Read about MASALA in the Washington Post!

Read about MASALA in the Washington Post!

Push Is On in US to Figure Out South Asians’ High Heart Risks

Vignesh Ramachandran

For years, Sharad Acharya’s frequent hikes in the mountains outside Denver would leave him short of breath. But a real wake-up call came three years ago when he suddenly struggled to breathe while walking through an airport.

An electrocardiogram revealed that Acharya, a Nepali American from Broomfield, Colorado, had an irregular heartbeat on top of the high blood pressure he already knew about. He had to immediately undergo triple bypass surgery and get seven stents.

Acharya, now 54, thought of his late father and his many uncles who have had heart problems.

“It’s part of my genetics, for sure,” he said.

South Asian Americans — people with roots in Nepal, India, Pakistan, Sri Lanka, Bangladesh, Bhutan and the Maldives — have a disproportionately higher risk of heart disease and other cardiovascular ailments. Worldwide, South Asians account for 60% of all heart disease cases, even though — at 2 billion people — they make up only a quarter of the planet’s population.

In the United States, there’s increasing attention on these risks for Americans of South Asian descent, a growing population of about 5.4 million. Health care professionals attribute the problem to a mix of genetic, cultural and lifestyle influences — but researchers are advocating for more resources to fully understand it.

Rep. Pramila Jayapal (D-Wash.) is sponsoring legislation that would direct $5 million over the next five years toward research into heart disease among South Asian Americans and raising awareness of the issue. The bill passed the U.S. House in September and is up for consideration in the Senate.

The issue could gain more attention after Sen. Kamala Harris (D-Calif.) becomes the nation’s first vice president with South Asian lineage. Harris’ mother, Shyamala Gopalan, moved from India to the U.S. in 1958 to attend graduate school. Gopalan, a breast cancer researcher, died in 2009 of colon cancer.

A 2018 study for the American Heart Association found South Asian Americans are more likely to die of coronary heart disease than other Asian Americans and non-Hispanic white Americans. The study pointed to their high incidences of diabetes and prediabetes as risk factors, as well as high waist-to-hip ratios. People of South Asian descent have a higher tendency to gain visceral fat in the abdomen, which is associated with insulin resistance. They also were found to be less physically active than other ethnic groups in the U.S.

One of the nation’s largest undertakings to understand these risks is the Mediators of Atherosclerosis in South Asians Living in America study, which began in 2006. The MASALA researchers, from institutions such as Northwestern University and the University of California-San Francisco, have examined more than 1,100 South Asian American men and women ages 40-79 to better understand the prevalence and outcomes of cardiovascular disease. They stress that high blood pressure and diabetes are common in the community, even for people at normal weights.

That’s why, said Dr. Alka Kanaya, MASALA’s principal investigator and a professor at UCSF, South Asians cannot rely on traditional body mass index metrics, because BMI numbers considered normal could provide false reassurance to those who might still be at risk.

Kanaya recommends cardiac CT scans, which she said help identify high-risk patients, those who need to make more aggressive lifestyle changes and those who may need preventive medication.

Another risk factor, this one cultural, is diet. Some South Asian Americans are vegetarians, though it’s often a grain-heavy diet reliant on rice and flatbread. The AHA study found risks in such diets, which are high in refined carbohydrates and saturated fat.

“We have to understand the cultural nuances [with] an Indian vegetarian diet,” said Dr. Ronesh Sinha, author of “The South Asian Health Solution” and an internal medicine physician. “That means something totally different than … a Westerner who’s going to be consuming a lot of plant-based protein and tofu, eating lots of salads and things that typical South Asians don’t.”

But getting South Asians to change their eating habits can be challenging, because their culture expresses hospitality and love through food, according to Arnab Mukherjea, an associate professor of health sciences at California State University-East Bay. “One of the things South Asians tend to take a lot of pride in is transmitting cultural values and norms knowledge to the next generation,” Mukherjea said.

The intergenerational transmission goes both ways, according to MASALA researchers. Adult, second-generation South Asian Americans might be the key to helping those in the first generation who are resistant to change adopt healthier habits, according to Kanaya.

In the San Francisco Bay Area, El Camino Hospital’s South Asian Heart Center is one of the nation’s leading centers for educating the community. Its three locations are not far from Silicon Valley tech giants, which employ many South Asian Americans.

