Co-Chairs:
Ilene Fennoy, MD and Ambika Ashraf, MD
Mission Statement:
Our mission is to affirm the ideology of the PES as a scientific community that fosters inclusion, acceptance, and support for every person independent of race, ethnicity, gender, sexual orientation, or religion. Towards this end, our focus is to:
- Recognize implicit and explicit bias in healthcare in Pediatric Endocrinology, and address related healthcare disparities that affect our patients and families, through research, quality improvement, health delivery science, education, and outreach efforts.
- Foster equity and diversity and provide an environment of equality and mentorship for all trainees, fellows, and faculty in Pediatric Endocrinology.
Goals:
Our task force goals for the coming year are to increase awareness in our society’s membership of implicit and explicit bias in medicine in general and Pediatric Endocrinology specifically, and the contribution of said biases to health care disparities as well as to career development of minority physicians. We also aim to start to amass resources to help us address and ameliorate these biases and resulting disparities. We will contribute regularly to the newsletter, develop a needs assessment survey of our society, and will plan to offer periodic education for the PES membership.
National Voter Registration Day and the Future of Pediatric Endocrinology
Submitted by Santhi Logel, MD, University of Virginia
National Voter Registration Day is September 15, 2026. Celebrated each September, it is a “nonpartisan civic holiday dedicated to celebrating our democracy”. This civic holiday was established in 2012 and is endorsed by the National Association of Secretaries of State (NASS), the National Association of State Election Directors (NASED), the U.S. Election Assistance Commission (EAC), and the National Association of Election Officials (The Election Center). National Voter Registration Day mobilizes volunteers across the country to help eligible citizens register to vote. It is easy to see this as a civic engagement with little connection to pediatric endocrinology. However, we as pediatric endocrinologists directly feel the effects of voting in the work that we do.
Children Cannot Vote. That’s Why We Must Get Out The Vote!
We have a voice in the decisions that shape our patients' care. Children with type 1 diabetes cannot vote on whether Congress caps the price of insulin or whether their state extends that cap to all insurance plans, not just Medicare. Transgender adolescents cannot vote on legislation that determines whether gender-affirming care remains available in their state. A rural teenager who sees their pediatric endocrinologist by video visit cannot vote on whether telehealth reimbursement parity is extended or allowed to expire, even though that policy decides whether they can see a pediatric endocrinologist at all. Every policy that determines what our patients can access is set by adults who can vote, for children who cannot.
Voting Access Is Itself a Health Equity Issue
The history of who has been able to vote in this country is intertwined with the history of who has faced barriers to receiving quality healthcare. As we noted in our August 2024 newsletter recognizing Women’s Equality Day, the 19th Amendment did not secure the right to vote for all women. Poll taxes continued to disenfranchise women voters until the 24th Amendment was passed in 1962. Literacy tests continued to disenfranchise black voters until the Voting Rights Act was passed in 1965. Language-minority communities did not gain full voting protections until 1975 when the Voting Rights Act was extended. Today, barriers such as strict ID requirements, limited polling locations, and inaccessible registration systems continue to disproportionately affect the same populations who already face barriers to receiving the best care we can provide. Framed in this way, voter registration and pediatric endocrine health equity are not separate issues. They are two expressions of the same structural problem, systems that were not designed with equitable access in mind.
What This Looks Like in Practice
National Voter Registration Day is a nonpartisan effort to help eligible people register to vote, regardless of how they intend to vote. Here are a few ways we can mark the day in our clinical practice:
- Include voter registration information in patient/family resource materials we already provide.
- Extend the same health equity lens we already apply to other areas such as food insecurity, transportation, and housing.
- Model the behavior we ask of our patients’ families by voting, writing to our legislators, and sharing our experiences.
A Call to Action
The PES Health System Disparity Committee has consistently argued that advocacy is not adjacent to our clinical work; it is central to it. National Voter Registration Day offers a concrete, nonpartisan way to act on that belief. Our patients cannot vote for policies that affect their pediatric endocrine care. Until they can, the least we can do is make sure the adults around them are registered and engaged.
For more information or to check your registration status, visit vote.org or nationalvoterregistrationday.org.
Archive - Monthly notable dates/events
When Misinformation Becomes Policy: The Harm to Transgender and Gender Diverse Youth
Written by Kara Connelly for the HSD Committee
Dissemination of misinformation and disinformation about healthcare for transgender and gender diverse (TGD) youth is not new. What has changed is the scale, sophistication, and institutional amplification of these narratives. “Many contemporary attacks on gender-affirming care arise from selective citation, misrepresentation of data, amplification of fringe viewpoints, and repetition of emotionally charged but inaccurate claims rather than from new science.1" False or misleading claims about gender affirming care now circulate widely through social media, political campaigns, legislative hearings, and governmental reports. Increasingly, these narratives are not simply misunderstandings of science; rather, they can be deliberate attempts to distort evidence in ways that shape public opinion and policy.
Disinformation differs from simple misunderstanding, because it is often strategic and repeated despite available evidence. Terms such as “mutilation,” “sterilization,” or “child abuse” are increasingly deployed not as scientific descriptors but as emotionally charged political messaging. These narratives can erode trust in clinicians, polarize families, and create fear around seeking medical care. In addition, disinformation campaigns effectively present a reality where the dignity and autonomy of individuals and their families are up for debate
Importantly, the harms of misinformation are not experienced equally. TGD youth already face substantial health disparities, and TGD youth of color often experience compounded marginalization at the intersection of racism, transphobia, poverty, and barriers to health care access. Disinformation campaigns frequently worsen these inequities by undermining trust in medical institutions, increasing stigma, and disrupting access to specialized care in communities that may already have limited pediatric subspecialty resources.
Research consistently demonstrates that TGD youth of color experience disproportionately high rates of bullying, discrimination, housing instability, and adverse mental health outcomes. Structural inequities — including insurance gaps, transportation barriers, under-resourced schools, and limited access to culturally responsive care — can make continuity of gender affirming care especially fragile. When misinformation fuels legislative restrictions or hospital closures, families with financial resources may be able to travel across state lines for care; many others cannot.
The historical context also matters. Communities of color have longstanding reasons to approach medical systems with caution due to histories of discrimination, exclusion, and unethical treatment in healthcare and research. Disinformation campaigns that portray clinicians as harmful or untrustworthy can therefore deepen existing mistrust and widen disparities further. For some families, repeated exposure to false narratives online or in the media may make it harder to distinguish evidence-based guidance from politicized rhetoric.
It is also important to recognize the unprecedented speed with which disinformation campaigns have translated into policy. In several states, legislative or administrative restrictions on gender affirming care were introduced using reports or “evidence reviews” that mischaracterized existing literature, cited opinion pieces from media outlets or elevated ideologically driven analyses above peer-reviewed consensus statements.2
For TGD youth, these narratives are not abstract political debates. They shape whether a child feels safe at school, whether parents trust physicians, whether hospitals continue offering care, and whether young people can access evidence-based treatment.
The consequences of these distortions extend beyond rhetoric. In many regions, misinformation has contributed to legislative restrictions, institutional retreat, and disruptions in care delivery. Hospitals and clinicians have faced legal threats, subpoenas, public harassment, and political pressure. Some health systems have scaled back or closed programs entirely, leaving families scrambling to maintain continuity of care.
The impact on providers should not be underestimated either. Pediatric endocrinologists and multidisciplinary gender clinics increasingly practice in environments marked by scrutiny, burnout, and moral distress. Many clinicians describe concerns about personal safety, professional targeting, and the ethical challenges of caring for patients amid shifting legal landscapes. At the same time, trainees may become hesitant to enter the field, threatening the future workforce needed to care for TGD youth and young adults.
Sifting through the information and disinformation about TGD youth care to determine what is accurate may feel daunting on top of our other professional responsibilities.. However, it is an act of allyship to do so, and it will take allyship on multiple levels - individual, interpersonal, and systemic - to stop the momentum of current discourse and change direction to protect care for TGD youth. Individually, we can commit to identifying reliable resources for gathering information. Interpersonally, we can correct others when we hear misinformation and advocate with our professional leaders to continue to stand for equity. Systemically, professional organizations can ensure equitable policies for their members, set clear standards for what is true intellectual debate and what is dissemination of disinformation, and take stands publicly to protect the care for those who need it.
References
- McNamara M, Abdul-Latif H, Boulware SD, et al. Combating Scientific Disinformation on Gender-Affirming Care. Pediatrics. Sep 1 2023;152(3)doi:10.1542/peds.2022-060943
- Dowshen N, Baker K, Garofalo R, et al. A Critical Scientific Appraisal of the Health and Human Services Report on Pediatric Gender Dysphoria. J Adolesc Health. Sep 2025;77(3):342-345. doi:10.1016/j.jadohealth.2025.06.002
From Bystander to Upstander: The Case for Allyship in Pediatric Endocrinology
Ambika Ashraf MD, Ilene Fennoy MD, MPH
Bias and microaggressions are not rare anomalies reserved for extreme cases. They are embedded in the daily routines of clinical and academic medicine. Research consistently shows that racial and ethnic minorities, women, LGBTQ+ individuals, trainees, and patients from lower socioeconomic backgrounds, as well as those with disabilities bear disproportionate harm from these everyday interactions. Over time, that harm accumulates, shaping well-being, career trajectories, and health outcomes.
In pediatric endocrinology, these moments are concrete and familiar:
A patient with obesity is met first with assumptions before anyone asks about food access, transportation, or the cultural meaning of meals at home.
A trainee who graduated from an international medical school is having their clinical reasoning and healthcare team interactions scrutinized in ways their U.S.-trained peers do not experience.
A family with limited English proficiency receives a serious diagnosis through a 12-year-old sibling acting as interpreter, despite policies designed to protect both informed consent and the child.
A patient labelled as “noncompliant,” placing responsibility on the individual without examining the structural conditions that shape whether medical advice can realistically be followed.
The student/trainee becoming silent to participation after experiencing rude or mocking behavior from peers.
These moments are often not malicious. More often, they reflect habit, inherited training, and systems that were never designed to interrupt bias. That is precisely why intentional, skills-based intervention matters — not to assign guilt, but to build the capacity to respond differently.
An UPSTANDER is someone who chooses to act. The term is deliberately distinct from “bystander”: it signals a willingness to speak up, step in, and take shared responsibility for the climate of the spaces we inhabit. In clinical medicine, where hierarchies are steep and time is scarce, being an UPSTANDER requires intention, preparation, and practice. It is not about confrontation for its own sake or public blame. It is about interrupting harm, supporting the person affected, and helping create a culture in which these incidents become less common over time.
Allyship is the broader commitment from which UPSTANDER action grows. An ally uses position, voice, and influence to support people who are marginalized or harmed — not only in dramatic moments, but in the ordinary rhythms of professional life. Allyship is not a credential earned once. It is a sustained practice of self-examination, humility, and accountability to the people one hopes to support.
Grounded in the Learning for Justice curriculum from the Southern Poverty Law Center, the UPSTANDER program offers a practical framework for intervention: IQEE.
Interrupt
The first step is to pause the harmful moment. That pause need not be confrontational; even a calm “Excuse me, may I ask a question?” can signal that something requires attention. The aim is to interrupt the momentum before harm compounds.
Question
A clarifying question can open space while lowering defensiveness. “Could you help me understand what you meant by that?” or “Why did it feel acceptable not to use an interpreter?” invites reflection rather than accusation. Questions engage the speaker’s own reasoning and often surface assumptions that otherwise remain unexamined.
Educate
Once that space exists, information can follow. This may mean naming a policy, sharing evidence on implicit bias, or reframing the situation through a more equitable lens. “I recently learned how weight stigma can undermine adherence” is an educational intervention, not a prosecution.
Echo
Amplifying the voice of the person affected is one of the most important — and most overlooked — acts of allyship. Saying, “I want to return to what Dr. [Name] said earlier,” validates the contribution and counters the erasure microaggressions often produce. Echo is also how allies strengthen one another over time: by crediting, repeating, and elevating voices that are too often talked over.
The evidence for structured intervention is growing. Wheeler and colleagues found that implicit bias contributes to measurable disparities in clinical decision-making, including in pediatric care, with differences in technology access, pain management, and diagnostic workups across racial and socioeconomic groups.¹ Wheeler and Harper (2023) further reported that structured allyship training significantly improved confidence in bystander intervention among medical trainees, with gains sustained at six months.² Together, these findings suggest that when training is interactive and well designed, it is not merely valuable; it is effective.
When we train members to interrupt bias, echo marginalized voices, and practice allyship consistently, we do more than improve isolated interactions. We help build a specialty culture that retains its people, earns the trust of its patients, and lives the equity values it professes.
The UPSTANDER program is one way to move those values from aspiration to daily practice.
A common question about allyship training is whether it produces lasting change. The answer depends on whether the skills are used, and the daily clinical environment offers opportunities to practice them constantly.
For patients and families, the benefits are immediate. When clinicians notice and interrupt bias, families receive fuller assessments, clearer explanations, and care plans that fit the realities of their lives. The child whose family eats fufu receives carbohydrate counseling that accounts for cassava rather than ignoring it. The transgender teen whose pronouns are finally consistent across every system may feel, perhaps for the first time in that clinic, fully seen. These are not small improvements; they are the difference between care that works and care that does not.
For trainees and junior colleagues, an active UPSTANDER culture changes what it feels like to come to work. Being credited, defended, and heard reshapes the daily experience of medicine, especially for those who have historically been overlooked. Research links experience to burnout, retention, and professional identity formation.
For the ally, practice builds fluency and confidence. The first use of the IQEE framework may feel awkward; by the fifth, it begins to feel like professional muscle memory, a way of moving through clinical environments that reflects one’s stated values. Many participants in UPSTANDER training report that the most transformative discovery was not simply learning what to do but realizing that they could do it and that doing so did not destroy the relationships they feared putting at risk.
For institutions and organizations, cultures with active allyship norms perform better across nearly every dimension: patient satisfaction, staff retention, error rates, and leadership diversity. When PES cultivates a membership that practices UPSTANDER principles, it strengthens the long-term health of the specialty itself.
Choosing to become an UPSTANDER is not a single act; it is a daily orientation toward the people around us, a commitment to notice, to speak, and to stay engaged. In a specialty as demanding and meaningful as pediatric endocrinology, that orientation is not an extra. It is part of what makes us physicians, APPS, educators, and colleagues we aspire to be.
References
Wheeler SM, Bryant AS. Racial and ethnic disparities in health and health care. Obstet Gynecol Clin North Am. 2017;44(1):1-11. doi:10.1016/j.ogc.2016.10.001
Tripp R, Burgess R. UPSTANDER Training: Building allyship skills and bystander intervention confidence among medical trainees. Adapted from: Learning for Justice, Southern Poverty Law Center. www.learningforjustice.org
Recognizing Autism Awareness Month
Submitted by Kate Citron-Zafrin, MD
April is Autism Awareness Month, which celebrates raising awareness, increasing inclusion and acceptance and providing resources for those with autism spectrum disorder (ASD). ASD is a heterogeneous neurodevelopmental condition with diverse genetic, neurological, and biological underpinnings — a complexity that shapes not only cognitive and behavioral profiles but also metabolic susceptibility. We would like to take this opportunity to discuss neuro-cognitive diversity and the increased risk of developing certain endocrine conditions in this population.
