Which racial or ethnic group is at risk for underdiagnosis of Diabetes Mellitus (DM) type 2 due to their Body Mass Index (BMI)?

Asian Americans Are at Risk for Underdiagnosis of Type 2 Diabetes Due to BMI Thresholds

Asian Americans are at significant risk for underdiagnosis of type 2 diabetes because standard BMI screening thresholds (≥25 kg/m²) miss approximately 36% of Asian Americans with diabetes, requiring a lower BMI cut point of ≥23 kg/m² for appropriate screening. 1, 2

The Core Problem: Standard BMI Thresholds Miss Asian American Cases

The American Diabetes Association guidelines explicitly state that Asian Americans develop diabetes at lower BMI levels than other populations, yet standard screening protocols using BMI ≥25 kg/m² fail to identify over one-third of Asian Americans with type 2 diabetes. 1

Key evidence demonstrates:

• At BMI ≥25 kg/m², sensitivity for detecting diabetes in Asian Americans is only 63.7%, missing 36% of cases 2
• At BMI ≥23 kg/m², sensitivity increases to 84.7%, missing only 15% of cases 2
• One-third to one-half of diabetes in Asian Americans remains undiagnosed, directly attributable to screening not occurring at lower BMI thresholds 1

Why Asian Americans Develop Diabetes at Lower BMI

Asian Americans have distinct metabolic characteristics that increase diabetes risk at lower body weights:

• Higher body fat percentage at equivalent BMI: Asian Americans have greater amounts of body fat and visceral adiposity compared to other populations at the same BMI 1, 3
• Earlier beta-cell dysfunction: Diabetes develops at younger ages with early beta-cell dysfunction in the setting of insulin resistance 3
• Increased visceral adiposity: Fat distribution is predominantly abdominal, increasing metabolic risk even at lower total body weight 3, 4

The Recommended BMI Threshold for Asian Americans

The American Diabetes Association recommends using BMI ≥23 kg/m² as the screening threshold for Asian Americans, which is approximately 15 pounds lower than the general population threshold. 1

This recommendation is consistent across multiple guideline years:

• The 2020,2021,2022,2023, and 2024 ADA Standards of Care all specify BMI ≥23 kg/m² for Asian Americans 1
• The WHO also supports BMI ≥23 kg/m² to define increased risk in Asian Americans 1
• This threshold achieves 80% sensitivity across nearly all Asian American subgroups 1

Which Asian American Subgroups Are Affected

All major Asian American subgroups are at risk for underdiagnosis:

• Chinese and Korean Americans 2, 5
• Japanese Americans (with slightly lower optimal thresholds) 1, 2
• Filipino Americans 2, 5
• South Asian Americans (Indian, Pakistani, Bangladeshi) 2
• Native Hawaiians and Pacific Islanders 1, 5
• Southeast Asian Americans (including Malay) 4

Research demonstrates that despite lower BMI, Asian Americans have 1.9 to 2.6 times higher diabetes risk compared to whites, with this excess risk persisting even after adjusting for lifestyle factors. 5

Other Racial/Ethnic Groups With Lower BMI Thresholds

While Asian Americans are the primary group requiring lower BMI thresholds, evidence suggests African Americans may also benefit from adjusted screening criteria:

• A BMI of 30 kg/m² in non-Hispanic whites is equivalent to a BMI of 26 kg/m² in African Americans for equivalent diabetes incidence 1
• However, current guidelines have not formally adopted lower BMI thresholds for African Americans as they have for Asian Americans 1

Clinical Implications to Prevent Underdiagnosis

To avoid missing diabetes cases in Asian Americans:

1. Screen at BMI ≥23 kg/m² (not ≥25 kg/m²) for all Asian American patients 1

2. Begin screening at age 35 years or earlier if overweight/obese by Asian-specific criteria 1

3. Consider screening at even lower BMI if additional risk factors are present (family history, gestational diabetes, hypertension, physical inactivity) 1

4. Recognize that "normal weight" Asian Americans may still be at high risk: BMIs in the 18.5-23.0 kg/m² range show significantly increased diabetes risk in Asian populations 6

5. Repeat screening every 3 years minimum, with more frequent intervals for high-risk individuals 1

Common Pitfalls to Avoid

• Do not apply standard BMI thresholds to Asian American patients - this is the primary cause of underdiagnosis 1, 2
• Do not assume lean Asian Americans are low-risk - diabetes risk is elevated even at BMIs considered "normal" 3, 6
• Do not delay screening until age 45 - Asian Americans may develop diabetes at younger ages 1, 3
• Do not rely solely on BMI - consider waist circumference and visceral adiposity patterns 3, 4