William C. Hsu

BMI Cut Points to Identify At-Risk Asian Americans for Type 2 Diabetes Screening

According to the U.S. Census Bureau, an Asian is a person with origins from the Far East (China, Japan, Korea, and Mongolia), Southeast Asia (Cambodia, Malaysia, the Philippine Islands, Thailand, Vietnam, Indonesia, Singapore, Laos, etc.), or the Indian subcontinent (India, Pakistan, Bangladesh, Bhutan, Sri Lanka, and Nepal); each region has several ethnicities, each with a unique culture, language, and history. In 2011, 18.2 million U.S. residents self-identified as Asian American, with more than two-thirds foreign-born (1). In 2012, Asian Americans were the nation’s fastest-growing racial or ethnic group, with a growth rate over four times that of the total U.S. population. International migration has contributed >60% of the growth rate in this population (1). Among Asian Americans, the Chinese population was the largest (4.0 million), followed by Filipinos (3.4 million), Asian Indians (3.2 million), Vietnamese (1.9 million), Koreans (1.7 million), and Japanese (1.3 million). Nearly three-fourths of all Asian Americans live in 10 states—California, New York, Texas, New Jersey, Hawaii, Illinois, Washington, Florida, Virginia, and Pennsylvania (1). By 2060, the Asian American population is projected to more than double to 34.4 million, with its share of the U.S. population climbing from 5.1 to 8.2% in the same period (2). Although it is clear that increased body weight is a risk factor for type 2 diabetes, the relationship between body weight and type 2 diabetes is more properly attributable to the quantity and distribution of body fat (3–5). Abdominal circumference and waist and hip measurements, although highly correlated with cardiometabolic risk (6,7), do not differentiate subcutaneous from visceral adipose abdominal depots and are subject to interobserver variability. Imaging and other approaches can be used to more accurately assess fat distribution and quantify adiposity (4,8), but they are not readily available, economical, or useable on …

Human Immunodeficiency Virus Type 1-Related Lipoatrophy and Lipohypertrophy Are Associated with Serum Concentrations of Leptin

The relationship between the adipocyte-derived hormone leptin, insulin resistance, and fat redistribution in patients with human immunodeficiency virus (HIV) infection has not been established. We classified a cohort of HIV type 1 (HIV-1)-infected patients with >or=6 months of antiretroviral exposure as having no lipodystrophy (51 patients [43% of the cohort]), lipoatrophy (23 patients [19% of the cohort]), mixed lipodystrophy (29 patients [24% of the cohort]), or lipohypertrophy (17 patients [14% of the cohort]), on the basis of physical examination, anthropometric measurements, and the findings of dual-emission x-ray absorptiometry and computed tomography. Measurements of insulin resistance were higher for patients with each category of lipodystrophy, compared with those observed for patients with no lipodystrophy (P<.001). Mean leptin levels (+/- standard deviation) were lowest in patients with lipoatrophy (1.76+/-1.20 ng/mL), highest in patients with lipohypertrophy (9.10+/-6.86 ng/mL), and significantly different from those in patients without lipodystrophy (3.14+/-2.30 ng/mL; both P<.01). In this cohort of antiretroviral-experienced HIV-infected patients, a low serum level of leptin was independently associated with insulin resistance in patients with lipoatrophy, after controlling for total and regional body fat.

Understanding and Addressing Unique Needs of Diabetes in Asian Americans, Native Hawaiians, and Pacific Islanders

The Asian American (AA) population is currently the fastest growing population in the U.S., having expanded six times faster than the general population in the 1990s (1). In addition, diabetes prevalence continues to rise in this population, as observed for other populations around the world. However, given the diverse natures, cultures, and physiologies among the AA, Native Hawaiian (NH), and Pacific Islander (PI) (AANHPI) populations, and in particular the distinct diabetes profiles, an understanding of these factors can provide important clues to understand the genesis, pathophysiology, and treatment response of diabetes, as well as characterize community outreach programs needed for the wider net of diverse communities throughout the U.S. In this regard, a meeting, whose theme was “Diabetes in Asian Americans, Native Hawaiians, and Pacific Islanders: A Call to Action,” was held in Honolulu, Hawaii, in September 2011 by a coalition of health care organizations and scientists with strong interests in the topic and in the health of AANHPI populations. There was consensus that there is a great need to understand the prevalence and pathophysiology and discuss potential intervention strategies regarding diabetes in AANHPI populations given the unique characteristics of this population. This information may help health care providers understand and improve diabetes prevention, treatment outcomes, and complications in AANHPI populations. In this review, we examine diabetes prevalence in different AANHPI populations to highlight the similarities and differences. The various groups that comprise AANHPI populations are hugely diverse geographically, culturally, and genetically. The U.S. census defines AAs as persons who have origins in the East, Southeast, or South Asia. NHs and PIs are people who have origins in Hawaii, Samoa, or any other Pacific island (2,3). Diversity within each of these groups is also large. For example, although grouped as AAs, the language, culture, and genetics of someone …

