Health Equity in Action: A Local LGBTQ+ Diabetes Prevention Pilot

Health Equity in Action: A Local LGBTQ+ Diabetes Prevention Pilot

Tessa Cushman, RDN

In my almost 2 years of being part of a local diabetes education program dedicated to reaching individuals at highest risk of diabetes and related complications, I have noticed that more often than not, those are the folks missing from the programs. I started questioning why.

To give some background, I am a registered dietitian nutritionist and diabetes coach that facilitates diabetes education classes with Tri-County Health Department (TCHD). Our Diabetes Education Program hosts the Center for Disease Control’s (CDC) National Diabetes Prevention Program – what we call Journey to Wellness – and Diabetes Self-Management Education and Support. Through the Cancer, Cardiovascular, and Chronic Pulmonary Disease grant from the Colorado Department of Public Health and Environment (CDPHE), we provide these services at no cost to participants with a mission to reach under- and uninsured community members.

This is where health equity comes in. Programs could (and should) look at social determinants of health and higher priority needs, but the best place to start analyzing is internally. What makes our program difficult to access? What makes it feel unwelcoming, uninviting, or unsafe to some communities? These questions led me to start the research for our Health Equity Quality Improvement project, which helped us further identify our priority populations, or those who could benefit greatest from our no-cost services. The most current studies and statistics reaffirmed notions I was already familiar with.

Diabetes Risk in the LGBTQ+ Population

LGBTQ+ folks such as myself make up one of the many marginalized demographic groups that face higher risk of unmet social determinants of health, poor health outcomes, and chronic diseases like type 2 diabetes. Sexual orientation and gender identity alone do not affect our risk of these conditions. Rather, discriminatory systems and oppressive policies that have been around since colonization – whether overt or covert – are what puts “sexual or gender minorities” in harm’s way.

LGBTQ+ health remains underreported in research and wasn’t included in the US Department of Health and Human Services 10- year national public health objectives until Healthy People 2010 (1,2). Despite this, the latest research confirms a clear trend of worse health outcomes and social determinants of health for LGBTQ+ folks. According to a 2021 study, transfeminine individuals are at a 40% greater risk of developing diabetes than their cisgender counterparts, unassociated with genderaffirming hormone therapy use (3). Bisexual and lesbian women have a higher prevalence of diabetes compared with heterosexual women (4). Gay and bisexual men and transgender women are disproportionately living with HIV, and more lesbians than heterosexual women are living with Polycystic Ovarian Syndrome (PCOS), both of which conditions are risk factors for developing type 2 diabetes (1,4). Lastly, research indicates up to 20% of people with diabetes engage in patterns of disordered eating (5), and a 2020 online survey showed that 28% of the LGBTQ+ respondents reported at least one behavior associated with eating disorders – while only 4.3% reported having sought treatment (6) – putting queer folks with diabetes at even higher risk of disordered eating and eating disorders.

These health inequities are clearly traced to discrimination and oppression. In the Envision:You Colorado LGBTQ+ Behavioral Health State of the State Survey Report, 37% of the 588 LGBTQ+ survey respondents reported experiencing discriminating or non-affirming language, practices, or interactions in medical or primary healthcare, with trans folks significantly more likely to report this (7). A report by the Center for American Progress found that almost half of all transgender people and 68% of transgender people of color have experienced mistreatment by their healthcare providers (8). Difficulty obtaining medical care and health insurance may be influenced by family estrangement, legal discrimination in housing, employment, marriage, or retirement benefits (9,10). According to a 2016 report, queer folks experienced food insecurity at almost double the rate of straight, cisgender folks in 2015 (11). LGBTQ+ people experience mental illnesses such as depression at a rate up to four times higher than cis, straight counterparts, and are at higher risk of experiencing adverse childhood events, both of which are associated with an increased risk of developing diabetes (12,13).

The compounding prejudices stemming from white supremacy increase the allostatic load, or cumulative burden from chronic stress, experienced by further oppressed populations. Queer Black, Indigenous, Latinx, and other people of color face the aggregate traumas of systemic racism and face a substantially higher risk of type 2 diabetes than queer white folks. Immigrants and refugees experience additional barriers to receiving healthcare diagnoses. Disabled queer folks must navigate the tribulations of ableism. Queer folks in larger bodies face weight discrimination – most namely in the healthcare setting – which increases risk of disease and death by up to 60% regardless of body mass index (BMI), according to a 2017 study on 10-year allostatic load of perceived weight discrimination (14). More research to fully understand the impacts of all kinds of discrimination on health should be prioritized in science and public health.

In addition to experiencing increased risk of type 2 diabetes, LGBTQ+ people may feel that programs aimed at preventing diabetes are not safe, inclusive, or accessible. Such programs may have high fees or require health insurance coverage, and often follow strict standards that may include white-centered, weight-centric, and heteronormative curriculum. As stated in the March 2022 issue of ADCES in Practice, the publication of the Association of Diabetes Care & Education Specialists (ADCES), “non-LGBTQ specific groups may be perceived as potentially homophobic and/or transphobic, and therefore intrinsically non-safe spaces,” (8). To counter this, and as recommended by a Center for Medicare & Medicaid Services (CMS) resource inventory, adapting evidence-based interventions for the intended audience is a “promising way of meeting the needs of diverse populations,” (15). That is exactly what our program at TCHD set out to accomplish.

