Chapter 12: Heart Attacks in South Asians: Understanding the Risks and Seeking Solutions(India, Bangladesh, Pakistan)

Top 10 reasons South Asians have the highest risk for heart disease or sudden cardiac event than any regions in the World.

Caution: Long read

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If you belong to the South Asian community anywhere on the globe, you may be well aware of the alarming incidence of premature and sudden cardiac events among individuals under the age of 55. Unfortunately, South Asians have the highest mortality rate due to heart disease. As someone who has personally survived this ordeal and a physician, my interest in preventive care compelled me to delve deeper into the factors that significantly impact this community as a whole.

The South Asian region, also known as the Indian Subcontinent, primarily comprises India, Pakistan, Bangladesh, Bhutan, Afghanistan, Nepal, Sri Lanka, Myanmar, and Maldives. The combined population of these countries exceeds 2 billion people, accounting for approximately 20% of the world's population or more. According to the World Health Organization (WHO), heart disease is the leading cause of premature death, particularly affecting men under the age of 55. The average life expectancy for men in this region is in their mid-sixties to early seventies.

Understanding the morbidity and mortality patterns in these countries is of utmost importance, as they will represent a significant portion of the future global workforce, particularly for aging populations in Western countries. To effectively address this challenge, it is crucial to comprehend the underlying disease processes that contribute to sudden deaths among younger populations and the immense burden this places on these communities.

Based on my experience as a physician working in various healthcare settings and conducting research, I have dedicated my efforts to understanding the pathophysiology behind the alarming number of premature deaths due to heart disease. Through my experience and firsthand encounters with patients who have survived such events, I have identified several factors that are believed to contribute to this phenomenon. Here are the top 10 reasons why South Asians tend to experience early mortality from heart disease.

Genetics of Heart disease…

Genetics plays a significant role in cardiovascular health, influencing various risk factors for heart disease. The impact of a family history of heart disease can be as substantial as having high blood pressure or high cholesterol levels. However, it's important to note that family history is not solely determined by DNA but is also influenced by shared lifestyles and home environments. Factors such as growing up in a household where people smoke or consuming a diet high in fast food can contribute to elevated blood pressure and cholesterol levels. Moreover, environmental factors like air pollution, poor water and food quality, and exposure to certain chemicals can also contribute to the development of heart disease.

Individuals with a family history of heart disease often share familiar environments and other factors that increase their risk of cardiovascular disease (CVD). Studies like the Framingham study have demonstrated that specific genes can significantly increase the risk of heart disease, sometimes even doubling or tripling it. The risk of heart disease can be further amplified when genetic factors combine with unhealthy lifestyle choices, such as smoking or following an unhealthy diet.

South Asians have a unique genetic makeup that may predispose them to a higher risk of heart disease. Studies have identified specific genetic variations that are more common in South Asians and are associated with conditions like coronary artery disease and myocardial infarction.

What to do about it…

 If you have a family history of heart disease in immediate family members, you need to closely monitor the overall health parameters in an optimal zone (5 B’s Blood pressure, Blood sugars, Blood cholesterol, Blood uric acid, Blood Vitamin D- refer to Chapter 9 for detailed analyses of each one with clinical studies) 

Smaller Coronaries…

South Asians have a high prevalence of coronary artery disease (CAD), and it often occurs at a younger age. Shockingly, 50% of all heart attacks in this population happen in individuals below the age of 55, with 25% occurring in those under 40. Previous studies have attributed this increased CAD risk among South Asians to structural factors, particularly smaller coronary arteries. However, our findings further support this notion as we discovered that Asian-Indian patients indeed have smaller coronary arteries. Importantly, even after accounting for body surface area, there was a statistically significant difference in the mean diameter of coronary arteries in this population.

The importance of monitoring blood pressure and prevention is the key from developing heart disease.

What to Do abut it?

South Asians are particularly vulnerable for heart disease as mentioned. People with abnormal Cholesterol would benefit from undergoing Coronary Calcium Score to risk profile and better management.

