact.
So, there's several of them, but I'm going to break it down and just start by talking about three of them. The first is that insulin is too expensive. And that for many Black Americans, particularly those of low income and or Black Americans who are uninsured, they can't afford their insulin. So that's number one.
And we know that insulin helps people manage their diabetes and decreases the risk of death. The second is that we really need policies that address other inequities that lead to diabetes mortality down the road. So, for example, we need to address employment equities and healthcare inequities. So, in our country, our healthcare is most often tied to our employment.
So, if we have, you know, inequities in terms of people's employment and the health insurance tied to that employment, then it's going to trickle down and have impact on marginalized communities such as Black Americans. We know that this is the case. Still in many cities, Black Americans are less likely to have jobs that give a full range of healthcare benefits.
In many cities, Black Americans are still less likely to have health insurance. Although we know the Affordable Care Act has helped in that regard to some extent. And then finally, we really need to figure out how to address inequities related to diet and physical activity, which we know is also linked to diabetes management. So, for example, expanding government funded nutrition assistance programs, and putting money into infrastructure for safe parks and active transit to allow people that live in neighborhoods that are predominantly low income to have safe spaces to be physically active.
So those are some of the ideas that I have in terms of policy recommendations that might help to address some of these Black, White inequities in terms of diabetes mortality.
Shireen: Can you talk a little bit about the impact that your study has had, um, in cities, in communities, even at the national level, what has that looked like? And more importantly, you know, you talked about you didn't quite look at, uh, you know, what led to that or what the causes were there, but can you talk a little bit more high level on what is also being done at the national level to address some of these things?
Joanna: Yes. I think that, as I mentioned, we can learn a lot from cities who are doing better with diabetes mortality, and inequities over time, rather than worse. So based on our findings, I dug into what's happening. For example, in Louisville. And I feel like they're, they're putting massive effort into some of the policies that I was just speaking about, that could be national level policies, but could certainly also be policies implemented at local levels. So, you know, expanding employment opportunities for Black Americans, ensuring access to healthcare for Black Americans, and also working on infrastructure and policies to make sure that there aren't inequalities in terms of access to fruits and vegetables, for example, and being active.
So, I think that those are some ways, um, at the national level, we do see shifts in these policies. Sometimes I feel like there, I think what's, what's interesting to think about with diabetes as a case study, is that a lot of these policies I'm talking about are going to trickle down to help people with cancer and heart disease, because the same inequities exist.
I mentioned I'm predominantly an obesity researcher, and again, the same inequities exist with obesity, where we see Black Americans and Latinx Americans having higher rates of obesity. And so, I do think that we could see more movement at the national level if we put in more funding into these types of programs that would, it would expand healthcare access and address some of these inequities more broadly.
Shireen: Can you, uh, speaking of national level, can you talk a little bit about the Build Back, Better Act? Um, and specifically as it relates to some of the things that you were talking about, insulin and all of that, and why, why that matters for someone with diabetes, but also just your overall thoughts on Build Back Better.
Joanna: Sure, overall, I do believe that Build Back Better would, would likely move the needle in terms of addressing broad-based health inequities, including diabetes, but the diabetes community patients with diabetes who looked at the Build Back Better act have had some critiques about it, particularly in terms of what they've done with insulin.
So, I could talk about that a little bit. The Build Back Better Act included a provision for capping the cost of the insulin co-pay. But what the diabetes community really wants is to cap the cost of insulin itself. And I would say even more than that, they want insulin for all. So, they want free insulin for everybody, not just capping the cost, but capping the cost of insulin would be better than capping the cost of the copay.
Because again, some people are uninsured. Or they might be in a situation where they're not eligible for Medicaid, but they don't have private health insurance either. And so, it just doesn't work for all Americans with diabetes. And so that's a criticism of Build Back Better from the diabetes community.
So, I think what we really want is to see that we want policy makers to take on the pharmaceutical companies that have been price gouging for far too long. And I think that's really what the message should be. So, while Build Back Better, had some positive implications for health inequities across the board, the insulin piece, and rightly so received some criticism for the reasons I mentioned.
Shireen: So, it almost assumes that there's an insurance you rely on to help cap the cost of the copay. When that may not always be the case, especially when we're talking about in underserved communities or communities where these disparities exist with lower insurance levels. And, you know, it's unfortunate, right. But it seems like a step in the right direction, but it still doesn't solve the root of the problem.
