Diabetes in Asian and Pacific Islander Americans
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Diabetes mellitus poses a rapidly growing health challenge to Asian and
Pacific Islander Americans in the United States. In 1997, the Asian and
Pacific Islander American (APIA) population was estimated to be about 10
million, almost a 50 percent increase since the 1990 Census and representing
about 3.8 percent of the total U.S. population.1 This group includes people whose origins are in the Far East, Southeast
Asia, the Indian subcontinent, and the Pacific Islands.2
Results of the 1990 census showed that the APIA population had the greatest
increase of any major ethnic group, doubling in size since the 1980 census.3
The Immigration Act of 1965 and the arrival of many Southeast Asian refugees
under the Refugee Resettlement Program after 1975 contributed to the increase
in population observed in the past two decades.
Asian and Pacific Islander Americans in the United States were classified
into 28 Asian and 19 Pacific Islander ethnic groups for the 1990 U.S.
census (see table 1). These populations include people whose families
originated in a variety of countries, providing great diversity in language,
culture, and beliefs. Nearly 75 percent are foreign-born, but other members
of this group are fifth-generation Asian-Americans.4
The 1990 census showed that 56 percent of the APIA population lived
in the western states. Seventy-three percent were located within seven
states: California, Hawaii, Illinois, New Jersey, New York, Texas, and
Washington.3
Table 1.--Asian and Pacific Islander ethnicities in the United States.
Asian Indian
Bangladeshi
Bhutanese
Bornean
Cambodian
Celebesian
Ceram
Chinese
Filipino
Hmong
Indochinese
Indonesian
Iwo Jiman
Japanese
Javanese
Korean
Laotian
Malayan
Maldivian
Nepali
Okinawan
Pakistani
Sikkimese
Singaporean
Sri Lankan
Sumatran
Thai
Vietnamese
|
Carolinian
Fijian
Guamanian
Hawaiian
Kosraean
Melanesian
Micronesian
Northern Mariana Islander
Palauan
Papua New Guinean
Ponapean
Polynesian
Samoan
Solomon Islander
Tahitian
Tarawa Islander
Tongan
Trukese (Chuukese)
Yapese
|
Source: Association of Asian Pacific
Community Health Organizations (1997).4 |
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What Is Diabetes?
Diabetes mellitus is a group of diseases characterized
by high blood levels of glucose. It results from defects in insulin secretion,
in insulin action, or both. Diabetes can be associated with serious complications
and premature death, but people with diabetes can take measures to reduce
the likelihood of these occurrences.
Most Asian and Pacific Islander Americans with diabetes have type 2
diabetes. This type usually develops in adults, but it can also develop
in children or adolescents. It is caused by the body's resistance to the
action of insulin and by impaired insulin secretion. It can be managed
with healthy eating, physical activity, oral diabetes medications, and/or
injected insulin. Until recently, type 2 diabetes was rarely diagnosed
in children and adolescents. However, recent reports highlight an increasing
incidence of type 2 diabetes in children and adolescents. A small number
of Asian and Pacific Islander Americans have type 1 diabetes, which usually
develops before age 20 and is managed with insulin, healthy eating, and
physical activity.
Diabetes can be diagnosed by three methods5:
- A casual (random) plasma glucose value of 200 milligrams per deciliter
(mg/dL) or greater in people with symptoms of diabetes.
- A fasting plasma glucose test with a value of 126 mg/dL or greater.
- An abnormal oral glucose tolerance test with a 2-hour glucose value
of 200 mg/dL or greater.
Each test must be confirmed, on another day, by any of the above methods.
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How Many Asian and Pacific Islander Americans Have Diabetes?
Type 2 Diabetes
Prevalence data for Asian and Pacific Islander Americans are limited,
but studies have shown that some groups within this population are at
increased risk for developing type 2 diabetes compared with non-Hispanic
white people in the United States. Table 2 shows how prevalence in several
studies was higher for selected Asian Americans and Pacific Islander Americans
than for non-Hispanic white people.
Table 2.--Prevalence of diabetes in the United States in non-Hispanic
white people, Asian Americans, and Native Hawaiians.
