Epidemiology of Diabetes and Atherosclerotic Cardiovascular Disease Among Asian American Adults: Implications, Management, and Future Directions: A Scientific Statement From the American Heart Association.

Asian American individuals make up the fastest growing racial and ethnic group in the United States. Despite the substantial variability that exists in type 2 diabetes and atherosclerotic cardiovascular disease risk among the different subgroups of Asian Americans, the current literature, when available, often fails to examine these subgroups individually. The purpose of this scientific statement is to summarize the latest disaggregated data, when possible, on Asian American demographics, prevalence, biological mechanisms, genetics, health behaviors, acculturation and lifestyle interventions, pharmacological therapy, complementary alternative interventions, and their impact on type 2 diabetes and atherosclerotic cardiovascular disease. On the basis of available evidence to date, we noted that the prevalences of type 2 diabetes and stroke mortality are higher in all Asian American subgroups compared with non-Hispanic White adults. Data also showed that atherosclerotic cardiovascular disease risk is highest among South Asian and Filipino adults but lowest among Chinese, Japanese, and Korean adults. This scientific statement discusses the biological pathway of type 2 diabetes and the possible role of genetics in type 2 diabetes and atherosclerotic cardiovascular disease among Asian American adults. Challenges to provide evidence-based recommendations included the limited data on Asian American adults in risk prediction models, national surveillance surveys, and clinical trials, leading to significant research disparities in this population. The large disparity within this population is a call for action to the public health and clinical health care community, for whom opportunities for the inclusion of the Asian American subgroups should be a priority. Future studies of atherosclerotic cardiovascular disease risk in Asian American adults need to be adequately powered, to incorporate multiple Asian ancestries, and to include multigenerational cohorts. With advances in epidemiology and data analysis and the availability of larger, representative cohorts, furthering refining the Pooled Cohort Equations, in addition to enhancers, would allow better risk estimation in segments of the population. Last, this scientific statement provides individual- and community-level intervention suggestions for health care professionals who interact with the Asian American population.

Disaggregating the Asian-American Breast Cancer Population: Disparities in Reconstruction Rates.

INTRODUCTION: Breast cancer (BC) incidence has been increasing among Asian-Americans (AsAms); recent data suggest these patients are less likely to undergo postmastectomy breast reconstruction (PMBR) compared to non-Asian women. Historically, AsAm BC patients are reported in aggregate, masking heterogeneity within this population. We aim to identify patterns of postmastectomy reconstruction among disaggregated AsAm BC patients at our institution. METHODS: A retrospective chart review was performed for BC patients who underwent mastectomy between 2017 and 2021. Patient demographic and clinical information was collected including self-reported race/ethnicity and reconstruction at time of mastectomy. Self-identified Asian patients were disaggregated into East Asian, Southeast Asian, South Asian, and 'Asian Other.' We examined rates of reconstruction between the different races and the disaggregated Asian subgroups. Univariable and multivariable analysis was performed to examine patient factors associated with PMBR. RESULTS: Six hundred and five patients met inclusion criteria. Forty seven percent of patients identified as Asian, 36% of which as East Asian. Forty four percent of all patients underwent PMBR. Southeast Asian and South Asian women were least likely to undergo reconstruction, while Hispanic and non-Hispanic Black women were most likely to pursue PMBR (P = 0.020). On multivariable analysis, Hispanic, non-Hispanic White, and non-Hispanic Black women were more likely to undergo reconstruction compared to Asian women. Other factors associated with reconstruction were coverage with private insurance and diagnosis of noninvasive disease. CONCLUSIONS: Rates of PMBR are lower among AsAms than non-Asian patients and vary between Asian ethnic subgroups. Further investigation is needed to identify patterns of reconstruction among the disaggregated AsAm population to address disparities.

Increased COVID-19 mortality among immigrants compared with US-born individuals: a cross-sectional analysis of 2020 mortality data.

