The influence of ethnicity on the prevalence of type 2 diabetes mellitus

Diabetes mellitus (DM) is a complex chronic disease that arises either as a result of insufficient production of insulin by the pancreas, or as a result of reduced tissue sensitivity to the effects of this hormone. Insulin plays a key role in regulating blood glucose levels. Inadequately managed glycemia can lead to damage to the cardiovascular system, kidneys, eyes, nervous tissue and other organs in the long term (World Health Organization, 2016). The incidence of this disease varies significantly between different ethnic groups. African Americans and Hispanics show higher rates of diabetes compared to other populations. American Indians and Alaska Natives are also particularly vulnerable groups, where genetic factors contribute to an increased risk of developing this disease (Galicia-Garcia et al., 2020).

According to projections by the International Diabetes Federation, by 2050, one in eight adults in the world – approximately 853 million people – could be living with diabetes, an increase of 46% compared to the current situation. In 2024, approximately 589 million adults between the ages of 20 and 79 are living with the disease, which corresponds to approximately one in nine adults worldwide (International Diabetes Federation, 2025).

More than 90% of patients suffer from DM2, the incidence of which is influenced by a complex combination of socioeconomic, demographic, environmental and genetic factors. Urbanization, the aging of the population, the decrease in physical activity and the increasing rate of overweight and obesity contribute significantly to its rapid spread. Although it is a disease with serious consequences, its impact can be significantly reduced by taking preventive measures, especially in DM2, as well as by ensuring early diagnosis and quality health care for all forms of this disease. These steps can help patients avoid or at least delay serious complications (Bodhini et al., 2023).

Estimates show that up to 81% of all adults with diabetes live in low- and middle-income countries, where access to treatment is often limited. In 2024, diabetes was responsible for approximately 3.4 million deaths, which is one death every six seconds. At the same time, it is estimated that up to 43% of adults with this disease, i.e. approximately 252 million people, are not diagnosed. Almost 90% of them are found in countries with lower incomes (International Diabetes Federation, 2025).

The economic consequences of diabetes are equally alarming. In 2024, global health expenditure associated with this disease will reach approximately 1.015 trillion US dollars, representing an increase of 338% over the last seventeen years. In addition to the diagnosed cases, there are also a large number of people living in the world with an increased risk of developing DM2. As many as 635 million adults have impaired glucose tolerance and 488 million suffer from elevated fasting glucose, placing them in a high-risk group. In addition, it is estimated that one in five live births is affected by hyperglycemia during pregnancy, which increases the likelihood of metabolic disorders in the future (International Diabetes Federation, 2025).

In 2018, the American Diabetes Association (ADA) established the following classification:

• Type 1 diabetes mellitus (DM1) – arises as a result of autoimmune destruction of β-cells of the pancreas, which leads to an absolute deficiency of insulin.
• Type 2 diabetes mellitus (DM2) – characterized by a gradual decrease in the secretory function of β-cells, while insulin resistance often occurs.
• Gestational diabetes mellitus (GDM) – diabetes diagnosed in the second or third trimester of pregnancy that was not present before pregnancy.
• Specific forms of diabetes caused by other factors - this includes monogenic forms of diabetes (e.g. neonatal diabetes, MODY - diabetes of young adults with autosomal dominant hereditary transmission), secondary diabetes arising from diseases of the exocrine pancreas (e.g. cystic fibrosis, chronic pancreatitis) and diabetes induced by pharmacotherapy or chemical substances (e.g. during the use of glucocorticoids, HIV/AIDS treatment or after organ transplantation).

Determinants of DM2 occurrence with a focus on ethnic differences

The incidence of DM2 shows significant differences between different ethnic groups, and these differences are influenced not only by genetic predispositions, but also by socio-economic, cultural and environmental factors. Certain ethnic groups are more susceptible to the development of this disease, which is manifested by a higher prevalence even with lower BMI values ​​or a lower calorie intake compared to other populations. In addition to genetic predispositions, the key risk factors for the development of DM2 are also an inactive lifestyle, inappropriate diet and obesity, which are increasingly associated with the occurrence of this disease in various ethnic groups. (Fig. 1)

Fig. 1: Risk factors for the development of type 2 diabetes, including ethnic origin

The diagram shows the main risk factors for developing type 2 diabetes, which include obesity, impaired glucose tolerance, insulin resistance, ethnicity, sedentary lifestyle, family history, age and polycystic ovary syndrome. Source: vedzdraviesport.sk

1. Ethnicity and genetic predispositions

Genetic factors play a significant role in the risk of developing DM2, with different ethnic groups showing different genetic predispositions that affect both insulin resistance and pancreatic β-cell function. These predispositions can be manifested by an increased prevalence of DM2 even with a relatively lower BMI or body fat percentage – typically the African-American population, Hispanics, Native Americans and some Southeast Asian groups (Ruze et al., 2023).

