T2DM and ASCVD in Asian American Subgroups: Lessons From the AHA Scientific Statement

Oct 12, 2023   |  Vennela Avula; Abhishek Gami, MD; Jaideep Patel, MD, FACC

Expert Analysis

Font Size
A
A
A

Quick Takes

  • Type 2 diabetes mellitus (T2DM) is a key cardiometabolic risk factor for atherosclerotic cardiovascular disease (ASCVD) that should be identified through early and routine screening.
  • Higher-risk ASCVD subgroups include Native Hawaiian and Pacific Islander, South Asian, and Filipino adults.
  • Future research on T2DM and ASCVD should aim to provide disaggregated Asian American data as a means of improving risk assessment and management recommendations.

This expert analysis is based on the 2023 American Heart Association (AHA) Scientific Statement on the Epidemiology of Diabetes and Atherosclerotic Cardiovascular Disease Among Asian American Adults.1

Introduction

The Asian American population is the fastest-growing ethnic group in the United States, and its largest subgroups include Asian Indian, Chinese, Filipino, Japanese, Korean, and Vietnamese Americans. Type 2 diabetes mellitus (T2DM) and atherosclerotic cardiovascular disease (ASCVD) are leading causes of mortality and morbidity in Asian American adults. However, there is significant variability in the prevalence of T2DM and ASCVD risk factors among different Asian American subgroups, which is an unfortunate shortcoming in the current literature that often aggregates racial and ethnic groups.

The 2023 AHA scientific statement on diabetes mellitus (DM) and ASCVD among Asian American adults aims to summarize existing research on the epidemiology, biological and social mechanisms, and interventions related to T2DM and ASCVD in Asian American adults.1 This statement highlights the need for culturally appropriate strategies and future research to address these disparities.1

Epidemiology of Outcomes and Risk Factors

Type 2 Diabetes Mellitus

The prevalence of T2DM varies significantly among Asian American subgroups, with the highest prevalence in Native Hawaiian and Pacific Islander adults (34.5%), Filipino adults (31%), and South Asian adults (29.1%), and with East Asian subgroups having a lower prevalence (~14%) (Table 1). There is a higher rate of T2DM among second-generation Filipino American adults, which is thought to be explained by the increased prevalence of obesity and poorer diet quality. Among South Asian adults, DM is diagnosed nearly 5-10 years earlier than in white Europeans, and control of blood glucose levels once diagnosed is challenging due to difficulty with, for example, diet management and social stigma. Factors such as visceral and hepatic fat, insulin resistance, and reduced beta cell function contribute to the susceptibility of T2DM in South Asian adults overall.2

Table 1: Prevalence of ASCVD Outcomes and Cardiometabolic Risk Factors Among Asian American Subgroups

Subgroup Prevalence
Outcome Risk Factors
CAD (%)1 CVA (%)1 PAD (%)1 T2DM (%)1 HTN (%) Dyslipidemiaa (%)2 Obesity (%)3
Chinese 6.4 (M)
2.5 (W)		 1.1 0.9 15.6 13.44 High LDLb: 45.8
Low HDLb: 31.8
High TGb: 29.9		 Standard BMIc: 6.5
BMI modified for Asiansd: 13.2
Korean 5.9 (M)
1.7 (W)		 0.3 0.8 18 23.24 High LDL: 51.7
Low HDL: 34.6
High TG: 29.8		 Standard BMI: 8.5
BMI modified for Asians: 17.4
Japanese 6.9 (M)
2.7 (W)		 1.2 0.3 18.1 NA High LDL: 54.2
Low HDL: 23.7
High TG: 36		 Standard BMI: 15.3
BMI modified for Asians: 26.7
Vietnamese 5.6 (M)
3.8 (W)		 1.7 0.5 95 22.94 High LDL: 56.1
Low HDL: 37.2
High TG: 39		 Standard BMI: 6.3
BMI modified for Asians: 13.6
Asian Indian 13 (M)
4.4 (W)		 1 1.4 29.4 10.46 High LDL: 54.8
Low HDL: 54.9
High TG: 37.4		 Standard BMI: 11.2
BMI modified for Asians: 22.4
Filipino 9.2 (M)
4.3 (W)		 1.8 1.3 31 23.96 High LDL: 63
Low HDL: 37.3
High TG: 41.5		 Standard BMI: 16.8
BMI modified for Asians: 28.7
Table 1: Prevalence of ASCVD Outcomes and Cardiometabolic Risk Factors Among Asian American Subgroups. Courtesy of Avula V, Gami A, Patel J.

a Dyslipidemia was determined from a 3-year cross-section from an outpatient health care organization in northern California and categorized into three subtypes
b Measured in milligrams per deciliter
c BMI of ≥30 kg/m2
d BMI of ≥27.5 kg/m2

ASCVD = atherosclerotic cardiovascular disease; BMI = body mass index; CAD = coronary artery disease; CVA = cerebrovascular accident; HDL = high-density lipoprotein level; HTN = hypertension; LDL = low-density lipoprotein level; M = men; NA = not available; PAD = peripheral artery disease; T2DM = type 2 diabetes mellitus; TG = triglyceride level; W = women.

