The Impact of Social Determinants of Health on Patients With Diabetes

It is crucial for pharmacy teams to identify and address social determinants of health (SDOH) in the care of patients with diabetes to improve their outcomes, according to a session presented at the American Pharmacists Association 2022 Annual Meeting and Exposition.

Erin E. Pauling, PharmD, BCACP, assistant dean for Academic Affairs and clinical assistant professor of Ambulatory Care at Binghamton University School of Pharmacy and Pharmaceutical Sciences, discussed the multiple different frameworks that exist in SDOH, which she defined as “conditions in the environments where people are born, live, work, play, worship, and age.”

Factors such as economic stability and education access can be categorized into SDOH, making this an expansive topic area in pharmacy.

“There is not a single consensus of the factors that comprise of (SDOH),” Pauling said.

Health literacy/numeracy and food insecurity were the 2 main factors addressed during the presentation, with the former being discussed with many different screening tools that can be used in the pharmacy. Examples of these tools are the EveryONE project, PRAPARE, and AHC-HRSN, which examine different factors related to money/resources, housing, and transportation for patients.

“Not one single tool is preferred over the other. It’s what fits you in your pharmacy practice and your patient population,” Pauling said.

Low literacy behaviors from patients may include missed appointments, incomplete forms, the inability to name medications, not asking questions, and a lack of follow-up. That is why there are general screening tools, such as the Newest Vital Sign (NVS) and Rapid Estimate of Adult Literacy in Medicine (REALM), which target reading level and comprehension of medical terms.

Some tips that Pauling uses is to avoid medical jargon and provide examples when communicating with patients so that there is a better connection and clarity in how to manage a treatment plan.

“Often we think about what we are verbally saying to a patient, and perhaps engaging in our body language and adjusting our language right there in that moment, but then we can provide a pamphlet for them to refer to later that has those original terms that were difficult to understand,” Pauling said.

Although there is not much information surrounding this area of diabetes, it is still important to learn about because pharmacists do not truly know the impact these issues may have on patients, according to Pauling.

Food insecurity is another major factor that is closely associated with diabetes management, according to presenter Megan Coleman, PharmD, BCPS, CPP, associate professor of Pharmacy at Wingate University School of Pharmacy.

There are many signs that a patient may be experiencing food insecurity, such as skipping meals, losing weight, feeling anxious that food budgets are not sufficient, and altering or reducing food intake to accommodate reduced food budget.

“Based on what we know, food insecurity is a risk factor for diabetes management, and there’s a lot of reason for that,” Coleman said.

Something that can become more dangerous for patients with diabetes is the onset of hyperglycemia, which can occur when patients practice suboptimal self-management behaviors due to anxiety, binging when food is available to overcompensate for future food shortages, and reduction of medication doses/frequency to afford food.

“Patients will pretty commonly forgo certain medications to put food on the table, and that’s absolutely understandable,” Coleman said. “What we see with these patients specifically is that they delay filling prescriptions…these patients may reuse needles that they are using in injectable diabetes medication, and they are also less likely to monitor their blood sugar as frequently as we would like them to.”

Coleman added that hyperglycemic episodes may be more sporadic because they tend to happen at the end of the month or during the time period in which their food budget is exhausted.

Screening tools, such as the USDA Food Insecurity Surveys and Hunger Vital Sign, are available in multiple formats and languages to cater to each patient population to combat food insecurity.

As for resources, Coleman mentioned food banks/pantries, soup kitchens, and free meal delivery programs to further assist patients who may be struggling with food insecurity.

Additionally, collaborating with community partners and resources is a great way to help increase access to healthy food for patients, such as incorporating “food prescriptions” into practice and creating more food pharmacies.

Some tricks that Coleman recommends for helping patients is nutrition counseling, decreasing portion sizes, and adjusting medications due to unreliable access to food.

“We know that patients may not always know when food will be available and when it is not,” Coleman said. “But during sicker fasting days, we definitely need to consider if medication adjustments need to be made to decrease the risk of hyperglycemia.”

Coleman emphasized the need for addressing SDOH as a team and integrating the practice into standard workflow. The better the education is with the whole staff, the more they can work to promote services and resources that are available in the pharmacy, such as having printed screening tools ready for patients while they wait to be counseled.

“If we identify that there is a need, we really have a responsibility to respond to that and either do a referral or do something just to provide the resources that are available,” Coleman said.