Engaging the ASEAN Diaspora: Type 2 Diabetes Prevalence, Pathophysiology, and Unique Risk Factors among Filipino Migrants in the United States
Type 2 diabetes prevalence is rising rapidly in Southeast Asia (SEA) where urbanization and adoption of ‘western’ behavioral lifestyles are attributed as predominant risk factors. The Southeast Asian diaspora to the United States has resulted in a sizable portion of migrant and US born SEAs, with approximately 4 million Filipino Americans, 2 million Vietnamese-Americans, Cambodians (330,000), and Thai (300,000) as the most populous. Their longer exposure to a western lifestyle and participation in clinical studies with other racial/ethnic groups, provide opportunities to evaluate etiologic factors which might inform trends and intervention opportunities among residents of Southeast Asia.
Epidemiologic studies in the US have identified higher T2D prevalence among Filipinos (16.1%) compared to groups perceived to be at highest risk for T2D, namely Latinos (14.0%), Black (13.7%), and Native Americans (13.4%), while SEAs (including Burmese, Cambodian, Indonesian, Laotian, Malaysian, and Thai, 10.5%) and Vietnamese (9.9%) had higher T2D risk compared to Whites (7.7%), despite their absence of general obesity. Asian-Americans, including SEAs, East and South Asians, collectively have higher rates of undiagnosed T2D compared to other racial/ethnic groups in the US. Almost half (44%) of Filipinos with newly diagnosed T2D have isolated post-challenge hyperglycemia and will remain undiagnosed if current screening practices remain limited to measures of glycosylated hemoglobin and fasting plasma glucose.
The University of California San Diego Filipino Health Study found excess visceral adipose tissue accumulation, low ratio of muscle to total abdominal mass area, low adiponectin concentration, multiparity (≥6 live births), and sleep insufficiency (<7 hours) to be unique T2D risk factors among Filipino-American women, even after adjusting for established T2D risk factors including hypertension and parental history of T2D. Social determinants such as low educational attainment (less than college completion), and sustained social disadvantage during childhood and adulthood were independently associated with T2D risk. Gestational diabetes is a known risk factor for future T2DM among women; Northern California data shows that following Asian Indians, gestational diabetes was highest among Filipina and SEA parturients, who had twice the GDM prevalence as Black, Hispanic, and White women. Identification of novel T2D risk factors among SEAs may guide early diagnosis, inform pathophysiology, and identify unique opportunities for T2D prevention and management.
Guariguata L, Whiting DR, Hambleton I, Beagley J, Linnenkamp U, Shaw JE. Global estimates of diabetes prevalence for 2013 and projections for 2035. Diabetes Res Clin Pract. 2014;103(2):137-49.
United States Census Bureau. 2017 American community survey. 1-year estimates. https://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?src=bkmk#
Pew Research Center. The rise of Asian Americans. April 4, 2013, Washington, DC. http://www.pewsocialtrends.org/2012/06/19/the-riseof-asian-americans/
Grandinetti A, Kaholokula JK, Theriault AG, Mor JM, Chang HK, Waslien C. Prevalence of diabetes and glucose intolerance in an ethnically diverse rural community of Hawaii. Ethn Dis. 2007;17(2):250-5.
Uchima O, Wu YY, Browne C, Braun KL. Disparities in diabetes prevalence among native Hawaiians/Other Pacific Islanders and Asians in Hawai’i. Prev Chronic Dis. 2019;21:16:E22. https://www.ncbi.nlm.nih.gov/pubmed/30789820. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6395081. https://doi.org/10.5888/pcd16.180187.
Menke A, Casagrande S, Geiss L, Cowie CC. Prevalence of and trends in diabetes among adults in the United States, 1988-2012. JAMA. 2015;314(10):1021-9. https://www.ncbi.nlm.nih.gov/pubmed/26348752.
Cheng YJ, Kanaya AM, Saydah S, Araneta MR, Kahn HS, Imperatore G. Prevalence of diagnosed and total diabetes among Asian-Americans, 2011-2014. Diabetes. 2017;67(Suppl 1):310. https://doi.org/10.2337/db18-310-OR.
