1. Pathophysiologic Differences Among Asians, Native Hawaiians, and Other Pacific Islanders and Treatment Implications Featured Article: William C. Hsu, M.D., Edward J. Boyko, M.D., MP.h., Wilfred Y. Fujimoto, M.D., Alka Kanaya, M.D., Wahida Karmally, DrPH, R.D., C.D.E., Andrew Karter, Ph.D., George L. King, M.D., Mele Look, M.B.A., Gertraud Maskarinec, M.D., Ph.D., Ranjita Misra, Ph.D., Fahina Tavake-Pasi, M.S., Richard Arakaki, M.D. Diabetes Care Volume 35: 1189-1198 May, 2012

2. Introduction Differences in pathophysiology may affect diagnosis, prevention and treatment of diabetes in Asian Americans, Native Hawaiians, and Pacific Islanders Differences in cultural beliefs, dietary habits, and behavioral patterns among AANHPIs require culturally effective translation of interventions into the community These issues were discussed by clinicians and researchers at a September, 2011 conference: Diabetes in Asian Americans, Native Hawaiians, and Pacific Islanders: A Call to Action Hsu W et al. Diabetes Care 2012;35:1189-1198

3. PATHOPHYSIOLOGIC DIFFERENCES Type 1 diabetes: less prevalent in AANHPIs than in Caucasians High-risk HLA haplotypes and other genes are less prevalent in AANHPIs Type 1 and type 2 can be difficult to distinguish in East Asian Americans, especially under age 35 years, because BMI is equally low (~ 24 kg/m 2 ) in both types Hsu W et al. Diabetes Care 2012;35:1189-1198

4. PATHOPHYSIOLOGIC DIFFERENCES Type 2 diabetes: Relationship between excess adiposity and diabetes is not straightforward in AANHPIs Native Hawaiians and Pacific Islanders have high prevalence of both type 2 DM and obesity South Asians and East Asians have lower average BMI and waist circumference but higher prevalence of diabetes compared with Caucasians Visceral fat is a strong determinant of diabetes risk in Japanese Americans Japanese-American and Filipino-Americans have higher more visceral fat even for equivalent waist circumference For all quartiles of BMI or weight change, diabetes risk is higher in Native Hawaiians and Japanese Americans Hsu W et al. Diabetes Care 2012;35:1189-1198

7. Diabetes Complications As an aggregate, AANHPIs have lower rates of CVD and lower extremity amputation than Caucasians, but higher rates of ESRD Differences by ethnicity: Pacific Islanders have higher rates of MI than Caucasians, and equivalent rates of LEA South Asians have equal rates of MI and lower rates of ESRD than Caucasians Hsu W et al. Diabetes Care 2012;35:1189-1198

8. TAILORING DIAGNOSIS, PREVENTION, AND TREATMENT TO REFLECT ETHNIC DIFFERENCES Diagnosis: Asian Americans tend to have more prominent post- challenge hyperglycemia than fasting hyperglycemia Both FPG and HbA1c have significantly lower sensitivity compared to OGTT Since Asians have high risk but often do not have overt obesity, consider test with the highest sensitivity (OGTT) Hsu W et al. Diabetes Care 2012;35:1189-1198

9. Treatment: Unclear whether there are differences in medication responses in AANHPI populations Cultural differences in food preferences need to be accounted for Many Asian cultures include foods high in sodium (sauces, pickled foods) “Plate method” may be difficult for some cultures that use communal plates or multiple small dishes Hsu W et al. Diabetes Care 2012;35:1189-1198 TAILORING DIAGNOSIS, PREVENTION, AND TREATMENT TO REFLECT ETHNIC DIFFERENCES

10. Hsu W et al. Diabetes Care 2012;35:1189-1198

12. COMMUNITY-BASED INTERVENTIONS AND CULTURE-BASED DIABETES EDUCATION Models: Community-based diabetes prevention and management program in South India reduced fasting blood glucose, reduced body weight, increased intake of dietary fiber Healthy Eating and Lifestyle Program, Mai ka Mala’ai: diabetes self-management programs for Pacific Islanders that combine classroom education with reconnecting to the land to grow produce Resources: NDEP AANHPI materials AAPCHO: Community Approach to Responding Early Hsu W et al. Diabetes Care 2012;35:1189-1198