In addition to regular screening for traditional risk factors, using a test called coronary artery calcium (CAC) can be beneficial for assessing subclinical atherosclerosis and improving risk stratification in South Asian individuals. Research has shown that the current risk assessment tools tend to underestimate the risk of atherosclerotic cardiovascular disease (ASCVD) in South Asian adults, particularly those at low or intermediate risk. By incorporating CAC testing, we can better identify individuals who may benefit from lifestyle changes and pharmacotherapy for hypertension management. CAC scoring is considered a preferred noninvasive method for refining risk assessment in South Asians compared to other available non-traditional risk markers.

Physical Inactivity…

The activity levels among South Asians are notably low and they are among the least active populations. The American College of Cardiology recommends 150 minutes of moderate exercise per week to maximize the health benefits. However, most South Asians have minimal outdoor activities and are heavily engaged in sedentary behaviors, such as spending excessive time on screens for entertainment purposes. Research indicates that only one out of ten individuals in this population meets the recommended weekly exercise guidelines. This lack of physical activity has significant consequences for their health, leading to various health issues.

A survey conducted in North India comparing rural and urban dwellers found that energy expenditure during routine and leisure time physical activities was higher in rural subjects. Additionally, a systematic review from the U.K. revealed that South Asians participate in 50-75% less physical activity compared to their European counterparts.

These low levels of physical activity have detrimental effects on the health of South Asians. For instance, a study conducted in an urban South Indian population demonstrated a significant increase in the prevalence of diabetes with decreasing levels of physical activity. Furthermore, individuals who engaged in lighter-grade physical activity had higher insulin resistance compared to those who participated in more intense physical activities. Moreover, the level of physical activity showed an inverse correlation with blood glucose and insulin levels, as well as other components of the metabolic syndrome.

In summary, the low levels of physical activity among South Asians have adverse effects on their health, contributing to the increased risk of various health problems, including diabetes and metabolic syndrome. Encouraging and promoting regular physical activity in this population is crucial for improving their overall health and well-being.

What to do About it?

Get up and get moving. South Asians need to work on getting those extra steps and exercise regularly with strength training, which will help mitigate the risk of future heart disease. My exercise hack; Try to brisk walk 15 min away from your house to meet the daily exercise goal or 30 min.

Diets (Including smoking and excess consumption of Alcohol)…

The South Asian region is known for its delicious and calorie-dense foods, often leading to significant insulin spikes. However, rapid changes in dietary habits over the past decade have resulted in a sharp increase in metabolic diseases like metabolic syndrome, prediabetes, and diabetes. The booming South Asian economy has contributed to the availability and consumption of high-calorie foods and desserts, which have become a daily indulgence. This shift in dietary patterns has led to a rise in health problems associated with these foods, traditionally consumed in moderation.

The MASALA study conducted by UCSF examined the impact of dietary choices among South Asians who immigrated to the US. It found that individuals who continued to follow traditional Indian eating patterns had a higher risk of coronary artery disease than those who adopted healthier Western diets. Furthermore, as we age, adopting a minimalistic approach to food becomes increasingly important. Our calorie requirements decrease and numerous studies have consistently shown that reducing caloric intake improves longevity and overall health. Therefore, self-control in food consumption is essential for maintaining good health and promoting longevity.

As we age, it becomes increasingly important to adopt a minimalistic approach to food. Our calorie requirements decrease, and numerous studies have consistently shown that reducing caloric intake improves longevity and overall health.

The typical South Asian diet has several imbalances, including low intake of healthy fats (monounsaturated and polyunsaturated fatty acids) and fiber, and high intake of saturated fats, carbohydrates, and trans-fatty acids. These imbalances are associated with insulin resistance and abnormal lipid levels. Urbanization and migration have worsened the effects of this imbalanced diet.

