Purpose of Review
The purpose of this review is to summarize our current knowledge of factors that influence clinical decision making and management of type 2 diabetes mellitus (T2DM) and atherosclerotic cardiovascular disease (ASCVD) among South Asians (SA).
ASCVD and T2DM in SAs have been examined in recent times. Pathophysiologic and genetic factors including the role of adiponectin, visceral adiposity, lower beta cell function, and psycho-social factors like sedentary lifestyle, poor adherence to medications, and carbohydrate dense meals play a role in early development and the high-risk presentation of both ASCVD and T2DM in SA. Recently, large population-based cohort studies have attempted to compare outcomes and interventions that can be translated to timely detection and targeted interventions in this high-risk group.
SAs in the USA are more likely to be diagnosed with T2DM and ASCVD when compared to non-Hispanic whites, non-Hispanic Blacks, and Hispanic populations. The development of personalized ethnic risk assessment tools and better representation of SAs in prospective studies are essential to increasing our understanding and management of cardio-metabolic disease in SA living in the USA.
This is a preview of subscription content, log in to check access.
Buy single article
Instant access to the full article PDF.
Price includes VAT for USA
Subscribe to journal
Immediate online access to all issues from 2019. Subscription will auto renew annually.
This is the net price. Taxes to be calculated in checkout.
Papers of particular interest, published recently, have been highlighted as: • Of importance
Karter AJ, Schillinger D, Adams AS, Moffet HH, Liu J, Adler NE, et al. Elevated rates of diabetes in Pacific Islanders and Asian subgroups: the diabetes study of northern California (DISTANCE). Diabetes Care. 2013;36(3):574–9.
Oza-Frank R, Ali MK, Vaccarino V, Narayan KM. Asian Americans: diabetes prevalence across U.S. and World Health Organization weight classifications. Diabetes Care. 2009;32(9):1644–6.
• Hatwalkar A, Agrawal N, Reiss DS, Budoff MJ. Comparison of prevalence and severity of coronary calcium determined by electron beam tomography among various ethnic groups. Am J Cardiol. 2003;91(10):1225–7 This study definitively concluded the implications of SA ethnicity on cardiovascular risk based on their significantly higher CAC scores. This was in spite of the fact that SAs had lower prevalence of hypertension and a similar prevalence of other cardiovascular risk factors compared to other ethnic groups.
Mukhopadhyay B, Forouhi NG, Fisher BM, Kesson CM, Sattar N. A comparison of glycaemic and metabolic control over time among South Asian and European patients with type 2 diabetes: results from follow-up in a routine diabetes clinic. Diabet Med. 2006;23(1):94–8.
Shah BR, Victor JC, Chiu M, Tu JV, Anand SS, Austin PC, et al. Cardiovascular complications and mortality after diabetes diagnosis for South Asian and Chinese patients: a population-based cohort study. Diabetes Care. 2013;36(9):2670–6.
Chong E, Wang H, King-Shier KM, Quan H, Rabi DM, Khan NA. Prescribing patterns and adherence to medication among South-Asian, Chinese and white people with type 2 diabetes mellitus: a population-based cohort study. Diabet Med. 2014;31(12):1586–93.
Rana A, de Souza RJ, Kandasamy S, Lear SA, Anand SS. Cardiovascular risk among South Asians living in Canada: a systematic review and meta-analysis. CMAJ Open. 2014;2(3):E183–91.
Jose PO, Frank AT, Kapphahn KI, Goldstein BA, Eggleston K, Hastings KG, et al. Cardiovascular disease mortality in Asian Americans. J Am Coll Cardiol. 2014;64(23):2486–94.
Joshi P, Islam S, Pais P, Reddy S, Dorairaj P, Kazmi K, et al. Risk factors for early myocardial infarction in South Asians compared with individuals in other countries. Jama. 2007;297(3):286–94.
Kanaya AM, Herrington D, Vittinghoff E, Ewing SK, Liu K, Blaha MJ, et al. Understanding the high prevalence of diabetes in U.S. south Asians compared with four racial/ethnic groups: the MASALA and MESA studies. Diabetes Care. 2014;37(6):1621–8.