Karter AJ, Schillinger D, Adams AS, et al. Elevated rates of diabetes in Pacific Islanders and Asian subgroups: The Diabetes Study of Northern California (DISTANCE). Diabetes Care. 2013:36(3):574-2.
Araneta MR, Wingard DL, Barrett-Connor E. Type 2 diabetes and metabolic syndrome in Filipina-American Women: A high-risk nonobese population. Diabetes Care. 2002;25(3):494-9. https://www.ncbi.nlm.nih.gov/pubmed/11874936.
Araneta MR, Barrett-Connor E. Subclinical coronary atherosclerosis in asymptomatic Filipino and white women. Circulation.2004;110(18):2817-23. https://www.ncbi.nlm.nih.gov/pubmed/15505100.
Araneta MRG, Barrett-Connor E. Ethnic differences in visceral adipose tissue and type 2 diabetes: Filipino, African-American, and white women. Obes Res. 2005;13(8):1458-65. https://www.ncbi.nlm.nih.gov/pubmed/16129729.
Araneta MR, Morton DJ, Lantion-Ang L, et al. Hyperglycemia and type 2 diabetes among Filipino women in the Philippines, Hawaii, and San Diego. Diabetes Res Clin Pract. 2006;71(3):306-12.
Langenberg C, Araneta MR, Bergstrom J, Marmot M, Barrett-Connor E. Diabetes and coronary heart disease in Filipino-American women: Role of growth and life-course socioeconomic factors. Diabetes Care. 2007;30(3):535-41. https://www.ncbi.nlm.nih.gov/pubmed/17327317. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2542981. https://doi.org/10.2337/dc06-1403.
Araneta MR, Barrett-Connor E. Adiponectin and ghrelin levels and body size in normoglycemic Filipino, African-American and white women. Obesity (Silver Spring). 2007;15(10):2454-62. https://www.ncbi.nlm.nih.gov/pubmed/17925471.
Magno CP, Araneta MR, Macera CA, Anderson GW. Cardiovascular disease prevalence, associated risk factors, and plasma adiponectin levels among Filipino American women. Ethn Dis. 2008; 18(4):458-63. https://www.ncbi.nlm.nih.gov/pubmed/19157250.
Wong CA, Araneta MR, Barrett-Connor E, Alcaraz J, Castañeda C, Macera C. Probable NAFLD, by ALT levels, and diabetes among Filipino-American Women. Diabetes Res Clin Pract. 2008;79(1):133-40.
Araneta MR, Grandinetti A, Chang HK. A1C and diabetes diagnosis among Filipino-Americans, Japanese-Americans, and native Hawaiians. Diabetes Care. 2010:33(12);2626-8. https://www.ncbi.nlm.nih.gov/pubmed/ 20833866. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2992202. https://doi.org/10.2337/dc10-0958.
Araneta MR, Barrett-Connor E. Grand multiparity is associated with type 2 diabetes in Filipino-American women, independent of visceral fat and adiponectin. Diabetes Care. 2010:33(2);385-9.
Medina-Torne S, Araneta MR, Macera CA, Kern M, Ji M. Dietary factors associated with adiponectin in Filipino-American women. Ethn Dis.2011;21(2):190-5. https://www.ncbi.nlm.nih.gov/pubmed/21749023.
Wassel CL, Laughlin GA, Araneta MR, et al. Associations of pericardial and intrathoracic fat with coronary calcium presence and progression in a multiethnic study. Obesity 2013;21(8):1704-12.
Calvo RY, Araneta MR, Kritz-Silverstein D, Laughlin GA, Barrett-Connor E. Relation of serum uric acid to severity and progression of coronary artery calcium in postmenopausal White and Filipino women (from the Rancho Bernardo study). Am J Cardiol. 2014;113(7);1153-8. https://www.ncbi.nlm.nih.gov/pubmed/24513465.
Larsen BA, Allison MA, Kang E, et al. Associations of physical activity and sedentary behavior with regional fat deposition. Med Sci Sports Exerc. 2014;46(3):520-8. https://www.ncbi.nlm.nih.gov/pubmed/23924920.
Armenta RF, Kritz-Silverstein D, Wingard D, et al. Association of breastfeeding with postmenopausal visceral adiposity among three racial/ ethnic groups. Obesity (Silver Spring). 2015;23(2):475-80.
