We have come a long way since our first meeting five years ago in Honolulu, HI. At that first meeting, we reviewed the known literature and highlighted the need for more disaggregated data. Since, more researches and data have shown that screening should begin at BMI >23, as had been done in Asia. We successfully advocated for the ADA to change its screening guidelines in 2015, and launched our Screen at 23 Campaign. More recent data shows that half of Asian Americans with prediabetes are unaware of their risk, and screening would save thousands of lives. We continue to need to better understand how diabetes affects our Native Hawaiian and Pacific Islander populations.
Edward A. Chow, M.D., CoChair, AANHPI Diabetes Coalition
The report includes a synopsis of each presentation and plenary, with slides and references, and is available for download (PDF 12 MB) and online viewing.
Maria Rosario (Happy) Araneta, Ph.D., M.P.H., Professor of Epidemiology, University of California San Diego School of Medicine, Member, Advisory Council, National Institute of Minority Health and Health Disparities, National Institutes of Health
ADA 2015 Guidelines for screening for type 2 diabetes (T2D) among asymptomatic individuals has reduced the body mass index (BMI) screening cutpoint for Asian Americans to >23 kg/m2 (from previous cutpoint of BMI>25 kg/m2. In one major study in northern California, Pacific Islanders (18.3%), Filipinos (16.1%), and South Asians (15.9%) had higher T2D prevalence compared to ethnic groups perceived to be at highest risk, including Latinos, AfricanAmericans, and Native Americans. Southeast Asian, Japanese, Vietnamese, Korean, and Chinese had higher T2D prevalence compared to Whites, despite low rates of obesity.
Edward Gregg, Ph.D., Chief, Epidemiology and Statistics Branch, Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention
How is diabetes the same, different, or unknown for Asian Americans? The National Health Interview Survey (NHIS) collected data about selfreported diabetes, including for Asian American subgroups, since 1997. The statebased Behavioral Risk Factor Surveillance System (BRFSS) also collects data about selfreported diabetes. If BRFSS data is combined across states, national estimates can be generated. For example, the combined BRFSS data from 201314 shows higher diabetes prevalence for Asian Indians and Filipinos. The National Health and Nutrition Examination Study (NHANES) has the smallest national sampling but has clinical testing that can identify undiagnosed cases of diabetes. NHANES has collected data from Asian American subgroups since 2011, and we now have four years of data. Among Asian Americans, 10% had been diagnosed with diabetes, but another 10.6% were undiagnosed.
Alka Kanaya, M.D., Professor of Medicine, University of California San Francisco
National, state, and local data all show higher prevalence of diabetes among Filipinos and Asian Indians. BRFSS data from 2013-14 shows that Filipinos and Asian Indians had the highest prevalence of selfreported diabetes, and the prevalence among Asian Indians and Filipinos in the BMI >23 kg/m2 category were higher than Chinese, Japanese and whites with BMI >23.
Similarly, data collected from 29 communities in 17 states from 2009-2012 in the Racial and Ethnic Approaches to Community Health (REACH) program showed self reported prevalence of diabetes of 19.4% among Asian Indians in New York, NY and about 15% among Filipinos in Los Angeles and Orange County, CA and King County, WA.
Christopher Holliday, Ph.D., M.P.H., Director, Population Health and ClinicalCommunity Linkages, American Medical Association
Diabetes is personal, with a mother that has had diabetes for ten years, and now cannot see out of one eye. There are 86 million Americans with prediabetes and 29 million with diabetes. In a typical physician panel of 100,000 patients, up to 40% have prediabetes. In 2012, the total cost of diabetes care was $245 billion, or $2,700 per diagnosis.
The American Medical Association (AMA) has a strategic focus on supporting physician satisfaction, providing practice improvement resources, and improving patient health outcomes through clinicalcommunity linkages. The AMACenters for Disease Control and Prevention (CDC) Prevent Diabetes STAT (Screen, Test, Act Today) toolkit27 supports physician awareness about diabetes, identification and education of atrisk patients, referral of patients to evidencebased diabetes prevention programs, and followup on patient progress. There is more work that could be done using electronic health records to automate the identification of patients for batch referrals to the Diabetes Prevention Program.
Sela Panapasa, Ph.D., Research Investigator, University of Michigan Institute for Social Research
Since 1997, there has been a federal mandate to collect separate data on Native Hawaiians and Pacific Islanders, a broad classification that includes indigenous, migrant, and immigrant populations. There are over 22 Pacific Island ethnicities, which are diverse culturally, and speak many languages. The Samoan culture is matriarchal and the Tongan culture is patriarchal.
For many years, we have raised the issue of the inadequacy of Native Hawaiian and Pacific Islander data, and asked for oversampling of Native Hawaiians and Pacific Islander in the National Health Interview Survey (NHIS). While we have been waiting, we have collected and analyzed our own data on Pacific Islanders.
The Pacific Islander Health Study focused on Tongan and Samoan populations.
