prevalence, risk factors and complications associated with type 2 diabetes in migrant south asians

DIABETES/METABOLISM RESEARCH AND REVIEWS REVIEW ART ICLEDiabetes Metab Res Rev 2012; 28: 624.Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/dmrr.1219

Prevalence, risk factors and complicationsassociated with type 2 diabetes in migrantSouth Asians

Sara D. Garduno-DiazSantosh Khokhar

School of Food Science & Nutrition,University of Leeds,Leeds LS2 9JT, UK

Correspondence to:Santosh Khokhar,School of Food Science & Nutrition,University of Leeds,Leeds LS2 9JT, UKE-mail:[email protected]

Received : 17 November 2009Revised: 2 January 2011Accepted: 10 May 2011

Summary

It is estimated that type 2 diabetes (T2D) currently affects about 246 millionpeople worldwide, with South Asians, especially Indians, having both thelargest number of cases and the fastest growing prevalence. South Asianethnicity has been identified as a major risk factor for the developmentof T2D with central adiposity, insulin resistance and an unfavourablelipid profile being identified as predominant signals of alarm. Leadingdatabases, including Web of Science, Medline, PubMed and Science Direct,were consulted and manual searches were conducted for cited referencesin leading diabetes-related journals. In all, 152 articles were included forthe final assessment reported in this review. Genetic predisposition, centraladiposity and unfavourable lifestyle, including physical inactivity and anunhealthy diet, were associated with the prevalence of T2D in migrant SouthAsians. Westernization, acculturation, socio-economic factors and lack ofknowledge about the disease have also been identified as contributors to thedevelopment of T2D in this population. Higher prevalence of T2D in migrantSouth Asians may not be entirely attributed to genetic predisposition; hence,ethnicity and associated modifiable risk factors need further investigation.Preventive measures and appropriate interventions are currently limited bythe lack of ethnic-specific cut-off points for anthropometric and biologicalmarkers, as well as by the absence of reliable methods for dietary andphysical activity assessment. This article describes the prevalence rate, riskfactors and complications associated with T2D in migrant South Asians livingin different countries. Copyright 2011 John Wiley & Sons, Ltd.

Keywords type 2 diabetes; risk factors; retinopathy; migrants; SouthAsians; ethnicity

Introduction

The worldwide prevalence of type 2 diabetes (T2D) continues to increase withparticularly high rates in Asia, especially among people of Indian, Pakistani,Bangladeshi and Sri Lankan descent (together referred to as South Asiansin this article). Studies involving migrant South Asians in developed coun-tries such as the United States, United Kingdom and Canada have reportedhigh prevalence rates of T2D [15]. It has been estimated that, by 2010,the global diabetic population be 285 million, with India having the largestnumber of cases, around 32 million [6,7]. T2D is now considered to be aserious disease because of its metabolic complications, attributed deaths andeconomic burden to nations. In most cases, T2D can be prevented by reliable

Copyright 2011 John Wiley & Sons, Ltd.

Type 2 Diabetes in South Asians 7

and early diagnosis, effective interventions and publiceducation. A number of factors including genetics,ethnicity, dyslipidaemia, migration, diet and lifestylehave been associated with the prevalence of T2D inmigrant South Asians. This article reviews data on theprevalence and risk factors for T2D in migrant SouthAsians (of Indian, Pakistani and Bangladeshi descent)with particular attention being paid to modifiable factorssuch as unhealthy diet and physical inactivity.

Methods

Leading international databases, including Web of Science,PubMed, Medline and Science Direct, were consulted in asearch using the terms diet, diabetes, ethnic groups,South Asians, migrant South Asians, Indians, coronaryheart disease, obesity, insulin resistance, nutrientintake, dietary pattern and physical activity, andtheir combinations. Manual searches were additionallycarried out from references cited in articles obtainedin this manner as well as by online searches ofthe primary diabetic journals: Diabetes, Diabetes Care,Diabetes and Metabolism, Diabetes/Metabolism Researchand Reviews, Diabetes Research and Clinical Practice,Diabetic Medicine, Clinical Diabetes and Diabetologia.The websites of a number of organizations were alsoconsulted, including the International Diabetes Federation,World Health Organization, American Diabetic Association,Research Society for the Study of Diabetes in India, SouthAsian Health Foundation UK and Diabetic Association ofBangladesh and Diabetes UK. Finally, relevant articlesin the Journal of Immigrant Minority Health were alsoconsulted. The initial searches provided 415 publications,which were subsequently critically assessed to ensuretheir relevance. Articles relevant to diabetes and/orspecific risk factors [e.g. insulin resistance, dyslipidaemiaand cardiovascular diseases (CVDs)] in South Asiansliving abroad (here referred to as migrant South Asians,including Indian, Pakistani and Bangladeshi subgroups)were included in the subsequent examination butexcluded when addressing primarily non-human subjects,children, ethnic groups other than South Asians and theirsubgroups. The search only considered articles writtenin English. In all, 152 peer-reviewed articles were takenforward for final assessment.

Results and discussion

Epidemiological trends of T2D inmigrant South Asians

Variations in the reported prevalence of T2D amongmigrant South Asians can be attributed to numerousfactors related to their geographical distribution, ethnicityand variation in the design of the studies (Table 1). Thereported prevalence of T2D was found to be higher

in migrant South Asians compared to those in theirhomeland. When compared to the host populations inthe United Kingdom, Europe, Norway, Canada, UnitedStates and Singapore, prevalence rates were higher formigrant South Asians. [1,812] (Table1). Additionally,studies from India showed higher prevalence rates inurban areas (cities and larger towns) compared to ruralsettings (countryside and smaller dwellings), a findingthat has been partly attributed to the acquisition of aWestern lifestyle as in the case of migrant South Asians.