Larsen BA, Allison MA, Laughlin GA, et al. The association between abdominal muscle and type ii diabetes across weight categories in diverse post-menopausal women. J Clin Endocrinol Metab. 2015;100(1):E105-9.
Djibo DA, Araneta MR, Kritz-Silverstein D, Barrett-Connor E, Wooten W. Body adiposity index as a risk factor for the metabolic syndrome in postmenopausal Caucasian, African American, and Filipina Women. Diabetes Metab Res 2015; 9(2):108-13. https://www.ncbi.nlm.nih.gov/pubmed/25470644. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4256139. https://doi.org/10.1016/j.dsx.2014.04.011.
Araneta MRG, Kanaya AM, Hsu WC, et al. Optimum BMI cut-points to screen Asian-Americans for type 2 diabetes. Diabetes Care. 2015; 38(5):814-20. https://www.ncbi.nlm.nih.gov/pubmed/25665815.
Shadyab AH, Kritz-Silverstein D, Laughlin GA, Wooten WJ, Barrett-Connor E, Araneta MR. Ethnic-specific associations of sleep duration and daytime napping with prevalent type 2 diabetes in postmenopausal women. Sleep Med. 2015;16(2):243-9. https://www.ncbi.nlm.nih.gov/pubmed/25637103.
Wassel CL, Laughlin GA, Saad SD, et al. Associations of abdominal muscle area with 4-year change in coronary artery calcium differ by ethnicity among post-menopausal women. Ethn Dis. 2015:25(4);435-42.
Nguyen BJ, Mac N, Faigl A, Araneta M. 390 Utility of video education for expansion of updated Asian American Diabetes screening guidelines. J Invest Med. 2018;66(1):A229. https://doi.org/ 10.1136/jim-2017-000663.390.
Hsu WC, Araneta MR, Kanaya AM, Chiang JL, Fujimoto W. BMI cut points to identify at risk Asian Americans for type 2 diabetes screening. Diabetes Care. 2015:38(1):150-8. https://www.ncbi.nlm.nih.gov/pubmed/25538311.
Baltazar JC, Ancheta CA, Aban IB, Fernando RE, Baquilod MM. Prevalence and correlates of diabetes mellitus and impaired glucose tolerance among adults in Luzon, Philippines. Diabetes Res Clin Pract 2004;64(2):107-15.
Araneta MRG, Wingard DL, Barrett-Connor E. Proportion of life years in the US is not associated with obesity or fat distribution in Filipina immigrants. American Public Health Association, 131st Annual Meeting. San Francisco, CA, November 15-19, 2003.
Chandran M, Philips SA, Ciaraldi T, Henry RR. Adiponectin: More than just a fat cell hormone. Diabetes Care. 2003;26(8):2442-50. https://www.ncbi.nlm.nih.gov/pubmed/12882876. https://doi.org/10.2337/diacare.26.8.2442.
Araneta MR, Barrett-Connor E. Ethnic differences in adiponectin, leptin and ghrelin levels in normal glucose tolerant Filipino, Caucasian and African-American Women. American Diabetes Association. 65th Annual Meeting and Scientific Sessions. San Diego, CA, June 10-14, 2005. Diabetes. 2005;54:A262.
Wu Y, Li Y, Lange EM, et al. Genome-wide association study for adiponectin levels in Filipino women identifies CDH13 and a novel uncommon haplotype at KNG1-ADIPOQ. Hum Mol Genet.2010;19(24):4955-64.
Medina S and Araneta MRG. Nutrition and Risk for Type 2 Diabetes among Filipino Women. San Diego Epidemiology Research Exchange. la Jolla, CA, May 14, 2004.
Stavig GR, Igra A, Leonard AR. Hypertension among Asians and Pacific Islanders in California. Am J Epidemiol 1984;119(5):677-91. https://www.ncbi.nlm.nih.gov/pubmed/6720667. https://doi.org/10.1093/oxfordjournals.aje.a113789.
Zhao B, Jose PO, Pu J, et al. Racial/ethnic differences in hypertension prevalence, treatment, and control for outpatients in northern California, 2010-2012. Am J Hypertens. 2015;28(5):631-9.
de Boo HA, Harding JE. The developmental origins of adult disease (Barker) hypothesis. Aust N Z J Obstet Gynaecol. 2006;46(1):4-14. https://www.ncbi.nlm.nih.gov/pubmed/16441686.