OBJECTIVE: Multiple studies have shown that racially minoritized groups had disproportionate COVID-19 mortality relative to non-Hispanic White individuals. However, there is little known regarding mortality by immigrant status nationally in the United States, despite being another vulnerable population. STUDY DESIGN: This was an observational cross-sectional study using mortality vital statistics system data to calculate proportionate mortality ratios (PMRs) and mortality rates due to COVID-19 as the underlying cause. METHODS: Rates were compared by decedents' identified race, ethnicity (Hispanic vs non-Hispanic), and immigrant (immigrants vs US born) status. Asian race was further disaggregated into "Asian Indian," "Chinese," "Filipino," "Japanese," "Korean," and "Vietnamese." RESULTS: Of the over 3.4 million people who died in 2020, 10.4% of all deaths were attributed to COVID-19 as the underlying cause (n = 351,530). More than double (18.9%, n = 81,815) the percentage of immigrants who died of COVID-19 compared with US-born decedents (9.1%, n = 269,715). PMRs due to COVID-19 were higher among immigrants compared with US-born individuals for non-Hispanic White, non-Hispanic Black, Hispanic, and most disaggregated Asian groups. Among disaggregated Asian immigrants, age- and sex-adjusted PMR due to COVID-19 ranged from 1.58 times greater mortality among Filipino immigrants (95% confidence interval [CI]: 1.53, 1.64) to 0.77 times greater mortality among Japanese immigrants (95% CI: 0.68, 0.86). Age-adjusted mortality rates were also higher among immigrant individuals compared with US-born people. CONCLUSIONS: Immigrant individuals experienced greater mortality due to COVID-19 compared with their US-born counterparts. As COVID-19 becomes more endemic, greater clinical and public health efforts are needed to reduce disparities in mortality among immigrants compared with their US-born counterparts.

Older Chinese and Filipino American Immigrants with Type 2 Diabetes and their Adult Child: A Qualitative Dyadic Exploration of Family Support.

Type 2 Diabetes (T2D) among older Asian American immigrants (AA) is a growing concern. Asian Americans represent 9% of diagnosed diabetes. Very little is known on how older Asian American immigrants with T2D navigate diabetes management, in particular the role of family support. This qualitative study examines Chinese and Filipino Americans, the two largest Asian subgroups in the US (4.2 million, and 3.6 million, respectively), and family support dynamics among adult children and their parents diagnosed with T2D. Ten dyads (n = 20) made up of adult children and aging parents participated in in-depth and dyadic interviews. Results indicate that family support occurs in a trajectory of stages. The following thematic patterns emerged in these dyads around support: independence, transitions, partnership, and stepping in. The findings point to various supportive stages that Asian American adult children and aging parents with T2D experience and the importance of developing supportive interventions for both adult children and aging parents at these various stages.

Researchers Are Working to Disaggregate Asian American Health Data-Here's Why It's Long Overdue.

This Medical News article discusses how aggregated data obscure large health disparities among the 24 million Asian American people in the US.

Chinese Immigrant Religious Institutions' Variability in Views on Preventing Sexual Transmission of HIV.

OBJECTIVES: We examined Chinese immigrant religious institutions' views on teaching about preventing sexual transmission of HIV and the consistency of their views with public health best practices in HIV prevention. METHODS: We used 2009 to 2011 survey data from 712 members of 20 New York City-based Chinese immigrant religious institutions to analyze their views on (1) teaching adolescents about condoms, (2) discussing homosexuality nonjudgmentally, and (3) promoting abstinence until marriage. RESULTS: Religion type was a significant predictor of views in the 3 domains, with Evangelical Protestants in least agreement with public health best practices, Buddhists in most agreement, and mainline Protestants between them. Greater HIV knowledge was significantly associated with agreement with best practices in all 3 domains. The frequency of prayer, meditation, or chanting and the level of acculturation were significant predictors of views on teaching adolescents about condoms and promoting abstinence until marriage. CONCLUSIONS: The best practice messages about HIV prevention that Chinese immigrant religious institutions find acceptable vary according to religion type and several other key factors, including HIV knowledge; frequency of prayer, meditation, or chanting; and level of acculturation.