In India, the 2001 census reported some 307 millionpeople as migrants by place of birth. Out of these, about259 million (84.2%) migrated from one part of the coun-try to another, that is, from one village or town to anothervillage or town while 42 million (2%) left the coun-try. Migration from one rural area to another was quitehigh (53 million) compared to migration from rural tourban areas (20 million). A much smaller number, about6 million migrants, moved from urban to rural areas. Themain reasons identified for these demographic changeswere marriage for women and work or education formen. The most popular host countries for South Asians inEurope include the United Kingdom and The Netherlandswhile in the rest of the world the United States, Canadaand Australia are leading countries [18]. Dietary changeslinked to urbanization include a more diverse food selec-tion and a higher consumption of macronutrients andfoods of animal origin, refined carbohydrates, processedfoods, saturated and total fat and less fibre [15,17,19,20].However, studies comparing rural and urban migrantSouth Asians are very limited. The Diabetes Epidemiol-ogy: Collaborative Analysis of Diagnostic Criteria in Asia(DECODA) study also reported that ethnicity increasesthe overall susceptibility to diabetes and might modifythe effect of established risk factors for T2D [21,22].These data might, therefore, suggest that ethnicity and itsassociated factors, including genetic predisposition, diet,lifestyle, anthropometry and other psycho-social factorsrelated to migration and living conditions, could play arole in the onset of T2D in this population.

Limitations of studies comparing prevalence rates ofT2D are mainly due to the type of studies and sampleselection. Initial differences among subjects could accountfor the variation, because not all were reported to behealthy to begin with and usually presented additionalconditions including stroke [23], hypertension [24]and other non-communicable diseases [8]. Furthermore,several studies involved populations having a widerange of ages. In regard to gender differences onthe prevalence of diabetes, the latest version of theDiabetes Atlas estimates that, in South Asian countries,1 million more women than men have diabetes (143versus 142 million, respectively) [6]. Although, in general,acceptable sampling methods were used in the studiesconsidered, both sample size and study populationwere area specific and not representative of migrantSouth Asians in those countries. This could lead tounderestimation of the prevalence of T2D in migrantSouth Asians and could account for differences in the

Copyright 2011 John Wiley & Sons, Ltd. Diabetes Metab Res Rev 2012; 28: 624.DOI: 10.1002/dmrr

8 S. D. Garduno-Diaz and S. Khokhar

Table1.

Prevalen

ceoftype2diabetes

amongAsian

Indiansan

dmigrantSo

uth

Asian

s

Stud

yYe

arSe

ttin

gSa

mpl

ing

Sam

ple

Num

ber

ofA

gePo

pula

tion

Dia

gnos

isPr

eval

ence

Refe

renc

ede

sign

met

hod

size

mal

es/f

emal

esty

pem

etho

d(%

)

Cro

ss-s

ecti

onal

surv

ey20

062

007

UK

Med

ical

prac

tice

sw

ith

depr

ived

popu

lati

on

3435

916

637/

1777

2>

20ye

ars

Pati

ents

regi

ster

ofSo

uth

Asi

ans,

Cau

casi

ans

and

Blac

ks

Dia

gnos

tic

read

code

for

type

2di

abet

es

11(S

outh

Asi

ans)

aD

reye

ret

al.

[12]

3.5

(Cau

casi

ans)

8(B

lack

s)C

ross

-sec

tion

alsu

rvey

2001

200

3U

KRa

ndom

435

271/

164

207

5ye

ars

Mig

rant

Sout

hA

sian

sO

GTT

20H

anifet

al.[

2]

Popu

lati

on-

base

dst

udy

2001

UK

Rand

om10

6351

7/54

635

79

year

sU

rban

mig

rant

Paki

stan

is,

Euro

pean

san

dA

fro-

Car

ibbe

ans

OG

TT33

(Pak

ista

nis)

aRi

steet

al.[

10]

20(E

urop

eans

)22

(Car

ibbe

ans)

Popu

lati

on-

base

dst

udy

1996

199

8C

anad

aSt

rati

fied

rand

om98

550

6/47

935

75

year

sU

rban

ethn

icSo

uth

Asi

ans,

Euro

pean

san

dC

hine

se

FGT

10(S

outh

Asi

ans)

aA

nand

etal

.[1]

5(E

urop

eans

)2

(Chi

nese

)C

omm

unit

y-ba

sed

stud

y

2004

Uni

ted

Stat

esRa

ndom

1046

537/

509

178

7ye

ars

Asi

anIn

dian

mig

rant

sin

Atl

anta

met

ro

Self-

repo

rted

18.3

Ven

kata

ram

anet

al.[

13]

Cro

ss-s

ecti

onal

surv

ey19

841

995

Sing

apor

eRe

gist

ryfr

ompr

evio

ussu

rvey

s

5707

2796

/291

124

64

year

sA

sian

Indi

an,

Mal

ayan

dC

hine

se

FGT

12.8

(Indi

ans)

aYe

oet

al.[

8]

4(M

alay

)3

(Chi

nese

)



Table1.

(continued

)

Stud

yYe

arSe

ttin

gSa

mpl

ing

Sam

ple

Num

ber

ofA

gePo

pula

tion

Dia

gnos

isPr

eval

ence

Refe

renc

ede

sign

met

hod

size

mal

es/f

emal

esty

pem

etho

d(%

)

Popu

lati

on-

base

dst

udy

1992

Sing

apor

eRa

ndom

3568

1712

/185

618

69

year

sA

sian

Indi

an,

Mal

ayan

dC

hine

se

OG

TTan

dFG

T12

.2(In

dian

s)a

Tanet

al.[

9]

10.1

(Mal

ay)

7.8

(Chi

nese

)Po

pula

tion

coho

rt10

-yea

rfo

llow

-up

1994

Sout

hA

fric

aSy

stem

atic

clus

ter

563

232/

331

>15

year

sSo

uth

Afr

ican

and

Indi

ans

OG

TT16

.2a

Mot

alaet

al.

[14]

Cro

ss-s

ecti

onal

surv

ey20

00N

orw

ayRa

ndom

2513

1101

/141

230

67

year

sSo

uth

Asi

ans

and

Wes

tern

volu

ntee

rs

Self-

repo

rted

14.3

/27.

5(S

outh

Asi

ans)

a,b

and

5.9/

2.9

(Wes

tern

)

Jenu

met

al.

[11]

Popu

lati

on-

base

dst

udy

2003

200

5In

dia

Stra

tifie

d44

523

2181

6/22

707

156

4ye

ars

Rura

land

urba

nSe

lf-re

port

ed4.

5 (rur

al/u

rban

;3.

1/7.

3)a

Moh

anet

al.

[15]

Cro

ss-s

ecti

onal

surv

ey20

022

005

Indi

aSt

rati

fied

3069

1479

/159

018

80

year

sU

rban

OG

TT9.

0aM

enon

etal

.[1

6]C

ross

-sec

tion

alsu

rvey

1999

200

2In

dia

Rand

om41

270

2053

4/20

736

25

year

sRu

rala

ndur

ban

FGT

4.3 (r

ural

/urb

an;

1.9/

4.6)

a

Sadi

kotet

al.

