Asian Americans may have diabetes risk, despite a low BMI

By Jay Bhatt, D.O., managing director of the Deloitte Health Equity Institute and the Deloitte Center for Health Solutions, Deloitte Services LP and Brittani Spaulding, program officer, the Deloitte Health Equity Institute, Deloitte Services LP

Asian Americans have higher rates of type 2 diabetes than the general population and are prone to develop the disease at lower body weights.¹ One explanation might be genetic. Among people of South Asian descent, body fat is often stored around abdominal muscles, the liver, and other organs, rather than below the skin.² This visceral fat can also contribute to insulin resistance.³

The Joslin Asian American Diabetes Initiative (AADI)—part of the Boston-based Joslin Diabetes Center—was created in 2000 to promote diabetes prevention and provide culturally sensitive care and education. The organization is also working to improve health outcomes through advocacy, education, outreach, and individually tailored care.⁴ Early this year, the Deloitte Health Equity Institute launched a collaboration with AADI. This includes a pro bono project and philanthropic donation to support the development and implementation of a community outreach strategy to raise awareness of diabetes risks and to help reduce health disparities among Asian Americans. Deloitte’s HealthPrism^TM team conducted an analysis of type 2 diabetes data in Boston and throughout Massachusetts. The analysis was used to develop a Diabetes Burden Assessment report, which evaluated diabetes risk among Asian populations. HealthPrism is an artificial intelligence-powered solution that uses demographic, socioeconomic, environmental, and behavioral data to identify communities facing health barriers and then determine how to remove those barriers.

We recently had an opportunity to speak with Chihiro Sato, AADI’s community outreach program manager, about the risk of diabetes among Asian American populations and how a targeted outreach effort could raise awareness. Here is an excerpt from that conversation:

Jay: Since 2015, the American Diabetes Association has recommended that Asian Americans be screened for diabetes if they have a BMI of more than 23, rather than 25. What is your organization doing to promote screenings and healthier lifestyles for those who may be at risk?

Chihiro: The first step is to raise awareness among communities, health care professionals, and researchers, which is why we started the national Screen at 23 campaign.⁵ We established a coalition—together with leading organizations across the country—and launched the campaign after a 2011 diabetes symposium in Hawaii. The goal of the campaign is to unmask diabetes and prediabetes among Asian Americans so they can take action. Asian Americans, as well as their health care providers, need to be aware that a BMI of 23 is a risk factor. Now that awareness has been raised, more people understand they need resources and tools to manage their diabetes or prediabetes.

Brittani: Asian Americans tend to have higher rates of diabetes than the general population, and more than half of their diabetes cases go undiagnosed.⁶ Why do you think diabetes rates are increasing among Asian Americans⁷?

Chihiro: It's concerning, but we can do many things to prevent or better manage type 2 diabetes. When I moved to the US, I’ve noticed how portion sizes were bigger here. I also walk less than when I lived in Tokyo; I eat more animal protein and fewer varieties of veggies. When I’m out in the Asian community, almost everyone I talk with either has, or knows someone who has, diabetes. And many of them also tell us that no one has ever suggested they might be at risk. It’s not as common for Asian Americans to speak up and ask questions while seeing their PCP [primary care physician], so it’s important to know the risks and ask for screening if needed.

Brittani: Diabetes is on the rise in Japan and other Asian countries. One study found that 13.5% of Japan’s population either has type 2 diabetes or has impaired glucose tolerance.⁸ What do you think is causing increased cases of diabetes in Japan and other Asian countries?

Chihiro: Prevalence of the disease has a lot to do with lifestyle.⁹ What I noticed when I moved to the US appears to be happening in some Asian countries. Some people might be less active, eating more processed foods and/or larger portions sizes. Bagels¹⁰ and even some fruits, have gotten bigger over the past 20 or 30 years.¹¹ Diabetes is increasing in many countries, not just in Asia.

Brittani: Do people from all Asian countries have the same risks?

Chihiro: There are more than 20 countries of origin for Asian Americans. We are diverse. A person of Indian descent and someone who is Taiwanese can both be considered Asian, but there can be some physiological differences, like how their bodies store fat. East Asians, like me, have different characteristics and different risks than South Asians. For example, the prevalence of gestational diabetes is higher among women of Indian descent when compared with women of Japanese descent.¹² When we talk about care and treatment, it is important to be mindful of those differences.

