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Heart Disease in South Asians Ronesh Sinha, M.D.

Internal Medicine
Twitter: RoneshSinha

South Asian Risks

Very high heart disease prevalence Early age onset (5-10 years earlier) Rampant insulin resistance is usual cause (will discuss) Small blood vessels with severe atherosclerosis

Cultural Risks

Tobacco and alcohol use are still problems Physical inactivity: Brains over Body Diet is worse: Western and festival foods Immigrant 15

Samir: A Case Study

Samir is a 38 year-old software engineer who:

Eats a vegetarian diet Has a BMI (body mass index) of 24 Has a normal blood pressure and blood sugar Has a total cholesterol level of 190 He visits the gym 2-3 times a week, but is otherwise sedentary and work stress is high

Samirs Wake-up Call

At 3am Sunday morning, Samir was woken up with progressive chest discomfort. He took an antacid with no relief. His wife called 911 and he was rushed to Stanford ER where he was diagnosed with a massive heart attack due to a blockage in a major coronary artery

Atherosclerosis Is The Culprit

Ingredients for Plaque Formation

Ingredients* High cholesterol High blood pressure High blood sugar Tobacco Obesity High risk genes (family history) High stress levels *Not all ingredients necessary to create a heart attack: 1 or 2 ingredients may be enough!

Step One: Make A Plaque (Atheroma)

LDL cholesterol deposits in artery: first trigger Cholesterol attracts white blood cells (inflammation) White blood cells devour the LDL and form foam cells

Formation of fatty streak or early plaque

Smooth muscle cells form fibrous cap or scar over the fatty streak (fibroatheroma)

Step Two: Make The Plaque Unstable

Tobacco smoke High blood pressure Increase inflammation Unhealthy diet (trans fats are the worst!) Increased stress levels

Step Three: Wait for Plaque Rupture

Time interval from unstable plaque to plaque rupture varies

Plaque rupture that blocks off the blood vessel leads to a heart attack

Evolution of Atherosclerosis

Stress testing only detects this stage!


Interheart Top Five Risks

Abnormal cholesterol levels High blood pressure Diabetes Obesity Smoking

The above 5 risk factors account for 80 percent of heart attack risk worldwide

How to Interpret Cholesterol Results

Problem with Current Guidelines

70% of heart attack patients have normal cholesterol levels LDL can be very misleading (size matters!) Not enough emphasis on triglycerides Most people dont know how to raise HDL effectively

What Are Triglycerides?

Storage form of fat inside fat cells Early sign of insulin resistance Early trigger to atherosclerosis Leads to formation of type B LDL and low HDL levels


HDL- Healthy cholesterol LDL- Lousy or Lazy cholesterol

Samirs Cholesterol Results

Cholesterol Tests Total cholesterol LDL

Sample Results 190 108

Target Level Not important <100

Triglycerides Total Chol/HDL Ratio Triglyceride/HDL Ratio

250 190/32=5.9 250/32=7.8

<150 (<100 ideal) <4.0 <3.0

Typical Insulin Resistant Profile Total cholesterol usually less than 200 LDL usually normal or slightly elevated, but type B HDL usually low Triglycerides usually high TC/HDL usually high TG/HDL usually high

Control Your Blood Pressure

High Blood Pressure and Heart Disease

Injures blood vessel wall

Contributes to plaque instability and rupture

Usually no symptoms until a severe event (heart attack, stroke, etc.) occurs


How High is Too High?

Every 20/10 point increase in blood pressure above 115/75 doubles risk of heart disease and stroke

Monitor Your Blood Pressure

Get a home monitor if youve ever had an abnormal reading Cuff should be large enough Share home recordings with your doctor

Contributing Factors

Genetics: family history plays a role High sodium (processed foods) and low potassium (natural foods) intake Excess weight, especially abdominal fat Inactivity Insulin resistance (will discuss) Excess alcohol intake Aging Stress-dont underestimate this! Lack of sleep Above effects are additive

Prevent Insulin Resistance

(Prediabetes and Diabetes)

Insulin Response

Insulin Resistance

Insulin Toxicity

Eat carb (glucose)

Insulin produced

Glucose cant enter cells

More Insulin produced

Insulin toxicity


How To Measure Insulin Resistance?

Fasting glucose above 100 mg/dL suggests pre-diabetes Level above 125 mg/dL defines diabetes If borderline, ask your doctor to order an A1C: -A1C of 5.7% and above is prediabetes -A1C of 6.5% and above is diabetes

Other Clues to Insulin Resistance

High triglycerides and/or low HDL cholesterol (pre-pre diabetes) Excess abdominal fat Family history of insulin resistance (diabetes, gout, heart disease, etc.) Medical conditions: high blood pressure, gout, PCOS, gestational diabetes (during pregnancy), acanthosis nigricans


Control your Waistline and Weight

Identical Identical BMIsBMIs: 22.3 22.3

Body fat:
Yajnik CS, Yudkin JS. Lancet, 2004;



Big difference in body fat

Biometrics: Asian BMI




Waist To Hip Ratio(WHR)

Superior to BMI as an index of heart attack risk More constant among various ethnicities Reflective of abdominal obesity

Waist To Hip Ratio

Male 0.95 or below 0.96-1.0 >1.0

Female 0.80 or below 0.81-0.85 >0.85

Risk Normal Moderate High

Dangers of Belly Fat

Obesity-Heart Disease Connection

Started with 3275 adults aged 18-30 years in 1985-1986 without obesity Atherosclerotic plaque found in nearly 40 percent of those who had obesity for 20 or more years Each additional year of obesity increased plaque risk by 2% to 4%, regardless of the level of obesity Childhood obesity means earlier onset of plaque Risk likely worse if you are insulin resistant!

