Disparity in diabetes risk across Native Hawaiians and different Asian groups: the multiethnic cohort

Examining Diabetes Status by the Social Determinants of Health Among Adults in Hawai'i

The social determinants of health (SDoH) influence health outcomes based on conditions from birth, growth, living, and age factors. Diabetes is a chronic condition, impacted by race, education, and income, which may lead to serious health consequences. In Hawai'i, approximately 11.2% of adults have been diagnosed with diabetes. The objective of this secondary cross-sectional study is to assess the relationship between the prevalence of diabetes and the social determinants of health among Hawai'i adults who participated in the Behavioral Risk Factor Surveillance System between 2018-2020. The prevalence of diabetes among adults was 11.0% (CI: 10.4-11.5%). Filipino, Japanese and Native Hawaiian adults had the highest prevalence of diabetes at 14.4% (CI: 12.7-16.2%), 14.2% (CI: 12.7-15.7%), and 13.2% (CI: 12.0-14.4%), respectively. Poverty level and education were significantly associated with diabetes status. Within employment categories, the adjusted odds ratio (AOR) for retired and unable to work adults were large at AOR: 1.51 (CI: 1.26-1.81) and AOR: 2.91 (CI: 2.28-3.72), respectively. SDoH can impact the development and management of diabetes. Understanding the role SDoH plays on diabetes status is crucial for promoting health equity, building community capacity, and improving diabetes management.

Incidence of Nontuberculous Mycobacterial Pulmonary Infection, by Ethnic Group, Hawaii, USA, 2005-2019

To further clarify differences in the risk for nontuberculous mycobacterial pulmonary infection (NTM-PI) among ethnic populations in Hawaii, USA, we conducted a retrospective cohort study among beneficiaries of Kaiser Permanente Hawaii (KPH). We abstracted demographic, socioeconomic, clinical, and microbiological data from KPH electronic health records for 2005-2019. An NTM-PI case-patient was defined as a person from whom >1 NTM pulmonary isolate was obtained. We performed Cox proportional hazards regression to estimate incidence of NTM-PI while controlling for confounders. Across ethnic groups, risk for NTM-PI was higher among persons who were underweight (body mass index [BMI] <18.5 kg/m²). Among beneficiaries who self-identified as any Asian ethnicity, risk for incident NTM-PI was increased by 30%. Low BMI may increase susceptibility to NTM-PI, and risk may be higher for persons who self-identify as Asian, independent of BMI.

Type 2 Diabetes Among Filipino American Adults in the Multiethnic Cohort

INTRODUCTION

Several Asian racial and ethnic groups, including individuals of Filipino ancestry, are at higher risk of developing type 2 diabetes than White individuals, despite their lower body mass index (BMI). This study examined determinants of type 2 diabetes among Filipino American adults in the Multiethnic Cohort Study.

METHODS

Participants in Hawaii and Los Angeles completed questionnaires on demographics, diet, and anthropometrics. Generational status was determined according to birthplace of participants and their parents. Based on self-reported data and data on medications, type 2 diabetes status was classified as no, prevalent, or incident. We used polytomous logistic regression, while adjusting for confounders, to obtain odds ratios.

RESULTS

Among 10,681 Multiethnic Cohort Study participants reporting any Filipino ancestry, 57% were 1st-, 17% were 2nd-, and 25% were 3rd-generation Filipino Americans. Overall, 13% and 17% of participants had a prevalent or incident type 2 diabetes diagnosis. Overweight and obesity and the presence of other risk factors increased from the 1st to subsequent generations. First-generation immigrants were less likely to report type 2 diabetes at cohort entry than immigrants of subsequent generations who were born in the US or whose parents were born in the US; only the prevalence of type 2 diabetes was significantly elevated in the 2nd generation compared with the 1st generation.

CONCLUSION

The results support the hypothesis that Filipino migrants adopt lifestyle factors of the host country and subsequent generations experience higher type 2 diabetes rates due to changes in risk factor patterns.