Population |
Percentage
of Men |
Percentage
of Women |
Percentage
Overall |
Non-Hispanic White People and Caucasians in Hawaii: |
Non-Hispanic white people* |
2.9-8.4 |
2.5-7.8 |
|
Caucasians (Hawaii)** |
|
|
0.7 |
Asian and Pacific Islander Americans: |
Chinese (Hawaii)** |
|
|
1.5 |
Filipino (Hawaii)** |
|
|
2.2 |
Native Hawaiians (Hawaii)** |
|
|
4.9 |
Japanese (Hawaii)** |
|
|
2.0 |
Korean (Hawaii)** |
|
|
2.0 |
Japanese (Seattle)*** |
20 |
16 |
|
* Age 30 to 64.
** Age 14 and older; adjusted to the 1950 U.S. Census, civilian labor force
for the Honolulu, Hawaii, standard metropolitan area (1958-59).
***Age 45 to 74; not age-adjusted.
Source: King & Rewers (1993)6; Sloan
(1963)7; Carter, Pugh, & Monterrosa (1996).8
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A study of the prevalence of diabetes and glucose intolerance was conducted
among Native Hawaiians in two rural communities. Results showed a 22.4
percent age-standardized prevalence of type 2 diabetes in people ages
30 or older. Prevalence was highest in people ages 60 to 64, who had a
rate of 40 percent. This prevalence was four times higher than that of
the non-Hispanic white population surveyed in the U.S. National Health
and Nutrition Examination Survey II.9
Analysis of data collected in Hawaii from 1996 to 2000 showed that Native
Hawaiians were 2.5 times more likely to have diabetes than non-Hispanic
white residents of similar age.10
In contrast, the prevalence of diabetes in some isolated Polynesian
groups is relatively low. For example, in 1976 in Funafuti, Tuvalu, the
prevalence was 1.1 percent in men and 7.2 percent in women. Researchers
attributed the difference in rates to differences in physical activity.
In that community, men were engaged in manual labor, but women were sedentary
and consumed more calories than needed for their level of activity.3
In Western Samoa, diabetes prevalence in a rural community (3.4 percent)
was less than half the rate in an urban setting (7.8 percent), even after
adjusting for body weight. Rural residents were much more active physically
than their urban counterparts.3
Recent reports in the literature highlight an increasing incidence of
type 2 diabetes in youth, particularly in members of minority groups.
Data about APIA youth are scarce, but trends among Asian youth may indicate
future trends in the larger group. For example, studies of Japanese school
children in Japan show a dramatic increase in the incidence of type 2
diabetes. Incidence in 1976 was 0.2 per 100,000 children; incidence in
1995 was 7.3 per 100,000. Junior-high-age children had an incidence of
13.9 per 100,000, which was nearly 7 times the rate of type 1 diabetes
in the same group. Researchers attribute the increase in incidence to
changes in food habits and rising rates of obesity.11
Type 1 Diabetes
Type 1 diabetes in Asian children is relatively rare; rates are significantly
lower than those among non-Hispanic whites. Data from one study suggested
that environmental factors might be involved in the etiology of type 1
diabetes, since rates in Japanese children in Hawaii were higher than
rates of type 1 diabetes in Japanese children in Tokyo.3
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What Risk Factors Increase the Chance That Asian and Pacific
Islander Americans Will Develop Type 2 Diabetes?
Two categories of risk factors increase the
chance of type 2 diabetes. The first is genetics. The second is medical
and lifestyle factors, including obesity, diet, and physical inactivity.
Individuals with impaired glucose tolerance, impaired fasting glucose, or
insulin resistance are at higher risk of progressing to diabetes.
Genetic Risk Factors
Genetic background is a determining factor in the prevalence of type
2 diabetes. Few data exist on specific genetic causes in the APIA population,
but some researchers have suggested that the "thrifty gene" theory may
be involved in the increased prevalence of diabetes in some minority populations,
particularly those with high rates of obesity. The thrifty gene theory,
first proposed in 1962, suggests that population groups that experienced
alternating periods of feast and famine gradually adapted by developing
a way to store fat more efficiently during periods of plenty to better
survive famines.