[17]

FGT,

fast

ing

gluc

ose

test

;OG

TT,o

ral-g

luco

seto

lera

nce

test

.aA

djus

ted

for

age

and

gend

er.

bV

alue

sre

port

edas

mal

es/f

emal

es.



number of detected cases. The method by which thepresence of T2D was established also differed from studyto study, ranging from self-reporting to confirmation bymedical records or biomarkers [1,36,8,23]. In general,there is great variability in the completeness and accuracyof data on prevalence rates of T2D in migrant SouthAsians. The available data might also suggest high ratesof undiagnosed T2D worldwide in this group. Reliable androbust population-based studies are, therefore, essentialto develop and encourage effective management andprevention of T2D.

Risk factors for T2D among migrantSouth Asians

There is considerable discussion and debate as to whySouth Asians, including migrant groups, possess anunenviable higher incidence of T2D. Underlying geneticcomponent/s along with environmental influences, suchas sedentary lifestyle and carbohydrate-rich diets, aremost usually cited as significant factors [7,2542].

DietIt is widely documented that a healthy diet is a keyrequirement for the primary prevention and effectivemanagement of T2D [43,44]. However, there areconflicting reports on which components of the diet aremost beneficial or harmful with respect to the onsetof this condition. It is established that high intakesof refined carbohydrates, and total and saturated fats,negatively influence glucose and insulin metabolism,leading to T2D [45,46]. Compared to South Asiansin their homeland, considerable changes in the dietsof migrant populations have occurred [4749]. Thisis largely a result of variability in food preparationpractices due to acculturation to the host country andthe non-availability of traditional ingredients [48,50,51].Migrant South Asians are substituting their traditional andvegetarian diets with lacto-vegetarian and ready-to-eat,animal-based and highly processed carbohydrate-basedfoods (e.g. pizzas) possessing high levels of total andsaturated fat [3,52]. From a diet rich in pulses and cerealsand which also contains large amounts of fruits andvegetables, migrant South Asians have changed to a less-healthy diet low in fruits, vegetables and fibre, high insugars and saturated and total fats [38,50,53,54]. Thesefoods are associated with adverse health consequences,including obesity, insulin resistance [55], adverse lipidprofiles [56] and the development of T2D.

Gilbert and Khokhar [54] have reported that, comparedto populations remaining in their homelands, theincreased availability of energy-dense foods such as fatsand oils, meat and sugary products, and conveniencefoods at affordable prices might be important contributorsto major changes in the diets of South Asians. A furtherfactor could be frying, a common food preparation methodamong British South Asians [57]. In most cultures food is

central to demonstrating high socio-economic status andis a sign of affluence; as such it unfortunately contributesto consumption of less-healthy foods and higher totalenergy intake. As shown in Table 2, irrespective of therecommended intake of the host country, energy intakefrom total and saturated fat was higher among SouthAsian migrants when compared to those remaining intheir homeland. The prescribed calorie intake for peoplewith diabetes is 5060% energy from carbohydrate,1520% from fat and the remainder from protein [3].While the reported carbohydrate intake was usuallywithin the prescribed limit, the consumption of refinedcarbohydrates may be higher than whole grains inthese groups, but evidence of this is currently lacking.High carbohydrate diets have been found to increasetriglyceride levels and reduce high-density lipoprotein(HDL) cholesterol concentration [58,59] and, therefore,to affect insulin metabolism [60]. Other studies foundno association between carbohydrate intake and insulinmetabolism [61].

Studies that reported fibre intakes (Table 2) werecomparable across all groups but intakes were lowerthan the levels recommended by the American DiabetesAssociation guidelines (14 g/1000 kcal) and Diabetes UK(1824 g/day) for improving glycaemic control [67,68].The detailed composition of nutrients and lipids in thediets of South Asians and their potential effect on T2Dhave been reviewed by Isharwal [69]; Misra [3] hassuggested that the total amount and type of carbohydrateconsumed (such as dietary fibre intake) may be animportant consideration for this population.

Diet plays a key role in the development of T2Dbut studies demonstrating its association with thiscondition have been carried out primarily on Caucasianpopulations. For instance, vitamins C and D have beenidentified as nutritional biomarkers for the risk of T2Din Caucasians, but this has not yet been fully testedin South Asians [41,70,71]. Studies evaluating nutrientintake in migrant South Asian groups have been directedprimarily towards validation of assessment tools [72],identification of preference for energy-dense food andconsumption of fruits and vegetable [38]. Moreover,national diet and nutrition surveys in host countries,such as the United Kingdom, do not measure nutrientintake in representative samples of ethnic groups. Thereliability of studies estimating macro- and micronutrientsin migrant populations has recently been questioned byNgo et al. [73] because of the diversity of their dietsand the difficulties in estimating food portion sizes. Lackof reliable food composition databases, data on nutrientintake and dietary habits and on the nutritional health ofmigrant South Asians might severely affect the confidencewith which their food intake could be associated withT2D [74]. Although prevention programmes have beencarried out and have yielded positive results via lifestylemodifications [75], a more accurate description andmeasurement of the dietary patterns and nutrient intakeof the migrant South Asian population is urgently needed



Table2.

Rep

orted

averag

een

ergyan

dnutrientintakesofAsian

Indiansan

dmigrantSo

uth

Asian

s

Sam

ple

Popu

lati

onTo

tal

Ener

gyEn

ergy

Ener

gySa

tura

ted

Poly

unsa

tura

ted

Mon

ouns

atur

ated

Fibr

eRe

fere

nce

size

type

ener

gyfr

omfr

omfr

omfa

tty

fatt

yac

id(%

)fa

tty

acid

s(%

)(g

)kc

al/d

ay)

fat

(%)

carb

ohyd

rate

(%)

prot

ein

(%)

acid

(%)

205

UK:

Mig

rant

Guj

arat

i22

21(m

ale)

38.5

(mal

e)43

.5(m

ale)

14.2

(mal

e)10

.1(m

ale)

Not

repo

rted

Not

repo

rted

Not

repo

rted

Hea

ldet

al.[

48]

1720 (fem

ale)

39.4 (fem

ale)

48.5 (fem

ale)

9.9

(fem

ale)

10.1 (fem

ale)

173

UK:

Mig

rant

Sout

hA

sian

s

2269

47

736

.5

5.9

46.6

6.

