Together We Will Stop Diabetes In The South Asian
Harpreet Singh Bajaj, MD, MPH, ECNU
Endocrinologist, Brampton, ON
Research Associate, Mount Sinai Hospital, Toronto
TV host, “Your Health” show, South-Asian Canadian Channel Y
Founder, “STOP Diabetes” Foundation
South Asians are the fastest-growing immigrant population in Canada. According to the 2001 census, individuals from India, Sri Lanka, Pakistan, Nepal and Bangladesh represented more than 3% of the Canadian population. By 2017, they are thought to have become the most prominent visible minority in this country, reaching over an estimated 1.7 million.
Type 2 diabetes (the kind of diabetes that occurs mostly in adults) affects South Asians at three-five fold rates than the White Caucasian population in Canada. The disease tends to develop at a younger age in South Asians, as do complications (which are more likely to be severe at the time of diagnosis in our community). At the same time, diabetes is underdiagnosed and more poorly controlled among these individuals. Rates of diabetes among the immigrant population are particularly high. The burden of diabetes among South Asians living in the United Kingdom, the United States and Canada has been found to be as high as 12 to 15% – or more than 1 in 7 adults. This increased risk among South Asian immigrants becomes apparent in young adulthood (after age 35), and increases with age. By age 65 years, more than a third of men and women from this region have diabetes. Even South Asian children and adolescents are at increased risk, as type 2 diabetes develops about 10 years earlier in this population than in Europeans. In addition to the high rates of diabetes, the rates of premature heart disease are also disproportionate: two to four-fold higher in South Asians, particularly among Indians, compared to Caucasians of European ancestry.
Explaining increased risk
High rates of diabetes and heart disease are paradoxical in the light of people of South Asian origin having a relatively low prevalence of obesity, defined by body mass index (Weight/Height2), compared to the Caucasians. For example, the prevalence of overweight and obesity in India is estimated to be less than 25%, compared to about 59% in Canada and about 65% in the U.S.A.
Even at relatively low body weights however, South Asians may have a propensity towards central (intra-abdominal) obesity that puts them at an especially high risk for diabetes and heart disease. Studies in Asian Indians suggest that either waist circumference alone or waist-hip ratio may be a better risk predictor of these diseases, as compared to BMI. Ethnic-specific waist circumference cut-offs have been incorporated into the International Diabetes Federation’s definition of metabolic syndrome. While the cut-off for European men is 94 cm, it is 90 cm for South Asian men. The cut-off for women – 80 cm – is the same in both of these racial-ethnic groups. So, if a person has higher waist circumference than these cut-offs, they should be considered to be high risk for developing diabetes and heart attacks in the future.
Barriers to diagnosis of obesity and diabetes
Despite the high rates of type 2 diabetes among South Asians, the disease is underdiagnosed in this population. Late diagnosis is associated with more advanced diabetes-related complications.
Until a generation ago, diabetes was not common in South Asia. As a result, the disease and its signs and symptoms are not well known to many, and individuals may fail to appreciate the need for medical attention.
Just 10 to 20 years ago, infectious diseases were the primary cause of death in South Asia. Consequently, excess weight or having a large waist size is perceived as being protective and a sign of good health, rather than being recognized as a risk for diabetes and other diseases. This perception is particularly strong among the elderly and first-generation South Asian origin Canadians.
Research has shown that diabetes can be prevented or delayed by adopting a healthier lifestyle. Such preventive efforts should be focused on high-risk groups e.g. people who have a family history of diabetes in their first relative, people who have early signs of high sugar values (pre-diabetes or gestational diabetes – the kind that happens in pregnancy) or high-risk ethnic groups e.g. South Asians. When discussing lifestyle improvements, the positive aspects of South Asian cultures should be exploited. For example, many foods in traditional diets can be part of a healthy meal plan with some slight adaptations (e.g. sprouted lentils, green vegetables, salads, etc). Emphasis should be on reducing total caloric intake, especially junk foods (pizza, bagels, burgers, fries, chips, cookies, soft drinks and liquor), avoiding traditional fried snacks (e.g. one samosa has around 250 calories, which will take about 30 minutes of running to burn) and eating less carbohydrates (most people need to eat only 1 or maximum of 2 rotis at one meal, depending on physical activity levels). Physical activities familiar to the ethnic group – such as yoga, bhangra, etc. – should be encouraged, as should be activities that include the entire family, such as walking. Families tend to be close-knit among South Asians, so a good approach to health education is to target the younger generation (who will share the information with their elders) or women who will then educate the family as a unit.
Reduction of waist circumference should be the goal of South Asian diabetes prevention efforts. Research suggests that a 5 cm (2 inch) reduction in waist size can reduce the risk of developing diabetes by about 25% and of heart disease by 20%.
