1 in 17 are Asian 1 in 7 are Asian 5.8% 15% Japanese Korean - PDF document

10/10/2017 58‐YEAR‐OLD ASIAN MALE WITH SHORTNESS OF BREATH Asian American Health – Learning from Diversity • “Asian” = ? • What is in your differential? Latha Palaniappan, MD, MS • Disease pattern differences? • Sociodemographic differences? • Treatment differences? • Patient satisfaction differences? Asian Population by County 50 100 500 1,000 5,000 10,000 50,000 100,000 500,000+ United States Asian Indian Chinese Filipino 1 in 17 are Asian 1 in 7 are Asian 5.8% 15% Japanese Korean Vietnamese 1

10/10/2017 Contra Costa San Joaquin 37% San Francisco 3.6 billion 30% San Mateo Alameda Stanislaus 1 in 3 are Asian 1 in 2 are Asian = 51% 29% Santa Clara 36% Asian Population by County Santa Cruz 50 100 500 1,000 5,000 10,000 50,000 100,000 500,000+ Population % Growth, 2000 – 2010: 43.3% 9.7% U.S. Census Bureau, The 2010 Census Questionnaire: Informational Copy , accessed online at http://2010.census.gov/2010census/pdf/2010_Questionnaire_Info_Copy.pdf, 9/7/15. 2

10/10/2017 Meet the New Immigrants: Asians overtake Hispanics 59% 55 53 46 42 Hispanic population 36% Asian rise 33 29 31% 23 23 19% SOURCES: 2010 American Community Survey and other Census Bureau data; Pew Research Center 2012 Asian‐American Survey; U.S. State Department Korean Immigration Patterns 1980 1990 2000 Sources: Social Explorer, www.socialexplorer.com; Minnesota Population Center; U.S. Census Bureau Matthew Bloch and Robert Gebeloff/The New York Times 3

10/10/2017 Asian Indian Immigration Patterns 1970 1990 2000 1980 Model Minority? Sources: Social Explorer, www.socialexplorer.com; Minnesota Population Center; U.S. Census Bureau. Matthew Bloch and Robert Gebeloff/The New York Times/ Income differences: % with income >200% of FPL % with bachelor’s and higher: Asian Indian Chinese Filipino Japanese Korean Vietnamese 70% 50% 77% 79% 79% NHW: 76% 29% 29% 69% 66% 57% 26% 14% Hmong Non‐Hispanic White Indian Asians (all) Vietnamese Cambodian SOURCES: 2012 American Community Survey http://factfinder.census.gov SOURCES: 2012 American Community Survey http://factfinder.census.gov. https://www.census.gov/prod/2012pubs/acsbr10‐19.pdf 4

10/10/2017 PAMF Racial/ethnic patient composition Coronary Artery Disease, Aggregated Asians: 24 medical centers; 900+ physicians; 933,104 active patients [OR] 1.02 0.92 3% Other Asian Hispanic Left Blank/ 1% Vietnamese 6% NHW 1% 8% Declined Korean Other 1% 11% Self‐pay Japanese 11% Men Women 9% 2% Filipino Medicare /cal 18% 66% Asian 7% Chinese HMO 25% PPO White 45% Black 10% Asian Indian Age‐adjusted 2% Holland AT, Wong EC, Lauderdale DS, Palaniappan LP . Spectrum of cardiovascular diseases in Asian American racial/ethnic subgroups. Annals of Epidemiology. 2011;21(8):608‐14. PMID: 21737048. NIH/NIDDK 5R01DK081371 Coronary Artery Disease, Disaggregated Asians: Coronary Artery Disease, Disaggregated Asians: OR: M W 1.02 0.92 1.77 1.26 0.78 0.72 0.72 0.76 0.69 0.34 1.12 1.78 1.47 1.66 NHW NHW All Asian Asian Indian Chinese Filipino Japanese Korean Vietnamese All Asian Asian Indian Chinese Filipino Japanese Korean Vietnamese Holland AT, Wong EC, Lauderdale DS, Palaniappan LP . Spectrum of cardiovascular diseases in Asian American racial/ethnic subgroups. Annals of Holland AT, Wong EC, Lauderdale DS, Palaniappan LP . Spectrum of cardiovascular diseases in Asian American racial/ethnic subgroups. Annals of Epidemiology. 2011;21(8):608‐14. PMID: 21737048. NIH/NIDDK 5R01DK081371 Epidemiology. 2011;21(8):608‐14. PMID: 21737048. NIH/NIDDK 5R01DK081371 5

