In 2021, Shaheen Aamir found herself too exhausted to engage in active play with her children. She recalls telling them, “‘You guys can play, Mom wants to sit.'” Aamir admits to never exercising and being concerned about her weight at the time.
Fast forward three years, and now 32-year-old Aamir begins each day with yoga or dancing. This transformation occurred after she enrolled in a four-month course focused on preventing Type 2 diabetes. “It changed my life, health- and fitness-wise,” says Aamir, adding that she feels “light and energetic” and has experienced a boost in self-esteem.
Aamir, an immigrant from Pakistan with a family history of diabetes, was among nearly 550 individuals who participated in the South Asian Healthy Lifestyle Intervention Program (SAHELI). The study aimed to address and prevent diabetes and heart disease among South Asians residing in the Chicago area.
Compared to whites, Asian Americans and Pacific Islanders have higher diabetes rates and are more likely to develop Type 2 diabetes at younger ages and lower body weights. South Asians, Filipinos, and Pacific Islanders face particularly high risks among Asian subgroups.
A team of Asian American researchers is working to uncover the reasons behind these disparities and develop programs like SAHELI to reduce diabetes rates. They are investigating root causes and improved solutions while advocating for their communities to adopt healthier habits. Here are some key findings that can make a difference.
Identifying the Dangers of ‘Skinny Fat’
In the mid-1990s, when epidemiologist Maria Rosario Araneta joined UC San Diego’s faculty, she noticed a pattern: numerous patients at a nearby Veterans Administration hospital suffering from kidney damage due to diabetes were slim Filipino men. “They weren’t obese, they weren’t overweight,” Araneta says, emphasizing that “they had access to care” and were required to exercise as part of their Navy service.
This trend resonated with Araneta, a Filipina, because her father and grandmother both developed diabetes while appearing slim and healthy. “I thought – I’m definitely at risk. My community’s at risk,” she remembers.
Although there is a well-established connection between being overweight or obese and the risk of diabetes, Asians in America are 40% more likely to be diagnosed with the disease than whites, despite having lower average BMIs.
Dr. Alka Kanaya, a diabetes researcher and professor of medicine at UC San Francisco, suggests that one explanation could be that Asian bodies tend to store fat “in all the wrong places.” Instead of accumulating fat under the skin around the hips or thighs, Asian Americans often deposit it “in the liver, around the abdominal organs, in the muscle, around the heart.”
This can result in a condition known as “skinny fat,” where an individual may appear thin externally but possess a significant amount of visceral fat deep within the belly and surrounding the organs. Araneta explains that “visceral fat is not just a place where we store excess calories,” but rather, this hidden fat may contribute to Type 2 diabetes risk by promoting inflammation and insulin resistance.
Researchers are currently trying to determine how to reduce visceral fat, suspecting that building muscle might help, but they have yet to gather sufficient data to confirm this theory.
Adapting Screening Guidelines for Asian Americans
There is limited U.S. research funding available for studying diabetes in Asian populations, leading to issues with screening and underdiagnosis due to the historical lack of data. However, Dr. George King, founder and director of the Asian American Diabetes Initiative at the Joslin Diabetes Center in Boston, emphasizes that “it’s not that we have to wait for that for the research [to act]. There’s plenty we can do ourselves.”
King, Araneta, Kanaya, and other Asian American and Pacific Islander healthcare professionals successfully advocated for changes to screening guidelines. This was based on research indicating that many Asians develop diabetes at lower weights. In 2015, the American Diabetes Association began recommending that Asian Americans be screened for diabetes at a body mass index (BMI) of 23, instead of the BMI of 25 recommended for the general population.
The “Screen at 23” campaign helped spread this message, as Asian Pacific Islander physicians and others pushed for increased awareness and policy changes. Several states with high Asian populations have adopted these changes. The Asian American Diabetes Initiative provides a calculator that allows Asian Americans to check their BMI and determine if it falls within the at-risk or healthy range.
Double Screening for At-Risk Individuals
Araneta highlights issues with diagnostic tests, such as the A1C test, which measures blood sugar levels without fasting. An A1C level of 6.5% or higher indicates diabetes based on current medical guidelines, primarily derived from research on people of European descent. However, Araneta’s research shows that many Asians may have diabetes at lower A1C levels. In a study, the A1C test missed half of the Native Hawaiians diagnosed with Type 2 diabetes using the “gold standard” test and two-thirds of Japanese Americans.
This means that many Asians with diabetes might go undiagnosed for years until complications arise. To address this issue, Araneta and other researchers recommend that Asians with A1C levels in the “prediabetes” range (5.7% to 6.4%) undergo further testing for a more accurate diagnosis and proper interventions.
Understanding Subgroup Differences
Araneta stresses the importance of researching differences in diabetes risk among the diverse Asian American and Pacific Islander population, as some groups have much higher rates overall – South Asians, Filipinos, and Pacific Islanders. For example, while Chinese Americans generally develop diabetes at age 70 or older, South Asians tend to develop low insulin production at a younger age, leading to a subtype of Type 2 diabetes often associated with heart disease but not kidney problems, according to Kanaya.
Behavioural Changes for Prevention
While researchers continue seeking answers, doctors aim to reduce people’s risk now. The SAHELI diabetes prevention course that Shaheen Aamir participated in focuses on improving diet, exercise, and stress levels, proving even more effective than commonly prescribed drugs for warding off diabetes. The program is specifically adapted for South Asian foods and culture, addressing the stress of being an ethnic minority and the challenges faced when immigrating to a new environment.
Aamir credits the program with helping her change her family’s diet and lifestyle, resulting in weight management and increased energy to play with her children. Advocacy and prevention programs are making a difference, but the number of Asians and Pacific Islanders with diabetes continues to rise. Long-term lifestyle changes are needed to address the issue, and researchers are committed to this work for years to come.
