By Janice Nesamani
NORTHWEST ASIAN WEEKLY
Almost one in three of the 3.5 million South Asians in the United States will die from heart disease before age 65 — that’s a four-fold higher risk than other ethnicities, but no one really knows why.
Most of us inherit certain traits from our parents or grandparents. I inherited a love for literature, but as an Indian from South Asia, it came with a predisposition for diabetes and heart disease.
Immigrants from Bangladesh, Bhutan, India, the Maldives, Nepal, Pakistan, and Sri Lanka get heart disease earlier, have higher rates of heart disease, and have higher mortalities compared to Caucasians. With most of my paternal family diagnosed with diabetes and a grandfather who died of cardiac arrest, I had to learn why Cardiovascular Disease (CVD) seems to affect the South Asian community so severely.
Dr. Sandeep Krishnan, a University of Washington (UW) Medicine cardiologist, thinks this is an alarming problem that needs to be publicized. “There’s a lot of data to show that South Asians have a higher risk of heart disease, but we don’t fully understand why that is.
The thought that the South Asian genetic make has a higher predilection for insulin resistance and diabetes is a strong causative agent of coronary disease,” Krishnan said. “So, we don’t have any particular effective means of combating that besides typical insulin and diabetic medications on the market. By then, its typically too late and patients with long-standing diabetes have already developed heart disease,” he said.
Dr. Francis Yuvienco, a cardiologist with CHI Franciscan Health, says they see a fair share of CVD, regardless of race or ethnicity. However, he said, “From a public health perspective, certain ethnicities, South Asians, seem more predisposed.”
Annu Luthra, president of the Indian Association of Western Washington (IAWW), confirms this. “We do have a very high rate of heart disease and it is taking lives of South Asians as young as the early 30s, who are otherwise active and eat well-balanced diets.”
IAWW’s vice president and community program director, Lalita Uppala, works directly with the community. The organization runs pop-up community centers in different cities throughout the region. “We run a resource desk and cultural navigator program to raise awareness and address insurance, transportation, and legal, business, or estate planning needs,” she said.
Through this endeavor, the organization comes across several people who need help. “We document when people reach out to us and discovered there have been many cardiac arrests among young Indo-Americans in the 30-50 age group. In the last six months, we recognized there have been a lot of fatalities in those instances,” Uppala said.
What makes heart disease difficult to detect in this group is individuals appear skinny.
“Their body fat composition is mostly visceral fat coating their organs and leading to insulin resistance. It’s tough to gauge, because when you look at South Asians, they are not fat. They compare themselves to Americans and think they must be healthy,” he said.
Krishnan said, “Obesity cut-offs for South Asians are less than they are for everyone else.
You would be considered overweight with a Body Mass Index (BMI) of 25 or greater, but for South Asians, that count is 23. That’s not widely advertised.”
Cultural and dietary factors
“More than one-third of South Asian men and 17 percent of South Asian women have metabolic syndrome, which is a cluster of conditions that include high blood pressure, high blood sugar levels, excess body fat around the waist, and abnormal cholesterol levels,” Yuvienco said. These conditions increase the risk of heart disease, stroke, and diabetes. If more than one of these conditions occur in combination, the risk is even greater.
“The group is more likely to have high triglycerides and low high-density lipoprotein (HDL), or good cholesterol. A variant of HDL known as HDL2b, which is thought to mediate the good effects of HDL, is low in as many as 93 percent of South Asian men and 63 percent of women,” Yuvienco added.
There are three main sources of nutrition — protein, carbohydrates, and fat, Krishnan explained. “Most South Asians are vegetarian due to cultural or religious reasons. When you’re a vegetarian, getting protein is difficult, so that leaves fat and carbohydrates, and together, that is a dangerous combination,” he said.
While lentils may be a good source of protein, they come with a heavy carbohydrate load.
Most South Asian cooking is based on legumes, lentils, dals, and carbohydrate-based ingredients. “It’s not like eating a candy bar, but the overall carbohydrate intake, especially for South Asian vegetarians, is much higher than a neighbor who may have a steak and vegetables or salmon and broccoli,” Krishnan said.
While a vegetarian wouldn’t be able to eat that, Krishnan calls the latter a healthier meal compared to a typical Indian meal of naan, bread, or rice, which are all pure carbohydrate foods, with dal or lentils adding more carbohydrates. “The ratios are all off and when you mix that with ghee or lard, the combination increases adiposity, glycogen, and glucose storage, which lead to an increase in the risk for diabetes,” he said.