10/10/2017 Diabetes, Disaggregated Asians: Diabetes, Aggregated Asians: [OR] 2.01 1.9 NHW OR: M W Men Women 2.01 1.9 3.54 3.44 1.24 1.27 1.48 1.56 2.19 1.11 1.14 1.14 4.56 3.94 NHW All Asian Asian Indian Chinese Filipino Japanese Korean Vietnamese Wang, E. J., Wong, E. C., Dixit, A. A., Fortmann, S. P., Linde, R. B., & Palaniappan , L. P. (2011). Type 2 diabetes: identifying high risk Asian Wang, E. J., Wong, E. C., Dixit, A. A., Fortmann, S. P., Linde, R. B., & Palaniappan , L. P. (2011). Type 2 diabetes: identifying high risk Asian American subgroups in a clinical population. Diabetes research and clinical practice , 93 (2), 248‐254. NIH/NIDDK 5R01DK081371 American subgroups in a clinical population. Diabetes research and clinical practice , 93 (2), 248‐254. NIH/NIDDK 5R01DK081371 Peripheral Vascular Disease, Aggregated Asians: Peripheral Vascular Disease: [OR] 0.45 0.35 NHW OR: M W Men Women 0.5 0.76 0.56 0.33 0.34 0.96 0.27 0.33 0.24 0.18 0.40 0.11 0.31 NHW Asian Indian Chinese Filipino Japanese Korean Vietnamese Holland AT, Wong EC, Lauderdale DS, Palaniappan LP . Spectrum of cardiovascular diseases in Asian American Holland AT, Wong EC, Lauderdale DS, Palaniappan LP . Spectrum of cardiovascular diseases in Asian American racial/ethnic subgroups. Annals of racial/ethnic subgroups. Annals of Epidemiology. 2011;21(8):608‐14. PMID: 21737048. NIH/NIDDK Epidemiology. 2011;21(8):608‐14. PMID: 21737048. NIH/NIDDK 5R01DK081371 5R01DK081371 6

10/10/2017 JA: Risk Factor: 37% JA: Risk Factor: Smoking VI: KO: 47% Hypertension KO: 37% 43% AI: FI: 31% AI: 53% 38% VI: 43% 32% CH: FI: 36% 60% 40% 37% CH: 33% 30% 50% 25% 40% 60% 26% 19% 20% 30% 70% 17% NHW HTN(%) 14% Men: 10% 20% 80% 8% 3% NHW 5% 46% 4% Women: 10% 90% 39% M W mm Hg Korean Vietnamese Non-Hispanic Asian Indian Chinese Filipino Japanese 0% 100% White Zhao, B., Jose, P. O., Pu, J., Chung, S., Ancheta, I. B., Fortmann, S. P., & Palaniappan , L. P. (2015). Racial/ethnic differences in Hypertension prevalence, treatment, and control for outpatients in c c Northern California 2010–2012. American Journal of Hypertension , 28 (5), 631‐639. NIH/NIDDK 5R01DK081371 Caraballo RS, Yee SL, Gfroerer J, Mirza SA. (2008). Adult tobacco use among racial and ethnic groups living in the United States, 2002–2005. Prev Chronic Dis 5(3). High LDL‐C Prevalence (OR) 1.31 1.16 1.66 1.71 1.25 1.31 1.68 0.87 0.94 0.82 1.15 1.84 NHW Asian Indian Filipino Japanese Korean Vietnamese Chinese Adjusted for: Age, BMI, Primary Insurance, and Smoking Status Frank, A. T., Zhao, B., Jose, P. O., Azar, K. M., Fortmann, S. P., & Palaniappan, L. P. (2013). Racial/ethnic differences in dyslipidemia patterns. Circulation , CIRCULATIONAHA‐113. NIH/NIDDK 5R01DK081371 7