Studies evaluating the diets of Indian migrants to the US have shown an increased consumption of fruit juice, chips, margarine, cola, and alcoholic beverages, regardless of the length of time they have been in the US. In summary, the South Asian population has experienced a shift towards calorie-dense foods, leading to an increased risk of insulin resistance and metabolic diseases. It is important to address these dietary imbalances by promoting healthier eating patterns and reducing the consumption of unhealthy fats and refined carbohydrates.

Smoking and excessive drinking are well known risk factors for heart disease. There is a dramatic increase in drinking alcohol, but smoking has lessened in South Asians.

What to do about it?

Shed the processed food, caloric-dense foods, and sweets. Increase consumption of unprocessed foods with raw vegetables, preferred non-starch vegetables, and non-tropical fruits in the diet. Studies have shown that daily fiber intake reduces heart disease by 85%. 95% of Americans do not meet this criterion; now imagine South Asians(I am being one too, tough to consume raw vegetables).

Metabolic disease(Insulin Resistance)…

In Chapter 3, I have discussed the vital role of metabolism in our daily lives. It highlights how excessive consumption of sugary calories and disrupted storage mechanisms due to constant overeating can give rise to various diseases, including heart disease. The chain of events triggered by high blood sugar levels and increased insulin production during continuous overfeeding leads to multiple health issues. One area of extensive research focuses on the pancreatic beta-cell insufficiency experienced by South Asians, contributing to the early development of prediabetes and Diabetes. Their diets, increasingly rich in heavily dense carbohydrate foods, contribute to a combination of beta-cell problems that lead to metabolic diseases. 

Studies have demonstrated that South Asians have higher basal insulin levels and more significant insulin response to glucose than Europeans, indicating their need for higher insulin levels to maintain normal blood sugar levels. Elevated insulin levels initiate a cascade of inflammatory pathways that contribute to a wide range of diseases. More research will shed why South Asians have this effect. 

A multi-ethnic study among healthy, young, and lean adults has also shown a two to three-fold higher prevalence of insulin resistance among Asian Indians, particularly men, than among other ethnic groups.

In summary, South Asians have a higher prevalence of insulin resistance, leading to an increased risk of developing Diabetes and being a significant contributor to heart disease. Recognizing and addressing insulin resistance in this population is crucial for effective prevention and management of Diabetes.

What to do about it?

Start with checking random blood sugar tests and yearly physical exams with your doctor. Now we have CGM (continuous glucose monitoring) for better tracking of prediabetes and Diabetes. Unfortunately, Prediabetes doesn't get enough press, possibly one of the underlying problems that cause damage to the coronaries(heart arteries) and, in some cases, heart attacks.     

Stress…

Stress is your body's reaction to a challenge or demand. It can come from any event or thought that makes you feel frustrated, angry, or nervous. Everyone deals with stress differently. People under stress experience mental and physical symptoms, such as irritability, anger, fatigue, muscle pain, digestive troubles, and difficulty sleeping.

The mechanism of chronic stress has been significantly studied in the last few decades. Studies showed mental stress with substantial blood pressure elevations and coronary artery vasoconstriction(Increased pressure in coronaries), especially in Coronary artery disease patients causing ischemia (decreased oxygen supply to the heart), leading to a heart attack.

The most common stressors with heart disease are Social Isolation, Depression and hopelessness, Childhood Socioeconomic status, Childhood abuse, Work-life stress, Marital problems, death of a child, or care of a sick spouse. Depressive symptoms have been associated with sudden death and Heart Attack risk. Meta-analytic reviews show that patients with chronic heart disease or other chronic conditions have a significantly worse prognosis if they experience social isolation.

According to the INTERHEART study, experiencing long-term work-related stress increases the risk of heart attacks by more than two times compared to those with no work pressure. Research suggests a direct link between childhood adversity and heart health. Many South Asians face significant stress and hardships during their childhood and teenage years. It is alarming to observe that heart disease affects them 10 to 15 years earlier than individuals of other ethnicities. More comprehensive research is necessary to better understand and address this issue.

