Journal of Immigrant and Minority Health

, Volume 18, Issue 1, pp 110–117 | Cite as

Diabetes and Cardiovascular Disease Risk in Cambodian Refugees

  • Grant N. Marshall
  • Terry L. Schell
  • Eunice C. Wong
  • S. Megan Berthold
  • Katrin Hambarsoomian
  • Marc N. Elliott
  • Barbara H. Bardenheier
  • Edward W. Gregg
Original paper


To determine rates of diabetes, hypertension, and hyperlipidemia in Cambodian refugees, and to assess the proportion whose conditions are satisfactorily managed in comparison to the general population. Self-report and laboratory/physical health assessment data obtained from a household probability sample of U.S.-residing Cambodian refugees (N = 331) in 2010–2011 were compared to a probability sample of the adult U.S. population (N = 6,360) from the 2009–2010 National Health and Nutrition Examination Survey. Prevalence of diabetes, hypertension and hyperlipidemia in Cambodian refugees greatly exceeded rates found in the age- and gender-adjusted U.S. population. Cambodian refugees with diagnosed hypertension or hyperlipidemia were less likely than their counterparts in the general U.S. population to have blood pressure and total cholesterol within recommended levels. Increased attention should be paid to prevention and management of diabetes and cardiovascular disease risk factors in the Cambodian refugee community. Research is needed to determine whether this pattern extends to other refugee groups.


Epidemiology Refugees Diabetes Cardiovascular risk 



This research was supported by grants from the National Institute of Mental Health (R01MH059555; R01MH082069) and the National Institute on Alcohol Abuse and Alcoholism (R01AA013818) awarded to Grant Marshall. The findings and conclusions in this report are those of the authors and do not necessarily reflect the opinions of the RAND Corporation, the U.S. Department of Health and Human Services, the Public Health Service, or the Centers for Disease Control and Prevention. The authors express appreciation to Judy Perlman, M.A., Suzanne Perry, M.A., and the RAND Survey Research Group team for their help with data collection. We gratefully acknowledge the contribution of our interviewers to the success of this research. We particularly thank Bryant Ben who served as a community advisor. Finally, we are indebted to the research participants who made this study possible.