The center’s medical director, Dr. César Molina, said the center treats many relatively young patients of South Asian descent without typical risk factors for cardiovascular disease.

“It was like the typical 44-year-old engineer with a spouse and two kids showing up with a heart attack,” he said.

The South Asian Health Center helps patients make lifestyle changes through meditation, exercise, diet and sleep. The nearby Palo Alto Medical Foundation’s Prevention and Awareness for South Asians program and the Stanford South Asian Translational Heart Initiative provide medical support for the community. Even patients in the later stages of heart disease can be helped by lifestyle changes, Sinha said.

Dr. Kevin Shah, a University of Utah cardiologist who co-authored the AHA study, said people with diabetes, hypertension and obesity are also at higher risk of COVID-19 complications so should now especially work to improve their cardiovascular health and fitness.

In Colorado, Acharya’s health is still an issue. He said he had to get four more stents this year, and the surgeries have put pressure on his family. But he’s breathing well, watching what he eats — and once more exploring his beloved mountains.

“Nowadays, I feel very, very good,” he said. “I’m hiking a lot.”

Subscribe to KHN's free Morning Briefing.

COVID and your health

This illustration, created at the Centers for Disease Control and Prevention (CDC).

This illustration, created at the Centers for Disease Control and Prevention (CDC).

We hope that you and your family are doing well during this difficult situation that is impacting the world.  We want to share a community webinar providing information about COVID-19 taking into consideration the needs of those living with hypertension, diabetes, and asthma. This webinar was presented by Dr. Namratha Kandula from Northwestern University, one of our MASALA study centers. Click on the link below to watch the video recording. We have also provided a shortlist of resources for you that may be beneficial. 

Video recording link:   

https://northwestern.zoom.us/rec/play/u8YtcL2hqW03HNWV5QSDAvF4W9W9KP6s2nAb-PMJykm3ACQAYwKvNeREZ7EuSRLDQGSsfQBXXEe4cwmi​

Reliable COVID Resources:

COVID information for people with chronic health conditions:

The most important thing for you to know is that if you are having any new medical symptoms, that you should seek care from a healthcare professional. This recent article in the New York Times article highlights two South Asian patients who waited too long to get care for their heart attacks because they were fearful of COVID. Hospitals, clinics, and emergency rooms in the Bay Area are not overwhelmed, and patients should not postpone their urgent medical needs. Please seek help with your primary care provider or at your local hospital if you are having any new concerning symptoms.

MASALA is turning 10 years old!

It's hard to believe that our study is turning 10 years old this year. What began as a small pilot study in 2006 with 150 participants in the SF Bay Area laid the foundation for our larger study which began recruitment in October 2010. We recruited 906 participants from 2010-2013 and then added another group of 258 participants in 2017-2018. We are so thankful for the journey that we have been on with our 1,164 participants, and grateful for all of the lessons we have learned about South Asian health. 

Each of our study sites will be celebrating this milestone 10 year anniversary this year. On Saturday, February 22nd, the Chicago team had a wonderful lunch event that was attended by over 100 participants. People spoke about what being in the MASALA study meant to them and placed sticky notes on a poster board sharing how being in MASALA made them feel.

Here are a few of the poster comments:

--informed and healthy

--visible

--more awareness

--feel healthy and confident

--makes me feel safe...like I am in good hands --feel the impact in our community

Please stay tuned to hear about our SF Bay Area events planned for this spring and summer.

Thank you for your help and interest in this landmark study. We couldn't do it without you!

Read about MASALA in the Chicago Tribune

Read about MASALA in the Chicago Tribune

South Asians make up 60 percent of heart disease patients: ‘Everyone knows somebody who has had a heart attack’

Kate Thayer

Chicago Tribune |

Nov 26, 2019 | 8:00 AM

Munaf Patel, 43, puts on his gym shoes before walking the roughly 1.5-mile loop path outside of his office in Glenview on Nov. 21, 2019. After surviving two heart attacks beginning at age 39, Patel now walks regularly during his lunch hour, takes part in other athletic activities and has made dietary changes to improve his health. (Heather Eidson/for the Chicago Tribune)

Munaf Patel is an active husband and father. He plays cricket, basketball and volleyball, and runs around with his young kids in the family’s yard near the city’s Far Northwest Side.

