Impact and Trends of Type 2 Diabetes in the AAPI Community
Prepared by Reshana Homma, PharmD (2023 grad from Northeastern University)
Reviewed by Katelyn O'Brien, PharmD, BCPS, CDCES, BC-ADM
AAPI Heritage Month
Asian American and Pacific Islander (AAPI) Heritage Month is observed during the month of May in the United States to celebrate the influence, history, and cultural diversity of Asian Americans and Pacific Islanders. It offers an opportunity to promote understanding of the experiences and achievements of the AAPI community while also raising awareness of the specific challenges they face.1
As clinicians, it is essential for us to be aware of the health disparities that exist within diverse patient populations to improve patient outcomes and practice culturally sensitive care. In recognition of AAPI Heritage Month, this post aims to discuss the impact of type 2 diabetes (T2D) in the AAPI community and its implications in clinical practice.
The AAPI community covers a broad range of ethnic backgrounds. They are often reported aggregately, but it is important to note that this is a significantly diverse group of individuals with distinct identities and cultures. Members from the Asian American subgroup may have origins from the Far East (China, Japan, Korea, and Mongolia), Southeast Asia (Cambodia, Malaysia, the Philippine Islands, Thailand, Vietnam, Indonesia, Singapore, Laos, etc.), or the Indian subcontinent (India, Pakistan, Bangladesh, Bhutan, Sri Lanka, and Nepal). Pacific Islanders may include Native Hawaiians, Samoans, Tongans, Chamorros, or Marshallese. Many treatment guidelines and screening tools do not take into account the specific subgroup that a member of AAPI may be a part of. As clinicians, appreciating the distinct identities and cultures within the AAPI population is essential for more targeted and effective care.1,2
Despite the differences that exist among the various AAPI subgroups, T2D continues to be a significant health concern in this population. Data collected from 2017-2018 found that Asian Americans are 40% more likely to be diagnosed with diabetes than the non-Hispanic white population.3 Furthermore, Pacific Islanders are 2.5 times more likely to be diagnosed with diabetes, as compared to the non-Hispanic white population.4 In 2021, the prevalence of diabetes for American Samoans was 20.3%, 23% for Marshallese adults and 23.4% of those living in the Northern Mariana Islands.4,16
Differences in Pathophysiology and Fat Distribution
The development of T2D is strongly linked to factors such as weight gain, obesity, a sedentary lifestyle, diet, and insulin resistance. However, the connection between excessive body fat and diabetes is more complex among individuals of Asian and Pacific Islander descent. It is surprising that South Asians and East Asians generally have lower average body mass index (BMI) and waist circumference. Due to variations in body composition and associated health risks, the BMI categories for Asian Americans is slightly different from the general population. The World Health Organization (WHO) and National Institute of Health (NIH) have a higher cutoff for overweight and obese categories that are adopted specifically for White, Hispanic, and Black individuals compared to the thresholds recommended by the Asia-Pacific specifically for individuals of Asian descent:6-9
WHO/NIH (non-specific to Asian individuals)
The above cutoffs indicated by WHO underestimate risk in those with Asian descent; thus, the WHO and NIH guidelines have defined overweight as a BMI between 23-24.9 kg/m2 and obesity as a BMI >25 kg/m2 for the Asian population.6-9
Despite exhibiting lower average BMI, AAPI exhibit a higher prevalence of diabetes and other metabolic disorders when compared to White Caucasians with similar BMI and waist circumference levels. To further explain this contradiction, many studies have revealed a higher volume of abdominal fat accumulation in Asian Americans such as Japanese and Filipino Americans compared to White Caucasians.17,18
The rate of obesity among Pacific Islanders in some communities are as high as 90%. Limited information exists regarding variations in regional fat distribution among other Asian, Pacific Islander, or Native Hawaiian ethnic groups. However, when comparing individuals with a BMI of 30 kg/m², European residents of New Zealand had a mean body fat percentage of 28.7% (men) and 42.5% (women), while Māori and Pacific Islander men and women exhibited similar body fat percentages at higher BMI cutoff points.15
The Hawaii component of the Multiethnic Cohort study examined the impact of excess body weight and weight change on diabetes incidence in Caucasians, Native Hawaiians, and Japanese Americans. Over a follow-up period of 1,119,224 person-years, the highest annual incidence rate of diabetes was observed in Native Hawaiians (15.5 cases per 1,000 person-years), followed by Japanese Americans (12.5) and Caucasians (5.8).10 Body mass index (BMI) was positively associated with diabetes incidence in all ethnic groups, with higher BMIs correlating with increased risk. Japanese Americans had the highest risk, followed by Native Hawaiians, across all BMI categories. Similarly, the risk pattern for weight gain was highest in Japanese Americans, intermediate in Native Hawaiians, and lowest in Caucasians.10,11
According to the Centers for Disease Control, one in three people of the Asian American population are unaware that they have T2D, which is the highest of all ethnic groups who are underdiagnosed.12
Research studies have shown that standardized screening tools and guidelines may overlook variations in health risks and outcomes across different AAPI subgroups which have contributed to disparities in chronic health conditions such as T2D. In the past, screening for T2D was recommended in asymptomatic adults with a BMI of 25 kg/m² or higher and at least one known risk factor, including Asian ethnicity.5 While lower BMI thresholds have been suggested to define obesity in Asians, it remained uncertain whether the same applied to Asian Americans, considering their distinct lifestyle behaviors and dietary choices compared to residents of Asia.