Brittani: What do you think can be done to reduce the risk of diabetes, particularly among Asian-American populations?

Chihiro: There is a Diabetes Prevention Program (DPP) that targets people who have not yet been diagnosed, which has proven to be effective.¹³ A referral is needed, but many insurers cover it at no or low cost. It can be a huge load for PCPs to provide diabetes education on their own. Effective programs like this—along with specialists, community health organizations, and health coaches—can all work with a person to prevent diabetes. Diabetes education, including nutrition, physical activities, and stress management can all help patients manage their condition. We are trying to create a repository of online resources and specialists that are available in Massachusetts and work with PCPs who might encounter Asian American patients who have diabetes or pre-diabetes.

Jay: What challenges might people in the Asian community face once they are diagnosed with diabetes?

Chihiro: People sometimes feel overwhelmed when they are diagnosed with diabetes because it is a chronic disease that can affect every aspect of their lives. But there are also myths and stigmas associated with it. Many people have told me they thought they could never eat rice or noodles if they have diabetes. Some people were worried it would be hard to have children, and some patients thought insulin was bad for them and refused to use it. These myths can push some people into denial and could keep people from seeking education or treatment. We want to provide guidance for navigating life with diabetes. Education is important but it needs to be relevant to Asian Americans. For example, we can’t provide nutrition guidance if we don’t know what they prefer to eat. Someone who came to our outreach event believed he was eating healthy because he was vegetarian. But his family often fried their vegetables in lots of ghee. He learned how to make meals healthier. We are all unique and each person living with diabetes has a different journey. We should be mindful in how we approach individuals and ask the right questions to better understand who they are. That’s how we can build trust and work together to better manage their diabetes and challenges that come with it.

Conclusion

More than 10% of the world’s adult population has diabetes, and almost half of them are unaware that they are living with the condition, according to the IDF Diabetes Atlas. By 2045, IDF estimates that 1 in 8 adults will be living with diabetes—an expected increase of 46%. While this includes a widely diverse population, there are commonalities around diabetes risk within this group. While GLP-1s have the potential to have a meaningful impact on obesity, without lifestyle intervention it is unlikely they will reduce long-term costs or meaningfully alter the current trajectory (see Growth of GLP-1s has implications for multiple stakeholders). Education and awareness efforts (with a focus on the individual) can be important in addressing needs of higher risk individuals.

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Endnotes

^{1_{The impact of type 2 diabetes in Asian Americans, US Food & Drug Administration, May 28, 2021}}

^{2_{For Asian Americans, preventing diabetes may start with earlier screenings , National Public Radio, June 8, 2023}}

^{3_{Visceral fat correlates with insulin secretion and sensitivity independent of BMI, Frontiers in Endocrinology, February 27, 2023}}

^{4_{Asian American Diabetes Initiative, Joslin Diabetes Center}}

^{5_{Screen at 23, Asian American Diabetes Initiative, Joslin Diabetes Center}}

^{6_{More than half of Asian Americans with diabetes are undiagnosed, National Institutes of Health, September 8, 2015}}

^{7_{Type 2 diabetes in Asian Americans, American Nurse, March 1, 2023}}

^{8_{Diabetes in Japan: a review of disease burden and approaches to treatment, National Institutes of Health, November 25, 2009}}

^{9_{6 lifestyle changes to help control diabetes, WebMD, May 21, 2023}}

^{10_{Bagels, the hole story, New York City Eats}}

^{11_{How fruits have evolved over time, Business Insider, October 16, 2014}}

^{12_{Influence of acculturation on risk for gestational diabetes among Asian women, Centers for Disease Control and Prevention, December 5, 2019}}

^{13_{National Diabetes Prevention Program, American Diabetes Association}}

^{14_{Diabetes facts and figures, International Diabetes Federation}}

^{15_{A Proclamation on Asian American, Native Hawaiian, and Pacific Islanders Heritage Month, 2024, The White House, April 30, 2024}}

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