People of South Asian descent may have a higher risk of type 2 diabetes than they would expect, even if they are not overweight.
South Asians – people who come from or trace their ancestry to the Indian subcontinent, which also includes India, Pakistan, Afghanistan, Bangladesh, Bhutan and Nepal – are up to four times more likely to develop type 2 diabetes than people with a different ethnic background. And many South Asians diagnosed with type 2 diabetes have normal weight and body mass index (BMI).
Afreen Idris Shariff, MD, an endocrinologist and assistant professor at Duke University School of Medicine, has seen this risk in her patients, her family, and even in herself. Here, she shares her thoughts on what people from South Asian backgrounds need to know to help prevent, get screened for, manage, or even reverse their type 2 diabetes. This interview has been edited for length and clarity.
WebMD: What led you to become an endocrinologist and focus on type 2 diabetes?
Share: After medical school, I applied and applied for jobs nephrology [a medical specialty focused on the kidneys] and then changed the paths to participate endocrinology after I was diagnosed gestational diabetes. In addition, my father has had type 2 diabetes since I was a child and since he was in his early 40s, but for a few years I have been a treating physician [physician] he started showing a very different pattern of diabetes. My journey began with my personal story and ended with diagnosing and caring for my own father.
WebMD: Why are South Asians who are thin at risk for type 2 diabetes?
Share: That’s because we have fatty tissue around our liver and muscles, which makes us insulin resistant. Name it visceral adipose tissue. It actually blocks the effect of insulin on these very important structures. The brain and muscles are two areas in your body that do not actually need insulin to absorb glucose. So… even though people exercise, they do [can] develop insulin resistance and type 2 diabetes [if] their muscles are unable to absorb that blood sugar level.
WebMD: How do BMI and insulin play a role in South Asians diagnosed with type 2 diabetes?
Share: Most of my patients who come in with type 2 diabetes are usually very healthy. They have a normal BMI, they exercise, and they still can’t understand why they can’t change that A1c.[Editor’s note: The hemoglobin A1c test checks your average blood sugar level for the past 2-3 months. A normal A1c level is below 5.7%. An A1c level of 5.7% to 6.4% is in the prediabetes range. And 6.5% or higher is in the diabetes range. You’d get that checked twice before diagnosing diabetes.]
I am a good example; I have a low BMI, but I still took 40 units of insulin when I was pregnant [and had gestational diabetes].
If you have type 2 diabetes, you usually have insulin resistance. You have a lot of insulin, but it doesn’t work very well. So you need a lot more insulin to do what it should have done without the resistance.
South Asians have both insulin resistance and insulin deficiency. [One theory says that] As a race, we inherently have beta cell dysfunction, or what we call beta cell blunting. When you eat a meal, your sugar levels rise, going to the pancreas and telling it to release insulin. You need a much higher amount of blood sugar to release insulin and your beta cells are not as active as they should be.
WebMD: When someone of South Asian descent goes to their doctor, what risk factors make screening for type 2 diabetes necessary?
Share:
- A BMI greater than 23. [Editor’s note: This is below the BMI threshold for being overweight.]
- Any first-degree relative [parent, child, or sibling] who has type 2 diabetes
- Any other family member with type 2 diabetes and a history of heart disease, hypertension, and triglycerides greater than 250
- Women with a history of polycystic ovary syndrome (PCOS)
WebMD: How can someone of South Asian descent advocate for getting tested for type 2 diabetes at their doctor’s office?
Share: It’s important for South Asians to stand up for themselves and tell their doctor, ‘I understand that you normally wouldn’t have gotten an A1c in someone like me, but because I’m South Asian, my risk is much higher at a lower BMI and I am at greater risk of developing type 2 diabetes. That’s why you have to screen me.”
WebMD: How do you advise your patients about diet and exercise?
Share: I never say you should stop eating anything [if you have] diabetes, which is a relief for most patients. I say, “I want you to understand what you can eat less of and what you should eat more of, and how to balance your diet.”
Many South Asians are vegetarian and it is a heavy carbohydrate diet. Whatever type of carbohydrates you choose to eat will raise your blood sugar levels. Try to stay true to your tastes and be creative with how you can adjust the carbohydrate portions of your meals to lower-carb or high-fiber and high-protein options.
Sometimes people exercise and other times they don’t. I place 70% emphasis on your diet. If you eat foods that match your diabetes diagnosis, your sugars will be better. This can reduce your insulin resistance.
WebMD: What message do you want to send to South Asians regarding a diagnosis of type 2 diabetes?
Share: You have to balance sustainability and understanding that you need to seek help. You don’t want diabetes to define you.