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.
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/
https://academic.oup.com/mend/article/28/8/1383/2623317
Archive - Monthly notable dates/events
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
Ethics in Pediatric Endocrinology: Curriculum for Fellows and Faculty
February 11, 2025, 7:30PM Eastern time
Join us for a discussion of the Ethics curriculum and how we might use this as a template for an EDI curriculum.
Henry R, Rossi W, Nahata L. Ethics in Pediatric Endocrinology: Curriculum for Fellows and Faculty. Ethics in Pediatric Endocrinology: Curriculum for Fellows and Faculty - PubMed
Join us for robust discussion: https://zoom.us/meeting/register/r_-lw02_T9q_foLhuEyciA
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
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- 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!