People of South Asian descent may have a higher risk of type 2 diabetes than they might expect, even if they’re not overweight.
South Asians – people who are from or trace their ancestry to the Indian subcontinent, which includes India, Pakistan, Afghanistan, Bangladesh, Bhutan, and Nepal – are up to four times more likely to have type 2 diabetes than people of other ethnic backgrounds. And many South Asians diagnosed with type 2 diabetes have a 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 herself. Here, she shares her thoughts on what people of South Asian background need to know to help prevent, get screened for, and manage or even reverse their type 2 diabetes.This interview was edited for length and clarity.
WebMD: What led you to become an endocrinologist and direct your concentration toward type 2 diabetes?
Shariff: After medical school, I applied and interviewed for nephrology [a medical specialty focused on the kidneys] and then changed paths to join endocrinology after I got diagnosed with gestational diabetes. Also, my father has had type 2 diabetes since I was a kid and since his early 40s, but a couple of years into me being an attending [physician] he started showing a very different pattern of diabetes. My journey started with my personal story and ended with me diagnosing and taking care of my own father.
WebMD: Why do South Asians who are thin have a risk of type 2 diabetes?
Shariff: That’s because we have adipose tissue around our liver and our muscle that makes us insulin resistant. Call it visceral adiposity. It basically blocks the effect of insulin on these very important structures. Now, the brain and the muscle are two areas in your body that really don’t need any insulin to uptake glucose. So … even though people are exercising, they [can] develop insulin resistance and type 2 diabetes [if] their muscles are not able to soak up that blood sugar.
WebMD: How do BMI and insulin play a role in South Asians who are diagnosed with type 2 diabetes?
Shariff: Most of my patients who come in with type 2 diabetes are typically very healthy. They have a normal BMI, they exercise, and they still cannot understand why they can’t budge 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.]
A good example is myself; I have a low BMI yet I took 40 units of insulin when I was pregnant [and had gestational diabetes].
Typically when you have type 2 diabetes, you have insulin resistance. You have a lot of insulin, but it doesn’t work as well. So you require a whole lot more insulin to do the job of what it should have done without the resistance.
South Asians have both insulin resistance and insulin deficiency. [One theory says that] Inherently as a race we have beta cell dysfunction, or what we call beta cell blunting. When you eat a meal, your sugar goes up, goes to the pancreas, and tells it to release insulin. You require a much higher amount of blood sugar to release insulin and your beta cells are not as active as they should be.
WebMD: If someone of South Asian descent goes to their primary care doctor, what risk factors necessitate screening for type 2 diabetes?
- 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] that has type 2 diabetes
- Any other family member who has type 2 diabetes plus a history of heart disease, hypertension, and triglycerides greater than 250
- Females who have a history of polycystic ovary syndrome (PCOS)
WebMD: How can someone of South Asian descent advocate for themselves to get tested for type 2 diabetes at their primary care doctor’s office?
Shariff: It’s important that South Asians advocate for themselves and tell their primary care physician, “I understand that you would typically not 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’m at a higher risk for having type 2 diabetes. This is why you should screen me.”
WebMD: How do you counsel your patients regarding diet and exercise?
Shariff: I never say you need to stop eating something [if you have] diabetes, which is a breath of fresh air for most patients. I say, ‘I want you to understand what you can eat less of and what you should be eating more of and how to balance your diet.’
Many South Asians are vegetarian and it’s a heavy carb diet. Whatever type of carb you’re going to eat, it’s going to raise your blood sugar. Try to stay true to your flavors and be creative with how you can modify the carb portions of your meals into less carbohydrates, or high fiber, high protein options.
Sometimes people exercise and other times they don’t. I put 70% emphasis on your diet. If you eat foods that work with your diagnosis of diabetes, your sugars are going to be better. This allows your insulin resistance to come down.
WebMD: What message do you want to send South Asians regarding a type 2 diabetes diagnosis?
Shariff: You have to balance sustainability and understand you need to seek help. You don’t want diabetes to define you.