Racial and Socioeconomic Disparities in Pediatric Type 1 Diabetes: Time for a Paradigm Shift in Approach.

Advancements in diabetes technology have improved quality of life and glycemic control in children with type 1 diabetes. However, a subset of children is being left behind. Those from low-income families and non-Hispanic Black (NHB) children are not experiencing these benefits of technology (1,2) and continue to be at higher risk for complications and adverse outcomes through ongoing poor glycemic control (3). As Addala et al. have demonstrated in a study reported in this issue of Diabetes Care (4), this is a serious problem in the U.S., and there has been no sign of improvement in recent years. These data should be a trigger for all of us to reflect on the factors contributing to these disparities and consider our roles in driving meaningful change. In this study, Addala et al. have compared technologyuseandsocioeconomic status (SES) in children aged ,18 years in the Type 1 Diabetes Exchange (T1DX) registry in the U.S. and the Diabetes Prospective Follow-up (Diabetes-PatientenVerlaufsdokumentation [DPV]) registry in Germany (4). They sought to assess disparities in diabetes outcomes in technology use and glycemic control in both populations in 2010–2012 and 2016– 2018 and have shone a light on a major problem. As expected, both registries demonstratedanoverall increase in technology use over an 8-year period, but the differences between those in the highest and lowest SES categories across both populations highlight the magnitude of disparities in the U.S. In 2016–2018, there was a much larger gap between those of higher and lower SES in the U.S. in comparison with Germany for insulin pump use (39% vs. ,6%), continuous glucose monitor use (37.3% vs. 8.6%), and hemoglobin A1c (HbA1c) (1.3% vs. 0.3%). Of particular concern is the almost identical disparity seen in the U.S. in 2010–2012 of 42% for insulin pump use and 1.2% for HbA1c. As the rate of continuous glucose monitor use has increased exponentially over the same time frame, the disparity has widened from 8% to 37.3%, highlighting that the introduction of new technology has the potential to add an additional disparity for children with type 1 diabetes. This is likely to continue unless the underlying etiologies of these disparities are addressed. Through analyzing two large population registries, Addala et al. describe diabetes management and outcomes and provide a temporal context to assess progress in mitigating disparities. There are challenges in comparing the two populations given that the DPV is an inclusive population-based registry whereas the T1DX includes registry data from recruited subjects, an approach that may introduce selection bias to disparity analysis. Furthermore, SES was defined differently for the two registries, and this may have complicated comparisons between populations. Despite these limitations, there is little doubt that the disparities described in the U.S. are much wider than in Germany and are not improving. Although the disparities highlighted in this article are not surprising, they clearly demonstrate that much work is required to address the factors that impede diabetes care and outcomes in marginalized children in the U.S. Measures of social determinants of health (SDOH) are associated with suboptimal glycemic control in children with type 1 diabetes (5). Despite this, clinical centers in the U.S. often do not incorporate screening forSDOH into routinediabetes care (6). In the absence of routine SDOH screening, we are often unaware of the challenges faced by many of our families. In 2018, more than 11 million children in the U.S. lived in households with food insecurity (7). The need to cope with poor access to food or with housing insecurity understandably takes priority over intensive diabetes management or attending frequent outpatient appointments (Fig. 1). Interventions focused on diabetes education,without screening for and addressing SDOH, have not improved diabetes control