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How Homelessness Complicates Treating Diabetes

“People say I should eat better because of my diabetes. Diabetes doesn't care if you're hungry. When you're homeless you eat what you can.” V. Batcher

Each year in Canada, an estimated 235,000 individuals are homeless. In the States, that number is 2.3 to 3.5 million.

In Canada, as in the States, homelessness has a complicated association with poor health. People at risk of losing their home tend to have heavier disease burdens. In New York City, for instance, 6.3 percent of a subset of newly homeless people had diabetes mellitus, compared to 1.9 percent of the same age group in the general population.

Homeless adults are

3 times more likely to have diabetes

than the general population.

Homelessness poses unique challenges to receiving and adhering to treatment for diabetes.

Barriers to health care are problematic. For many homeless people in the US, a lack health insurance has them seeking care from emergency rooms. In Canada, emergency rooms are often the main source of health care for people who are homeless. Single men who are homeless make an average of two visits a year to emergency rooms, nine times more than men in the general population. Such encounters are poorly suited to long-term control of diabetes.

The disease-management woes do not end for this population after access to health care has been secured.

A Canadian study showed glycemic control was inadequate in 44 percent of homeless diabetics, and 72 percent of the participants in the study reported difficulty managing their diabetes. For one, the daily measures required of diabetics can be expensive. For example, self-monitoring of blood glucose (SMBG) is recommended for patients who have frequent hypoglycemic episodes or require multiple daily insulin injections. Unfortunately, testing strips cost $0.98 apiece on average; if a patient on insulin carries out SMBG thrice daily, this amounts to $91.14 per month.

In addition to the challenges of poverty, the lifestyle imposed by homelessness is fraught with barriers to good diabetes management.

Medical nutrition therapy – with its focus on weight loss, carbohydrate counting, and avoidance of saturated fat – may be impractical. Despite poverty, the prevalence of obesity is over 30% among homeless adults, and the mean body-mass index is in the overweight range. Possible contributing factors include an adaptive metabolic response to periods of food shortage, sleep debt, and stress.

Foot care is made difficult by excessive standing or walking and by footwear that may be of poor condition or fit. Additionally, many patients sleep in chairs when what they really need is to elevate their legs whenever possible to prevent fluid stasis. If a homeless diabetic patient develops ulcers, but does not require hospital admission, it may be difficult for the patient to convalesce, as most shelters are not open during the day.

Isolation and depression can lead to poor adherence, which is more common among the homeless and patients may have few or no available social supports to help in a hypoglycemic emergency.

Haven Toronto reduces barriers to health care for elder men who are homeless.

In the first 10 months of 2019, the drop-in centre's new, full-time nurse was visited 1,400 times by clients. With the nurse onsite and Haven Toronto open every day, all year, clients can access the supports they need to maintain and improve their health and wellbeing, including managing illnesses like diabetes which are made more complicated by homelessness.

By Sara Gallant




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