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Socioeconomic status

Numerous studies show a proven link between higher socioeconomic status and better glycemic control in people with Type 1 (T1) diabetes. Financial and social causes have been cited to explain this correlation.

The 2014 National Diabetic Statistics Report found that “the average medical expenditure among people with diagnosed diabetes was 2.3 times higher than people without diabetes.” These costs are largely attributed to hospital inpatient care (50% of total cost) and diabetic medication and supplies (12%). Most states (with the exception of Alabama, Idaho, North Dakota, and Ohio) require partial coverage for equipment. Thus, although diabetic costs are partially subsidized by state governments, T1 diabetics are, to some degree, financially responsible for their medical costs. The 2014 Report strongly suggests that those unable to afford proper diabetes care are at higher risk of developing diabetic complications.

The financial burden of diabetes can have damaging biologic ramifications, particularly on individuals of low socioeconomic status (SES). For instance, it is more difficult for patients of lower SES to stay technologically up to date with medical changes and innovations. In a study done on 1500 patients with TID, researchers found that insulin pump therapy, which supports tight control of blood sugars, is much more likely to be used by patients of higher SES. Because insulin pumps cost upwards of $4,000, many government insurance plans do not provide them. This lack of access to supplies and expensive treatments have been cited as a potential reason for poorer glycemic control in patients of lower SES.

Social reasons may also account for the correlation between socioeconomic status and glycemic control. Wealthy people not only have greater means with which to purchase necessary supplies and devices, but can also more ably provide additional forms of support. A study done on glycemic control and socioeconomic status concluded that, for financially stressed families, “providing adequate food, housing and clothing may have to come before devoting time to diabetes-related care.” Furthermore, financially secure parents can more easily “look at blood sugar patterns and adjust insulin doses, food intake and exercise level accordingly.” This is of particular importance as the affected individual often continues childhood management patterns when transitioning from adolescence to adulthood.

Other SES linked behaviors, such as the increased rate of alcohol and cigarette consumption amongst individuals of lower SES, have also been cited as reasons for the disparity in glycemic control between diabetics of varying SES.

Ethnicity

In a 2011 study comparing glycemic control amongst Hispanics, African Americans, and Caucasians, Hispanics had the highest baseline A1C levels (average blood sugar levels for past two to three months), Caucasians had the lowest, and African American's fell in between the two ethnic groups. It is important to note, however, that African American's and Hispanics had significantly fewer glucose uploads than Caucasians, making their data less accurate than that pertaining to Caucasian's. In addition, Hispanics had the lowest level of education, income, BMI, and suffered most from depression.

The disparity in glycemic control between varying ethnic groups has been attributed to multiple social factors. Researchers have credited poor glycemic control in Hispanics to a potential distrust of medication and difficulty with numeracy. In addition, compliance differences could be explained by annual household income. Hispanic participants made, on average, $5,000-$10,000, whereas the majority of Caucasians made between $10,000-$30,000 a year. Factors associated with low SES, like less available free time and more pressing baseline issues, may account for differences in glucose uploads.

The established correlation between health and education can help explain disparities in glycemic control between ethnic groups. Due to “multiple different mechanisms that operate at different levels of society,” individuals who have completed more years of schooling tend to be in better health and exhibit healthier behaviors than high-school and college dropouts. In fact, a 2002 study done by Goldman and Smith found that diabetics who are less educated tend to frequently switch treatment, leading to poorer glycemic stability. This study is reinforced by a 2014 report which found that the rate of 18-24 year old Hispanic students dropping out of high school was 14%, compared to 8% of African American's students and 4% of Caucasian students. Thus, ethnicity interacts with external factors, like education (which is inherently related to socioeconomic class), to affect metabolic processes. Blood glucose levels, in essence, do not operate alone. Rather, evidence suggests that they are a biological function heavily influenced by the social world.

Age

Studies have consistently found that glycemic control worsens with age.

Puberty, a period characterized by rapid growth and hormonal change, causes greater insulin insensitivity. During this transitional stage, diabetic's, whose pancreas cannot appropriately adjust to metabolic changes, frequently suffer from high blood sugars. Because insulin requirements increase between 30% and 50% during puberty, pediatric endocrinologists should adjust patient insulin dosage accordingly.

Behavioral and psychological changes inherent in puberty can also affect blood glucose levels. Puberty is a time when young people seek independence from their parents and caregivers. However, due to the nature and severity of diabetes, this transition can be difficult for adolescents and their caregivers. It is not uncommon for young teens to assert their freedom and independence by refusing to monitor blood sugars. Additionally, teens start to establish their sexual identity during puberty, which can pose psychological problems for those that feel detached and betrayed by their bodies. This cognitive volatility can result in liberal self-care. Thus, as stated in the “Diagnosis and Management of Type 1 Diabetes in Children and Young People,” produced by the National Collaborating Centre for Women’s and Children’s Health, “there is a need to assist young people with type 1 diabetes in maintaining a sense of competence and self-esteem and to provide reassurance that they have not lost control of their life or body during this critical period of change.” Psychological support can help diabetic’s combat the worsening of metabolic control during puberty.

Due to the age-related transition from parental to independent insurance coverage, 23%-33% of U.S. youth and young adults are uninsured. As a result, glycemic control declines in diabetic individuals aged 18-39.

