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2014 AANHPI Diabetes Coalition Conference

The 2014 conference put in high relief the diabetes disparities that exist among Asian Americans, Native Hawaiians, and Pacific Islanders (AANHPI). From the "Asian BMI" issue and associated masking of the real risk Asian Americans have of developing diabetes, to the highest diabetes rates in the world occurring within Native Hawaiian and Pacific Islander populations both within and outside the mainland United States, researchers and policy makers came together to move the mission of the AANHPI Diabetes Coalition forward: increasing awareness and advancing the study and treatment of diabetes among AANHPI populations.

The report includes a synopsis of each presentation and plenary, with slides and references, and is available for download (PDF 4.7 MB) and online viewing.

Opening Remarks
George L. King, MD,Joslin Diabetes Center, Harvard Medical School
Co­Chair, Asian American Native Hawaiian Pacific Islander Diabetes Coalition

We now know that Asian Americans are at risk for diabetes even at Body Mass Index (BMI) cut­points below 25. There could be up to 5 million individuals, including many Asian Americans, who have diabetes but are not obese. The information we learn about Asian Americans and diabetes will be applicable to other populations who have diabetes but are not obese.

We have very little data about Type 1 diabetes among Asian Americans, except that it is rare. This lower prevalence also is worthy of further research to understand Type 1 diabetes.

Meanwhile, there is an increasing prevalence of diabetes in Asia; the rate in China is now 11.6%. The diabetes prevalence rate in Hong Kong and Singapore also are 12%. In ten years, half of the diabetes cases in the world will be in Asia. We need to look globally when considering how diabetes impacts Asian Americans.

Going forward, we need to continue to raise awareness about diabetes among Asian Americans, Native Hawaiians, and Pacific Islanders, and to create and provide tools for prevention. We also need to improve diabetes care, and reduce diabetes­related disparities for Asian Americans, Native Hawaiians, and Pacific Islanders. This includes more education for providers and reimbursements for early interventions, even at lower BMI cut­points. There are over 20 Asian American subgroups. While some interventions such as increased physical activity, exercise, changes in diet work across all populations, we need to focus on the cultural background and lifestyle of our patients to provide the most effective care. Finally, we need further research to find specific solutions for diabetes among Asian Americans, Native Hawaiians, and Pacific Islanders, funded by the National Institutes of Health, Centers for Disease Control and Prevention, Centers for Medicare and Medicaid, American Diabetes Association, and other funders.

Deepening Knowledge by Oversampling Asian Americans
Wilfred Y. Fujimoto, MD University of Washington

While the common risk factors for diabetes are older age, family history of diabetes, previous gestational diabetes, physical inactivity, being overweight or obese, hypertension, dyslipidemia (high triglycerides, high cholesterol, and/or low HDL­cholesterol), we are learning more and more about diabetes among Asian Americans, Native Hawaiians, and Pacific Islanders. Native Hawaiians have the highest prevalence of diabetes in Hawaii. The higher prevalence of diabetes among Native Hawaiians, Filipinos, South Asians cannot be explained by the usual correlation with being overweight or obese. Diabetes among these populations often occurs at lower BMI cut­points. Many Asian Americans have higher visceral and subcutaneous fat levels that corresponds with higher risk for diabetes.

Survey Data from the Centers for Disease Control and Prevention: Oversampling of Asians in the United States
Judith A. McDivitt, PhD, National Diabetes Education Program, CDC

The National Health and Nutrition Examination Survey (NHANES) is a continuous Centers for Disease Control and Prevention (CDC) household interview survey that also includes a physical examination and lab tests. Each year, NHANES assesses a nationally­ representative sample of 5,000 respondents, with an oversample of Asians, and other populations. Interviewers receive cultural competency training, and some survey materials are available in Chinese, Korean, Vietnamese, and Hindi.

In the 2011­-2012 cycle, 754 Asians were included in the total sampling of 9,756 adults. The 2011­2012 data identified a 10.2% prevalence rate of diabetes among the Asian respondents. Data from the 2013­2014 cycle will be needed to ensure acceptable statistical reliability of detailed analyses with the Asian sample (with approximately 1,500 combined Asian respondents.

Addressing Diabetes Among Hmong Adults
Moon S. Chen, Jr., PhD, MPH, University of California, Davis, Comprehensive Cancer Center
Kendra Thao, Hmong Women’s Heritage Association

The Hmong were the fastest growing population in Sacramento from 1990­-2000, now totaling nearly 30,000 residents. It is the third largest Hmong community in the U.S. Out of that community, 31% are below the federal poverty level, only 14% have a bachelor’s degree or higher education, and 46% are limited English proficient.

The only two previously published studies about diabetes in the Hmong community estimated a prevalence rate between 16% and 40%, and at 32%, much higher than among the overall U.S. population. The Thousand Asian American Study in Sacramento (2012­-2013) reported a diabetes prevalence rate among Hmong of 14.5%, with 33.5% at increased risk for diabetes.

