Intro: This is Weekly Dose of Wellness, brought to you by Memorial Care Health System. Here's Deborah Howell.

Deborah Howell (Host): In recent years, there's been an alarming rise of heart disease within the South Asian population. In today's episode, Dr. Kevin Shah, Program Director, Heart Failure Outreach at Memorial Care Heart and Vascular Institute at Long Beach Medical Center, will talk to us about genetic predispositions, lifestyle choices, and dietary habits that contribute to this pressing issue and will include some real life stories. Welcome, Dr. Shah.

Kevin Shah, M.D.: Thanks so much for having me, Deborah.

Host: What a pleasure. And I understand that you have a personal connection to our topic at hand today.

Kevin Shah, M.D.: I do. I do. Thank you for asking. So, one of the reasons I actually went into Medicine and even pursued Cardiology and the work that I do is I actually lost my father almost 20 years ago, September actually. I'm South Asian. He is South Asian and he had coronary artery disease. And we're going to talk about some of that today, I think. So, it really catalyzed my interest to both pursue medicine and to also really speak and reach out to this community.

Host: It's a beautiful tribute to your dad. So, what are the big factors contributing to the rising rates of heart disease among South Asians?

Kevin Shah, M.D.: The statistics are really sobering. South Asians are 25% of the world's population, and they account for almost 60% of the heart disease cases globally. Just in the United States, South Asians, they have a 40% higher mortality related to heart attacks compared to the general population.

To your question, like a lot of things in Medicine, it's complicated. There's multiple reasons for why people believe South Asians tend to have heart disease that's both more aggressive and particularly impacts people at younger ages, and just a few of them have to do with genetics. There's a high burden of traditional risk factors for heart disease. So, these are things like high blood pressure, cholesterol abnormalities. And then, there's certainly a lifestyle contribution, which tends to impact everybody who has heart disease, at least as an adult.

Host: You mentioned genetics. How does genetics play a role in the prevalence of heart disease in South Asians?

Kevin Shah, M.D.: South Asian genetics, it's an area that's really being investigated now by a few different teams. What has been sort of established from one of the larger cohort studies was a study that was based out of UC San Francisco and Northwestern University. The Cardiology loves to put clever acronyms for their study names. This study was called the MASALA Study, which is a great name for a study if you're going to study South Asians. They've done a lot of the pivotal work. One of the genetic risks that has come up and emerged from their data is a blood test that we're measuring more frequently in the clinic now, something called lipoprotein A. And lipoprotein A is a cholesterol marker. It's very tied to genetics. And there's been a few studies that have showed this marker seems to be higher in South Asians compared to other populations. And so, that's just probably the tip of the iceberg on the genetics angle. There is another team based out of Boston. And a few other centers that they're running a study called the OurHealth Study, where they're actually trying to do cheek swabs to actually get full genetic testing on people who are South Asian living in the U.S. And that's a study that's ongoing.

Needless to say, there's a few different teams that are really working on this, because there's certainly something about the genetics. And as you know, even if you immigrated from another country and you come here, you still bring those genetics with you.

Host: For sure. Are there any specific lifestyle or dietary habits in the South Asian community that significantly impact heart disease rates?

Kevin Shah, M.D.: The traditional South Asian diet, it's almost a paradox. It's kind of fascinating. There's a lot of South Asians who are actually predominantly vegetarian. I'm vegetarian myself too, which at its face value you would think would be protective. Unfortunately, a lot of vegetarian South Asian diets and homes, particularly when you adapt them to kind of a western environment, you tend to see foods that are high in saturated fats, refined carbohydrates, added sugars. You know, I don't know if you've ever been to an Indian restaurant and had Indian food, it can be very tasty. But that food is also, you know, like a lot of restaurant food at its core is not necessarily healthy for you.

So, there are different dietary patterns that are being identified. That could probably be modified to really try to emphasize heart healthiness. and it's a challenge because like any culture that celebrates its own traditions, the dietary patterns of South Asians are very tied to cultural identity. And so, trying to weave that where you can still maintain the tastes and flavors that you want, but also keeping them heart healthy, it's a challenge.

Host: Right. Since you said Indian food, that's all I want to do right now is eat a big plate of Indian food. It's just so delicious and so spicy and so wonderful. But I'm sure there are modifications that can be made, right?