Pathophysiologic Differences Among Asians, Native Hawaiians, and Other Pacific Islanders and Treatment Implications

Differences in pathophysiology may affect the diagnosis, prevention, and treatment of diabetes in Asian Americans, Native Hawaiians, and Pacific Islanders (AANHPIs). Equally important are differences in cultural beliefs, dietary habits, and behavioral patterns among AANHPIs that require culturally effective translation of interventions into the community. These issues were discussed by clinicians and investigators at a conference held in Honolulu, Hawaii, in September 2011 with the theme “Diabetes in Asian Americans, Native Hawaiians, and Pacific Islanders: A Call to Action” by a coalition of health care organizations, clinicians, and scientists with strong interests in the topic and in the health of AANHPI populations (1). The discourse begins with an evaluation of pathophysiologic differences, followed by a discussion of the standard diagnostic criteria and current treatment algorithms as well as dietary recommendations. The focus then shifts to various diabetes prevention studies specific to AANHPIs and their relevance to this growing ethnic minority group in America. This review concludes with two investigations that demonstrate culturally appropriate interventions and a brief description of the role played by the National Diabetes Education Program (NDEP). ### Pathophysiology—type 1 diabetes Diabetes has reached an epidemic level around the world, with most of the increase attributable to type 2 diabetes in developing Asian countries such as India and China (2). Type 1 diabetes is also increasing, although at a much less dramatic rate than type 2 diabetes and is now also increasingly associated with obesity and insulin resistance (3). The highest rates for type 1 diabetes are found in Northern European and Scandinavian countries and among the Caucasian population of the U.S. In contrast, type 1 diabetes is approximately 5 to 10 times lower in prevalence in those of Asian than those of European descent (4). In the U.S., the incidence of type 1 diabetes is lower by two- to fivefold in …

Improvement in Highly Active Antiretroviral Therapy—Induced Metabolic Syndrome by Treatment with Pioglitazone but Not with Fenofibrate: A 2 × 2 Factorial, Randomized, Double-Blinded, Placebo-Controlled Trial

We designed a 2 x 2 factorial, randomized, double-blinded, placebo-controlled trial to evaluate the effects of treatment with pioglitazone and/or fenofibrate in patients with highly active antiretroviral therapy (HAART)-induced metabolic syndrome. We found that the administration of pioglitazone, but not fenofibrate, improved insulin resistance, blood pressure, and lipid profile over a 12-month period.

Optimum BMI Cut Points to Screen Asian Americans for Type 2 Diabetes

OBJECTIVE Asian Americans manifest type 2 diabetes at low BMI levels but may not undergo diagnostic testing for diabetes if the currently recommended BMI screening cut point of ≥25 kg/m2 is followed. We aimed to ascertain an appropriate lower BMI cut point among Asian-American adults without a prior diabetes diagnosis. RESEARCH DESIGN AND METHODS We consolidated data from 1,663 participants, ages ≥45 years, without a prior diabetes diagnosis, from population- and community-based studies, including the Mediators of Atherosclerosis in South Asians Living in America study, the North Kohala Study, the Seattle Japanese American Community Diabetes Study, and the University of California San Diego Filipino Health Study. Clinical measures included a 2-h 75-g oral glucose tolerance test, BMI, and glycosylated hemoglobin (HbA1c). RESULTS Mean age was 59.7 years, mean BMI was 25.4 kg/m2, 58% were women, and type 2 diabetes prevalence (American Diabetes Association 2010 criteria) was 16.9%. At BMI ≥25 kg/m2, sensitivity (63.7%), specificity (52.8%), and Youden index (0.16) values were low; limiting screening to BMI ≥25 kg/m2 would miss 36% of Asian Americans with type 2 diabetes. For screening purposes, higher sensitivity is desirable to minimize missing cases, especially if the diagnostic test is relatively simple and inexpensive. At BMI ≥23 kg/m2, sensitivity (84.7%) was high in the total sample and by sex and Asian-American subgroup and would miss only ∼15% of Asian Americans with diabetes. CONCLUSIONS The BMI cut point for identifying Asian Americans who should be screened for undiagnosed type 2 diabetes should be <25 kg/m2, and ≥23 kg/m2 may be the most practical.

Exercise and Vitamin E Intake Are Independently Associated with Metabolic Abnormalities in Human Immunodeficiency Virus—Positive Subjects: A Cross-Sectional Study

We investigated the relationship among habitual exercise, diet, and the presence of metabolic abnormalities (body fat redistribution, dyslipidemia, and insulin resistance) in a cross-sectional study of 120 human immunodeficiency virus (HIV)-infected subjects with use of bivariate and multivariate regression-analysis models. Total and aerobic exercise were significantly and negatively associated with fasting plasma triglyceride levels in the entire sample and in the fat redistribution group. Inverse associations between total or aerobic exercise and insulin resistance were suggestive but did not achieve statistical significance. Diastolic blood pressure was significantly and inversely associated with supplemental or total but not habitual dietary intake of vitamin E. In conclusion, exercise and vitamin E intake were independently and negatively associated with several phenotypic manifestations of HIV-associated metabolic syndrome, whereas other macro- or micronutrients did not have comparable significance.