Those with autism spectrum disorder are at increased risk of developing diabetes, obesity, metabolic syndrome and nutritional deficiencies, such as vitamin D deficiency rickets. Restrictive diets, often with high glycemic index, as well as certain medications, such as atypical antipsychotics, put individuals with autism at increased risk of these metabolic conditions. There is also emerging evidence of increased prevalence of thyroid dysfunction in ASD. Also impaired linear growth can occur secondary to dietary restriction, antipsychotic use, and nutritional deficiencies. In fact, a meta-analysis found a 2.84 relative risk of developing diabetes and 2.54 relative risk of developing hypertension in children with autism compared to children without autism. A cross-sectional study found that 75.9% of children with autism spectrum disorder had vitamin D deficiency and that in boys with autism, higher BMI was correlated with lower vitamin D levels. Further, it is reported that there is a 55% prevalence of metabolic adverse drug reactions (hyperglycemia and hyperlipidemia) in those with autism on atypical antipsychotics. Atypical antipsychotic medications (e.g., risperidone and olanzapine carry the highest metabolic risk; aripiprazole is comparatively lower but not negligible) causing weight gain, hyperglycemia, and hyperlipidemia.
It is important as pediatric endocrinologists to appreciate this increased risk and the interaction it may have with higher prevalence of these conditions in certain socioeconomic and racial groups. Considering an equity-focused approach is important. This would include access to specialized nutritional counseling, subspecialty care and increased monitoring, particularly in the setting of rapid weight gain or initiation of antipsychotic medications. Detecting these conditions early in this at-risk population is important to limit morbidity and best support patients with neurodiversity.
Citations:
Dhanasekara CS, Ancona D, Cortes L, et al. Association Between Autism Spectrum Disorders and Cardiometabolic Diseases: A Systematic Review and Meta-analysis. JAMA Pediatr. 2023;177(3):248–257. doi:10.1001/jamapediatrics.2022.5629
Hartman JS, Silver AH. Nutritional Rickets Due to Severe Food Selectivity in Autism Spectrum Disorder. J Dev Behav Pediatr. 2021 Jan 1;42(1):66-72. doi: 10.1097/DBP.0000000000000856. PMID: 32890122.
Aljead M, Qashta A, Jalal Z, Jones AM. Metabolic and Endocrine ADRs of Atypical Antipsychotics (AAPs) in Paediatric Patients with Autism Spectrum Disorder (ASD): A Review of Prevalence, Risk Factors, and Implications for Clinical Monitoring. J Clin Med. 2025 Nov 9;14(22):7942. doi: 10.3390/jcm14227942. PMID: 41302979; PMCID: PMC12653775.
Shared Decision Making
Submitted by Ilene Fennoy and Ambika Ashraf
Shared decision making is based conceptually on principles of medical ethics (1) of which one of the four core principles is autonomy. (2). It requires that there be:” (1) at least two participants, physician and patient involved; (2) that both parties share information; (3) that both parties take steps to build a consensus about the preferred treatment; and (4) that an agreement is reached on the treatment to implement.” (3) Thus, it is a collaborative process in which the patient has a contributory role to the final choice of actions, not just to adherence with the physician plan.
It does require the provider/physician to make use of the evidence base in medicine, to use a patient centered communication process, as well as to assess and accommodate health literacy skills with the goal of optimal patient care (3) while restoring the patient’s autonomy (1). It is often needed when the patient is in a state of illness and has a compromised sense of autonomy due to the sense of uncertainty and vulnerability that arises when ill.(4) Difficulty in engaging in shared decision-making may occur because the patient is in an emotional state and not ready to make decisions, thus deferring to the provider. However, most often difficulty engaging in shared decision-making occurs where substantial differences in patient and providers lived experience, knowledge and power exist, as well as where differences in goals of care are present. (5)
At the center of shared decision making is patient centered care which is based on respect for the individual and family in their social setting with the obligation to care for them according to their own terms (6, 7). In pediatric type 1 diabetes care, HgbA1c levels have been linked to the extent to which shared decision making occurred between the caregiver and provider demonstrating lower HgbA1c with greater shared decision making (8). Studies have also shown that patient centered care provides benefits for patients in terms of satisfaction and perceived quality of care (9). Also, a 'technology gap' persists; even when controlling for socioeconomic status, Black and Hispanic youth are significantly less likely to be prescribed insulin pumps or CGMs. This disparity is often driven by clinician reliance on subjective factors like perceived 'readiness' rather than objective criteria. However, there is limited data on the role of shared decision making in the adolescent (10). The AAP has developed a policy endorsing patient and family centered care that acknowledges the roles played by emotional, social and developmental support in provider -patient/family interactions and the resultant better health outcomes, use of resources and patient-family satisfaction.(7) They identify 6 core principles of which the first is: “Listening to and respecting each child and his or her family. Honoring racial, ethnic, cultural, and socioeconomic background and patient and family experiences and incorporating them in accordance with patient and family preference into the planning and delivery of health care” (7), integrating both patient centered care and shared decision-making. As members of the Health Systems Disparities Committee, it is critical to recognize shared decision making not only as a communication strategy, but as a tool for advancing health equity. Differences in health literacy, language access, prior healthcare experiences, and structural barriers can all influence whether families feel invited into decision making or excluded from it. When clinicians unintentionally “gatekeep” options based on assumptions about resources, readiness, or perceived adherence, inequities can be reinforced rather than reduced. True shared decision making requires that all reasonable options are offered transparently and respectfully, with attention to cultural humility and power dynamics. Shifting from a framework of “compliance” to one of collaboration and concordance can reduce stigma, build trust, and result in care plans that are both medically sound and realistically sustainable for families.
In 2026, let us focus on healthcare equity as defined by the Robert Wood Johnson Foundation: “everyone has a fair and just opportunity to be as healthy as possible” (11). Let us work to enhance our patient care outcomes by engaging in shared decision-making and patient centered care that is based on knowledge and sensitivity to the varied cultural experiences and social background experienced by the diverse patient population for whom we provide care with a focus on engaging our patients/families in identifying the healthcare goals of importance to them.
Reference List
1. Elwyn G. Shared decision making: What is the work? Patient Educ Couns. 2021;104(7):1591-5.
2. Gillon R. Medical ethics: four principles plus attention to scope. BMJ. 1994;309(6948):184.
3. Muscat DM, Shepherd HL, Nutbeam D, Trevena L, McCaffery KJ. Health Literacy and Shared Decision-making: Exploring the Relationship to Enable Meaningful Patient Engagement in Healthcare. J Gen Intern Med. 2021;36(2):521-4.
4. Gulbrandsen P, Clayman ML, Beach MC, Han PK, Boss EF, Ofstad EH, et al. Shared decision-making as an existential journey: Aiming for restored autonomous capacity. Patient Education and Counseling. 2016;99(9):1505-10.
5. Elwyn G, Gulbrandsen P, Leavitt H, Abukmail E, Clayman ML, Edwards A, et al. Shared Decision-Making. A Primer for Clinicians. Journal of General Internal Medicine. 2025;40(16):3889-99.
6. Epstein RM, Street RL, Jr. The values and value of patient-centered care. Ann Fam Med. 2011;9(2):100-3.
7. CARE COH, PATIENT- IF, CARE F-C. Patient- and Family-Centered Care and the Pediatrician's Role. Pediatrics. 2012;129(2):394-404.
8. Valenzuela JM, Smith LB, Stafford JM, D’Agostino RB, Lawrence JM, Yi-Frazier JP, et al. Shared Decision-Making Among Caregivers and Health Care Providers of Youth with Type 1 Diabetes. Journal of Clinical Psychology in Medical Settings. 2014;21(3):234-43.
9. McMillan SS, Kendall E, Sav A, King MA, Whitty JA, Kelly F, et al. Patient-centered approaches to health care: a systematic review of randomized controlled trials. Med Care Res Rev. 2013;70(6):567-96.
10. Sobode OR, Jegan R, Toelen J, Dierickx K. Shared decision-making in adolescent healthcare: a literature review of ethical considerations. Eur J Pediatr. 2024;183(10):4195-203.
11. Cheng TL, Unaka NI, Nichols D. Crossing the Quality Chasm and the Ignored Pillar of Health Care Equity. Pediatric Clinics of North America. 2023;70(4):855-61.
Recognizing American Heart Month in February
Submitted by Andrew Kanouse, MD
As Valentine’s Day approaches, hearts beat in a variety of flutters, rates, and patterns. As one shops for heart shaped balloons, cards, and candies, we should remember that February is American Heart Month, a time to highlight cardiovascular health as a lifelong priority that begins in childhood. While heart disease is often thought of as a condition of adults, the beginnings of these risks frequently trace back to pediatric health, especially in various areas of endocrinology such as lipidology and diabetology. For pediatric endocrinologists, this month offers an opportunity to think about how endocrine disorders contribute to heart health and how inequities in care and resources may shape long-term outcomes.
Many of the conditions managed by pediatric endocrinology, such as diabetes, obesity, dyslipidemia, and polycystic ovary syndrome, carry important implications for future cardiovascular disease. For example, patients with diabetes have a 2- to 4-fold increased risk of cardiovascular disease, a risk thought to be somewhat independent of whether their hemoglobin A1c is in goal range or not. Further, data demonstrates that such issues can begin early, ultimately making early prevention and screening critical given the difficulty in reversing the path already begun towards disease.
Ultimately, endocrinologists should recognize that these risks are not distributed equally across race, culture, or socioeconomic status, which results in higher rates and earlier disease onset of obesity and type 2 diabetes, as well as more limited access to preventive care. This should lead to consideration of an equity-focused approach toward disease prevention. This includes culturally adapted counseling around nutrition and physical activity, attention to social determinants of health such as food insecurity and neighborhood safety, and advocacy for equitable access to screening, medications, diabetes technologies, and subspecialty care. As we see these patients in our clinics this month, it's worth asking how many of these barriers are visible in our own patient panels and how we may help reach these patients where they are reachable, adapting clinical approaches to something that is not only appropriate but practical and achievable. These efforts may help to mitigate such inequities in the cardiovascular care of children who also have endocrinopathies that put them at inherent risk for disease.
Beyond the Prescription: Navigating Systemic Barriers
Ambika Ashraf MD, University of Alabama at Birmingham; Ilene Fennoy MD, Columbia University Medical Center
As December brings a time of reflection and family, it also casts a sharp light on the immense pressures our patients and their families navigate. Beyond managing complex endocrine conditions, many are struggling with systemic barriers, from insurance gaps to transportation hurdles, that are often amplified at the end of the year. As pediatric endocrinologists, our advocacy in these moments is not adjacent to our work; it is central to our mission.
Consider the (de-identified) story of 'David,' a 14-year-old with type 1 diabetes. His family’s insurance plan is changing on January 1st. Our clinic staff, already stretched thin, spends hours on prior authorizations for his insulin pump and CGM. The family calls, worried, because their new high-deductible plan means the first insulin refill of the year will cost them over $800—a choice between their child's health and paying their heating bill.
This experience is not an isolated anecdote. We see it in the family that cannot afford the co-pay for genetic testing for a child with a suspected rare endocrine disorder, leaving them in a diagnostic limbo. We see it in adolescents with type 2 diabetes whose insurance denies coverage for a CGM, removing a critical tool for managing their condition. We see it in the enormous co-payments required for vital medications like SGLT2 inhibitors, placing proven cardiovascular and renal protection out of reach for many.
We see these systemic failures when insurance plans categorically refuse to cover new weight loss medications for children with obesity, or even for those with type 1 diabetes and concurrent obesity, despite clear evidence of their benefits. We see it in the family from a rural community, driving three hours each way for an appointment, missing a full day of wages and school.
These are not individual problems; they are systemic gaps. Insurance limitations, geographic isolation, and unaffordable drug pricing are barriers that disproportionately affect low-income, immigrant, and minority populations, perpetuating generational cycles of poor health outcomes.
As 2025 comes to a close, let this reflection be our call to action for the new year. Our expertise as clinicians and researchers positions us to lead.
- Advocate in Our Clinics: Let's be as intentional about screening for social determinants of health as we are about monitoring A1c or bone age. When we identify a family struggling, we must connect them with social workers, patient assistance programs, and community resources. This is a critical clinical intervention.
- Advocate in Our Institutions: We must challenge our hospital leadership and insurance partners to simplify access. This includes pushing for streamlined prior authorization processes for essential medications and technology and advocating for expanded telehealth access to bridge geographic divides.
- Advocate in Our Communities: We must use our collective voice. Our patient stories, backed by data, are the most powerful tools we have to demand policy change. Whether writing an op-ed or joining a PES or Endocrine Society "Hill Day", we can advocate for policies that cap insulin costs, protect access to gender-affirming care, and fund vital pediatric research.
This December, as we reflect on the past year, let us recommit to this essential work. The health of our patients depends not only on our clinical skill but on our courage to challenge the systems that create and perpetuate disparity. Let's make the coming year one that not only recognizes these systems that negatively impact on our patients, but one in which we engage in meaningful, collective action to resolve them.
Inheriting Risk and Responsibility, A Call for Equitable Family-Centered Care
Mary Margaret Barr MD, University of Alabama at Birmingham
As we approach Thanksgiving – a time when families gather and stories are shared – we're reminded that family history is not only made of our family stories but our family health conditions too. This month, in recognition of National Family Health History Day (November 25), we spotlight a case that underscores the importance of understanding inherited risk and ensuring access to appropriate care, regardless of insurance status or socioeconomic background.
A Case That Reveals the Gaps
We recently cared for a 12-year-old patient who presented with extensive xanthomas that have been present since age 2. Initially misdiagnosed as warts, the lesions were a sign of homozygous familial hypercholesterolemia (HoFH) – a rare but life-threatening genetic lipid disorder characterized by severely elevated LDL and accelerated cardiovascular disease.
Clinical and Systemic Challenges
Delayed Recognition Due to Diagnostic Bias
Xanthomas are a hallmark of HoFH, yet the patient’s skin findings were, per family’s report, misdiagnosed for years (family had recently moved to the US, and we did not have access to early childhood medical records). This delay illustrates how knowledge gaps and bias in visual diagnosis can lead to missed or late diagnoses. It is likely that limited access to healthcare due to insurance status prevented a timely diagnosis for this family.
Suboptimal Treatment Access
Once the diagnosis was established, with xanthomas and an LDL level exceeding 600 mg/dL, therapy was initiated: high-intensity statin, ezetimibe, and colesevelam. The next intensification is to imitate weekly LDL apheresis, which family could not afford to come from their home. Through a patient-assistance program, we secured evinacumab, which reduced LDL from >600 to ~180 mg/dL. Yet, this level remains far above the LDL goal of <115 mg/dL, sustaining cardiovascular risk. Even patients with HoFH and minimal LDL receptor function can sometimes benefit from an additional 10–25% LDL reduction, every incremental decrease matters. Unfortunately, due to insurance limitations, the family could not afford a PCSK9 inhibitor out of pocket.
Genetics and Equity
HoFH is inherited, whether from two copies of mutations on the same locus or compounding mutations (named Compound Heterozygous Familial Hypercholesterolemia which is phenotypically indistinguishable from HoFH). Without equitable access to screening and treatment, the entire family, including a newborn sibling, may be at risk. National Family Health History Day encourages all clinicians to ask about inherited conditions—but we must also ensure that families can act on that knowledge, regardless of insurance coverage or language barriers.
Clinical and Advocacy Takeaways
When evaluating children with severe dyslipidemia, consider the broader family. Cascade screening can identify affected siblings, parents, and relatives—but only if systems are in place to support access to affordable genetic testing and follow-up care.
Recognize the Cost of Access Gaps
For rare disorders like HoFH, newer biologic therapies are not luxury add-ons—they are essential. Denial of access based on cost or insurance status is a structural health disparity with long-term, life-altering consequences.
Thanksgiving as an Opportunity
As families come together this season, clinicians can empower patients to learn and share their health histories. Encourage open conversations around cholesterol, heart disease, and early symptoms—and offer resources to help families act on that knowledge.