Diabetes-Related Complications and Pancreatic Cancer Incidence in the Multiethnic Cohort

Background

People with diabetes are at an increased risk of developing pancreatic cancer. However, it is unclear whether diabetes-related complications are associated with risk of pancreatic cancer.

Methods

A nested matched case-control analysis was conducted among the fee-for-service Medicare participants of the prospective Multiethnic Cohort (n = ∼123 000). Between 2001 and 2014, 433 incident cases of pancreatic ductal adenocarcinoma were matched to 1728 controls by birth year, sex, race and ethnicity, and age at cohort entry. Participants were linked to data from the California and Hawaii cancer registries and Medicare claims. We used the diabetes complications severity index (DCSI) for the presence of 7 complications within 2 years prior to the diagnosis date of the index case. Multivariable conditional logistic regression was used to examine the association of DCSI with pancreatic cancer incidence.

Results

Diabetes was present among 45.4% of cases and 34.1% of controls. Cases had higher DCSI score compared with controls (score ≥4: 32.8% in cases; 21.2% in controls). The most prevalent diabetes-related complications for cases were cardiovascular disease (61.2%), nephropathy (31.2%), and cerebrovascular disease (21.7%). Individuals with diabetes (odds ratio [OR] = 1.48, 95% confidence interval [CI] = 1.14 to 1.91), nephropathy (OR = 1.75, 95% CI = 1.32 to 2.33), cardiovascular disease (OR = 1.88, 95% CI = 1.45 to 2.44), and metabolic complications (OR = 6.61, 95% CI = 2.49 to 17.50) were at increased risk of pancreatic cancer. For every 1-unit increase in DCSI score, participants had 18% greater risk of pancreatic cancer (OR = 1.18, 95% CI = 1.11 to 1.25).

Conclusions

Participants with diabetes-related complications have an elevated risk of pancreatic cancer. Identifying diabetes-related complications may help identify high-risk groups who can be studied for development of early markers for this fatal cancer.

Relationship Between Health Behaviors and Obesity in a Sample of Hawai'i's 4 Most Populous Ethnicities

Proactive health behavior change and maintenance are essential for preventing obesity and other lifestyle diseases. Few studies have examined the relationship between eating behavior and physical condition among multiethnic samples. In this study, ethnic differences were examined to obtain basic data on health education for improvement of obesity in Hawai'i. The intake of fruits and vegetables and exercise habits in each of the transtheoretical model stages of change were evaluated in the 4 most populous ethnic groups in Hawai'i in terms of how the participants' health behaviors were associated with obesity. The participants comprised 2795 white, Native Hawaiian, Filipino, and Japanese adults (age range, 18-55 years). There are 4 main findings of this study. First, there were differences in fruit and vegetable intake and exercise habits in each transtheoretical model stage among the ethnic groups. Second, there were differences in attitudes regarding nutrition and healthy food intake and self-efficacy regarding exercise in each ethnic group. Third, items that have the potential to improve obesity in the theory of planned behavior differed, particularly among men, in the 4 ethnic groups. Finally, a low percentage of participants recognized that the recommended number of servings of fruits and vegetables was 5 or more. Education for men may be particularly important. The findings indicate that modified health education approaches may be needed in accordance with the ethnicity of the population.

Identifying Urban Immigrant Food-Cultivation Practices for Culturally-Tailored Garden-Based Nutrition Programs

Garden-based nutrition programs are used to address food access and nutrition in low-income communities. In urban immigrant communities, food-growing practices may be shaped by environmental and cultural factors, and may not reflect the assumptions behind these curricula. Built-environment research was adapted to develop a protocol for assessing a community's gardening practices. A random sample of census blocks was generated and mapped, observational protocols developed, iteratively tested and refined, then fieldworkers trained and deployed. Daily debriefings were conducted to identify challenges in field implementation. Nearly all (93%) sampled blocks contained evidence of food cultivation. Garden structures, land-use patterns, and plant choices reflected cultural preferences, differing substantively from USDA home gardening curricula. This tool successfully identified food-growing practices within an urban immigrant Asian and Pacific Islander community, and provides a replicable methodology for community assessment. Results support the need to culturally-tailor garden-based nutrition programs for urban immigrant populations.

