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Chronic Conditions Among U.S. South Asians in the Context of COVID-19

Pre-existing conditions such as diabetes, hypertension, obesity, heart disease, and chronic lung disease that are known to increase risk of COVID-19 severity and mortality are common among South Asians in the U.S.1-3 Lack of data disaggregation among Asian Americans has long hidden many South Asian chronic health disparities; other Asian subgroups often have lower rates on these conditions that influence combined estimates.4 Additionally, the impact of COVID-19 on South Asians in the U.S. is likely being undercounted due to common misclassification in mortality records as “other” or “unknown”, even though early data indicates higher mortality among South Asians hospitalized for COVID, in part due to pre-existing diabetes, in the UK.5-6

Almost 1 in 4 U.S. South Asians have diabetes.7-9 Diabetes prevalence among South Asians in the U.S. is high (~23%), with estimates from ranging 17% to 35%. This is approximately twice the rate as non-Hispanic Whites (~12%) and East Asians (~14%), and similar to the rate as Hispanics (~22%). The BMI cut point for diabetes risk is much lower among Asians than other racial/ethnic groups. Even at lower BMI, South Asians in the U.S. have higher plasma insulin levels, increased insulin resistance and higher prevalence of diabetes.

Over 1 in 4 U.S. South Asians have hypertension (based on data from New York City).10-11 National estimates are not available, but New York City data indicates high prevalence (~27%) of hypertension among South Asian migrants, who were likely to be younger, have a lower BMI, and have a poorer diet than non-Hispanic White adults. The Mediators of Atherosclerosis in South Asians Living in America (MASALA) Study, which is the first longitudinal study to assess factors associated with heart disease among South Asians in the U.S., reported hypertension prevalence of 43% in men and 35% in women. They also found women living in neighborhoods with higher social cohesion had lower risk of hypertension.

Asian Indians have the highest rate of being overweight (BMI 25-29.9) among all Asian subgroups (although not for BMI ≥30).12-14 South Asians in the U.S. have less favorable body composition compared to other major racial/ethnic groups even without elevated BMI — this includes higher excess body fat around the stomach and lower lean muscle mass. The World Health Organization (WHO) and American Diabetes Association (ADA) recommend lower BMI cutoffs for overweight and obesity among Asian Americans including South Asians to improve detection of increased risk for diabetes and heart disease.

South Asian migrants have 3-5x risk of heart attacks and death than other ethnic groups.15-16 Heart disease among South Asians in the U.S includes earlier onset, higher incidence and higher mortality than many other racial/ethnic groups, largely due to greater prevalence of a range of risk factors. This American Heart Association scientific statement provides a comprehensive overview of the epidemiology, risk factors and treatments for heart disease among South Asians in the U.S.

U.S. South Asians could be at higher risk for chronic lung disease but more data are needed. Limited data exist on chronic lung disease such as asthma and chronic obstructive pulmonary disease (COPD) among South Asians in the U.S. Among Asian Americans, risk of asthma is concentrated among Filipino men and women and South Asian men. In one study, Asian Indians had lower lung function than the general population. One study found Asian Indians had lower lung function than the general population.UK South Asians who never smoked had more chances of getting COPD than most other minority groups. Canadian South Asians had higher rates of asthma-related hospitalizations plus rapidly increasing asthma prevalence that exceeded other ethnic groups.

These conditions increase the likelihood of becoming severely ill or dying from COVID-19 yet we have no data focused on South Asians in the U.S. In New York City, home to the largest concentration of South Asians in the U.S., the majority of COVID-19 deaths involved at least one of these medical conditions. In San Francisco, early data showed over half of COVID-19 deaths were among Asian Americans. In the UK, preliminary data suggest that South Asians are at greater risk of dying from COVID-19, due at least in part to a higher prevalence of pre-existing diabetes.5-6

There is an urgent need for accurate, disaggregated COVID-19 data on the U.S. South Asian population. Earlier this year, 50+ organizations joined us in calling on the U.S. government to address public health gaps in the COVID-19 response for Asian Americans and South Asian Americans including this lack of data.

