Introduction
Type 2 diabetes and cardiovascular disease are major health challenges for South Asian populations. South Asians have a particularly high burden of these conditions, which may also occur at younger ages than in many other populations. (1,2)
South Asian populations have an increased risk of insulin resistance, type 2 diabetes, metabolic syndrome, and cardiovascular disease at comparatively lower BMI levels than White populations. (3)
In recent years, glucagon-like peptide-1 receptor agonists, commonly known as GLP-1 receptor agonists or GLP-1 RAs, have become important treatment options for type 2 diabetes. Depending on the specific medication and the individual patient, these therapies can improve blood glucose control, support weight management, and, for medications with demonstrated benefits in specific populations, reduce cardiovascular and/or kidney-related risks. (4)
Improving awareness of these medications can help patients understand their available treatment options so that they can make informed decisions with healthcare professionals.
Why Are South Asians at Greater Risk?
South Asians have a distinct cardiometabolic risk profile. Body weight alone does not provide a complete picture of metabolic health because abdominal fat distribution, insulin resistance, blood glucose, blood pressure, lipid levels, family history, and other factors also influence risk.
Migration and changes in lifestyle and nutrition have been associated with increasing adiposity and type 2 diabetes risk among South Asian populations. (5) Physical inactivity, urbanization, dietary transitions, and genetic susceptibility may all contribute to this burden. (3,5)
Research examining South Asian dietary patterns has also identified, in some populations, relatively high intake of refined carbohydrates, saturated fats, and trans fats together with relatively low intake of fiber and beneficial unsaturated fats. (6)
Because diabetes risk can occur at lower BMI levels in Asian populations, the American Diabetes Association (ADA) uses a lower BMI threshold when considering diabetes screening in Asian American adults: BMI ≥23 kg/m² rather than ≥25 kg/m², together with relevant risk factors. (4)
What Are GLP-1 Receptor Agonists?
GLP-1 is a naturally occurring hormone involved in the body's response to food. GLP-1 receptor agonists activate the GLP-1 receptor and influence several processes involved in blood glucose regulation, appetite, and digestion.
These medications can:
- increase insulin secretion when blood glucose levels are elevated;
- reduce glucagon secretion;
- slow gastric emptying;
- increase feelings of fullness;
- reduce food intake;
- lower HbA1c; and
- support weight reduction.
For appropriate patients, certain GLP-1 receptor agonists also provide cardiovascular benefits, and current ADA guidance recognizes these medications as important options for people with type 2 diabetes who have established cardiovascular disease or elevated cardiovascular risk. (4)
Although GLP-1-based medications have received widespread attention because of their effects on body weight, their role in diabetes care is broader and may include glycemic control, weight management, and reduction of cardiovascular risk.
Metformin and GLP-1 Medications: Understanding the Difference
Metformin has been widely used for decades in the treatment of type 2 diabetes. It primarily decreases glucose production by the liver and improves insulin sensitivity. It remains a commonly used therapy because of its established effectiveness, extensive clinical experience, and relatively low cost.
However, modern diabetes treatment does not necessarily follow a rigid sequence in which every patient must first use metformin before another medication can be considered.
Current ADA guidance emphasizes individualized treatment. Medication selection should consider cardiovascular disease, chronic kidney disease, heart failure, weight-management goals, degree of glucose lowering required, risk of hypoglycemia, tolerability, treatment burden, cost, access, and patient preferences. (4)
For some people, metformin may be an appropriate initial therapy. For others, medications with demonstrated cardiovascular or kidney benefits, including appropriate GLP-1 RAs or SGLT2 inhibitors, may be prioritized based on the person's clinical circumstances. (4)
The Hidden Challenge: Unequal Use of GLP-1 Therapy
Despite the growing role of GLP-1 receptor agonists in diabetes care in the U.S, there have been differences in their use across racial, ethnic, and socioeconomic groups.
A large U.S. cohort study involving more than 1.18 million patients with diabetes found lower GLP-1 RA use among Asian, Black, and Hispanic patients compared with White patients. (7) Asian patients had the lowest GLP-1 RA use among the racial and ethnic groups examined. After adjustment for multiple clinical and socioeconomic factors, Asian patients had an adjusted odds ratio of 0.59 compared with White patients, corresponding to approximately 41% lower adjusted odds of GLP-1 RA use. (7) Importantly, the study classified participants broadly as Asian and did not report South Asian individuals as a separate subgroup. The study also found that higher household income was associated with greater GLP-1 RA use. Possible contributors to treatment inequities include medication costs, healthcare access, and patient-provider interactions. These factors should be considered possible explanations rather than proven causes. (7)
Why Awareness Matters
Several messages are particularly important for South Asian communities, including the Sikh community:
- Type 2 diabetes can occur at comparatively low BMI levels.
