Diabetes Risk in Plainsboro's Asian-Indian Community: A Windshield Survey

Introduction: Plainsboro Township and Its Asian-Indian Community

Established in 1919, the Township of Plainsboro, New Jersey (hereinafter alternatively "Plainsboro" or "the Township") has been transformed from a quiet, rural community into a vibrant, upscale suburb (Brooks, 2004). Originally called the "Borough of the Plains" or "The Plains," the local U.S. Post Office eventually changed the name to Plainsboro (Brooks, 2004). The Township's origins trace to 1897, when the site was selected as the home for an innovative certified dairy farm that produced some of the only high-quality infant formulas available at that time (Brooks, 2004). The community's transformation into its modern suburban form began when this company ceased operations in 1971 (Brooks, 2004). Although transformed, Plainsboro remains a highly desirable place to live, work, and recreate. As Brooks notes, "Today, with Princeton University as its largest property owner, Plainsboro is a quality suburban community that retains much of its agricultural and open-space heritage" (2004, p. 8).

A windshield survey of this community confirms these observations, and there is a general consensus among civic leaders and residents alike that the Township is a bucolic oasis amid surrounding urbanity. According to the township's website, "Plainsboro Township is a highly desirable community that has successfully balanced economic growth and open space preservation. Home to renowned corporations and award-winning schools, Plainsboro residents enjoy an exceptional quality of life" (About Plainsboro, 2015, para. 1). New Jersey Monthly magazine has designated Plainsboro as one of the top ten "Best Places to Live" among the state's premier suburban communities (About Plainsboro, 2015, para. 2).

Unlike many highly urbanized communities, Plainsboro enjoys an extensive public parks network, including the Plainsboro Preserve — a 1,000-acre facility featuring walking trails, healthy wetlands, a 50-acre lake, and large forest areas that serve as natural habitats for the region's flora and fauna (About Plainsboro, 2015). Other community resources include an expansive environmental education center operated by New Jersey Audubon, a world-class public library system, and a recreation and cultural center for senior residents (About Plainsboro, 2015). The community also boasts some of the best public schools in the state, ranking among the top five in New Jersey for SAT scores, with nearly all (96%) of high school graduates entering college (About Plainsboro, 2015). Plainsboro enjoys an average family income of $163,415 (Plainsboro Village Center, 2015), and the Township's careful planning has provided the community with a strong economic base, open spaces accounting for more than half of the Township's land, and a wide range of housing opportunities across budget levels (About Plainsboro, 2015). In 2011, a new $441 million hospital opened in Plainsboro on a 160-acre healthcare campus as part of the Bristol-Myers Squibb Community Health Center complex.

Given its numerous aesthetic qualities and mature infrastructure, it is not surprising that many immigrants have made their home in Plainsboro, including approximately 4,000 residents who identify themselves as having Indian ancestry (Sahney, 2010). Plainsboro is home to the second-largest community of people from India in the United States, topped only by Edison, another town in New Jersey (Sahney, 2010). According to Sahney, many Asian-Indians "prefer to live in Plainsboro because they point out that it has good schools" (2010, p. 40). The Indian-Asian population in Plainsboro has grown further over the past decade due to expatriate assignments to the United States from information technology firms in India (Sahney, 2010). Out of a total population of around 23,500, 16.97% of Plainsboro's residents — approximately 4,000 people — describe themselves as having Indian ancestry (Sahney, 2010).

The Asian-Indians living in Plainsboro are among more than 1.5 million individuals of Asian-Indian ancestry currently living in the United States, the majority of whom arrived within the last 50 years during the third wave of extensive immigration during the 1960s (Sheehan, 2001). Many of the Asian-Indians who have relocated to the United States have prospered more than other demographic groups; however, they have also encountered the same types of racially and ethnically based discrimination and prejudice that linger in the American consciousness (Sheehan, 2001). Moreover, despite their large numbers, Asian-Indians have frequently been ignored in public health care research (Sheehan, 2001). As Sheehan observes, "Two themes hold New Jersey's diverse Indian-American population together. As they strive for success, they struggle for acceptance. As they embrace America, they hold on to India. These thematic threads — individual economic achievement coupled with American racism, cultural transition alongside Indian tradition" (2001, p. 118).