REFERENCES

  1. Pareek, M., Bangash, M. N., Pareek, N., Pan, D., Sze, S., Minhas, J. S., … & Khunti, K. (2020). Ethnicity and COVID-19: an urgent public health research priority. The Lancet, 395(10234), 1421-1422.
  2. Richardson, S., Hirsch, J. S., Narasimhan, M., Crawford, J. M., McGinn, T., Davidson, K. W., … & Cookingham, J. (2020). Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area. JAMA, 323(20), 2052-2059.
  3. Shahid, Z., Kalayanamitra, R., McClafferty, B., Kepko, D., Ramgobin, D., Patel, R., … & Jones, K. (2020). COVID‐19 and older adults: what we know. Journal of the American Geriatrics Society, 68(5), 926-929.
  4. Islam, N. S., Khan, S., Kwon, S., Jang, D., Ro, M., & Trinh-Shevrin, C. (2010). Methodological issues in the collection, analysis, and reporting of granular data in Asian American populations: historical challenges and potential solutions. Journal of Health Care for the Poor and Underserved, 21(4), 1354.
  5. Harrison, E. M., Docherty, A. B., Barr, B., Buchan, I., Carson, G. et al. (2020). Ethnicity and Outcomes from COVID-19: The ISARIC CCP-UK Prospective Observational Cohort Study of Hospitalised Patients (5/31/2020). Available at SSRN: https://ssrn.com/abstract=3618215 or http://dx.doi.org/10.2139/ssrn.3618215.
  6. Williamson, E. J., Walker, A.J., Bhaskaran, K., Bacon, S., Bates, C. et al. (2020). OpenSAFELY: factors associated with COVID-19 death in 17 million patients. Nature. Available at: https://doi.org/10.1038/s41586-020-2521-4.
  7. Cheng, Y. J., Kanaya, A. M., Araneta, M. R. G., Saydah, S. H., Kahn, H. S., Gregg, E. W., … & Imperatore, G. (2019). Prevalence of diabetes by race and ethnicity in the United States, 2011-2016. JAMA, 322(24), 2389-2398.
  8. Chan, K., De Souza, L. R., Kobayashi, K., & Fuller-Thomson, E. (2019). Diabetes and diabetes care among non-obese South Asian Americans: findings from a population-based study. Diabetes & Metabolic Syndrome: Clinical Research & Reviews, 13(1), 96-102.
  9. Shah, A. D., Vittinghoff, E., Kandula, N. R., Srivastava, S., & Kanaya, A. M. (2015). Correlates of prediabetes and type II diabetes in US South Asians: findings from the Mediators of Atherosclerosis in South Asians Living in America (MASALA) study. Annals of Epidemiology, 25(2), 77-83.
  10. Yi, S. S., Thorpe, L. E., Zanowiak, J. M., Trinh-Shevrin, C., & Islam, N. S. (2016). Clinical characteristics and lifestyle behaviors in a population-based sample of Chinese and South Asian immigrants with hypertension. American Journal of Hypertension, 29(8), 941-947.
  11. Lagisetty, P. A., Wen, M., Choi, H., Heisler, M., Kanaya, A. M., & Kandula, N. R. (2016). Neighborhood social cohesion and prevalence of hypertension and diabetes in a South Asian population. Journal of Immigrant and Minority Health, 18(6), 1309-1316.
  12. Barnes, P. M., Adams, P. F., & Powell-Griner, E. (2008). Health characteristics of the Asian adult population: United States, 2004–2006. Advance Data, 394(394), 1-22.
  13. Shah, A. D., Kandula, N. R., Lin, F., Allison, M. A., Carr, J., Herrington, D., … & Kanaya, A. M. (2016). Less favorable body composition and adipokines in South Asians compared with other US ethnic groups: results from the MASALA and MESA studies. International Journal of Obesity, 40(4), 639-645.
  14. Araneta, M. R. G., Kanaya, A. M., Hsu, W. C., Chang, H. K., Grandinetti, A., Boyko, E. J., … & Onishi, Y. (2015). Optimum BMI cut points to screen Asian Americans for type 2 diabetes. Diabetes Care, 38(5), 814-820.
  15. Gupta, M., Brister, S., & Verma, S. (2006). Is South Asian ethnicity an independent cardiovascular risk factor?. Canadian Journal of Cardiology, 22(3), 193-197.
  16. Volgman, A. S., Palaniappan, L. S., Aggarwal, N. T., Gupta, M., Khandelwal, A., Krishnan, A. V., … & Shah, S. H. (2018). Atherosclerotic cardiovascular disease in South Asians in the United States: epidemiology, risk factors, and treatments: a scientific statement from the American Heart Association. Circulation, 138(1), e1-e34.
  17. Fulambarker, A., Copur, A. S., Javeri, A., Jere, S., & Cohen, M. E. (2004). Reference values for pulmonary function in Asian Indians living in the United States. Chest, 126(4), 1225-1233.
  18. Gilkes, A., Hull, S., Durbaba, S., Schofield, P., Ashworth, M., Mathur, R., & White, P. (2017). Ethnic differences in smoking intensity and COPD risk: an observational study in primary care. NPJ Primary Care Respiratory Medicine, 27(1), 1-6.
  19. Tran, H. N., Siu, S., Iribarren, C., Udaltsova, N., & Klatsky, A. L. (2011). Ethnicity and risk of hospitalization for asthma and chronic obstructive pulmonary disease. Annals of Epidemiology, 21(8), 615-622.
  20. Stanojevic, S., Shah, B. R., Anand, S. S., Sears, M. R., Su, J., & Subbarao, P. (2014). The burden of asthma among South Asian and Chinese populations residing in Ontario. Canadian Respiratory Journal, 21.
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