Welcome back to our weekly diabetes advice column, Ask D'Mine, hosted by veteran type 1 and diabetes author Wil Dubois in New Mexico. Here, you can ask all the burning questions you may not want to ask your doctor.

Today, a reader asks a tough question, about how society deals with our least fortunate diabetes brethren.

{Got your own questions? Email us at AskDMine@diabetesmine.com}

 

Joey, type 1 from Arizona, writes:It seems like there are homeless people on every street corner nowadays, and it got me wondering about homeless people with diabetes. What percentage of the homeless have the big D? How on earth do they manage? Diabetes is hard enough with infrastructure, is there anything I can do to help out?

 

Wil@Ask D’Mine answers: Thank you for asking, and it’s a pretty frickin’ depressing situation. In recent years, around half a million American citizens are homeless on any given night. Some are sleeping in shelters. Some in cars. But fully a third are living in “a place not meant for human habitation,” according to a report by the National Alliance to End Homelessness.

And contrary to what people who like to look the other way think, the homeless aren’t just a bunch of whacked-out Vietnam vets (no offense intended to traumatized Vietnam vets). Many are young people, about 40% are families, and a fully a quarter of the homeless population are children.

Why are so many people homeless? The National Coalition for the Homeless points to many factors, including rising foreclosures, increasing rental rates, and stagnant low-income wages. The good news, such as it is, is that homelessness has been declining over the last few years, albeit by small numbers given the human tragedy we’re dealing with here. Still, at least the situation isn’t getting worse.

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Image: Shawn Honnick Flickr

How many of those in the huddled homeless masses have diabetes? As you can imagine, any stats on a nomadic group like the homeless are hard to nail down, and there’s no scientific consensus on the rate of diabetes among the homeless. While one study that looked at the health status of the newly homeless found a rate of diabetes more than three times the national average, other studies show similar rates to the general population.

But what everyone does agree on is that, not unexpectedly, the glycemic control of homeless PWDs (people with diabetes), whatever their true percentage, is awful, and homeless PWDs find themselves in diabetes emergencies more often than PWDs with more secure housing. That’s because homeless PWDs face two nearly insurmountable challenges when it comes to diabetes control: Eating right and taking their medicine. 

Medication Challenges

Let’s say you become homeless. Hey, it can happen to anyone. Somehow, you manage to wrangle transportation, and you’re able not only to get a doctor’s appointment, but you’re able to scrape up the money for the copay. But now your problems have just begun. If you’re a type 1, you need insulin, which is expensive! But let's you get assistance and obtain the insulin -- if you’re homeless you have no butter compartment to store it in, because you have no refrigerator.

And storage of insulin is just the beginning, because you also have a precious resource that other people want, and have no compunctions about taking from you. Grab some Kleenex and read the story of one of our homeless T1 sisters who was a chronic ER visitor with DKAs because her syringes were routinely stolen from her while she slept by IV drug users at the shelter where she was staying. And it’s not just an American problem. Here’s a story about a homeless T1 in England, where they have national healthcare, who died of DKA in the tent he was living in a city park called Hamadryad, which, ironically, is named after a famous hospital ship. 

Food Challenges

If you have no home, you most likely have food security challenges, as well. Where do the homeless eat? Apparently, in “soup kitchens,” fast food restaurants where a dollar goes farther, and to some extent out of boxes given out by food banks.

Food banks often have the most nutritious offerings, but the food bank model is plagued with troubles when it comes to serving the homeless. Where are you going to store a box of fresh veggies? How are you going to prepare a meal with no stove?

The problem for the homeless PWD is that both soup kitchens and fast food joints tend to be high carb, which beats the hell out of the no-carb, no food option, but presents challenges to blood sugar control. Yet even the homeless know that beggars can’t be choosers. Most are simply grateful for the food and will take what is offered, diabetes be damned.

Frankly, homelessness changes priorities. With no roof over your head, and no certain knowledge of where your next meal is coming from, diabetes control takes a back seat. The potential problems of tomorrow are trumped by the realities of today.

Homelessness Sucks 

Oh, and in addition to med and food access, all of you remember what stress can do to your diabetes control, right? I’m having a hard time imagining anything more stressful than being homeless with all its challenges and uncertainties.

Doctors' Help

So what about the white coats? What can they do to try to care for homeless PWDs? Back in 2007, the HCH Clinicians’ Network, a professional organization for docs who serve homeless populations, actually adapted the American Diabetes Association (ADA) standards of care at the time for the challenges of the homeless. What did that look like? Well, here’s a sample:

  • Adjust meds for one meal a day, common for the homeless.
  • Ask patients to save half of their one meal for later in the day to reduce glycemic impact. 
  • In addition to a foot inspection, assess the condition of the patient’s shoes and socks as poor socks greatly increase the risk of foot ulcers.
  • Subscribe pens to reduce needle theft.
  • Advise patients to avoid carrying insulin in pants or shirt pockets, instead using outer clothing or tote bags to reduce the risk of heat damage.

The Clinicians' Network also called for less-stringent glucose goals long before the ADA acknowledged that one-size-fits-all glucose targets are an idiotic idea. And, recognizing the transient nature of homelessness, they recommended issuing diabetes status cards, similar to immunization records used for kids, so that homeless PWDs had a portable “health record” (remember this was pre-electronic medical records) to take with them to the next doc. 

How Can We Help? 

If there’s any sort of national program or organization addressing the issue of homelessness and diabetes, I was unable to locate it. That said, there’s a lot of grassroots action happening on the local level with shelters, food banks, community and faith-based organizations, homeless advocacy groups, and community health centers. Investigate what’s happening on the ground in your own backyard, because homelessness—like diabetes—is nationwide, urban and rural. It exists in your community, so find out who’s trying to help. Then donate.

Donate from your wallet, from your pantry, or from your free time.

 

This is not a medical advice column. We are PWDs freely and openly sharing the wisdom of our collected experiences — our been-there-done-that knowledge from the trenches. But we are not MDs, RNs, NPs, PAs, CDEs, or partridges in pear trees. Bottom line: we are only a small part of your total prescription. You still need the professional advice, treatment, and care of a licensed medical professional.