DISEASE Physicians gear care to distinct ethnic groups
Stephanie M. Lee | Published 4:21 pm, Tuesday, November 6, 2012
No one has ever accused Dr. Bhupendra Sheoran of packing on the pounds. At 5 foot 10, the Oakland resident is a healthy 175 pounds. A physician for most of his life, he habitually avoids fast food and hits the gym.
So it came as a shock five years ago when he was diagnosed with Type 2 diabetes - a disease traditionally associated with being overweight or obese.
A phone call home put the situation in perspective, said Sheoran, 40, who lived in his native India until he moved to the Bay Area in 2005. He discovered that his sister and two uncles have the disease, and his father had symptoms.
"I don't think anybody talked about it," he said. "It didn't seem that they were taking any dietary precautions. They would eat whatever I ate: dessert, white-flour stuff, high-carb stuff."
Sheoran's case is not unique. Diabetes is a rapidly growing epidemic that affects almost 26 million people in the United States, according to the Centers for Disease Control and Prevention.
A disproportionate number of racial minorities have it, but Asian Americans have historically been seen as less affected. About 8 percent of Asian adults were reported to have the disease in a recent national survey, while about 16 percent of American Indians, 13 percent of African Americans and 12 percent of Latinos had it.
Now, increasingly nuanced data argue against lumping Asians into a single group. Certain subgroups - such as Filipinos, South Asians and Pacific Islanders - actually appear to suffer from Type 2 diabetes more than previously believed and, in some cases, more than other minorities altogether, studies suggest.
The statistics on Asian subgroups can help physicians provide the best treatment for the fastest-growing ethnic population in the nation, health experts say, whether it's devising healthy alternatives to traditional dishes or urging less fasting during religious observances.
"Each group is extremely different, with different lifestyles, different diets, different levels of physical activity, and beliefs and traditions and cultural issues that impact food and lifestyle changes," said Alka Kanaya, associate professor of medicine at UCSF. "How can we impact this diabetes epidemic in Asians if we don't start looking at them as distinct ethnic groups?"
No longer ignored
Until 2000, Asians were statistically overlooked by most national health surveys, which classified them as part of "other races," or combined them with Pacific Islanders.
Since then, Asians have become difficult to ignore as an increasing number of them make the United States their home. Asians and Pacific Islanders made up 5 percent of the U.S. population in the 2010 census - a 43 percent rise from 2000. About 5.6 million Asians live in California, more than any other state.
Diabetes has also become an epidemic both domestically and abroad, particularly in Asia. One in 3 U.S. adults is expected to have the disease by 2050. Most troubling to experts is diabetes' link to more serious complications such as cardiovascular disease and blindness.
"It's a costly disease, not only to individuals, but to families and societies," saidWilliam Hsu, co-director of the Asian American Diabetes Initiative in Boston. "I think this is one of the health issues that will continue to plague the Asian American community for a long time."
In an October study, Kanaya and other researchers examined diabetes rates among 1.7 million adult members of Kaiser Permanente in Northern California, including Asians, and found surprising results.
Exceeding other races
At the beginning of 2010, diabetes rates among Pacific Islanders, South Asians and Filipinos were 18 percent, 16 percent and 16 percent, respectively - rates that exceeded those of all other races, including African Americans and Latinos, the researchers said.
As 2010 went on, diabetes diagnosis rates in those same subgroups also exceeded other Asian subgroups, the study found.
Until Kanaya and her colleagues broke down the data, the numbers had been masked by the comparatively lower rates of a much larger Chinese population and several smaller Asian subgroups, the researchers said.
"When you put it all together, Asians look not so high risk," said Andrew Karter, the study's lead author and a senior research investigator with the Kaiser Permanente Division of Research in Oakland. "But in fact, there are subgroups that are at very high risk."
In screening for diabetes, one of the biggest possible indicators is a patient's body mass index, which is a measurement of how much fat a person is carrying based on height and weight. But this new research indicates that slimness in Asians can be deceiving, Karter said.
For example, the average body mass index of a Filipino patient in the study was 26.6 - just slightly overweight.
"If we target patients based on their BMI or obesity alone, we may miss individuals in Asian subgroups who are often at high risk of diabetes even when they're not obese," Karter said.
The theories that attempt to explain why some people have diabetes more than others boil down to a somewhat mysterious mix of nature and nurture.
On one hand, studies show that some Asians appear to be genetically predisposed to developing Type 2 diabetes.
A factor may be a protein known as adiponectin. In high levels, it does its normal job of regulating blood sugar in the body. But low levels can lead to Type 2 diabetes and cardiovascular disease.
Fat held in wrong spots
Compared with whites, Chinese, Japanese, Koreans, native Hawaiians, Filipinos and South Asians have been shown to have lower levels of adiponectin.