Table References
  1. Kwan TW, Wong SS, Hong Y, et al.; American Heart Association Council on Epidemiology and Prevention; Council on Lifestyle and Cardiometabolic Health, Council on Arteriosclerosis, Thrombosis and Vascular Biology, Council on Clinical Cardiology, Council on Cardiovascular and Stroke Nursing, Council on Genomic and Precision Medicine. Epidemiology of diabetes and atherosclerotic cardiovascular disease among Asian American adults: implications, management, and future directions: a scientific statement from the American Heart Association. Circulation 2023;148:74-94.
  2. Frank AT, Zhao B, Jose PO, Azar KM, Fortmann SP, Palaniappan LP. Racial/ethnic differences in dyslipidemia patterns. Circulation 2014;129:570-9.
  3. Shah NS, Luncheon C, Kandula NR, et al. Heterogeneity in obesity prevalence among Asian American adults. Ann Intern Med 2022;175:1493-500.
  4. Jung MY, Lee S, Thomas SB, Juon HS. Hypertension prevalence, treatment, and related behaviors among Asian Americans: an examination by method of measurement and disaggregated subgroups. J Racial Ethn Health Disparities 2019;6:584-93.
  5. De Souza LR, Chan KT, Kobayashi K, Karasiuk A, Fuller-Thomson E. The prevalence and management of diabetes among Vietnamese Americans: a population-based survey of an understudied ethnic group. Chronic Illn 2022;18:306-19.
  6. Ye J, Rust G, Baltrus P, Daniels E. Cardiovascular risk factors among Asian Americans: results from a National Health Survey. Ann Epidemiol 2009;19:718-23.

Other ASCVD Risk Factors

Genetic

Studies have identified genetic variants associated with ASCVD risk in Asian populations, including those specific to certain Asian ancestries. Polygenic risk scores developed in European cohorts may not perform as well for those of non-European ancestral backgrounds, which emphasizes the need for ancestry-specific risk assessment.3

Acculturation

Higher rates of acculturation are associated with increased risk factor burden, poorer cardiovascular health, and increased risk of ASCVD events, which may be associated with higher uptake of the Western diet.4 Physical activity levels and smoking behaviors, however, are positively influenced by acculturation.4

Social Context

Structural characteristics (e.g., size and interconnectedness) and functional aspects (e.g., social support and social norms) influence smoking behaviors, dietary patterns, and physical activity in both a positive and negative fashion.

Socioeconomic Status

Differences in immigration patterns contribute to variations in socioeconomic status (SES) among Asian American subgroups, with household incomes ranging from >$90,000 for Filipino and Asian Indian adults to <$60,000 for more recent Asian immigrants such as Burmese and Nepalese Americans.5 These factors, along with sociodemographic characteristics, influence the social determinants of health and contribute to different patterns of risk of T2DM and ASCVD observed among Asian American subgroups.

Conclusions and Future Directions

Poor cardiometabolic health in certain Asian American subgroups is multifaceted, likely driven in part by a high prevalence of traditional risk factors, genetics, acculturation, social context, and SES. T2DM is a key cardiometabolic risk factor that can be targeted through early and routine screening. Conversely, if ASCVD is detected, screening for prediabetes, T2DM, and other traditional risk factors remains imperative. Specific subgroups such as South Asian and Filipino adults have an especially high prevalence of T2DM and should be targeted with culturally relevant interventions (similar to other subgroups) to increase awareness and individualize treatment when necessary, considering earlier progression from prediabetes and poorer DM management than in other racial groups in the United States. Other interventions to address T2DM and ASCVD in Asian American populations are shown in Figure 1. Future research on T2DM and ASCVD should examine Asian American subgroups individually when possible.

Figure 1: Interventions to Address T2D and ASCVD in Asian American Populations

Figure 1
Figure 1: Interventions to Address T2D and ASCVD in Asian American Populations. Courtesy of Avula V, Gami A, Patel J.
ASCVD = atherosclerotic cardiovascular disease; GLP1 = glucagon-like peptide-1; HbA1C = hemoglobin A1c; SGLT2i = sodium-glucose cotransporter-2 inhibitor; T2D = type 2 diabetes mellitus.

References

  1. Kwan TW, Wong SS, Hong Y, et al.; American Heart Association Council on Epidemiology and Prevention; Council on Lifestyle and Cardiometabolic Health, Council on Arteriosclerosis, Thrombosis and Vascular Biology, Council on Clinical Cardiology, Council on Cardiovascular and Stroke Nursing, Council on Genomic and Precision Medicine. Epidemiology of diabetes and atherosclerotic cardiovascular disease among Asian American adults: implications, management, and future directions: a scientific statement from the American Heart Association. Circulation 2023;148:74-94.
  2. Shah AD, Kandula NR, Lin F, et al. Less favorable body composition and adipokines in South Asians compared with other US ethnic groups: results from the MASALA and MESA studies. Int J Obes (Lond) 2016;40:639-45.
  3. Agarwala A, Satish P, Al Rifai M, et al. Identification and management of atherosclerotic cardiovascular disease risk in South Asian populations in the U.S. JACC Adv 2023;Mar:[ePub ahead of print].
  4. Wong SS, Dixon LB, Gilbride JA, Kwan TW, Stein RA. Measures of acculturation are associated with cardiovascular disease risk factors, dietary intakes, and physical activity in older Chinese Americans in New York City. J Immigr Minor Health 2013;15:560-8.
  5. Budiman A, Ruiz NG. Key facts about Asian Americans, a diverse and growing population (Pew Research Center website). 2021. Available at: https://www.pewresearch.org/short-reads/2021/04/29/key-facts-about-asian-americans/. Accessed 10/12/2023.

Clinical Topics: Prevention, Diabetes and Cardiometabolic Disease

Keywords: Diabetes Mellitus, Type 2, Asian Americans, Cardiovascular Diseases, Atherosclerosis


< Back to Listings