Is Hawaii really that healthy?
Let us not be too sanguine from the recent report that Hawaii is the healthiest state in the U.S. for the fourth straight year. There is more to the data than has been presented, in particular with regard to obesity and diabetes. Overall, Hawaii ranks second with respect to obesity with only Colorado being better (22.1 percent vs 21.3 percent). This sounds wonderful since obesity is linked to many diseases, perhaps foremost being type 2 diabetes, by far the most common of the various types of diabetes. With respect to diabetes, however, Hawaii ranks No. 24 at 9.8 percent vs. No. 2 Colorado at 7.3 percent. Is there a reason behind these discordant data, near the top in one but in the middle of the pack for the other? The answer lies in the racial/ethnic composition of our state.
Here are the data for obesity by race/ethnicity in Hawaii: Hawaiian/Pacific Islander 51.9 percent, Black 34.3 percent, Hispanic 32.3 percent, White 17.6 percent, and Asian 15.2 percent. For these same groups, the data regarding diabetes are 15.4 percent, 7.2 percent, 8.2 percent, 4.4 percent, and 12.8 percent, respectively. Asians have the lowest prevalence of obesity yet have higher prevalence of diabetes than blacks, whites and Hispanics with only Hawaiians/Pacific Islanders being higher. These data suggest that Asians are at risk for diabetes at a lower body weight than other racial/ethnic groups. The fact that Asians comprise more than 50 percent of the population in Hawaii, compared to 5.2 percent of the population in the U.S., provides a clue to the discordant obesity and diabetes data from Hawaii.
How is obesity defined? The standard definition is a body mass index or BMI of 30 or greater while overweight is a BMI between 25 and 30. For all racial/ethnic groups, including for Asians, there is a very good correlation between body weight and diabetes risk. However, if Asians have high rates of diabetes in spite of low rates of obesity, this means that the current weight standards for overweight and obesity may not be appropriate for Asians. Some have recommended that the values defining overweight and obesity should be lower in Asians, based upon data gathered worldwide although more work is needed to define the exact cut point values for Asians. If this is indeed the case, then the prevalence of obesity will be much higher in Hawaii than has been reported.
How is this relevant to screening for diabetes? Based upon the association between body weight and diabetes risk, the recommendation from the American Diabetes Association previously has been that a BMI of 25 or greater was a signal to health care providers to screen for diabetes. Because we felt that this BMI was probably too high for Asians, I was part of a work group that was formed to look at data collected from Asian Americans to find the appropriate BMI level at which they should be screened for diabetes.
Based upon data from community-based studies of Japanese, Filipino and South Asian populations without a prior diagnosis of diabetes residing in Chicago, Hawaii, San Diego, San Francisco and Seattle, we found that a BMI of 23 was a more appropriate level at which we should screen Asian Americans for previously undiagnosed diabetes. Based upon this, the American Diabetes Association in its most recent “Standards of Medical Care in Diabetes” now recommends that Asian Americans should be screened for diabetes if they have a BMI of 23 or greater while other racial/ethnic groups should be screened at BMI 25 or greater.
Is Hawaii the healthiest state in the U.S.? Perhaps it is but with respect to diabetes, a chronic disease that leads to many serious complications, and with respect to obesity, which has been based upon a BMI of 30 or greater for all racial/ethnic groups, we need to keep in mind that we have many cases of diabetes in Hawaii and that the data regarding obesity may be wrong. Hawaii has many individuals of Asian origin. An Asian individual with a BMI of 23 will appear to be of normal weight but may have diabetes. Health care providers must be vigilant about undiagnosed diabetes when they are faced with an Asian patient and remember that they should “Screen at 23.”
If you are Asian, please discuss this with your health care provider.
Wilfred Fujimoto is a physician residing in Kailua-Kona.
My Turn opinions are the views of the writer and not necessarily of West Hawaii Today.