With a focus on reducing the burden of diabetes in our community, STOP Diabetes Foundation (SDF) was launched as a Brampton-based registered charitable organization in 2013, and includes certified healthcare providers on its board – all of whom work purely on a volunteer basis. The board consists of Endocrinologists like myself, other Specialist and Family physicians, Diabetes Nurse Educators, Registered Dietitians as well as Pharmacists. SDF’s mission is to remove the infamous #1 tag of diabetes on Peel region (Brampton and Mississauga – as having the highest burden of Diabetes in Ontario) before the year 2020 – we’ve coined this as “Vision 2020”. All of our volunteer members are committed to this Vision 2020 and have together launched several community initiatives to educate the public on the prevention of diabetes and heart disease. These initiatives include the most recent pharmacy initiative (using Health Canada approved CANRISK questionnaire), a social media directed campaign focused on youth (including an #IAMFAUJA facebook app); a workplace health initiative aimed at adults with sedentary jobs (taxi and truck drivers, office employees); religious places (including healthy snacks at langar) and restaurant initiatives aimed to provide healthy meal and snack options at these public places; a holidays healthy eating campaign during Diwali and Christmas; a myth busters initiative focused on busting common diet and fitness myths; and a women’s preventive health initiative linking to health issues such as infertility and pregnancy complications among young women of childbearing age. While SDF’s focus is on providing credible health education within Peel region, we’ve also collaborated with other like-minded, non-profit organizations to help spread health awareness in other parts of Canada e.g. Guru Gobind Singh Children’s Foundation based in Scarborough, ASAP (Apni Sehat Apni Parvah) based in Montreal and Dilwalk Foundation based in Calgary. Readers can join the SDF movement and receive more information on our community health awareness events by following our social media pages (Facebook, Twitter, Instagram, YouTube).
Treatment gaps among people who suffer from Diabetes
Research suggests that diabetes-related heart and kidney complications tend to occur much earlier in the South Asian population, hence particular attention should be paid to reduce the risk factors for these complications by controlling blood glucose, blood pressure, cholesterol levels
There are several challenges to achieving optimal diabetes management in South Asian patients, however.
The first is a poor understanding of the disease, its permanent and progressive nature, and the importance of achieving and maintaining blood glucose, cholesterol and blood pressure goals. Without having witnessed diabetes-related complications in family or friends, South Asian immigrants may be less likely to appreciate the need for early and lifelong treatment. Like many people from developing countries, South Asians tend not to put much value on preventive care. Doctors are seen and medications are taken only when a person with diabetes falls ill.
Some South Asians believe in fate or destiny and therefore consider treatment to be inevitably futile. Even when patients accept the need for treatment, poor adherence i.e. missed medication doses, is a significant problem. They may seek out herbal or homeopathic remedies, instead of prescribed medications, as the alternatives are perceived by them to be free of side effects. If patients do not feel sick to begin with, if they do not feel better taking the medication, or – worse – if they experience any adverse effects (such as temporary diarrhea associated with the most commonly prescribed diabetes medication metformin), patients are less likely to comply with the daily treatment.
Financial barriers may hinder some South Asian patients from following their treatment plan as well. Many new immigrants have lower-paying jobs without drug benefits, placing medications and home glucose level testing out of reach.
Education is the key to overcoming these barriers to prevention and treatment of diabetes. When a patient is first diagnosed with diabetes, emphasis should be placed on the long-term consequences of the disease. On the other hand, they need to appreciate that these complications can be prevented or delayed by reaching and then maintaining their glucose, blood pressure and cholesterol goals.
Educational efforts should also focus on helping patients understand the positive effects of their medications (i.e., even if they can’t feel a difference, there is a benefit to taking their meds as prescribed as it reduces their future complication rates). It’s like financial planning for the future, if people take their medications they can plan their future healthy living years better and avoid complications. Concerns about any adverse effects of their medication can be addressed by comparing them to the adverse effects of diabetes (i.e., complications such as heart disease and nerve damage are much worse than the temporary stomach upset with metformin).
Because of their particular risk profile, South Asians should be made aware of their high-risk and educated on prevention strategies. Particular attention should be paid to the ethnically-specific food choices, avoiding fast foods, reducing fried snacks and improving exercise routines with a goal of reducing waist circumference below the cut-off points of 90 cm for South Asian men and 80 cm for women.
Diabetes prevention and management strategies – including healthy meal planning, increased physical activity and medication – must be tailored to the community in order to be effective. From a public health standpoint, community-based diabetes prevention and education programs should be established to target this population so that the rates of diabetes can be brought down to an equitable level to other Canadian ethnicities (e.g. White Caucasians) and the future generations of South Asian kids can be saved from the dual evils of diabetes and heart attacks.