Why do South Asians have heart disease?


Why Do South Asians Have Such High Rates of Heart Disease?:

Some of the most striking findings to come out of Masala relate to body composition. Using CT scans, Dr. Kanaya and her colleagues found that South Asians have a greater tendency to store body fat in places where it shouldn’t be, like the liver, abdomen and muscles. Fat that accumulates in these areas, known as visceral or ectopic fat, causes greater metabolic damage than fat that is stored just underneath the skin, known as subcutaneous fat.

…. Cardiovascular risks tended to be highest in two groups: those who maintained very strong ties to traditional South Asian religious, cultural and dietary customs, and those who vigorously — embraced a Western lifestyle. Those with lower risk are what the researchers call bicultural, maintaining some aspects of traditional South Asian culture while also adopting some healthy Western habits.

This discrepancy plays out in their dietary behaviors. Almost 40 percent of Masala participants are vegetarian, a common practice in India that is widely regarded in the West as heart healthy. But vegetarians who eat traditional South Asian foods like fried snacks, sweetened beverages and high-fat dairy products were found to have worse cardiovascular health than those who eat what the researchers call a “prudent” diet with more fruits, vegetables, nuts, beans and whole grains (and, for nonvegetarians, fish and chicken). People who eat a Western style diet with red and processed meat, alcohol, refined carbohydrates and few fruits and vegetables were also found to have more metabolic risk factors.

I think one of the issues with the “traditional” lifestyle combined with modern affluence is that they aren’t actually eating like their (our) ancestors would eat. Though fried snacks and sweetened beverages are acceptable in vegetarian diets, I doubt that this was on the menu for many Indians who lived on vegetarian diets in the past. The two “bad” dietary options are really converging on modern processed/high cal diets from different pathways.

13 Replies to “Why do South Asians have heart disease?”

  1. Agree to the point that what is called traditional (because it complies with dietary taboos) does not reflect the actual content of what past generations ate. The food of urban people also deviates from the past in that it is no longer a working man’s diet. Chaat, wada pav, farsan, savoury pastry puffs and various other deep fried starchy snacks are mainstays of the modern diet. Not to mention the amount of sweets people eat nowadays. Vegetarian communities , in lieu of celebrating feasts by roasting or stewing big cuts of meat, tend to go decadent on sweets of all types for special occasions, not to mention chai and biscuits multiple times a day.
    Not more than a generation ago the rural diet relied more on unrefined grains like sorghum, millets or unpolished rice. Sweets were not made with refined sugar, but with jaggery. This leads to the question of how much sampling bias (too many urban vegetarians) is affecting the cardiovascular health studies on south asian origin people. Purely anecdotally, I don’t feel the rural people I see have the same pot belly/scrawny limbs body type that is common in the cities.

    1. VijayVan,
      hours of cooking esp of vegetables and leaves. Eating raw is discouraged

      First note: Sri Lankans have life expectancys comparable to First world countries (75 in 2017). Diet or Genes.?

      Not quite in Sri Lanka. Agree about the veggies been over cooked for a long time, not hours like sambar.

      Leaves, which we call mallun. Two methods (all leaves/salad thinly chopped). Lime juice absolutely essential to kill the bacteria.
      a) Chopped leaves (can be a mix), slightly sauteed with onions, green chillies and coconut added at end.
      b) Chopped leaves, onions, green chillies mix the lot add salt and lime and then coconut shavings.

      A very standard Sri Lankan rice meal (Tamil or Sinhalese) includes a Mallum. The SL version of a salad.

      I grew up eating mallum, beef curry and raw red rice and some veggie for lunch (60’s to late 70s). Sounds like a lot of beef, 500 gm (1 lb) among six that was the cheapest. Chicken was a treat on some Sundays either with white rice or noodles and my mother would make chillie sauce.

      I have no idea what my paternal grandparents ate. My paternal grandmother died at 60+ after 8 children. My paternal grandfather lived to something like 70+. Apparently a heavy drinker, tennis player and secondary native administrator in the rural hinterlands of the North and East. He is mentioned in the Spittel book on Veddas.

      My father brother dropped dead on the Tennis court at age 49 (I think 1958 just before I was born). My father lived till 84, he stopped playing Tennis after his brother died. Both fathers brother and father were teetotalers, only drank wine at communion.

      Maternal grandmother lived till 94. Grandfather till 84. Died putting on his boot to go to work, surveying. My mother is 94 and still active, some memory loss.

      Some things I see about all of the long lived relatives,
      a) No belly and worked out doors
      b) No big meals. Still recall my m-grandfather for breakfast on sunday, 1 piece of bacon, a cutlet and 1 piece of toast. I’ll probably gulp as much bacon and toast as possible.

    2. The sugar intake is in tea

      As kid we used to drink about 6-10 cups of milk tea. Sweet as possible.
      At least 3 teaspoons for a cup.

      Other sweet stuff were treats, rarely.

  2. The article lumps all South Asians into one group, and presents a single risk profile. Does anyone know if differences among South Asians have been studied, and if so, were they found to be meaningful? Even if we consider only vegetarians, cuisine can widely vary from the north to the south to coastal areas to Bengal to the NE. Most of my (south Indian) family tends to go easy on fried and sweet stuff, and barring the odd heart attack, I haven’t heard of serious cases of cardiovascular disease, let alone fatalities.

