Type 2 Diabetes Education for Asian Americans: A Review

Introduction and PICOT Question

PICOT question: In Asian Americans with type 2 diabetes (P), does a culturally tailored diabetes education program, including patient-specific dietary and lifestyle modifications (I), reduce A1C levels (O) after 2 months (T) versus a control group of Asian Americans (C)?

According to Nguyen, Fischer, Ha, and Tran (2015), "type 2 diabetes mellitus (T2DM) is a growing epidemic in the United States." This is further corroborated by Wang, Wang, and Chan (2013), who observe that the condition is a concern not only in the United States but across the world. According to these authors, this is especially true given that type 2 diabetes has been associated with "multiple complications and comorbidities." Some of the well-documented complications of type 2 diabetes include, but are not limited to, nerve damage and heart disease.

Prevalence of Type 2 Diabetes Among Asian Americans

To demonstrate just how serious the condition is, Laakso (2010) points out that while an estimated 151 million people had diabetes in the year 2000, this figure was projected to grow by almost 50% within a decade. If recent estimates are accurate, the number of persons with type 2 diabetes "is projected to increase to 552 million by 2030" (Thomas and Ashcraft, 2013). It is for this reason that a considerable number of research undertakings have been instituted on the nature, control, and management of type 2 diabetes, so as to ensure that adequate strategies are put in place to address the condition.

Various studies indicate that type 2 diabetes is more prevalent in some demographic groups than in others, with that prevalence specifically noted for Hispanic Americans, non-Hispanic Blacks, and Native Americans (Nguyen, Fischer, Ha, and Tran, 2015). Laakso (2010) observes that "changes in human environment, behavior, and lifestyle have resulted in a dramatic increase in the incidence and prevalence of diabetes in people with genetic susceptibility to diabetes." With regard to environmental changes, Thomas and Ashcraft (2013) observe that Asian Indians, a subgroup of Asian Americans, tend to be at higher risk of developing the condition, which the authors attribute to "the metabolic impact of a westernized diet or reasons based on tissue resistance to insulin." This warrants focused attention to the entire demographic group. In recent times, Nguyen, Fischer, Ha, and Tran (2015) point out that "increasing attention has been drawn to the problem of T2DM among Asian Americans."

Quite a number of studies have been conducted to investigate the claim that Asian Americans have a high risk of type 2 diabetes, most comparing its prevalence in Asian Americans relative to other ethnic groups. In their research piece, Trends in the Prevalence of Type 2 Diabetes in Asians versus Whites, Lee, Brancati, and Yeh (2011) conclude that "compared with their white counterparts, Asian Americans have a significantly higher risk for type 2 diabetes, despite having substantially lower BMI." Thomas and Ashcraft are in agreement, stating that "type 2 diabetes is the fifth leading cause of death in the Asian American population" (Thomas and Ashcraft, 2013), with Asian Indians being the most afflicted subgroup.

Alpert and Thomason (2016) note that the prevalence of the condition in this demographic group is largely misunderstood, particularly given the lower BMI levels of Asian Americans in comparison to other groups. More specifically, the authors observe that "Asian Americans are not frequently thought of as being obese or overweight, yet some of the Asian American subgroups have a disproportionate risk for cardiovascular disease and type 2 diabetes mellitus." In a study assessing the relationship between BMI and type 2 diabetes risk, Ganz, Wintfeld, Li, Alas, Langer, and Hammer (2014) concluded that "not only is BMI strongly and independently associated with the risk of being diagnosed with T2D, but also that the magnitude of this positive association is larger for higher BMI values." It is little wonder, therefore, that higher diabetes type 2 prevalence rates among Asian Americans despite lower BMI values raise concern. Alpert and Thomason (2016) conclude that "although the standardized body mass index (BMI) assessment is an adequate tool for reporting secular prevalence trends for overweight/obesity across populations, it falls short in accuracy when assessing Asian Americans."

According to Lee, Brancati, and Yeh (2011), one reason advanced to explain the high prevalence of type 2 diabetes among Asian Americans is genetic predisposition. As the authors state, "Asians appear to be more genetically predisposed to develop type 2 diabetes compared with their white counterparts." Other possible explanations include immigration acculturation stress and high visceral fat levels. The authors further note that "both BMI and diabetes prevalence are rising in all Asian subgroups, especially Filipinos" (Lee, Brancati, and Yeh, 2011). This rising prevalence is supported by Nguyen, Nguyen, Fischer, Ha, and Tran (2015), who also maintain that, based on available data, type 2 diabetes has been on the increase among Asian Americans.