Patel SA, Shivashankar R, Ali MK, Anjana RM, Deepa M, Kapoor D, et al. Is the “South Asian Phenotype” unique to South Asians?: comparing cardiometabolic risk factors in the CARRS and NHANES Studies. Glob Heart. 2016;11(1):89–96.e3.
• Kanaya AM, Wassel CL, Mathur D, Stewart A, Herrington D, Budoff MJ, et al. Prevalence and correlates of diabetes in South asian indians in the United States: findings from the metabolic syndrome and atherosclerosis in South asians living in america study and the multi-ethnic study of atherosclerosis. Metab Syndr Relat Disord. 2010;8(2):157–64 The landmark MASALA study was one of the first large pilot studies that focused on SA immigrants and brought to light the higher odds of type 2 diabetes in this population. This was despite likely underestimating the true prevalence of diabetes in the US SA population given their exclusion of those with history of cardiovascular disease. The study also noted critical associations of certain metabolic factors, e.g. visceral adiposity, as well as the equally important absence of others, such as BMI.
Mohan V, Sharp PS, Cloke HR, Burrin JM, Schumer B, Kohner EM. Serum immunoreactive insulin responses to a glucose load in Asian Indian and European type 2 (non-insulin-dependent) diabetic patients and control subjects. Diabetologia. 1986;29(4):235–7.
Dowse GK, Qin H, Collins VR, Zimmet PZ, Alberti KG, Gareeboo H. Determinants of estimated insulin resistance and beta-cell function in Indian, Creole and Chinese Mauritians. The Mauritius NCD Study Group. Diabetes Res Clin Pract. 1990;10(3):265–79.
Eastwood SV, Tillin T, Wright A, Heasman J, Willis J, Godsland IF, et al. Estimation of CT-derived abdominal visceral and subcutaneous adipose tissue depots from anthropometry in Europeans, South Asians and African Caribbeans. PLoS One. 2013;8(9):e75085.
Sachdev HS, Fall CH, Osmond C, Lakshmy R, Dey Biswas SK, Leary SD, et al. Anthropometric indicators of body composition in young adults: relation to size at birth and serial measurements of body mass index in childhood in the New Delhi birth cohort. Am J Clin Nutr. 2005;82(2):456–66.
Hales CN, Barker DJ. Type 2 (non-insulin-dependent) diabetes mellitus: the thrifty phenotype hypothesis. Diabetologia. 1992;35(7):595–601.
Flowers E, Lin F, Kandula NR, Allison M, Carr JJ, Ding J, et al. Body composition and diabetes risk in South Asians: findings from the MASALA and MESA Studies. Diabetes Care. 2019;42(5):946–53.
Premanath M, Basavanagowdappa H, Mahesh M, Suresh M. Correlation of abdominal adiposity with components of metabolic syndrome, anthropometric parameters and insulin resistance, in obese and non obese, diabetics and non diabetics: a cross sectional observational study. (Mysore Visceral Adiposity in DiabetesStudy). Indian J Endocrinol Metab. 2014;18(5):676–82.
Sulistyoningrum DC, Gasevic D, Lear SA, Ho J, Mente A, Devlin AM. Total and high molecular weight adiponectin and ethnic-specific differences in adiposity and insulin resistance: a cross-sectional study. Cardiovasc Diabetol. 2013;12:170.
Shah AD, Kandula NR, Lin F, Allison MA, Carr J, Herrington D, et al. Less favorable body composition and adipokines in South Asians compared with other US ethnic groups: results from the MASALA and MESA studies. Int J Obes. 2016;40(4):639–45.
Brister SJ, Hamdulay Z, Verma S, Maganti M, Buchanan MR. Ethnic diversity: South Asian ethnicity is associated with increased coronary artery bypass grafting mortality. J Thorac Cardiovasc Surg. 2007;133(1):150–4.
Gujral UP, Narayan KM, Pradeepa RG, Deepa M, Ali MK, Anjana RM, et al. Comparing type 2 diabetes, prediabetes, and their associated risk factors in Asian Indians in India and in the U.S.: the CARRS and MASALA studies. Diabetes Care. 2015;38(7):1312–8.