Acculturative Stress, Self-Esteem, and Eating Pathology in Latina and Asian American Female College Students.

OBJECTIVE: The overarching purpose of this study was to explore the relationships among acculturative stress, self-esteem, and eating pathology in Asian American and Latina female college students. METHOD: Participants (N = 638, mean age = 19.88) completed self-report measures of the variables of interest online. RESULTS: Bivariate correlations indicated that for women of both ethnic groups, acculturative stress was negatively correlated with self-esteem and positively correlated with eating pathology. Multigroup structural equation modeling indicated that for Asian American and Latina women, self-esteem partially mediated the relationship between acculturative stress and eating pathology. However, self-esteem did not serve as a significant moderator of this relationship for either ethnic group. CONCLUSION: Overall, data suggest that acculturative stress is associated with increased eating pathology and self-esteem may mediate this relationship. These relationships suggest that assessment of eating pathology and self-esteem may be indicated for women presenting clinically with acculturative stress concerns.

KOREAN AMERICAN PARENTS' PERCEPTIONS OF EFFECTIVE PARENTING STRATEGIES IN THE UNITED STATES.

This study aimed to explore the perceptions of Korean American parents on effective parenting strategies taught in a standardized U.S. parenting program. Participants in the study were interviewed using semi-structured open-ended questions, and audio taped interview data were transcribed and analyzed using content analysis. Themes that emerged were: effective parenting strategies, impact of learning effective parenting strategies on parents, and learning effective parenting strategies: impact on children. Findings indicated that Korean American parents felt the program was based on Western parenting strategies but they were effective. They also believed the program strategies would be useful in regulating their emotions, increasing their abilities to be patient and consistent with their children, and helping them explore issues from their child's perspective, all of which they believed improved their parenting self-efficacy and intimacy with their children. Additionally, parents reported that their children acquired more self-confidence, better self-expression, increased obedience and decreased misbehaviors, and increased emotion regulation and problem solving as a result of their participation in the program. These findings could contribute to develop an effective, culturally and linguistically relevant parenting program for Korean American parents.

Racial/ethnic differences in dyslipidemia patterns.

BACKGROUND: No studies have comprehensively examined the prevalence of dyslipidemia, a major risk factor for cardiovascular disease, among diverse racial/ethnic minority groups. The primary aim of this study was to identify racial/ethnic differences in dyslipidemia among minorities including Asian Americans (Asian Indian, Chinese, Filipino, Japanese, Korean, or Vietnamese), Mexican Americans, and blacks compared with non-Hispanic whites. METHODS AND RESULTS: Using a 3-year cross section (2008-2011), we identified 169 430 active primary care patients (35 years or older) from an outpatient healthcare organization in northern California. Age-standardized prevalence rates were calculated for 3 dyslipidemia subtypes: high triglycerides (fasting laboratory value ≥150 mg/dL), low levels of high-density lipoprotein cholesterol (fasting laboratory value <40 mg/dL [men] and <50 mg/dL [women]), and high levels of low-density lipoprotein cholesterol (fasting laboratory value ≥130 mg/dL or taking low-density lipoprotein-lowering agents). Odds ratios were calculated by multivariable logistic regression, with adjustment for patient characteristics (age, measured body mass index, smoking). Compared with non-Hispanic whites, every minority subgroup had an increased prevalence of high triglycerides except blacks. Most minority groups had an increased prevalence of low high-density lipoprotein cholesterol, except for Japanese and blacks. The prevalence of high low-density lipoprotein cholesterol was increased among Asian Indians, Filipinos, Japanese, and Vietnamese compared with non-Hispanic whites. CONCLUSIONS: Minority groups, except for blacks, were more likely to have high triglyceride/low high-density lipoprotein cholesterol dyslipidemia. Further research is needed to determine how racial/ethnic differences in dyslipidemia affect racial/ethnic differences in cardiovascular disease rates.

