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- My name is Dr. Latha Palaniappan.
Today, we're going to be talking about health risks
and prevention strategies for Asians.
We're going to be talking about the newly established
Stanford Center for Asian Health Research and Education,
how decisions around Asian health are mainly made
using non-Asian data.
We'll talk about the role of diversity
and the case for disaggregation of Asian subgroups.
I'm going to present to you new findings
on COVID-19 discrimination in Asian subgroups
and upcoming publications
in the areas of Asian health at Stanford,
and also new resources
from the Center for Asian Health Research and Education,
otherwise known as CARE,
resources and events that you might be interested in.
First, we're going to talk about why it's important
to study diverse populations.
Studying diverse populations
helps us understand disease pathophysiology
and discover new treatments.
There are examples across the world in biomarker prevalence
and differences in drug safety and efficacy,
which enables us to make new scientific discoveries.
There are examples across the world in breast cancer,
lung cancer, asthma, and seizure disorders
in very diverse populations
ranging from Latina, European ancestry,
African American ancestry, as well as East Asians.
Asians make up 60% of the world's population,
6% of the US population, and 30% of the Bay Area population,
which is why it's uniquely Stanford
to be able to study this diverse population
and do work here at Stanford
that will impact most of the world.
Less than 1% of NIH funding
goes to Asian American health research
despite the fact that they make up 60%
of the world's population
and 30% of the Bay Area population.
Similarly, Asians are underrepresented
in clinical trials for drug discovery.
Asians make up 12% of those in drug trials
and 60% of the world's population.
So they are very underrepresented in drug trials.
Decisions around Asian health are made
mainly using non-Asian data.
That's why in 2018,
we established the Center for Asian Health
Research and Education at Stanford.
Our vision is to become the premier academic leader
in precision Asian health.
Our goals are to increase research and knowledge
in Asian and Asian-American health,
to improve the delivery of healthcare
for Asians and Asian Americans,
and to educate patients, providers and the community
about the health needs of Asians and Asian Americans.
So at Stanford, we've studied national datasets
with regard to Asian health,
including the National Health
and Nutrition Examination Survey
and the National Health Interview Survey.
And we've studied a wide variety of diseases
including mental health, cigarette smoking,
complimentary alternative therapy, pre-diabetes, diabetes.
We've also had the opportunity to study Asian subgroups
using de-identified electronic health records at Stanford,
and we've studied a wide variety of diseases
including cardiovascular disease, type two diabetes,
outcomes after stents, machine learning,
postpartum depression, and patient satisfaction scores.
We have also gained important insights at Stanford
into Asian health
by looking at death records or mortality records.
We have been able to look at geographic differences
in cardiovascular disease mortality,
examine immigrant health looking at countries of origin
and immigrants in the United States.
We've looked at gastric cancer,
the transition from cardiovascular disease to cancer,
and breast cancer trends among Asian American women.
So at Stanford, we've studied diversity
using many examples of real world data,
including national datasets, electronic health records,
and mortality records.
Using all of these methods,
we've been able to uncover consistent signals on health
in Asian-Americans
and we're moving towards solutions
with culturally competent intervention studies
in diet and exercise and drugs for specific Asian subgroups.
We've done important work in pharmacogenetic differences.
uncovering prescribing differences
necessary for Asian-Americans
in cardiology drugs, cancer drugs,
and infectious disease and rheumatology drugs.
Now let's look at social determinants of health
among Asian immigrants.
Immigrants accounted for 81%
of the growth of the Asian adult population
from 1970 to 2016,
while the foreign born share increased among Asians
from 45% to 78%,
and this is mainly due to H1B visas during this time.
Asians are often considered a model minority
but this is really a myth.
When we look at all Asians,
the percent living in poverty is 12%,
similar to non-Hispanic whites.
But when we disaggregate the Asian subgroups,
important patterns emerge,
with Cambodian and Thai populations
having much higher rates of poverty,
similar to Blacks and Hispanics in the United States.
So it's important as we study Asian subgroups,
to remember that there are vast socioeconomic differences
among the groups.
Similarly, when looking at college graduation,
Asians appear to have a higher proportion
of college graduates than non-Hispanic whites.
However, when you disaggregate the Asian subgroups,
you see that some groups,
including Vietnamese and Cambodians,
have much lower rates of college graduation.
So this is important to include
as we move forward in our studies
of Asian-Americans in the United States.
Over 2006 to 2018,
on the left graph, you see when Asians are aggregated,
it looks like they have lower rates of high blood pressure
compared to non Hispanic whites.
On the graph on the right,
you can see when we disaggregate the Asian subgroups,
there are some groups
that we have to be particularly concerned about
with their risk for high blood pressure;
and in this case, it is the Filipino group.
Similarly, for diabetes from 2006 to 2018,
on the left, when we look at Asians aggregated,
it doesn't look like there's any difference in diabetes
compared to non-Hispanic whites.