Consequences of delaying progression to optimal therapy in patients with type 2 diabetes not achieving glycemic goals.

As a result of the progressive nature of diabetes, glycemic control deteriorates with time, and the risk of associated complications increases. To delay the onset of complications, effective antihyperglycemia therapy should be initiated as soon as possible after diagnosis. Insulin is the most efficacious therapy for diabetes, but its administration is often delayed. This delay, which adversely affects patients’ long-term prognosis, stems partly from clinical inertia and psychological factors affecting both patients and physicians, and partly from a treatment paradigm that advocates the sequential addition of oral interventions before eventual insulin initiation. Starting insulin therapy sooner can help to minimize complications, and modern insulin formulations, used in a well-designed treatment regimen with modern delivery devices, can help patients take advantage of this effect, with minimal hypoglycemia and weight gain.

Ethnic differences in psychological outcomes among people with diabetes: USA results from the second Diabetes Attitudes, Wishes, and Needs (DAWN2) study

Abstract Objective: To assess differences in psychological outcomes as well as risk and protective factors for these outcomes among several USA ethnic groups and identify correlates of these psychological outcomes among adults with diabetes in the second Diabetes Attitudes, Wishes and Needs (DAWN2) study. Research design and methods: The core USA DAWN2 sample was supplemented by independent samples of specific ethnic minority groups, yielding a total of 447 White non-Hispanics, 241 African Americans, 194 Hispanics, and 173 Chinese Americans (n = 1055). Multivariate analysis examined ethnic differences in psychological outcomes and risk/protective factors (disease, demographic and socioeconomic factors, health status and healthcare access/utilization, subjective burden of diabetes and social support/burden). Separate analyses were performed on each group to determine whether risk/protective factors differed across ethnic groups. Main outcome measures: Psychological outcomes include well-being, quality of life, impact of diabetes on life domains, diabetes distress, and diabetes empowerment. Clinical trial registration: NCT01507116. Results: Ethnic minorities tended to have better psychological outcomes than White non-Hispanics, although their diabetes distress was higher. Levels of most risk and protective factors differed significantly across ethnic groups; adjustment for these factors reduced ethnic group differences in psychological outcomes. Health status and modifiable diabetes-specific risk/protective factors (healthcare access/utilization, subjective diabetes burden, social support/burden) had strong associations with psychological outcomes, especially diabetes distress and empowerment. Numerous interactions between ethnicity and other correlates of psychological outcomes suggest that ethnic groups are differentially sensitive to various risk/protective factors. Potential limitations are the sample sizes and representativeness. Conclusions: Ethnic groups differ in their psychological outcomes. The risk/protective factors for psychological outcomes differ across ethnic groups and different ethnic groups are more/less sensitive to their influence. These findings can aid the development of strategies to overcome the most prominent and influential psychosocial barriers to optimal diabetes care within each ethnic group.

Heat shock protein 70 and tumor necrosis factor alpha in Taiwanese patients with dementia.

This study was to determine whether polymorphisms of heat shock protein 70-1 (HSP70-1) and tumor necrosis factor α (TNF-α) are associated with the risk of Alzheimer’s disease (AD) and vascular dementia (VaD). Using the criteria of the NINCDS-ADRDA and NINDS-AIREN, 125 AD patients, 57 VaD patients and 109 ethnically matched nondemented controls were enrolled. The HSP70-1 –110 A/C and TNF-α –1031 T/C, –863 C/A and –857 C/T polymorphisms were analyzed by means of genotype or haplotype association methods. None of the four genotypes examined showed a statistically significant difference in genotype distribution between the AD cases and controls. However, the HSP70-1 –110 CC genotype occurred more frequently among AD cases (p = 0.0821; odds ratio: 2.08; 95% confidence interval, CI: 0.92–4.98). The overall genotype distribution among the VaD cases tended to be different at the HSP70-1 –110 and TNF-α –1031 sites (p = 0.0604 and 0.0316, respectively). The HSP70-1 –110 CC genotype was more frequent (p = 0.0459), and the association of the –110 CC genotype with VaD was evident (p = 0.0207; odds ratio: 3.22; 95% CI: 1.20–8.87). The more frequent TNF-α –1031 TC genotype (p = 0.0614) was also evidently associated with VaD (p = 0.0209; odds ratio: 2.32; 95% CI: 1.14–4.78). Multivariate analysis demonstrated the synergistic effect of the HSP70-1 –110 CC and TNF-α –1031 TC/CC genotypes on VaD (p = 0.0091; odds ratio: 10.09; 95% CI: 2.01–75.97). Haplotype analysis among TNF-α –1031, –863, –857 sites revealed that –1031C–857C may act as a risk haplotype among VaD cases (p = 0.0132, odds ratio: 2.26; 95% CI: 1.19–4.33). Our results suggest a potential protective role for HSP70 in both VaD and AD, whereas TNF-α may act as a risk factor only for VaD, and not for AD.