A Longitudinal Investigation of Race, Socioeconomic Status, and Psychosocial Mediators of Allostatic Load in Midlife Women: Findings From the Study of Women's Health Across the Nation.

OBJECTIVES: This research sought to assess racial and socioeconomic status (SES) differences in level and change in allostatic load (AL) over time in midlife women and to test whether psychosocial factors mediate these relationships. These factors were discrimination, perceived stress, and hostility. METHODS: Longitudinal data obtained from the Study of Women's Health Across the Nation were used (n = 2063; mean age at baseline = 46.0 years). Latent growth curve models evaluated the impact of demographic, menopausal, and psychosocial variables on level and change in AL for 8 years. RESULTS: Direct effects: high levels of discrimination and hostility significantly predicted higher AL (path coefficients = 0.05 and 0.05, respectively). High perceived stress significantly predicted a faster rate of increase of AL (path coefficient = 0.06). Racial and SES differentials were present, with African American race (path coefficient = 0.23), low income (path coefficient = -0.15), and low education (path coefficient = -0.08) significantly predicting high AL level. Indirect effects: significant indirect effects were found for African American race, less income, and lower education through higher discrimination, perceived stress, and hostility on level and rate of AL. CONCLUSIONS: This was one of the first studies that investigated AL over multiple periods, and results supported AL as a cumulative phenomenon, affected by multiple psychosocial and demographic factors. The results suggest the complex ways in which race, SES, and psychosocial factors operate to influence AL.

Health Literacy as a Social Determinant of Health in Asian American Immigrants: Findings from a Population-Based Survey in California.

BACKGROUND: Asian American immigrants have a lower level of health literacy than non-Latino whites, but their level of health literacy and its impact on health outcomes may differ among subgroups. OBJECTIVE: We investigated the level of health literacy across five subgroups of Asian American immigrants and explored the association between health literacy and self-rated health status and symptoms of depression. DESIGN: We utilized a cross-sectional survey research design and a population-based sampling strategy using the 2007 California Health Interview Survey (CHIS). PARTICIPANTS: We sampled 30,615 non-Latino whites and 3,053 Asian American immigrants (1,058 Chinese, 598 Koreans, 534 Filipinos, 416 South Asians, and 447 Vietnamese). MAIN MEASURES: We used two questions as proxy measures to assess the level of health literacy in non-Latino whites and in both aggregated and disaggregated Asian American immigrant groups. We then investigated the effect of health literacy on two main health outcomes: self-rated health status and depression symptoms. KEY RESULTS: The level of health literacy varied across the five subgroups of Asian American immigrants. Chinese, Korean, and Vietnamese groups had the lowest levels of health literacy, while Filipinos showed the highest level. Health literacy was positively correlated with health status in Chinese and Korean immigrants, and negatively correlated with depression symptoms in Korean and South Asian immigrants. CONCLUSION: We found heterogeneity in health literacy among Asian American immigrants and found that health literacy had varying associations with health outcomes. The aggregated Asian American immigrant group results may mask the true health disparities that each Asian American immigrant group faces. Koreans were the only group found to have a significant association between the proxy for health literacy and both health outcomes. Further research is needed to better understand the causes of heterogeneity and to investigate health literacy as a critical determinant of immigrant health.

Endogenous sex steroid hormones and glucose in a South-Asian population without diabetes: the Metabolic Syndrome and Atherosclerosis in South-Asians Living in America pilot study.