10/10/2017 Leading Causes of Death Not for Asians Asian Indian Chinese Filipino Japanese Korean Vietnamese Heart disease Cancer Heart Heart Heart M Cancer Cancer Cancer Disease Disease Disease M Cancer Heart disease Heart W Cancer Cancer Cancer Cancer Cancer 31% Disease 18% 19% 34% Lung 23% Hastings, K. G., Jose, P. O., Kapphahn, K. I., Frank, A. T., Goldstein, B. A., Thompson, C. A., Eggleston, K., Cullen, M.R., & Palaniappan, L. P. (2015). Leading Causes of Death among Asian American Subgroups (2003–2011). NIH/NIMHD 7R01MD007012‐04 Pharmacological Reviews June 2011 vol. 63 no. 2 437-459 dosing for Chinese, Japanese, and Korean dosing for Blacks/African Americans and Asian Indians 8

10/10/2017 CYP2C19: Loss of function (LOF) Gain of function (GOF) CYP2C19*3 CYP2C19*17 Increased risk of thrombosis Increased Risk of Bleeding Japanese Korean Chinese Asian Indian 24% 15% 9% 28% Agewall, Stefan, et al. "Expert position paper on the use of proton pump inhibitors in patients with cardiovascular disease and antithrombotic therapy." European heart journal 34.23 (2013): 1708‐1713. Hawaii Attorney General Sues Plavix manufacturers for $10,000,000+ Warfarin • 38‐79% of Pacific Islanders and 40‐50% of East Asians are poor metabolizers of Plavix (variations in the CYP2C19 gene) Plavix • Hawaii’s demographics: 48% Asian/Pacific Islander Simvastatin Source U.S. Census Bureau: State and County QuickFacts. 9

10/10/2017 Patient Satisfaction: Summary "Very Good" on "Overall Recommendation" question 100% Asians are diverse 90% Mean 80% 70% 60% Clinically significant Better data 81% 64% 66% 74% differences collection needed! 50% NHW Asian Indian Chinese Other Asian Acknowledgments Maria R. Araneta Elizabeth Barrett‐ Stanley Heshka Connor Steven Heymsfield Susan Ivey Michael Criqui Anjali Dixit Amlu Natesan Andrea Kwan Hamang Patel Venkat Narayan Arnab Mukherjea Ranjit Mohan Anjana Thomas Pearson Reena Oza‐Frank Fahim Abbasi Cindy Lamendola Shankuan Zhu Kamala Krishnaswamy Peter Wilson Themistocles Assimes Tracy McLaughlin Nagappa Malleshi Dipanjan Banerjee Gerald Reaven Viswanathan Mohan Vivek Bhalla Fatima Rodriguez Dr. Latha Palaniappan: lathap@stanford.edu Nilay Shah Shanmugam Shobana Christopher Gardner Abby King Randall Stafford Vasudevan Sudha Elsie Wang Gordon Fung Mona Pandey Mercedes Carnethon Catherine Crespi Christopher Koenig Namratha Kandula Larissa Aviles‐Santa Annette Maxwell Regina Otero‐ Sabogal Leonard Lesser Jia Pu Randolph Linde Laurel Trujillo Monique‐Nicole Anthony Cetin Ozturk Hal Luft Eric Wong Donald Glacherio Michael Elliott Beinan Zhao Anthony Killeen Amy Muzaffar Wan‐Li Wei Kristen Azar Stephen Fortmann Diane Lauderdale Melvyn Rubenfire Jose Powell Lisa Diamond Sukyung Chung Francesca Gany Lora Burke Treveor Orchard 10