While the obese American is the stereotypical poster child for the nation's type 2 diabetes epidemic, a demographic we least suspect could be at the greatest risk of the disease: the skinny Asian.
In recent years, health experts have begun warning doctors that Asian-Americans whose weights are within normal ranges still have a relatively high risk of developing type 2 diabetes because of differences in body composition, genetics and diet.
Compared to white Americans, Asians develop diabetes at a younger age, at lower levels of obesity and at higher rates with the same amount of weight gain, according to American Diabetes Association (ADA).
Asian-Americans also have the highest rate of undiagnosed diabetes at 51 percent, according to a 2015 study in the Journal of the American Medical Association, and among the highest rates of diabetes at 21 percent.
Type 2 diabetes is a condition in which the body can no longer use insulin properly to turn sugar into energy. If caught early on, patients can – through diet and lifestyle changes – save themselves from a condition that can lead to blindness, amputation and early death.
But 30 percent of people who have diabetes don’t even know it, and we are now facing a global epidemic, fueled by urbanization and increasingly sedentary lifestyles. In the United States, 9.3 percent of the population has diabetes, or 29.1 million people, according to the Centers for Disease Control.
Asia accounts for 60 percent of the world’s diabetic population, with rates as high as 10 percent in China and 20 percent in some urban parts of India.
“In Asian-Americans, diabetes looks and acts very different,” said Mai Phuong Nguyen, a physician and advocate for communities of color.
Nguyen is among the local ethnic physicians and advocates who have joined a public health campaign called “Screen at 23,” a movement spearheaded by the National Council of Asian Pacific Islander Physicians to push doctors to screen Asian American patients for diabetes at a lower weight.
“We do know there are physicians who have been aware of this for years and years,” said David Hawks, spokesman for the National Council of Asian Pacific Islander Physicians, which spearheaded the Screen at 23 campaign.
“But the general population of doctors is not aware…[and] because the Asian population is growing fast, they’re moving out of urban pockets and spreading to places where they won’t just be served by Asian doctors.”
The American Diabetes Association has long recommended that doctors screen for type 2 diabetes in patients who are over 45 and have a body mass index (BMI) of 25 and above, the point at which an individual is generally considered overweight.
But other factors besides weight come into play with diabetes risk, and new research has shown that doctors should begin testing for diabetes at a BMI of 23, which is considered within a healthy weight range.
“If we [only screened at] the BMI of 25, you would miss a bunch of folks. By moving down to 23, you can pick up many more pre-diabetics,” said Nguyen.
Researchers believe that one of the major differences behind the increased risk of diabetes among Asians is where fat is stored in the body.
When Asians gain weight, fat tends to accumulate mainly in the abdominal area rather than other parts of the body, experts say. And the belly area is the most harmful place to gain weight when it comes to increased disease risk.
Asians also have a higher percentage of body fat compared to people of European descent. At the same body mass index, Asians have 3 to 5 percent higher body fat compared to people of European ancestry. For the same body fat percentage, Asians have a body mass index 3 to 4 points lower, according to the Asian Diabetes Prevention Initiative.
In Asians, fat also has a tendency too be distributed inside the body and around the organs rather than underneath the skin as subcutaneous fat.
This “visceral fat” may not be visible when a patient walks into the exam room, but cross-sectional scans of the body reveal that more fat is more likely to end up inside the body cavity in Chinese and South Asian patients compared to Europeans, according to a 2007 article in the American Journal of Clinical Nutrition.
Meanwhile, the opposite is true for some Pacific Islanders, who have a gene that increases obesity, but makes them less likely to develop diabetes.
“Samoans…have a gene that was designed to historically keep them alive when very little food was available, and that’s not the problem anymore,” said Hawks. “So obesity might not be an indicator in that population.”
Different Asians subgroups have varying risk of diabetes, with Pacific Islanders, South Asians and Filipinos have the highest rates of diabetes of any racial group, according to 2014 figures.
Other lifestyle factors can increase one’s risk of diabetes, including heavy alcohol use, eating too many refined carbohydrates (such as white rice) and low activity levels. Researchers have also found that poor nutrition in the womb, combined with switching to a poor diet high in carbohydrates and sugars later in life, with contributing to rising diabetes rates in Asia.
Smoking regularly, which is prevalent in many Asian countries, is associated with more abdominal fat and a 45 percent increase in developing diabetes.
Still, even if patients know they are at risk of diabetes, managing diets and lifestyle changes is extremely challenging.
In addition to barriers like language, many health care providers may not understand how to help a patient plan their meals and alter their diet based on cultural foods and eating habits.
“The only model we have [in Orange County] is in the Latino community, through Latino Health Access,” said Nguyen, pointing to a program at Latino Health Access, which provides free community classes that walk patients – many poor, monolingual or undocumented immigrants -- through the basics of nutrition, physical activity, and dietary changes.
“We need more people in our [Vietnamese and other Asian] communities to be advocates,” said Nguyen.
Nguyen notes that nutrition therapy is not available in every health plan unless a patient already has a condition that requires it. Medicare and Medicaid provide free nutrition counseling to obese patients at a BMI of 30 – but an Asian-American who appears to be healthy wouldn’t qualify for coverage, even though they may be at significant risk for diabetes.
Even when it is covered, many dieticians and physicians don’t know enough about their patients’ cultural diet to give them helpful advice.
Hawks, the spokesman for the Asian physicians group, said that nationwide, there are some locally-based initiatives for culturally based nutrition counseling, although that is still a major challenge for healthcare providers.
He also points to the Joslin Diabetes Center’s “Drag’n Cook” application, which includes nutritional information about staples in Chinese, Indian, Japanese, Korean, and Vietnamese cuisine, as well as recipes and ingredient substitutions.
Another issue, Nguyen said, is many pharmaceutical companies have yet to incorporate Asian American patients into their clinical trials. As a result, the medical industry knows less about how medications for diabetes affect Asian patients.
“Pharmaceutical companies have tested white men and white women…and only in the last five or ten years have we started including blacks and Latinos,” said Nguyen.
Ultimately, patients need to be aware of their increased risk, and press their doctors to screen them for diabetes, Nguyen said.
“I want all my skinny Asian friends to say, ‘I’m 55, I have a BMI of 20, but would you check my [blood sugar]?’"
Contact Thy Vo at email@example.com or follow her on Twitter @thyanhvo.