Statement Highlights:

  • Health research that considers Asian Americans as a single race and ethnic group may result in over- or under-estimating the risk of Type 2 diabetes and cardiovascular disease among people of diverse Asian American subgroups, by geographic region of descent.
  • Together, cardiovascular disease and Type 2 diabetes are the leading causes of death and disease in Asian American adults, however, rates vary widely among subgroups. For example, the latest data on the prevalence of Type 2 diabetes in Asian American adults, ages 45-84, reveals a range of Type 2 diabetes from 15.6% among Chinese Americans to 31.9% among Filipino Americans.
  • Recognizing differences in cultural, socioeconomic, lifestyle, diet and other factors among various subgroups of Asian Americans may aid in the development of successful and culturally appropriate education and support programs to reduce cardiovascular risk and improve treatment.
  • Asian subgroups need to be identified and collected routinely in health care records and research, including as many people as possible within each of the subgroups so that enough data is available to draw meaningful conclusions.

Newswise — DALLAS, May 8, 2023 —

A new scientific statement from the American Heart Association published in the journal Circulation highlights that Asian Americans have unique risk factors for heart disease and Type 2 diabetes. These factors include differences in genetics, culture, diet, lifestyle, health interventions, socioeconomic factors, and acculturation levels that vary based on the Asian region of their ancestry.

Despite often being grouped together as a single race and ethnic group in scientific research and health data collection, Asian Americans have significant differences in genetics, socioeconomic factors, culture, diet, lifestyle, and health interventions, which can impact their risk for heart disease and Type 2 diabetes. Therefore, it is necessary to collect data on individual subgroups to better understand and manage their health risks. Acculturation level, which refers to the extent to which individuals have adopted some aspects of U.S. culture or maintained their traditional lifestyle and diet, may also have an impact on their health.

According to the new American Heart Association scientific statement, Asian Americans can be categorized into subgroups based on their geographic region of Asian descent. These subgroups include South Asia, East Asia, Southeast Asia, and Native Hawaiian/Pacific Islander.

According to data analyzed by the Pew Research Center from 2010-2019, Asian Americans are the fastest-growing racial and ethnic group in the United States and make up 7.2% of the population. They may have recently immigrated to the U.S. or come from families who have lived in the country for multiple generations.

Dr. Tak W. Kwan, the chair of the scientific statement writing committee, emphasized the importance of examining Asian subgroups separately to better understand their unique health risks and cultural needs. He explained that the lack of subgroup data among Asian Americans is a significant issue that needs to be addressed to improve healthcare outcomes for this rapidly growing population. By understanding the distinctions among Asian subgroups and how these differences affect their risk of Type 2 diabetes and atherosclerotic disease, healthcare professionals can provide culturally appropriate care and support.

The new scientific statement is a follow-up to a 2010 American Heart Association Science Advisory call to action to seek data on the health disparities among Asian American subgroups, and a 2018 scientific statement addressing cardiovascular disease risk in South Asians (Asian Indian, Pakistani, Sri Lankan, Bangladeshi, Nepali or Bhutanese).

Varied rates for cardiovascular disease and Type 2 diabetes

Together, cardiovascular disease and Type 2 diabetes are the leading causes of death and disease in Asian American adults. Data on the rates of coronary artery disease (plaque build-up in coronary arteries feeding the heart muscle) among Asian Americans overall indicate a prevalence of 8% in men and about 3% in women. However, data for Asian American subgroups indicate wide variations in prevalence:

  • The highest rate of coronary artery disease was among the Asian Indian American subgroup, with 13% for men and 4.4% for women.
  • Among Filipino Americans, the rate was about 9% in men and approximately 4% in women.
  • Among Chinese Americans, the rate was more than 6% for men and over 2% for women.
  • Among Japanese Americans, the rate was nearly 7% for men and about 3% for women.
  • Among Korean Americans, the rate was about 6% in men and nearly 2% in women.
  • Among Vietnamese Americans, almost 6% of men and nearly 4% of women had coronary artery disease.

