South Asians, particularly Indian women, face a higher risk of diabetes due to genetic and lifestyle factors, often presenting as “skinny-fat,” which complicates traditional health assessments.
When Snigdha was diagnosed with diabetes in 2008, she felt a mix of betrayal and shock. “I was thin, did not have a sweet tooth, and had never been a foodie. I am lactose intolerant, so I didn’t even have ice cream! Nobody in my immediate family had diabetes. And yet here I was,” she recalled.
Snigdha, a resident of the Bay Area, was six months pregnant with her first child when a routine glucose test revealed she had gestational diabetes. Her glucose screening, conducted during her pregnancy, measured at 163 mg/dL, well within the diabetes range. She also failed the subsequent glucose tolerance test. Despite her healthy lifestyle and low body mass index (BMI), Snigdha did not fit the typical profile of someone with diabetes.
In South Asian families, diabetes is often perceived as a condition that arises after weight gain, middle age, and clear warning signs. It is frequently associated with older relatives who casually mention, “I have a sugar problem.” However, Snigdha’s diagnosis highlights a hidden truth: Asian Indian women have the highest rates of gestational diabetes in the United States.
Dr. Venkat Narayan, executive director at the Emory Global Diabetes Research Center, explains that South Asians face unique challenges regarding diabetes. “One, we don’t secrete enough insulin, so we don’t have the metabolic capacity. Second, our muscle mass is low, so we don’t burn glucose readily. Third, we are easily prone to depositing liver fat,” he said.
After eating, blood sugar levels rise, prompting the pancreas to release insulin to help cells absorb glucose. In Type 2 diabetes, however, cells become insulin-resistant, leading to rising blood sugar levels and eventually diabetes. During pregnancy, hormones from the placenta can further interfere with insulin function. Gestational diabetes can lead to complications such as miscarriage, hypertension, and increased risks for the baby, including respiratory problems, obesity, and Type 2 diabetes later in life.
Dr. Alka Kanaya, an expert in Type 2 diabetes, obesity, and cardiovascular disease at UCSF, emphasizes the importance of understanding one’s health status. “If we don’t know our numbers, the stress of pregnancy can reveal underlying factors like diabetes,” she said. She advocates for women to have their health metrics evaluated before becoming pregnant to mitigate risks associated with gestational diabetes.
After her diagnosis, Snigdha had to navigate managing her condition while pregnant. She was prescribed metformin, a medication for high blood sugar levels, and referred to a nutritionist. “That’s the first time counting carbs came into my life,” she recalled. The nutritionist provided dietary suggestions that prompted Snigdha to make significant lifestyle changes, including moving her dinner time earlier.
Despite these adjustments, Snigdha struggled to control her glucose levels and ultimately required insulin shots. With little body fat apart from her baby bump, she found it challenging to locate a suitable injection site. Her sister-in-law, who shared a similar health profile, also experienced gestational diabetes, which helped Snigdha feel less isolated.
Snigdha welcomed a healthy baby, and within weeks of her son’s birth, her glucose levels returned to a safe range, allowing her to stop all medications. However, her OB/GYN warned her that she was at high risk for diabetes in the future and needed regular testing.
Despite maintaining a slim figure, Snigdha faced another shock seven years later during her second pregnancy when early testing revealed gestational diabetes again. This time, she accepted the diagnosis with quiet resignation and followed a similar treatment path through delivery.
After her second child was born, her blood sugar levels normalized again, and she discontinued her diabetes medications. However, in 2020, three years after her second child, Snigdha noticed her fasting glucose numbers rising. At just 44 years old and with a BMI of 23, her glucose level reached 111 mg/dL, placing her in the pre-diabetic range. Her HbA1C levels also increased, indicating a concerning trend.
Research indicates that individuals who experience gestational diabetes are more than 11 times as likely to develop diabetes within nine years after delivery compared to those who do not.
Dr. Deepika Reddy, an endocrinologist at the University of Utah, notes that diabetes is often linked to excess body fat, particularly visceral fat around the organs, which triggers inflammation and contributes to insulin resistance. However, BMI does not always accurately reflect this risk in populations like South Asians.
The phenomenon of the “thin Indian with a pot belly” illustrates a growing epidemic of obesity and Type 2 diabetes, particularly among Asian Indians. Research from the National Institutes of Health shows that Indians tend to develop diabetes at younger ages and lower BMI levels than white Caucasians.
Individuals who appear lean may still have a higher body fat percentage, a condition often referred to as “skinny-fat.” This body type may develop before birth due to genetic factors, including low levels of vitamin B12 and folate in the mother, combined with high blood sugar during pregnancy.
Dr. Narayan has been researching diabetes since 1992 and emphasizes the need to consider both biological and lifestyle factors when addressing diabetes risk among South Asians. His team has hypothesized that Type 2 diabetes may not be a single disease but could represent different types based on insulin resistance and deficiency.
Snigdha’s primary care physician has not yet prescribed medications, encouraging her to focus on diet and lifestyle changes. “I am not good with that,” Snigdha admits, noting her busy schedule as a media professional raising two children. However, she has found success in making small dietary adjustments, such as reducing her carbohydrate intake.
“I probably should dedicate time for actual exercise,” she acknowledges, recognizing the importance of physical activity in managing insulin sensitivity. Dr. Kanaya emphasizes that increasing physical activity is crucial for reducing insulin resistance.
As Snigdha navigates her health journey, she remains committed to monitoring her blood sugar levels and making healthier lifestyle choices. If left unmanaged, diabetes can lead to serious complications, including heart disease, strokes, kidney damage, nerve problems, dementia, and vision loss.
Dr. Narayan points out that more than 800 million people worldwide have diabetes, with a significant portion being of Indian descent. “Our knowledge is borrowed from other populations. The amount of research focused on Indian populations is minimal, representing only 1 to 2% of the total,” he said. “Unless we invest more in research to understand why South Asians are more prone to diabetes, we won’t solve the problem.”
At UCSF, Dr. Kanaya is working on developing better risk prediction models for South Asians through the MASALA Study. “It’s crucial for people to participate in research studies. We have very little data on South Asians because they often do not participate. If you hear about a study, please join,” she urged.
This article was produced in partnership with the USC Annenberg Center for Health Journalism’s “Healing California” Ethnic Media Collaborative.