Kevin Shah, M.D.: Absolutely.

Host: And what preventive measures can be taken to reduce the risk of heart disease in this demographic?

Kevin Shah, M.D.: Number one is-- and this goes even beyond South Asians, I would say-- it's really just knowing your numbers. And what I mean by that is South Asians tend to develop heart disease a little bit younger than other populations. So, I encourage most people, even starting off in their 30s and 40s to really make sure that they're having certain metrics measured. Whether it's their primary care doctor or a cardiologist who's paying attention in this area, but these are things like A1c, their blood sugar, lipid panels being tightly monitored. There's this issue with obesity tracking. Obesity, we often define by a ratio of your height and your weight. And the challenge there is a lot of South Asians will keep their fat in their abdomen. So, their waist circumference may be high, which is kind of an independent risk factor for heart disease, but their BMI or their body mass index is actually not terribly elevated. So, there's certain clues that people can track if you're South Asian, and that includes your waist circumference, that includes the markers that I measured earlier. In some cases, we do start doing testing that's non-invasive. These are things like calcium scans of the heart to look for any calcium deposition in the heart arteries. And these are tests that in a vulnerable population like this. I tend to reach for a little bit at younger ages because like anything in Cardiology, ideally we can prevent disease development versus treating it after it's there.

Host: Yeah, absolutely. And when you say younger, what type of age groups are you talking about?

Kevin Shah, M.D.: For South Asians, they tend to start to develop significant coronary disease in their 40s and 50s. So, I think even in people's 30s, even again if it's just with their primary care physician, keeping track of these numbers, and tracking them over time is a good step in trying to prevent the development of heart disease.

Host: That leads me to my next question. How do healthcare providers tailor their approach to better manage heart disease within the South Asian community?

Kevin Shah, M.D.: So, healthcare providers in general are starting to recognize that the standard risk calculators that we tend to use when we see patient after patient in the clinic, they probably underestimate the risk for South Asian patients. Using specialized approaches that-- I mentioned this earlier-- but using a lower BMI or body mass index cutoff, using lower blood sugar thresholds for interventions. The guidelines haven't caught up necessarily. The guidelines still treat South Asian ethnicity as an independent risk factor. But in an optimal world, and this wouldn't just be South Asian specific, this would be Hispanic American specific, African-American specific, we would have cutoffs that are based on the individual risk for those populations. And for some populations, you may have a lower threshold to potentially start a medication. Maybe at a lower A1c, you're thinking about diabetes treatment or at lower cholesterol levels, you're thinking about starting medical therapy. Part of it is, as I mentioned, being plugged in with someone who's being pretty aggressive about these numbers, knowing that the long-term risk is higher if you're South Asian. But particularly for this community, they tend to be very family centric. They tend to be very oriented with community partnerships and temples. So, trying to partner with these different organizations to kind of get the word out is really something that I found particularly impactful in my career.

Host: Speaking of getting the word out, what role does community awareness and education play in addressing this particular health issue?

Kevin Shah, M.D.: It's very significant. In my prior role, I used to be in Salt Lake City in Utah, and we developed a partnership there and it's work that I'm building up here locally in Southern California, partnering with community organizations, partnering with temples. Where people are gathering anyways for their personal and religious reasons. Working with those community leaders to try to provide family education and really starting at the younger age, getting people that are now second and third generation South Asians living here, helping them understand their inherited risk and helping them understand that they can actually make a difference by trying to prevent the development of the heart disease at an early age is something that I'm very passionate about.

Host: Yeah, I can hear it in your voice for sure. So, how about this, let's look to the future, can you tell us about any ongoing or upcoming research focused on heart disease prevention and management in South Asians?

Kevin Shah, M.D.: You know, there's a few studies that have been ongoing for some time. One of the ones that stands out, I mentioned it earlier, there's one called the OurHealth Study that anybody could google the OurHealth study. Their goal is to identify genetic and non-genetic factors of heart disease amongst South Asians, and they're building a nationwide biobank where they're collecting DNA samples, and it's a pretty easy study to enroll in. That would be one, if somebody is just hoping to kind of contribute science to this issue.