So when he had an “uneasy” feeling in his chest in September 2015, he took some aspirin and followed up with his doctor. He was concerned but didn’t expect to hear what test results showed — at age 39, Patel was having a heart attack.

Despite the placement of a stent to unblock his artery, a quick recovery and watching what he ate, Patel had his second heart attack just eight months later.

“I was very active, and you don’t think about it when you’re young,” he said. “At the age that I am at, you don’t expect those things.”

But a part of him knew to be vigilant about his health; Patel, who is Indian, has an extensive family history of heart disease that many South Asians share. His family represents the heightened risk carried by South Asians, who experts say are about four times more at risk for cardiovascular disease — the leading cause of death in the U.S. — than other groups, and are stricken at younger ages.

As a young boy, Patel lost his father, who died in his 40s after a heart attack. Several other close relatives have had heart attacks at young ages, and one needed a heart transplant.

Munaf Patel, 43, checks his phone while walking the roughly 1.5-mile loop path outside of his office in Glenview on Nov. 21, 2019. After surviving two heart attacks beginning at age 39, Patel now walks regularly during his lunch hour, takes part in other athletic activities and has made dietary changes to improve his health. He also often turns on an app on his phone to track his steps during his walk. (Heather Eidson/for the Chicago Tribune)

Researchers continue to probe why it seems that, in the South Asian community, everyone knows someone who has had a heart attack. Experts say that while the group represents about a quarter of the world’s population, it accounts for about 60% of heart disease patients.

The alarming risk has prompted researchers to study South Asians in the long-term Mediators of Atherosclerosis in South Asians Living in America study, known as Masala (meaning spice blend), in part because medical guidelines physicians historically use come from data derived from white men. Yet South Asians, researchers say, often do not show some of the typical signs of cardiovascular disease and need their own guidelines. Experts also say it’s important to distinguish South Asians — those from India, Pakistan, Sri Lanka and other countries in the region — from other Asian groups because their risks differ.

This work has led to a shift in recommendations last year from the American Heart Association and other medical organizations, directing physicians to consider ethnicity when assessing patients’ cardiac health. The move recognized that South Asian patients tend to carry lower levels of good cholesterol in their blood, among other health distinctions.

There’s also an effort to educate South Asians about the risk they carry that might be surprising or go unnoticed, but possibly could be offset by diet and exercise. At Advocate Lutheran General Hospital’s South Asian Cardiovascular Center, clinicians have amped up their efforts with a video series that provides heart healthy recipes and encourages sound lifestyle choices.

Dr. Shoeb Sitafalwalla, a cardiologist and medical director of the center, works with a team that treats South Asian patients and also goes into the community, spreading the word that healthy eating and exercise could help offset their genetic predisposition. That includes regular visits to speak at churches, mosques, restaurants and grocery stores that sell ingredients used in South Asian recipes.

Dietitian Srisakthi Ramanathan helps shopper Leena Joshi, from Roselle, with a healthy diet plan at Patel Brothers Grocery Store on Nov. 21, 2019, in Schaumburg. South Asians are about four times more likely to have heart disease, and it affects them earlier. As researchers continue to look into exactly why, a team at Lutheran General hospital that works to educate South Asians about their risk, heart healthy eating and lifestyle had developed a series of videos. Some offer recipes, and some work to dispel myths and encourage good health practices. (John Konstantaras/for the Chicago Tribune)

To expand its audience, the group created a video series, called “Dil Se,” a Hindi phrase that means “from the heart.” The first seven in the 25-video series launched over the past few months.

Sitafalwalla said that while South Asians likely have heard of this risk because of knowing others affected, it’s not talked about enough.

“You talk about how your daughter got into law school,” he said. “You don’t talk about how your son just had a heart attack.”

The advocacy work of the cardiovascular center “started as a grass-roots operation, going into communities ... taking our message of health and wellness,” he added. “But we were limited in scale. There are 300,000 South Asians living in Illinois. We needed to find a way that could help us bring that message to a greater amount of people.”

The team came up with the video series concept as a way to “interact with the community, especially where their eyes are most — their mobile phones,” Sitafalwalla said. A grant from Boehringer Ingelheim Pharmaceuticals helped fund the project.