Lifestyle and Medical Risk Factors
Obesity
Obesity is a major risk factor for type 2 diabetes among all races and
ethnic groups. The degree to which obesity is a risk factor for diabetes
depends not just on overall weight, but also on the location of the excess
weight. Central or upper-body obesity is a stronger risk factor for type
2 diabetes than excess weight carried below the waist.3
In a study comparing Japanese people in Japan with Japanese people who
had emigrated to Hawaii, the Hawaiian Japanese had a higher rate of obesity
and double the prevalence of type 2 diabetes.8
The sharp increase in type 2 diabetes in youth has paralleled the dramatic
increase of obesity in youth.11
Diet and Physical Inactivity
As a result of migration and modernization, the food choices of some members
of APIA subgroups have changed. Many of the APIA populations have abandoned
a traditional plant- and fish-based diet and are choosing foods with more
animal protein, animal fats, and processed carbohydrates. One study compared
the dietary content of similarly aged Japanese-American men living in
Seattle, Washington, with that of Japanese men in Japan. The Japanese-American
diet was higher in calories, protein, fat, and carbohydrates. The mean
daily intake of fat in Japanese-American men was 32.4 grams, in contrast
to a mean intake of only 16.7 grams of fat in Japanese men.3
Other studies have shown that, for many Asian Americans, their diet in
America is higher in calories and fat and lower in fiber than in their
countries of origin.8
Most studies have shown lower rates of physical activity in minorities
than in non-Hispanic whites in the United States.8
With the increase in migration and urbanization, physical activity has
been greatly reduced in the APIA population. Urbanization has caused this
population to change from a lifestyle characterized by hard labor to a
more sedentary one.3
Findings in a study of 8,000 Japanese-American men living in Hawaii
suggested that a Japanese lifestyle was associated with a reduced prevalence
of type 2 diabetes. Components of this lifestyle included higher levels
of physical activity and consumption of more carbohydrates and less fat
and animal protein.12
Pre-diabetes (Impaired Glucose Tolerance and Impaired Fasting Glucose)
Recent recommendations describe two categories of the physiological state
between normal blood glucose and the diabetic range of blood glucose.
Individuals are described as having impaired glucose tolerance (a 2-hour
glucose value of between 140 and 199 mg/dL during the oral glucose tolerance
test) or impaired fasting glucose (a fasting plasma glucose value of between
110 and 125 mg/dL).5
Asian Americans have shown higher rates of impaired glucose tolerance
than have non-Hispanic whites in a number of studies.8
The prevalence of impaired glucose tolerance among Native Hawaiians in
one study was 15.6 percent; prevalence rates were constant across age
groups.9
Hyperinsulinemia and Insulin Resistance
Hyperinsulinemia (higher than normal levels of fasting insulin) and insulin
resistance (the inability of the body to use its own insulin to properly
control blood glucose) are both associated with an increased risk of developing
type 2 diabetes. Hyperinsulinemia often predates diabetes by several years.
These factors, possibly linked to the APIA population through genetics
and obesity, increase the risk of developing type 2 diabetes.3
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How Does Diabetes Affect Asian and Pacific Islander American
Women During Pregnancy?
Gestational diabetes, in which blood glucose
levels are elevated above normal during pregnancy, occurs in about 2 to
5 percent of all American pregnant women. Perinatal problems such as macrosomia
(large body size) and neonatal hypoglycemia (low blood sugar) are higher
in babies born to women with gestational diabetes. Although blood glucose
levels generally return to normal after childbirth, an increased risk of
developing gestational diabetes in future pregnancies remains. In addition,
studies show that many women with gestational diabetes will develop type
2 diabetes later in life. Asian-American women seem to have rates of gestational
diabetes that are similar to those of non-Hispanic white women in the United
States.8
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How Does Diabetes Affect Cardiovascular Health in Asian
and Pacific Islander Americans?
Diabetes is a major risk factor for cardiovascular
disease; data suggest that minorities in general have a rate of risk for
this disease similar to that of the non-Hispanic white population. Both
impaired glucose tolerance and type 2 diabetes were risk factors for coronary
artery disease among Japanese Americans in a Seattle study.8
Although data on the relationship of stroke and hypertension to diabetes
in this population are limited, ischemic heart disease is one of the leading
causes of death for both men and women.2
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How Do Diabetes Complications Affect Asian and Pacific
Islander Americans?