AIMS: To examine the associations between endogenous sex steroid hormones (oestradiol, testosterone and sex hormone-binding globulin) with diabetes risk in a South-Asian population living in the USA. METHODS: We used data from the Metabolic Syndrome and Atherosclerosis in South-Asians Living in America pilot study. The analytical sample included 60 women and 45 men of Asian Indian origin living in the San Francisco Bay Area, who were free from diabetes and cardiovascular disease and did not use exogenous sex steroids. Sex steroid hormone levels were assessed by validated conventional radioimmunoassays, and visceral and hepatic adiposity were assessed by computed tomography. We used multivariable regression to examine the association between endogenous sex steroid hormone levels (log-transformed) and fasting glucose and 2-h glucose levels in a series of sex-stratified models adjusted for age, waist circumference, visceral and hepatic adiposity, and insulin resistance. RESULTS: In age-adjusted models, lower levels of sex hormone-binding globulin (ß = -0.18, 95% CI -0.30, -0.06) and higher levels of free testosterone (ß = 0.14, 95% CI 0.02, 0.26) were associated with elevated fasting glucose levels in South-Asian women, whereas lower levels of sex hormone-binding globulin (ß = -0.14, 95% CI -0.26, -0.02) and lower levels of total testosterone (ß = -0.12, 95% CI -0.24, 0.00) were associated with elevated fasting glucose levels in South-Asian men. Adjustment for waist circumference, visceral adiposity and insulin resistance attenuated most of these associations, while adjustment for hepatic adiposity strengthened some of the observed associations. Similar results were found for 2-h glucose levels. CONCLUSIONS: Results were consistent with previous research, which suggests that endogenous sex steroid hormones are a risk factor for diabetes across multiple race/ethnic groups. Additional studies are needed to determine whether visceral fat is a mediator or confounder of associations between sex steroid hormone and glucose levels.

Folk and biological perceptions of dementia among Asian ethnic minorities in Hawaii.

OBJECTIVE: To study if Asian ethnic groups in Hawaii today maintain folk-based beliefs about dementia, have inadequate biomedical understanding of dementia, and differ among each other regarding perceptions of dementia. DESIGN: The study adapts and expands a 2004 survey of ethnic groups on perceptions of Alzheimer disease demonstrating that ethnic minority groups hold more folk perceptions and less biomedical perceptions of dementia than Caucasians. This study surveys particular ethnic minority family members of elders admitted to four long-term care and inpatient facilities in Hawaii. Seventy-one family members completed surveys, including 23 Chinese, 18 Filipino, and 30 Japanese participants. Elders may or may not have had the diagnosis of dementia, though an estimated half of elders in all four facilities already held the diagnosis of dementia. RESULTS: Findings indicated that Japanese and Chinese respondents in this study held perceptions about dementia that were more consistent with current biomedical understanding compared with their Filipino counterparts (mean differences/percent correct for Japanese: 57%, Chinese: 56% versus Filipino: 38%; F = 6.39, df = 2,55, p = 0.003). Filipino respondents were less likely than Japanese and Chinese respondents to report that persons with dementia can develop physical and mental problems-97% of Japanese participants and 82% of Chinese participants responded correctly compared with 63% of Filipino participants (Fisher's Exact test p = 0.009). With regard to folk beliefs about dementia, variation occurred with no consistent trend among the groups. CONCLUSION: Low levels of biomedical understanding of dementia were reflected by all three subgroups of Asians living in Hawaii with less prominence of folk beliefs compared with prior studies of ethnic minority perceptions. Education did not predict variability in dementia perceptions among the groups. Lower levels of acculturation, suggested by primary home language other than English, may correlate with a perception of dementia that is less consistent with current biomedical understanding of dementia. Persisting folk beliefs about dementia and the evident lack of biomedical understanding, particularly the belief that dementia is a normal part of aging, emphasizes the need for more culturally tailored strategies in patient education about dementia and the importance of early intervention.

Longitudinal study of acculturation and BMI change among Asian American men.