There are over 184,000 Samoans and over 57,000 Tongans in the U.S. The largest populations live in California, with 32% Samoans and 40% Tongans residing. Our sampling (n=240) was based on 20 faithbased registries of adults and adolescents. Questions were based on both NHIS and California Health Interview Survey, including selfreport of BMI (waist/hip measurements). We weighted our data based on U.S. Census data.
Samuel Wu, Pharm.D., Public Health Advisor and Asian American, Native Hawaiian, and Pacific Islander Policy Lead, U.S. Department of Health and Human Services Office of Minority Health
The Office of Minority Health (OMH) strategies include data, partnerships, and demonstration and evaluation research. Under section 4302 of the Affordable Care Act, OMH established data collection standards for seven subcategories of Asians (Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese and Other Asian) and for four subcategories of Native Hawaiians and Other Pacific Islanders (Native Hawaiian, Guamanian/Chamorro, Samoan, and Other Pacific Islander). 2010 Census reported that there were over 1.2 million Native Hawaiians and Other Pacific Islanders in the U.S., 0.4% of the total U.S. population.
Raynald Samoa, M.D., Assistant Professor of Diabetes, Endocrinology & Metabolism and Endocrinologist, City of Hope, Los Angeles
The prevalence of diabetes is as high as 47% in the Pacific jurisdictions, and 20.6% among Pacific Islanders in the U.S. The University of California Los Angeles used data from the California Health Interview Survey and the National Health and Nutrition Examination Survey to estimate a prediabetes rate of 55% among Pacific Islanders in California and 43% among Pacific Islanders in California ages 1339 years old. Native Hawaiians and Samoans have later diagnoses of diseases and higher mortality rates (see Table 9, next page). There also may be significant comorbidity between diabetes and cancer. We are trying to bring parity to Pacific populations but if the Pacific is the forecast for what diabetes in the U.S. may look like in the future, there is fertile ground for learning and prevention.
Ryan Minster, Ph.D., M.S.I.S., Assistant Professor of Human Genetics, University of Pittsburgh School of Public Health
According to the World Health Organization, the prevalence of obesity is highest among Polynesians and Micronesians (50.8 in the Cook Islands, 47.6 in Palau, 43.4 in Samoa, 43.3 in Tonga, and 42.8 in the Marshall Islands). A genome-wide association study (GWAS) was conducted in 17 villages in Samoa, with n=3,072 in the discovery group (1,235 men and 1,837 women), and n=2,102 in a replication group. The average BMI in the discovery group among men was 31.3, and among women was 34.9. The rate of diabetes was 16% among men, and 17% among women.
Nicola Hawley, Ph.D., Assistant Professor of Epidemiology, Yale School of Public Health
The rate of obesity in American Samoa is nearly 75% among adults (BMI >3p0). We know that prevention of diabetes is better than treatments or a cure. The focus of our research for the past six years has been on Samoan pregnant women and infants. Over 35% of Samoan infants already are obese at 15 months of age, increasing to over 43% by kindergarten.
Using a prevention perspective, we began looking at pregnant women to try to break the cycle of intergenerational obesity. We know that, regardless of weight, pregnant women experience a number of physiological changes, including an increase in adipose tissue, higher triglycerides, and insulin resistance. For obese women, these physiological changes are magnified. Fatty acids, glucose, and inflammatory markers can cross the placenta, leading to increased adipose tissue in the developing infant. Since insulin does not cross the placenta, the infant also begins to increase insulin production to respond to the glucose, and can also begin to become insulin resistant. Prior to our research, there had not been any interventions to reduce obesity focused on Pacific Islander pregnant women.
Joseph Keawe‘aimoku Kaholokula, Ph.D., Associate Professor and Chair, Native Hawaiian Health, John A. Burns School of Medicine, University of Hawai`i at Mānoa
The PILI ‘Ohana Project is a community based lifestyle and diabetes self care program that has been implemented for 12 years in Hawaii.17 Pili means “stick to” or come together, and ‘Ohana means family. We have conducted community based participatory research to develop and implement the program, integrating community wisdom and scientific inquiry to develop an effective community based health promotion program to achieve health equity in Hawaii and in the larger Pacific region.
Obesity among Native Hawaiians and Pacific Islanders is 4 times higher than among Asian Americans, and 30% higher than Whites. Diabetes among Native Hawaiians and Pacific Islanders is up to 4 times higher than Whites. Prevailing strategies to address obesity and diabetes neglect the social determinants of health, do not have any sociocultural context, often are too intense, are based on ideals rather than reality, are not easily accessible by those at risk, and are not sustainable across settings. Even in the Diabetes Prevention Program, only 42% of the participants achieved the weight loss goal. In Hawaii, there is a high cost of living, community members are often working two jobs and have hourlong commutes, so they eat fast food and have no time for physical activity.