A Call to Action
The PES Health Systems Disparities Initiative is committed to identifying and addressing the inequities that affect our patients every day. This case reminds us that the burden of genetic disease doesn’t fall equally—and neither does access to the care that can change outcomes.
This November, let’s reflect not only on what runs in our families, but also on what runs through our health systems—both the gaps and the opportunities. Together, we can build a more inclusive, informed, and equitable future for all families living with endocrine and metabolic disorders.
Wishing you all a meaningful Thanksgiving season!
Recognizing Pediatric Bone Health During World Osteoporosis Day:
Submitted by Andrew Kanouse, MD
In October, skeletons fill the cultural landscape as Halloween approaches. As autumn sets upon those of us in the northern hemisphere with its subsequent transition to shorter days of sun, skeletons are also recognized in celebration of World Osteoporosis Day (October 21). While osteoporosis is often framed as an adult disease, pediatric endocrinologists know that bone health begins much earlier. Bone is a metabolically active organ and the process of building peak bone mass starts in childhood. Supporting optimal bone accretion during childhood and adolescence is one of the most effective ways to reduce fracture risk and prevent osteoporosis later in life. Pediatric endocrinologists play a key role in this effort, identifying and managing various aspects of childhood that may impact this. One vital consideration is how health systems disparities may shape outcomes in this realm.
Disparities affect pediatric bone health at multiple levels. Bone metabolism, like many areas of medicine, relies on an interplay between genetic predisposition and environmental factors. The latter becomes important when considering the availability of such things as calcium- and vitamin D-rich foods to supplement pediatric diets, safe areas of play for children outdoors to begin the mechanistics of vitamin D metabolism through sunlight, and access to routine preventative care. Specific attention needs to be given to the issue of exposure to sunlight, as this not only pertains to safe areas for play outdoors, but even living in areas with reduced green space or dense housing limiting sun exposure. Such areas depend on indoor community facilities for cultural enrichment, and even the climate in which children live minimizing or limiting UV ray exposure. Cultural factors also play a role—differences in recognition of clinical signs, perceptions of treatment necessity, or trust in medical providers can delay diagnosis and intervention to disorders of vitamin D deficiency. Additionally, even were appropriate recognition to occur, those in low- and middle-income areas (towns, cities, even countries) with immigrant/minority populations may still face inherent difficulties with nutritional rickets that remains sometimes unavoidable without viable and sustainable supplemental intervention.
Insurance limitations compound these inequities, restricting timely referrals to endocrinologists, medication available in forms easily administered to pediatric patients, or access to diagnostic tools like DXA scans, physical therapists, and bisphosphonate treatment. Finally, with regards to DXA scans, as practitioners we must recognize that while some standards do exist to compare various populations, bone mineralization disorder algorithms and treatment decisions are classically based on stereotypical (white affluent) populations and risk misclassifications so thus have the possibility of under-treatment for such at risk populations.
Ultimately, lack of recognition of these barriers can perpetuate the risk for generational cycles of poor bone mineralization in already at risk populations and miss opportunities for early intervention. Pediatric endocrinologists can help close these gaps by encouraging equitable screening—such as routine assessment of vitamin D status particularly those with restrictive diets such as seen in children with autism, careful fracture history, and auxological monitoring—while also advocating for broader community supports. School-based programs that promote outdoor activity and provide bone-healthy nutrition are one way to address disparities upstream. Efforts can continue where available to advocate for the expansion of efforts to recognize and manage barriers to pediatric bone health that have already begun. Finally, we must continue to emphasize the bidirectional connection between pediatric and adult bone health: the skeletal outcomes of childhood shape lifelong trajectories and the lessons from adult osteoporosis care must also inform how we support children today.
For more information, visit: https://www.worldosteoporosisday.org/.
September is Suicide Prevention Awareness Month
Submitted by Jennifer Raymond
September is Suicide Prevention Awareness Month, a vital reminder of the mental health challenges faced by youth living with chronic diseases, including endocrine disorders, diabetes, and obesity. These conditions not only affect physical health, but they also increase vulnerability to depression, anxiety, and suicidal ideation.
Key Points for Pediatric Endocrinologists:
- Prevalence in type 1 diabetes:
- Youth living with type 1 diabetes have higher rates of depression and suicidal ideation compared to peers without chronic illness.
- Risk for those living in larger bodies:
- Adolescents living with obesity are at significantly increased risk for bullying, stigma, low self-esteem, and depression—all risk factors for suicidality.
- Risk for those living with type 2 diabetes:
- Youth with type 2 diabetes frequently live with obesity and the burden of chronic disease management, which are often compounded by psychosocial stressors, including socioeconomic challenges and weight-related stigma
- Warning Signs:
- Social withdrawal, changes in management of health and chronic disease, hopelessness, lack of interest in previous activities, and verbal or behavioral cues related to self-harm warrant urgent evaluation.
Clinical Recommendations:
- Clinician Role:
- Normalize conversations about mental health, validate lived experiences of stigma and stress, and provide culturally sensitive care.
- Address Weight Stigma:
- Cultivate a weight-neutral, affirming environment. Focus on behaviors, not body size. Screen for and respond to self-perceived weight distress.
- Routine Screening:
- Incorporate routine screening for depression, anxiety, and suicide risk into endocrinology visits, especially for youth with chronic endocrine disorders, diabetes, or obesity.
- Safety Planning:
- Prepare individualized safety plans, including restrictions on insulin access when needed, and ensure mental health follow-up.
- Collaborative Care:
- Work closely with psychologists, psychiatrists, social workers, and integrated behavioral health teams.
- Follow up after positive depression and/or suicidal ideation screens can improve outcomes over time.
- Educate and Support Families:
- Raise awareness of the relationship between chronic physical conditions and mental health.
- Encourage open conversation, early intervention, and training in crisis resource use.
- Share Resources:
- Provide 988 Suicide & Crisis Lifeline and information on local pediatric mental health services as standard parts of care.
- Ensure resources are available in multiple languages and feasible for different literacy and numeracy levels.
As pediatric endocrinologists, we have a unique opportunity to provide whole-person care by addressing both the physical and emotional well-being of our patients and their families. Early recognition and intervention can be lifesaving.
Additional Resources:
The Intersection of Culture and Health Care
Submitted by Ambika Ashraf and Ilenne Fennoy
To truly heal and serve patients, healthcare must first understand them. Cultural understanding is essential in healthcare as culture shapes how individuals perceive health, illness, and healing, influencing their responses to medical interventions (1, 2). Culture represents the unwritten rules that help people understand the world they live in, dictating their beliefs about medicine, traditional remedies, preventative care, and even the appropriate level of family involvement in health decisions, “reinforcing social cohesion, dialogue, creativity, and innovation”(2). This deep connection between culture and health is further illuminated by broader definitions, such as UNESCO's concept of cultural heritage. UNESCO has defined cultural heritage as a representation of generational inheritance including both tangible and intangible elements. These elements include physical elements such as artifacts, monuments, sites, as well as such intangible elements as oral traditions, craftsmanship, language, and culinary practices(3).
To ensure equitable and effective care, cultural competence must be a core component of medical training, healthcare delivery, and research. When we develop cultural competence we attempt to take the shared beliefs, values, ideas and customs of a group of people into context, tailoring the medical care to meet the individual need(4). Effective cultural competence training seeks to develop methods to train health care providers to identify issues that arise often between individuals of different backgrounds and help them develop tools that provide for meaningful interactions with patients from any background (5). A positive outcome example of culturally competent care is the Special Diabetes Program for Indians (SDPI), launched by the Indian Health Service (IHS), and implementing culturally tailored diabetes care across tribal communities. This model showed that when care is adapted to the cultural, linguistic, and historical context of a community, outcomes improve both medically and relationally. Cultural misunderstandings in healthcare can at times lead to misdiagnosis or delayed diagnosis due to differing explanatory models of health and illness across cultures. In some instances, patients/ parents may delay seeking help or resist diagnosis, leading to delayed early intervention missing critical periods for improving outcomes.
As a country, we have become increasingly diverse. The 2020 census documents an increase in multiracial and ethnic groups with a decline in White alone race from 63.7% to 57.8% since 2010(6). Despite our increasingly multicultural society, recent discourse has seen a notable shift away from, or heightened scrutiny of, the principles of diversity, equity, and inclusion in various sectors, including healthcare. Legislative bans may prohibit implicit bias training, or bar collection of race/ethnicity data, limiting the ability to address health disparities and deliver culturally competent care. Providers may be less equipped to recognize and address their own biases, potentially worsening communication gaps, misdiagnoses, and patient mistrust. Censorship of language and metrics can lead to self-censorship, fear of advocacy, and erasure of the structural roots of health disparities in research and policy. Resistance to inclusive curriculum will lead to students graduating with insufficient understanding of how race, culture, gender identity, and social determinants of health impact care delivery. Marginalized populations such as immigrants and racial minorities may disengage from the healthcare system, worsening outcomes. Barriers to effective communication in healthcare occur when cultures differ including: 1) differences in explanatory models of health and illness; 2) differences in values; 3) differences in patients’ preferences for doctor-patient relationships; 4) racism and perceptual biases; as well as 5) linguistic barriers. Since effective physician-patient communication leads to improved health care outcomes(7), addressing these barriers is important to delivering effective health care.
Effective cultural competence training seeks to develop methods that equip healthcare providers with essential tools, such as advanced communication strategies, empathy-building exercises, and realistic case studies, to navigate common issues arising between individuals from diverse backgrounds and foster meaningful interactions. While the aim is to foster meaningful interactions with patients from any background, it is crucial to acknowledge the immense complexity that arises from the vast diversity of cultures, underscoring that cultural competence is an ongoing journey of learning and adaptation, not a destination.
Furthermore, as we move to provide precision medicine there is ongoing recognition that our data are limited by the absence of many groups resulting in non-generalizable results and an inability to provide the optimal health outcomes at the individual level(8). It becomes imperative therefore, that we continue to focus on diversity, equity and inclusion in health care and health care research. It is imperative for dismantling systemic barriers, reducing persistent health disparities, fostering increased patient satisfaction and trust, and ultimately driving improved public health for all. Only through sustained commitment to diversity, equity, and inclusion, both in care delivery and research, can we hope to achieve the best possible outcomes for every individual, regardless of background.
Reference List
1. Gregg J, Saha S. Losing culture on the way to competence: the use and misuse of culture in medical education. Acad Med. 2006;81(6):542-7.
2. Bouchenaki M. Cultural Heritage: Tangible and Intangible Values. Workshop on Research Infrastructures of Cultural Heritage and Global Change.2012 07/22/2025 [cited 2025 7/25]:[1-7 pp.]. Available from: https://unesdoc.unesco.org/ark:/48223/pf0000225454?posInSet=1&queryId=7d3a8a02-3163-4beb-ba56-53503beaff29.
3. Cultural Heritage: Definition and Importance. 2009 UNESCO Framework for Cultural Statistics [Internet]. 2024 07/22/2025 [cited 2025 07/22]. Available from: https://cultures.fr/en/post/articles/cultural-heritage-definition-and-importance-1256?utm_medium=share;
https://uis.unesco.org/en/glossary-term/cultural-heritage#slideoutmenu.
4. Henderson S, Horne M, Hills R, Kendall E. Cultural competence in healthcare in the community: A concept analysis. Health & Social Care in the Community. 2018;26(4):590-603.
5. Betancourt JR. Cultural Competence and Medical Education: Many Names, Many Perspectives, One Goal. Academic Medicine. 2006;81(6):499-501.
6. Jensen E, Jones N, Rabe M, Pratt B, Medina L, Orozco K, et al. 2020 U.S. Population More Racially, Ethnically Diverse Than in 2010. Washington, DC: US Census Bureau; 2021.
7. Stewart MA. Effective physician-patient communication and health outcomes: a review. Canadian Medical Assoication Journal. 1995;152(9):10.
8. Washington V, Franklin JB, Huang ES, Mega JL, Abernethy AP. Diversity, Equity, and Inclusion in Clinical Research: A Path Toward Precision Health for Everyone. Clinical Pharmacology & Therapeutics. 2023;113(3):575-84.
The Power of Advocacy in Pediatric Endocrinology: Leading with Compassion, Evidence, and Action in a Politically Complex Time
Ambika Ashraf, Shana Mccormack, Ilenne Fennoy
As pediatric endocrinologists, we are uniquely positioned at the intersection of science, compassion, and advocacy. Our daily work reflects the deepest values of our profession, ensuring that every child, regardless of background or circumstance, has access to evidence-based and equitable care. It is easy to feel disillusioned about the impact we can have as pediatric endocrinologists. But our roles as clinicians, scientists, and advocates, have never been more essential.
A Bipartisan Opportunity: Research Advocacy
While many aspects of healthcare remain politically divisive, research advocacy is an area where we often find bipartisan support and we must act now to protect it. Losing funding midstream would not only waste millions in taxpayer dollars already invested but also derail years of progress and jeopardize the future of countless children. These delays affect not only our ability to produce high-quality science but also threaten the careers of emerging physician-scientists, bright young minds with innovative ideas.
How We Can Lead Effective Advocacy
Be Anchored in Stories and Science. Share your data. Whether advocating for research funding, coverage of diabetes technology, or culturally competent nutrition programs, we must lead with the strength of our science. Data opens doors that ideology may try to close. Also share your patient stories. Policy changes happen when science is made human. Advocacy can be emotionally taxing, especially when progress is slow. Recognize the emotional labor involved, build supportive communities within and beyond PES, and give yourself permission to rest. Sustainable advocacy requires sustainable advocates.
Elevate Research as a Unifying Priority. Unlike other aspects of health policy, federal investment in NIH research remains one of the few bipartisan areas of consensus. We must remind legislators that funding prevention research saves lives and saves money.
Mentor the Next Generation. Junior investigators face enormous challenges securing support. We must advocate for more pilot grant mechanisms and NIH opportunities to cultivate early-career researchers.
Use Your Platforms. Whether it's testifying before a committee, engaging hospital leadership, writing op-eds, or joining Hill Day through PES or Endocrine Society, let your expertise inform public dialogue. Advocacy is more effective when it’s collective.
Build Coalitions Beyond Medicine. Partner with educators, nutritionists, public health officials, and families. Change happens when we advocate with the community, not just for them.
Remember: Advocacy Is Leadership. It’s not about politics, it’s about showing up. Advocacy is not outside our scope; it is central to our mission.
A Call to Action for Research Funding
The critical importance of robust research funding in pediatric endocrinology cannot be overstated. It fuels innovation, deepens our understanding of complex endocrine disorders, and ultimately leads to improved outcomes for our young patients. Without consistent and ample funding, our capacity to conduct groundbreaking studies, translate findings into clinical practice, and attract the brightest minds to our field is severely hampered.
We urge all members of the Pediatric Endocrine Society, and all stakeholders invested in the health and well-being of children, to actively engage in advocating for increased research funding. Your voice is powerful, and when combined with the collective voices of your colleagues, it becomes an undeniable force.
Contact your representatives. The Pediatric Endocrine Society and the Endocrine Society regularly distribute letters to Congress, urging sustained and increased investment in pediatric endocrine research. These letters are carefully crafted to reflect both the scientific urgency and the human impact of our work. We encourage you to sign and send these letters to your elected officials.
Even a simple phone call or email can convey the tangible benefits of research; improved health outcomes, cost savings, and a stronger future for our nation's children. Emphasize that this is a bipartisan issue. Investing in pediatric research is investing in our children’s future, a cause that transcends politics.
In closing, the challenges we face require courageous, collaborative, and sustained action. The future of pediatric health depends not only on the prescriptions we write, but on the policies we shape and the research we defend.
Let us lead together with clarity, compassion, and conviction.
