Diabetes among Indian Americans

• Asian Indians in the US have the highest risk for diabetes that develops at a younger age and at lower body mass index (BMI).¹ Compared with whites, Asian Indians have three times the risk of diabetes, when adjusted for age, sex, and BMI and the risk is substantially higher than all minorities in the US (Figure 011).^2-5

• The higher prevalence of diabetes reported among Asian Americans is primarily due to the very high risk among Asian Indians and to a less extent than Filipinos, both of whom have more unfavorable distribution of fat with higher visceral fat depot.^{3, 6, 7}

• The CADI Study, done in the 90’s showed a diabetes prevalence of 8% among Asian Indians in the US.⁸  Recent studies have showed a dramatic increase in the prevalence of diabetes 17% to 26% over the past 20 years.^{4, 5, 8-12} Another 33% to 37% of Asian Indians have prediabetes.^{5, 10} Nearly half of the diabetes among Asian Indians remain undiagnosed.¹²

• In the MASALA Study the crude prevalence of diabetes among Asian Indians in California was 29% and prediabetes 37% which became 26% and 25% respectively when adjusted for the age (Table 103A).¹⁰ In this well-designed study, the prevalence of diabetes among Asian Indians was 400% higher than whites, 200% higher than Chinese, and 50% higher than blacks and Hispanics.¹⁰

• Asian Indians in the US enjoy a higher socioeconomic status (SES) than whites, which is a protective factor for diabetes in western societies. Ironically, adjusting for SES actually exaggerated the prevalence of diabetes among Asian Indians.¹⁰

• Asian Indians however, have the highest odds being physically inactive ─a well known risk factor for diabetes.¹³ But the diabetes risk is 300% higher even after adjusting for physical inactivity.²

• The diabetes prevalence rate in MASALA is higher than all other studies reported to-date but probably more accurate given the very robust protocol used.¹⁰ The prevalence may be an underestimate since those with known cardiovascular disease (CVD) were excluded.¹⁴ The rates are also higher than those reported from urban India where the rates range from 14% to 19%.^15-17

Table 103A. Ethnic Differences in Age-adjusted  Prevalence of  Diabetes,  Prediabetes, and Metabolic Syndrome in MASALA and MESA Studies10
	Asian Indians	Chinese	Whites	Blacks	Hispanics
Diabetes	26%	14%	7%	19%	19%
Prediabetes	25%	33%	25%	28%	30%
Diabetes plus prediabetes (dysglycemia)	51%	47%	32%	47%	49%
Metabolic syndrome	41%	26%	30%	36%	43%

• The prevalence of diabetes increases dramatically with age and BMI among Asian Indians. The prevalence increases from 6-7% among those with the normal weight, to 19-33% among the obese.³

• During the past decade, BMI has increased among all Americans, but age- and sex-adjusted BMI remained consistently lower in Asian Americans than whites. Yet, compared with their white counterparts, Asian Americans have a significantly (30-50%) higher risk for diabetes with Asian Indians having the highest followed by Filipinos, other Asians, and Chinese.²

• The prevalence increases nearly 8-fold between those <30 years of age and those >60 years of age.³

• South Asians in New York City were five times more likely to have diabetes and six times more likely to have metabolic syndrome. These rates are as high as or higher than that observed in Europe.⁹

• A novel finding was that strong traditional Indian beliefs and practices, including arranged marriages and high glycemic loads, were important predictors of prediabetes and diabetes. ¹⁰

• Visceral adiposity as measured by waist circumference is most closely associated with prediabetes and diabetes than overall adiposity measured with BMI or total body fat from whole body DEXA.¹⁰ This is a critical clinical finding because clinicians who focus on body weight to guide their screening practices or lifestyle recommendations will miss patients if they do not use a measurement of visceral adiposity, in their clinical encounters.¹⁰

• Asian Indians in the US also have the highest rates of gestational diabetes (11%) than whites (4%).¹⁸

• The major determinants of prediabetes and diabetes among Indians included high blood pressure, fatty liver, abdominal obesity (visceral adiposity), microalbuminuria, higher levels of subclinical (carotid) atherosclerosis.¹⁰ Microalbuminuria is a very strong risk factor conferring a 5-fold risk.¹⁰

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3. Oza-Frank R, Ali MK, Vaccarino V, Narayan KM. Asian Americans: diabetes prevalence across U.S. and World Health Organization weight classifications. Diabetes Care. Sep 2009;32(9):1644-1646.

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5. Misra R, Patel T, Kotha P, et al. Prevalence of diabetes, metabolic syndrome, and cardiovascular risk factors in US Asian Indians: results from a national study. J Diabetes Complications. Mar 18 2009.

6. Araneta MR, Barrett-Connor E. Ethnic differences in visceral adipose tissue and type 2 diabetes: Filipino, African-American, and white women. Obes Res. Aug 2005;13(8):1458-1465.

7. Rush E C., 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. Aug 2009;102(4):632-641.

8. Enas EA, Garg A, Davidson MA, Nair VM, Huet BA, Yusuf S. Coronary heart disease and its risk factors in first-generation immigrant Asian Indians to the United States of America. Indian Heart J. Jul-Aug 1996;48(4):343-353.

9. Rajpathak SN, Gupta LS, Waddell EN, et al. Elevated risk of type 2 diabetes and metabolic syndrome among Asians and south Asians: results from the 2004 New York City HANES. Ethn Dis. Summer 2010;20(3):225-230.

10. Kanaya AM, Wassel CL, Mathur D, et al. Prevalence and correlates of diabetes in South asian indians in the United States: findings from the metabolic syndrome and atherosclerosis in South asians living in america study and the multi-ethnic study of atherosclerosis. Metab Syndr Relat Disord. Apr 2010;8(2):157-164.

11. Venkataraman R, Nanda NC, Baweja G, Parikh N, Bhatia V. Prevalence of diabetes mellitus and related conditions in Asian Indians living in the United States. Am J Cardiol. Oct 1 2004;94(7):977-980.

12. Wang ET, de Koning L, Kanaya AM. Higher protein intake is associated with diabetes risk in South Asian Indians: the Metabolic Syndrome and Atherosclerosis in South Asians Living in America (MASALA) study. J Am Coll Nutr. Apr 2010;29(2):130-135.

13. Ye J, Rust G, Baltrus P, Daniels E. Cardiovascular risk factors among Asian Americans: results from a National Health Survey. Ann Epidemiol. Oct 2009;19(10):718-723.

14. Kanaya AM, Barrett-Connor E, Gildengorin G, Yaffe K. Change in cognitive function by glucose tolerance status in older adults: a 4-year prospective study of the Rancho Bernardo study cohort. Arch Intern Med. Jun 28 2004;164(12):1327-1333.

15. Ramachandran A, Mary S, Yamuna A, Murugesan N, Snehalatha C. High prevalence of diabetes and cardiovascular risk factors associated with urbanization in India. Diabetes Care. May 2008;31(5):893-898.

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17. Mohan V, Deepa M, Deepa R, et al. Secular trends in the prevalence of diabetes and impaired glucose tolerance in urban South India–the Chennai Urban Rural Epidemiology Study (CURES-17). Diabetologia. Jun 2006;49(6):1175-1178.

18.  Hedderson M M, Darbinian JA, Ferrara A. Disparities in the risk of gestational diabetes by race-ethnicity and country of birth. Paediatr Perinat Epidemiol. Sep 2010;24(5):441-448.

19. Oza-Frank R, Ali MK, Vaccarino V, Narayan KM. Asian Americans: diabetes prevalence across U.S. and World Health Organization weight classifications. Diabetes Care. Sep 2009;32(9):1644-1646.