Diabetes in South Asians: Findings from the MASALA Study
Alka Kanaya, MD, PhD, University of California San Francisco School of Medicine

There are over 3.4 South Asians in the U.S. (from Bangladesh, Bhutan, India, Nepal, Pakistan, and Sri Lanka). The prevalence of diabetes among South Asians in the U.S. is 17.4%.

The Mediators of Atherosclerosis in South Asians Living in the America (MASALA) Study uses a similar design and measures from the national MESA study (with over 6,800 White, African American, Latino and Chinese American participants from 2000­2007). There are 900 South Asian participants in the MASALA study, enrolled through the University of California San Francisco and Northwestern University. While the South Asians in the MASALA study were less likely to be smokers and drank less alcohol compared to the participants in the MESA study, the South Asians had significantly lower levels of exercise and physical activity.

The adjusted prevalence of diabetes among the South Asians in the MASALA study was 26.4%, significantly higher than the ethnic populations in the MESA study, after adjusting for all known risk factors associated with diabetes.

Type 2 Diabetes Prevalence: University of California San Diego Filipino Health Study
Maria Rosario (Happy) G. Araneta, PhD, University of California San Diego School of Medicine

According to the American Community Survey, there were over 3.4 million Filipinos in the United States in 2011. Data from the Diabetes Study of northern California (DISTANCE) in 2010 showed Type 2 diabetes prevalence rates of 18.3% for Pacific Islanders, 16.1% for Filipinos, and 15.9% for South Asians, exceeding the prevalence among African­Americans, Latinos, and Native Americans, groups traditionally perceived to be at highest risk for type 2 diabetes. That data set also showed gestational diabetes prevalence of 11.1% among Asian Indian women, 9.6% among Filipina women, and 8.8% among Southeast Asian women exceeding the prevalence of white women.

George L. King, MD, Joslin Diabetes Center, Harvard Medical School

Physiological and genetic differences among individuals affect pathogenesis of disease, and the pharmacokinectics, metabolism, and side effects of treatments. There also are cultural and environmental differences in how treatment is received, including stress, socio­political factors, and diet. For example, for patients with diabetes being treated with an insulin lispro mix 50/50 three times daily (LMTID), hemoglobin A1c outcomes are comparable across patient groups. However, during treatment with LMTID, Asian patients experienced higher incidence and rate of severe hypoglycemia than White patients.

The FDA has used race­specific information from clinical trials in its drug safety information. For example, in 2005, the FDA noted results from a Phase 4 pharmacokinetic study in Asian­Americans to highlight important information on the safe use of Crestor (rosuvastatin ) and to reduce the risk for serious muscle toxicity (myopathy/ rhabdomyolysis). Clinical treatment trials in the U.S. need to include adequate number of minorities which can provide guidelines for the use of a drug or treatment in each significant minority populations.

Translating Data into Community and Patient Benefit
Jonca Bull, MD, Office of Minority Health, Food and Drug Administration

Part of the mission of the Food and Drug Administration (FDA) is effective communication to the public about approved drugs and about drug safety. It is vital to use plain language and address health literacy in health communications. The agency has a language access plan, with consumer materials and press releases translated into multiple languages. For example, FDA’s consumer diabetes information for women is available in Bengali, Chamorro, Urdu, Cambodian, Chinese, Samoan, Japanese, Korean, Laotian, Taglish, Thai, Tongan, and Vietnamese. The FDA wants to become more of a health information provider of choice for the American public.
Diabetes in the U.S. Pacific Islands
Nia Aitaoto, PhD, MS, MPH, Faith in Action Research Alliance
Raynald Samoa, MD, City of Hope Medical Center

The reported prevalence of diabetes in the U.S.­associated Pacific Islands are as high as 47% in American Samoa, 39% in the Republic of Palau, 30% in the Republic of Marshall Islands and 24% in the Federated States of Micronesia.

Community members, health practitioners, and systems of care all need to work together to improve diabetes management and prevention in the Pacific Islands. For example, Micronesians trust faith­based leaders the most for information about diabetes. An intervention with faith­based leaders, health care providers, and community members in Chuuk and Hawaii identified and incorporated cultural and spiritual constructs in addressing diabetes medication adherence, nutrition, and physical activity. Among the findings were the barriers to improved nutrition (lack of access affordable healthier alternatives such as non­canned food, overcoming the stigma of fruit and vegetables contaminated by radiation from U.S. bombings of the islands during World War II, cultural and emotional connections to certain food). Some “sedentary” behaviors were associated with “purposeful sitting” and “resting”, which had positive cultural meanings. Much physical activity was defined by cultural age and gender roles. Since Western medicine is viewed as only treating the body, Pacific Islanders also use traditional and local healing methods to treat the spirit and the mind in addition to the body. Having a relationship of trustworthiness with healers and health practitioners is essential. According, a framework based on stewardship, that addresses the spirit, mind, and body, was developed to address the needs of Pacific Islanders with diabetes.

National Council of Asian Pacific Islander Physicians
American Diabetes Association Chinese American Independent Practice Association
Kaiser Permanente Asian American Diabetes Initiative, Joslin Diabetes Center
Lilly Chinese Community Health Care Association