Cardiometabolic Risk in Asian Americans by Social Determinants of Health: Serial Cross-sectional Analyses of the NHIS, 1999-2003 to 2014-2018

Prediabetes Prevalence by Adverse Social Determinants of Health in Adolescents

Importance

Several clinical practice guidelines advise race- and ethnicity-based screening for youth-onset type 2 diabetes (T2D) due to a higher prevalence among American Indian and Alaska Native, Asian, Black, and Hispanic youths compared with White youths. However, rather than a biological risk, this disparity likely reflects the inequitable distribution of adverse social determinants of health (SDOH), a product of interpersonal and structural racism.

Objective

To evaluate prediabetes prevalence by presence or absence of adverse SDOH in adolescents eligible for T2D screening based on weight status.

Design, Setting, and Participants

This cross-sectional study and analysis used data from the 2011 to 2018 cycles of the National Health and Nutrition Examination Survey. Data were analyzed from June 1, 2023, to April 5, 2024. Participants included youths aged 12 to 18 years with body mass index (BMI) at or above the 85th percentile without known diabetes.

Main Outcomes and Measures

The main outcome consisted of an elevated hemoglobin A1c (HbA1c) level greater than or equal to 5.7% (prediabetes or undiagnosed presumed T2D). Independent variables included race, ethnicity, and adverse SDOH (food insecurity, nonprivate health insurance, and household income <130% of federal poverty level). Survey-weighted logistic regression was used to adjust for confounders of age, sex, and BMI z score and to determine adjusted marginal prediabetes prevalence by race, ethnicity, and adverse SDOH.

Results

The sample included 1563 individuals representing 10 178 400 US youths aged 12 to 18 years (mean age, 15.5 [95% CI, 15.3-15.6] years; 50.5% [95% CI, 47.1%-53.9%] female; Asian, 3.0% [95% CI, 2.2%-3.9%]; Black, 14.9% [95% CI, 11.6%-19.1%]; Mexican American, 18.8% [95% CI, 15.4%-22.9%]; Other Hispanic, 8.1% [95% CI, 6.5%-10.1%]; White, 49.1% [95% CI, 43.2%-55.0%]; and >1 or other race, 6.1% [95% CI, 4.6%-8.0%]). Food insecurity (4.1% [95% CI, 0.7%-7.5%]), public insurance (5.3% [95% CI, 1.6%-9.1%]), and low income (5.7% [95% CI, 3.0%-8.3%]) were each independently associated with higher prediabetes prevalence after adjustment for race, ethnicity, and BMI z score. While Asian, Black, and Hispanic youths had higher prediabetes prevalence overall, increasing number of adverse SDOH was associated with higher prevalence among White youths (8.3% [95% CI, 4.9%-11.8%] for 3 vs 0.6% [95% CI, -0.7% to 2.0%] for 0 adverse SDOH).

Conclusions and Relevance

Adverse SDOH were associated with higher prediabetes prevalence, across and within racial and ethnic categories. Consideration of adverse SDOH may offer a more actionable alternative to race- and ethnicity-based screening to evaluate T2D risk in youth.

Screening for social determinants of health among populations at risk for MASLD: a scoping review

Background

Social determinants of health (SDoH) have been associated with disparate outcomes among those with metabolic dysfunction-associated steatotic liver disease (MASLD) and its risk factors. To address SDoH among this population, real-time SDoH screening in clinical settings is required, yet optimal screening methods are unclear. We performed a scoping review to describe the current literature on SDoH screening conducted in the clinical setting among individuals with MASLD and MASLD risk factors.

Methods

Through a systematic literature search of MEDLINE, Embase, and CINAHL Complete databases through 7/2023, we identified studies with clinic-based SDoH screening among individuals with or at risk for MASLD that reported pertinent clinical outcomes including change in MASLD risk factors like diabetes and hypertension.

Results

Ten studies (8 manuscripts, 2 abstracts) met inclusion criteria involving 148,151 patients: 89,408 with diabetes and 25,539 with hypertension. Screening was primarily completed in primary care clinics, and a variety of screening tools were used. The most commonly collected SDoH were financial stability, healthcare access, food insecurity and transportation. Associations between clinical outcomes and SDoH varied; overall, higher SDoH burden was associated with poorer outcomes including elevated blood pressure and hemoglobin A1c.

Conclusion

Despite numerous epidemiologic studies showing associations between clinical outcomes and SDoH, and guidelines recommending SDoH screening, few studies describe in-clinic SDoH screening among individuals with MASLD risk factors and none among patients with MASLD. Future research should prioritize real-time, comprehensive assessments of SDoH, particularly among patients at risk for and with MASLD, to mitigate disease progression and reduce MASLD health disparities.