“Children cannot vote. That’s why we must raise our voices for them.”
*The following article is intended to foster dialogue and awareness around the evolving role of pediatric endocrinologists in promoting equitable care for all patients.
From Berlin to Compton's to Stonewall to the Clinic: Carrying Forward a Legacy of Trans Healing
Submitted by Kara Connelly, MD
In 1933, the Nazi regime burned the Institute for Sexual Research in Berlin. Founded by Jewish physician and sexologist Magnus Hirschfeld, the Institute was a groundbreaking center for understanding gender diversity, advocating for legal reform, and providing compassionate care to trans individuals. Its destruction was not just an attack on science—it was an effort to erase gender-variant lives from public memory.
But the fire didn’t put out the fight.
In 1966, in San Francisco’s Tenderloin district, trans women, drag queens, and queer people—most of them Black and Brown—fought back at Compton’s Cafeteria against police brutality and harassment. This act of rebellion, three years before Stonewall, was one of the first recorded LGBTQ+ uprisings in U.S. history. It was not a spontaneous riot; it was the culmination of daily resistance by people denied healthcare, housing, and safety—demanding to be treated with humanity.
Then, in June 1969, the Stonewall Uprising in New York City, led again by trans women of color such as Marsha P. Johnson and Sylvia Rivera, sparked a national movement. Stonewall was not the beginning—but it was a turning point. It challenged the nation to reckon with the criminalization of queerness and the denial of bodily autonomy.
These events—separated by decades and continents—are part of the same story: a struggle against erasure, against the criminalization of gender and sexual diversity, and against the denial of fundamental rights—including the right to healthcare.
Why This History Matters to Pediatric Endocrinologists
Today, pediatric endocrinologists are at the frontlines of a new chapter in that struggle. Transgender and gender-diverse youth, especially youth of color, are under unprecedented attack. In states across the U.S., legislation seeks to criminalize gender-affirming care, ban medical discussions about gender identity, and punish providers who offer evidence-based treatment.
The same fear and misinformation that fueled the book burnings in Berlin and the police raids in Greenwich Village now underpin many of the current assaults on transgender healthcare. These are not isolated policy debates—they are part of a long legacy of attempts to erase trans people from public life, science, and medicine.
But history also shows us another truth: resistance is powerful, and care is an act of defiance.
At a time when transgender youth are often framed only through risk or controversy, creating spaces for joy, hope, and affirmation is revolutionary. When a trans teen hears their correct name and pronouns used in a clinical setting, when they are given space to talk about their goals, when they imagine futures where they thrive—these moments are therapeutic and healing in the deepest sense.
As providers, we are in a unique position to protect and nurture that joy. To make it central, not secondary, to our work.
Stonewall’s Legacy Lives On—in Washington D.C., and in Us
This year, the U.S. took a powerful symbolic step with the establishment of the Freedom to Be national monument in Washington, D.C – a powerful artistic installation uplifting the voices of the trans community who were asked to answer the question, “What does freedom to be mean to me?” The installation took over the National Mall on May 17, during the PES annual meeting. I was able to visit the monument with several other PES members and was touched and inspired by the strength and resilience of the trans community – an energy I am privileged to witness every time I see a gender diverse young person in my clinic.
The Freedom to Be monument is a powerful recognition—but it is only symbolic if it is matched by real protections, policy change, and equitable care.
What We Must Do—Every Day
To honor this legacy, we must:
- Defend gender-affirming care as safe, evidence-based, and essential, in both clinical settings and public discourse.
- Speak out against laws that criminalize care or restrict families’ rights to make medical decisions for their children.
- Educate colleagues, lawmakers, and communities about the science and humanity of healthcare for gender diverse individuals.
- Create trauma-informed, culturally responsive clinics that center the experiences of trans youth—especially those who are Black, Brown, disabled, or undocumented.
Joy is not a byproduct of care—it is a therapeutic outcome. In a world that treats trans lives as threats or debates, joy is resistance.
May 2025
Celebrating Asian American and Pacific Islander Heritage Month
Submitted by Santhi Logel, MD
May marks Asian American and Pacific Islander (AAPI) Heritage Month, a time to honor the rich histories, cultures, and contributions of AAPI communities in the United States. This observance, which began as a week-long celebration in 1978 and expanded to a full month in 1990, commemorates important milestones such as the arrival of the first Japanese immigrants in May 1843 and the completion of the transcontinental railroad in May 1869, built with significant Chinese labor.
In pediatric endocrinology, AAPI professionals have made invaluable contributions to our field. For example, Dr. Jokichi Takamine, a Japanese chemist, was the first to isolate adrenaline (epinephrine) in 1900— "the blood-pressure-raising principle of the suprarenal glands”— marking the dawn of hormone research. In 1968 Dr. Shutsung Liao, originally from Taiwan, unveiled that testosterone must be converted to dihydrotestosterone (DHT) by the enzyme 5-alpha-reductase to exert its biological effects in certain androgen target tissues.
Further advancing the field, Dr. Krishna Chatterjee first discovered resistance to thyroid hormone receptor-alpha, a rare form of congenital hypothyroidism. He and his team also identified different mutations in the PPARγ gene, which can cause a rare form of diabetes that is also associated with early-onset hypertension. In diabetes care, Dr. Yutaka Seino's research highlighted that type 2 diabetes in the Japanese population is primarily characterized by impaired insulin secretion rather than insulin resistance. This insight has influenced diabetes treatment strategies in Asian populations.
As we celebrate AAPI Heritage Month, the Pediatric Endocrine Society encourages all members to reflect on these and many other AAPI contributions that have shaped our field. Let us honor the enduring legacy and future leadership of AAPI endocrinologists by fostering a more inclusive and equitable community for all.
References:
https://pmc.ncbi.nlm.nih.gov/articles/PMC11776489/
https://endocrinenews.endocrine.org/deciphering-science-qa-with-v-krishna-chatterjee-md/
April 2025
Heart Health
Heart health is often associated with adults, but cardiovascular health begins in childhood and adolescence. Developing healthy habits early in life can significantly reduce the risk of cardiovascular diseases (CVD) later. Despite advances in medical care, the rising prevalence of risk factors such as obesity, diabetes, and dyslipidemia in youth has made addressing heart health a pediatric priority. Moreover, disparities in healthcare access and socioeconomic factors exacerbate the burden of cardiovascular risk among vulnerable populations.
Understanding Cardiovascular Diseases in Youth
Cardiovascular diseases in children and adolescents are rare but often stem from risk factors that manifest early, such as elevated body mass index (BMI), obesity, hypertension, diabetes, and dyslipidemia. Conditions like familial hypercholesterolemia (FH), where genetic mutations cause persistently elevated LDL cholesterol, highlight the importance of early detection and treatment. Left untreated, these conditions lead to premature atherosclerosis and cardiovascular events. The interplay between endocrine disorders such as type 1 and type 2 diabetes and CVD risk further underscores the need for a multidisciplinary approach to pediatric heart health.
Disparities Driving Cardiovascular Risks
Despite these preventive measures, disparities in access to healthcare, education, and nutrition contribute to inequities in cardiovascular outcomes. Children from low-income families and underrepresented racial and ethnic groups are disproportionately affected by obesity, diabetes, and hypertension. Limited access to nutritious foods, safe environments for exercise, and healthcare resources amplifies their risk.
These disparities are deeply intertwined with social determinants of health. For example, food insecurity and limited access to preventive care can delay diagnosis and treatment of modifiable risk factors. Structural racism and bias in healthcare systems further exacerbate these inequities, necessitating systemic change to promote equity in pediatric cardiovascular care.
Preventing Cardiovascular Diseases in Childhood
Prevention is the cornerstone of improving pediatric heart health. Strategies include promoting a healthy diet rich in fruits, vegetables, whole grains, and lean proteins while minimizing sugar and saturated fat intake. Encouraging regular physical activity and reducing sedentary behavior are also vital. Routine screening for blood pressure, lipid levels, and evaluation for diabetes in children at risk ensures early identification and intervention.
Pediatric endocrinologists are uniquely positioned to address cardiovascular risk in youth by managing underlying endocrine and metabolic disorders. Children with type 1 and type 2 diabetes face an increased risk of atherosclerosis due to chronic hyperglycemia and associated lipid abnormalities. Similarly, the management of obesity and conditions like polycystic ovary syndrome (PCOS) overlaps with cardiovascular prevention efforts. Pediatric endocrinologists play a crucial role in managing conditions like obesity, metabolic syndrome, and dyslipidemia, which significantly impact cardiovascular risk. For instance, timely initiation of statins in children with FH and glycemic control in youth with diabetes can mitigate long-term cardiovascular complications.
The Path Forward
Promoting heart health in children and adolescents requires a collaborative approach that integrates preventive strategies, early diagnosis, and equitable access to care. Addressing disparities and advocating for policies that support equitable healthcare access, such as universal cholesterol screening and lifestyle intervention programs, is imperative.
By fostering awareness and encouraging early interventions pediatric endocrinologists and primary care providers can work together to reduce the burden of cardiovascular diseases. Investing in the heart health of today’s youth not only ensures healthier futures for individuals but also strengthens communities and reduces the long-term burden of cardiovascular disease on society.
Suggested readings:
Kelishadi, R. (2022). "Metabolic syndrome burden in children and adolescents." The Lancet Child & Adolescent Health 6(3): 138-139.
Noubiap, J. J., et al. (2022). "Global, regional, and country estimates of metabolic syndrome burden in children and adolescents in 2020: a systematic review and modelling analysis." The Lancet Child & Adolescent Health 6(3): 158-170.
March 2025
International Transgender Day of Visibility (TDOV)
March 31st is International Transgender Day of Visibility (TDOV). Visibility is a nuanced and complex topic in the trans community. TDOV brings the resilience of the trans community to top of mind, as it highlights the community’s accomplishments and contributions. But visibility without safety is a trap – the trap we currently find ourselves in with continued attempts to “eradicate [transgender people] from public life entirely.” The cruel and dehumanizing attacks on the transgender community have now escalated on a federal level. Concurrently, the very existence of those with intersex traits/differences of sex development/variations of sex characteristics has been fundamentally ignored by the new administration. As pediatric endocrinologists – experts in reproductive development – we would be hard-pressed to draw a neat line between the “two sexes, male and female,” nor can we or should we point to a specific constellation of factors that determine gender identity. We applaud the recent PES statement in response to the Executive Order quoted above. Attempts to neatly and strictly categorize the beautiful diversity of humanity completely miss the point. We can say with certainty that trans people, gender-diverse people, people with intersex traits/DSD have always existed and always will, but we are equally sure that access to basic human rights such as equitable and inclusive health care is at significant risk on a national level. There are numerous paths forward and your voice and expertise can make a difference. Advocate for continued access to gender-affirming care at your institution through conversations with your leadership. Have meaningful discussions in your communities (with friends, family, in your places of worship or community centers) about what gender-affirming care for youth really is, and the life-saving effects of providing this care. Donate to, or volunteer with, organizations that provide medical, legal, and social services for the trans community. Continue to display your pronouns and make it a habit to use them in your visits with all patients. Write to your lawmakers as an expert in child health. There is a role for every type of contribution, big or small. Your patients and their families need your help building a world where their identities are celebrated and they are able to live safely and openly as themselves.
Authors:
Jacob Miller, DO, Fellow, Pediatric Endocrinology
Jax Whitehead, MD, Assistant Professor, Pediatric Endocrinology
February 2025
Black History Month is Celebrated in February (A Brief History)
Submitted by Ilene Fennoy and Ambika Ashraf
This historian Carter Woodsen and the Association for the Study of Negro Life and History, now known as the Association for the Study of African American Life and History (ASAALH) initiated the formal commemoration of Black history in 1926 with the calling for Negro History Week as the second week in February in honor of Abraham Lincoln’s birthday on February 12 and Frederick Douglas’ birthday on February 14th. (1)
Students at Kent State University first proposed Black History Month as a celebration in 1969 and organized an event on the campus of Kent State University in February 1970.(2) On February 10, 1976, President Gerald Ford announced February as Black History Month, a time to acknowledge the accomplishments of African Americans to every endeavor in American history. In 1986, Congress passed a Public Law designating February as National Black History Month. Today, Black History month is celebrated in February in the US and Canada, and in October in the United Kingdom.
This year’s theme for Black History Month 2025: African Americans and Labor, focuses on the role of African Americans in the Workforce. The ASAALH describes the goal of this year’s theme as:
“(a focus) on the various and profound ways that work and working of all kinds – free and unfree, skilled, and unskilled, vocational and voluntary – intersect with the collective experiences of Black people. Indeed, work is at the very center of much of Black history and culture. Be it the traditional agricultural labor of enslaved Africans that fed Low Country colonies, debates among Black educators on the importance of vocational training, self-help strategies and entrepreneurship in Black communities, or organized labor’s role in fighting both economic and social injustice, Black people’s work has been transformational throughout the U.S., Africa, and the Diaspora. The 2025 Black History Month theme, “African Americans and Labor,” sets out to highlight and celebrate the potent impact of this work.”
A comprehensive historical presentation of the role of labor in American economic development by those of African heritage is described in the book by J. William Trotter, “Workers on Arrival: Black Labor in the Making of America”(3).
As medical professionals we should recognize the contributions of Black medical pioneers and the role they have played in paving the way for greater equity in healthcare. Dr. Charles R. Drew, a trailblazer in blood banking and plasma storage, revolutionized modern medicine, saving countless lives. Dr. Drew advocated against racial segregation in blood donation policies. Dr. Daniel Hale Williams performed one of the first successful open-heart surgeries in 1893. Dr. Williams founded Provident Hospital in Chicago, the first Black-owned hospital in the U.S. Alexa Canady, the first African American female neurosurgeon, by focusing on hydrocephalus and congenital spinal disorders, broke barriers in the medical field.
Although not a physician, Henrietta Lacks has had an indelible impact on medical research. Her immortal HeLa cells have been integral to breakthroughs such as the development of the polio vaccine, cancer treatments, and advancements in gene mapping. Her story has sparked vital conversations about ethics, equity, and the importance of informed consent in medical research, reminding us of the need to safeguard the rights and dignity of all individuals.
Black History Month is more than a commemoration of the past; it is an opportunity to recognize the ongoing contributions of African Americans to every field, including medicine, labor, and social justice. As we celebrate this month, let us also reaffirm our commitment to fostering equity, diversity, and inclusion in all aspects of our work. Together, we can honor the past, celebrate the present, and inspire a future of greater equality and opportunity for all.
Reference List
- Chambers V. How Negro History Week Became Black History Month and Why It Matters Now. New York Times. 2021 February 25, 2021.
- Scott DM. The Origins of Black History Month2011 1/21/2025 [cited 2025 1/22/2025]. Available from: https://asalh.org/about-us/about-black-history-month/#origin.
- Trotter JW. Workers on Arrival: Black Labor in the Making of America: Univ of California Press; 2019 January 8, 2019. 328 p.
January 2025
January is Poverty in America Awareness Month
Submitted by Luz “Lucy” Castellanos, MD
Poverty in America Awareness Month, observed in January, highlights the systemic inequalities that contribute to economic hardship and promotes advocacy efforts to reduce poverty. With approximately 36.8 million people living below the poverty line in 2023, including 13.7% of children, poverty is an ongoing challenge that disproportionately impacts vulnerable populations.
Child poverty affects nearly 10 million children in the U.S. Efforts to combat child poverty include programs like SNAP, Medicaid, and the Children’s Health Insurance Program (CHIP). Advocacy for expanding the Child Tax Credit and initiatives led by organizations such as the Children’s Defense Fund (CDF) also play a significant role in addressing disparities. The CDF, founded in 1973, has influenced policies supporting children’s healthcare, education, and equitable opportunities, including the development of CHIP and juvenile justice reforms.