Judith Fradkin, M.D., Ph.D., Director, Division of Diabetes and Endocrinology, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health
Data from the 2011-2012 National Health and Nutrition Examination Survey reports that Asian Americans had the highest rate of undiagnosed diabetes. Is there a higher risk for diabetes among Asian Americans at younger ages, for example, ages 20-44? The current U.S. Preventive Services Task Force recommendation is to screen individuals age 40 and older if they are obese or overweight.
Among the current research being funded by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) are projects examining stress and lifestyle interventions for diabetes among immigrant Chinese Americans, smartphone and social media interventions for diabetes among Filipino Americans, and identifying diabetes prevalence among Asian Americans, Native Hawaiians, and Pacific Islanders through electronic health records (being conducted by Kaiser Permanente Health Plan in Hawai`i).
Maria Rosario (Happy) Araneta, Ph.D., M.P.H., Professor of Epidemiology, University of California San Diego School of Medicine Member, Advisory Council, National Institute of Minority Health and Health Disparities, National Institutes of Health
The mission of the National Institute on Minority Health and Health Disparities (NIMHD) at the National Institutes of Health is to lead scientific research to improve minority health and reduce health disparities. To accomplish its mission, NIMHD plans, coordinates, reviews, and evaluates NIH minority health and health disparities research and activities; conducts and supports research in minority health and health disparities; promotes and supports the training of a diverse research workforce; translates and disseminates research information; and fosters innovative collaborations and partnerships.
NIMHD has an advisory council of 14 members;45 currently, Dr. Araneta is the only Asian American on the Council (Dr. Marjorie Mau was a former member). The NIMHD Director is Dr. Eliseo PerezStable, who was the Chief, Division of General Internal Medicine, at the University of California, San Francisco. Fiscal Year 2016 budget for NIMHD is $282 million compared to NIDDK budget of $1.9 billion.
William C. Hsu, M.D., Medical Director, Asian Clinic and Vice President, International Programs, Joslin Diabetes Center
There are currently 29 million cases of diabetes in the U.S. We know that there are potentially millions more cases, with many cases currently undiagnosed. From a health workforce perspective, there are only 3,000 endocrinologists and 1,500 certified diabetes educators to take care of these millions of patients. We also know that the healthcare delivery model of officebased visits to doctor for medication is becoming antiquated. We already have 12 classes of diabetes medications, while diabetes education programs are underutilized, with participation by only 5% of patients on Medicare and less than 7% of patients with private health insurance who are newly diagnosed with diabetes participate in diabetes selfmanagement programs. So what interventions are there beyond prescribing drugs? We have learned from Native Hawaiian and Pacific Islander communities how to develop and implement effective communitybased interventions. We have to think outside the box, and outside the doctor’s office.
There is the recent example of Pokemon Go; is it just a game or is it a physical activity app? It has increased physical activity among its users with no recommendations, no incentives, no penalties, and no costs. 100 million users downloaded Pokemon Go.
George King, M.D., Chief Scientific Officer, Joslin Diabetes Center
Professor of Medicine, Harvard Medical School
We are seeing that research on diabetes among Asian Americans, Native Hawaiians, and Pacific Islanders may have implications for all populations, for example, the genetics study among Samoans. The causes of diabetes are complex, involving both one’s genes and one’s environment.
In the SEARCH study, while 85% of the White youth with type 1 diabetes have autoimmune antibodies, only 30% of the Chinese American youth had these antibodies. As we are understanding heterogeneity among type 1 diabetes, what can we learn from this difference? We need more research to characterize the genotype, autoimmune markers, insulin sensitivity, beta cell function, pathologies, and epidemiology of type 1 diabetes among various Asian American, Native Hawaiian, and Pacific Islander populations.
Edward A. Chow, M.D., CoChair, AANHPI Diabetes Coalition
Our AANHPI Diabetes Coalition advocated for a change in the diabetes screening guideline to a lower BMI for Asian Americans. Researchers laid the foundation and evidence base for the American Diabetes Association (ADA) to change its screening guideline for Asian Americans in January 2015 to screening at a BMI of >23.18.
However, we know that it can take ten years to implement a guideline change in clinical practice. Therefore, we need to educate providers and professional organizations and the Asian American community about this new diabetes screening guideline. And we need to make sure that our messages are correct; for example, this is not new standard for obesity. The Screen at 23 campaign received important media coverage in a Los Angeles Times article.19 The ADA Asian American Pacific Islander Diabetes Action Council and ADA chapters also have been disseminating information about the Screen at 23 campaign. We now have a refined message and a slide presentation that is available for provider and community education.
Elisa Choi, M.D., Chairperson, Asian American Commission, Commonwealth of Massachusetts
From 2000 to 2010, Asian Americans were the fastest growing racial group (47% increase) in Massachusetts; there are significant Asian American populations in Boston, Quincy, and Lowell. The Asian American Commission (with 21 members) was created by the Massachusetts legislature ten years ago; prior commissions and advisory bodies were created by governors and were not permanent. There now is an Asian Pacific Islander Political Caucus of elected officials in Massachusetts. Our commission hopes to work with communitybased and faithbased organizations, and healthcare providers.