Understanding the Risk: Asian Americans and Diabetes
By E.J. Saunders
Why do Asians and Asian Americans face an increased risk for diabetes and prediabetes? Joanne Saunders shares her father’s diabetes story to help shed light on this concerning problem.
My father (pictured here with his grandson) was a 67-year-old Chinese American who immigrated to the United States in 1971. At 5’5” and approximately 150 pounds, he entered the emergency room on July 30, 2017, complaining of a severe headache, vomiting, and nausea.
That morning, he had walked a mile on the treadmill and lifted free weights while watching television. He appeared to be healthy, and active and normally these symptoms would not warrant a visit to the emergency room. However, his medical history included two strokes, diabetes and hypertension.
Asians are stereotypically known to be slimmer and eat healthier diets. Even the emergency room doctor wrote in her notes that my father was “a thin Asian male.” However, two in five Asian American adults have diabetes or prediabetes, with more than half of these cases going undiagnosed.
“It is not well known that Asians have a prevalence for type 2 diabetes,” Dr. George King said, who is the founder, director, chief scientific officer and senior vice president of the Asian American Diabetes Initiative at Joslin Diabetes Center at Harvard Medical School. For years, King has researched the high rate of diabetes in Asian Americans.
Only in recent years have the CDC and the National Institute of Health recognized that Asian Americans may be at risk for or develop diabetes in a way that differs from other groups.
The American Diabetes Association now recommends that Asian Americans get screened for diabetes if their Body Mass Index (BMI) values are 23 or higher, versus the 25-or-higher guideline for the rest of the population. It found that environmental factors such as stress and a poor diet may increase the risk of diabetes, which is higher in Asian Americans than most other American ethnicities. Not only did my father have a family history of diabetes, he was also an obsessive eater, especially overeating desserts.
Fat storage and BMI among Asians
My father enjoyed sailing, walking, hiking, fishing, and paddling around the pool in the backyard. Over the years, a hunch developed in his shoulders from sitting at a desk at his very stressful corporate job. He had a slight belly but otherwise appeared to be your average, healthy senior. He enjoyed eating out with friends and family but often gorged himself to the point of not even being aware that he was full.
Fat storage and distribution in the body differs between ethnicities and even among individuals. Where an individual stores body fat could influence the development of medical conditions such as diabetes. Asians have a greater amount of visceral adipose tissue, or fat located around the organs, and fat storage, despite lower body mass values. Having visceral fat is associated with metabolic and heart diseases.
“One of the major differences we still don’t quite understand is the body mass index differences between Asians and other ethnicities,” said King, who is a Chinese American. “In Asian populations, the risk of diabetes skyrockets with a BMI of 25. In 30 years, the development of diabetes went up sixfold. This cannot be due to genetics because genes cannot change in 30 years, so this must be due to environmental factors.”
King acknowledges that Asians are a collection of a large group of people with various genetic backgrounds and that “the prevalence of diabetes is different for Asian Americans depending on where you come from,” referring to the parts of the world where one’s ancestors originated.
For instance, Pacific Islanders and Southeast Asians tend to hold visceral fat more easily than those from other areas. He advocates that more resources and funding be dedicated to studying why Asians store more visceral fat.
"Asians tend to have more fat in the liver or fat in the muscles, which may even be worse in affecting insulin sensitivity,” he said. “I can't give you the reason because I don't actually know. Hopefully, with all the interest in the disparity of care, we can get some resources to understand that problem."
Nutritional and environmental conditions may contribute to diabetes
My father was one of nine children born into a poor family in Taishan, China. Most of the family has since moved to the United States. One of the family’s favorite meals was drinking a soup made from fish bones, then breading the fish bones and frying them to eat afterwards – a telling example of his family’s struggles for proper nutrition, and probably the reason my father became obsessed with food as an adult. My father’s older brother died at the age of 50 from a heart attack, and his mother and younger brother both have diabetes.
Environmental factors such as prenatal nutrition may play a role in contributing to fat distribution, as shown through studies of fetal, infant, and childhood exposure to famine.
“In 30 years, the development of diabetes went up six fold,” King said. “This may be due to genes, which are less obvious in this short time period, or more likely due to environmental factors.”
When individuals exposed to malnutrition early in life moved to a nutritionally rich environment, they experienced a higher rate of diabetes, likely due to reduced beta cell functioning. Studies show that a common environment shared by siblings had a stronger influence on health conditions than the genetic inheritance of poor insulin secretion, which supports the theory that environmental factors may be a greater contributor to diabetes than genetics.
Diet and exercise are important for good health
One of my father’s greatest loves in life was eating good food, especially desserts. After his first stroke in 2011, he asked me, “Why can’t I enjoy life and just eat what I want to? It’s not fair.”
In his mind, a “normal person” would be able to eat whatever they wanted and not have the health problems he had.
When he was diagnosed with diabetes after his first stroke, he started exercising regularly, turned to a plant based diet, and lost around 30 pounds. His cholesterol levels dropped and his glucose levels went back to normal. Studies on the susceptibility of Asians to diabetes had been uncommon at that time. Many of the federal agency recommendations for diabetes in Asian Americans came after 2015.
Joslin Diabetes Center, the world’s largest diabetes research center, created the Asian American Diabetes Initiative (AADI), which focuses on diabetes care, research, education and advocacy specifically for Asian communities. They created a guide book in 2021 for Asian Americans on preventive and management measures for diabetes such as reducing body weight, eating healthy, and being active.
Changes in lifestyle like adding exercise and eating plant based diets can help in decreasing visceral fat. A plant-based diet has proven to lower type 2 diabetes risk in Chinese populations. Dr. King recommends a high fiber diet, consisting of mostly vegetables and complex carbohydrates.
Many Asian immigrants are not interested in exercising due to cultural reasons. Dr. King encourages his Asian patients to stay active and do things they enjoy (such as dancing), rather than recommending formal exercise training.
Recommendations for Asian Americans
If you’re Asian and have a direct relative with diabetes, King recommends getting screened for diabetes as early as 20 years of age every couple of years. Though the standard age for testing in the US begins at 40-45 years of age, King believes early testing is easy to do and can help detect early signs of diabetes.
Be proactive in asking your provider to screen for diabetes with a hemoglobin A1C test, which measures your average blood sugar levels and is used to diagnose prediabetes and diabetes. For those who are thinking of having children, improving fetal and childhood nutrition and maintaining a healthy BMI may prevent diabetes later in life.
In the last few months of my father’s life, he returned to his old ways of eating, slipping back to his pre-stroke diet. He had just retired and made a list of things he wanted to do like travel, learn Chinese medicine, and take his grandchildren fishing. He appeared healthy, but the numbers from his glucose and cholesterol meters told him the truth. My mother said in the last weeks, he had stopped checking as frequently.
That night in the emergency room, the CT scan showed he had a brain aneurysm, something that seniors with diabetes have an increased risk of experiencing. He died two weeks later.
As much as I still grieve over my father’s death, I’ve taken his death as an opportunity to teach myself, my family and friends how to proactively monitor their health earlier in life.