The American Medical Association has recognized poverty and systemic inequities as critical social determinants of health. Through the Center for Health Equity, the AMA focuses on addressing health disparities by training physicians on structural racism, advocating for policy changes like Medicaid expansion, and promoting equitable healthcare access. Its initiatives, such as the Strategic Plan to Embed Racial Justice and Advance Health Equity, empower physicians to address poverty's impact on health and drive systemic changes in their communities.
The American Academy of Pediatrics has developed a Social Determinants of Health Screening Tool to help pediatricians assess non-medical factors affecting children's health, such as economic stability, education, healthcare access, neighborhood conditions, and social support. This tool aims to provide a more holistic approach to care by identifying social issues that may impact a child’s well-being. By recognizing these challenges, physicians can connect families with community resources and social services, helping address underlying issues that contribute to poor health outcomes.
By combining direct care, advocacy, and collaboration with our communities, we can play an important role in improving outcomes for our pediatric patients facing poverty. Supporting these children holistically can break cycles of poverty and foster healthier futures.
Further reading:
https://www.census.gov/library/publications/2024/demo/p60-283.html
https://www.census.gov/library/stories/2024/10/child-supplemental-poverty-measure.html
https://www.ama-assn.org/about/leadership/ama-s-2024-2025-strategic-plan-advance-health-equity
December 2024
Universal Human Rights Month: Promoting Equity in Pediatric Endocrine Care
Submitted by Chineze Ebo, MD
Healthcare as a Human Right: Ensuring Equity in Endocrine Care
This December, as we observe Universal Human Rights Month, we recognize healthcare as a fundamental human right and emphasize the important role of health equity in improving pediatric endocrine care. Access to endocrine care is often challenged by disparities related to socioeconomic status, race, and geographic location, which may create barriers for some children in receiving the specialized endocrine care they need. The Pediatric Endocrine Society is dedicated to advancing health equity and ensuring that every child’s right to endocrine care is upheld.
Identifying Health Disparities in Endocrine Health
Children from marginalized racial, ethnic, and low-income communities often face obstacles in accessing essential endocrine care for conditions such as diabetes, growth disorders, obesity, and gender-affirming treatments. These disparities stem from systemic inequities in healthcare, contributing to delayed diagnosis, limited access to advanced treatments, and poorer outcomes. Some key disparities include:
· Cost Barriers: Treatments such as insulin and growth hormone therapy, as well as diabetes technologies such as continuous glucose monitors and insulin pumps remain financially inaccessible for some families, with out-of-pocket costs and restrictive insurance policies disproportionately burdening underinsured and low-income families.
· Geographic Disparities: Children in rural or underserved areas may have limited access to specialized care, leading to delays in diagnosis and treatment. Limited access to telehealth services, inadequate digital infrastructure, and provider shortages in these regions can further exacerbate disparities.
· Racial and Socioeconomic Biases: Implicit biases among healthcare providers and structural inequities within the healthcare system result in delayed referrals, misdiagnoses, or suboptimal treatment for children from marginalized communities. Additionally, structural barriers, including policies and healthcare delivery systems not designed to meet the needs of diverse populations, disproportionately disadvantage low-income families and communities of color.
· Research Gaps: Many research studies on endocrine conditions lack representation from racially and ethnically diverse populations, with current norms and diagnostic criteria often derived from data based on predominantly European populations, leading to biased diagnostic and treatment guidelines.
How Pediatric Endocrinologists Can Promote Equity and Rights in Care
Pediatric endocrinologists can play a pivotal role in addressing these challenges and advocating for equitable care through several key actions:
· Practice Cultural Sensitivity: Understanding and respecting diverse cultural and socioeconomic backgrounds is essential to improving patient engagement and outcomes. Using interpreters, developing culturally relevant education materials, and engaging in open, respectful communication are important steps.
· Bridge Access Gaps: Address barriers to care by collaborating with local health programs through community-based partnerships, such as working with schools and community centers to provide health screenings and educational workshops. Initiatives like mobile clinics, expanding satellite clinics in high-need areas, and enhancing telehealth services can significantly improve access to specialty care for underserved communities, offering solutions to families in remote or resource-limited areas.
· Educate and Empower Families: Providing families with the knowledge and resources to navigate complex healthcare systems including insurance appeals, financial assistance programs, and community resources, can reduce delays in treatment and improve care continuity.
· Advocate for Policy Change: Engaging in advocacy efforts can help address systemic barriers to care, such as the affordability of essential treatments and technologies. Participating in Pediatric Endocrine Society-led initiatives, committees, or local advocacy groups can strengthen collective efforts to ensure endocrine care is accessible to all children.
Universal Human Rights Month reminds us that equity in endocrine care is fundamental to upholding every child’s right to health. Together, we can make a difference by identifying disparities, supporting affected families, and advocating for a more just healthcare system. For more information on health disparities in endocrine care and actionable solutions, refer to the resource below.
Resource: Diaz-Thomas, A.M., Golden, S.H., Dabelea, D.M., Grimberg, A., Magge, S.N., Safer, J.D., Shumer, D.E., and Stanford, F.C., 2023. Endocrine health and health care disparities in the pediatric and sexual and gender minority populations: An Endocrine Society scientific statement. The Journal of Clinical Endocrinology & Metabolism, 108(7), pp.1533–1584. https://doi.org/10.1210/clinem/dgad124
November 2024
Honoring Indigenous Contributions: Celebrating National Native American Heritage Month and the Enduring Impact of Native Cultures on North American Society
November is national Native American Heritage Month first identified as such by a proclamation made by President George W. Bush in 1990( Native American Heritage Month | National Archives). It is a time for acknowledging the many contributions made by Indigenous peoples to our North American culture and for recognizing that we are a multicultural society having embraced, assimilated and expanded on many concepts and tools originating in Indigenous peoples’ culture. The Encyclopedia of American Indian Contributions to the World(1) documents 15,000 years of additions.
Examples include:
Political innovations such as the Iroquios Confederacy is dated as occurring in 1142, centuries before the Constitution of the United States. It served as a model for federalism, separation of powers, and participatory democracy inspiring Benjamin Franklin and James Madison and others in the formation of our government(2).
Socio-political contributions included a culture of equality amongst men and women that was characteristic of the Iroquios Confederacy. Theirs was a matriarchal society where authority ran through the women who had rights to their own property with final authority over land transfers, and decisions regarding war. Such independence and authority were unknown to Euroamerican women up until the 20th century. Political decisions involved everyone in a democratic fashion and provided a major inspiration to the women’s suffrage movement (3).
Agricultural innovations included the cultivation and breeding of plants indigenous to North America with resulting introduction of corn, potatoes, and new varieties of beans, squash, peppers, tomatoes, and other foods(1). Native American agriculture is considered important to the world representing more than 50% of its agricultural wealth.(4)
Native Americans developed and used various medical techniques and tools long before European-Americans including oral contraception, syringes, surgical techniques of debridement and wound drainage(1). Over 2500 species of plants were used for medicinal purposes (5) with over 200 plants becoming a part of the US Pharmacopeia(1). Currently 7 of the 10 most common herbal supplements sold in the US were used by Native Americans(6). Ethnobotany, the study of how plants are used for varied purposes by people, has become a major contributor to drug development(7).
This month also serves as a reminder of the significant role Native Americans have played in shaping the nation, while acknowledging the challenges they have faced, including colonization, displacement, and discrimination. National Native American Heritage Month provides an opportunity to celebrate the diverse cultural heritage and recognize the resilience, strength, and enduring spirit of Native peoples across the United States. Much has been learned and appropriated from Native American cultures to our benefit. Let’s honor this heritage in our recognition of how profoundly we have been affected by Native American culture.
Ilene Fennoy and Ambika Ashraf
Reference List
- Johansen BE. Encyclopedia of American Indian Contributions to the World: 15,000 Years of Inventions and Innovations. The American Indian Quarterly. 2002;26(4):667-73.
- Evans TT. How the Iroquois Confederacy was formed. A&E Television Networks; 2021. p. https://www.history.com/news/iroquois-confederacy-hiawatha-peacemaker-great-law-of-peace.
- Wagner SR. How Native American Women Inspired the Women's rights Movement. On Their Shoulders: The Radical Stories of Women's Fight for the Vote. Women’s Suffrage Centennial Commission (WSCC): National Park Service; 2020.
- Park S, Hongu N, Daily JW. Native American foods: History, culture, and influence on modern diets. Journal of Ethnic Foods. 2016;3(3):171-7.
- Moerman DE. An analysis of the food plants and drug plants of native North America. Journal of Ethnopharmacology. 1996;52(1):1-22.
- Borchers AT, Keen CL, Stern JS, Gershwin ME. Inflammation and Native American medicine: the role of botanicals123. The American Journal of Clinical Nutrition. 2000;72(2):339-47.
- Heinrich M. Ethnobotany and its role in drug development. Phytotherapy Research. 2000;14(7):479-88.
October Hispanic Heritage Month, "Pioneers of Change: Shaping the Future Together"
Submitted by Luz “Lucy” Castellanos, MD
This year's Hispanic Heritage Month theme, "Pioneers of Change: Shaping the Future Together," celebrates the trailblazers who have paved the way for future generations, advocating for progress and inclusion.
Among these pioneers includes Dr. Carlos Juan Finlay, who was a Cuban physician who solved the yellow fever mystery by discovering that the disease is transmitted by Aedes aegypti mosquitoes. Despite initial skepticism, his research led to the adoption of mosquito control measures that drastically reduced yellow fever outbreaks. His work, later confirmed by the U.S. Army Yellow Fever Commission, not only saved countless lives but also laid the foundation for modern strategies to combat vector-borne diseases.
In pediatrics, a notable pioneer is Dr. Helen Rodríguez-Trías, who was a Puerto Rican pediatrician and advocate. She was the first Latina president of the American Public Health Association, a founding member of the Women's Caucus of the APHA, and a recipient of the Presidential Citizens Medal due to her instrumental work in expanding public health services for marginalized women, children, and those with HIV/AIDS. Her legacy continues to influence healthcare policy.
Among the current scientist pioneers being recognized this year is Ellen Ochoa, the first Hispanic/Latinx woman astronaut, who inspires children, especially those of color, to embrace their curiosity and pursue STEM fields without fear of stereotypes (see link below to her bilingual STEAM book).
This year’s mission of change is also reflected in recent efforts, like the Hispanic Health Council’s Breastfeeding Heritage and Pride™ program, which tackles breastfeeding disparities among Hispanic/Latinx women. A recently published study of this program highlights the need for culturally tailored education and advocacy, supporting that community-driven interventions have the potential to significantly improve health outcomes.
Together, these examples show that we can all aspire to be pioneers of change by embracing diversity in our practices and advocating for inclusive, culturally competent healthcare.
Further readings:
https://cfmedicine.nlm.nih.gov/physicians/biography_273.html
September is Childhood Obesity Awareness Month!
Submitted by Andrew Kanouse, MD
Childhood obesity is one of the most prevalent chronic diseases in the pediatric population. Although combatting childhood obesity has been a CDC Healthy People goal for over 2 decades, rates of children with obesity continue to rise. According to the World Health Organization, pediatric obesity is “one of the most serious public health challenges of the 21st century”. Today, 1 in 5 children are considered obese, amounting to 15 million children. As the obesity epidemic propagates, as does the risk for and ultimately prevalence of comorbidities associated with high BMI. These include type 2 diabetes, hypertension, cardiac disease, dyslipidemia, sleep apnea, musculoskeletal problems, mental health difficulties, and continued obesity into adulthood, ultimately resulting in 2.6 million deaths annually from being overweight or obese.
To appreciate the impact of childhood obesity is to be aware that not all children are affected equally by this chronic illness. It is well-established that obesity is disproportionately more prevalent in specific populations, namely Hispanic and non-Hispanic children-about 2.5-3 more times than non-Hispanic white children. Importantly, these disparities start early. Data from WIC (which serves children <5 years old) in 2020 found that not only were young children increasingly reaching obesity-level BMIs (12.7% in 2 year olds, 15.2% in 3 year olds, and 16.3% in 4 year olds), but also that there was a major discrepancy in household income (11.5% of children whose family income was >350% of the Federal Poverty Level vs. 25.8% of children whose family income was <130% the Federal Poverty Level). There were also similar discrepancies in Hispanic and non-Hispanic Black children versus non-Hispanic White children, suggesting an early start in racial disparities.
Treatment options for obesity include behavioral & lifestyle interventions (the mainstay of treatment/prevention of obesity), pharmacotherapy, and bariatric surgery. Unfortunately, not all children are equipped with the same level of access to these effective treatment options. For one, lifestyle intervention looks much different for a child in areas where going outside, playing in a park, or swimming in a pool may not be available or safe options, let alone the ability to spend money for access to a gym. Additionally, for children who live in food deserts with energy-dense foods high in fat and sugar and without access to fresh nutritious food options, behavioral interventions are more difficult to employ and obesogenic environments more difficult to avoid. In terms of pharmacotherapy, anyone whose practice includes the prescribing of potentially life-changing anti-obesity medications knows the difficulties in attempting to do so for a patient with Medicaid, an entity that often does not cover these therapies. Furthermore, the price-tag on some of these makes paying out-of-pocket prohibitively expensive. Bariatric surgery, too, has a similar set of hurdles (for a helpful primer from the American Society of Metabolic and Bariatric Surgery, read:
https://asmbs.org/patients/adolescent-obesity/). Utilization of these therapies also relies on access to specialists, ability to follow-up with a practitioner frequently, parental education on these options, and social acceptance, all of which contribute to widening health access disparities.
Obesity is a chronic, relapsing, and progressive disease that is becoming increasingly more prevalent in our pediatric population starting younger and younger. While there are factors we as providers may not be able to change, there are factors at the individual, community/school, societal, and international levels that are amenable to intervention and can be helpful in combating the rising tide of obesity. It is also imperative that we as providers are mindful of the potential for implicit bias in our evaluation and management of minority populations for the sake of learning to educate ourselves on the ways in which we can ensure that any child, regardless of background, receives equitable care in all aspects of health, but especially in the realm of obesity. In the end, though, the most effective way to combat these trends is through prevention and doing so with the knowledge that prevention strategies for one population may not apply to another. We are encouraged to bring about creativity and flexibility in working with our patients to provide the best approaches that are tailored to each situation, as we do in all aspects of medicine.
For more reading about ways to approach pediatric obesity:
- Tools from WIC: https://wicworks.fns.usda.gov/topic/health-observances/national-childhood-obesity-awareness-month
- Move Your Way: https://health.gov/moveyourway/get-kids-active
- Boston Children’s Fit Kit: https://www.childrenshospital.org/programs/new-balance-foundation-obesity-prevention-center/boston-childrens-fit-kit
- Clinical review: Guide to pharmacological management in pediatric obesity medicine: doi.org/10.1016/j.obpill.2023.100066
- Pediatric Obesity—Assessment, Treatment, and Prevention: An Endocrine Society Clinical Practice Guideline: doi.org/10.1210/jc.2016-2573
- Where a child lives matters: neighborhood deprivation and pediatric obesity: doi.org/1097/MOP.0000000000001317
Women's Equality Day, August 26
Submitted by Ambika Ashraf and Ilene Fennoy
Women's Equality Day, observed annually on August 26, commemorates the certification of the 19th Amendment in 1920, which granted women the right to vote in the United States. It also should serve as a reminder that the certification of the 19th Amendment in 1920 was still insufficient to expand voting rights to all women as states based the right to register to vote on the payment of poll taxes until the passage of the 24th Amendment in 1962. Even then voting rights were limited by race until 1965 with the passage of the Voting Rights Act. And finally on August 6, 1975, the Voting Rights Act was extended to bar discrimination in the right to vote based on being a member of the “language minorities” community including Mexican Americans of Texas and California, Puerto Ricans, Native Americans, Asian Americans, Alaskans, Hawaiians. For women physicians, this day holds special significance as it highlights the ongoing journey towards gender equality in medicine and the need for relentless pursuit of the goal Since Elizabeth Blackwell became the first woman to earn a medical degree in the United States in 1849, the role of women physicians has evolved dramatically. Women now constitute a significant portion of the physician workforce, comprising 37.1% of active physicians in the U.S. as of 2021, compared to just 6% in 1950.