Some of the videos resemble rapid-fire cooking videos popular on social media, and include facts on wise food choices for those concerned about cholesterol or blood sugar. South Asians are also at a greater risk for diabetes, Sitafalwalla said.

Others tackle myths or home remedies Sitafalwalla said are common within South Asian communities, from drinking apple cider vinegar to unblock arteries to rubbing lemons on skin to get rid of dark spots on the skin — a sign of diabetes.

Dietitian Srisakthi Ramanathan said the video recipes for healthier versions of South Asian cuisine include a mock-up of a nutrition label for the dish. “That’s hard to find in Indian recipes. That’s a big gift.”

During community demonstrations, Ramanathan said, she’ll hear from South Asians that it’s eye-opening to learn about the nutritional makeup of certain foods, as well as portion control, especially with oil.

Dietitian Srisakthi Ramanathan helps shoppers with healthy diet plans at Patel Brothers Grocery Store on Nov. 21, 2019, in Schaumburg. (John Konstantaras / Chicago Tribune)

South Asians have a cultural connection with oil, she said, as well as a desire not to waste it. “Even now, my mom will hide the oil because they don’t want us to find it and throw it away.”

“When you’re entertaining or serving your family, adding more oil is considered a sign of generosity,” added Sitafalwalla. “So when the pot of curry sits down on the table, if there isn’t an oil slick you can see, it’s not generous. What you don’t realize is you’re also being really generous in how you’ll clog up their arteries.”

But educating the community doesn’t mean wiping away traditions, he said, and the team tries to be culturally sensitive. “All of the choices that we lay out … are pragmatic ones. We’re under no illusion that people are going to give up staple items that are culturally ingrained.”

Given the inherited risk, eating right and exercising are especially important for South Asians, Sitafalwalla said, and it’s important to learn from a young age, noting that 25% of heart attacks among South Asians occur before age 40, and half occur before 50.

Dr. Namratha Kandula, a Northwestern University researcher involved in the ongoing, long-range Masala study, said it’s vital to better understand why the group has these risks “because they don’t fit the typical pattern of someone at risk of heart attack and stroke.”

South Asians are typically not overweight and do not use much tobacco, common risk factors for heart disease.

But through the ongoing study, researchers have learned the group has other risk factors, like high blood pressure, less lean muscle mass and a tendency to store fat in the liver and abdomen.

Kandula said there are also cultural differences, like not regularly exercising. Yet “exercise is very important because of the South Asian body type,” she said.

“The goal isn’t really to lose weight,” but to build lean muscle, she said.

Kandula promotes this and other healthy concepts in another study she’s leading: the South Asian Healthy Lifestyle Initiative, or Saheli (meaning friend), which helps participants change behaviors by incorporating exercise and healthy foods into their lives. The 16-week program, in its third year, works with community partners and so far has recruited more than 300 South Asian participants in the area. The goal is to reach about 550 in the next couple of years, Kandula said.

While members of the South Asian community are aware of these risks, they might be reluctant to discuss and seek guidance, Kandula said.

“Everyone knows somebody who has had a heart attack at a young age. It’s very common,” she said. “But how do you get support to help manage them? It’s sort of your own problem.”

Saheli study participant Ravi Natarajan, 48, of Naperville, enrolled in the study last fall after hearing about it at his temple. While Natarajan said he’s “pretty healthy,” his father had a heart attack at 68, and he also has had friends in their 30s experience heart attacks.

“I wanted to learn more about prevention,” he said.

Through the study, he learned to keep food logs, received regular cholesterol and blood sugar checks, and talked about ways to manage stress. Natarajan said he now incorporates more fruit and healthy grains into his diet, and added strength training to his walking and running routine.

The result is lower cholesterol and he shed a few pounds, but Natarajan said he also has benefited from awareness of his risks, now leading a healthy life and setting an example for his sons.

“My sons are watching me,” he said. “We cannot control ... some of the family history. What we can control is the exercise as well as the food habits.”

Patel, now 43, said he’s doing well and is fully recovered from his two heart attacks. He said he remains active and only indulges in fried shrimp and some of his other less nutritious favorites every once in a while.

He also tries to talk to others in his community about their shared risks, especially those hesitant to pay attention to markers like high blood pressure, or those who don’t get regular doctor checkups.

“It can happen to anyone; it doesn’t matter how old,” Patel said. “You get worried about your family, your kids, yourself.”