613

.7

2.2

16.3

4.

38.

2

3.5

11.9

2.

53.

2

0.83

Seva

ket

al.[

62]

126

UK:

Mig

rant

Asi

ans

2411

4046

14.6

168

1632

Smit

het

al.[

63]

101

Uni

ted

Stat

es:

Mig

rant

Indi

ans

1867

54

4(m

ale)

2564

146

(mal

e)6

(mal

e)8

(mal

e)33

(mal

e)Jo

nnal

agad

daet

al.[

62]

1472

44

8(f

emal

e)7

(fem

ale)

5(f

emal

e)9

(fem

ale)

28(f

emal

e)

189

Uni

ted

Stat

es:

Mig

rant

Guj

arat

iIn

dian

s

1944

54

2(m

ale)

33.8

9.

3(m

ale)

57

8.5

(mal

e)11

.7

2.6

(mal

e)7.

9

4.2

(mal

e)8.

0

4.0

(mal

e)7.

8

3.5

(mal

e)29

12

(mal

e)Jo

nnal

agad

daet

al.[

64]

1571

52

7(f

emal

e)33

.1

11.2

(fem

ale)

57

9.7

(fem

ale)

12.6

3.

5(f

emal

e)8.

2

4.3

(fem

ale)

8.3

5.

3(f

emal

e)8.

2

4.0

(fem

ale)

26

12(f

emal

e)89

2U

nite

dSt

ates

:M

igra

ntIn

dian

sfr

omfo

urst

ates

1831

225

4(m

ale)

343

7(m

ale)

454

9(m

ale)

16(m

ale)

121

3(m

ale)

Not

repo

rted

Not

repo

rted

142

0(m

ale)

Zeph

ieret

al.

[65]

1431

165

1(f

emal

e)33

36

(fem

ale)

495

1(f

emal

e)16

(fem

ale)

111

3(f

emal

e)12

17

(fem

ale)



Table2.

(continued

)

Sam

ple

Popu

lati

onTo

tal

Ener

gyEn

ergy

Ener

gySa

tura

ted

Poly

unsa

tura

ted

Mon

ouns

atur

ated

Fibr

eRe

fere

nce

size

type

ener

gyfr

omfr

omfr

omfa

tty

fatt

yac

id(%

)fa

tty

acid

s(%

)(g

)kc

al/d

ay)

fat

(%)

carb

ohyd

rate

(%)

prot

ein

(%)

acid

(%)

153

Uni

ted

Stat

es:

Asi

anIn

dian

s

1857

65

1to

1579

58

8

32

856

9

13

48

3

Not

repo

rted

16

4N

otre

port

edYa

galla

etal

.[5

3]

206

Indi

a:In

dian

Asi

ans

1812

(mal

e)24

27

59

6012

13

6.6

(mal

e)1.

3(m

ale)

4.7

(mal

e)8.

5(m

ale)

Hea

ldet

al.[

48]

1395 (fem

ale)

6.5

(fem

ale)

1.7

(fem

ale)

5.7

(fem

ale)

6.1

(fem

ale)

227

Indi

a:G

auta

mN

agar

1478

(mal

e)32

.6(m

ale)

54.1

(mal

e)14

.1(m

ale)

7.3

(mal

e)N

otre

port

edN

otre

port

edN

otre

port

edM

isra

etal

.[49

]

1260 (fem

ale)

32.9 (fem

ale)

54.8 (fem

ale)

12.2 (fem

ale)

7.9

(fem

ale)

500

Indi

a:A

ndhr

aPr

ades

h

2464

(mal

e)14

.2(m

ale)

Not

repo

rted

10.8

(mal

e)N

otre

port

edN

otre

port

edN

otre

port

edN

otre

port

edRe

ddyet

al.

[66]

2158 (fem

ale)

15.0 (fem

ale)

12.5 (fem

ale)

And

hra

Prad

esh,

stat

ein

the

sout

heas

tern

coas

tof

Indi

a;G

auta

mN

agar

,Ind

ian

loca

lity

inD

elhi

;Guj

arat

i,et

hnic

grou

pfr

omth

eno

rthw

est

ofIn

dia.



if reliable interventions are to be conducted and dietaryadvice provided for this particular at-risk population.

Physical activityLack of adequate physical activity is a well-establishedrisk factor for many diseases including T2D [7679].Migrant South Asians, especially those from Bangladesh,are much less physically active than other ethnic groups[5,78,80]. Comparison between British Asians and AsianIndians showed the latter to be more physically active[81]. Among subjects not classified as sedentary, phys-ical activity had a favourable effect on blood pressure,reduced body mass index (BMI), mean serum insulin andtriglyceride levels [82]. A 1994 study from the UnitedKingdom also showed that twice as many British Asians(especially females) took no physical exercise, as com-pared to Asian Indians [83]. Furthermore, migrant SouthAsians also exhibit lower physical activity levels thanEuropeans in the United Kingdom [84]. Urbanization,including the greater use of automobiles as the primarysource of transport compared to the use of bicycles anda physically active and agrarian lifestyle, has been linkedto sedentary lifestyle among Indians in India and China[85,86]. Ramachandran et al. [87] found that physicalactivity level decreased whereas BMI and upper body adi-posity increased significantly with urbanization in India,thereby increasing the risk of T2D. This evidence is sup-ported by the high prevalence rates of T2D reported inurban areas as shown in Table 1.

A health and life style survey of the minority populationin an area of Manchester (United Kingdom) also reportedlowest physical activity levels among migrant SouthAsians compared to Afro-Caribbeans [88]. Current dataindicated that as South Asians move from rural to urbanareas in their homeland and then as they migrate to west-ernized countries, the level of physical activity tends todiminish, with respect to both everyday activities (as theyadopt a more sedentary lifestyle) and exercise regimes.

Furthermore, findings from a survey conducted inthe United Kingdom indicated that, when questionedabout diseases related to physical inactivity, only 6%of the migrant South Asians mentioned diabetes whilethe majority limited their responses to overweight [89].There appears to be a certain level of awareness ofthe importance of physical activity on health amongmigrant South Asians, but there is a lack in puttingthe knowledge into practice in everyday life [82,9092].This has been reportedly attributed to religious beliefs,time constraints, poor socio-economic status and healthproblems [9396]. At present, data on physical activitypatterns, barriers to taking exercise and an individualsperception of what constitutes physical activity within thisgroup are very limited. Reliable and direct measures ofphysical activity rather than self-reported levels of exercise[97] in migrant South Asians are needed. Even thoughaerobic and resistance exercises have been shown toeffectively improve insulin sensitivity and, therefore, T2D

[76,98100], there is also a lack of culturally acceptablephysical exercise interventions for this group.

