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Harnessing social determinant of health data to identify and engage high risk populations for diabetes prevention

Award Number: K01MD017270
ORGANIZATION: NATIONAL CENTER ON MINORITY HEALTH AND HEALTH DISPARITIES
OPDIV: NIH
AWARD CLASS: DISCRETIONARY
AWARD ACTIVITY TYPE: TRAINING/TRAINEESHIP
PERIOD OF PERFORMANCE START DATE: 06/26/2022
PERIOD OF PERFORMANCE END DATE: 03/31/2026

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Harnessing social determinant of health data to identify and engage high risk populations for diabetes prevention - Type 2 diabetes disproportionately affects those with low socioeconomic status (SES), while unfavorable neighborhood factors — such as lack of physical activity resources, limited healthy food options, socioeconomic disadvantage and barriers to health care — often intersect with low individual SES, compounding disparity. This intersectionality of multiple levels of influence (individual, neighborhoods, society) results in populations at greater risk for developing diabetes, and likely contributes to marked regional variations in diabetes risk. Given that approximately 88 million adults in the U.S. have prediabetes, and most structured diabetes prevention approaches (e.g. lifestyle modification and medications) require significant time and financial investment, efforts that enable health care providers to prioritize the most high-risk patients would optimize benefit. Diabetes risk prediction models can be used to identify individuals at high-risk for progression to diabetes; however, traditional models include clinical parameters with little integration of social factors, ignoring the multiple levels of influence on disease prevention. Thus, integrating social determinants of health (SDoH) data into risk stratification has the potential to identify individuals at high risk for diabetes based on clinical and social vulnerabilities, facilitating better targeted interventions and reductions in disparities. Importantly, risk stratification approaches that utilize SDoH in the electronic medical record (EMR) may provide an avenue to improve diabetes outcomes and address disparity at the population level. Moreover, understanding how to recruit and engage high-risk patients, as well as how to individualize prevention efforts — such as the Diabetes Prevention Program — has potential to improve diabetes outcomes and healthcare access at the population level. Therefore, the goals of this K01 proposal are to: (1) evaluate the addition of SDoH to a validated diabetes risk prediction model — the cardiometabolic disease staging (CMDS) — to determine improvement of risk classification in two population-based cohorts; (2) determine the prevalence of adults at high-risk for diabetes, both clinically and socially, in the UAB Health System using risk stratification; and (3) identify strategies to engage individuals at high risk for diabetes in diabetes prevention using stakeholder engagement. Conducting this research, in combination with the training and mentoring plan proposed, will help me to obtain skills and experience in health disparities and SDoH measurement; stakeholder engagement and qualitative methods; and diabetes clinical outcome measurement. This award will allow me to develop my independent research path focusing on utilizing social determinants of health (SDoH) data to inform the design of better tailored initiatives for the prevention of cardiometabolic disease. This study will provide the groundwork to inform a future trial to assess the effectiveness of delivering the Diabetes Prevention Program, based on clinical and SDoH factors, to ultimately decrease disparities.


Issue Date FY	Funding FY	Legal Entity Name	Legal Entity Address	Legal Entity City	Legal Entity State	Legal Entity Zip Code	Legal Entity COUNTY	Legal Entity COUNTRY	Assistance Listing	Award Code	Budget Year	Action Date	Action Type	Action Amount

Issue Date FY: 2025 ( Subtotal = $129,524 )
2025	2025	UNIVERSITY OF ALABAMA AT BIRMINGHAM	701 S 20TH STREET	BIRMINGHAM	AL	35294	JEFFERSON	USA	Minority Health and Health Disparities Research	002	4	4/18/2025	NON-COMPETING CONTINUATION	$129,524
2025	2025	UNIVERSITY OF ALABAMA AT BIRMINGHAM	701 S 20TH STREET	BIRMINGHAM	AL	35294	JEFFERSON	USA	Minority Health and Health Disparities Research	003	4	8/25/2025	NON-COMPETING CONTINUATION	$0
2025	2024	UNIVERSITY OF ALABAMA AT BIRMINGHAM	701 S 20TH STREET	BIRMINGHAM	AL	35294	JEFFERSON	USA	Minority Health and Health Disparities Research	000	3	3/18/2025	NON-COMPETING CONTINUATION	$0
2025	2024	UNIVERSITY OF ALABAMA AT BIRMINGHAM	701 S 20TH STREET	BIRMINGHAM	AL	35294	JEFFERSON	USA	Minority Health and Health Disparities Research	001	3	4/18/2025	NON-COMPETING CONTINUATION	$0
														Subtotal = $129,524

Issue Date FY: 2024 ( Subtotal = $128,579 )
2024	2024	UNIVERSITY OF ALABAMA AT BIRMINGHAM	701 S 20TH STREET	BIRMINGHAM	AL	35294	JEFFERSON	USA	Minority Health and Health Disparities Research	001	3	5/26/2024	NON-COMPETING CONTINUATION	$12,857
2024	2024	UNIVERSITY OF ALABAMA AT BIRMINGHAM	701 S 20TH STREET	BIRMINGHAM	AL	35294	JEFFERSON	USA	Minority Health and Health Disparities Research	000	3	3/31/2024	NON-COMPETING CONTINUATION	$115,722
														Subtotal = $128,579

Issue Date FY: 2023 ( Subtotal = $125,377 )
2023	2023	UNIVERSITY OF ALABAMA AT BIRMINGHAM	701 S 20TH ST	BIRMINGHAM	AL	35294	JEFFERSON	USA	Minority Health and Health Disparities Research	000	2	3/25/2023	NON-COMPETING CONTINUATION	$125,377
														Subtotal = $125,377

Issue Date FY: 2022 ( Subtotal = $129,967 )
2022	2022	UNIVERSITY OF ALABAMA AT BIRMINGHAM	701 S 20TH ST	BIRMINGHAM	AL	35294	JEFFERSON	USA	Minority Health and Health Disparities Research	000	1	6/26/2022	NEW	$129,967
2022	2022	UNIVERSITY OF ALABAMA AT BIRMINGHAM	701 S 20TH ST	BIRMINGHAM	AL	35294	JEFFERSON	USA	Minority Health and Health Disparities Research	001	1	8/2/2022	NEW	$0
														Subtotal = $129,967

Grand Total All Awards = $513,447

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Harnessing social determinant of health data to identify and engage high risk populations for diabetes prevention

Award Number: K01MD017270

ORGANIZATION: NATIONAL CENTER ON MINORITY HEALTH AND HEALTH DISPARITIES

OPDIV: NIH

AWARD CLASS: DISCRETIONARY

AWARD ACTIVITY TYPE: TRAINING/TRAINEESHIP

PERIOD OF PERFORMANCE START DATE: 06/26/2022

PERIOD OF PERFORMANCE END DATE: 03/31/2026

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