Diabetic Retinopathy
Diabetic retinopathy is a deterioration of the blood vessels in the
eye caused by high blood glucose levels. It can lead to impaired vision
and, ultimately, to blindness. In general, age-standardized rates of blindness
from diabetes for nonwhites are double those for non-Hispanic whites.
However, no data on Asian and Pacific Islander Americans are available.8
Diabetic Nephropathy
Minority groups in general have higher rates of end-stage renal disease
related to diabetes than do non-Hispanic white people. Among the minority
groups, Asian Americans and Pacific Islanders have the lowest prevalence
of end-stage renal disease. Minorities have better survival rates after
treatment with dialysis than do non-Hispanic white people.8
Lower Extremity Amputation
There are no published reports on the rate of amputations among this
population.8
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Does Diabetes Cause an Inordinate Number of Deaths in Asian
and Pacific Islander Americans?
Because mortality rates are based on the underlying
cause of death on death certificates, the impact of diabetes on mortality
among Asian and Pacific Islander Americans has been underestimated.
For APIA populations as a whole, diabetes ranked as the fifth-highest
cause on death certificates for people between 45 and 64. Among non-Hispanic
whites, diabetes is the seventh leading cause of death. However, the age-adjusted
mortality rate for Asian and Pacific Islander Americans from diabetes
is 12.4 per 100,000, which falls below the rate of 15.9 per 100,000 for
non-Hispanic white Americans. The APIA rate is well below rates for other
minority populations (African American, 35.7; American Indian and Alaska
Native, 30.3; and Hispanic American, 28.3).2
A review of death records in American Samoa for the years 1962 to 1974
showed that the age-adjusted, diabetes-related mortality rate for Samoa
was more than double that of the United States.3
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How Is NIDDK Addressing the Problem of Diabetes in Asian
and Pacific Islander Americans?
Diabetes Prevention Program
In 1996, NIDDK launched its Diabetes Prevention Program (DPP). The goal
of this research effort was to learn how to prevent or delay type 2 diabetes
in people with impaired glucose tolerance (IGT), a strong risk factor
for type 2 diabetes.
The findings of the DPP, which were released in August 2001, showed that
people at high risk for type 2 diabetes could sharply lower their chances
of developing the disease through diet and exercise. In addition, treatment
with the oral diabetes drug metformin also reduced diabetes risk, though
less dramatically. These results were so striking that the DPP's external
data monitoring board advised ending the trial early.13
Participants randomly assigned to intensive lifestyle intervention reduced
their risk of getting type 2 diabetes by 58 percent. On average, this
group maintained their physical activity at 30 minutes per day, usually
with walking or other moderate intensity exercise, and lost 5 to 7 percent
of their body weight. Participants randomized to treatment with metformin
reduced their risk of getting type 2 diabetes by 31 percent.
Of the 3,234 participants enrolled in the DPP, 45 percent were from minority
groups that suffer disproportionately from type 2 diabetes: African Americans,
Hispanic Americans, Asian Americans and Pacific Islanders, and American
Indians. The trial also recruited other groups known to be at higher risk
for type 2 diabetes, including individuals age 60 and older, women with
a history of gestational diabetes, and people with a first-degree relative
with type 2 diabetes. Participants ranged from age 25 to 85, with an average
age of 51.
Lifestyle intervention successfully reduced the risk of getting type
2 diabetes for both men and women, and across all the ethnic groups. It
reduced the development of diabetes in people age 60 and older by 71 percent.
Metformin was also effective in men and women and in all the ethnic groups,
but was relatively ineffective in the older volunteers and in those who
were less overweight.
Researchers will continue to analyze the data to determine whether the
interventions reduced cardiovascular disease and atherosclerosis, major
causes of death in people with type 2 diabetes. The DPP is the first major
trial to show that diet and exercise can effectively delay diabetes in
a diverse American population of overweight people with IGT.
National Diabetes Education Program
NIDDK and the Centers for Disease Control and Prevention are jointly
sponsoring the National Diabetes Education Program (NDEP). Its goal is
to reduce the death and disability associated with diabetes and its complications.
NDEP conducts ongoing diabetes awareness and education activities for
people with diabetes and their families. Special efforts are being made
to address the needs of the ethnic groups that are hardest hit by diabetes,
including African Americans, Alaska Natives, American Indians, Asian and
Pacific Islander Americans, and Hispanic Americans. Through these efforts,
NDEP hopes to improve the treatment and outcomes for people with diabetes,
promote early diagnosis, and, ultimately, prevent the onset of diabetes.