Obesity and dislipidaemiaExcess adiposity, or obesity, is a key risk factor fordiabetes, mainly due to its potential as insulin-resistantaggravator [84,97,101105]. Higher BMI values havebeen observed in migrant Asian Indians compared tothose living in their homeland [52,106,107], and theformer exhibit greater central adiposity than CaucasianEuropeans [37,101,108]. In the DECODA study (2003),population-based studies from European, Maltese, Indian,Chinese and Japanese surveys were examined todetermine the effect of ethnicity on the association amongage, BMI and the prevalence of T2D. The study reportedthat the association between BMI and diabetes starts at aBMI of 1520 in Maltese and Indians, in comparison with25 in Europeans. The mean BMI for Chinese men andwomen was 24.7 and 25.0, for Indians 23.0 and 23.3 andfor Europeans 26.4 and 26.4. These differences shouldbe considered when proposing BMI recommendations atnational and international levels [22].

Obesity is usually determined by BMI; however, thismeasure has been shown to underestimate adiposity inSouth Asians where BMI levels, as well as percentageof body fat, are frequently found to be normal althoughcentral adiposity is present [35,52,109,110]. As a conse-quence,waisthip ratio has been shown to be a better indi-cator for this ethnic group (Table 3). The DECODA studygroup also reported a stronger association between dia-betes and waist-to-stature ratio than between diabetes andBMI [111]. In some countries, including the United King-dom, WHO/IDF guidelines regarding ethnic-specific limitsfor waist circumference for men (90 cm) and women(80 cm) are used alongside established screening proce-dures to predict T2D risk in migrant South Asians [112].In the DECODA study, two-step screening, fasting plasmaglucose and oral-glucose tolerance tests, as recommendedby WHO, were used for 30- to 89-year olds in six differentcountries (China, India, Japan, United States, Indonesiaand Singapore). The findings showed that almost a quar-ter of newly diagnosed patients with diabetes would beleft unidentified in Asian countries if these criteria wereapplied and emphasized the need to establish differentthreshold levels for prognosis in Asian populations [21].

For the assessment of dyslipidaemia, Bhopal et al.[95] have reported the acceptable lipid profile for bothmigrant and non-migrant South Asians to be: total choles-terol


Table3.

Anthropometrican

dbiochem

icalindicators

oftype2diabetes

inAsian

Indiansan

dmigrantSo

uth

Asian

s

Sam

ple

Popu

lati

onA

geBM

IW

HR

Fast

ing

Fast

ing

Trig

lyce

ride

Hig

h-de

nsit

yTo

tal

Con

clus

ion

Refe

renc

esi

zety

pe(y

ears

)(k

g/m

2)

gluc

ose

insu

linlip

opro

tein

chol

este

rol

Con

clus

ion

(mm

ol/L

)(

U/m

L)(m

mol

/L)

(mm

ol/L

)

48U

K:M

igra

ntIn

dian

s48

.5

8.8

29.9

4.

5N

ot rep

orte

d4.

716

.01.

31.

03

0.25

4.8

0.

8W

HR

was

asso

ciat

edw

ith

low

high

-den

sity

lipop

rote

inch

oles

tero

l

Val

sam

akis

etal

.[1

13]

55.1

15

30.1

6

6.3

14.0

1.3

1.26

0.

465.

2

1W

hite

Brit

ish

200

UK:

Mig

rant

Sout

hA

sian

s

51.9

7.

125

.7

3.2

1.02

0.

055.

3428

.22.

391.

026.

16W

HR

posi

tive

lyco

rrel

ated

wit

hin

sulin

and

trig

lyce

ride

inm

igra

ntan

dA

sian

Indi

ans

Dha

wan

etal

.[83

]

Whi

teBr

itis

h56

.7

8.7

25.5

9.

91.

00

0.6

5.58

18.4

1.91

0.89

5.44

Indi

a:A

sian

Indi

ans

50.0

8.

623

.9

2.9

0.97

0.

064.

7712

.71.

791.

086.

32

76U

K:40

69

Not r

epor

ted

Not r

epor

ted

Seru

min

sulin

,tr

igly

ceri

dean

dto

talc

hole

ster

olle

vels

wer

ehi

gher

inth

ose

wit

hgr

eate

rW

HR

Seva

ket

al.

[62]

Mig

rant

Sout

hA

sian

sLo

w

23.9

0.92

4.32

1.44

1.26

Inte

rmed

iate

24.7

0.96

9.89

1.39

1.38

Hig

hin

sulin

leve

ls26

.00.

9819

.65

2.28

1.03



Table3.

(continued

)

Sam

ple

Popu

lati

onA

geBM

IW

HR

Fast

ing

Fast

ing

Trig

lyce

ride

Hig

h-de

nsit

yTo

tal

Con

clus

ion

Refe

renc

esi

zety

pe(y

ears

)(k

g/m

2)

gluc

ose

insu

linlip

opro

tein

chol

este

rol

Con

clus

ion

(mm

ol/L

)(

U/m

L)(m

mol

/L)

(mm

ol/L

)

323

UK:

406

9N

ot rep

orte

dN

ot rep

orte

dN

ot rep

orte

dN

ot rep

orte

dIm

pair

edgl

ucos

eto

lera

nce

was

mor

eas

soci

ated

wit

hW

HR

than

BMI

McK

eigu

eet

al.[

84]

Mig

rant

Sout

hA

sian

s

26.3

1.00

14.7

Whi

teBr

itis

h27

.80.

9912

.387

6Si

ngap

ore:

Mig

rant

Indi

ans

186

923

.59

2.

82(m

ale)

0.85

0.

04(m

ale)

5.41

0.

37(m

ale)

10.4

0

9.53

(mal

e)

1.53

0.

67(m

ale)

1.03

0.

14(m

ale)

5.26

0.

67(m

ale)

Aft

erco

rrec

ting

for

age,

BMIa

ndW

HR,

mig

rant

Sout

hA

sian

sha

dhi

gher

insu

linre

sist

ance

than

Mal

ays/

Chi

nese

Tanet

al.[

9]

23.6

8

2.84

(fem

ale)

0.73

0.

04(f

emal

e)5.