Prediabetes, diabetes, and other CVD-related conditions among Asian populations in Los Angeles County, 2014

Objective: To assess the prevalence of four common health conditions related to cardiovascular disease risk among Asians in Los Angeles County. Methods: A survey of Asians in Los Angeles County was conducted utilizing purposive sampling to recruit from the region's Service Planning Areas 3 and 4; these underserved areas contain high density of Asian populations. Descriptive and multivariable regression analyses were performed to explore and describe potential associations between self-reported diagnoses of prediabetes, diabetes, hypertension, and high cholesterol and body mass index (measured with non-Asian versus Asian cut points) by race/ethnicity (Chinese/Filipino/Korean/Taiwanese/Thai/Vietnamese). Results: The survey response rate was nearly 60%. The analysis included 1,377 Asians, self-identified as either Chinese (n = 700), Filipino (n = 69), Korean (n = 339), Taiwanese (n = 48), Thai (n = 115), or Vietnamese (n = 106). Results showed that, in comparison to other Asians, Filipinos had the highest risks for two of the four conditions described. Other results by subgroup affirmed a similar heterogeneous pattern of Asian health locally. Conclusions: These and other results from the survey point to potential gaps in healthcare needs of Asians, and to opportunities where local public health efforts could help increase these populations' access to cardiovascular disease-related health and social services.

Interethnic differences in pancreatic cancer incidence and risk factors: The Multiethnic Cohort

While disparity in pancreatic cancer incidence between blacks and whites has been observed, few studies have examined disparity in other ethnic minorities. We evaluated variations in pancreatic cancer incidence and assessed the extent to which known risk factors account for differences in pancreatic cancer risk among African Americans, Native Hawaiians, Japanese Americans, Latino Americans, and European Americans in the Multiethnic Cohort Study. Risk factor data were obtained from the baseline questionnaire. Cox regression was used to estimate the relative risks (RRs) and 95% confidence intervals (CIs) for pancreatic cancer associated with risk factors and ethnicity. During an average 16.9-year follow-up, 1,532 incident pancreatic cancer cases were identified among 184,559 at-risk participants. Family history of pancreatic cancer (RR 1.97, 95% CI 1.50-2.58), diabetes (RR 1.32, 95% CI 1.14-1.54), body mass index ≥30 kg/m² (RR 1.25, 95% CI 1.08-1.46), current smoking (<20 pack-years RR 1.43, 95% CI 1.19-1.73; ≥20 pack-years RR 1.76, 95% CI 1.46-2.12), and red meat intake (RR 1.17, 95% CI 1.00-1.36) were associated with pancreatic cancer. After adjustment for these risk factors, Native Hawaiians (RR 1.60, 95% CI 1.30-1.98), Japanese Americans (RR 1.33, 95% CI 1.15-1.54), and African Americans (RR 1.20, 95% CI 1.01-1.42), but not Latino Americans (RR 0.90, 95% CI 0.76-1.07), had a higher risk of pancreatic cancer compared to European Americans. Interethnic differences in pancreatic cancer risk are not fully explained by differences in the distribution of known risk factors. The greater risks in Native Hawaiians and Japanese Americans are new findings and elucidating the causes of these high rates may improve our understanding and prevention of pancreatic cancer.

Immediate and long-term effects of a very-low-calorie diet on diabetes remission and glycemic control in obese Thai patients with type 2 diabetes mellitus

AIM

A very-low-calorie diet (VLCD) can reverse the underlying defects of type 2 diabetes mellitus (DM) in obese subjects. We determined the efficacy, safety, and durability of VLCD in Thai patients with DM and obesity.