Cardiovascular Health, Lifestyle Factors, and Social Determinants in Asian Subpopulations in the United States

Asian Americans are often aggregated in national public health surveillance efforts, which may conceal important differences in the health status of subgroups that are included in this highly diverse population. Little is known about how cardiovascular health varies across Asian subpopulations and the extent to which lifestyle and social risk factors contribute to any observed differences. This national study used data from the National Health Interview Survey to evaluate the burden of cardiovascular risk factors (hypertension, hyperlipidemia, diabetes mellitus) and cardiovascular diseases (heart attack, coronary heart disease, angina, stroke) across Asian groups (Chinese, Asian Indian, Filipino, Other Asian), and determine whether differences are related to lifestyle factors and/or social determinants of health. The weighted study population included 13,592,178 Asian adults. Filipino adults were more likely to have hypertension than Chinese adults (29.4% vs 15.4%; adjusted odds ratio [OR] 2.40, 95% confidence interval [1.91 to 3.02]), as were Asian Indians (15.7%; OR 1.59 [1.25 to 2.02]). These patterns were similar for hyperlipidemia and diabetes mellitus. For cardiovascular diseases, Filipino adults were significantly more likely to have coronary heart disease (4.2% vs 1.9%; OR 2.19 [1.32 to 3.56]), heart attack (2.6% vs 0.9%; OR 2.79 [1.44 to 5.41]), angina (1.8% vs 0.9%; OR 2.15 [1.06 to 4.32]), and stroke (2.1% vs 0.8%; OR 2.54 [1.42 to 4.55]) compared with Chinese adults, whereas there were no differences compared with Asian Indian adults. Adjustments for lifestyle factors and social determinants completely attenuated differences in coronary heart disease, heart attack, and angina among subpopulations. In conclusion, these findings demonstrate that cardiovascular risk factors and diseases vary significantly across Asian subpopulations, with Filipino adults experiencing the highest burden and Chinese adults the lowest, and that differences in cardiovascular disease are largely attenuated after adjustment for lifestyle and social determinants.

Cardiometabolic Health in Asian American Children

BACKGROUND

The aim was to compare cardiometabolic health between Asian American children and Non-Hispanic White (NHW) children as well as to compare cardiometabolic health among Asian American children by birthplace.

METHODS

Children aged 6-17 years enrolled in the National Health and Nutrition Examination Survey (NHANES) from 2011 to 2018 who self-identified as non-Hispanic Asian and NHW were included. Among Asian Americans, place of birth was defined as foreign born vs United States (US) born. Regression models were adjusted for age, sex, household income, food insecurity, passive smoke exposure, and body mass index (BMI) z-score.

RESULTS

Among 3369 children, 8.4% identified as Asian American (age 11.7 years) and 91.6% identified as NHW (age 11.7 years). Compared to NHW children, Asian American children had significantly lower BMI z-scores and odds of obesity. Asian American children had higher HOMA-IR, and greater odds of dyslipidemia and microalbuminuria compared to NHW children. Among Asian Americans, 30.5% were foreign born. Compared to foreign-born Asian American children, US-born Asian American children had significantly higher non-HDL, triglycerides, and uric acid, lower HDL, and lower odds of hyperfiltration. There were no differences in blood pressure by racial group or place of birth.

CONCLUSIONS

Although Asian American children have lower odds of obesity, they have significantly worse glucose intolerance, more dyslipidemia, and more microalbuminuria compared to NHW children. US-born Asian American children have worse cardiometabolic health profiles compared to foreign-born Asian Americans.

Cardiometabolic Health in Asian American Children

Background

The aim was to compare cardiometabolic health between Asian American children and Non-Hispanic White (NHW) children as well as to compare cardiometabolic health among Asian American children by birthplace.

Methods

Children aged 6-17 years enrolled in the National Health and Nutrition Examination Survey (NHANES) from 2011-2018 who self-identified as non-Hispanic Asian and NHW were included. Among Asian Americans, place of birth was defined as foreign-born vs United States (US)-born. Regression models were adjusted for age, sex, household income, food insecurity, passive smoke exposure, and body mass index (BMI) z-score.

Results

Among 3369 children, 8.4% identified as Asian American (age 11.7 years) and 91.6% identified as NHW (age 11.7 years). Compared to NHW children, Asian American children had significantly lower BMI z-scores and odds of obesity. Asian American children had higher HOMA-IR and uric acid, and greater odds of dyslipidemia, microalbuminuria and glomerular hyperfiltration compared to NHW children. Among Asian Americans, 30.5% were foreign-born. Compared to foreign-born Asian American children, US-born Asian American children had significantly higher non-HDL, triglycerides, HOMA-IR and uric acid, lower HDL, and lower odds of hyperfiltration. There were no differences in blood pressure by racial group or place of birth.

Conclusions

Although Asian American children have lower odds of obesity, they have significantly worse glucose intolerance, higher serum uric acid levels, more dyslipidemia and more microalbuminuria compared to NHW children. US-born Asian American children have worse cardiometabolic health profiles compared to foreign-born Asian Americans.

Assessing the clinical utility of major indices for nonalcoholic fatty liver disease in East Asian populations

Nonalcoholic fatty liver disease (NAFLD) is currently the most common form of chronic liver disease. The growing prevalence of NAFLD is strongly associated with the high incidence of metabolic syndrome. NAFLD affects as much as 19% of the US population with a disproportionate impact on minority racial groups such as Asian Americans. If not promptly managed, NAFLD may progress to more feared complications. Liver indices for NAFLD screening have been proposed but were often developed using study populations with different anthropometrics than patients of East Asian descent. This review compares the accuracy of five indices for NAFLD screening in Asian cohorts. The Fatty Liver Index performed well in multiple large-scale community studies, although other indices may be more suited for specific patient cohorts. This is important, as the utilization of liver indices could accelerate screening for NAFLD for early management and to reduce liver disease-related health disparities among Asian Americans.