22

0.28

(fem

ale)

9.14

4.

39(f

emal

e)1.

02

0.32

(fem

ale)

1.24

0.

17(f

emal

e)5.

16

0.64

(fem

ale)

30In

dia:

Asi

anIn

dian

s24

50

24.1

2.

841.

0

0.2

10.0

7

2.0

Not r

epor

ted

1.99

0.

61.

19

0.08

4.58

0.

7D

ecre

ase

inad

ipos

ity

coul

dim

prov

ein

sulin

regu

lati

onin

Indi

ans

Mis

raet

al.

[76]

277

Indi

a:A

sian

Indi

ans

186

619

.5

4.3

(mal

e)0.

84

0.07

(mal

e)4.

78N

ot rep

orte

d1.

34(m

ale)

1.04

(mal

e5.

04(m

ale)

WH

Rw

ashi

ghan

dhi

gh-d

ensi

tylip

opro

tein

chol

este

roll

owde

spit

elo

wBM

I

Mis

raet

al.

[49]

20.5

4.

2(f

emal

e)0.

81

0.07

(fem

ale)

4.83

1.46 (f

emal

e)1.

03 (fem

ale)

4.74 (f

emal

e)

BMI,

body

mas

sin

dex;

WH

R,w

aist

hip

rati

o.



acculturation. Despite their total cholesterol levels beinglow, South Asians are predisposed to high-risk lipid pro-files [40,56]. They tend to present high levels of LDLcholesterol, low levels of HDL cholesterol and high triglyc-eride concentrations, all recognized risk factors for T2D[115,116]. Consequently, there is a pressing need forrigorous assessment protocols for risk of T2D and activeattempts to reduce the prevalence of this condition inmigrant South Asians.

Genetic susceptibilityT2D has been shown to be heritable in South Asians andgenetic factors appear to play a significant role in the onsetof the condition in this population group [42,73,117,118].A number of T2D genes, including KCNJ11, KCNQ1,THADA, HHEX, FTO, CDKAL1, TCF7 L2, ENPP1 121Qand PAI-1 4G/5G, have been identified in population-based genome-wide association studies. Despite the non-reproducibility of gene variant associations in somepopulations, a meta-analysis [119] involving 29 195control subjects and 17 202 cases showed TCF7 L2to be reproducibly associated with T2D in variousethnic groups, including migrant South Asians. Geneticsusceptibility to T2D has been further demonstrated byMisra [52] who took country of residence as one ofthe external factors to control. In this study, prevalenceof insulin resistance was compared between SouthAsian populations living in their country of origin andabroad. As prevalence remained high within both groups,when compared to control groups of different ethnicity,regardless of their location the authors concluded thatgenetic factors were implicated.

However, interethnic differences in allele frequenciesand polymorphism associations have been reported inother studies, as shown in Table 4. In general, genesassociated with risk factors for T2D have been linkedwith insulin metabolism and allele polymorphism. Radhaet al. [120] investigated the protective role of geneticpolymorphisms since. Some genetic polymorphisms havebeen associated with an improvement in insulin sensitiv-ity, thereby exerting a positive effect on the preventionof T2D. The same study showed that, with regard toperoxisome proliferator-activated receptor- 2 Pro 12Alapolymorphism, the protection was only present in Cau-casian but not South Asian subjects. In a later study bythe same group [121], an association was found betweena polymorphism on the lipoprotein lipase gene and T2D;among Asian Indians G53C single nucleotide polymor-phism appears to offer protection against T2D as well asfor obesity.

Data might suggest that insulin resistance leading toT2D is not caused by environmental factors but onlyby genetics; however, it remains an open question asto whether or not other aspects that are known tocause insulin resistance [108,128,129] change with themovement of a population group from one country toanother. These aspects include dietary habits, physicalactivity and socio-economic status, all of which have the

potential to influence the onset of insulin resistance inmigrant groups [35]. Overall, genome-wide associationstudies on T2D have been limited by small samplesize, poor reproducibility of results with similar anddifferent ethnic groups and interethnic differences inallele frequency and location. Further studies of SouthAsians, both in their homeland and abroad, are requiredto allow better understanding of the pathogenesis of T2Dand the prevention and control of this disease.

Other risk factorsA number of studies have reported patterns of asso-ciation of socio-economic indicators and risk of mostdiseases (e.g. T2D and CVD) in several populations,including South Asians in their homeland and over-seas [49,51,94,130133]. The associations were mainlyrelated to factors such as employment status, level of edu-cation, social class, housing tenure, household income andnumber of people in the household. These factors clearlyinfluence food choices, lifestyle and access to health care.However, inconsistencies have been identified in patternsof association of these socio-economic indicators with riskof T2D in South Asians living in their homeland or over-seas [130,134,135]. Similarly, due to the heterogeneityof these population groups, there are ethnic variations inobserved patterns; hence, there is need for ethnic-specific,health-related deprivation or socio-economic indicators.

Lower socio-economic status has also been found tobe positively associated with prevalence of T2D [136]and related risk factors in migrant South Asians and,especially, among Pakistanis and Bangladeshis who arecomparatively worse off economically than Indians [137].Socio-economic position tends to influence dietary habitsby determining food accessibility and lifestyle, includinglevel of physical activity [138140]. When income islow, food selection is driven by price rather than bynutrient content and generally results in intakes of high-carbohydrate energy-dense foods which lead to higherwaist/hip ratios, higher triglyceride levels and, therefore,to the development of T2D [141]. Diabetes morbidityand mortality are inversely related to income and socio-economic status which are usually linked to the quality ofhealth care available to the population [142].

Other important risk factors for T2D in migrant SouthAsians are the lack of knowledge and understanding ofthe condition. Studies in the United Kingdom and Indiashowed that 28% of the subjects did not understand theterm diabetes, 13% could not provide any descriptionof the condition at all, 22% were unable to name anyrisk factors involved and 20% could not identify anypreventive measures [143,144]. In general, ethnic andminority populations are much less well targeted byinformation about healthy lifestyles than the majorityof the population. Baradaran et al. [23] showed it to bepossible to conduct a culturally appropriate educationalintervention programme to increase the understanding ofT2D by ethnic minority groups; however, no net benefitwas found compared to that of the control group. These



Table4.