- BMI alone does not capture all cardiometabolic risk.
- Abdominal adiposity, blood glucose, blood pressure, lipid levels, and family history are also important.
- Risk-based screening can help identify prediabetes and diabetes earlier.
- Some GLP-1 receptor agonists provide benefits beyond lowering blood glucose.
- Diabetes treatment should be individualized.
Awareness can encourage patients to ask informed questions about diabetes screening, cardiovascular risk, weight management, and available treatment options. The goal of community education should help people understand that options exist and that treatment choices should be made through informed discussion with healthcare professionals.
Beyond Medication
Medication is only one component of diabetes prevention and management. Healthy eating patterns, regular physical activity, adequate sleep, avoidance of tobacco, weight management, and routine preventive healthcare remain important components of diabetes care. The ADA continues to emphasize lifestyle and behavioral strategies as part of comprehensive diabetes prevention and management. (4)
Practical approaches may include increasing vegetables, legumes, and dietary fiber; choosing less-refined carbohydrate sources; reducing excess added sugars; and paying attention to portion sizes and the quality and quantity of dietary fats. (6)
Lifestyle recommendations should also be realistic and sustainable. Diabetes develops through a complex interaction of genetic, biological, behavioral, environmental, and socioeconomic factors, so healthy lifestyle practices can be an important part of reducing risk.
The Role of Community Education
Improving diabetes outcomes requires understandable health information, preventive care, trust, and equitable access to healthcare. Community-based education can help make scientific information more accessible. Programs delivered in familiar community settings and adapted to the language and cultural context of the intended audience may help people better understand risk factors, screening, and treatment options.
Organizations such as Sikhs in Clinical Research (SICR) can contribute through culturally relevant health education, preventive health awareness, and information about available treatment options.
Looking Ahead
South Asian populations face substantial cardiometabolic risk, including an elevated burden of type 2 diabetes and cardiovascular disease. Continued attention to prevention, appropriate screening, and evidence-based treatment is therefore important.
Improving diabetes outcomes will require collaboration among patients, healthcare professionals, researchers, and community organizations. Accurate information, appropriate screening, and informed conversations about treatment options can help individuals make decisions that support long-term health.
References
- Volgman AS, Palaniappan LS, Aggarwal NT, Gupta M, Khandelwal A, Krishnan AV, et al. Atherosclerotic cardiovascular disease in South Asians in the United States: Epidemiology, risk factors, and treatments. Circulation. 2018;138(1).
- Gholap N, Davies M, Patel K, Sattar N, Khunti K. Type 2 diabetes and cardiovascular disease in South Asians. Primary Care Diabetes. 2011;5(1):45-56.
- Misra A, Khurana L. Obesity-related non-communicable diseases: South Asians vs White Caucasians. International Journal of Obesity. 2011;35(2):167-187. doi:10.1038/ijo.2010.135.
- American Diabetes Association Professional Practice Committee for Diabetes. Standards of Care in Diabetes—2026. Diabetes Care. 2026;49(Suppl 1).
- Misra A, Ganda OP. Migration and its impact on adiposity and type 2 diabetes. Nutrition. 2007;23(9):696-708.
- Misra A, Khurana L, Isharwal S, Bhardwaj S. South Asian diets and insulin resistance. British Journal of Nutrition. 2009;101(4):465-473. doi:10.1017/S0007114508073649.
- Eberly LA, Yang L, Essien UR, et al. Racial, ethnic, and socioeconomic inequities in glucagon-like peptide-1 receptor agonist use among patients with diabetes in the US. JAMA Health Forum. 2021;2(12). doi:10.1001/jamahealthforum.2021.4182.
Medical disclaimer: This article is intended for general educational purposes and does not constitute individual medical advice. Decisions about diabetes screening or treatment, including the use of GLP-1 receptor agonists, should be made with a qualified healthcare professional based on an individual's medical history, health risks, treatment goals, preferences, and other clinical considerations.
~ Ekta Grewal
(Founder, Sikhs in Clinical Research)