I mentioned some other studies. The MASALA study is working on a second generation cohort where they're studying individuals that are born and raised in the U.S. And they're trying to identify again how much this issue of heart disease with this community, how much of it has to do with genetics, and where you come from versus the westernization of lifestyle, which happens to any immigrant population when you move to the United States.

Those are the two big ones that are really actively, I would say, growing and recruiting. But there are South Asian programs and centers that are slowly popping up across the country, because there's a lot of people within Cardiology and within Medicine that recognize this issue.

Host: Yeah. I'm wondering if there's any data out there now about the difference in maybe higher numbers in American South Asians versus in the countries that their forefathers came from.

Kevin Shah, M.D.: Right. it's a great question because, on one hand, sometimes it's harder to study these issues from the countries that people originate from. There's certainly alarmingly high burden of heart disease in places like India, Pakistan, Bangladesh. But to your point, I think we're just now starting to collect meaningful data for people who are first generation or second generation immigrants here. And then, comparing and contrasting those populations are important because, as you know, living in the United States, it's an amazing blessing for any of us to have. But there's also some trade-offs that come with kind of the westernization of lifestyle.

Host: Absolutely. What about male versus female numbers?

Kevin Shah, M.D.: That's a great question. We tend to see similarly, unfortunately, high burden of heart disease for both men and women. Men still tend to develop it at an earlier age. There are some challenges, I would say, with stigma within the community and the culture about potentially men not necessarily wanting to discuss or report symptoms or underreporting symptoms. And similarly with females, not just the heart disease issue, but even other issues related to mental health. There's a lot of stigma within the community to discuss these issues openly, to discuss them amongst family and community members. And even just this morning, I was rounding in the hospital and I was actually seeing one of my South Asian patients here, and we were having some of these conversations about important details about end-of-life discussions and what patients really want. This comes up again and again where I could tell culturally, it's a very uncomfortable conversation because it hasn't happened in generations in the past. And so, helping families become more comfortable talking about whether it's heart disease or mental health, or some of these issues that are not often covered is an important first step because once you start discussing it with community members, family, et cetera, it becomes a lot easier to get help.

Host: Is this something you talk about with your patients?

Kevin Shah, M.D.: Discussing heart disease, like the stigma around heart disease?

Host: Being more open about what's really going on with them?

Kevin Shah, M.D.: I do, I do. And I find for some patients it's very natural and comfortable to talk about it with family members. But many first generation immigrants that are here, a lot of times, and it's a generalization, but I found it to be often true, there may be a stigma around discussing your health issues in general. So, letting patients know, helping them become aware that culturally this may be a challenge, and kind of walking them through the process of talking about risk factors, treatment plans, other people that may have the same condition, programs that we're trying to build to increase awareness about this issue. I think talking about it more openly can help some individuals. I'm certainly aware and comfortable with the fact that, culturally, it can be a challenge.

Host: Is there anything else you'd like to add before we wrap up today?

Kevin Shah, M.D.: There's one other resource I think I would point individuals to if they're interested in this area. It's actually a documentary that I just watched a few weeks ago. It also has a nice title, it's called The Brown Heart.

Host: Oh, I heard about that. Yeah.

Kevin Shah, M.D.: Yeah. And it's free, it's online. Anybody can google The Brown Heart. I think it's at thebrownheart.com. It was wonderfully made. It's by a couple of physicians. They went to India. They interviewed physicians in the U.S. And it's really tailored towards the general audience in terms of unpacking everything we've talked about today. Why is this a problem? What can we do about it? How do people work together on it? What kind of numbers you should be looking for for your own health if you're South Asian? I thought they did a really nice job in terms of messaging. So, that would be one resource if someone's looking to either better inform themselves or maybe relay it to a family member that has some concerns in this area.

Host: Once again, that's thebrownheart.org or dot com?

Kevin Shah, M.D.: That is thebrownheart.com.

Host: Okay, great. Well, we thank you so much, Dr. Shah, for taking the time to be with us today on the podcast. It was really, really informative.

Kevin Shah, M.D.: I appreciate your time. Thanks so much, Deborah.

Host: To learn more about managing and preventing heart disease, you can visit memorialcare.org/lbheart, or call 844-662-6484. That's all for this time. I'm Deborah Howell. Have yourself a great day.