Gen

eticassociationwithtype2diabetes

inIndiansan

dmigrantSo

uth

Asian

s

Popu

lati

onG

enes

/sin

gle

nucl

eoti

deG

ene

Con

clus

ions

Refe

renc

epo

lym

orph

ism

UK:

Sout

hA

sian

sof

Punj

abia

nces

try

ofPa

kist

anTC

F7L2

Rs79

0314

6Re

gula

tes

insu

linse

cret

ion

and

tran

scri

ptio

nfa

ctor

TCF7

L2is

age

neti

cri

skfa

ctor

for

T2D

inm

ulti

ple

ethn

icgr

oups

Rees

etal

.[12

2]

UK:

Euro

pean

Whi

tes,

Indi

anA

sian

s,A

fro-

Car

ibbe

ans

and

non-

diab

etic

ethn

ical

lym

atch

edsu

bjec

ts

TCF7

L2Rs79

0314

6rs12

2553

72Re

gula

tes

insu

linse

cret

ion

and

tran

scri

ptio

nfa

ctor

TCF7

L2ge

noty

peis

am

ajor

risk

fact

orfo

rT2

DH

umph

ries

etal

.[12

3]

Indi

a:So

uth

Asi

anIn

dian

sTC

F7L2

Rs79

0314

6rs12

2553

72rs45

0656

5Re

gula

tes

insu

linse

cret

ion

and

tran

scri

ptio

nfa

ctor

TCF7

L2m

aypl

aya

cruc

ialr

ole

inth

epa

thog

enes

isof

T2D

espe

cial

lyin

Sout

hA

sian

Indi

ans,

byin

fluen

cing

insu

linse

cret

ion

and

resi

stan

ce

Cha

ndak

etal

.[11

8]

Sout

hA

fric

a:In

dian

s,W

hite

san

dA

fric

ans

PAI-

14G

/5G67

5PA

I-14G

/5G

Prom

oter

geno

type

InIn

dian

san

dA

fric

ans,

but

not

Cau

casi

ans,

the

abili

tyof

met

abol

icsy

ndro

me-

rela

ted

fact

ors

toin

fluen

cePA

I-1

leve

lsis

mod

ulat

edby

the

675

geno

type

Nar

anet

al.[

124]

Uni

ted

Stat

es:S

outh

Asi

ans,

Cau

casi

ans

inU

nite

dSt

ates

and

Sout

hA

sian

sin

Indi

aPP

AR-

12

AlaPro12A

laPr

otec

tive

role

indi

abet

esri

skPP

AR

Pr

o12A

lapo

lym

orph

ism

ispr

otec

tive

agai

nst

diab

etes

inC

auca

sian

sbu

tno

tin

Sout

hA

sian

s

Radh

aet

al.[

120]

Uni

ted

Stat

es:N

on-m

igra

ntSo

uth

Asi

ans

inIn

dia,

mig

rant

Sout

hA

sian

sin

Texa

s,no

n-m

igra

ntC

auca

sian

sin

Texa

s

ENPP

1K1

21QEN

PP112

1QPr

edic

tion

ofT2

DEN

PP1

121Q

pred

icts

gene

tic

susc

epti

bilit

yto

T2D

inbo

thSo

uth

Asi

ans

and

Cau

casi

ans

Aba

teet

al.[

125]

Uni

ted

Stat

es:A

sian

Indi

anSi

khs

PPA

RG2Pro12A

laA

lipid

-act

ivat

edtr

ansc

ript

ion

fact

orG

enet

icva

riat

ion

inPP

ARG

and

ADIPOQ

loci

coul

dco

ntri

bute

toth

eri

skfo

rth

ede

velo

pmen

tof

T2D

inIn

dian

Sikh

s

Sang

hera

etal

.[12

6]

AD

IPO

QAD

/rs182

052AD

/rs764

9121

Mod

ulat

esgl

ucos

em

etab

olis

mU

nite

dSt

ates

:Asi

anSi

khco

mm

unit

yfr

omN

orth

Indi

aPP

ARG

2rs18

0812

82G

row

thfa

ctor

2bi

ndin

gpr

otei

nTh

efo

urlo

ciar

eas

soci

ated

wit

hT2

Das

show

nin

othe

rst

udie

sw

ith

Cau

casi

ans

Sang

hera

etal

.[12

7]

IGF2

BP2rs44

0296

0G

row

thfa

ctor

bind

ing

prot

ein

TCF7

L2rs10

8854

09Re

gula

tes

insu

linse

cret

ion,

tran

scri

ptio

nfa

ctor

and

fat

mas

sob

esit

y-as

soci

ated

gene

FTOrs99

3960

9

T2D

,typ

e2

diab

etes

.



results place migrant South Asians at higher risk makingit difficult to encourage self-management and preventionwhich is an essential component of treatment of thecondition [84].

Complications associated with T2D inmigrant South Asians

The development of complications resulting from T2Dvaries, mostly depending on the management andduration of the disease and not always correspondingto time since, on many occasions, early diagnosis is notable to be made because South Asians develop T2D ata significantly younger age (45.9 years of age comparedto 57.3 years of age in Caucasians); as a consequencethey experience higher risk of complications [145]. Somestudies have also reported poor control of T2D and thatprogression to CVD is more common in ethnic minoritygroups than in Caucasians [32,137,142,146,147].

The most common complications associated with T2Dinclude foot ulcer and renal disease. South Asians withT2D have about one third the risk of foot ulcers ofEuropeans and, although reasons for this are unclear,a possible explanation may be the association withlower levels of peripheral arterial disease, neuropathyand foot deformities [8]. Foot ulcers are the leadingprecursors of diabetes-related amputations and are moreprevalent among rural than urban (8 versus 3%) SouthAsians [148]. Barefoot walking, lesser use of customizedfootwear, smoking and bacterial infections have beenidentified as possible underlying reasons for footulceration leading to rapid and vast tissue destruction withsubsequent amputation [148,149] (Figure 1). Reductionsin amputation have been reported in several studies whenfoot care programmes have been implemented, awarenessand education improved and subjects motivation to takeresponsibility for their condition.

South Asians develop more nephropathy and exhibitprogressive renal failure at a much younger age thando European patients with diabetes. This, together withhigher levels of microalbuminuria and ischaemic heartdisease, has been attributed to the high prevalence ofinsulin resistance [150]. Microalbuminuria, linked tonephropathy, is an independent cardiovascular risk factorin T2D [151] and Davies concluded that Indian Asianethnicity was an independent predictor of albuminuriawhen analysing the results of the UK Prospective DiabetesStudy [28]. As renal function deteriorates, South Asianethnicity is associated with higher levels of proteinuriaas well as with the more severe form of chronic kidneydisease [12,143]. Only one study reported on neuropathyand T2D in South Asians; its main findings included a 26%prevalence of diabetic neuropathy associated with age andduration of diabetes. Neuropathy was also strongly linkedto foot ulceration and amputation among urban Indians[144].

