Housing and diabetes

Jada Renee Louis from Virginia had type 1 diabetes. She was 24 years old when she died in 2019, a week after hospital care for diabetic ketoacidosis. ‘Louis, who did not have health insurance coverage, couldn’t afford the cost of her insulin doses and pay her rent. She chose to skip doses in order to pay her rent.’1 In an online survey by the American Diabetes Association, among 3539 respondents with diabetes, 32.4% had experienced missed payments on bills or cut down spending since the start of the COVID pandemic. Default or imminent default on mortgages or other debts affected 15.6%, twice the national rate, and 7.6% had become temporarily or fully homeless, 48 times the national average.2 Worldwide, 1.6 billion people live in inadequate housing and about 15 million are evicted by force annually.3 ‘On a single night in 2022, roughly 582,500 people were experiencing homelessness in the United States. Six in ten (60%) were staying in sheltered locations…and four in ten (40%) were in unsheltered locations such as on the street, in abandoned buildings, or in other places not suitable for human habitation.’4 In England, between January and March 2023, 83,240 households were homeless or threatened with homelessness, 5.7% more than the same quarter in 2022. In addition, 37,890 were threatened with homelessness.5 Homeless people may be ‘street homeless’, for example sleeping rough in doorways, or ‘hidden homeless’ – sofa surfing or staying in hostels or shelters.6 In England, since 2018, specified public bodies must ‘refer, with consent, users of their service who they think may be homeless or threatened with homelessness to a local housing authority of the individual's choice.’ The local authority must provide temporary accommodation to an applicant who is unintentionally homeless, eligible for assistance and has priority need. Priority needs include people who are vulnerable, or have a disability. ‘104,510 households were in temporary accommodation on 31 March 2023…up 10.0% from the same time last year.’5 Homeless people can also claim benefits (universal credit) if they are on the streets, sofa surfing or staying in a hostel. They need an address to do this – the hostel, day centre, local job centre. People with diabetes may be able to claim disability benefits. (See Box 1.) Cost of living, including diabetes and benefits • Diabetes UK Helpline 0345 123 2399 • Diabetes UK. Cost of Living. https://www.diabetes.org.uk/guide-to-diabetes/life-with-diabetes/cost-of-living • Diabetes and Benefits. https://www.diabetes.co.uk/diabetes-and-benefits.html Housing advice • Shelter Helpline 0808 800 4444 • https://www.shelter.org.uk/ Housing options for older people • Age UK. Homelessness. https://www.ageuk.org.uk/information-advice/care/housing-options/homelessness/ Dietary guidance for homeless people • Diabetes UK. Dietary guides for people with diabetes who are homeless or in temporary living. https://www.diabetes.org.uk/professionals/resources/shared-practice/homeless-or-temporary-living • East End Health Network. Diabetes diet guide for people that are street homeless. http://www.eehn.co.uk/street-homeless-t2d-guide.html Factors contributing to homelessness include the person's or household's financial, psychological, cognitive, health, physical, and behavioural state. Geography, availability of affordable, accessible, or appropriate housing, local or national systems or barriers, and discrimination may contribute, as may natural disasters. Homeless people often have multiple health issues including chronic diseases, mental health disorders, infectious diseases, and substance abuse, as well as injuries (the streets are hard on the feet), and heat or cold exposure. Their health problems may be worsened by poverty, poor access to health care, inability to pay for health care, non-adherence to treatment, lack of access to clean water, and poor hygiene. ‘For these reasons, a cycle is created in which poor health is a risk factor for homelessness and homelessness increases health needs.’7 Premature mortality is high among homeless people. Among the Boston Homeless Program population, mean age at death was 51.2 (19.3–93.5) years; men comprised 61% of the study cohort but 81% of those who died. Compared with the general population locally, mortality was nine times higher among 25–44 year olds and 4.5 times higher in 45–64 year olds. The commonest cause of death was drug overdose, then cancer and heart disease.8 One US review and meta-analysis found a prevalence of self-reported diabetes in 39 studies of homeless people to be 8.0% (6.8–9.2%), similar to that of people with homes.7 People on low incomes are more likely to require emergency hospital treatment for hypoglycaemia or hyperglycaemia. In a Canadian study, people on the lowest income quintile were 44% more likely to have glucose emergencies than those in the highest quintile.9 In a UK study, diabetes complications were more common among people with diabetes with lower income and lower educational achievement, particularly retinopathy and heart disease.10 In a survey of US safety-net health centres, unstable housing was defined as ‘not having enough money to pay rent or mortgage, moving two or more times in the past 12 months, or staying at a place one does not own or rent.’ Among people with self-reported diabetes and unstable housing, 13.7% had had a diabetes-related hospital emergency attendance or admission in the past year, OR 5.17 (2.08–12.87) compared with those in stable housing. Just 0.9% of people with unstable housing had been given help with housing through their diabetes clinic.11 In a study in Wisconsin, 38.1% of adults reported housing insecurity; they were less likely to attend a physician's visit (0.58 [0.37–0.92]), A1c check (0.45 [0.26–0.78), or eye check (0.61 [0.44–0.83]) than other people.12 A review of type 2 diabetes management interventions for homeless adults in 2020 found 223 articles for potential inclusion but only six (all in developed countries) met inclusion criteria, highlighting the difficulties of studying this. There were few statistical analyses. Diabetes education was offered and may have contributed to a fall in HbA1c. Medication access, safe storage, concordance, and adjustment were major issues, particularly for those on insulin. Homeless people were unlikely to have health insurance. Blood glucose testing systems were supplied but their effect on glucose control was unclear. One study provided dietetic input and intake of healthier foods improved.13 A small study showed that chronic disease self-management training was feasible among some homeless people.14 After being rehoused Dwayne said: ‘[L]et's get real… do you care what you are fed in a shelter?! The important thing is whether I’m being fed or if I’m going to bed hungry… Being able to prepare my meals is such a blessing, one that I won’t take for granted, because I know how quickly I can lose everything AGAIN!!!’15 Georgina said: ‘Now I have a home where I can keep my medications and I know where they are. I don’t have to keep them in a backpack or garbage bag that I carried around with me. I keep my blisterpacked medications on the table, where I can remember to take them. And I don’t have to worry about people stealing my medications anymore. My diabetes is bad, but it would have been a lot worse if I didn’t get a home.’15 A clinic for homeless people with diabetes was established in Westminster, UK. (Box 2.) Multi-agency working was vital. ‘[T]he programme works with the homeless person and very often the key worker to encourage attendance at clinics. We also work with third sector organisations and the local dedicated homeless person primary care units to put in support to encourage attendance if required. This could include asking the person to attend clinic alongside someone from these organisations, or allowing the homeless person to use the organisation's office as an address.’ Among their patients, 95% of hidden homeless and 50% of street homeless managed to attend their first diabetes team appointment.6 1. Within your diabetes team, review how you care for homeless people and how you might improve this 2. Make it easy for health and social care staff to refer homeless people with diabetes to the diabetes team 3. The main aim is that the person maintains contact with the diabetes team 4. Allocate a case manager if possible 5. Don’t make assumptions. For example, street homeless people may have mobile phones so can receive and respond to messages, and appointment reminders 6. Provide very practical advice, with achievable goals. Even small improvements in care will help 7. Food is crucial. Where are your local free food suppliers and when are meals provided? Work with local hostels. Help patients choose healthier options from what is available 8. Help with foot care and foot wear 9. Know all your local health and social care providers and work with them. Network, attend case conferences. You and your patient need their help 10. Help homeless people navigate the system I’m embarrassed to say that I’ve rarely asked people with diabetes about their housing situation. It was only after repeated admissions with serious infections that a patient with diabetes told me that their house had no roof. We spend a lot of time discussing glucose control yet housing problems are a greater risk to health than the minutiae of blood glucose tests. We need to know our patients better. Homelessness has increased with the COVID pandemic. The recent American Diabetes Association survey showed it affected people with diabetes more than those without diabetes. Homeless people are more likely to die prematurely than those with a home. People with diabetes and no home or housing instability are more likely to have problems with glucose control and diabetes complications than those with stable housing. Locally tailored multidisciplinary, multi-agency diabetes, health, and social care can help people with diabetes with homelessness or housing instability. Ask your patients about their housing and social situation. Guide them to national or local help if they have housing problems. (See Box 1.)

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