For unknown reasons, South Asians are also inclined to "store fat in all the wrong places," said Kanaya, who is recruiting such patients in the Bay Area for a study on heart disease and diabetes.
The "right" place for fat is under the skin, where it can be accessed in times of starvation, Kanaya said.
In contrast, she said, "South Asians tend to store fat in the areas around their abdominal organs and their liver and their heart and in their muscles."
That fat placement can eventually damage the organs, she said.
Culture and cuisine
But genetics don't tell the whole story. Socioeconomic factors unique to Asian cultures may also contribute to diabetes, experts say.
A big part of the equation is food. Traditional South Asian cuisine, for instance, tends to be rich and heavy. A popular Indian entree is samosas, which consist of deep-fried sweet potatoes and peas. Sweets, known as mithai, are usually made with big doses of milk and sugar.
Those dishes are difficult to avoid during parties, weddings and other gatherings, said 76-year-old Nemi Jain of Davis, who is Indian and has had diabetes for 25 years.
"While you talk to friends, you're taking this and this and that, and it all adds up," Jain said.
The calories aren't always burned off through physical activity. Studies have found that some traditional Muslim women don't exercise as much as they should because, out of a culturally instilled modesty, they dislike exposing their body, Kanaya said.
Rice and noodles are also staples of many Asian and Pacific Islander diets, but diabetics can consume them only sparingly because as carbohydrates, they break down into glucose that is absorbed into the bloodstream. Eating too much can make a diabetic's blood sugar soar.
Fast food's heavy toll
Traditional cuisine aside, there is also the matter of fast food - very American and very unhealthy.
Chinese and Japanese Americans reportedly have higher rates of diabetes than those in rural China and Japan. Burgers, soda and other foods rife with sodium, fat and sugar are apparently wreaking havoc on immigrants' bodies.
When Roderick Daus-Magbual was a stressed student, his default fare was carne asada burritos and fries. Although the Filipino American knew his mother had diabetes, he was shocked when he, too, was diagnosed at 21.
Now 34, Daus-Magbual, associate director of a Filipino studies program at San Francisco State University, cooks the fish and vegetables favored by his Philippine ancestors. Fast food, he said, is a rare indulgence.
"Our bodies weren't made to eat these types of foods every single day," he said.
As health care providers begin to understand which Asian subgroups need more help, they hope to learn how to treat them - without bewildering or offending them.
In some cases, concepts of proper medicine can wildly differ among Eastern and Western perspectives.
For example, American doctors would recommend a diabetic to avoid carbohydrates, but that concept may not register with traditional Chinese, who are likely to evaluate a dish's health benefits based on whether it is hot or cold.
Older generations may also skip insulin treatments out of embarrassment.
Religion may be another factor in developing diabetes. A South Asian's risk of diabetes may be exacerbated by prolonged fasting during some religious holidays. Regularly forgoing food can trick the body's metabolism into hoarding extra calories when the person does eat, resulting in excess stored fat, Kanaya said.
"It's a cultural belief and religious tradition for people to fast," she said. "To tell people to stop doing that is not going to be well received."
Language barriers may also prevent physicians from getting their message across to new immigrants.
Doctors', patients' tasks
Doctors should be trained to address these hurdles in culturally sensitive ways, employ interpreters when necessary, and take the time to understand a patient's ethnic background, whether he or she has just arrived in the United States or was born here, Kanaya said.
A patient should also be his or her "best advocate," especially if he or she has a family history of diabetes, is overweight or physically inactive, said Hsu of the Asian American Diabetes Initiative. Asians also tend to develop diabetes a little earlier than the general population, so being 45 or above merits a screening.
"Diabetes is here to stay with us," Hsu said. "We need to do something to reduce its impact in the years to come."
Diabetes doesn't appear to be a huge problem in Asians overall, until the population is broken down into subgroups. A recent study of adult Kaiser Permanent patients from Northern California reveals how the numbers break down.
Number of patients: 968,943
Body mass index: 28.3
Diabetes rate at beginning of study: 7.3 percent
(Hawaiian, Guamanian, Samoan or other)
Number of patients: 7,732
Body mass index: 29.8
Diabetes rate at beginning of study: 18.3 percent
Number of patients: 82,781
Body mass index: 26.6
Diabetes rate at beginning of study: 16.1 percent
South Asians (Asian Indian, Pakistani, Bangladeshi, Sri Lankan Or Nepalese)
Number of patients: 6,768
Body mass index: 26.4
Diabetes rate at beginning of study: 15.9 percent
Source: "Elevated Rates of Diabetes in Pacific Islanders and Asian Subgroups," Diabetes Care, October 2012