Changes in Indian culture in New Jersey occur among people who frequently see themselves as atypical and who place the process of cultural assimilation within a larger context of personal and cultural transformation (Sheehan, 2001, p. 118). These dynamics suggest that powerful cross-cultural issues shape how Asian-Indians in Plainsboro view available healthcare services and their need for them. Although Plainsboro enjoys a high standard of living and state-of-the-art medical facilities, some Asian-Indian residents remain marginalized due to an inability to afford these services, and cross-cultural differences in views about healthcare may further exacerbate this lack of access.

These are important issues because Asian-Indians are among the highest-risk groups for contracting diabetes. A combination of cultural factors, limited knowledge about diabetes, and insufficient financial resources often causes Asian-Indians to avoid the healthcare system or fail to adhere to prescribed medication or lifestyle regimens (Chandras & Eddy, 1999). Assuming receipt of a three-year, $300,000 grant to address this problem, the following sections outline a feasible community collaborative intervention to address the gaps in care and services for this priority problem among the Asian-Indian population of Plainsboro.

Diabetes Risk Among Asian-Indians: Rationale for Intervention

Some demographic groups are more genetically susceptible to developing diabetes than others, and Asian-Indians appear to be at double the risk of the global population for developing the disease (Pantalone & Hobbs, 2015). This inordinately high prevalence rate has been attributed to increasingly sedentary lifestyles combined with high intakes of fat, sugars, and simple starches characteristic of many Asian-Indian dietary patterns (Anderson, 2014). The prevalence of diabetes is also increasing rapidly in India itself (Anderson, 2014). A growing body of evidence indicates that Asian-Indians are at much higher risk of developing Type 2 diabetes compared to the general American population (Li, 2009). As Misra (2014) emphasizes, "Asian Indians are markedly prone to developing diabetes" (p. 37).

The American Diabetes Association (ADA) recommends that different body mass index (BMI) thresholds be applied to Asian-Indians compared to their Caucasian counterparts in the United States, specifically a lower BMI cut-off of 23 (Mohan, 2014). This recommendation reflects longstanding research showing that the Asian — and particularly South Asian — population, comprising Indians, Bangladeshis, and Pakistanis, are more vulnerable to diabetes even at lower BMI levels (Mohan, 2014, p. 7). Even a BMI cut-off score of 23 represents a warning sign of diabetes for Asian-Indians, and physicians recommend culturally specific BMI calculation approaches for this population (Mohan, 2014). As Mohan explains, "We have been working on BMI specifically for Asian Indians for nearly 15 years and on various international fora for diabetes and obesity it was agreed and accepted that there is a need for a lower BMI cut-off to prevent the diabetes epidemic" (2014, p. 7).

A study published by the American Diabetes Association in January 2015 further recommended that "Asians, as against their white counterparts, must screen for diabetes after reaching the BMI of 23. South Asian, Chinese, and black subjects developed diabetes at a higher rate, at an earlier age, and at lower ranges of BMI than their white counterparts. Our findings highlight the need for designing ethnically tailored prevention strategies and for lowering current targets for ideal body weight for non-white populations" (cited in Mohan, 2014, p. 7).

A study by Fernandez and Everett (2015) found that the ethnic-specific prevalence of diabetes ranged from 6–7% among normal-weight Asian-Indians to 19–33% among obese Asian-Indians, compared to non-Hispanic whites in the United States. Based on their findings, Fernandez and Everett concluded that Asian-Indians are at increased risk and that culturally sensitive strategies extending beyond the health sector should be developed to target lifestyle changes in this high-risk population (Fernandez & Everett, 2015). A study by Edwards (2014) also found that many American clinicians are not using culturally sensitive communication approaches in diabetes management, reinforcing the need for improved cultural competencies among healthcare providers.