The First LGBTQ+ Diabetes Prevention Program Pilot

OFM Journey to Wellness is a novel pilot intervention for LGBTQ+ diabetes prevention and health promotion. We have partnered with OUT FRONT Magazine (OFM), a local Colorado queer publication, to host the first (to our knowledge) LGBTQ+ focused diabetes prevention program. The program goals include expanding the equity and inclusiveness of all of our diabetes education programs, gathering program feedback from LGBTQ+ community members, and submitting our findings and curriculum to the CDC for consideration of national implementation through the National Diabetes Prevention Program.

As a Bloomberg Fellow with the Johns Hopkins Bloomberg School of Public Health, I plan to use knowledge gained from the graduate program, insight from collaborating agencies and other fellows, and university research arms to help achieve the goals of this program. Program evaluation will be strengthened, and curriculum will be refined and standardized before submission to the CDC. With the hopes of continuing this pilot intervention into the future, the program could be a candidate for future research conducted through the university.

The program’s novel diabetes prevention approach is in alignment with research and recommendations for LGBTQ+ health promotion. The aforementioned CMS Resource Inventory, Diabetes Prevention Programs: Equity Tailored Resources, recommends emphasizing overall health improvement rather than weight loss when tailoring services for the LGBTQ+ community. Such strategies include promoting increased physical activity, decreased consumption of sugar-sweetened beverages, and increased fruit and vegetable intake, rather than focusing on BMI and weight loss (15). A 2022 analysis of 55 women engaging in Health At Every Size®-based interventions found that, alongside the participants who lost weight, those who maintained weight or even gained weight also improved waist circumference, clustered metabolic and cardiovascular risk, and quality of life, “suggesting that weight-neutral, lifestyle modification interventions may improve healthand wellness-related markers even in the absence of weight loss,” (16). This approach is especially critical in a population with higher risks of disordered eating, eating disorders, and healthcare discrimination.

OFM Journey to Wellness supports achieving individual health goals with this approach. We prioritize queer peer support, body-neutrality and acceptance, inclusive and joyful movement, anti- diet culture, and attention to mental health and trauma-informed care, all in an affirming environment. The program runs for a year, with one class per month held in-person and the other half held online. As our first hybrid program structure, we aim to break down barriers of both in-person (e.g. reliable transportation, additional time, childcare, immunocompromising conditions), and online formats (e.g. technology and stable internet access, visual or auditory impairment). Any participant with barriers to either format is offered flexibility and resources.

The adapted LGBTQ+ inclusive curriculum invites and honors open dialogue to promote “messy peer learning,” a term I have borrowed from a good friend and coworker. As the facilitator, I acknowledge the privileges that come with my identities of being white, cisgender, able-bodied, thin, and holding a degree in higher education; while simultaneously bringing my perspective as a bisexual woman with a family history of diabetes, nutrition insecurity, and low socioeconomic status. Each session encourages the sharing of topic ideas, resources, input, and realtime feedback or constructive criticism to uplift and value the unique perspectives that each participant brings.

Considering the privileges I hold, it is imperative for me to call out that white, thin women are the main demographic profiting and receiving credit as the leaders of the body-neutral, antidiet,

Health At Every Size® movement. As Marquisele Mercedes – a writer, doctoral student, and Presidential Fellow at the Brown University School of Public Health – writes, the movement arose as a response from Black, Indigenous, disabled, and LGBTQ+ folks to the injustices against marginalized bodies (17). The Association for Size Diversity and Health states that the community movement was heavily influenced by the 1960s Fat Underground organization (18). Body image and fat acceptance advocate Stephanie Yeboah once said, “[Body positivity] stems from the fat acceptance movement, which is more political than anything, [and] was created as a safe space for fat women to celebrate themselves as no one was celebrating us or seeing us — and all our interior amazingness — for what we were. Now it’s used as a marketing term and has forgotten about the very bodies that created it…,” (17). The voices of leaders like Marquisele and Stephanie should be uplifted and followed by any program or agency that is adopting these approaches.

The Bottom Line

OFM Journey to Wellness launched in January 2022 with a cohort full of inspiring, supportive, and kind-hearted folks. Participants are both aware of and eager to support the program’s mission by providing feedback on curriculum and approach. The rapport that has already been built is unmatched to any other group that I have facilitated, and I chalk that up to the environment we’ve created together. Below is a powerful quote from a participant that speaks to their experience thus far.

"This program has been nothing short of lifechanging for me. Over the years, I have tried several different programs to help improve my health and nutrition, from apps to point systems to inperson groups. Unfortunately, most of these programs were rooted in toxic diet culture – and I never felt like I learned anything sustainable. This group busts through that toxicity, and creates a place to engage in collective wellness in a productive and inclusive way. Beyond that, the social support is something I have never experienced before as a trans, disabled and queer person of color. With community to support rather than judge, I have been hitting my goals, and finding myself motivated to reach for the next ones. I hope that this program is able to run again, so that more people will have the opportunity to try it. I know for me personally, I am healing because I am incredibly supported – and I've made some new friends too!"

Health equity has been an integral part of public health conversations for years, and has been substantially pushed to the forefront since the racial reckoning of 2020. It is the responsibility of agencies delivering health services to reduce harm and promote health of communities impacted most by oppressive systems. Any pilot that is the first of its kind has the potential to make the necessary waves of change and serve as a paradigm for other equitable programs to come to fruition. Let’s put the health equity conversation into action, and allow vulnerability to birth new opportunities for meaningful change.

To connect more on this topic, please feel free to reach out to me at tcushman@tchd.org.