Typically older adult type 1 Diabetics have better glycemic control. In a study done by the Centers for Disease Control and Prevention, researchers found that diabetic patients aged 50-64 were more than twice as likely as patients aged 45-49 to have “good” glycemic control. Greater financial and emotional stability, as well as improved access to healthcare have been cited as potential reasons for this difference.

It is important to note, however, that due to the numerous long-term health implications of T1 diabetes, glycemic control declines again from age 65-79.

Understanding the cause of glycemic fluctuations has begun to shape the way diabetes is managed and treated. For instance, juvenile endocrinologist Hala Tfayli used empirically backed evidence to link puberty with poor glycemic control, and has since proposed reasonable medical responses that would help alleviate these age-related health issues.

Mental Health

Research finds that diabetic patients with severe mental illness are at “significantly increased risk of not receiving appropriate elements of care such as eye examinations, plasma lipid testing, and glycated hemoglobin monitoring.” As a result, psychological instability in diabetic patients is shown to cause a markedly reduced life expectancy.

Stress and depression

Due to the labor intensive and persistent nature of the disease, diabetics often suffer from chronic stress. The effects of chronic stress are serious, as it strongly correlates to anxiety and depression.

Stress can affect blood glucose levels in varying ways. Depending on the type of stress, blood sugars either rise or fall. For instance, in a fight or flight situation, when the body responds to a perceived harmful event or attack, breathing, heart rate, blood pressure and blood sugar all rise. On the other hand, a long term-fight against stress (chronic stress) reduces the body’s energy and makes an individual more susceptible to depression, sleeplessness, poor appetite, and volatile blood sugars. This established understanding of chronic stress supports a study published in The Journal of Health and Behavior, which states that people with type 1 Diabetes are more susceptible to physical harm from stress. It is important to note, however, that of these studied individuals, those who felt in control of their life had more stable blood glucose levels and less indication of physical harm from stress than the more emotional, reactive type who suffered from fluctuating, unstable blood sugars.

Individuals with chronic conditions are three times more likely to suffer from depression than the general population. Depression can have negative biological ramifications, especially on diabetics, as it has been shown to make patients less likely to take medication, eat properly, and function well on a physical and mental level. In fact, depression, in conjunction with diabetes, has been said to have “the greatest negative effect on the quality of life compared to diabetes or depression alone.”

Patients with diabetes are at an increased risk for suicide. A British Study found that individuals with type 1 diabetes had 11 times the suicide rate as the general population. Of these, a large number were insulin induced overdoses. Interestingly, numerous studies and researchers have found a strong association between medical noncompliance and suicidal thoughts.

There are numerous empirically backed studies that indicate a relationship between anxiety, depression and glycemic control. As such, the first step to combating these forms of mental illness in diabetic patients is proper diagnosis.

Three quarters of depression cases in diabetics go undiagnosed. Due to poor detection techniques, a lack of patient reporting, and difficulty distinguishing one disease from another, symptoms of depression, such as fatigue, change in appetite, and loss of energy might be misinterpreted as signs of hyperglycemia. Having said that, the need to screen diabetics for depression has been magnified over the past few years, however there is still no unanimous agreement or established rubric on how to best do so.

Once diagnosed with depression, an individual should receive proper treatment. Cognitive-behavioral therapy, support groups, electroconvulsive therapy and anti-depressants are all effective methods of alleviating depression. Moreover, a study found that these approaches can also improve glycemic control, mood, weight, and overall quality of life. Educating patients about the importance of exercise and sleep have also been cited as additional methods to combating mental illness.

Optimal diabetic care, in essence, incorporates much more than daily insulin injections, routine check ups, and dietary monitoring. Psychological support is also important, as factors like stress and depression affect the mental, physical and metabolic health of diabetic individuals.

Eating disorders

Both eating disorders and diabetes involve consciously and systematically controlling food (specifically carbohydrate) intake. As a result, the two diseases often run hand-in-hand, especially in adolescent females.

Females with type 1 diabetes are at twice the risk of developing eating disorders than those without diabetes. Issues relating to the self-management of the disease, such as stringent monitoring of diet, exercise, and frequent blood glucose monitoring have been cited to explain this relationship. In addition, insulin therapy is associated with weight gain (especially after initial diagnosis), which can cause diabetics to be heavier on average than their non-diabetic counterparts, and, in turn, more dissatisfied with their bodies.

Poor self-perception can have biologic consequences, as there is a proven correlation between self-esteem and blood glucose levels. Diabetic patients with low self-esteem are more emotionally unstable, less agreeable and suffer more from diabetes-related health problems than patients with high self-esteem. Furthermore, children in better control of blood sugars have significantly higher-self esteem than their counterparts. As such, type-1 diabetes, low-self esteem and anorexia are all distinct entities, but, at the same time, entangled.

Eating disorders cause adverse health consequences, especially on diabetic individuals. Anorexia nervosa and Bulimia nervosa can lead to severe hypoglycemia (below 70mg/dL), which, left untreated, can result in unconsciousness, seizures, and/or diabetic coma’s. On the other hand, diabulimia, a condition in which diabetic’s deliberately restrict insulin to lose weight, results in hyperglycemia (above 250mg/dL). High-blood sugars lead to an increased risk of microvascular complications, diabetic retinopathy, diabetic ketoacidosis, and potential death. Diabulimia is becoming increasingly common, and is said to affect 30% to 40% of young females. However, because this form of insulin misuse is a relatively new phenomenon, and has yet to be recognized as a mental health disorder in many countries, healthcare professionals are having difficulty recognizing the condition and responding appropriately to it.