Despite significant progress, women physicians still face challenges in achieving parity with their male counterparts, including issues of pay equity, leadership opportunities, and work-life balance. In pediatric endocrinology, where women make up a substantial portion of the workforce, Women's Equality Day serves as a reminder of the importance of fostering inclusive environments that support the advancement of female physicians irrespective or racial and ethnic backgrounds. Women in this specialty still face challenges such as underrepresentation in leadership positions and disparities in recognition and awards. Additionally, there is a need to address gender-specific health issues and promote research that considers sex and gender differences in endocrine disorders affecting children and adolescents from all racial and ethnic backgrounds.
By celebrating Women's Equality Day, the medical community can reflect on the achievements of women in medicine while recommitting to creating equitable opportunities for all physicians, regardless of gender, race or ethnicity. For women in pediatric endocrinology, this day underscores the importance of fostering an inclusive environment where female endocrinologists can thrive. It serves as a call to actively promote equity, diversity, and inclusion, and to address implicit and explicit biases in healthcare. This includes providing mentorship for all trainees, fellows, and faculty in pediatric endocrinology, ensuring that female pediatric endocrinologists have equal opportunities for advancement and leadership roles. Celebrating Women's Equality Day within this field emphasizes the need to advocate for fair opportunities and support the professional development of women of all racial and ethnic backgrounds, ensuring they can contribute fully to advancements in pediatric healthcare.
Celebrating the Discovery of Insulin in July
Submitted by Ambika Ashraf, MD and Ilene Fennoy, MD
The discovery of insulin in July 1921 by Canadian scientists Dr. Frederick Banting and Charles Best revolutionized the treatment of diabetes, forever changing the lives of millions worldwide. This milestone highlights the profound impact of innovative research on medical science and patient care along with continued disparity in access to this vital resource. .
Despite the groundbreaking discovery of insulin over a century ago, managing diabetes through insulin therapy still presents numerous challenges. The high cost of insulin remains a significant barrier for many patients. Even in well-developed healthcare systems, the price of insulin can be prohibitively expensive, leading to rationing and suboptimal treatment. Those without adequate insurance or financial resources may struggle to afford their medication, leading to poor diabetes management and outcomes. Insurance coverage varies widely, and policies may not cover the latest diabetes technologies. Advocacy for broader and more equitable insurance coverage is necessary. This includes advocating for policies that control insulin price regulations, expand insurance coverage for advanced diabetes technologies and investment in healthcare infrastructure.
In many parts of the world, especially low- and middle-income countries, inconsistent supply chains lead to frequent shortages of insulin. International organizations are working towards global health equity, focusing on making insulin and diabetes care accessible and affordable in all regions of the world.
Continuous Glucose Monitors (CGMs) provide real-time blood sugar readings, which help in better management of insulin dosing. Insulin pumps deliver precise doses of insulin, reducing the risk of hypoglycemia and the burden of multiple daily injections. Access to these technologies is limited for those with lower income or inadequate insurance coverage. Efforts are being made to make these technologies more affordable and accessible to diverse populations through subsidies and insurance coverage improvements.
Historically, clinical trials for diabetes treatments and technologies have underrepresented minority populations. This lack of representation can lead to treatments that are less effective for these groups. Inclusive clinical trials and research initiatives ensure that advancements in diabetes care are applicable to all populations, including those historically underrepresented in medical research.
Moreover, patients in rural or underserved areas may have limited access to endocrinologists and advanced diabetes care technologies. Telemedicine and mobile health units can help bridge this gap but require investment and infrastructure.
While significant strides have been made in the treatment of diabetes since the discovery of insulin, challenges remain. High costs, administration complexity, and individual variability continue to hinder optimal diabetes management. Through continuous innovation and a commitment to equity, the future of insulin therapy and diabetes management holds promise for better health outcomes for all.
June is LGBTQIA+ Pride Month!
Submitted by: J Whitehead, MD
Pronouns: they/them
Attending Physician, Pediatric Endocrinology, Ann & Robert H. Lurie Children's Hospital of Chicago
Assistant Professor, Northwestern University Feinberg School of Medicine
June is LGBTQIA+ Pride Month. Pride Month honors the progress achieved towards equality while acknowledging the ongoing struggles faced by LGBTQIA+ individuals. Soon everything from cookies to company logos will be covered in rainbow colors – but just because it is rainbow colored doesn’t mean it is truly advocating for the LGBTQIA+ community. Do you know if your hospital has implemented best practices for equitable and inclusive care for LGBTQIA+ patients and employees? The Human Rights Campaign's Healthcare Equality Index Resource Guide is a great resource – and includes a special section for children’s hospitals. These activities not only foster community and solidarity but also serve as powerful reminders of the need for acceptance and equal rights. The number of pieces of proposed legislation restricting so many facets of LGBTQ+ life is staggering, and has increased over ten-fold in the last five years. Are there ways you could advocate for the trans and gender diverse youth in your state?
For many of us in academic settings, June also brings graduation ceremonies and signals the end of the academic year, while the excitement builds for the arrival of new trainees in July. With so many folks moving across state lines, it seems like an excellent time to remind everyone to update their voter registration! It may be the single most important thing you can do to advocate for acceptance and equal rights for all.
May is national Mental Health Awareness Month!
Submitted by: Andrew Kanouse MD, Cohen Children’s Medical Center
The 1940s was a decade where adequate mental health was difficult to come by. Following World War II, there was a notable increase in mental health difficulties amongst soldiers returning home. To this end, in July of 1946 then President Harry S. Truman passed the National Mental Health Act. This act became a beacon of hope for mental health by establishing it as a federal priority, emphasizing the need for identification and treatment of mental health disorders and encouraging medical health professionals to pursue careers in the field. A byproduct of this act was the creation of the National Institute of Mental Health, the underlying doctrine of which is described by its first director, Dr. Robert Felix, as the following: “The guiding philosophy which permeates the activities of the National Institute of Mental Health is that prevention of mental illness, and the production of positive mental health, is an attainable goal”. In 1949, National Mental Health Awareness Month was founded by Mental Health America and has been celebrated every May since.
Globally, It is estimated that 1 in 6 adolescents experience a mental health disorder. While necessary to recognize the importance and difficulties of maintaining adequate mental health and seeking resources to do so, especially in the pediatric population, it is also essential to recognize the specific difficulties so faced by minority populations for this purpose. Lack of treatment for mental health disorders can result in more debilitating, more pervasive, more persistent, and more severe manifestations of the disorder. Despite the goal of eliminating health disparities listed as a Healthy People goal in 2010 and 2020, such disparities in mental health persist. The most common mental health disorders in children in the U.S. include ADD/ADHD, anxiety, and depression. Overall, rates of these disorders being diagnosed in the pediatric population have been increasing, resulting in long-term negative consequences such as poor school performance, substance abuse, violence, long-term physical disorders, suicidal ideation/attempt, and persistence into adulthood.
It is estimated that about 50% of children in the U.S. with a mental health disorder remain untreated. While it is well known that treatment for these conditions improves outcomes, utilization of such treatment remains low particularly among minority populations. In a survey between 2016-2021, surveyors found that non-Hispanic African-American children were at increased risk for unmet needs for any mental health condition in general, but especially behavioral problems, as compared to their peers. Further, Asian and Hispanic children were both at increased risk for unmet needs for anxiety disorders compared to non-Hispanic White peers. Additionally, Hispanic children were also more likely to have unmet needs for depression.
There are notable barriers that lead to disparities in mental health care between race/ethnicities. These include physical access to treatment facilities and transportation barriers or travel distance, the ability to schedule/attend an appointment depending upon the structure of the child’s household (for example, a single parent household), insurance, language differences, health literacy, and social stigma. Utilization is notably less in those without insurance and those of lower socioeconomic status, often delaying treatment until symptoms become severe and require escalated level of treatment. In the end, lack of physical access especially to outpatient care results in increased mental health-related hospitalization for minorities. Access to psychiatric care for individuals with Medicaid is a particular challenge and results in more limited options for these children. Intra-cultural stigma and ideas of mental health play an important role in seeking care. Minority parents are more likely to find disagreement with a physician in their assessment of psychiatric symptoms, leading to no care/delayed care. Further, Hispanic and African-American parents are often more resistant to pharmacotherapy as an acceptable treatment modality for their children. Even the initiation of discussing mental hygiene varies widely between groups, cutting off the ability for care from the start for children. Whether from stigma or other reason, African-American and Hispanic children report seeking care for mental health at about half of the rate as their White counterparts-an important aspect of a healthcare model that traditionally focuses on treating those who seek care. Finally, minority individuals are more receptive to treatment from individuals of their own race/ethnicity, which becomes itself a barrier to find such available practitioners. Minorities, especially those who are born outside of the U.S., are also more likely to discontinue treatment altogether prematurely, possibly for this reason.
What can be done? For one, providers can be cognizant of the cultural differences inherent in mental health, such as familiarizing ourselves with cultural-specific symptoms of particular disorders. For example, not assuming that the behaviors exhibited by a particular child are second to their cultural norms and not an underlying mental health disorder. This would help to decrease the influence that race has on providers as key gatekeepers of referral to mental health resources. Providers can expand their efforts beyond the traditional practice focus and extend their advocacy efforts into community-based projects more likely to align with differences of cultural mindset. Finally, we can utilize the efforts made to expand insurance coverage, such as the Mental Health Parity and Addiction Equity Act, Children’s Health Insurance Program, and Medicaid, to increase access for eligible children to receive the care they need and ultimately prevent the long-term sequelae of untreated mental health disorders.
The theme of this year’s Mental Health Awareness Month is “Where to Start: Mental Health in a Changing World”. In an ever-changing world full of potential threats to mental health for individuals of any age, from a pandemic to global wars to climate change to increasing racial tensions and everything in between, it can be difficult for people to know where begin to address their mental wellbeing. And if you want to celebrate even further, May 9 specifically is Children’s Mental Health Awareness Day. So much mental health awareness to spread around!
Further Resources:
- Where to Start Campaign: https://mhanational.org/mental-health-month
- Addressing the Mental Health Needs of Racial and Ethnic Minority Youth- a guide for practitioners: https://www.apa.org/pi/families/resources/mental-health-needs.pdf
- Barriers and Facilitators for Mental Health Service Use Among Racial/Ethnic Minority Adolescents: A Systematic Review of Literature: doi.org/10.3389/fpubh.2021.641605
- Framework for Understanding and Addressing Racial and Ethnic Disparities in Children's Mental Health: doi: 10.1016/j.chc.2021.11.001
April is National Minority Health Month
Championing Diversity and Representation in Politics
Authored by Kara Connelly
Disparities identified in minority health have often been attributable to social determinants of health that result from social structures amenable to changes in policy coming out of the political process. With just over 6 months out from the election, all eyes are turned to the national stage. As this attention heightens, we continue to watch extraordinary numbers of bills/laws targeting transgender youth enter the legislative landscape. We have seen many pass and signed into law over the last few years, demonstrating the importance of local politics. While it would be easy to lose hope at a time like this, we are also seeing historic gains in the number of politicians representing diverse communities elected into public office. The PES EDI task force would like to highlight two such individuals.
Andrea Jenkins made history in 2017 by becoming the first openly transgender black woman elected to public office in the United States. After working as a vocational counselor for over 10 years, she returned to graduate school and completed two master’s degrees. She then served on the campaigns of several local politicians and worked as an aide for City Council members. In 2017, motivated by the results of the 2016 presidential election, she decided to run for office herself and was elected to the Minneapolis City Council. Throughout her tenure on the City Council, Jenkins has been a vocal advocate for marginalized communities, working to address issues of racial inequality, LGBTQ+ rights, affordable housing, and police reform. One of Jenkins' notable achievements is her role in establishing the Transgender Equity Council in Minneapolis, which focuses on advancing the rights and well-being of transgender and gender-nonconforming individuals. Her advocacy within the council has led to significant policy changes aimed at combating discrimination and improving access to healthcare, housing, and employment for transgender people.
Beyond her work in politics, Andrea Jenkins is also a celebrated artist and poet whose creative expression explores themes of identity, resilience, and the human experience. Her poetry collection, "The T is Not Silent," eloquently captures the complexities of being transgender in a society that too often marginalizes and erases the experiences of transgender individuals.
In 2020, Stephanie Byers, a member of the Chickasaw Nation and a transgender woman, became the first openly transgender state lawmaker in Kansas and one of the first Indigenous transgender people elected to a state legislature in the United States. Her victory was not just a personal triumph but a groundbreaking moment for transgender and Indigenous representation in politics.
Prior to entering politics, Byers worked at a local high school for 29 years teaching band, orchestra, and jazz. She was named Educator of the Year by the Gay, Lesbian & Straight Education Network. During her time in the Kansas House of Representatives, she was a vocal proponent of policies that promote diversity, equity, and inclusion in schools, including measures to support LGBTQ+ students and educators. She actively engages with her constituents and community organizations and recognizes the importance of grassroots organizing and coalition-building in effecting meaningful progress on issues ranging from healthcare access to environmental justice.
“With each election, we see the various state legislatures begin to resemble more and more the constituencies they represent,” she said in a speech she gave after winning her election. “Each election we see more of ourselves in the people we elect to power.”
In this negative news cycle, transgender youth, specifically BIPOC transgender youth, are experiencing high degrees of anxiety and fear. Both the youth and their families worry about the future and have few positive examples of transgender adults to look to as role models. Andrea Jenkins and Stephanie Byers are shining examples of the power of representation and the transformative impact of diverse voices in shaping our democracy. They represent two pathways and beacons of hope that change will come.
March: The Article of Confederation
Ambika Ashraf and Ilene Fennoy
The Articles of Confederation, ratified by all thirteen states on March 1, 1781, marked a seminal moment in American history, serving as the United States' first constitution. Although the Articles themselves were replaced by the current U.S. Constitution in 1789, they have had a lasting influence on the political landscape of today in several key areas of American political thought, governance, and federal-state relations.
The Articles of Confederation emerged from the Continental Congress, a body formed by representatives from the thirteen colonies initially convened to coordinate resistance against British rule. As the American Revolution gained momentum, it became clear that a form of government was needed to manage the collective efforts of the colonies. The Articles were drafted in 1777, amidst the uncertainties of war and the strong libertarian ethos that characterized the American revolutionary spirit. The Articles of Confederation were primarily focused on common defense, securing liberties, and fostering mutual welfare.
One of the most significant contributions of the Articles of Confederation to the modern political landscape is the concept of federalism and the emphasis on state sovereignty. The Articles established a confederation of states where the central government had limited powers, and the states retained a significant degree of autonomy. This framework laid the groundwork for the federal system under the current Constitution, where power is divided between the national government and the states. The tension between state and federal authority continues to be a central theme in American politics, influencing debates on issues ranging from education and health care to immigration and environmental regulation.