Chen Y, Copeland WK, Vedanthan R, Grant E, Lee JE, Gu D, et al. Association between body mass index and cardiovascular disease mortality in east Asians and south Asians: pooled analysis of prospective data from the Asia cohort consortium. BMJ. 2013;347:f5446.
Kumar K, Greenfield S, Raza K, Gill P, Stack R. Understanding adherence-related beliefs about medicine amongst patients of South Asian origin with diabetes and cardiovascular disease patients: a qualitative synthesis. BMC Endocr Disord. 2016;16(1):24.
Tang JW, Mason M, Kushner RF, Tirodkar MA, Khurana N, Kandula NR. South Asian American perspectives on overweight, obesity, and the relationship between weight and health. Prev Chronic Dis. 2012;9:E107.
Afaq S, Kooner AS, Loh M, Kooner JS, Chambers JC. Contribution of lower physical activity levels to higher risk of insulin resistance and associated metabolic disturbances in South Asians compared to Europeans. PLoS One. 2019;14(5):e0216354.
Volgman AS, Palaniappan LS, Aggarwal NT, Gupta M, Khandelwal A, Krishnan AV, et al. Atherosclerotic cardiovascular disease in south Asians in the United States: epidemiology, risk factors, and treatments: a scientific statement from the American Heart Association. Circulation. 2018;138(1):e1–e34.
Gupta SS, Aroni R, Teede H. Experiences and perceptions of physical activity among South Asian and Anglo-Australians with type 2 diabetes or cardiovascular disease: implications for clinical practice. Qual Health Res. 2017;27(3):391–405.
Bansal M, Kasliwal RR, Trehan N. Relationship between different cardiovascular risk scores and measures of subclinical atherosclerosis in an Indian population. Indian Heart J. 2015;67(4):332–40.
Goff DC Jr, Lloyd-Jones DM, Bennett G, Coady S, D’Agostino RB, Gibbons R, et al. 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association task force on practice guidelines. Circulation. 2014;129(25 Suppl 2):S49–73.
Yasuda SU, Zhang L, Huang SM. The role of ethnicity in variability in response to drugs: focus on clinical pharmacology studies. Clin Pharmacol Ther. 2008;84(3):417–23.
The Diabetes Prevention Program Research Group. The diabetes prevention program: baseline characteristics of the randomized cohort. Diabetes Care. 2000;23(11):1619–29.
Cainzos-Achirica M, Fedeli U, Sattar N, Agyemang C, Jenum AK, McEvoy JW, et al. Epidemiology, risk factors, and opportunities for prevention of cardiovascular disease in individuals of South Asian ethnicity living in Europe. Atherosclerosis. 286:105–13.
Kim YG, Hahn S, Oh TJ, Kwak SH, Park KS, Cho YM. Differences in the glucose-lowering efficacy of dipeptidyl peptidase-4 inhibitors between Asians and non-Asians: a systematic review and meta-analysis. Diabetologia. 2013;56(4):696–708.
Kang YM, Cho YK, Lee J, Lee SE, Lee WJ, Park JY, et al. Asian subpopulations may exhibit greater cardiovascular benefit from long-acting glucagon-like peptide 1 receptor agonists: a meta-analysis of cardiovascular outcome trials. Diabetes Metab J. 2019;43(4):410–21.
Conflict of Interest
The authors declare that they have no conflicts of interest.
William S. Yancy Jr. is a consultant for Dietdoctor.com and Guideline central.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
This article is part of the Topical Collection on Macrovascular Complications in Diabetes
About this article
Cite this article
Shariff, A.I., Kumar, N., Yancy, W.S. et al. Type 2 Diabetes and Atherosclerotic Cardiovascular Disease in South Asians: a Unique Population with a Growing Challenge. Curr Diab Rep 20, 4 (2020). https://doi.org/10.1007/s11892-020-1291-6
- Diabetes mellitus
- South Asian
- Atherosclerotic cardiovascular disease
- Asian Indian