Franks PW, Hanson RL, Knowler WC, et al. Childhood predictors of young-onset type 2 diabetes. Diabetes. 2007:56(12):2964–72. https://www.ncbi.nlm.nih.gov/pubmed/17720898.
Dulloo AG, Jacquet J, Seydoux J, Montani JP. The thrifty 'catch-up fat' phenotype: Its impact on insulin sensitivity during growth trajectories to obesity and metabolic syndrome. Int J Obes (Lond). 2006:30(Suppl 4):S23-35. https://www.ncbi.nlm.nih.gov/pubmed/17133232. https://doi.org/10.1038/sj.ijo.0803516.
Philippine Nutrition Facts and Figures 2011. Food and Nutrition Research Institute, Department of Science and Technology. Manila, Philippines December 2012. http://22.214.171.124/facts_figures2011.pdf. Accessed on February 13, 2016.
Alejandro EU, Gregg B, Wallen T, et al. Maternal diet-induced microRNAs and mTOR underlie β cell dysfunction in offspring. J Clin Investig. 2014:124(10):4395-410.
Jansson T, Aye I, Goberdhan DC. The emerging role of mTORC1 signaling in placental nutrient-sensing. Placent.a 2012:33(Suppl 2):e23-9. https://www.ncbi.nlm.nih.gov/pubmed/22687819.
Hedderson M, Ehrlich S, Sridhar S, Darbinian J, Moore S, Ferrara A. Racial/ethnic disparities in the prevalence of gestational diabetes mellitus by BMI. Diabetes Care. 2012:35(7):1492-8. https://www.ncbi.nlm.nih.gov/pubmed/22619080. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3379591.
Hedderson MM, Darbinian J, Havel PJ, et al. Low prepregnancy adiponectin concentrations are associated with a marked increase in risk for development of gestational diabetes mellitus. Diabetes Care. 2013:36(12):3930-7. https://www.ncbi.nlm.nih.gov/pubmed/23990523. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3836148.
Caulfield LE, Richard SA, Rivera JA,et al, Stunting, wasting and micronutrient deficiency disorders. In Jamison DT, Breman JG, Meacham AR, et al, eds. Disease control priorities in developing countries. 2nd edition. Washington DC: World Bank; 2006. Chapter 28.
Lumey LH, Stein AD, Kahn HS, et al. Cohort profile: The Dutch Hunger Winter families study. Int J Epidemiol. 2007:36(6):1196–1204. https://www.ncbi.nlm.nih.gov/pubmed/17591638. https://doi.org/10.1093/ije/dym126.
Roseboom TJ, Painter RC, van Abeelen AF, Veenendaal MV, de Rooij SR. Hungry in the womb: What are the consequences? Lessons from the Dutch famine. Maturitas 2011:70(2):141-5.
Li Y, He Y, Qi L, et al. Exposure to the Chinese famine in early life and the risk of hyperglycemia and type 2 diabetes in adulthood. Diabetes. 2010:59(10):2400–6. https://www.ncbi.nlm.nih.gov/pubmed/20622161.
Ravelli AC, van der Meulen JH, Michels RP, et al. Glucose tolerance in adults after prenatal exposure to famine. Lancet. 1998:351(9097):173–7. https://www.ncbi.nlm.nih.gov/pubmed/9449872. https://doi.org/10.1016/s0140-6736(97)07244-9
Copyright (c) 2019 Journal of the ASEAN Federation of Endocrine Societies
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
Journal of the ASEAN Federation of Endocrine Societies is licensed under a Creative Commons Attribution-NonCommercial 4.0 International. (full license at this link: http://creativecommons.org/licenses/by-nc/3.0/legalcode).
To obtain permission to translate/reproduce or download articles or use images FOR COMMERCIAL REUSE/BUSINESS PURPOSES from the Journal of the ASEAN Federation of Endocrine Societies, kindly fill in the Permission Request for Use of Copyrighted Material and return as PDF file to firstname.lastname@example.org or email@example.com.
A written agreement shall be emailed to the requester should permission be granted.