When Veronica Chan learned she would have to lose weight to manage her diabetes, her immediate reaction was one of dismay.
She was proud of her soft hips, full cheeks and round belly. It was a weight she maintained deliberately in accordance with Chinese beliefs — that obesity is a positive sign of affluence and good health.
“I didn’t want to lose weight,” Chan, 65, said in her Scarborough home. “I liked being fat.”
Chan uses the word “fat” to describe herself when she was 15 pounds heavier.
A quick look at her tiny frame today suggests this is an overstatement.
Or is it?
Despite their lower body weight, Asians are more likely to develop Type 2 diabetes than Caucasians. Rates of diabetes are skyrocketing among Asians in North America and East Asia.
Experts describe diabetes as a runaway disease of epidemic proportions.
At 43 million people with the disease, China is second only to India in the number of people living with diabetes, according to the International Diabetes Federation. Although Canada doesn’t keep statistics on diabetes rates among ethnic groups, U.S. data says Asian Americans are twice as likely to develop diabetes as Caucasians.
Complications arising from Type 2 diabetes also differ among ethnic groups. The rate of kidney failure is elevated among diabetic Asians compared to Caucasians, as are incidents of stroke.
Although Type 2 is commonly associated with obesity, this is misleading in Asian populations.
“Body types of Asians are different from other ethnic groups,” says Dr. William Hsu, co-director of the Asian American Diabetes Initiative, at the Joslin Diabetes Centre, a teaching affiliate of Harvard Medical School.
“Almost every other ethnic group develops diabetes at a higher body weight, but it’s the way we accumulate fat, in our belly. I always joke that we hide our fat well.”
Carrying extra weight around the midsection —known as visceral or abdominal fat — has been shown to significantly increase both the chances of developing diabetes and the risk of high blood pressure.
Although a BMI (body mass index) of 25 is considered overweight for Caucasians, some experts have suggested the cut off for Asians should be 23.
BMI is based on a person’s height-to-weight ratio. That means an Asian man standing 5-feet, 10 inches and weighing more than 160 pounds would be considered overweight, while an Asian woman standing 5 feet, 6 inches should try to keep her weight below 143 pounds.
Hsu cautions that BMI can be an inaccurate predictor of diabetes for Asians, as most of the body fat is deposited around the belly.
Another way to gauge risk of diabetes is to measure the circumference of the waist. A girth of more than 97 cm for men or 80 cm for women increases the chance of developing Type 2 diabetes.
It’s because of the link between weight and diabetes that the Chinese call it a “rich person’s disease,” says Ivy Yeung, chair of the Canadian Diabetes Association’s Toronto Chinese chapter. “The Chinese believe diabetes is caused by eating too well.”
Most Asian diets are based on rice and are heavy on starchy staples such as noodles, which rank high on the glycemic index and can cause blood-glucose levels to soar.
The Chinese diet is full of starchy sauces, processed flour and is low in fibre, Yeung says, and deep-frying is a common cooking method.
“We don’t eat raw salads, either, which is good for digestion,” she adds. “We like to cook vegetables until they’re almost dead.”
Researchers at the Joslin Centre believe Asians have a smaller insulin secretory capacity, or a smaller pool for making insulin, Hsu said.
“And now, with more environmental pressures, the body just can’t keep up.”
The pattern of food consumption has changed drastically in Asian countries. What were developing countries just a few decades ago have morphed into wealthier, industrialized nations. People are consuming more calories than ever before, in the form of fats, and more animal protein.
Asians living in North America are eating more calorie-rich, processed Western foods, which their bodies aren’t genetically programmed for, adds Dr. Jason Kwok.
“The Asian diet contains more rice, fish and vegetables,” explains the Scarborough doctor. “But in the Western diet, there’s less vegetables and more meat.”
Not only is food a central part of Asian culture, certain foods are considered to be medicinal. Bitter melon, a long, green, warty vegetable, for instance, is commonly used among Chinese diabetics for its ability to lower blood sugar levels. But widespread misconceptions have led to an over-reliance on bitter melons as an antidote and they are taken inappropriately.
Registered nurse Esther Cheung recalls an incident when a diabetic patient panicked at his soaring blood sugar levels and consumed three whole bitter melons on the advice of friends. In the middle of the night, he was taken to the emergency room suffering from hypoglycemia — dangerously low blood glucose levels. Bitter melon may lower blood glucose levels temporarily but should not be used as a substitute for medication, Cheung says.
“Word of mouth in the Chinese community is very powerful,” notes the certified diabetes educator.
She adds Asians also tend to be sedentary, especially new immigrants, and Canadian winters often overrule the desire to exercise.
There are hosts of other diabetes-related myths doctors have to demystify to patients who believe strongly in unscientific, sometimes folkloric, medicine. And for many, the prescription can be a tough pill to swallow.
For many Asians, diabetes and other health afflictions signify a major imbalance of forces in the body, which can be restored with ancient Chinese herbs.
“Because Chinese herbs don’t come with long lists of side effects, people have this concept that Chinese herbs only do good,” Kwok says.
Nor do they disclose that they’re taking supplemental herbs to their family doctor, a combination that can increase the potency of the drugs and skew prescribed dosages, Cheung adds.
Another misconception about diabetes can be traced back to the Chinese translation of the word for the disease, which means sweet urine, Chan says.
Many believe diabetes is caused by consuming too much sugar or sweets, which is then passed into the urine — a belief Chan held as well.
The notion of piercing the body with insulin injections also strikes fear among many Chinese. Chan, for instance, refused to take insulin, afraid she would insert it incorrectly. But her resistance also came from a deeply ingrained, cultural belief in the body as a reincarnated vessel.
“We don’t like to hurt our bodies; it’s in our culture,” she says, who takes oral pills instead. “The body comes from our parents, so we don’t want to destroy it.”
Many Asians mistakenly believe that insulin injections are only for those in the advanced stages of the disease, and delay treatment, Kwok adds.
Such a visible display of ill health is like a badge of dishonour, Hsu says, since having a chronic, incurable disease is seen as an embarrassment among many Asian cultures.
Unlike the Western world, which creates heroes out of cancer survivors and organizes walk-a-thons to raise awareness for diseases, Asians can tend to hide their afflictions.
It’s a secrecy that comes from a “different world view,” Hsu explains.
“The Eastern understanding is that there’s a hidden retribution from your last life. If your body is a reflection of the sins of your past, why would you want to wear a pump?”
Chan, the Chinese chapter’s vice-chair, also says she’s met many people who’ve expressed shame at having the disease, or cloak their questions by asking on behalf of a “friend.”
She’s has been helping people get over their reservations and back to good health.
“If I knew obesity caused diabetes, I would have taken care of myself more,” she says.
Tips for prevention
Registered nurse and Certified Diabetes Educator Esther Cheung offers some tips on how to manage diabetes and prevent early onset:
Also, Joslin's Asian American Diabetes Initiative site (an affiliate of Harvard University) has a fun, interactive game, The Joslin Wok where cooks can put an ingredient into the virtual wok and see the nutritional content of each item, so they cook healthy meals.
Check out the sizzling sounds!