However, when we disaggregate the groups,
we see high risk groups again,
notably Filipinos in this case.
One thing that we have to be particularly concerned about
is the risk of diabetes
at even lower levels of body weight among Asian subgroups.
So for body mass index of 18 to 23,
which is considered normal for Asians,
Asian Indians and Filipinos at the same level of body weight
have higher risk of diabetes.
Also at a BMI of 23 to 25,
and even in the overweight category at a BMI of 25 to 30,
Asian Indians and Filipinos at every level of weight
have higher risk of diabetes
compared to Chinese and non-Hispanic whites.
Looking at electronic health records,
we've seen differences in coronary artery disease
in the Asian subgroups.
With the reference group being non-Hispanic whites,
when we group all Asians together,
it doesn't look like there's any difference
in coronary disease for men and women.
However, when we disaggregate the Asian subgroups,
as we see on the right-hand side,
Asian Indians have higher risk and Chinese have lower risk.
And the other Asian subgroups,
we don't even have enough sample size
to see statistically significant differences;
and this is where further studies need to be done
with disaggregating Asian subgroups
and increasing sample sizes for the smaller Asian subgroups
so we can detect the signals.
So let's look at a disease where studying Asian Americans
can help us understand about the pathophysiology of disease.
Let's take this as an example, peripheral vascular disease,
which is clots in the arteries of the legs.
When we compared to non-Hispanic whites,
when we group all Asians together for both men and women,
there are lower rates of peripheral vascular disease.
And when we disaggregate the Asian subgroups,
we see that for all Asian subgroups,
they have lower risk of peripheral vascular disease.
Studying agent subgroups may help us understand
the pathophysiology of peripheral vascular disease,
so we can find new treatments
for this disease for all populations.
Now let's look at some risk factors
that lead to some of the major causes of mortality.
So here we have smoking rates
for non-Hispanic white men and women on the left,
and then Asian Indian, Chinese, and Filipino.
And we can see in the Asian subgroups,
that there's quite a gender difference in smoking rates.
And similarly,
you can see when we disaggregate the Asian subgroups,
that some Asian subgroups have much higher rates,
Filipino Americans, for instance,
that have decreased significantly over time,
and other groups, Chinese,
we haven't seen the same decrease,
leading to the idea that it might be good
to have targeted public health campaigns
for these Asian subgroups
to make sure that we lower risk factors appropriately
across all groups.
Now let's look at leading causes of death
in these six major Asian subgroups that are disaggregated
on death records.
For most Asian subgroups,
cancer is the leading cause of death.
However, you can see for some groups,
both for men on the top and women on the bottom,
heart disease is the major cause of death;
and this varies widely across the groups.
Let's take the example of an Asian Indian male.
One out of three Asian Indian males die of heart disease
and only one out of five die of cancer.
This is exactly opposite for the Korean male.
Only one out of five die of heart disease
and one out of three die of cancer.
And importantly, lung cancer is an important cause of death
for Korean American men;
and this may be related to some of the risk factors
that we observe in this group,
including high rates of smoking.
Now let's look at pharmacogenetic differences.
So warfarin is a drug that we commonly use to thin the blood
and prevent clotting.
And there's differences in the cytochrome P450 system
in the liver in the CYP2C9 enzyme
that recommend decreased dosing
for Chinese, Japanese, and Korean Americans.
However, differences in VCORC-1 recommend increased dosing
for Blacks African-Americans and Asian Indians.
So we can see that there's quite a divergence
in terms of dosing among Asian subgroups.
And we need to understand these pharmacogenetic differences
so we can do precision prescribing for all groups.
So one of the things that we're doing
with the Center for Asian Health Research and Education
is starting a journal,
so we can aggregate all of this important health information
in Asian Americans.
One of the first studies that we've done is a survey
on self-reported bias during COVID-19 in Asian subgroups.
And you can see Chinese, Korean, Japanese,
and Vietnamese populations
are experiencing much more discrimination during COVID;
and this is unfortunately during this time
higher than the rates of discrimination
than has been reported by Blacks
and Hispanics in the same time period.
We are also creating a dashboard on Asian health
to aggregate all of the data on Asian health
to increase opportunities for potential linkage,
recruitment, and longterm followup
for transdisciplinary research across many health outcomes.
Upcoming programs that we have
within the Center for Asian Health Research and Education
focus on research, community interaction, and education.
We have a monthly community health talk series
in partnership with the health library
and we've done many conferences
on topics of interest in Asian health,
including gastric cancer,
evidence-based traditional Asian medicine,
and COVID-19 conference both in 2020,
and a lessons learned planned in 2021.
So in summary, Asians are diverse.
There are clinically significant differences
that we need to be aware of as physicians
as well as patients,
and better data collection is needed,
so we can understand more
about the diverse populations that we serve
so we can provide precision health to everyone.
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