It has been established in various studies that migrantSouth Asians have a greater risk of developing CVD than

their Caucasian counterparts, due to a predisposition ofrisk factors including hypertension, high-risk lipid profilesand T2D. Migrant South Asians diabetic patients showeda greater predisposition to CVD associated with glucoseintolerance and insulin resistance. Emerging vascularrisk factors in South Asians include increased plasmafibrinogen levels, higher levels of plasminogen activatorinhibitor-1, elevated C-reactive protein concentrationsand plasma homocysteine levels [152], all of which areaggravated by the presence of T2D [41].

Visual impairment or blindness is a common complica-tion of T2D and has a high prevalence (up to 40%) inmigrant South Asians with diabetes [153155]. Preva-lence of sight-threatening retinopathy was reported to behigher in South Asians in 2004 in the United Kingdom[156] and delayed diagnosis in this group, comparedto Caucasians, might have been a contributory factoras some diabetic patients were not regularly attendingthe clinics due to social and income factors. A studyon the prevalence of vascular retinal lesion among dia-betic patients reported a higher prevalence among SouthAsians than Caucasians for both retinopathy (46 ver-sus 31.3%) and severe retinopathy (1.7 versus 1.2%)[157]. Another study confirmed the higher prevalence ofmicro- and macrovascular disease [158], both retinopathyand sight-threatening retinopathy (late-stage retinopathy)being higher among South Asians (45 and 16%, respec-tively) than White Europeans (37 and 12%) [153]. Thisstudy also pointed out that screening for retinopathy is notyet routine among diabetic patients, although it is becom-ing more so in the United Kingdom and other developedcountries. This, however, must be especially consideredand encouraged when addressing at-risk populations suchas South Asians.

The duration of diabetes and age at onset have bothbeen shown to be strong predictors of retinopathy in thispopulation group [159]. A large study from the UnitedKingdom also reported that the duration of diabetes(7.6 7.3 years), early-age onset (53 12 years), poorglycaemic control, high blood pressure and adverse lipidprofile were all stronger predictors of retinopathy inmigrant South Asians than in White Europeans [153,160].Therefore, early diagnosis of diabetes and screening forretinopathy might both help delay the onset of retinopathyand its consequences in migrant South Asians.

Death rates attributable to diabetes are estimated bythe International Diabetes Federation as 476 900 for malesand 666 000 for females (2079 years) in the SoutheastAsia region which is projected to have the highest rateof diabetes mortality in 2010 [6]. Gender differencescan be appreciated as death rates due to diabetes arehigher among women than men. This might also be dueto differences in access to health care, diagnosis andtreatment as well as to higher number of women beingaffected by the condition, including gestational diabetes.Longer life expectancies among South Asian women [161]might also play a role as they are more likely to developcomplications and hence attributable death to diabetes.



Figure 1. Identified underlying reasons leading to amputation among people with type 2 diabetes

Conclusions

Increased susceptibility to T2D may be associated withethnicity which, in turn, is associated with a number offactors, including genetic predisposition, diet, living con-ditions, lifestyle factors and anthropometry. On the basisof the studies evaluated, the prevalence rate of T2D inmigrant South Asians was highest in the United Kingdom(1133%) followed by Norway (1428%), United States(18%), Singapore (12.8%) and Canada (10%), whereasthe prevalence in native South Asians of Pakistan, Indiaand Bangladesh is 7.6, 7.1 and 6.1%, respectively.

The majority of the studies reported an unhealthy dietto be a strong risk factor for T2D in migrant South Asians,in particular the consumption of energy-dense foods thatare rich in total fat, saturated fat and refined sugar andlow in fibre. Such foods have also been found to causeunfavourable lipid profiles including high triglyceride andlow HDL levels. The main sources of trans and satu-rated fatty acid were reported to be ghee and milk fat,whereas inadequate intake of fish and fruits and veg-etables accounted for deficiencies in n3 fatty acids andfibre, respectively. However, in the absence of reliablefood composition data and validated dietary assessmenttools such information may be incomplete. This popula-tion might benefit from a reduction in total and refinedcarbohydrate intake to guidance levels found to favourinsulin metabolism.

Compared to subjects living in their homeland, migrantSouth Asians have limited physical activity that mightpredispose them to T2D. Physical inactivity has beenattributed to religious believes, time constraints, illhealth, poor socio-economic status and lack of publichealth education. Culturally acceptable interventions areurgently needed to encourage a physically active lifestyle.

Table 5. Ideal indicators for the prevention of type 2diabetes in South Asians

Variable indicator Target for intervention

Waist circumference(males/females)

90 cm/80 cm

Blood pressure 130/80 mmHgLow-density lipoprotein

cholesterol2.5 mmol/L (97 mg/dL)

High-density lipoproteincholesterol

1.0 mmol/L (39 mg/dL)

Total cholesterol 4.5 mmol/L (174 mg/dL)Triglyceride 1.5 mmol/L (133 mg/dL)Fasting glucose (venous

plasma)7.0 mmol/L (126 mg/dL)

IDF [164].

While various genes have been linked to T2D, TCF7L2appears to be a strong predictor of T2D in variousethnic groups, including South Asians. Some geneticpolymorphisms have been found to have a positiveeffect on the prevention of T2D in certain populationgroups but these might not offer similar protection to allpopulations. For example, for peroxisome proliferator-activated receptor- 2 Pro 12Ala polymorphism, theprotection was only found to be present in Caucasiansbut not in South Asians. However, G53C single nucleotidepolymorphism appears to be protective against T2D,as well as against obesity, in Asian Indians. Furtherstudies are required to better understand the roleof genetic factors in a representative sample usingcasecontrol studies. Modifiable factors including diet,exercise and socio-economic indicators attributed tothe onset and prevalence of T2D in migrant SouthAsians need further investigation with representativesample size and reliable assessment methods. Such



studies will enable better understanding of the risk factorsfor T2D, which are necessary for developing effective andappropriate interventions. Sensitive, ethnic-specific andreliable anthropometric (BMI 23 and waist circumfer-ence


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