JAMA. 2013;310(3):280-288. doi:10.1001/jama.2013.7833 34

Asian-adjusted BMI

Waist-to-hip ratio

CarbsInsulinUnlocks Fat Cells

Insulin, Fat and Inflammation




Which is More Fattening???

Vegetarian Indian Thali

Steak & Vegetables

Vegetarian Asian Noodle Dish

Metabolic Syndrome


Strongest reversible risk factor for heart disease Increases LDL, triglycerides and lowers HDL Increases blood clotting Damages and constricts the blood vessel wall Raises blood pressure Increases inflammation

Heart Healthy Lifestyle

Reducing Insulin Resistance

Diet can significantly improve insulin resistance and its consequences (high triglycerides, low HDL, high blood sugar, abdominal obesity, etc.) Cut carbs, cut carbs, cut carbs! (Major culprit in Asian diets) Low fat diet can worsen triglycerides if you eat excess carbs (sugar, rice, noodles, breads, etc.)

Exercise: walking, aerobic, and resistance

OTC Omega-3s are overrated for lowering TGs

How to Improve LDL levels

Increase fiber in diet, mostly through vegetables If you are overweight, be careful of excess intake of oats, wheat, grains Emphasize healthier fats, especially monounsaturated (will discuss) Increased activity and exercise help Consider plant sterols to help lower LDL

South Asian Dietary Risks

Excessive refined carbohydrate intake (rice, noodles, flatbreads, etc.) Excess trans fat (vanaspati) intake Low vegetable intake

Social and family pressures

High sodium intake (processed foods, special sauces, chutneys, etc.)

Eat More Vegetables Than Fruit

Choose more crunchy and leafy vegetables Choose a variety of colors Get at least 5 servings daily Great vegetable snacks: baby carrots, celery sticks, mini cucumbers, sugar snap peas, mini peppers, grape tomatoes

Carb Copycats

Cauliflower Rice

Zucchini Pasta

Spaghetti Squash

Shredded Cabbage

Miracle Noodles or Miracle Rice (Shirataki Noodles)

Broccoli Slaw

Monunsaturated FatsThe Other Healthy Fat

Oils: olive oil, canola oil and peanut oil Nuts: hazelnuts, almonds, brazil nuts, cashews and peanuts/peanut butter Seeds: sesame and pumpkin seeds Avocados

Omega-3 Sources


Fish oil capsules Walnuts

Leafy Greens

Fortified Foods: Eggs w/Omega-3s

Fish: Salmon, Mackerel, Lake Trout, Herring, Albacore Tuna, etc.

Fish Oil Capsules

DHA &EPA are the active Omega-3s Lowering triglycerides: Need at least 3g of DHA/EPA, but effects are modest Heart protection: Need 250-500mg of DHA/EPA

Side effects: Nausea,upset stomach, bleeding in some patients when dose>3g/day(discuss with doctor)

Sitting Time Increases Death

Increased sitting time increases death from all causes This is independent of physical activity Sitting may activate LPL, a potent fat-storing hormone Keep sitting time to less than 8 hours/day and meet the standard recommendations for physical activity

Arch Int Med-vol 172; 3.26.12

Measure baseline steps Increase steps weekly Initial goal>5,000 Next 8-10,000

Iphone/Ipod App

One Mile Run Time

Highest Fitness Level (10% lifetime risk of heart disease) Men: 8 minutes or less Women: 9 minutes or less Moderate Fitness Men: ~ 9 minutes Women: ~10.5 minutes Low Fitness (30% lifetime risk of heart disease) Men >10 minutes Women >12 minutes
Run time in your 40s or 50s strongly correlates with heart disease risk later in life

Resting Heart Rate (RHR)

2010 study tracking middle-aged adults for an average of 12 years, found that an RHR over 90 beats per minute doubled heart attack death rates in men and tripled them in women.

Stress and Heart Disease

Stress raises heart disease risk

Stress increases inflammation Stress may lead to plaque instability and rupture Anger, internalization and time pressure stress are some specific risks Be sure to incorporate stress reduction into your lifestyle plan (exercise, meditation, yoga, socialization, peer support, etc.)


Track Your Numbers

Date Triglyceride HDL LDL Glu or A1C Weight Waist circumf # Daily steps Daily grams carbs



Dr. Rons Data (some learning points)

TG/HDL Ratio





As Triglycerides decrease, HDL increase Total cholesterol not useful to follow (increased as my numbers improved) LDL cholesterol shifts from bad B to better A (may cause LDL to go up, but not a concern)

TG/HDL ratio significantly improved


Be a Role Model for Your Family!

South Asian kids are now showing early signs of insulin resistance For the first time in human history, children are sedentary The whole family needs to make healthy changes. You are responsible for what your children eat.


South Asian Patient Resources

Topics Specific to South Asians Comprehensive South Asian Health Website

Culturally Tailored Tools (South Asian adjusted BMI calculator)

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