The Asian Paradox: What puts Asians and South Asians at a higher risk for Type 2 diabetes!

The Asian Paradox: What every Asian must know!

Type 2 diabetes is among the fastest growing diseases in the world due to a combination of unfavorable changes in modifiable risk factors and a high genetic susceptibility in certain populations.

Asia is at the epicenter of the diabetes epidemic with 60% of the world’s diabetic population residing in Asia. With sky rocketing rates of obesity worldwide, the metabolic disorders that go hand in hand with obesity are rising proportionately with it. While most ethnic minorities are affected, Asians and South Asians both in their native countries and abroad are disproportionately affected.

Why do we need to pay attention to this? 

Given the magnitude of the diabetes epidemic, and given that Asian Americans are one of the fastest growing ethnic groups in the United States, with their numbers projected to double by the year 2060, it is imperative that we take a hard look at contributing factors and explore meaningful interventions.

The Paradox:

Asians have twice the prevalence rates of diabetes despite lower rates of obesity compared to Caucasians.

The disparity:

Type 2 diabetes occurs at a younger age, at a higher rate and at a lower Body Mass Index (BMI), in Asians and South Asians, compared to whites. This was demonstrated in a population based, multi-ethnic cohort study in Ontario, Canada, which compared incidence rates of diabetes across white, South Asian, black and Chinese individuals aged greater than or equal to 30 years, who were followed up for 12.8 years for diabetes incidence.

What was striking about the study was that after adjusting for age, sex, Body Mass Index (BMI) and socio-demographic characteristics, the study showed that South Asians were 3.4 times more likely, blacks were 1.99 times more likely and Chinese subjects were 1.87 times more likely to develop diabetes compared to white subjects. On average, diabetes occurred 9 years earlier in South Asians, 3 years earlier in Chinese and a year earlier in blacks compared to whites. Moreover, while diabetes was diagnosed at a BMI of 30 in whites, it was diagnosed at a BMI of 24 in South Asians, 25 in Chinese and 26 in blacks. The study clearly demonstrated that while the definition of obesity using a BMI of 30 has been well validated in whites, it is not a reliable measure in non–white populations, and underscores the need for ethnic specific BMI cut-offs in these populations.

What creates this disparity??

Asians have the dubious distinction of having more belly fat and less muscle mass compared to Caucasians at comparable BMIs.  Emerging evidence shows that visceral fat is a significant risk factor for impaired glucose tolerance* among Japanese Americans. At any given(BMI), South Asians  have higher body fat, visceral or abdominal fat, waist circumference (WC) and lower skeletal muscle mass, which translates to increased insulin resistance**, metabolic syndrome, and increased heart disease risk compared to Caucasians. This appears to be a defining characteristic of the Asian population, the so-called “Asian Indian phenotype” and is also frequently referred to as “normal weight, metabolically obese phenotype”.

What does epigenetics have to do with this??

Epigenetic changes***  in gene expression that occur secondary to malnutrition related stressors in the intra-uterine environment can lead to the deposition of central fat as an adaptive response in infants that are exposed to nutrient scarcity because of maternal under nutrition. Despite having lower birth weight, South Asian babies have more central obesity compared to their Caucasian counter parts. Thus, fetal programming in the uterus can lead to fat preservation, which can become maladaptive later in life when these insulin resistant babies are exposed to calorie dense foods as adults, increasing their risk of Type 2 diabetes. This phenomenon is explained by the “the thrifty phenotype hypothesis” which postulates a mismatch between the uterine environment (nutrient scarcity) and adulthood (calorie abundance). This is noted with rapid urbanization and nutrient transitions in developing countries as a result of rapid economic development. This may also be seen when folks who faced food scarcity in early childhood in their native developing nations, migrate to the more affluent countries of the West where food is more abundant.  Thus an inherent genetic susceptibility along with unfavorable changes in lifestyle factors brought on with migration to the West, may set the stage for increased insulin resistance and subsequent diabetes.

How does diet play a role?

Rapid urbanization and industrialization in Asia has fueled a concomitant shift in nutrient patterns. The traditional diets of Asia, high in coarse, unprocessed grains are being replaced with polished white rice and refined wheat, not to mention the consumption of fast and convenience foods as the population transitions from an agriculture based to a faster paced, service based, global economy. On the same token, acculturation in the West (think “diet transplantation”), has been instrumental in migrant Asian populations adapting to Western diets that are calorie dense, higher in animal protein and high in refined grains and sugar.

A recent meta-analysis showed that a 2 serving per day increase in whole grain intake was associated with a 21% lower risk of Type 2 diabetes.  The Nurses’ Health Study showed that intake of white rice is associated with increased risk of diabetes, while brown rice has a protective effect. The adverse effects of high glycemic load diets  are more prevalent  in overweight people secondary to insulin resistance. Prior to rapid urbanization throughout Asia, the detrimental effects of such  diets were off set by increased physical activity as most of the population was engaged in hard, physical labor and sedentary lifestyles were less common.

