‘Lumping Diverse People into One Group Is a Disadvantage’

Posted on: December 7, 2018 Topics: diabetes, epidemiology, hypertension, prenatal exposure, Q&A, Signature Programs

Despite being thin and physically active, several members of Maria Rosario “Happy” Araneta’s family have been diagnosed with type 2 diabetes and hypertension.

“All the public health messages about losing weight, exercising, and eating well didn’t seem to apply to my family,” says Araneta, a professor of epidemiology at the University of California San Diego.

Of Filipina descent, Araneta’s family represents a growing public health concern over the health disparities that exist among certain subgroups of the Asian American population. In San Francisco, where 1 in 3 residents are Asian American, the prevalence of type 2 diabetes is highest among Filipinas, Pacific Islanders, and South Asians. In New York City, Asian Americans have the highest poverty rate. Yet, the “model minority myth”—the perception of high education, income, and success—prevents many Asian Americans from receiving proper screening and care for these conditions. Asian Americans are the fastest-growing ethnic category, and for the past decade, have surpassed Latinos as the largest group of new immigrants—yet they remain an understudied population.

At UCSD, Araneta has studied the biological, behavioral, and social determinants of these health conditions among the Asian American population. She is the co-principal investigator of the Diabetes Prevention Program Outcomes Study, principal investigator of the UCSD Filipina Health Study, and co-investigator of the Rancho Bernardo Study, where she directs health disparities research among Filipinas, African Americans, and Caucasians. Her research findings have prompted the American Diabetes Association to adjust their screening guidelines for Asian Americans; instead of the previous recommendation to screen anyone aged 45 and older with a body mass index (BMI) of 25 or higher, the ADA now recommends screening for Asian Americans with a BMI of 23 or higher.

On Wednesday, December 12, from 4:30 to 6 p.m., Araneta will visit the School of Public Health to speak at the public health forum “The ‘Skinny’ on Health Disparities Among Asian Americans: Biological, Behavioral, and Social Determinants.” Ahead of the event, she spoke more about her work, and why these health disparities have received little research and attention.

You’ve conducted many clinical studies to identify the biological, behavioral, or social factors that seem to explain the high risk of type 2 diabetes among Filipina Americans. How does this population’s risk differ from other racial/ethnic populations?

Asian Americans have the highest prevalence of undiagnosed diabetes in the United States. In our [Rancho Bernardo] study, we conducted an oral glucose tolerance test to compare the prevalence of diabetes among Filipina women, African American women, and Caucasian women. When we compared the diabetes prevalence among Filipina women, it was 32 percent, versus 6 percent in White women.

But it wasn’t until we compared our Filipina participants to the African American women participants—and it was 32 percent among Filipina women and 12 percent among African American women. That’s when our findings had impact. People anticipate people of color to have poorer outcomes if you compare them to whites, but if you compare them to a group that’s traditionally been perceived to have the highest risk of diabetes, that’s when it has impact and people pay attention.

So we asked, “Why did Filipinas with a BMI of 24, who probably wear a size 6 dress, have almost three times the diabetes prevalence of African American women with a BMI of 30 and who are already at the definition of clinical obesity?” Then we did CT scans of participants’ visceral fat, and we found out that Filipina women who were underweight had three times more harmful visceral fat compared to African American women who were overweight. So, these findings started to raise the question of how do you define fat? Maybe African American women with a BMI of 30 isn’t that bad if she doesn’t have much visceral fat, but how do you identify the “thin” Asian who is loaded with visceral adiposity, and how do you get rid of it?

What are some of the social factors that can lead to higher diabetes prevalence among Filipinas?

One of my medical students, Naeemah Munir, presented a paper at the American Public Health Association a couple of weeks ago, and the question she asked is “Is social connectedness associated with your risk for diabetes or hypertension?” What she found was that African Americans were the most socially connected, and Filipinas had fewer memberships in social, religious, and work organizations, and they had fewer friends. Having fewer than four friends was associated with a higher risk of diabetes among Filipinas, but not African Americans.

Another important social factor is poverty. Filipinas who experienced poverty during childhood and who sustained poverty in adulthood were also at risk for diabetes. There were studies conducted among World War II survivors in the Netherlands, where people were crushing tulip bulbs into flour during the wintertime, because there was no food available. The studies found that the women who were experiencing prenatal malnutrition had babies who are now in their 70s and have a higher risk of heart disease and diabetes. This type of prenatal malnutrition affects the pancreas and the ability to produce enough insulin in adulthood.

So what does that mean for survivors of the Vietnam War or Korean War? Or Syrian refugees? Or at the Mexican border? What does it mean for the kids who have walked for the last three weeks from Honduras and who aren’t getting enough food? What does it mean for the women who are pregnant and malnourished?

Does the challenges and barriers to health resources differ among subgroups within the Asian community?

I think language ability is a big barrier. My sister works at Asian Health Services, a health center in Oakland, and there are ready translators available for patients who speak Mandarin or Cantonese, but fewer resources for people from places such as Burma or Bhutan. 

In the Philippines, we have 7,000 islands and 87 languages. I only speak two. India has 125 languages. Communication and finding an interpreter are important. Cultural nuances also can differ among Chinese and East Asian cultures, versus Indian and Filipino cultures—in East Asian cultures, you generally don’t disagree with your doctor, it’s often considered disrespectful to look them in the eye, and you don’t challenge authority. You also don’t talk about conditions that are stigmatized, such as sexually transmitted infections or mental health issues. 

What do you hope to impart through your research?

It’s important to recognize that, just as Mexican Americans and Hondurans are different from Puerto Ricans, Cubans, and Dominicans, the Asian subgroups are also different. Asian Indians don’t look like Chinese people or Filipinas. Our languages are completely different. Our cultures, cuisines, and behaviors are very different, and the biological factors that exacerbate adverse health outcomes also differ. Lumping people into one group is a big disadvantage. It doesn’t allow identification of the etiology of what’s causing these disparities.

What I hope comes across is that the application of our findings to other diverse populations—that it is relevant to any population that experiences disparities. As an epidemiologist, there are many opportunities to look at the etiology of these disparities, whether it’s a social, behavioral, or biological factor, or an interaction of all of the above, so we can inform relevant interventions to achieve health equity.

Jillian McKoy

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