Joanna: Right. Or are there situations where, for example, they will be needing more insulin, but the insurance company dictates when they should be ready instead of their bodies dictating that. And then what happens even with people who are insured is they're ready for more insulin and they can't get it covered.
And then there's other situations with Medicaid where people land in the donut hole, where they no longer have coverage when they've met sort of the maximum coverage that they could receive. So as long as we're sort of basing it off of the flaws of the private and public health insurance coverage, it's always going to be problematic for people with diabetes to get the insulin they need to live.
Shireen: Um, what direction is good, further research into this topic take. And what is your current focus and future plans on this research?
Joanna: Well, in our study, here's some ideas I've been thinking about. In our study we look at Black, White inequities. But we also know there’s inequities and other groups as well. So, for example, trying to expand this to look at diabetes mortality inequities between White Americans, and Latinx Americans, because we know there are inequities that exist there as well is one future direction, I'm interested in. The other future direction is that I would like to empirically study which policies can move the needle the most in terms of diabetes mortality inequities.
Which we don't really have enough data about, but I'm interested like which specific policies at these local levels or national levels have the most impact. And maybe we could put our efforts into advocating for those. So, I'm interested in more like higher level policy research to figure out what can, what can be done in these cases.
Shireen: Any particular areas that stand out to you?
Joanna: In terms of specific policies? Because of my interest in diet and physical activity, I'm interested in, in those policies because they're a little bit harder to define operationally and sort of figure out exactly what needs to be in these policies to have an impact.
So, I'm interested in those pieces specifically, but I have a feeling that the insulin and the access to healthcare, you know, that those would have the greatest impact. And then at the behavioral level, I'm wondering about those diet and physical activity related policies.
Shireen: Tie more to the nutrition assistance programs. Right. Okay. Makes sense. I still can't get over the insulin thing because quite honestly it seems like almost a low-hanging fruit when it comes to diabetes management and it almost seems like, oh, this is an obvious thing that can just be taken care of. And so much going on behind the scenes with big pharma and insurance payers, health systems, all of that, where, while it may be a very simple problem to solve, it's been set up in such a way within our health system to where there aren't the right tools in place.
There aren't the right policies in place that sort of help us overcome again, this, something that seems like a very obvious answer to managing diabetes.
Joanna: Absolutely. And it's, like I said, with some of these other policies where I can imagine a trickle-down effect where it would help other disease presentations, where we see inequities as well.
If legislators figuring out how to take on pharmaceutical companies, then we could also see similar advocacy efforts for people to afford their chemotherapy or other types of lifesaving treatments that are completely unaffordable for many people, particularly those who have experienced systemic oppression.
So, it seems very obvious to people like you and me, but, um, for whatever reason at the policy level, there's still a long way to go. And a lot, that's not understood by policymakers. And that's part of why I love doing things like this and engaging in science communication, because I feel like it's so important for legislators to understand the impact they could have on people's health and on their lives and on their quality of life.
And I think, you know, I think patients need to be at the table because you really only understand this if you're living it and a lot of policymakers aren't living it, so it's not real for them. So, I also really think it's important to have patients at the table and policy decisions are being made. In addition to scientists like me.
Shireen: Thank you so much for this conversation, Dr. Buscemi. At this point, I'd love for our listeners to know how they can connect with you and just really learn more about your work.
Joanna: Sure. You can follow me on Twitter @Joanna_Buscemi or also my lab website, um, choicelabdepaul.com.
Shireen: Lovely. Thank you so much.
And thank you again for your time here.
Joanna: Thank you for having me.
Shireen: And to our listeners out there, uh, head over to our social media, head over to our Facebook or Instagram and answer this question. What could your city be doing better to help all individuals with diabetes access better care? Head over to our Facebook or Instagram
and answer this quick question. What could your city be doing better to help all individuals with diabetes access better care? We'll see you there after this episode. Thank you again, Dr. Buscemi.
Joanna: Thank you so much.
Shireen: Thank you for listening to the Yumlish Podcast. Make sure to follow us on social media @Yumlish_ on Instagram and Twitter and @Yumlish on Facebook and LinkedIn for tips about managing your diabetes and other chronic conditions and to chat and connect with us about your journey and perspective. You can also visit our website Yumlish.com for more recipes advice, and to get involved with all of the exciting opportunities @Yumlish has to offer. If you like this week's show, make sure to subscribe so you can hear more from us every time we post. Thank you again, and we'll see you next time. Remember your health always comes first.