Are Race and Ethnicity Risk Factors for Developing Heart Disease? According to the American Heart Association, yes. In 2018, the organization added race and ethnicity as factors in its guidelines for high cholesterol risk, highlighting an overlooked health difference: Relative to the general population of the United States, South Asians have the highest risk of developing heart disease.
As part of the fastest growing race and ethnic group in the country, South Asians are often lumped together with other Asian Americans, despite large differences in income levels, educational levels, cultural norms and health risks, according to the 2020 census. The ancestral roots of the group are in India, Pakistan, Bangladesh, Nepal and Sri Lanka. Even among South Asians, religious and cultural practices are very different from Hindu and Jain practitioners, many of whom eat a vegetarian diet; to Muslims from all over the subcontinent who avoid pork.
Long before the AHA considered race and ethnicity in treatments for high cholesterol, medical researchers were studying how and why South Asians overall are at increased risk for heart disease. Although research is still ongoing, scientists have uncovered a mix of biological and cultural factors influencing lifestyle habits – results that can lead to interventions that can help South Asians across the country stave off diabetes, heart disease and stroke.
Since 2006, the Mediators of Atherosclerosis in South Asians Living in America (MASALA) study has followed more than 900 South Asians in Chicago and the Bay Area. Researchers are studying how lifestyle habits, social and cultural norms, and possible biological differences are driving the development of heart disease and related conditions such as diabetes and metabolic syndrome.
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The MASALA study, conducted by researchers from Northwestern University and the University of California at San Francisco, carved out the unique health risks faced by South Asians from other Asians and uncovered some startling statistics about the group. South Asian Americans are four times more likely to develop heart disease than the entire US population. They are also more likely to have heart attacks before age 50 and have the highest prevalence of type 2 diabetes, a leading cause of heart disease.
South Asian Americans are four times more likely to develop heart disease than the entire US population.
Alka Kanaya, Dr, persuaded you to start studying MASALA. “Before that there was really no data on it in the US,” says Dr. Kanaya. “It’s really hard to see any of the nuances when you put 40 very different cultural groups together.” Today the study expanded to include an additional 250 subjects in the hope of adding more Pakistani and Bangladeshi patients to the study. (Currently 83 percent of Indian Americans make up the study.)
In addition to other important findings, MASALA has also uncovered a link between body composition and diabetes in South Asians. Using CT scans, Dr. Kanaya found that the group had a tendency to store visceral fat, or fat, in and around the liver, intestines, and abdomen. This tendency towards belly fat is also found in other Asian ethnic groups.
As a collective group, Asian Americans have a lower risk of dying from heart disease, but South Asians actually have a higher risk of death than non-Hispanic Whites and other Asian groups when the health data of the East and Southeast Asian populations is factored out. The biological and sociocultural reasons for this increased risk are difficult to determine, according to Abha Khandelwal, MD, a cardiologist and researcher at the Stanford South Asian Translational Heart Initiative.
“One reason it is very difficult to really understand cardiovascular disease in South Asians is that they are such a heterogeneous group of patients,” says Dr. Khandelwal and refers to both genetics and lifestyle behavior shaped by cultural practices and norms. However, she adds that dietary practices go a long way in contributing to this and that there is evidence that South Asians tend to have higher levels of lipoprotein A, a type of cholesterol particle that increases the risk of heart disease.
On the whole, however, Khandelwal says that high blood pressure and diabetes, both of which contribute to heart disease, are still prevalent in South Asians around the world. Some of this is due to a vegetarian diet high in processed starches and fried foods. (Although many South Asians follow a vegetarian diet for religious and cultural reasons, not all do.)
Internist Ronesh Sinha, MD, wrote The South Asian Health Solution in 2015 after realizing that the standard health guidelines most general practitioners gave to South Asian high-risk patients did not align with their culturally informed eating habits. Many South Asians may fly under the radar because they may be lacking subcutaneous fat, which can help make them look visibly overweight, he adds. Instead, they have hidden visceral fat, which the MASALA study also identified, and are often lacking in muscle mass. Visceral fat, typically wrapping around organs, is linked to a higher risk of heart disease. “Weight is pretty misleading – for all races,” says Dr. Sinha. Instead, he focuses more on waist size, or the waist-to-height ratio. “If you take your height and divide it by two, your waist should really be that number or less.”
“Weight is quite misleading – for all races.” – Ronesh Sinha, MD
South Asians are also more likely to develop diabetes or metabolic syndrome, a prediabetic disease, at lower body weights than the rest of the population, which helped the American Diabetic Association recommend lowering the BMI limit for Asian Americans when measuring diabetes risk in the year 2015, to whose co-author Dr. Kanaya was involved. In the middle of his life, Sinha himself developed metabolic syndrome, a collection of symptoms that suggest insulin resistance or the first signs of diabetes. “See young patients coming” [with early heart disease and diabetes] and then watching me develop some of these risk factors in parallel was an eye-opening experience, ”says Dr. Sinha.
While a large percentage of Native Americans (who make up the majority of the South Asian population of the United States) eat a vegetarian diet, it is not necessarily healthy, he adds. Compared to a plant-rich Western vegetarian diet, a South Asian vegetarian diet might be more grain-focused, with lots of flatbreads, fried snacks, and large servings of rice and starchy vegetables. In his practice, Dr. Sinha encourages vegetarian South Asian patients to incorporate more vegetable protein sources and reduce carbohydrates. “You can still enjoy your carbohydrates, but you just need to be aware of the amount you’re consuming,” he says.
Overall, Dr. Kanaya, lead researcher of the MASALA study, pointed a finger at the biological factors that cause this inequality in heart disease and diabetes. Instead, it emphasizes cultural and social determinants, including sticking to traditional culture versus assimilation. Among South Asian women, the MASALA study found that women with a more Western cultural outlook had fewer risk factors for heart disease. “This is completely different from other immigrant groups,” says Dr. Kanaya, citing evidence from Japanese Americans who, with each generation and increasing assimilation, have noted higher rates of obesity, heart disease, and diabetes. Some of this is diet based, but some can also be attributed to less cultural beliefs that encourage regular physical activity. “Things can change in younger generations now because of the message that it is better to be physically active than in a culture that has never promoted physical activity so much,” says Dr. Kanaya.
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