The prevalence of hypertension among non-U.S. born Asian adults is higher than that among U.S. born Asian adults. According to a study conducted in New York, the prevalence of self-reported hypertension among non-U.S. born Asian adults, with a mean age of 49.5 years, was found to be 22.2%-27.1%. South Asian immigrants, including those from India, Pakistan, Sri Lanka, Bangladesh, Nepal or Bhutan, had the highest prevalence of hypertension at 27.1%, while Chinese immigrants had the lowest prevalence at 22.2%. Hypertension is a leading risk factor for heart disease among Asian subgroups.

Compared to non-Hispanic whites in the U.S., Asian American adults have a higher risk of stroke, especially of bleeding strokes, which tend to be more severe and disabling. This increased risk is likely due to a higher incidence of hypertension. However, the rates of stroke differ significantly among Asian subgroups, with the highest risk observed among Filipino and Vietnamese men, and Japanese and Vietnamese women.

Asian American subgroups' estimates of Type 2 diabetes have mostly been obtained from health system data, limited group comparison studies, and a few state and national surveillance surveys. The available data indicate a diverse prevalence and risk of Type 2 diabetes among Asian American subgroups. A study conducted on Asian Americans residing in California provided the following subgroup information on Type 2 diabetes prevalence: 

  • Overall, Asian American adults had higher rates of Type 2 diabetes (range of 15.6%-34.5%) compared to non-Hispanic white adults (12.8%).
  • Among Chinese Americans, the rate was 15.8%.
  • Among Korean and Japanese Americans, rates were similar at about 18%.
  • Among Americans with Filipino ancestry, the rate was 31.9%.

Lifestyle contributors to heart disease and Type 2 diabetes risk

Diet: The scientific statement categorizes Asian cuisines into three main regions: Southeastern Asian Diet, Southwestern Asian Diet, and Northeastern Asian Diet. The statement provides a chart outlining the dietary characteristics that may increase the risk of heart disease and Type 2 diabetes and provides suggestions for modifying ingredients and cooking methods that may help lower these risks. For instance, the use of coconut milk, which is prevalent in Southeast Asian cuisine, can lead to high intake of saturated fats. Therefore, using low-fat coconut milk is recommended. Similarly, cultural foods in other regions are often preserved or deep-fried, leading to high levels of sodium and/or fat. To address this, the statement suggests consuming brown rice instead of white rice, which is a common staple in several Asian diets and may contribute to low fiber intake. Additionally, non-tropical oils such as olive, canola or other vegetable oils can be used as a substitute for palm or coconut oils, which are high in saturated fats, across Asia.

Tobacco use.Tobacco use is a significant risk factor for heart disease, and its prevalence varies among different Asian subgroups and acculturation levels. For instance, Filipino American adults tend to have a higher prevalence of tobacco use and obesity with greater acculturation, but this pattern is not seen in other Asian subgroups. Although there is limited data on which smoking cessation strategies may be most effective for specific Asian subgroups, it is important to consider family characteristics, social networks, and community resources when developing culturally appropriate smoking prevention and cessation programs.

Physical activity. Participating in moderate to vigorous physical activity more frequently and for longer durations can help decrease the risk of heart disease and Type 2 diabetes. However, there is limited information available about the typical levels and types of physical activity among Asian subgroups. Less acculturated Asian Americans are more likely to engage in lower levels of moderate to vigorous physical activity. Interventions aimed at increasing physical activity should therefore consider ways to reach out to non-English speaking Asian immigrants and recent immigrants.

Sleep. A sufficient amount of sleep is now acknowledged as a crucial aspect of cardiovascular health and is included in the American Heart Association’s Life’s Essential 8, a list of health behaviors and factors that promote optimal cardiovascular health. While there is limited data on sleep patterns among Asian Americans, existing research emphasizes that the stress of adapting to a new culture can lead to sleep disturbances. Intervention programs aimed at reducing acculturation stress among recent immigrants could potentially mitigate the negative effects of poor sleep.