Conclusion

The research showed that the Township of Plainsboro, New Jersey is an upscale, relatively prosperous community that is home to the second-largest concentration of Asian-Indians in the United States today. The research also demonstrated that this demographic group faces significantly higher risk of developing diabetes compared to the general American population, yet many Asian-Indians remain unaware of their risk or are reluctant to seek medical care due to cross-cultural constraints. Because diabetes is both a preventable and highly treatable condition, raising awareness of this public health issue among the Asian-Indian residents of Plainsboro represents a practical and meaningful step toward improving the quality of their lives and the health of the broader community in which they live.

References

About Plainsboro. (2015). Township of Plainsboro. Retrieved from

Anderson, E. N. (2014). Everyone eats: Understanding food and culture. New York: New York University Press.

Brooks, J. (2004, July 26). NLC membership offers many benefits to cities, towns. Nation's Cities Weekly, 27(30), 8.

Chandras, K. V. & Eddy, J. P. (1999, Winter). Counseling Asian-Americans: Implications for training. Education, 120(2), 239.

Edwards, K. (2014, Spring). Health disparities: What can we do? Journal of Cultural Diversity, 21(1), 3.

Fernandez, R. & Everett, B. (2015, Summer). Migratory implications for coronary heart disease risk prevention in Asian Indians: Evidence from the leading health indicators. Journal of Cultural Diversity, 22(1), 30–33.

Glycosylated hemoglobin. (2015). MedicineNet. Retrieved from http://www.medicinenet.com/script/main/art.asp?articlekey=16295.

Li, S. (2009, July 10). Higher levels of certain protein associated with lower risk of Type 2 diabetes. Manila Bulletin, 7.

Misra, A. (2014, October 19). Go nuts this Diwali. Hindustan Times (New Delhi, India), 3.

Mohan, V. (2014, December 28). Indians with BMI of 23 should start worrying: Doctors. Hindustan Times (New Delhi, India), 7.

Pantalone, K. M. & Hobbs, T. M. (2015). Clinical characteristics, complications, comorbidities and treatment patterns among patients with type 2 diabetes mellitus in a large integrated health system. BMJ Open Diabetes Research and Care, 3(1), 888–893.

Perry, P. (2000, July). Checklist for diabetes. The Saturday Evening Post, 272(4), 48.

Plainsboro Township. (2015). U.S. Census Bureau. Retrieved from http://www.census.gov/quickfacts/table/PST045214/.

Plainsboro Village Center. (2015). Sharbell Development Corp. Retrieved from http://sharbell.com/commercial/plainsboro-village-center.

Sahney, P. (2010, Fall–Winter). Hindu domestic mandirs: Home temples in greater New York. The Journal of New York Folklore, 36(3–4), 39–43.

Sheehan, S. (2001, Spring). Coming from India: A radio documentary. The Oral History Review, 28(1), 118.

Appendix A: How to Calculate BMI for Asian-Indian Adults

[Source: Mohan, 2014, p. 7]

There are two methods for determining BMI — the metric and imperial systems:

Divide the person's weight in kilograms by the square of their height in metres.

Example:
Weight: 90 kg
Height: 1.92 metres
1.92² = 3.69 m²
90 ÷ 3.69 = BMI of approximately 24.39

Multiply the person's weight in pounds by 703, then divide by the square of their height in inches.

Example:
Weight: 190 lbs
Height: 72 inches (6 feet)
72² = 5,184
190 × 703 ÷ 5,184 = BMI of approximately 25.76

A BMI of 23 kg/m² is now considered overweight (compared to the earlier threshold of 25 for the general population). A BMI of 25 kg/m² is now considered clinically obese (compared to the earlier threshold of 30). The waist circumference considered unhealthy for Indian men is 90 cm (35.4 inches), compared to 102 cm (40.1 inches) globally. For Indian women, the threshold is 80 cm (31.5 inches), compared to 88 cm (34.6 inches) globally.