The Articles of Confederation underscored the importance of civic engagement and democratic participation. By granting significant powers to the states, the Articles encouraged political participation at a local level, a principle that remains vital in American democracy. The emphasis on local governance under the Articles has influenced the decentralized nature of political engagement in the U.S., where state and local governments play a key role in addressing the needs and concerns of their citizens. This decentralization fosters a closer connection between citizens and their government, encouraging active participation in the democratic process.
The process of ratifying the Articles of Confederation, which required unanimous consent from all thirteen states, highlighted the importance of compromise in governance. The lengthy ratification process, particularly the resolution of disputes over western land claims, demonstrated the necessity of finding common ground among diverse interests. This spirit of compromise is a foundational principle of the American political system, evident in the structure of the Constitution itself, which resulted from revision of the Articles of Confederation in 1787.
The Constitution, was the product of numerous compromises (e.g., the Great Compromise resulting in the creation of our two congressional houses: one providing each state with representation by population, the other providing each state equal representation irrespective of size; and the Three-Fifths Compromise resolving the issue of whether slaves were property or people by permitting States with slaves to count the slaves as 3/5 of a person for the purpose of determining population size and taxes). It is the 3/5 compromise that is often referred to as the enshrinement of African American slavery in the formation of this country and the constitution which ultimately was repealed with the 14th Amendment to the Constitution in 1868. The ability to negotiate and compromise remains crucial in contemporary American politics, facilitating the functioning of a diverse and pluralistic society.
The Articles of Confederation represent a critical step in the evolution of American constitutionalism. By establishing the United States' first national government, albeit a weak one, the Articles set the stage for the development of the U.S. Constitution. Although the Articles of Confederation represented a critical step towards nationhood, its weaknesses became apparent soon after its implementation. The lack of a strong central government to regulate commerce, levy taxes, or maintain a standing army left the United States vulnerable and financially strained. These deficiencies led to the Constitutional Convention of 1787, which resulted in the drafting of the Constitution, a document that significantly enhanced the powers of the national government while also embedding checks and balances within the system.
The principles of federalism, the importance of compromise, the evolution of American constitutionalism, and the emphasis on civic engagement and democratic participation are all legacies of the Articles that continue to shape American political thought and governance. By laying the foundational principles of the United States' political system, the Articles of Confederation have had a lasting impact on the nation, underscoring the importance of unity, governance, and democracy in the American context.
February is Black History Month: Celebrating the Legacy of James McCune Smith, MD
Dr. James McCune Smith was the first Black person from the US to earn his medical degree. He had an impressive resume, graduating from the University of Glasgow with a BA in 1835, MA in 1836 and MD in 1837 (either at or near the top of his class no less!). He returned to his birthplace of New York City in 1839 to open a medical practice, the first Black-owned pharmacy in the US and an evening school that were accessible to people of all races.
As a physician, Smith cared for children at the Colored Orphan Asylum in New York City. He walked almost 7 miles a day from his home to the orphanage as a local rail company did not allow him to ride on its streetcars due to his race. When the directors of the orphanage learned of this, they arranged transportation on his behalf. Smith served as medical director of the Colored Orphan Asylum for 20 years, treating children with measles, whooping cough, smallpox and tuberculosis.
In 1844, Smith became the first Black person from the US to publish in a peer-reviewed medical journal. Of interest to us, he published a case series of 5 women who developed secondary amenorrhea due to opium use. This paper was notable at the time for several reasons. Drawing on his previous experiences in Glasgow, Smith observed that discontinuing opium led to return of regular menses in most of the women. This was contrary to contemporary works at that time. Smith’s paper also alluded to the influence of addiction and social determinants of health on women’s health. One of the women Smith described was an 18-year-old who Smith had prescribed opium to treat menstrual cramps. Smith stated, “without my knowledge, [she] continued using the pills”. Of the 5 women, he also reported that 4 did sex work, 3 had physical pain and 2 had psychological ailments.
In 1846, Smith became the first Black physician to author a scientific publication exposing racism in medicine. Smith wrote A Dissertation on the Influence of Climate on Longevity in response to US Secretary of State John C. Calhoun’s proslavery efforts. Calhoun used the racially biased 1840 Census to condemn abolitionism, claiming free Blacks in the North had higher mortality rates than those that were enslaved in the South. In A Dissertation on the Influence of Climate on Longevity, Smith used biostatistics to show that Black people lived longer in states that had abolished slavery. He challenged the idea that racial differences in mortality rates were biological: “there are sufficient grounds for the belief that the slaves…under all [their] disadvantages, would, if freed from slavery, attain a longevity not very much below that attained by the Europ-American population”. More than 180 years later, racial and ethnic disparities still exist in medicine. In our field, we look no further to disparities in outcomes related to diabetes, obesity, growth hormone deficiency and Cushing disease to name a few.
In addition to his clinical and scientific pursuits, Smith was a fierce proponent of social justice. He used his academic prowess to write on a wide range of issues including Black citizenship after the Supreme Court’s decision in Dred Scott v. Sandford as well as edit newspapers where free Black people could express their opinions. He aided enslaved Blacks on the Underground Railroad and pushed for Black and women’s suffrage. He worked with Frederick Douglass to establish the National Council for Colored People in 1853 and the interracial Radical Abolitionist Party in 1855. Smith was a trailblazer.
As pediatric endocrinologists who provide clinical care, advance scientific research, and educate future leaders, it is important for us to recognize the part we play in addressing systemic racism. We can follow in the example of those who came before us, like Dr. John McCune Smith, by celebrating their accomplishments and building on the work that remains.
Further readings:
https://jamanetwork.com/journals/jama/article-abstract/2786889
https://journals.physiology.org/doi/epdf/10.1152/advan.00119.2018
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2594637/pdf/jnma00311-0106.pdf
https://www.smithsonianmag.com/history/james-mccune-smith-america-first-black-physician-180977110/
Diabetes Technology Equity
Sarah Allan, MD, University of Alabama at Birmingham
Continuous glucose monitors (CGM) and insulin pump technologies have changed the landscape of diabetes management through improvements in glycemic control and reducing burden of disease management. In 2022, the American Diabetes Association made CGM standard of care and recommended offering automated insulin delivery systems to all patients who are capable of safely using them. The American Diabetes Association Standards of Care 2023 state that for all patients “the use of CGM devices should be considered from the outset of diagnosis of diabetes that requires insulin management.” In pediatrics, early use of CGM in pediatric patients with diabetes has been shown to decrease A1C and improve parental satisfaction with management strategies.
Despite the clear benefits of technology in terms of health outcomes, access remains challenging for many patients. Patients with Medicaid have been shown to be two to five times less likely to be prescribed CGM. This effect is more pronounced for non-White patients. Non-White patients, independent of insurance type, have lower rates of pump and CGM use. Importantly for those of us caring for patients with diabetes, non-White patients are less likely to have CGM or pump discussed or prescribed by their diabetes care team. Ensuring quality care for these patients must include physician led advocacy for the use of these evidence-based technologies to improve outcomes.
Medicaid coverage of CGM and insulin pumps may also play a role in the inequities seen in diabetes technology. According to ADA standards, patients who are using CGM and automated insulin delivery systems need to have continuous access to supplies. Patients on Medicaid may face greater bureaucratic hurdles in order to maintain insurance and these plans are less consistent in coverage compared to private commercial plans of CGM and pump. In our state, we have had success with an advocacy campaign in getting CGM coverage for all patients with Medicaid and type 1 diabetes, but there remains significant work to be done in order to advocate for patients with Medicaid to have equal access to CGM and pump therapies.
Multiple previous studies have demonstrated that non-White patients with diabetes have increased frequency of diabetic ketoacidosis, increased Hemoglobin A1C, and more frequent rates of hypoglycemia. These findings are more pronounced for those with Medicaid compared to commercial insurance. CGM with or without use of an automated insulin delivery system has been shown to reduce both hypoglycemia and rates of diabetic ketoacidosis. Given the known benefits of CGM and pump technology in reducing the risk of many of these poor outcomes, limitations in access to these technologies among groups of patients who have higher risk of short and long term health outcomes related to diabetes deserves urgent attention.
Traditional teaching tended to reserve insulin pump therapy for patients with lower A1Cs due to slight increase in diabetic ketoacidosis (DKA) risk. However, we must recognize that this risk does not necessarily apply to modern hybrid closed loop pumps used in conjunction with CGM. When we hesitate to discuss or prescribe automated insulin delivery systems for patients with elevated A1Cs, we are failing to offer them tools shown to consistently improve glycemic control. Moreover, our reluctance disproportionately limits access for non-White, non-English speaking patients for whom multiple studies have shown to have higher A1Cs and increased risk of DKA. Importantly, there is no evidence that these patients derive less benefit than their White counterparts from use of automated insulin delivery systems in terms of improving health outcomes.
Our patients with diabetes rely on us for specific guidance when navigating choices related to managing their disease. We recognize that technology improves outcomes and that those most at risk of poor outcomes have the least access to these technologies. We must work to check our biases in order to offer technology equitably and continue to advocate for better access to standard of care technologies for all patients.
Further Reading:
Agarwal S, Simmonds I, Myers AK. The Use of Diabetes Technology to Address Inequity in Health Outcomes: Limitations and Opportunities. Curr Diab Rep. 2022 Jul;22(7):275-281. doi: 10.1007/s11892-022-01470-3. Epub 2022 Jun 1. PMID: 35648277; PMCID: PMC9157044.
Charlene W. Lai, Terri H. Lipman, Steven M. Willi, Colin P. Hawkes; Racial and Ethnic Disparities in Rates of Continuous Glucose Monitor Initiation and Continued Use in Children With Type 1 Diabetes. Diabetes Care 1 January 2021; 44 (1): 255–257. https://doi.org/10.2337/dc20-1663
ElSayed NA, Aleppo G, Aroda VR, Bannuru RR, Brown FM, Bruemmer D, Collins BS, Cusi K, Das SR, Gibbons CH, Giurini JM, Hilliard ME, Isaacs D, Johnson EL, Kahan S, Khunti K, Kosiborod M, Leon J, Lyons SK, Murdock L, Perry ML, Prahalad P, Pratley RE, Seley JJ, Stanton RC, Sun JK, Woodward CC, Young-Hyman D, Gabbay RA, on behalf of the American Diabetes Association. Introduction and Methodology: Standards of Care in Diabetes-2023. Diabetes Care. 2023 Jan 1;46(Suppl 1):S1-S4. doi: 10.2337/dc23-Sint. PMID: 36507647; PMCID: PMC9810461.
Sarah Kanbour, Marissa Jones, Mohammed S. Abusamaan, Caitlin Nass, Estelle Everett, Risa M. Wolf, Aniket Sidhaye, Nestoras Mathioudakis; Racial Disparities in Access and Use of Diabetes Technology Among Adult Patients With Type 1 Diabetes in a U.S. Academic Medical Center. Diabetes Care 2 January 2023; 46 (1): 56–64. https://doi.org/10.2337/dc22-1055
Tanumihardjo, Jacob P., et al. "Integrating Technology and Human Capital to Address Social Needs: Lessons to Promote Health Equity in Diabetes Care." Journal of Health Care for the Poor and Underserved, vol. 32 no. 2, 2021, p. 241-261. Project MUSE, https://doi.org/10.1353/hpu.2021.0061.
December
December is full of holidays and observances! But in all the end-of-year bustle, don’t sleep on learning about the 2023 Nobel Prize winners, celebrated during the annual ceremony on December 10th. Several of the winners this year exemplify themes relevant to EDI work.
The Nobel Peace Prize was awarded to Narges Mohammadi recognizing her unwavering activism in championing women’s rights in Iran. Regrettably, she is currently incarcerated.
The Sveriges Riksbank prize in Economic Sciences was awarded to Claudia Golden for her research to understand historic and contemporary drivers of the pay gap between men and women.
The Nobel Prize in Physiology or Medicine was shared by Katalin Karikó and her colleague Drew Weissman. Dr. Karikó grew up in Hungary and came to the US for a postdoc in the mid-1980s. Though she has faced many obstacles in her research career, she and her colleagues pioneered the mRNA research that allowed the development of the COVID-19 vaccines. https://www.carnegie.org/awards/honoree/katalin-kariko/
Information about all the laureates this year can be found here: https://www.nobelprize.org/all-nobel-prizes-2023/
November is Native American Heritage Month and Diabetes Awareness Month
The Native American Heritage Month is also referred as American Indian and Alaska Native Heritage Month.
This month is a special time to celebrate the rich and diverse cultures, traditions, and histories and to acknowledge the important contributions of Native people to the current society. Heritage Month is also a special time to educate everyone about tribes and the ways in which tribal citizens have worked to conquer these challenges.
One of the most beautiful traditions of the Native people is the respect of the Land and Land Awareness acknowledges. This respect affirms the connections between Indigenous Peoples and the land, emphasizing the importance of tribal communities, the occupied or unceded status of native lands, and all surrounding history. Land Awareness also brings to light the experiences, perspectives, and histories that hold crucial significance in both contemporary and future narratives.
Land Awareness can be practiced by anyone and this can be practiced through an acknowledgment, such as the universal inclusion of one within email signatures, stationery, and publications. In the current context of global warming, and the terrible consequences of the highly developed industry, and many other actions including pollution, deforestation and others, the respect of the Land in general can help us to learn new strategies to protect our planet.
November is also Diabetes Awareness Month, and I think we can link and celebrate these two important events as there could be a connection between these 2 events. Diabetes mellitus affects about 37 million Americans, including adults and youth. Diabetes can damage the eyes, kidneys, nerves, and heart, and it is linked to some types of cancer. This year the focus in on the prevention of diabetes’ health related problems.
There are three ABC goals to focus in diabetes mellitus care, A for hemoglobin A1C, B for blood pressure, and C for high cholesterol. It is very important to incorporate healthy life style habits, including daily exercise, planning healthy meals, getting enough sleep, and avoiding smoking.
Planning healthy meals may include activities such as gardening to grow our own vegetables and fruits, eating more produce and also practicing mindful eating habits. Mindful eating also involve appreciation for the food we eat, and all the elements involved in bringing foods to our tables: the land, the nature elements supporting the grow of the vegetables/fruits/legumes and even the animals raised by the farmers, and all the other steps needed to bring any fresh food to our table.
Protecting our lands, mother nature and the planet, can also make an impact into our overall global health.
Let’s take a moment to celebrate these two important events this month.
October is Health Literacy Month
Health Literacy Month has been observed every October. Author Helen Osborne established the month in 1999 as a tool to increase access to healthcare information. The overarching goal is to raise awareness about the importance of health literacy and promote better understanding of health information among individuals and communities. The Institute for Healthcare Advancement, National Institute of Health, and U.S. Department of Health and Human Services all provide extensive resources and training in health literacy.
Definition of Health Literacy:
Health literacy refers to an individual's ability to access, understand, evaluate, and apply health information to make informed decisions about their health and well-being. It encompasses various skills, including reading, listening, analytical assessments, and decision-making skills.
Goals of Health Literacy Month:
- Raise awareness about the importance of health literacy in improving healthcare outcomes.
- Empower individuals to take an active role in managing their health.
- Encourage healthcare team members to communicate effectively and provide understandable health information to patients.
- Promote policies and initiatives that enhance health literacy at the community level.
Challenges Associated with Low Health Literacy:
- Misunderstanding of medical instructions and health information.
- Difficulty in navigating the healthcare system.
- Increased risk of medication errors and healthcare disparities.
- Limited ability to make informed healthcare decisions.
Activities and Initiatives:
- Health organizations, schools, and communities often organize events and workshops to promote health literacy.
- Healthcare providers may focus on improving communication with patients, using plain language and visual aids.
- Educational campaigns are launched to provide tips and resources for improving health literacy. (See resources and references below.)
Promoting Health Literacy:
- Use plain language when creating health materials and instructions.