BMI disparities :

Given the discrepancies in BMI between Asian and European populations, BMI cut offs have had to change, underscoring the fact that traditional methods for assessing metabolic disease risk may not be applicable to the Asian population. We just cannot use the same yard stick any more for assessing disease risk as we would miss the bulk of the folks at risk in Asian populations. To this end, the American Diabetes Association recently lowered its screening criteria for diabetes for Asians to 23 as opposed to 25 used in Caucasians. Thus testing for diabetes should be considered for all Asian American adults who present with a BMI of ≥23 kg/m2

What does this mean for you?

If you are of Asian descent, you might want to start with determining what your BMI is by clicking on this link from the Joslin Diabetes Center.  For example, let’s assume you are an Asian male who is 5’10” and weighs 172 lbs., with a BMI of 24.7. While you would be considered of normal weight by Caucasian standards based upon BMI, you would be at a higher risk by Asian standards given lower screening criteria and should get tested for diabetes.

South Asian tidbits:  How do I reduce my risk?

  • Know thy numbers:  For starters as noted above, know what your BMI is, as well as waist circumference. (Click on this link from Joslin to find out.)
  • Small changes, big results: Secondly, just a modest 5-10% weight loss targeting the waist line can make a significant difference in lowering your risk for prediabetes/diabetes or preventing its progression if you already have either condition.
  • Make fiber your friend:  Fiber slows down digestion, thus reducing blood glucose or sugar spikes seen with refined foods that are low in fiber. Aim for approximately 30-35 grams of fiber per day if you are a woman or 35-38 grams per day if you are a man. Be sure to increase your water intake as you increase your fiber intake.  Bear in mind that if you have certain conditions such as inflammatory bowel disease, your fiber intake may need to be individualized by consulting a registered dietitian or your physician.
  • Wholesome whole grains: Replace refined grains (foods made with white flour or maida), and white rice with whole grains such as quinoa, or farro.  Make high fiber rotis by mixing 2/3 cup whole wheat flour with 1/3 cup high fiber ragi (millet flour) to make a very high fiber roti. Don’t forget to pair with a source of protein such as channa (chickpeas) or rajma (kidney beans), and some veggies sautéed in olive oil to create a complete and satisfying meal. Make upama with bulghur or dalia, instead of refined rava or try a whole moong dal cheela (pancake) for breakfast.
  • Love the lentils: Toss a ½ cup of whole, cooked moong, masoor, preferably in  a sprouted form into that salad at lunch or toss with fresh salsa, a tamarind chutney and/or your favorite choice of chutney to make a quick “chaat”. Simple, healthy and delicious to boot!
Cooked math beans. © Copyright July 2015 Sangeeta Pradhan, RD, LDN, CDE

Pack a fiber punch with lentils, approximately 6-8 grams of fiber for 1/2 a cup. Cooked, sprouted  math beans. © Copyright 2015-2018,  Sangeeta Pradhan, RD, LDN, CDE

  • Fill up with fruit: 1 cup of blackberries can give you a hefty 8 grams of fiber and a pear provides as much as 6 grams, so dig in and enjoy! If you have diabetes, consult a Registered Dietitian for recommendations for the number of fruit servings per day that is tailored to your specific needs.
  • Load up on veggies: Veggies are practically calorie free, high in fiber and nutrient dense. Fill your plate with  vegetables for an additional burst of antioxidants and fiber. For more delicious tips, be sure to check out my post on  Whole grains and fiber: Unraveling the puzzle!
  • Power up with probiotics: Round out your meals with a cup of yogurt or buttermilk with live and active cultures to harness the power of beneficial bacteria.  Emerging evidence shows that your gut bacteria can influence a host of functions, ranging the gamut from the digestion and absorption of nutrients to regulating the immune response, the inflammatory tone in your body, and indeed modulating the course of chronic disease itself.

A 21st century version of a healthy Indian thaali. Clockwise from the bottom: High fiber rotis, quinoa, lentils, green beans, yogurt, lime and sliced tomatoes. This meal is carb controlled, high in fiber,  adequate in protein from lentils , probiotics from yogurt and is packed with antioxidants!  Please consult a Registered Dietitian for portions tailored to your unique needs. © Copyright 2018,  Sangeeta Pradhan, RD, LDN, CDE

  • Dump added sugars and excess fat, especially undesirable fats: Avoid fried foods and foods with added sugars including sugar sweetened beverages such as sodas which may have as many as 10 teaspoons of sugar in a 12 oz can. Excess sugar has been associated with increased oxidative stress and chronic inflammation. Emphasize whole plant fats from nuts, seeds, avocados, or fatty fish.
  • Get moving: Experts recommend 150 minutes of aerobic activity per week , but if you have been sedentary all your life, even 5-10 minute short spurts of activity such as a walk around the block or up to the corner store and back may be enough to get you started.
exercise, free from pixabay

Photo courtesy of Pixabay free image.