Improving patient care

Even with the limited data available, some important differences among Asian American subgroups are clear:

  • Existing cardiovascular disease risk calculators (which are based on data validated in non-Hispanic Black adults and non-Hispanic white adults and less extensively studied in Asian Americans) may underestimate the risk of Type 2 diabetes and heart disease in South Asian adults, those with lower socioeconomic status or those with chronic inflammatory diseases (e.g., rheumatoid arthritis, psoriasis, HIV/AIDS). These tools may also overestimate the CVD risk among East Asians, those with higher socioeconomic status or those who are already participating in preventive health care services.
  • Nutritional counseling and education may be improved with an understanding of acculturation by Asian American subgroups, as well as cultural and dietary differences among the subgroups. Research to detail the different diets of each subgroup may lead to more tailored and meaningful suggestions for food choices and heart-healthy menu planning.

Filling the information and research gaps

The statement outlines areas to consider for strengthening the data about Asian American adults:

  • Include disaggregated Asian American subgroups in clinical trials and government-sponsored studies.
  • Standardize ways of collecting ethnic and subgroup data for Asian Americans for national health systems, surveys and registries. National surveillance surveys should also consider oversampling Asian Americans to increase representation for the various subgroups.
  • Research that analyzes changes over time in body mass index (BMI), blood pressure and blood lipids is an important area for future investigation of Type 2 diabetes and cardiovascular risk prediction for Asian Americans. Most current data examine BMI cross-sectionally, or at a single point in time, rather than measuring long-term change patterns.
  • There is little data about medication interventions for Asian American adults with Type 2 diabetes and cardiovascular disease. Because of the high prevalence of Type 2 diabetes among Asian Americans, studies that assess medication efficacy and safety in Asian American subgroups are needed.
  • In addition, there is limited research about complementary and alternative treatments that may be more common in some Asian subgroups, such as traditional Chinese medicine, acupuncture, yoga, reflexology, meditation or herbal medicines.
  • Future research on cardiovascular risk needs to include enough Asian American subgroups and multigenerational participants to generate reliable findings for these populations.

“The speaker emphasizes the importance of advocating for increased health research funding for Asian Americans and the inclusion of Asian American subgroup information in clinical trials and government-sponsored research. They suggest that having a platform to share and disseminate data on Asian Americans would be beneficial for both the scientific and research community and healthcare professionals who care for this population. It is essential for healthcare professionals, policymakers, community leaders, and patients to work together towards this goal.”

The scientific statement on cardiovascular health among Asian Americans was prepared by a volunteer writing group representing various councils under the American Heart Association. The statement aims to raise awareness about cardiovascular diseases and stroke issues among Asian Americans and promote informed healthcare decisions. It provides an overview of the current state of knowledge in the field and identifies areas where additional research is needed. While the statement helps guide the development of guidelines, it does not provide specific treatment recommendations. Official clinical practice recommendations are issued by the American Heart Association guidelines.

Co-authors are Vice Chair Latha Palaniappan, M.D., M.S.; Sally S. Wong, Ph.D., R.D., C.D.N., FAHA; Yuling Hong, M.D., Ph.D., FAHA; Alka Kanaya, M.D., FAHA; Sadiya S. Khan, M.D., M.Sc., FAHA; Laura L. Hayman, Ph.D., R.N., FAHA; Svati H. Shah, M.D., M.H.S., FAHA; Francine K. Welty, M.D., FAHA; Prakash C. Deedwania, M.D., FAHA; and Asma Khaliq, M.D. Authors’ disclosures are listed in the manuscript.

The Association receives funding primarily from individuals. Foundations and corporations (including pharmaceutical, device manufacturers and other companies) also make donations and fund specific Association programs and events. The Association has strict policies to prevent these relationships from influencing the science content. Revenues from pharmaceutical and biotech companies, device manufacturers and health insurance providers, and the Association’s overall financial information are available here.

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About the American Heart Association

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Journal Link: Circulation