BACKGROUND: Cross-sectional studies examining the association between Western acculturation and BMI in Asians have been inconsistent, and studies on BMI change are lacking. OBJECTIVE: This study examined the associations between indicators of acculturation (generational status, length of US residence, and age at immigration) and overweight (BMI ≥25kg/m(2)) as well as 5-year BMI changes in 7,073 Chinese, Japanese, Korean, Filipino, and Vietnamese men who lived in the US and were 44-71years old at baseline of the California Men's Health Study (2002-2003). METHODS: Indicators of acculturation were reported at baseline. Repeated clinical measures of BMI were extracted from electronic health records (2005-2012). RESULTS: Using generalized estimating equations we found that lower generational status, shorter duration of US residence and older age at immigration were inversely associated with being overweight. However, analysis of BMI curves using linear mixed models showed that shorter length of US residence and older age at immigration were associated with larger 5-year increases in BMI. CONCLUSIONS: Asian immigrants who were less acculturated had larger BMI increases as they became more acculturated but had not achieved overweight status. Healthy weight interventions among Asians immigrants may be most effective when targeting weight maintenance early in the process of acculturation.

Predictors of the Nicotine Dependence Behavior Time to the First Cigarette in a Multiracial Cohort.

BACKGROUND: The time to first cigarette of the day (TTFC) is a strong indicator of nicotine dependence behaviors such as nicotine uptake and quit success in young and older smokers. There are substantial differences in levels of nicotine dependence by race and ethnic group. METHODS: Data from Wave III of the multiracial National Longitudinal Study of Adolescent Health were analyzed for young smokers between the ages of 21 and 28 (N = 1,425). Time to first cigarette data was compared between Hispanic, White, Black, Native American, and Asian smokers. RESULTS: Black smokers were significantly more likely to smoke within 5min of waking than White, Hispanic, and Asian smokers. Lower personal income predicted smoking within 5min of waking for both White and Black smokers. For White smokers, increased number of cigarettes per day and increased years of smoking also predicted smoking within 5min of waking. The number of days smoked or number of cigarettes per day did not predict smoking within 5min of waking among smokers. CONCLUSIONS: The higher prevalence of early TTFC among Blacks indicates increased nicotine and carcinogen exposure, and may help explain the increased lung cancer rates and failed cessation attempts among Black smokers. TTFC may be an important screening item, independent of cigarettes per day, for clinicians and interventions to identify those at highest risk for cessation failure and disease risk.

Cross-ethnic friendships and intergroup attitudes among asian american adolescents.

This study examined cross-ethnic friendship choices and intergroup attitudes in a sample of 762 sixth-grade Asian American students (Mage  = 11.5 years) attending 1 of 19 middle schools that varied in ethnic composition. Multiple measures of friendship (quantity and quality) and intergroup attitudes (affective, cognitive, behavioral) toward White, Latino, and Black grademates were assessed. The results showed that Asian American students overnominated White students and undernominated Latino and Black students as their friends when school availability of each ethnic group was accounted for. Cross-ethnic friendships were related to better intergroup attitudes, especially the behavioral dimension of attitudes. Cross-ethnic friendships were least likely to change attitudes toward Blacks. Implications for future research, educational practice, and attitude intervention programs were discussed.

The role of consensus and culture in children's imitation of inefficient actions.

A significant body of work has demonstrated children's imitative abilities when learning novel actions. Although some research has examined the role of cultural background in children's imitation of inefficient actions, to our knowledge no research has explored how culture and conformity interact when engaging in imitation. In Study 1, 87 Caucasian American and Chinese American preschoolers were presented with either one model or three models performing an inefficient action. Whereas there were no cultural differences in imitation in the Single Model condition, Chinese Americans were significantly more likely to copy the model's preference for an inefficient tool in the Consensus condition. Children's tool choice was associated with their justification for their choice as well as their memory for the model's action. Study 2 explored the impact of immigration status on the cultural differences in children's tool choice by including 16 first-generation Caucasian American children. When comparing the findings with the rates from Study 1, both groups of Caucasian American preschoolers imitated at rates significantly lower than the Chinese American preschoolers. We suggest that the tool choices of Caucasian American children relate to a tendency to engage in a perceptually driven mode of learning, whereas the choices of the Chinese American children reflect a greater likelihood to use a socially driven mode.