“Did you eat too much sugar as a kid?”, “Should you really be eating that with diabetes?”, “Are you injecting drugs in public?” – These and similar questions often sound familiar to many people with diabetes, too often do they need to explain themselves and their condition to other people. In public media, diabetes is often depicted in a stigmatised way, fostering misconceptions and judgment in people who do not know much about life with diabetes. But also, people who should know – healthcare professionals and people in the diabetes community – are not exempt from exhibiting misconceptions and fostering stigma.  

Most people with diabetes have experienced stigma

In psychology, stigma is defined as “the negative social attitude attached to a characteristic of an individual that may be regarded as a mental, physical, or social deficiency. A stigma implies social disapproval and can lead unfairly to discrimination against and exclusion of the individual.” [1] Thus, diabetes stigma in particular discriminates people based on their condition and can lead to blame, rejection, or exclusion due to the perceived stigmatisation. 

Most people living with diabetes have experienced social stigma [2]. It can present itself in many ways and in different parts of their lives, whether it is in their private lives, in the medical field, at the workplace or in politics – and whether it is from outside or inside the community. It can be all-encompassing, from seemingly meaningless interactions with strangers in the street, to influencing political decisions and fostering systemic discrimination of those living with diabetes. 

Efforts on ending diabetes stigma in the community

In the past years, there have been many efforts in the diabetes community to develop guides on how to minimise diabetes stigma, especially by reflecting on the language we use. The in-depth guides, reflecting the international #languagematters movement are available online. Most importantly, the use of active first-person language is recommended (“people living with diabetes” instead of “diabetics”) and judgmental language (e.g. “failing to have control”, “non-compliant”,…) should be avoided as to not reinforce negative stereotypes. 

Life with diabetes is a 24/7 challenge and everyone is trying their best, so blame or judgment are not going to help anyone on their journey with diabetes – on the contrary, diabetes stigma is strongly related to psychological distress in people living with diabetes [3]. It has been shown to have negative effects on people’s mental and physical health, fostering diabetes distress and having negative impact on diabetes-related health outcomes such as Time in Range and HbA1c [4, 5]. It is crucial that diabetes stigma and the fight against it caption the attention of all of us – in medical treatment, product development, policy action and all interactions with all people living with diabetes. 

What can we do to end diabetes stigma?

Recently, the “international consensus recommendations to bring an end to diabetes stigma and discrimination” were developed by a group of 51 experts around the world and a campaign for the pledge to end diabetes stigma was launched [6]. 

The pledge identifies different actions needed to end diabetes stigma and discrimination:

• “respecting people with all types of diabetes, 
• recognising diabetes stigma exists and has harmful impacts, 
• acknowledging and challenging my/our own prejudices about (people with) diabetes, 
• using accurate, respectful, inclusive, non-judgmental, and strengths-based language, messaging, and imagery when communicating with or about people with diabetes, 
• avoiding and challenging fear-based messaging and imagery, 
• condemning discrimination due to diabetes and advocating for equal treatment and support for people with diabetes, 
• encouraging initiatives, policies, and laws that promote equity for all people with diabetes.” [6]
   

Listening to those living with diabetes is crucial

To truly #EndDiabetesStigma, it is crucial that we listen to those living with diabetes and experiencing it firsthand. That is why we believe in user- and patient-centric research and product development. Together, we can pro-actively work on the language and imagery we use to reflect diabetes. 

At DCB, we have happily endorsed the pledge and we invite you to do the same. Let’s end diabetes stigma together! You can endorse the pledge now as an individual or an organisation: https://enddiabetesstigma.org/  

Thanks so much for reading and we’ll provide you with the next episode of this series soon!

Read more about the #languagematters movement and explore the international guides: https://www.languagemattersdiabetes.com/the-documents  

[1] American Psychological Association. APA Dictionary of Psychology. American Psychological Association. https://dictionary.apa.org/stigma 

[2] The Lancet Diabetes; Endocrinology. (2018). Diabetes stigma and discrimination: Finding the right words. The Lancet Diabetes; Endocrinology, 6(9), 673. https://doi.org/10.1016/s2213-8587(18)30235-3  

[3] Guo, X., Wu, S., Tang, H., Li, Y., Dong, W., Lu, G., Liang, S., & Chen, C. (2023). The relationship between stigma and psychological distress among people with diabetes: A meta-analysis. BMC Psychology, 11(1). https://doi.org/10.1186/s40359-023-01292-2  