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Points to Remember
- Prevalence data for diabetes among Asian and Pacific Islander Americans
are limited, but studies have shown that some groups within this population
are at increased risk for developing type 2 diabetes compared with non-Hispanic
white people in the United States.
- Type 1 diabetes in APIA youth is relatively rare; however, recent
reports highlight an increasing incidence of type 2 diabetes in children
and adolescents.
- Asian and Pacific Islander Americans have genetic, medical, and lifestyle
risk factors for type 2 diabetes.
- For Asian and Pacific Islander Americans ages 45 to 64, diabetes ranked
as the fifth-highest cause of death.
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References
1. Hooper LM, Bennett CE. The Asian and Pacific Islander population in the United States: March 1997 (update). In Current population reports: Population characteristics. 1998; Washington, DC: U.S. Department of Commerce.
2. Centers for Disease Control and Prevention. Chronic diseases in minority populations: African-Americans, American Indians and Alaska Natives, Asians and Pacific Islanders, Hispanic Americans. 1994; Atlanta: Centers for Disease Control and Prevention.
3. Fujimoto WY. Diabetes in Asian and Pacific Islander Americans. In National Diabetes Data Group, Diabetes in America 1995;(NIH Publication No. 95-1468, 2nd ed., pp. 661-681). Bethesda, MD: National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health.
4. Association of Asian Pacific Community Health Organizations.
Summary of Asian Pacific Islander Health Issues. Available at:
http://www.aapcho.org.
5. Expert Committee on the Diagnosis and Classification
of Diabetes Mellitus. Report of the Expert Committee on the Diagnosis
and Classification of Diabetes Mellitus. Diabetes Care. 1997;20(7):1183-1197.
6. King H, Rewers M. Global estimates for
prevalence of diabetes mellitus and impaired glucose tolerance in adults.
Diabetes Care. 1993;16(1):157-177.
7. Sloan NR. Ethnic distribution of diabetes mellitus in Hawaii. Journal of the American Medical Association. 1963;183(6):123-128.
8. Carter JS, Pugh JA, Monterrosa A.
Non-insulin-dependent diabetes mellitus in minorities in the United States.
Annals of Internal Medicine. 1996;125(3):221-232.
9. Grandinetti A, Chang HK, Mau MK, Curb JD, Kinney EK, Sagum R, Arakaki RF. Prevalence of glucose intolerance among Native Hawaiians in two rural communities. Diabetes
Care. 1998;21(4):549-554.
10. National Diabetes Information Clearinghouse. National diabetes statistics. NIH publication 02-3892. 2002. Fact sheet. Available at: www.niddk.nih.gov/health/diabetes/pubs/dmstats/dmstats.htm.
Accessed April 4, 2002.
11. Rosenbloom AL, Joe JR, Young RS, Winter WE. Emerging epidemic of type 2 diabetes in youth. Diabetes Care. 2002;22(2):345-354.
12. Huang B, Rodriguez BL, Burchfiel CM,
Chyou P, Curb JD, Yano K. Acculturation and prevalence
of diabetes among Japanese-American men in Hawaii. American Journal
of Epidemiology. 1996;144(7):674-681.
13. Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. New England Journal of Medicine. 2002;346:393-403.
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National Diabetes Information Clearinghouse
1 Information Way
Bethesda, MD 20892-3560
Email: ndic@info.niddk.nih.gov
The National Diabetes Information Clearinghouse (NDIC) is a service of
the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK).
The NIDDK is part of the National Institutes of Health under the U.S. Department
of Health and Human Services. Established in 1978, the clearinghouse provides
information about diabetes to people with diabetes and to their families,
health care professionals, and the public. NDIC answers inquiries, develops
and distributes publications, and works closely with professional and
patient organizations and Government agencies to coordinate resources
about diabetes.
Publications produced by the clearinghouse are carefully reviewed by both NIDDK scientists and outside experts.
This e-text is not copyrighted. The clearinghouse encourages users of
this e-pub to duplicate and distribute as many copies as desired.
NIH Publication No. 02-4667
May 2002
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