- Ensure cultural sensitivity in healthcare communication.
- Encourage questions and active engagement from patients during medical visits.
- Practice person-centered care and shared decision making.
- Provide accessible and easy-to-understand health resources.
Positive Impact of Health Literacy:
- Improved health outcomes as individuals are better equipped to manage their health conditions.
- Reduced healthcare costs through prevention and early intervention.
- Enhanced patient-clinical team communication and trust.
- Better understanding and adherence to medical advice and treatment plans.
- By increasing health literacy, we can enhance healthcare outcomes, reduce disparities, and ultimately lead healthier lives.
Resources:
- Health Literacy Online
- Institute for Healthcare Advancement
- Tips, Training, and Resources from National Institute of Health
- My Healthfinder – resource and tool for patients and families
September is Latinx and Hispanic Heritage Month: A Closer Look at Debates and Disparities
Is it Latinx or Hispanic?
It's important to note that this debate is complex and varies among individuals and communities. Some people prefer "Hispanic" due to its familiarity, while others appreciate the inclusive intent of "Latinx." Ultimately, the term used can be a personal choice, and it's important to respect individuals' preferences when referring to their identity. Here's a brief overview of the key points in this debate:
- The term "Hispanic" emerged in the United States in the 1970s as a way to categorize people from Spanish-speaking countries.
- Critics of the term argue that it primarily emphasizes Spanish language and heritage, often overlooking the diverse indigenous, African, and other cultural influences that contribute to the identities of people from Latin America.
- Some people identify with and prefer the term "Hispanic" because it reflects their linguistic and cultural ties to Spanish-speaking countries.
- The term "Latinx" is a more recent development and seeks to be gender-neutral, as Spanish is a gendered language where nouns and adjectives are assigned masculine or feminine forms.
- "Latinx" aims to be more inclusive of gender identities beyond the binary and acknowledges that the terms "Latino" and "Latina" might not fully encompass the diversity of gender identities within the community.
- Advocates for "Latinx" argue that it is a more inclusive and respectful term that reflects the complexity of identities within the Latin American and Spanish-speaking community.
What does the month celebrate?
It is an annual observance in the United States that celebrates the culture, contributions, and history of Latinx and Hispanic Americans. It is observed from September 15 to October 15 each year, encompassing the independence anniversaries of several Latin American countries, including Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua, Mexico, and Chile.
What health disparities exist in this population?
The Latinx and Hispanic population in the United States continues to experience significant health disparities that can be attributed to a combination of socioeconomic, cultural, and structural factors. Some key health disparities include:
- Access to Healthcare: According to the CDC, Hispanics are nearly 3 x as likely to be uninsured compared to non-Hispanic Whites. This can lead to delayed or inadequate medical care, making it difficult to manage chronic conditions and receive preventive care.
- Chronic Conditions: The Office of Minority Health reports that Hispanics are 1.3x as likely to die from diabetes compared to non-Hispanic whites. Hispanics have dramatically higher rates of certain chronic health conditions such as diabetes, obesity, and hypertension compared to other ethnic groups. These conditions are often linked to lifestyle factors, genetics, and socioeconomic disparities.
- Language Barriers: Limited English proficiency can hinder effective communication between healthcare providers. It is important to always work with interpreters to reduce misunderstandings and misdiagnoses.
- Cultural Factors: Some Hispanics may prefer traditional remedies or distrust mainstream medical practices, affecting their willingness to seek medical care or adhere to treatment plans. See links below for more information.
- Socioeconomic Status: Socioeconomic factors, such as poverty and limited educational opportunities, contribute to health disparities. Hispanics are more likely to live in poverty and have lower educational attainment, which can impact their overall health and access to healthcare.
- Immigration Status: Undocumented immigrants within this population may face additional barriers to healthcare access due to fears of deportation, lack of legal status, and limited eligibility for public health programs.
What can healthcare professionals do? Cultural competency is critical to have the understanding and skills necessary to effectively interact with diverse patient populations.
Addressing health disparities among the Latinx and Hispanic population requires a multi-faceted approach that includes improving access to culturally sensitive healthcare services, promoting health education and awareness, addressing socioeconomic inequalities, and fostering a more inclusive healthcare system that takes into account the diverse needs and experiences of Latinx and Hispanic individuals and communities.
Relevant links:
Diabetes and Hispanics: https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=63
Hispanic heritage month: https://www.minorityhealth.hhs.gov/hispanic-heritage-month/
https://www.cdc.gov/healthequity/features/hispanic-heritage-month/index.html
Hispanic and Latinx terminology discussion: https://www.npr.org/2021/09/17/1037741009
Hispanic traditional remedies: https://holisticprimarycare.net/topics/traditions/a-guide-to-hispanic-healing-herbs/
Resources for doctors treating immigrant patients: https://doctorsforimmigrants.com/resources/
Future Leaders Advancing Research in Endocrinology (FLARE): https://www.endocrine.org/our-community/career-and-professional-development/future-leaders-in-endocrinology
ExCEL Workshop: https://www.endocrine.org/our-community/diversity-equity-and-inclusion/excel-program/excel-workshop
A history of protection for persons with limited English proficiency in the United States
Submitted by: Jessica. A. Schmitt MD, University of Alabama at Birmingham
August 9th is International Day of the World’s Indigenous Peoples and is an important time to reflect upon how language impacts our patient encounters. According to the UN, there are approximately 476 million indigenous people living in 90 countries and these indigenous peoples speak the majority of the world’s 7000 languages. Currently, many providers are accustomed to using an interpreter during clinical encounters. The history of legal protections for language in healthcare, however, is relatively new.
Much of the current protections for patients with limited English proficiency (LEP) are based on the 14th Amendment (equal protection) and the Civil Rights Act. In 1964, title VI of the Civil Rights Act passed stating “No person in the United States shall, on the ground of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance.”
Discrimination based upon national origin and access to language services was addressed in the 1974 US Supreme Court case Lau vs. Nicholas. The Court ruled 9-0 in favor of Kinney Kimmon Lau, a non-English speaking student of Chinese descent who attended the San Francisco Unified School District. At the time, some students with LEP in the district had access to English proficiency courses, but not all did. The court ruled that not providing supplemental classes in English language violated Lau’s equal protection under the 14th amendment and violated the Civil Rights Act (1964) by discriminating based upon national origin. While this case did not directly discuss healthcare, all providers and institutions receiving Federal assistance could be considered affected by this ruling.
The late 1990s and first decade of 2000s were filled with milestones for those with LEP. In 1995, Health and Human Services (HHS) Office of Minority Health established a Center for Linguistic and Cultural Competence in Health Care (CLCCHC). Five years later, this office released formal National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health Care. The same year (2000), the HHS Office for Civil Rights issued its first Limited English Proficiency Guidance, and President Clinton signed Executive Order 13166 which required (under Department of Justice oversight) Federal agencies to “examine the services they provide, identify any need for services to those with LEP, and develop and implement a system to provide those services so LEP persons can have meaningful access to them.”
In 2010, the Affordable Care Act included Section 1557 which further codified protections and provisions for patients with LEP. This section includes language access as a key component of equitable care. Protections include preventing patients from paying for oral interpretation services, preventing automated translation for written materials without a quality check by a qualified translator.
In contemporary medical practice we accept that quality interpretation services are an essential component of delivering quality healthcare and should be delivered at no cost to the patient. As you can see however this is the result of tireless efforts to protect the rights of patients with LEP. While not all indigenous peoples speak the non-majority language, many do. Of the 7000 languages currently spoken, 40% of them are endangered. Ensuring patients can receive healthcare in the language of their choice goes a long way to showing indigenous peoples respect for their culture and a more welcoming health care system.
Further readings:
https://www.dol.gov/agencies/oasam/regulatory/statutes/title-vi-civil-rights-act-of-1964
https://www.justice.gov/crt/executive-order-13166
https://www.britannica.com/topic/Lau-v-Nichols
https://thinkculturalhealth.hhs.gov/clas/health-equity-timeline
Americans with Disabilities Act – July 26, 1990
On July 26, 1990, Congress passed the Americans with Disabilities Act, or ADA. This Act attempted to extend the types of rights provided under the Civil Rights Act of 1964 to individuals with disabilities. In brief, the ADA made it illegal to discriminate against individuals with disabilities in areas such as public accommodation, employment, transportation, and access to local government programs and services.
Of note, the ADA was not the first national law trying to protect against discrimination. Section 504 of the Rehabilitation Act of 1973 was the first national law to protect qualified individuals from discrimination based upon their disability. The Rehabilitation Act covers federal contractors and programs receiving federal funds. The ADA expanded this by prohibiting discrimination in employment, public services, public accommodations, and telecommunications. Under both statutes, employers are prohibited from discriminating against qualified applicants and employees with disabilities, and are required to provide accommodations for such individuals, unless doing so would cause an "undue hardship" on the business.
For us as pediatric endocrinologists, an important question is what services schools are required to provide for our patients, whose illnesses (e.g. diabetes) may qualify as a disability.
Vis-a-vis requirements for education of students with disabilities, the two main pertinent laws are Section 504 of the Rehabilitation Act and the Individuals with Disabilities Education Act (IDEA). IDEA is a federal law governing special education services in the US and provides some federal funding to state and local education agencies to guarantee special education and related services for students who meet eligibility criteria. Section 504, by contrast, is a civil rights statute requiring that schools (public or private) which receive federal financial assistance for educational purposes not discriminate against children with "handicaps (ie disabilities) and provide reasonable accommodations to these students, comparable to those provided to their peers. Section 504 is not a financing statute but does provide for enforcement of the mandate - schools that are found by the Office of Civil Rights to be out of compliance with Section 504 risk having their federal funding removed.
NOTE: ~10% of children in the US attend private institutions. ~80% of those children attend religious schools. Private schools which do not receive federal funding are not required to provide accommodations for students with disabilities; however, many private schools (including religious schools) do receive some federal funds and are thereby obligated to provide accommodations for students with disabilities under section 504. Possible forms of federal assistance include but are not limited to:
- Free or reduced breakfast and lunch programs
- Special education grants
- Funding for at-risk students
- Technology assistance or program grants
- Funding for textbook or supplies
- Professional development programs for teachers and staff
- School choice voucher programs
There was a Supreme Court ruling of some pertinence to this in 2023. The Supreme Court recently considered the interplay between the Individuals with Disabilities Education Act (IDEA) and other federal laws protecting students with disabilities, particularly the Americans with Disabilities Act (ADA). In Perez v. Sturgis Public Schools, a deaf student sought money damages under the ADA for his school district’s alleged failure to provide him with any interpreting services for most of his schooling. The questions before the Court were (1) whether the IDEA requires children with disabilities and their parents to complete state-level administrative proceedings before filing related ADA claims in court, even when further administrative proceedings are “futile”—that is, when they cannot provide the child with any further relief; and (2) whether plaintiffs seeking only money damages under the ADA must pursue the IDEA administrative process at all, when money damages can never be awarded in IDEA proceedings.
The Court issued its decision in Perez on March 21, 2023, declining to rule on the first question. On the second, contrary to the position of every circuit court to consider the issue, the Court held that plaintiffs do not have to go through the IDEA’s administrative process when they seek damages or other remedies under the ADA or Section 504 of the Rehabilitation Act of 1973 (Section 504) that the IDEA does not allow. This Sidebar reviews the statutory and legal background of the case, the implications of the Court’s ruling and the issues that remain undecided, and some potential considerations for Congress.
March 28, 2024: State of the Art: EDI
Title: Disparities in Diabetes Technology: An Evidence-based Roadmap to Equity
Description:
In this webinar, we will discuss multi-factorial drivers of disparities in pediatric type 1 diabetes with a specific focus on the role of diabetes technology utilization. We will cover evidence-based solutions to address disparities relevant to clinicians and researchers alike. We will also discuss emerging technology disparities and system-level solutions to mitigate new disparities.
Learning Objectives
- Recognize diabetes technology as a modifiable risk factor in type 1 diabetes and identify populations at risk of inequitable diabetes care.
- Illustrate how diabetes technology is underutilized in minoritized populations and is subject to inequity.
- Recognize ways to identify and mitigate inequities in diabetes technology use.
Speaker: Ananta Addala, DO, MPH, Assistant Professor of Pediatrics at Stanford University
Podcast Club
Please join the PES Health Systems & Disparities Committee for a virtual Podcast Club on Tuesday, June 9, 2026, at 6:15 PM Eastern. This moderated community discussion will focus on the New York Times audio article, “Genetic Data From Over 20,000 U.S. Children Misused for ‘Race Science.’”
New York Times audio article · January 24, 2026
nytimes.com/2026/01/24/us/children-genetics-race-science.html
The 20-minute audio piece raises important questions about research ethics, community trust, race as a social versus biological construct, and the responsibility of scientific and medical communities to advocate for ethical data governance. Participants are encouraged to listen to the article in advance and come prepared for a thoughtful discussion with HSD colleagues across PES.
The session will be facilitated by Dr. Ilene Fennoy, MD, MPH. All PES members are welcome Zoom link will follow.
Resources for Addressing Implicit Bias
We encourage you to review these links:
- AAMC Addressing Implicit Bias in Virtual Interviews Video
- AAMC Unconscious Bias in Virtual Interviews Resources
- Harvard Project Implicit for Health Care: https://implicit.harvard.edu/implicit/user/pih/pih/index.jsp
- Mosquito bite video: https://www.youtube.com/watch?v=hDd3bzA7450&ab_channel=FusionComedy
Additional EDI Resources of Interest
-
- The importance of having a diverse physician workforce: https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2769772?guestAccessKey=99147c6d-8204-4930-bcbb-881ff12de18e&utm_source=fbpage&utm_medium=social_jamaim&utm_term=4053501956&utm_campaign=article_alert&linkId=103462324
- Resource to help understand and address vaccine hesitancy in minority communities:
- C:\Users\if1\Dropbox\PES EDI Task Force\Vaccine Hesitancy in Minority Communities[4522].docx
- https://freakonomics.com/podcast/compassionomics/ This is a podcast on the compassion crisis in medicine.
- Future Leaders Advancing Research in Endocrinology (FLARE)If you are a basic science or clinical research trainee from an underrepresented community in endocrinology, FLARE is for you. The program will equip you with leadership and professional skills and the chance to meet and grow your network of colleagues and mentors. Please apply today! www.endocrine.org
- Excellence in Clinical Endocrinology LeadershipExCEL provides clinical trainees from underrepresented communities with the resources needed to develop professional skills and a network of colleagues and mentors that will help advance their careers. www.endocrine.org
PES Addressing Health Disparities Research Grant
Each year we solicit applications for the Addressing Health Disparities Research Grant. The Purpose of this grant is to support the development of research and education in equity, diversity and inclusion involving pediatric endocrinology that will enhance pediatric endocrinologists’ ability to understand the needs of their patients and colleagues and deliver more equitable and inclusive education and services to a diverse population of trainees, colleagues, and patients. The current open call will close December 16, 2024!
Click here for more information
PES Cookbook Initiative
On behalf of The Health Systems Disparity Committee Committee of The Pediatric Endocrine Society, we are very pleased to inform the PES membership of a new initiative: The “PES Community Cooking Initiative.”
Each day is a new opportunity for us to eat healthily. We are creating a PES Cultural Cookbook, a collection of culturally diverse recipes. Please share your favorite recipes here https://pedsendo.org/pes-cooking-initiative/ it can vary from a family recipe from your ancestors or one you have invented yourself. We believe this initiative will help us understand our history, diversity, interactions, cultures, and traditions. Please include carbohydrate counting information with your recipe.
GET INVOLVED!
Email Info@pedsendo.org if you are interested in getting involved!