[4] Hansen, U. M., Olesen, K., & Willaing, I. (2020). Diabetes stigma and its association with diabetes outcomes: A cross-sectional study of adults with type 1 diabetes. Scandinavian Journal of Public Health, 48(8), 855–861. https://doi.org/10.1177/1403494819862941  

 [5] Liu, N. F., Brown, A. S., Folias, A. E., Younge, M. F., Guzman, S. J., Close, K. L., & Wood, R. (2017). Stigma in people with type 1 or type 2 diabetes. Clinical Diabetes, 35(1), 27–34. https://doi.org/10.2337/cd16-0020 

[6] End diabetes stigma and discrimination. https://enddiabetesstigma.org/ 

Since the beginning of 2023, José García-Tirado has been a professor specialising in diabetes technology at the University Department of Diabetology, Endocrinology, Nutritional Medicine and Metabolism (UDEM) and at the DCB (Diabetes Center Berne). Together with his team, he is involved in the development of even more precise therapies such as closed-loop systems for people with diabetes and other metabolic diseases.

José, what is your research about?

In our research, we are investigating the effects of type 1 diabetes and how we can develop technological solutions to better manage glucose in the body. We use computer models to understand different aspects of metabolism. Part of our work involves developing automated systems that deliver insulin like a fully functioning pancreas. We test these ideas on the computer and in clinical trials to ultimately make them useful for people with diabetes.

What motivates you to work in the field of diabetes technology? How did you get involved in this topic?

I am an engineer, was diagnosed with type 1 diabetes myself 10 years ago and had to overcome some hurdles, like most people with this disease. Coincidentally, I was attending a conference on the subject a few months later when I had an “aha” moment. I realized that I needed to get involved with the topic and contribute to the advancement of the field.

This has inspired me to research better technologies for diabetes management. I find it exciting to turn complex ideas into practical solutions and help other people with diabetes.

What is your biggest challenge as a professor?

Being a professor nowadays takes most of your energy and thoughts every day. Balancing my passion and work with family/hobbies time proves to be very challenging. From the work perspective, being the leader of a research group demands constant planning, supervision of human resources, and progress evaluation. Making plans to work in this field also entails close collaboration with experienced medical doctors and knowing very well the regulatory pathways to working with human beings in an ethical and caring way.

Professor Dr. José García-Tirado. Assistant professor with tenure track in diabetes technology.

What goals do you want to achieve with your team and your lab, the PrecisionLab?

Our goal is to develop technologies that can better support people with type 1 diabetes. We not only want to manage blood sugar, but also reduce other health risks. To this end, we are investigating new therapies and developing intelligent algorithms for insulin pumps.

What projects are you currently researching and how can they make life easier for people with diabetes?

The first project deals with the construction of an algorithm deployment platform in collaboration with Universitat Politècnica de Valencia. Such a platform will allow us to test every AID (“automated insulin delivery”) design in a clinical setting.

The second project is the design and testing of the actual smart algorithm to modulate insulin from an insulin pump for people with type 1 diabetes. Such an algorithm will be deployed and tested in our algorithm deployment platform. To do so, we need to go through a rigorous regulatory process with Swiss Medic. After approval, we will test our algorithm on five (5) participants with T1D with real-life challenges.

The third project relates to the understanding and mathematical modeling of macronutrient (carbohydrates, fats, and proteins) absorption in the bloodstream and how different compositions of meals affect glucose absorption.

Where do you hope your research field will be in 5-10 years? What is your vision ?

In the next few years, diabetes management technologies will evolve, with better sensors and insulin preparations. There is even the possibility of developing implantable systems that are even more similar to a pancreas. Similarly, we need to develop more accessible technologies for people with type 1 diabetes, as current options are often expensive and unavailable in many countries.

All these advances can significantly improve the quality of life of people with diabetes.

About José García-Tirado

José García-Tirado is an Assistant Professor of Smart Algorithms in Diabetes Technology at the University of Bern. He has a B.Sc. from the Universidad Nacional de Colombia, a M.Sc. from CINVESTAV (Mexico), and a Ph.D. from the Universidad Nacional de Colombia, all in the field of control systems engineering. He later did a postdoctoral fellowship at the Rheinisch-Westfälische Technische Hochschule Aachen (RWTH Aachen) in 2013 and from 2017-2021 at the University of Virginia where he specialized in advanced control strategies for AID systems. Prof. García-Tirado has been faculty in three countries, at the Instituto Tecnológico Metropolitano (2014-2017 – Medellin, Colombia), University of Virginia (2021-2023, Charlottesville, US), and University of Bern (2023).

Thanks so much for reading and we’ll provide you with the next episode of this series soon!