  1. 1.
    Refugee council USA. History of the U.S. refugee resettlement program. Accessed 21 Aug 2014.
  2. 2.
    Marshall GN, Schell TL, Elliott MN, et al. Mental health of Cambodian refugees 2 decades after resettlement in the United States. JAMA. 2005;294:571–9.PubMedCrossRefGoogle Scholar
  3. 3.
    Sabin M, Cardozo BL, et al. Factors associated with poor mental health among Guatemalan refugees living in Mexico 20 years after civil conflict. JAMA. 2003;290:635–42.PubMedCrossRefGoogle Scholar
  4. 4.
    Fazel M, Wheeler J, Danesh J. Prevalence of serious mental disorder in 7000 refugees resettled in western countries: a systematic review. Lancet. 2005;365:1309–14.PubMedCrossRefGoogle Scholar
  5. 5.
    Steel Z, Chey T, Silove D, et al. Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement: a systematic review and meta-analysis. JAMA. 2009;302:537–49.PubMedCrossRefGoogle Scholar
  6. 6.
    Chang AH, Perry S, Du JN, et al. Decreasing intestinal parasites in recent Northern California refugees. Am J Trop Med Hyg. 2013;88:191–7.PubMedPubMedCentralCrossRefGoogle Scholar
  7. 7.
    Thorpe LE, Laserson K, Cookson S, et al. Infectious tuberculosis among newly arrived refugees in the United States. N Engl J Med. 2004;350:2105–6.PubMedCrossRefGoogle Scholar
  8. 8.
    Wagner J, Burke G, Kuoch T, Scully M, Armeli S, Rajan TV. Trauma, healthcare access, and health outcomes among Southeast Asian refugees in Connecticut. J Immigr Minor Health. 2013;15:1065–72.PubMedCrossRefGoogle Scholar
  9. 9.
    Wong EC, Marshall GN, Schell TL, Elliott MN, Babey SH, Hambarsoomians K. The unusually poor physical health status of Cambodian refugees two decades after resettlement. J Immigr Minor Health. 2011;13:876–82.PubMedPubMedCentralCrossRefGoogle Scholar
  10. 10.
    Kinzie JD, Riley C, McFarland B, Hayes M, Boehnlein J, Leung P, Adams G. High prevalence rates of diabetes and hypertension among refugee psychiatric patients. J Nerv Ment Dis. 2008;196:108–12.PubMedCrossRefGoogle Scholar
  11. 11.
    Sparén P, Vågerö D, Shestov DB, Plavinskaja S, Parfenova N, Hoptiar V, Paturot D, Galanti MR. Long term mortality after severe starvation during the siege of Leningrad: prospective cohort study. BMJ. 2004;328(7430):11.PubMedPubMedCentralCrossRefGoogle Scholar
  12. 12.
    Huang C, Li Z, Wang M, Martorell R. Early life exposure to the 1959–1961 Chinese famine has long-term health consequences. J Nutr. 2010;140(10):1874–8.PubMedCrossRefGoogle Scholar
  13. 13.
    Räikkönen K, Matthews KA, Kuller LH. Depressive symptoms and stressful life events predict metabolic syndrome among middle-aged women. Diabetes Care. 2007;30:872–7.PubMedCrossRefGoogle Scholar
  14. 14.
    Rich-Edwards JW, Spiegelman D, Lividoti Hibert EN, et al. Abuse in childhood and adolescence as a predictor of type 2 diabetes in adult women. Am J Prev Med. 2010;39:529–36.PubMedPubMedCentralCrossRefGoogle Scholar
  15. 15.
    Rich-Edwards JW, Mason S, Rexrode K, et al. Physical and sexual abuse in childhood as predictors of early-onset cardiovascular events in women. Circulation. 2012;126:920–7.PubMedPubMedCentralCrossRefGoogle Scholar
  16. 16.
    Scott KM, Von Korff M, Angermeyer MC, et al. Association of childhood adversities and early-onset mental disorders with adult-onset chronic physical conditions. Arch Gen Psychiatry. 2011;68:838–44.PubMedPubMedCentralCrossRefGoogle Scholar
  17. 17.
    Needham S, Quintiliani K. Cambodians in long beach. Mount Pleasant: Arcadia Publishing; 2008.Google Scholar
  18. 18.
    Flaherty JA, Gaviria FM, Pathak D, et al. Developing instruments for cross-cultural psychiatric research. J Nerv Ment Dis. 1988;176:257–63.PubMedGoogle Scholar
  19. 19.
    McCaffrey DF, Ridgeway G, Morral AR. Propensity score estimation with boosted regression for evaluating causal effects in observational studies. Psychol Methods. 2004;9:403–25.PubMedCrossRefGoogle Scholar
  20. 20.
    Centers for Disease Control and Prevention (CDC). National Health and Nutrition Examination Survey (NHANES). Laboratory Procedure Manual. Cholesterol (CHOL) in Refrigerated Serum NHANES 2009–2010. 2011. Accessed 21 Sept 2013.
  21. 21.
    Centers for Disease Control and Prevention (CDC). National Health and Nutrition Examination Survey (NHANES). Laboratory Procedure Manual. Glycohemoglobin. NHANES 2009–2010. 2011 . Accessed 9 Sept 2013.
  22. 22.
    Affan ET, Praveen D, Chow CK, Neal BC. Comparability of HbA1c and lipids measured with dried blood spot versus venous samples: a systematic review and meta-analysis. BMC Clin Pathol. 2014;14:21.PubMedPubMedCentralCrossRefGoogle Scholar
  23. 23.
    Jeppsson JO, Jerntorp P, Almër LO, et al. Capillary blood on filter paper for determination of HbA1c by ion exchange chromatography. Diabetes Care. 1996;19:142–5.PubMedCrossRefGoogle Scholar