The key locus associated with DM2 risk is the TCF7L2 gene, which represents the strongest signal in genome-wide linkage studies and was first massively reported in multiple populations (Sarhangi, et al. 2020). Variants of this Wnt pathway transcription factor (especially the rs7903146-T allele) are associated with impaired compensatory insulin hypersecretion, increased β-cell vulnerability, and reduced efficacy of sulfonylureas in the early stages of treatment (Bonnefond et al., 2020).

Other important genes include PPARG, which regulates adipogenesis and insulin sensitivity, and FTO, associated with mechanisms affecting obesity, appetite, and energy balance. In South Asian populations, these risk alleles are significantly more frequently represented, which partially explains the higher incidence of diabetes even with a relatively low BMI (Chauhan et al., 2010). Genome-wide association studies of more than 2.5 million individuals have identified 1,289 independent signals, many of which show specific frequencies in these ethnic groups (Suzuki et al., 2023).

Family history emphasizes the polygenic architecture of DM2, e.g. first-line relatives of South Asian patients have a 2- to 4-fold higher risk of the disease compared to European individuals, reflecting the cumulative effect of multiple risk genetic loci (Zhang et al. 2017). In addition, interactions between genetic variants and the environment, such as a Western diet or a sedentary lifestyle, modulate the penetrance of these genes and contribute to the dynamic increase in the incidence of DM2 in migrants (Parackal, 2017).

In addition to polygenic effects, a significant burden of pathogenic mutations in genes associated with the monogenic form of diabetes (MODY) - especially GCK, HNF1A, KCNJ11, ABCC8 and HNF4A - is demonstrated in the DM2 population. More than 2% of patients with DM2 carry at least one pathogenic or likely pathogenic variant in the relevant genes. These genetic variations are associated with lower BMI, earlier disease onset and different therapeutic response. The identification of such mutations enables a personalized approach to treatment – ​​for example, discontinuation of pharmacotherapy in GCK-MODY or preference for sulfonylureas in patients with mutations in the HNF1A or HNF4A genes (Bonnefond et al., 2020).

Overall, ethnicity represents a complex interplay of genetic profiles, evolutionary selection pressures, and environmental factors that together shape various pathways of insulin resistance and β-cell dysfunction – from the "thrifty genotype" phenomenon in African-American populations to altered epigenetics in the descendants of Native Americans exposed to famine (Munns et al., 2025). In order to understand the heterogeneity of the clinical picture of DM2 and to design targeted preventive and therapeutic strategies, it is therefore necessary to take into account not only polygenic, but also monogenic and epigenetic components in the context of ethnicity.

Another important knowledge is the finding that isolated populations, such as Greenlandic Inuit show the occurrence of gene variants that significantly affect insulin secretion. These variants, even if specific to individual populations, may contribute to a better understanding of the pathophysiology of diabetes (Olsson, Goedecke, 2020). Likewise, studies in African-Americans have shown that hyperinsulinemia, present even with normal insulin sensitivity, can be either a predisposing factor or a consequence of insulin resistance, highlighting the difference in metabolic mechanisms between ethnic groups (Olsson and Goedecke, 2020).

2. Obesity and overweight

Obesity, and especially obesity in the abdominal area (higher waist circumference), is the most significant risk factor for the development of DM2. This factor is present in all populations, but its impact and severity varies by ethnic group. While in some populations, such as in European and American countries, DM2 is associated with a higher BMI and overweight, in the populations of Southeast Asia and the Indian subcontinent, the development of diabetes is observed even with a lower BMI (World Health Organization, 2016). This difference suggests that even a relatively lower body weight can lead to metabolic problems that increase the risk of developing diabetes in these regions. A high waist circumference is primarily associated with metabolic disorders that affect insulin sensitivity, which in turn increases the risk of DM2 even in people with a lower BMI.

