Carl G Streed Jr, Assistant Professor of Medicine at Boston University Chobanian and Avedisian School of Medicine and Research Lead at the GenderCare Center at Boston Medical Center began with the context of the increase in prevalence of diabetes across the US, as is being seen across the globe. In terms of how this relates to LGBTQ [lesbian, gay, bisexual, transgender and queer or questioning]+ populations, we are limited by the data available, he said, as not every surveillance system is asking questions about sexual orientation or gender identity.
The data he presented was from Gallup 2023 – it showed that there are about 20 million LGBTQ people in the US. For Europe, Germany has the highest percentage of people identifying at LGBT at 7.4% in 2016 and Hungary the lowest at 1.5%. He also showed more recent data from market research firm, Ipsos, which shows that this is a large and growing population as younger generations become more comfortable with coming out and finding more support and acceptance from their families and communities.
So how does this relate to diabetes, he asked. There are a number of factors that are modifiable that have differences across different populations, particularly those that are marginalised by society. The factor that Professor Streed focused on was stress – there is a growing body of research, he said, to show that this is leading a significant amount of the disparities that we see in marginalised populations.
A lot of the early research on how this plays out has been done on racial and ethnic marginalised populations and so they’ve drawn on similar theories on minority stress. He displayed a graphic from the American Heart Association’s (AHA) statement on LGBTQ cardiovascular health on minority stress theory and its link to cardiometabolic outcomes from Caceres et al (2020). It demonstrates that people from marginalised groups have unique layers of stress that can play out from discrimination, such as being targeted by family, institutions and also by governments (for example, being denied access to certain services), hypervigilance (fear of discrimination) and self-stigma and concealment. Research has shown that these stressors are related to disparities in outcomes arising from factors such as depression and anxiety, tobacco use and diet quality, and physiological factors such as inflammation and changes in the hypothalamic-pituitary-adrenal (HPA) axis.
Persistently elevated levels of cortisol from being stressed has been connected to issues around diabetes but there are also issues around inflammatory pathways as well as autonomic processes that are affecting people’s metabolic health. Professor Streed also showed a graphic demonstrating how stress affects people who have diabetes, with a vicious cycle of affecting behaviour as well as physiology.
The other areas in which they have data are overweight/obesity, sedentary behaviours and low physical activity. Professor Streed drew attention to work from 2018 showing that the risk factors for diabetes are higher among non-heterosexual US high-school students. Issues come up around engaging in physical activity and higher excess weight.
With regard to what this means for adults, he showed data on self-reported diabetes by sexual orientation that he described as ‘a start’ because it’s from the government and data on sexual orientation was not collected uniformly across different states and therefore probably an underestimate. It found that bisexual men have a higher prevalence of diabetes than their heterosexual peers and bisexual women had lower rates compared with heterosexual women.
Professor Streed and colleagues looked at a larger data set from almost 200,000 veterans. Publication is pending but they found that sexual minority status was associated with 1.12 times the odds of prevalent diabetes, adjusted for age, race, Hispanic ethnicity, marital status, BMI, smoking, enrolment priority group and service connectedness.
For further reading on the specifics of the evidence available in the US on addressing cardiometabolic health for LGBTQ adults, Professor Streed directed the audience to the AHA statement on LGBTQ cardiovascular health.
They also took the next step, he said, to be more specific for transgender individuals as they feel there are unique factors for trans people, including how hormone therapy affects risk – the AHA statement on this is also available to read.
Cardiovascular disease
He moved on to discuss forthcoming work on cardiovascular disease (CVD) risk and outcomes among veterans by sexual orientation. When accounting for traditional risk factors for cardiovascular disease, LGB veterans had 1.12 times the odds of prevalent CVD compared with non-sexual-minority veterans. With additional adjustment for other factors such as BMI, diabetes, hypertension, lipids etc, there is still 1.08 times the odds of CVD prevalence. We’re missing something in the measurable clinical data, he said – there’s some unmeasured factor that’s accounting for a higher likelihood of poor outcomes in this population. This might be unmeasured stress or additional factors that get left out such as inflammatory processes.
When it comes to understanding the mechanisms behind the impacts of stress, Professor Streed emphasised that we need to understand more about the physiological changes that occur, whereas much of the research centres on psychosocial and behavioural factors. He and others are working on trying to understand how vascular function changes in the face of stress, how it changes under hormone therapy for trans individuals and how that may play out downstream.
There is more research highlighting the unique factors of minority stress, he said, drawing attention to work from 2021 on cardiovascular and cortisol responses to experimentally induced minority stress. Two groups had to give a talk to a crowd – a placebo group gave the talk but had no interaction with the crowd; the other gave a talk and also didn’t interact with the crowd but were told that the crowd was anti-gay/lesbian/bisexual/trans. After five to 30 minutes rest after the talks, the intervention group’s heart rate remained elevated, heart rate variability dropped and cortisol remained elevated compared with the placebo group – this is essentially testing for hypervigilance, said Professor Streed, and the fear was affecting people’s cardiovascular health.
- A report on cardiometabolic aspects of transgender healthcare from the 59th Annual Meeting of the EASD is upcoming on Horizons on January 10 2024.
Any opinions expressed in this article are the responsibility of the EASD e-Learning Programme Director, Dr Eleanor D Kennedy.