METHODS

Twenty Thai patients with DM and obesity were enrolled. After a 2-week trial, VLCD (600 kcal/day) was continued for 8 weeks, followed by a 4-week transition period. Data on diabetes remission (fasting plasma glucose level <126 mg/dl and HbA1c <6.5% without the use of glucose-lowering medications), glycemic control, metabolic parameters, and quality of life (QOL) were collected along with indices of insulin resistance (IR) and beta cell function. Glycemic control 12 months after discontinuation of VLCD was also examined.

RESULTS

Among 19 patients (age 48 ± 2 years, BMI 27.7 kg/m2) who completed the study, rapid improvement in glycemic control was observed in the first 2 weeks of VLCD. At both 8 and 12 weeks, diabetes remission was achieved in 79%. Significant weight loss was accompanied by a significant reduction in IR and an increase in beta cell function, starting at 4 weeks of VLCD. QOL also significantly increased. At 12 months after VLCD, however, DM remission was achieved in approximately 30%.

CONCLUSION

Very-low-calorie diet was effective and safe in inducing short-term diabetes remission in Thai subjects by ameliorating beta cell function and IR. Optimal long-term glycemic control was potentially durable as one-third of subjects remained without diabetes medication 12 months after VLCD.

Disparities in Diabetes Prevalence Among Native Hawaiians/Other Pacific Islanders and Asians in Hawai'i

Introduction

The prevalence of diabetes varies widely among racial/ethnic groups in Hawai‘i. How prevalence varies by age for Asian subgroups and Native Hawaiian/Other Pacific Islanders (NHOPIs) is understudied. We examined diabetes prevalence by age and race/ethnicity and assessed how socioeconomic status and lifestyle behaviors affected prevalence among Japanese, Filipino, Chinese, NHOPI, and white populations in Hawai‘i.

Methods

We studied 18,200 subjects aged 18 or older from the Hawai‘i Behavioral Risk Factor Surveillance System. We performed Poisson regression analyses to examine the prevalence of diabetes by race/ethnicity, age, sex, marital status, education, income, health care coverage, obesity, smoking and drinking status, physical activity, and fruit and vegetable consumption and examined the interactions of these factors with age and race/ethnicity.

Results

We found disparities in diabetes prevalence among respondents aged 35 to 44 and among Asians and NHOPIs, and disparities increased with age. NHOPIs and Filipinos had the highest prevalence of diabetes after controlling for other demographic factors and lifestyle variables. Japanese adults were less likely than NHOPIs and Filipinos to have diabetes; however, whites had the lowest prevalence. Income, physical activity, and obesity were the strongest predictors of diabetes.

Conclusion

NHOPIs and Filipinos have higher rates of diabetes compared with other races/ethnicities in Hawai‘i. More research is needed to reduce diabetes disparities among NHOPI and Filipino populations in Hawai‘i. This study also shows the importance of conducting age-specific analyses of racial/ethnic-subgroups for health disparities.

Echoes from Gaea, Poseidon, Hephaestus, and Prometheus: environmental risk factors for high blood pressure

High blood pressure (BP) affects over one billion people and is the leading risk factor for global mortality. While many lifestyle and genetic risk factors are well-accepted to increase BP, the role of the external environment is typically overlooked. Mounting evidence now supports that numerous environmental factors can promote an elevation in BP. Broadly speaking these include aspects of the natural environment (e.g., cold temperatures, higher altitude, and winter season), natural disasters (e.g., earthquakes, volcanic eruptions), and man-made exposures (e.g., noise, air pollutants, and toxins/chemicals). This is important for health care providers to recognize as one (or several) of these environmental factors could be playing a clinically meaningful role in elevating BP or disrupting hypertension control among their patients. At the population level, certain environmental exposures may even be contributing to the growing pandemic of hypertension. Here we provide an updated review of the literature linking environment exposures with high BP and outline practical recommendations for clinicians.