Research has shown that South Asians have a lower incidence of so-called favorable adiposity alleles, which are associated with a higher amount of subcutaneous fat, but lower visceral fat. This difference may explain why South Asians have a higher risk of developing diabetes even at a lower BMI compared to other populations (Olsson and Goedecke, 2020).

3. Eating habits

Dietary habits represent another key factor influencing the prevalence of DM2 in different ethnic groups. In areas of Asia and Latin America, the consumption of highly processed foods, sugary drinks, and foods high in fat and sugar is increasing, which can increase the risk of developing diabetes. High intake of saturated fat, associated with low fiber consumption, is often observed in Hispanic and African American populations and is associated with a higher incidence of DM2. In recent years, it has been shown that a high intake of sweetened beverages has a particularly risky nature, since in 2020 it was the excessive consumption of these beverages that was responsible for more than 2.2 million new cases of DM2 worldwide, with the greatest burden in Latin American and Caribbean countries (Lara Castor et al., 2025). At the same time, it is shown that in individuals with a genetic predisposition, especially with a high polygenic risk score, the relationship between the intake of sweetened beverages and the glucose level is even more pronounced, which was described in a study among the Latin American population (López Portillo et al., 2021). The importance of eating habits in the prevention of this disease should be emphasized especially in populations where these habits are common.

Discussion

Ethnicity significantly influences the prevalence, clinical course and risk factors of DM2. Studies show that different ethnic groups have different risk profiles, pathophysiological mechanisms, and responses to treatment.

South Asia: India and Pakistan

In South Asia, especially in India and Pakistan, the incidence of DM2 is on the rise. According to 2017 data from the International Diabetes Federation, the prevalence of diabetes in adults ranges from 4.0% in Nepal to 8.8% in India, which is a consequence of urbanization, sedentary lifestyles and inappropriate diets (Anjana et al., 2017). Adults of South Asian descent have a lower body mass index (BMI) and lower rates of insulin resistance compared to African American and white American populations, but show a higher incidence of diabetes, especially in normal weight groups. This paradox points to significant differences in the pathophysiology of DM2 and highlights the role of reduced insulin secretion as a major mechanism of disease in this population (Narayan et al., 2021).

United States of America

In the US, the incidence of type 2 diabetes among South Asian Americans is among the highest. According to data from 2011-2016, the prevalence reaches 23.3%, which is significantly higher than in the white population (Cheng et al., 2019). Among ethnic minorities, especially non-Hispanic blacks and Hispanics, an earlier onset of disease is more often observed, which is related to social determinants of health, such as level of education, smoking, obesity, and the process of acculturation (Foutsa et al., 2025).

Great Britain

In Great Britain, people of South Asian origin have a 3- to 5-fold higher risk of developing type 2 diabetes compared to the Caucasian population. Although the second generation of migrants shows a lower risk than their parents, the prevalence of the disease among them remains significantly higher than in the majority population (Farmaki et al., 2022). However, there is limited evidence of systematic discrimination in the diagnosis of diabetes; differences in treatment outcomes are probably more related to long-term control of risk factors or genetic predispositions (Pham et al., 2019).

South Asian migrants in high-income countries

In South Asian migrants in Western countries, diabetes often appears at lower BMI values than in the European population, which has prompted the need to revise existing diagnostic standards. According to a study by Tillin et al. (2013), the traditional BMI limits for obesity are inappropriate for this ethnic group, as metabolic disorders already appear at a BMI below 25 (Tillin et al. 2013). A UK Biobank analysis also showed that South Asians have a higher proportion of visceral fat and lower insulin secretion compared to the Caucasian population, explaining the earlier onset of DM2 (Goff et al., 2013). These findings clearly support the need for ethnically specific thresholds for screening and prevention in high-risk populations.

African Americans

African Americans show a higher prevalence of DM2 compared to white Americans. According to a study by Cheng et al. (2019) the incidence of diabetes in African Americans is 12.1%, while it is 7.4% in white Americans. This difference likely reflects the interplay of genetic predispositions, socioeconomic factors, and limited access to health care.

Hispanics

DM2 is equally prevalent in the US Hispanic population at a higher rate – according to Aguayo-Mazzucato et al. (2019) presents a prevalence of 12.5%, which exceeds the values ​​reported in non-Hispanic Caucasians. This disparity can be attributed to a combination of genetic factors, high rates of obesity, and socioeconomic determinants such as lower income and poorer access to health care (Aguayo-Mazzucato et al. 2019).

