Addressing racial inequalities in paediatric diabetes

Summary

Dita Aswani and Fulya Mehta are both consultant paediatricians and NHS England national advisors for Children and Young adults’ (CYA) diabetes. In this blog, they outline racial inequalities that persist in paediatric diabetes and present five key areas for change. In summary they talk about what healthcare professionals can do to reduce inequalities through their own practice. 

This blog is part of our World Patient Safety Day 2025 (WPSD 25) series - Safe care for every newborn and every child.

Content

Racial inequalities – stark and persistent

A key objective of the Children and Young adults’ diabetes programme at NHS England is to reduce unwarranted variation in diabetes care and outcomes. Children of all ages, regardless of where they live, the colour of their skin, or the economic circumstances of their family, should receive equitable care in order to thrive, and live well with their diabetes.

Racial inequalities in paediatric diabetes are stark and persistent, with multiple data highlighting disparities in outcomes, access to technology, and care experiences.

Disparities in glucose levels

HbA1c is a blood test that reflects your blood glucose levels over the past two to three months. It is used to diagnose and manage diabetes. Higher readings indicate worse blood sugar control.

Children and young people of Black ethnicity with type 1 diabetes consistently have higher average HbA1c levels than their White peers, even when using the same diabetes technologies and with similar mean glucose levels. Data also shows that Black children in the least deprived areas have similar HbA1c levels to White children in the most deprived areas. These gaps have persisted for years despite overall National improvements.

These disparities increase the likelihood of long-term complications—including retinopathy, kidney disease, and cardiovascular issues—especially when combined with systemic delays in intervention.

Children and young people with type 2 diabetes are more likely to come from ethnic minority backgrounds or live in more deprived areas (six times as likely if living in most deprived quintile versus least deprived).[1]

Preventable medical emergencies

Hybrid Closed Loop systems (sometimes known as an artificial pancreas) help to keep blood glucose levels in target range by automatically adjusting insulin levels using real time sensor readings. Better blood glucose levels lead to improved HbA1c outcomes. Access to this technology is lower among Black and Asian children, independent of socioeconomic status. If children don’t have equal access to diabetes technology like Hybrid Closed Loop systems, episodes of hypoglycaemia or ketoacidosis may go unnoticed until they become emergencies. [2]

Diabetic ketoacidosis (DKA), where a lack of insulin causes harmful substances to build up in the blood, can be life threatening and needs urgent treatment. DKA at diagnosis is a preventable medical emergency—it’s a symptom of delayed recognition, reduced access, and missed opportunities for earlier intervention.

DKA at diagnosis follows the lines of social and racial inequality with the following comparative rates; White 39.6%, Asian 42.7% and Black 48.6%. [2]

Barriers to equitable, safe care

There are genetic and biological factors which predispose individuals or groups to certain health conditions, and these cannot be altered. However, these risks are compounded by discrimination within healthcare systems.

When services are not equitably accessible, culturally responsive, or designed to meet diverse needs, existing vulnerabilities are intensified. What begins as a biological risk can escalate into a systemic injustice—where people aren’t just more likely to get sick, but less likely to be cared for appropriately when they do. If services aren’t inclusive or fail to adapt to local needs, early signs of problems—like psychosocial distress or erratic blood glucose—may be overlooked.

• Structural factors like bias, cultural mismatch, and systemic barriers, contribute to disengagement from services and reduced trust in healthcare professionals.
• Reduced trust undermines shared decision-making. When families experience bias or feel culturally misunderstood, they may disengage from services, making it harder for clinicians to tailor treatment or catch safety concerns early.
• Inconsistent communication. Language barriers, unconscious bias, or lack of culturally safe care can lead to miscommunication about insulin dosing, sick day rules, or when to seek help—all of which raise safety risks.

Five key areas for change

1. Equity-focused commissioning

This means allocating resources not based on equal distribution, but in proportion to need. For example, targeting investment in areas of deprivation or in communities with poorer health outcomes can close the gap over time. Metrics should measure fairness as well as overall performance.

2. Data transparency and granularity

Gathering and disaggregating data by ethnicity, socioeconomic status, geography, and age uncovers patterns that aggregate figures hide. There are still big gaps in ethnicity data. But the real impact comes when this data is complete and drives local action—such as redesigning pathways that currently disadvantage certain groups.

3. Co-production and community leadership

Communities affected by inequality must be central in designing solutions. That doesn’t just mean “feedback,” but real influence over priorities, language, and delivery—especially in populations historically underserved or blamed.

4. Workforce representation and cultural safety

A healthcare system that reflects the diversity of the population and fosters safe, inclusive environments is more likely to build trust and reduce disparities. That includes tackling racism, both interpersonal and systemic.

5. Narrative change

We need to replace deficit-based narratives (“non-compliant families,” “hard-to-reach groups”, “poor attender”, “frequent flyer”, “lack of motivation”) with systemic ones with full understanding of what they mean (“health inequities”, “institutional racism”, “under-resourced systems,” “barriers to access”, “structural vulnerability”, “cumulative disadvantage”) and shift responsibility to where it belongs.

What can healthcare professionals do?

On a personal level we should develop genuine and compassionate curiosity of lives by trying to imagine being in someone else’s shoes to understand what they experience and how that feels. This means questioning your own bias, building relational safety by asking questions to listen, and having a trauma-based approach in order to consider structural barriers, not just clinical ones. Document the context of a person, and not just their behaviour.

Wider than that:

• collect and use data with purpose
• use the data as a mirror, not a defence, and let the data speak even when it is uncomfortable
• understand the structural determinants of your organisation
• understand how other systems intersect with health (eg education, immigration, housing)
• name and acknowledge racism for what it is, not just ‘inequality’ or ‘diversity’.

Engage in Poverty Proofing training with your teams and managers, seeking to identify, challenge, and remove the structural barriers that perpetuate disadvantage, ensuring that no child, young person, or family is excluded, stigmatized, or underserved due to financial hardship.

Use tools such as YoungType2 (by DigiBete), a dedicated platform and app for young people up to age 25 living with type 2 diabetes or at risk of it, co-produced with families and communities. It includes culturally sensitive content which is accessible and easy to understand, and translated in other languages, on food, activity, sleep, relationships, emotional wellbeing, school and work and school life—especially relevant for communities disproportionately affected by early-onset type 2 diabetes. 

Diabetes Africa is doing some standout work, especially when it comes to equity in diabetes technology access for Black, African, and African-Caribbean populations in the UK. Their Technology Equity Toolkit is particularly relevant for paediatric and young adult care, and highlights awareness to promote culturally responsive solutions.

References

[1] National Paediatric Diabetes Audit (NPDA) spotlight audit, 2025.

[2] National Paediatric Diabetes Audit Admissions report (NPDA) 2015-2020, July 2023.

About the Author

Dita Aswani is a consultant paediatrician at Sheffield Children’s Hospital, and NHSE National GIRFT clinical advisor for Children and Young adults’ (CYA) diabetes. Fulya Mehta is a consultant paediatrician at Alder Hey Children’s Hospital and NHSE National Speciality Advisor for CYA diabetes.