Psychosocial Factors and Dietary Practices in Korean Americans

This study was to identify the role of demographics and social support from family and friends in predicting self-efficacy for a healthy diet and healthy dietary practices. A descriptive, cross-sectional study was conducted with a sample of 112 Korean American adults in the southwestern United States. Most were college educated (85.3%), with mean age of 54.0 (± 10.6), and women (66.4%). The findings indicate that gender and education played a moderating role between family support and self-efficacy for a healthy diet, whereas age and education were moderators between support from family and friends and healthy dietary practices. Diet interventions tailored to demographic subgroups may increase self-efficacy, promote healthy dietary practices, and ultimately contribute to a reduction in the rates of critical health conditions and health costs in the community.

Ethnic admixture affects diabetes risk in native Hawaiians: the Multiethnic Cohort

BACKGROUND/OBJECTIVES

Obesity and diabetes rates are high in Native Hawaiians (NHs) who commonly have mixed ancestries. People of Asian ancestry experience a high risk of type 2 diabetes despite the relatively low body weight. We evaluated the impact of ethnic admixture on diabetes risk among NHs in the Multiethnic Cohort (MEC).

SUBJECTS/METHODS

On the basis of self-reports, 11 521 eligible men and women were categorized into NH/white, NH/other, NH alone, NH/Asian and the most common three ancestry admixture, NH/Chinese/white. Cox proportional hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated with the NH/white category as the reference group; covariates included known confounders-that is, body mass index (BMI), dietary and other lifestyle factors.

RESULTS

The NH alone category had the highest proportion of overweight and obese individuals and the NH/Asian category the lowest proportion. During 12 years of follow-up after cohort entry at 56 years, 2072 incident cases were ascertained through questionnaires and health plan linkages. All NH categories had higher HRs than the NH/white category before and after adjustment for BMI. In the fully adjusted models, the NH/Asian category showed the highest risk (HR=1.45; 95% CI: 1.27-1.65), followed by NH/other (HR=1.20; 95% CI: 1.03-1.39), NH/Chinese/white (HR=1.19; 95% CI: 1.04-1.37) and NH alone (HR=1.19; 95% CI: 1.03-1.37). The elevated risk by Asian admixture was more pronounced in normal weight than overweight/obese individuals.

CONCLUSIONS

These findings indicate that Asian admixture in NHs is associated with a higher risk for type 2 diabetes independent of known risk factors and suggest a role for ethnicity-related genetic factors in the development of this disease.

Diabetes Among Asians and Native Hawaiians or other Pacific Islanders--United States, 2011-2014

Asians and Native Hawaiians or other Pacific Islanders (NHPIs) are fast-growing U.S. minority populations at high risk for type 2 diabetes. Although national studies have described diabetes prevalence, incidence, and risk factors among Asians and NHPIs compared with non-Hispanic whites, little is known about state-level diabetes prevalence among these two racial groups, or about how they differ from one another with respect to diabetes risk factors. To examine state-level prevalence of self-reported, physician-diagnosed (diagnosed) diabetes and risk factors among Asians and NHPIs aged ≥18 years, CDC analyzed data from the 2011-2014 Behavioral Risk Factor Surveillance System (BRFSS). Among five states and Guam with sufficient data about NHPIs for analysis, the age-adjusted diabetes prevalence estimate for NHPIs ranged from 13.4% (New York) to 19.1% (California). Among 32 states, the District of Columbia (DC), and Guam that had sufficient data about Asians for analysis, diabetes prevalence estimates for Asians ranged from 4.9% (Arizona) to 15.3% (New York). In the five states and Guam with sufficient NHPI data, NHPIs had a higher age-adjusted prevalence of diabetes than did Asians, and a higher proportion of NHPIs were overweight or obese and had less than a high school education compared with Asians. Effective interventions and policies might reduce the prevalence of diabetes in these growing, high-risk minority populations.