Sixty people with diabetes were identified at 11 homeless shelters, of whom 50 agreed to participate (response rate 83%). Characteristics of the participants are shown in . The median age was 49 years, and the median monthly income was $516. During the month before the survey 40% of the participants had experienced difficulties obtaining the necessities of life. CAGE scores of 3 to 4 (strongly suggestive of alcoholism) were found in 38% of the subjects. A previous diagnosis of depression, manic-depressive illness or schizophrenia was reported by 40% of the group. The diabetes history of the participants is shown in . The age at which diabetes was diagnosed ranged from 10 to 73 years (median 44 years).
Overall 72% of the participants reported experiencing difficulties managing their diabetes. Qualitative analysis of free-response comments revealed that most of the difficulties could be classified into a limited number of categories (). More than half of the group (64%) reported difficulties and concerns with the diet available at shelters: the most commonly mentioned issues were excessive amounts of starch and sugars (cited by 14%), relatively few fruits and vegetables (cited by 12%) and large amounts of fat (cited by 8%). Others stated, in more general terms, that meals at shelters were not appropriate for people with diabetes. A lack of choice in their diets was reported by 16% of the participants, who typically described their options as eating the food provided, even when it was ill-suited for people with diabetes, or simply forgoing most of their meal. Typical comments are quoted from 3 individuals: ”The food in the shelter has a lot of fat and is high in carbohydrate. I can‚t control my diet here anyway, so I don‚t bother measuring my blood sugar.” ”I have no choice [in my diet] at the shelter, so I skip a large proportion of each meal.” ”The diet here has a lot of starch, very little vegetable, … lots of gravy and sauces. I can‚t choose proportions; I throw out half the meal.”
The second major category of difficulties involved scheduling and logistic issues (). Representative comments are quoted from 2 individuals: ”I can‚t schedule anything. I must revolve around the shelter schedule, so nothing is consistent.” ”I can‚t time my insulin with my food; I‚m supposed to take insulin half an hour before my meals and usually I can only get it 10 minutes before.”
Shelter residents taking insulin face particular problems. Because of concerns about injection drug use, some shelters forbid residents to possess needles. One individual stated, ”I give myself insulin in the bathroom most mornings, but if I ever got caught, they‚d give me a hard time.” Others described a constant fear of theft: ”I hope that no one takes my insulin or my needles. I‚m dealing with junkies and crackheads and they want the needles.”
None of the respondents spontaneously mentioned difficulty obtaining health care services as a problem for their diabetes management. On specific questioning, however, 12% reported having difficulties making appointments and 20% experienced difficulties keeping their appointments with their usual physician. Only 6% stated that they did not feel comfortable or welcomed when they saw their physician. Potentially important barriers to health care included lack of a health insurance card (reported by 24%) and lack of a drug benefit card (reported by 52%), although only 2 respondents reported difficulties obtaining prescription medications or insulin syringes. Sixteen percent of the participants reported difficulties storing their medications (for diabetes or other conditions) in a safe place.
Of the 48 participants who underwent hemoglobin A1c testing 21 (44%) had inadequate glycemic control as defined by Canadian Diabetes Association guidelines. Hemoglobin A1c levels were significantly higher in the study participants than in US adults with type 2 diabetes (). Inadequate glycemic control was not significantly associated with age (less than 50 years v. 50 years and older), sex, self-reported difficulties with diabetes management, difficulties obtaining the necessities of life, having a regular source of diabetes care, possession of a blood glucose self-monitoring unit, major mental illness or CAGE score. Inadequate glycemic control was more common among subjects with a history of crack or cocaine use than among those without such a history (73% v. 35%), but this trend did not reach statistical significance (p = 0.06).
Fig. 1: Distribution of hemoglobin A1c levels in a group of homeless adults in Toronto with type 2 diabetes mellitus (white bars) and in a population-based sample of adults in the United States with type 2 diabetes13 (black circles).