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EClinicalMedicine 2022;43: 101244 Published online xxx https://doi.org/10.1016/j. eclinm.2021.101244 In the United States (U.S.), changes in healthcare decision making are a result of the acquisition of new knowledge from a spectrum of sources. These sources span randomized clinical trials (RCTs) to real-world observational evidence (RWE). Currently, acquisition of data begins later in the life course of both the individual and the disease when a diagnosis occurs or a cluster of risk factors for developing diabetes is recognised. Information on the social gradient of a community − and an individual’s position on that gradient − is less often discussed, let alone measured. The social gradient in health refers to the phenomenon whereby the lower an individual’s socioeconomic position, the worse their health. This inverse association between social class and health plays out across the entire community. An individual’s position in this downward social gradient begins early in life and ascending the social ladder can be a major challenge. Reliance on healthcare “solutions” based solely on easily-measured biological data while failing to consider population-level social gradients will perpetuate the status quo to the detriment of both individuals and communities facing a disproportionate burden of diabetes. A microcosm of the impact of a social gradient in the U.S. today can be seen in the nation’s capital within a stone’s throw of the seats of legislative power. Washington, D.C., is divided into 8 wards spanning 6.5 miles. Despite geographic proximity, wards vary by race and by clustering of social factors known to impact diabetes care. For the Black community of Washington D.C., socioeconomic status, neighborhood and built environment, health access and social context are perpetual drivers of the progression of diabetes. For example, Wards 7 and 8, home to overwhelmingly Black constituents approximately 93% and 90% respectively have rates of diabetes 1.5 to 5 times greater than Wards 2 and 6, which are populated by a much lower proportion of Black residents. These dynamics repeat across the social determinants, revealing a consistent downward social gradient from the healthy white wards to the comparatively unhealthy Black Wards (Table 1). With the recent pivot to virtual diabetes care, existing disparities are likely to be exasperated by the high rate of