Pathophysiologic Differences Among Asians, Native Hawaiians, and Other Pacific Islanders

and Treatment Implications

Featured Article:

William C. Hsu, M.D., Edward J. Boyko, M.D., MP.h., Wilfred Y. Fujimoto, M.D., Alka Kanaya, M.D., Wahida Karmally, DrPH, R.D., C.D.E., Andrew Karter, Ph.D.,

George L. King, M.D., Mele Look, M.B.A., Gertraud Maskarinec, M.D., Ph.D., Ranjita Misra, Ph.D., Fahina Tavake-Pasi, M.S., Richard Arakaki, M.D.

Diabetes Care Volume 35: 1189-1198

May, 2012

Introduction

• Differences in pathophysiology may affect diagnosis, prevention and treatment of diabetes in Asian Americans, Native Hawaiians, and Pacific Islanders

 • Differences in cultural beliefs, dietary habits, and behavioral

patterns among AANHPIs require culturally effective translation of interventions into the community

 • These issues were discussed by clinicians and researchers

at a September, 2011 conference:

Diabetes in Asian Americans, Native Hawaiians, and Pacific Islanders: A Call to Action

Hsu W et al. Diabetes Care 2012;35:1189-1198

PATHOPHYSIOLOGIC DIFFERENCES

 • Type 1 diabetes: less prevalent in AANHPIs than in

Caucasians • High-risk HLA haplotypes and other genes are less

prevalent in AANHPIs

• Type 1 and type 2 can be difficult to distinguish in East Asian Americans, especially under age 35 years, because BMI is equally low (~ 24 kg/m2) in both types

Hsu W et al. Diabetes Care 2012;35:1189-1198

PATHOPHYSIOLOGIC DIFFERENCES

• Type 2 diabetes: Relationship between excess adiposity and diabetes is not straightforward in AANHPIs

• Native Hawaiians and Pacific Islanders have high prevalence of both type 2 DM and obesity

 • South Asians and East Asians have lower average BMI and

waist circumference but higher prevalence of diabetes compared with Caucasians

 • Visceral fat is a strong determinant of diabetes risk in Japanese

Americans • Japanese-American and Filipino-Americans have higher more

visceral fat even for equivalent waist circumference • For all quartiles of BMI or weight change, diabetes risk is higher

in Native Hawaiians and Japanese Americans

Hsu W et al. Diabetes Care 2012;35:1189-1198

Hsu W et al. Diabetes Care 2012;35:1189-1198

Hsu W et al. Diabetes Care 2012;35:1189-1198

Diabetes Complications

• As an aggregate, AANHPIs have lower rates of CVD and lower extremity amputation than Caucasians, but higher rates of ESRD

• Differences by ethnicity: 

Pacific Islanders have higher rates of MI than Caucasians, and equivalent rates of LEA

  South Asians have equal rates of MI and lower rates

of ESRD than Caucasians

Hsu W et al. Diabetes Care 2012;35:1189-1198

TAILORING DIAGNOSIS, PREVENTION, AND TREATMENT TO REFLECT ETHNIC

DIFFERENCES

Diagnosis:

• Asian Americans tend to have more prominent post-challenge hyperglycemia than fasting hyperglycemia

•  • Both FPG and HbA1c have significantly lower sensitivity

compared to OGTT•  • Since Asians have high risk but often do not have overt

obesity, consider test with the highest sensitivity (OGTT)

Hsu W et al. Diabetes Care 2012;35:1189-1198

Treatment: 

• Unclear whether there are differences in medication responses in AANHPI populations

 • Cultural differences in food preferences need to be

accounted for • Many Asian cultures include foods high in sodium (sauces,

pickled foods) • “Plate method” may be difficult for some cultures that use

communal plates or multiple small dishes

Hsu W et al. Diabetes Care 2012;35:1189-1198

TAILORING DIAGNOSIS, PREVENTION, AND TREATMENT TO REFLECT ETHNIC

DIFFERENCES

Hsu W et al. Diabetes Care 2012;35:1189-1198

Hsu W et al. Diabetes Care 2012;35:1189-1198

COMMUNITY-BASED INTERVENTIONS AND CULTURE-BASED DIABETES EDUCATION

Models:

• Community-based diabetes prevention and management program in South India reduced fasting blood glucose, reduced body weight, increased intake of dietary fiber

 • Healthy Eating and Lifestyle Program, Mai ka Mala’ai:

diabetes self-management programs for Pacific Islanders that combine classroom education with reconnecting to the land to grow produce

Resources:  • NDEP AANHPI materials

• AAPCHO: Community Approach to Responding Early

Hsu W et al. Diabetes Care 2012;35:1189-1198

Hsu W et al. Diabetes Care 2012;35:1189-1198