  3. This is a topic of much interest to me (more precisely, the genetics behind the results), and I went through all of the MASALA publications (thanks Razeeb, “https://www.masalastudy.org/publications”) but there is a lack of proof of the assertions
    “But vegetarians who eat traditional South Asian foods like fried snacks, sweetened beverages and high-fat dairy products were found to have worse cardiovascular health than those who eat what the researchers call a “prudent” diet with more fruits, vegetables, nuts, beans and whole grains (and, for nonvegetarians, fish and chicken). ” I could not find proof for the above line, even if I do believe it, especially, “South Asians have a greater tendency to store body fat in places where it shouldn’t be, like the liver, abdomen and muscles. Fat that accumulates in these areas, known as visceral or ectopic fat, causes greater metabolic damage than fat that is stored just underneath the skin”.

    The point is that the genetics may be more important to the whole thing, and that even eating no “fried snacks, sweetened beverages and high-fat dairy products” might lead to similar outcomes, because of the high grain nature of the food. Earlier another commenter pointed out that the vegetables and nuts eaten are always well cooked, and even eating vegetables may not help. In any event, the MASALA publications do agree with all of this, and do not call out the above.

    I am partial to Wells and his extrapolations of thrifty genotype (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4935697/) rather than pointing to specified foods. Such evidence can be seen in TN and Kerala where there is no large consumption of fried snacks, beverages and dairy, but the diabetes, CVD diseases is no less than the north. Genes and evolution have led to exaggerated fat storage in liver, abdomen and muscles, and this was, where I had hoped that the next stage of genetics research will lead to, in India. The analogy to Pima Indians in US is striking.

    1. Such evidence can be seen in TN and Kerala where there is no large consumption of fried snacks, beverages and dairy, but the diabetes, CVD diseases is no less than the north.

      Agreed, though some how Keralites an Sri Lankans seem to manage to survive longer.

      1. CHD+diabetes is not a life threatening illness. With a proper dose of medication, people can have a long life expectancy, although obesity works against this. So, no need to confuse the two. However, the metabolic conditions bring a host a of related diseases in the kidney, eye that can be life threatening, or should i say quality of life diminishing.

        however, it appears sBarkkum that the Srilankan diabetic issue is no worse than the Indian. A somewhat older study (The diabetes epidemic in Sri Lanka – a growing problem Article in Ceylon Medical Journal · April 2006) says that the two are converging or Srilanka is wrse. Compare Table 1 of Katulanda snd Sheriff with Table 1 of Lancet study (https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(18)30387-5/fulltext). Things are not great in SriLanka either, but this should be considered an outcome of growing wealth (??) verus the burden of 10,000 years of evolution.

  4. When I think back to my youth, in my mother’s extended family compound, separate meals would be made for my grandfather, who was Diabetic. His meals were simple, lacking in oils and heavy spices. Very plant based. Partly this must have been driven by health concerns, but now that I think about it, it was likely also driven by taste.

    The last time I was in India, there was an older female servant visiting from the village. In addition, they had hired a “chef” to make lunch and dinner. I asked why the lady wasn’t cooking, and they advised me her cooking was too rustic and no good. But one day she made dinner and I thought it was pretty decent.

    I get the impression that there’s a big divide between traditional, “country” cooking in India which is plant based, minimal in oil and spices, and “city” cooking which is what now predominates (and what you’ll find served at Indian buffets in America). The heavy oil/cream/spiced food makes me sick. I bet in the old India only kings could afford to eat like that and probably even they weren’t eating that stuff every day, unless they were fat.

    People also used to eat regional varieties of parboiled rice, but nowadays everyone is just straight cooking the basmati rice. Not sure what dietary effects that has, but must count for something. Patna rice used to be world famous, but now you don’t hear about it anymore.

    The other aspect is that Indian people have a habit of constantly stuffing themselves with something. Maybe I’m too white in my ways. Every time Indian people are over they are constantly grabbing sweets, samosas, western pastries… Then it’s time for dinner and people go back for multiple servings. Makes me want to vomit.

    Then there’s the obvious genetic adaptation to living in the tropics shared with blacks, which has to do with salt balance, early hypertension, etc. which leads to heart disease. The only solution is to be as lean as possible.

    The other thing that I’ve noticed is that whites will tend to gain weight all over, which would have been useful for surviving the winters in Europe. Indians only tend to gain it around the core (lean limbs are needed for surviving the heat). Core fat is much worse than distributed fat.

    1. Raj:

      What you are saying is true, but not the whole truth. Lancet published “Prevalence of diabetes and pre-diabetes in 15 states of India: Results from the ICMR–INDIAB population-based cross-sectional study”, over 55,000 people in 15 states across the country. It did show that the prevalence of diabetes was almost double in urban areas (11.2 percent) compared to rural areas (5.2 percent).

      However, straightforward extrapolations were not possible because the relationship was mired with association with poverty. Poor people in rural areas were less prone to diabetics because they ate much less than 2200 kcal/day, and when they moved to urban areas, they ate minimum requirements of food. This kind of proves the thrifty genotype models where the genetics of the body has a memory, and attempts to store fat when supplied with more food (I am being devious here, but the intent is truthful). So, it is not evident that eating more “healthy” food will reduce diabetics. The problem is the life history, and the body is attuned to store the fat in liver, kidney, abdomen, both because of famine and poverty at an earlier age, or 10,000 years of genetic history. Evolution is a powerful force.

      The need may be to give up cars, two-wheelers, airconditioning, machinery that avoids physical labor, and so forth. This is not the direction that civilzation wants to go.

  5. While it is true that urban Indian diet changed a lot in the last century, I don’t think wealth is as much to blame as lack of religious observances.

    Devote housewives fasted every Saturday (and also at special festivals), went to temple and circumambulated at least three times around main sanctum at least 4-5 times a week. Hiking Tirumala hill was another common occurrence. Even if they didn’t work around the house much or needed hard labor (maids) but religion had built in the diet and exercise.

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