In 2015, with the emergence of compelling evidence, the American Diabetes Association (ADA) lowered the BMI cutoff to 23 for Asians and Asian American adults.13 The 2023 ADA guidelines recommend testing for diabetes or prediabetes in asymptomatic adults with a BMI of ≥25 kg/m2 or a BMI of ≥23 kg/m2 if they are Asian American and at least one risk factor.14
It is important to note that the determination of an appropriate BMI threshold to identify Asian Americans at higher risk for diabetes has been a complex challenge due to the significant diversity among Asian American subgroups. For example, findings from the DISTANCE study indicate a BMI cut point of 25 kg/m² would be a suitable threshold, particularly for South Asians and Southeast Asians.2 However, other studies such as the Women’s Health Initiative, Seattle Japanese-American Community Diabetes Study, multiethnic cohort study in Canada, and Multiethnic Cohort in Hawaii suggested that lowering the BMI cut point, especially for East Asians (Chinese and Japanese), could be warranted.2,3 The rationale behind establishing a lower BMI cutoff for Asian Americans was to support increased opportunities for intervention, education, and diagnosis.
Barriers to Achieving Health Equity
As healthcare providers, it is crucial for us to recognize and understand the barriers that hinder the AAPI community from attaining health equity. By being aware of these challenges, we can identify and address them proactively to ensure effective patient care.
Health Equity Barriers for Asian Americans
Health Equity Barriers for Pacific Islanders
· Insufficient clinical and health outcomes data specific to Asian American populations
· Aggregated findings mask significant health disparities which do not address unique drivers of diabetes within these communities
· Language barriers and cultural differences that lead to inadequate care and negatively impacts effective communication
· Resistance to diet modification recommendations that make it challenging to maintain traditional meals
· Underrepresentation in health-related federal expenditures: Asian Americans account for only 0.2% of total funding5
· Ongoing changes in eligibility for insurance programs such as the Compact of Free Association Act leads to confusion regarding eligibility criteria, hindering access to healthcare services
· Many Pacific Islanders have limited access to tertiary care facilities, forcing these individuals to travel off-island to receive treatment
· Workforce shortages due to geographically isolated locations and emigration of healthcare professionals
· Historical impact of colonization, tourism and military engagement contributing to socioeconomic and health-related disparities
Diabetes Management in AAPI
Below are examples of interventions clinicians can implement for diabetes management in the AAPI community:
· Using BMI cutoffs specifically adjusted for the AAPI community to identify individuals at risk for diabetes
· Checking for family history of diabetes for early detection and intervention
Scheduling Regular Follow-ups:
· Many individuals of the Asian community may not be accustomed to the concept of having a personal doctor or primary care provider as it is considered adequate to seek medical services only when acutely ill
· Emphasizing the importance of scheduling regularly appointments to monitor diabetes management
Culturally-Sensitive Educational Resources:
· Providing educational resources such as MyPlate. Handouts and diet/nutrition education materials that are available in the patient’s preferred language
· Providing handouts with examples of meals that align with their cultural preferences to promote better understanding of dietary modifications
Collaboration and Insurance Support:
· Collaborating with patients to ensure they have clear understanding of their insurance coverage for diabetes-related services and medications
· Recognizing potential transportation barriers and offering telehealth appointments as an alternative for individuals who find it challenging to travel to healthcare facilities
AAPI Heritage Month serves as an important reminder for clinicians to recognize the health disparities that exist within diverse patient populations. It is important to understand that many of the screening tools used in clinical practice do not recognize the diversity of subgroups in an entire ethnic population. By understanding the nuances and implementing tailored screening and intervention strategies, clinicians can play a vital role in addressing the impact of T2D in the AAPI community and improve health outcomes. A patient-centered approach that respects cultural differences and validates their unique challenges will lead to more effective diabetes management and prevention. Listed below are additional resources clinicians can refer to for more information regarding health care in the AAPI and other ethnic communities:
National Council of Asian Pacific Islander Physicians: http://www.ncapip.org/
Asian and Pacific Islander American Health Forum:
U.S. Department of Health and Human Services Office of Minority Health: https://minorityhealth.hhs.gov/
FDA Office of Minority Health and Health Equity Forum Podcast Series: https://www.fda.gov/consumers/minority-health-and-health-equity/health-equity-forum-podcast
1. Congress TL of, Administration NA and R, Humanities NE for the, et al. Asian Pacific American Heritage month 2023. Asian Pacific American Heritage Month 2023. Accessed May 10, 2023. https://www.asianpacificheritage.gov/.