Native Americans

Native Americans, including American Indians and Alaska Natives, show the highest prevalence of DM2 in the US. According to a study by Golden et al. (2019) the incidence of the disease in this population reaches up to 15.1%. At the same time, this population faces an increased risk of serious complications such as kidney failure and amputations. Genetic predispositions, rapid urbanization and deviation from traditional lifestyles contribute to this risk (Golden et al., 2019).

East Asian populations

East Asian populations, especially the Japanese, are predisposed to developing DM2 already at lower BMI values, which is related to reduced insulin secretion rather than significant insulin resistance (Seino, Yamazaki, 2025). The pathogenesis of the disease in this group is characterized by weakened β-cell function, often conditioned by mitochondrial dysfunction, which leads to impaired insulin response to glucose. Considering this pathophysiological phenotype, treatment with incretins, which improve glucose homeostasis by stimulating residual insulin secretion, appears to be an effective therapeutic strategy. These findings support the need to lower BMI thresholds for screening and to consider ethnic differences in the diagnosis and treatment of diabetes (Seino, Yamazaki, 2025).

European Populations

Eastern Europe, Russia and the Balkan countries are among the regions with a high prevalence of DM2, but are often underrepresented in international databases and recommendations. In the Russian adult population, according to the NATION study, the prevalence of DM2 is around 11.7%, while it increases significantly with age (Dedov et al., 2016). Long-term data from the HAPIEE project confirm the high risk of DM2 in the Russian cohort and point to the importance of classic risk factors including obesity, hypertension and low physical activity (Mustafina et al., 2021). From the point of view of the European area, there are significant regional differences in the incidence of diabetes, while higher values ​​are repeatedly recorded in the countries of Central and Eastern Europe (Elek and Bíró, 2021). These differences are conditioned not only by socioeconomic factors, but also by the quality of national diabetes care systems, which are still insufficient in many countries (Altobelli et al., 2020). As a result, it is necessary to focus prevention mainly on areas with high prevalence and limited access to quality diabetes care, while the emphasis should be on improving health literacy, screening programs and treatment availability.

Clinical Implications

These ethnic differences in the prevalence and pathophysiology of DM2 suggest the need for tailored approaches to diagnosis and treatment. Lowering BMI thresholds for screening in at-risk groups such as South and East Asian populations is recommended. In addition, it is important to consider cultural and socioeconomic factors when designing prevention and treatment programs.

Conclusion

Ethnicity is a significant determinant in the etiology, prevalence and clinical course of DM2. An analysis of available scientific studies shows that individual ethnic groups – especially populations of South Asian, African American, Hispanic and Native American origin – show a different level of risk of developing the disease, as well as differences in its pathophysiology. In South Asian migrants, diabetes develops at a lower BMI due to genetic predispositions, reduced insulin secretion and increased visceral fat accumulation. Similarly, African Americans and Hispanics face a higher incidence and complications, which are conditioned by a combination of genetic factors, socioeconomic disadvantage and lifestyle.

Differences in the distribution of risk factors between ethnic groups highlight the need to revise existing diagnostic and screening thresholds, which are currently set predominantly according to the parameters of the Caucasian population. In addition to biological factors, environmental and cultural determinants also have a significant influence, which influence the health behavior of individuals after migration. Implementation of ethnic-specific approaches in the field of prevention, diagnosis and treatment of DM2 is therefore essential for effective reduction of morbidity, improvement of patient prognosis and targeted reduction of health inequalities in multi-ethnic societies.

Authors: M.Sc. Anastasiia Ostafiichuk, Institute of Public Health and Hygiene, Faculty of Medicine UPJŠ, Košice prof. Mgr. MUDr. Erik Dorko, PhD., MPH, MBA., Institute of Public Health and Hygiene, Faculty of Medicine UPJŠ, Košice prof. MUDr. Kvetoslava Rimárová CSc., Institute of Public Health and Hygiene, Faculty of Medicine UPJŠ, Košice Doc. MUDr. Ingrid Dravecká PhD., I. internal clinic UPJŠ LF and UNLP, Košice

Work supported by grants KEGA 001UPJŠ-4/2024 and 003UPJŠ-4/2024 of the Ministry of Education, Research, Development and Youth of the SR.

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