  24. 24.
    Amundson DM, Zhou M. Fluorometric method for the enzymatic determination of cholesterol. J Biochem Biophys Methods. 1999;38:43–52.PubMedCrossRefGoogle Scholar
  25. 25.
    University of Washington. Department of Laboratory Medicine. Summary report, Cambodian refugee study. February 5, 2013.Google Scholar
  26. 26.
    National Cholesterol Education Program. ATP III guidelines at-a-glance quick desk reference. National Heart, Lung, and Blood Institute, National Institutes of Health. U.S. Department of Health and Human Services, 2001. NIH Publication No. 01–3305.Google Scholar
  27. 27.
    American Diabetes Association. Executive summary: standards of medical care in diabetes—2010. Diabetes Care. 2010;33:S4–10.CrossRefGoogle Scholar
  28. 28.
    The International Expert Committee. International Expert Committee report on the role of the A1C assay in the diagnosis of diabetes. Diabetes Care. 2009;32:1327–34.PubMedCentralCrossRefGoogle Scholar
  29. 29.
    Centers for Disease Control and Prevention. National Health and Nutrition Examination Survey (NHANES). Data documentation, codebook, and frequencies. Blood pressure. NHANES 2009–2010. 2011. Accessed 18 Aug 2014.
  30. 30.
    Mattu GS, Heran BS, Wright JM. Overall accuracy of the BpTRU—an automated electronic blood pressure device. Blood Press Monit. 2004;9:47–52.PubMedCrossRefGoogle Scholar
  31. 31.
    Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure: the JNC 7 report. Hypertension. 2003;42:1206–52.PubMedCrossRefGoogle Scholar
  32. 32.
    Lloyd-Jones D, Adams RJ, Brown TM, et al. Heart disease and stroke statistics—2010 update: a report from the American Heart Association statistics committee and stroke statistics subcommittee. Circulation. 2010;121:e1–170.CrossRefGoogle Scholar
  33. 33.
    California Department of Health Services Sentinel health indicators for California’s multicultural population: 1999–2001. Center for Health Statistics. 2004. Office of health information. Accessed 11 Sept 2014.
  34. 34.
    Holland AT, Palaniappan LP. Unique challenges in the management of cardiovascular disease in Asian Americans. In: Saha SA, editor. Current advances in cardiovascular risk. Hauppauge: Nova Science; 2012. p. 605–26.Google Scholar
  35. 35.
    Bhatta MP, Shakya S, Assad L, Zullo MD. Chronic disease burden among Bhutanese refugee women aged 18–65 years resettled in Northeast Ohio, United States, 2008–2011. J Immigr Minor Health. 2014 May 22.Google Scholar
  36. 36.
    Culhane-Pera KA, Moua M, DeFor TA, Desai J. Cardiovascular disease risks in Hmong refugees from Wat Tham Krabok, Thailand. J Immigr Minor Health. 2009;11:372–9.PubMedCrossRefGoogle Scholar
  37. 37.
    Steptoe A, Shamaei-Tousi A, Gylfe A, Henderson B, Bergström S, Marmot M. Socioeconomic status, pathogen burden and cardiovascular disease risk. Heart. 2007;93(12):1567–70.PubMedPubMedCentralCrossRefGoogle Scholar
  38. 38.
    Steffen PR, Smith TB, Larson M, Butler L. Acculturation to western society as a risk factor for high blood pressure: meta-analytic review. Psychosom Med. 2006;68:386–97.PubMedCrossRefGoogle Scholar
  39. 39.
    Adebiyi A, Cheng A, Kim J, Kim T, Luna M, Men A, Pech C, Sestich M, Sithounnolat D, Tse L. Report on the state of Cambodia Town. 2013. Accessed 26 Oct 2014.
  40. 40.
    McDade TW, Williams S, Snodgrass JJ. What a drop can do: dried blood spots as a minimally invasive method for integrating biomarkers into population-based research. Demography. 2007;44:899–925.PubMedCrossRefGoogle Scholar
  41. 41.
    Bry L, Chen PC, Sacks DB. Effects of hemoglobin variants and chemically modified derivatives on assays for glycohemoglobin. Clin Chem. 2001;47:153–63.PubMedGoogle Scholar
  42. 42.
    Little RR, Rohlfing CL, Hanson S, Connolly S, Higgins T, Weykamp CW, D’Costa M, Luzzi V, Owen WE, Roberts WL. Effects of hemoglobin (Hb) E and HbD traits on measurements of glycated Hb (HbA1c) by 23 methods. Clin Chem. 2008;54:1277–82.PubMedCrossRefGoogle Scholar
  43. 43.
    Dookeran NM, Battaglia T, Cochran J, Geltman PL. Chronic disease and its risk factors among refugees and asylees in Massachusetts, 2001–2005. Prev Chronic Dis. 2010;7:1–8.Google Scholar

Copyright information

© RAND Corporation 2015

Authors and Affiliations

  • Grant N. Marshall
    • 1
  • Terry L. Schell
    • 1
  • Eunice C. Wong
    • 1
  • S. Megan Berthold
    • 1
    • 3
  • Katrin Hambarsoomian
    • 1
  • Marc N. Elliott
    • 1
  • Barbara H. Bardenheier
    • 2
  • Edward W. Gregg
    • 2
  1. 1.RAND CorporationSanta MonicaUSA
  2. 2.Centers for Disease ControlAtlantaUSA
  3. 3.University of ConnecticutWest HartfordUSA

Personalised recommendations