 What to do about it?

Shed the screens; it's becoming difficult for many of us to live without. Constant work, entertainment, home chores, shopping, everything has evolved with the screens. Also, demarcating work from home is challenging but essential; sleep, identifying stress factors, seeking support, and mindfulness meditation help mitigate the risks of developing heart disease.

Sleep deprivation…

During the 1980s, Japan witnessed an economic boom. Still, it also brought attention to the issue of work exhaustion and sleep deprivation, which were believed to be responsible for many deaths. The term "karoshi," meaning "death from overwork," emerged, with many cases involving acute cardiovascular events.

A recent poll by the National Sleep Foundation in the United States revealed many Americans suffer from long-term sleep deprivation. Surprisingly, only about one-third of the population reported getting the recommended 8 hours of sleep per night, while 31% reported getting 6 hours or less. Sleep insufficiency has become a prevalent problem in modern society, with evidence showing an average nightly sleep duration of only 6.8 hours, 1.5 hours less than a century ago. Prolonged periods of inadequate sleep may have detrimental effects on cardiovascular health. For example, prospective studies conducted in the United States, the Netherlands, Denmark, and Sweden found associations between long working hours and a higher risk of coronary heart disease.

South Asians are increasingly adopting the Western trend of working around the clock, leading to a lack of sufficient sleep and resulting in sleep deprivation.

Several biological explanations have been proposed to understand the heightened risk of coronary heart disease associated with sleep deprivation. Increased sympathetic nervous system activity and hypertension may underlie this relationship. Sleep deprivation has been shown to elevate sympathetic nervous system activity, heart rate, vasoconstriction, and salt retention. These factors may contribute to hypertension by placing excessive strain on the heart and increasing fluid volume, thus aiding in causing heart attacks.

What to do about it?

Just sleep 7-8 hours a day. Pure and simple.

Normal weight Obesity (Normal weight Obesity)…

The term "NWO" refers to Normal Weight Obesity, or Skinny fat, for individuals with a body mass index (BMI) of 25 kg/m2 or lower but possessing a higher percentage of body fat. The body fat percentage can vary depending on the population under study, sex, and ethnicity. For example, the American Society of Endocrinologists defines obesity based on body fat percentage as 35% or higher in women and 25% or higher in men. However, among individuals of Asian origin, the cutoffs are lower, with 33.4% or higher for women and 20.6% or higher for men.

In clinic settings, healthcare professionals often rely on measuring waist circumference and waist-hip ratio as indicators of visceral fat. Dual-energy X-ray absorptiometry (DXA) provides a more accurate and cost-effective approach to assessing the increasing prevalence of NWO in these populations.

Emerging evidence suggests that individuals with NWO or skinny fat experience increased inflammatory state, insulin resistance, elevated blood pressure, and abnormal lipids. These factors can predispose them to a higher risk of heart disease. Furthermore, an analysis of data from the National Health and Nutrition Examination Survey III revealed that women with NWO had an independent association with cardiovascular mortality.

South Asians tend to be leaner and possibly have skinny or visceral fat, which internally causes ongoing inflammation. Again one needs to work on diagnosing the problem, mitigating the risks from worsening, and creating an environment to cause heart attacks in these populations.

What to do about it?

 For high-risk individuals(lean but have high cholesterol, fatty liver, and high blood pressure), checking waist-to-hip ratio is more than 0.8 for women, and 0.9 in men shown to have excessive abdominal fat(visceral adiposity). Also, the DXA scan is more specific to reveal hidden visceral fat(fat around organs), especially in South Asians. 

