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Diabetes Misdiagnosed in Asians, Native Hawaiians, and Other Pacific Islanders

May 18, 2012

Asian Americans have an almost 50% higher risk than other Americans of developing diabetes, especially type 2 diabetes….

George L. King, M.D., Chief Scientific Officer at Joslin Diabetes Center and Professor of Medicine at Harvard Medical School (HMS), explained: “The medical profession needs to be aware of and address the unique characteristics of this population. Without this understanding, diabetes could be misdiagnosed or missed altogether.”

Dr. King, together with a team of diabetes specialists, published a report highlighting study findings that were presented in September 2011 at an international symposium held in Honolulu.

The researchers gathered evidence on the Asian American population, those born in the United States, as well as immigrants from several East Asian countries. In addition, they investigated the incidence of diabetes in Native Hawaiians and Pacific Islanders.

Even though immigration patterns and lifestyle adaptations to U.S. culture vary significantly among these groups, common threads and new insights are emerging. According to the researchers, there are considerable differences in how diabetes affects the body’s chemistry, how to view body weight, and why standard diabetes tests may not be reliable in people of Asian descent.

Dr. William C. Hsu, M.D., an assistant professor of medicine at MHS, who with Dr. King co-directs the Asian American Diabetes Initiative at Joslin, explained, “Type 1 diabetes can be difficult to clinically differentiate from type 2 diabetes in Asians.” Dr. Hsu, together with a team of experts, wrote a second report also published in the same edition of Diabetes Care. The team focused on the pathophysiology (disease process) of diabetes.

People of Asian descent are around 5 to 10 times less likely than people of European descent to develop type 1 diabetes. However, genetic markers and blood factors usually associated with type 1 diabetes are only present in 30% of patients of Asian descent, making it more difficult to diagnose the disease. Therefore, solely relying on standard diabetes tests would result in a large percentage of Asians with the disease being misdiagnosed.

According to the authors, further research is required in order to identify what other biological factors in Asian patients result in the destruction of insulin-making beta cells, which leads to type 1 diabetes. Tests could then be developed to identify these specific factors.

The most common form of diabetes in Asian Americans is type 2 diabetes. The prevalence of type 2 diabetes in Asian Americans has increased from 1 or 2% in recent years to 10% today, vs. 6% in the general population. According to the researchers, several others are undiagnosed or at risk, falling into the “pre-diabetes” category.

The average BMI for Asian Americans with type 2 diabetes is between 24 and 25, within the normal BMI range (19-25) for the general population.

“The BMI in Asian patient can be misleading. They can look quite skinny. Instead, we’re learning that a better indicator of type 2 diabetes risk in Asians is fat deposits at the waistline.”

Further research is required in order to lean how visceral fat contributes to the onset of type 2 diabetes. Often, the disease can be prevented if it is identified in the pre-diabetes stage.

In many Asian Americans, a commonly used tool to diagnose diabetes called “the fasting plasma glucose” fails to identify abnormal glucose tolerance. According to the researchers, although the oral glucose tolerance test is more cumbersome to do, its reliability and sensitivity is greater in Asian populations.

The researchers highlight that physicians need to be aware that Asian Americans with diabetes are less likely to develop cardiovascular disease, but more likely to develop end-stage renal disease, and should be monitored and treated accordingly. According to the researchers, more studies need to be conducted regarding pre treatments for diabetes.

“The unique features of diabetes pathophysiology within this very heterogeneous population may indicate a need for different treatment guidelines.”

Oral medications, lifestyle factors, such as physical exercise and nutrition, and insulin dosing should be enfolded into a diabetes care program tailored to individual patients, families, as well as cultural practices.

According to the experts at Joslin’s Asian Diabetes Initiative, educational materials are most effective when they are published in both the English and Asian languages. They explain that this allows both young and old generations to communicate fluidly. In addition, Joslin has developed multilingual websites.

Although community-based education programs have proven to be very effective, they need to be expanded. Furthermore, it is vital to include Asian groups as subsets of the general population in national data collection, and that culturally appropriate methods need to be incorporated into the design of surveys.

Dr. Hsu concluded: “While there is much to be gained from ethnically sensitive care, these considerations are only a starting point. Ultimately, all diabetes care needs to be tailored to the individual. That’s the direction that medicine is going, and all populations will benefit.”

Pathophysiologic Differences Among Asians, Native Hawaiians, and Other Pacific Islanders and Treatment Implications. Diabetes Care, May 2012, doi: 10.2337/dc12-0212