  • Seek the advice of an expert: Please consult a Registered Dietitian or Certified Diabetes Educator for specific guidelines, including portion sizes tailored to your unique needs. These professionals are trained to discuss with you the prevention of acute and chronic complications from diabetes and will work with you on home blood glucose monitoring and customizing your meal plan to achieve the desired results.
  • Take home message: Remember diabetes is a consequence of modifiable risk factors such as weight, diet, and activity in folks who are at risk. A modest 5-7% weight loss targeting the waistline may be adequate to overcome insulin resistance. Take small steps today to achieve dramatic results tomorrow, starting with getting screened for diabetes. Please spread the word. Here’s to your health!!

(Stay tuned for more guidelines for meal planning in the coming months).

*Impaired glucose tolerance: Blood sugar is above normal, but not high enough to fall in the “diabetic range”.

**Insulin resistance: A condition when the cells in your body do not respond to signals received from the hormone insulin as it tries to move sugar (fuel) from your blood to your cells. This leads to increased blood sugar levels and may act as a precursor to full-blown diabetes.

***Epigenetic changes: Changes in DNA, often related to environmental influences that can switch genes on and off, without changing the DNA sequence itself.



Disclaimer: All the content on this blog is strictly for informational purposes only, and should not be construed as medical advice. Please consult your doctor or registered dietitian for recommendations tailored to your unique needs.






About Sangeeta Pradhan RD, CDE

Hi there! Welcome to my blog! If you are confused with all the conflicting messages you get bombarded with every day on carbs, fats, proteins, gluten and anything you can think of related to nutrition, look no further! The purpose of my blog is to cut through all this clutter, utilizing scientific, evidence based guidelines to help you, the consumer, navigate the complex, dietary landscape, and thus empower you to make informed decisions.
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23 Responses to The Asian Paradox: What puts Asians and South Asians at a higher risk for Type 2 diabetes!

  1. Great article! Very interesting.

    Liked by 1 person

  2. Thank you, Desiree! Appreciate the feedback. Trying to increase awareness.

    Liked by 1 person

  3. Very informative, thank you!

    Liked by 1 person

  4. You’re welcome! Thank you for stopping by!


  5. Carolyn Page says:

    An excellent post; Thank You!

    Liked by 1 person

  6. This is pretty interesting, and a good reminder for all of us!

    Liked by 1 person

  7. Thank you so much! Trying to raise awareness that the traditional BMI cut off used in Caucasians would grossly under estimate disease risk in Asians, hopefully people will become more vigilant after reading this. Appreciate your feedback as always!😊

    Liked by 1 person

  8. Hi Carolyn,
    Thank you so much! Appreciate the kind feedback:))

    Liked by 1 person

  9. vietnamtravelandculture says:

    Reblogged this on Vietnam Travel & Trade Portal.

    Liked by 1 person

  10. Thank you so much; appreciate your helping me spread the word on this very crucial topic:))


  11. smilecalm says:

    valuable lesson
    and accessible
    encouragement, Sangeeta 🙂

    Liked by 1 person

  12. Thank you so much for your kind feedback and encouragement as always 😊!

    Liked by 1 person

  13. Very important article! Thanks


  14. Thank you so much, Martina! Appreciate the kind feedback. Hoping to spread the word. Have a wonderful week!

    Liked by 1 person

  15. What a great summary of a very complicated subject! I have noticed that all of my diabetes patients of Asian descent are much lower BMI than other folks. I’m so glad that the ADA changed their guidelines to reflect the different risk profiles in populations.

    Liked by 1 person

  16. Thank you so much, Joanna! So kind of you to say that. Yes, I had been researching this topic for several years, so it was heartening to see the ADA revise the BMI cut offs in Asians. More folks need to be educated about their risk, hence the post. Thank you so much for visiting. Have a great weekend!


  17. Thanks for sharing, very informative

    Liked by 1 person

  18. Thank you very much, appreciate the kind feedback. Please spread the word if you can. Have a great weekend!


  19. Pingback: The Asian Paradox: What puts Asians and South Asians at a higher risk for Type 2 diabetes! — Web Dietitian

  20. A nice and informative article. I would like to add that due to ethnic differences, Asians are shown to have higher body fat than the Caucasians. At lower BMI values, Indians tend to have higher body fat percentage. And the excess fatness is the culprit for increased risk of cardio-metabolic diseases.

    Liked by 1 person

  21. Thank you so much for visiting, appreciate the feedback 🙂 ! Yes, you are right. The excess visceral fat compared to Caucasians puts Asians at a significant cardio-metabolic risk secondary to increased insulin resistance. Have a great weekend!


  22. AJ says:

    Wow, thanks for this useful and informative post. Yeah I’ve noticed this among Malays in particular. Koreans and Japanese consume as much alcohol (or even more) as Malays, but they don’t get any beer belly. Malay men, though, look pregnant.

    Liked by 1 person

  23. Thanks, AJ, and for stopping by:)


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