Environmental Pollution…

Air pollution profoundly impacts health, comparable to risk factors like smoking, hypertension, and physical inactivity. It leads to premature deaths, with heart disease being the primary cause in 70-80% of cases, while lung diseases and cancer account for the rest. In 2015, pollution-related diseases caused an estimated 9 million premature deaths globally, representing 16% of all deaths. The most severely affected countries see over one in four deaths attributed to pollution-related diseases, and approximately 92% of pollution-related deaths occur in low- and middle-income countries. In India, air pollution was responsible for 1.67 million deaths in 2019, accounting for 17.8% of total deaths in the country. Ambient air pollution contributes more to these deaths than household air pollution. Short-term exposure to fine particulate matter (PM2.5) and nitrogen dioxide (NO2) increases heart disease mortality. The effects of air pollution cause an increase in inflammation, alteration in arterial wall dysfunction, increase in clotting, etc., resulting in chronic conditions like hypertension and plaque buildup in arteries.

What to do About it?

Not an easy answer. South Asian cities are some of the most polluted cities in the world. Vigilant about air quality warnings, using masks when appropriate and filters and screens can reduce some risk.

Vitamin D and Sunlight…

The sun is a wonderful natural resource that provides numerous benefits for our well-being. It plays a crucial role in helping our bodies heal and maintain balance. One important aspect is its ability to help us produce vitamin D, essential for bone and calcium metabolism. Recent research has also shown that vitamin D impacts our immune system and metabolism and improves blood pressure. While clinical studies have yielded mixed results regarding its effects, it's essential to consider that sunlight has been a part of our evolution alongside plants and animals. Our skin has the remarkable ability to produce vitamin D when exposed to the sun. However, if it's impossible to get enough sunlight, supplements or fortified foods can be used to maintain adequate vitamin D levels. It's crucial to monitor vitamin D levels when taking supplements to ensure they don't reach toxic levels, although the risk of toxicity is rare but not unheard of.

Unfortunately, the sun has received negative attention due to the sunscreen industry emphasizing the risks of sun exposure, such as skin cancer. However, the benefits of sun exposure outweigh the risks, especially for individuals with darker skin tones. Some countries are now adopting a more balanced approach to sun exposure, encouraging sensible and moderate time spent in the sun. When the weather is suitable, and the sun is out, lying down and soaking up some sun for improved health can be beneficial. Sensible sun exposure has been linked to improved cardiometabolic health, cancer prevention, and a reduced risk of autoimmune diseases. We must protect our eyes by wearing sunglasses mid-afternoon when the sun's UV light is strongest and could potentially harm our eyes.

Remember, prevention is always better than cure. The sun is a natural and essential element that we often overlook due to our modern lifestyles and dependence on technology. So, the next time you're outdoors, allow your skin to enjoy the sun's rays and embrace the positive feelings it brings. Just remember to practice sensible exposure, as moderation is key.

What to do about it?

Spend some time outdoors. It's not just Vitamin D; Folks who spend outdoors every day for at least an hour have improved mood, overall positive outlook, and healthy longevity.

Conclusion…

Heart disease is a significant concern among South Asians, with the highest rates of premature mortality and morbidity related to cardiovascular conditions. Raising awareness in this population about the importance of enhancing their well-being is crucial. A key reason for this emphasis is the potential emergence of South Asians as a global workforce, as Western populations age and birth rates decline. Although information about heart disease is readily available, it can be challenging to comprehend and interpret. Insufficient awareness and limited knowledge about heart disease contribute to the issue. Educating South Asians about prevention, risk factors, and early symptoms is vital to facilitate prompt diagnosis and treatment. Cultural practices, such as a preference for fried and carbohydrate rich foods contribute to an unhealthy diet and heighten the risk of heart disease. Prioritizing awareness and knowledge about health among South Asians can empower individuals to make informed choices, seek appropriate healthcare, and ultimately lead longer, healthier, and more prosperous lives.

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Suman Manchireddy MD FACP FHM, Internal Medicine, Leesburg, VA.

Email : Care@ReliantMD.com

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Disclaimer: This is purely informational and educational purposes only, seek medical advise prior to starting any testing or treatment regimen. The data presented here is researched extensively and has been condensed for a broader audience.