2. William C. HsuDiabetes Care 1 January 2015; 38 (1): 150–158. Maria Rosario G. Araneta Alka M. Kanaya Jane L. Chiang Wilfred Fujimoto; BMI Cut Points to Identify At-Risk Asian Americans for Type 2 Diabetes Screening. https://doi.org/10.2337/dc14-2391
3. Office of Minority Health. Diabetes and Asian Americans. The Office of Minority Health. Accessed May 10, 2023. https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=48.
4. Office of Minority Health. Diabetes and Native Hawaiians/Pacific Islanders. The Office of Minority Health. Accessed May 10, 2023. https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=78.
5. George L. KingDiabetes Care 1 May 2012; 35 (5): 1181–1188. Marguerite J. McNeely Lorna E. Thorpe Marjorie L.M. Mau Jocelyn Ko Lenna L. Liu Angela Sun William C. Hsu Edward A. Chow; Understanding and Addressing Unique Needs of Diabetes in Asian Americans, Native Hawaiians, and Pacific Islanders. https://doi.org/10.2337/dc12-0210
6. National Institutes of Health. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults – the evidence report. Obes Res 1998; 6 Suppl 2:51S
7. Obesity: Preventing and managing the global epidemic. Report of a WHO consultation. World Health Organ Tech Rep Ser 2000; 894:i.
8. Diabetes and Asian American people. Centers for Disease Control and Prevention. November 21, 2022. Accessed May 10, 2023. https://www.cdc.gov/diabetes/library/spotlights/diabetes-asian-americans.html.
9. WHO Expert Consultation. Appropriate body mass index for Asian populations and its implications for policy and intervention strategies. Lancet 2004; 363:157
10. Maskarinec G, Erber E, Grandinetti A, et al. Diabetes incidence based on linkages with health plans: the multiethnic cohort. Diabetes. 2009;58(8):1732-1738. doi:10.2337/db08-1685
11. Morimoto Y, Schembre SM, Steinbrecher A, et al. Ethnic differences in weight gain and diabetes risk: the Multiethnic Cohort Study. Diabetes Metab. 2011;37(3):230-236. doi:10.1016/j.diabet.2010.10.005
12. Diabetes and Asian American people. Centers for Disease Control and Prevention. November 21, 2022. Accessed May 10, 2023. https://www.cdc.gov/diabetes/library/spotlights/diabetes-asian-americans.html.
13. Maria Rosario G. AranetaDiabetes Care 1 May 2015; 38 (5): 814–820. Alka M. Kanaya William C. Hsu Healani K. Chang Andrew Grandinetti Edward J. Boyko Tomoshige Hayashi Steven E. Kahn Donna L. Leonetti Marguerite J. McNeely Yukiko Onishi Kyoko K. Sato Wilfred Y. Fujimoto; Optimum BMI Cut Points to Screen Asian Americans for Type 2 Diabetes. https://doi.org/10.2337/dc14-2071
14. American Diabetes Association, 2. Classification and Diagnosis of Diabetes: Standards of Care in Diabetes—2023. Diabetes Care 1 January 2023; 46 (Supplement_1): S19–S40. https://doi.org/10.2337/dc23-S002
15. Rush EC, Freitas I, Plank LD. Body size, body composition and fat distribution: comparative analysis of European, Maori, Pacific Island and Asian Indian adults. Br J Nutr. 2009;102(4):632-641. doi:10.1017/S0007114508207221
16. AMA Center for Health Equity Report: AAPI Community Data. Accessed May 10, 2023. https://www.ama-assn.org/system/files/2020-05/che-aapi-data-report.pdf.
17. Hoyer D, Boyko EJ, McNeely MJ, Leonetti DL, Kahn SE, Fujimoto WY. Subcutaneous thigh fat area is unrelated to risk of type 2 diabetes in a prospective study of Japanese Americans. Diabetologia. 2011;54(11):2795-2800. doi:10.1007/s00125-011-2275-5
18. Araneta MR, Barrett-Connor E. Ethnic differences in visceral adipose tissue and type 2 diabetes: Filipino, African-American, and white women. Obes Res. 2005;13(8):1458-1465. doi:10.1038/oby.2005.176