BMI, Obesity, and Misunderstood Risk

In the past, obesity rates have been reported to be lower among Asian Americans in comparison to their white counterparts (Lee, Brancati, and Yeh, 2011). According to Wang, Wong, Dixit, Fortmann, Linde, and Palanippan (2011), NHANES data indicates that, on average, Asian Americans have a lower average BMI in comparison to other demographic groups. Generally, persons with a BMI above 25 are considered overweight, and those exceeding 30 are considered obese. The NHANES survey indicates that Asian Americans have an average BMI below 25. As Alpert and Thomason (2016) point out, this leads to the mistaken belief that Asian Americans are at lower risk of type 2 diabetes than other demographic groups. According to Herman and Rothberg (2016), "the greater prevalence of undiagnosed diabetes among Asian American individuals suggests that less screening and diagnostic testing is being performed among less obese Asian American individuals, despite the greater cardiometabolic risk that occurs at lower BMI levels."

As Sun, Tsoh, Saw, Chan, and Cheng (2012) point out, very few studies have assessed how effective culturally sensitive diabetes education programs really are, especially among Asian Americans. In a study assessing various populations — Asian American (AA), Native Hawaiian (NH), and Pacific Islander (PI) — and the best strategies to address the special needs of these groups in managing type 2 diabetes, King, McNeely, Thorpe, and Mau (2011) note that these demographic groups are significantly diverse on genetic, cultural, and geographic fronts. On this basis, the authors conclude that "there is a great need to understand the prevalence and pathophysiology and discuss potential intervention strategies regarding diabetes in AANHPI populations given the unique characteristics of this population."

References

Alpert, P.T. & Thomason, D. (2016). Metabolic syndrome: Differences for Asian Americans is in their body fat percentages. Asian/Pacific Island Nursing Journal, 1(3), 70–81.

Bodenheimer, T., Chen, E. & Bennett, H.D. (2009). Confronting the growing burden of chronic disease: Can the U.S. health care workforce do the job? Health Affairs, 28(1), 64.

Ganz, M., Wintfeld, N., Li, Q., Alas, V., Langer, J. & Hammer, M. (2014). The association of body mass index with the risk of type 2 diabetes: A case-control study nested in an electronic health records system in the United States. Diabetology & Metabolic Syndrome, 25(2), 93–102.

Herman, W. & Rothberg, A.E. (2016). Prevalence of diabetes in the United States: A glimmer of hope? JAMA, 314(10), 92–107.

Ivey, S., Tseng, W., Kurtovich, E., Lui, B., Weir, R.C., Liu, J., Song, H., Wang, M. & Hubbard, A. (2012). Evaluating a culturally and linguistically competent health coach intervention for Chinese-American patients with diabetes. Diabetes Spectrum, 25(2), 93–102.

King, G.L., McNeely, M.J., Thorpe, L.E. & Mau, M.L. (2011). Understanding and addressing unique needs of diabetes in Asian Americans, Native Hawaiians, and Pacific Islanders. Diabetes Care, 35(5), 1181–1188.

Konchak, J.N., Moran, M.R., O'Brien, M.J., Kanduls, N.R. & Ackermann, R.T. (2016). The state of diabetes prevention policy in the USA following the Affordable Care Act. Curr. Diab. Rep., 16(1), 55.

Laakso, M. (2010). Cardiovascular disease in type 2 diabetes from population to man to mechanisms. Diabetes Care, 33(2), 442–449.

Lee, J.W., Brancati, F.L. & Yeh, H. (2011). Trends in the prevalence of type 2 diabetes in Asians versus whites. Diabetes Care, 34(2), 353–357.

Lorig, K., Ritter, P.L., Turner, R.M., English, K., Laurent, D.D. & Greenberg, J. (2016). JMIR, 18(12), 322–339.

Nguyen, T.H., Fischer, T., Ha, W. & Tran, T.V. (2015). Type 2 diabetes among Asian Americans: Prevalence and prevention. World J Diabetes, 6(4), 543–547.

Sun, A.C., Tsoh, J.Y., Saw, A., Chan, J.L. & Cheng, J.W. (2012). Effectiveness of a culturally tailored diabetes self-management program for Chinese Americans. Diabetes Educ., 38(5), 685–694.

Thomas, A. & Ashcraft, A. (2013). Type 2 diabetes risk among Asian Indians in the US: A pilot study. Nursing Research and Practice, 24(6), 324–341.

Wang, Z., Wang, J. & Chan, P. (2013). Treating type 2 diabetes mellitus with traditional Chinese and Indian medicinal herbs. Evidence-Based Complementary and Alternative Medicine, 93(2), 118–136.

Wang, E.J., Wong, E.C., Dixit, A.A., Fortmann, S.P., Linde, R.B. & Palanippan, L.P. (2011). Type 2 diabetes: Identifying high risk Asian American subgroups in a clinical population. Diabetes Res Clin Pract, 93(2), 248–254.