“South Asians’ genetics don’t seem to metabolize carbohydrates as well as the rest of the world. This leads to higher incidence of diabetes, inherently linked with CVD,” Krishnan said.
Krishnan recalled a 45-year-old patient who came into his clinic with diabetes. “He was what I attempt to call Uncle Skinny-Fat because he looked skinny, but had visceral fat, predisposing him to diabetes.”
Krishnan talked to him about his weight and diabetes. “He was a typical vegetarian, came from a quintessential Indian household, and thought he was doing the right things. While the man’s diabetes was moderately well controlled, he was not interested in changing his diet. “He was reluctant to take medications for his cholesterol, even though I strongly encouraged him to make dietary changes necessary and take cholesterol medications,” Krishnan said.
Unfortunately, a few months later, the patient had a fatal heart attack, leaving two children and his wife on their own. “This is all too common, and is repeated in the community,” said Krishnan.
With Indians in the United States as young as 30 having cardiac arrests, Uppala believes stress can also be a factor. “I believe that in this younger group, fatalities occur because of stress and sedentary lifestyles in the tech community, with long work hours, no breaks, and no physical activity,” she said. Uppala cites evolutionary changes and adds, “We are no more a healthy immigrant community. We have to consider what we are doing to ourselves with a sedentary lifestyle.”
A May 2018 study, led by cardiologist Dr. Annabelle Volgman for the American Heart Association, found that threats to South Asians’ cardiovascular health are obscured as researchers have been looking at Asian Americans as a monolithic group, rather than examining them individually.
“We’ve observed the increased risk, but we are still looking for the smoking gun,” said Dr. Latha Palaniappan, an internist and clinical researcher who focuses on the gap in medical knowledge about Asian subgroups. She co-chaired the new report with Volgman.
“Disproportionate levels of heart disease in the South Asian community are a red flag with a preventable cause,” Rep. Pramila Jayapal said in introducing H.R. 3592. “By dedicating funding to research and ways to get the word out on the importance of heart health, we will not only save more lives in the South Asian community, we will also open a door to a new and better understanding of heart health that will benefit all Americans.”
Jayapal recently met with heart specialists at UW Medical Center in Seattle to understand what life-saving and life-alternating therapies are available and to gather support to increase funding through the National Institutes of Health (NIH) to understand why South Asians are more predisposed to CVD with worse outcomes.
“I think getting a better understanding of why it is that there is such a high prevalence of insulin resistance and a better education of the community of what they can do is critical,” Krishnan said. “There are a number of things that can be better understood. The South Asian community has a lot of myths that I think can be clarified in terms of diet and exercise, that definitely are cultural,” he added.
Krishnan and Yuvienco are grateful that Jayapal is bringing this issue to the fore.
“I would like to see funding for early screening and continued support for preventive services, early screening, education, and above all quality of care,” said Yuvienco.
Doing their bit to raise awareness is the IAWW — they organize two talks on diabetes, and two on cardiovascular health each year. “We have a Heart Health campaign in September and are working with Evergreen and Overlake hospitals to bring talks and awareness with screenings and preventives,” Uppala said. It will also take awareness to grocery stores in the area on lean food. As an example, Uppala said, “You get lean steak, but our community prefers goat or lamb, which is fattier than a beef steak.”
IAWW also works with employers to make them cognizant of the issue. “I believe Microsoft is starting CPR classes after advocacy we have done. A lot of their employees have cardiac arrests that are fatal,” Uppala said.
Yuvienco suggests that South Asians accept that they are predisposed and at risk for CVD.
“It is the number 1 cause of death worldwide. Certain ethnicities appear to be more at risk at an earlier age, and acceleration to full blown heart disease appears more rapid and aggressive,” he said.
Statistics show almost one in every three South Asians will die from heart disease before age 65 and one study found that South Asians developed heart disease 10 years earlier than other groups. With these odds, Dr. Yuvienco has some tips:
- Make a concerted effort early with diets and activity levels — Start not only with yourself, but in your homes with your children and in schools to encourage a healthier, more active lifestyle. A diet rich in fruits, vegetables, nuts, and whole grains, while low in red meat, saturated fats, and sugar is advised.
- Increase your activities like moderate exercise (e.g. brisk walking). He recommends at least 30 minutes of exercise a day.
- Continue to educate about the health hazards of smoking (including vaping).
- Maintain a BMI between 18.5 and 25.
- Have no more than one 150ml glass of wine a day for women, or two for men.
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