Melanie Cole, MS (Host): Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole. And we have such an interesting topic for you today, highlighting interrelated social factors effects on the cardiovascular health of Asian American subgroups. Joining me is Dr. Nilay Shah. He's a physician scientist, Assistant Professor of Cardiology and Preventive Medicine, and general and preventive cardiologist in the Bluhm Cardiovascular Institute at Northwestern University Feinberg School of Medicine.

Dr. Shah, it's a pleasure to have you join us today. As we get into this topic, what are the specific cardiovascular health needs and disparities that you have observed within individual Asian ethnic subgroups that need to be addressed?

Dr. Nilay Shah: Hi. It's really a pleasure and honor to be here and I appreciate the opportunity to talk about this topic. One of the most important things I think we need to keep in mind is that our patients of different Asian American subgroups have different needs with respect to promoting their cardiovascular health and preventing cardiovascular disease.

One of the biggest challenges about taking care of patients and doing research for communities that are Asian American is that these populations are so frequently put together into a single category called Asian. And they have been for the last several decades. And the problem is that the Asian group of people is incredibly diverse. And there are some groups that are disproportionately affected by cardiovascular disease and cardiovascular risk factors. And I think that the way that we take care of patients and the way that we conduct research often masks some of these disparities.

For example, there are communities that are South Asian, like people who are Indian, Pakistani, and Bangladeshi, who have excess rates of cardiovascular disease, sometimes two to five times higher rates of cardiovascular disease than experienced by other Asian groups or other non-Asian groups. That is a statistic that's often masked by population data that puts everybody into one group. We know that Filipino Americans have really high rates of diabetes and high blood pressure, which are strong risk factors for heart disease. And so when we meet patients who may self-identify as Asian or Asian American, I think it's really important that as clinicians, we're really mindful of what the different risks are within individual Asian ethnic populations so that we are better tailoring our advice and our recommendations and better understanding how to prevent heart disease in this group.

Melanie Cole, MS: That's so interesting, Dr. Shah. And so, when we talk about risk. And this is across the board with different ethnic communities, but specifically we're talking about Asian ethnic subgroups and how did the social determinants of health, such as immigration-related factors, discrimination, socioeconomic status, English proficiency, cultural beliefs. I mean, there's so many things that we could point to differences in access and utilization. How do these things together influence cardiovascular health behaviors among Asian Americans?

Dr. Nilay Shah: Yeah, I think that's an incredibly important question, especially that point about health behaviors, because that's really the underlying crux of how we prevent heart disease and how we promote health, cardiovascular and cardiometabolic health and health overall in all of the patients that we meet, is to really think about the intersection of all of these social risk factors that an individual might experience, a community or a population might experience, and how somebody's experience kind of conspires to prevent them from achieving good health or promotes their opportunity for good health.

And Melanie, you focused on a couple of really important ones, particularly for the Asian American community. Take, for example, immigration-related factors. Immigration is a really complex social determinant of health that influences things like educational opportunity, income, reasons for immigration also influence people's health. Some people immigrate because of economic opportunity or to study. Others arrive to the United States as refugees or asylum seekers. Still, others are migrants because of the role of colonialism in their own regions or countries. This is not to say that this is something that we're necessarily expecting clinicians to spend time asking about in their clinical encounters, but the point is that there are very diverse, complex, upstream social factors that result in people's opportunity for health or detract from their health. And at the community level and the population level, it's particularly important that we're not only understanding what some of these social risk factors are for Asian American communities and other diverse populations in the U.S., but how these upstream factors can actually lead to downstream opportunities for health and influence health behavior.

There are relatively few systematic investigations of how some of these social risk factors might intersect for individuals and communities. That's a really important area for future work. But suffice it to say that there are really kind of unique aspects of social determinants that influence health outcomes for Asian American populations that include things like immigration-related factors and cultural beliefs.

Melanie Cole, MS: Well then, Dr. Shah, discuss your guidance panel and your involvement as chair in looking into this.

Dr. Nilay Shah: So, in September of 2024, a group of experts and I had the opportunity to put forward a scientific statement from the American Heart Association titled Social Determinants of Cardiovascular Health in Asian Americans. This was a scientific statement that was endorsed by the American Heart Association and led by the Council of Epidemiology and Lifestyle, and brought together a group of experts on Asian American health, immigrant health, cardiovascular disease and prevention, and included my colleague and mentor, Dr. Namratha Kandula, who's a Northwestern Medicine primary care physician and Professor of General Internal Medicine. And this group together summarized the state of science of social determinants and social risk factors for cardiovascular health in Asian American communities.

And in so doing, I think not only pointed out that we actually know quite a bit of how upstream social risk factors and structural factors may influence health for Asian American communities, but also what the next steps are not only to advance the research in this field, but how to translate some of the insights from this work towards taking better care of our patients.

Melanie Cole, MS: But then, Dr. Shah, when we look at the underrepresentation of the Asian American community in medical research studies, what would you want to change in your opinion or looking forward? How can we better that?

Dr. Nilay Shah: I think that's a really important question for two reasons. The first reason I think it's important is that we don't always know that the interventions that we say have evidence for improving health will necessarily operate the same way in Asian American patients. And the second reason that question is particularly important is it speaks to how well the diversity of the American population is represented in clinical trials that we do, particularly because these clinical trials are really what drive and change the way we take care of patients.

Asian American people are misrepresented and underrepresented in clinical trials. There's really no way around that. People who identify as Asian, whether that may be Indian, Chinese, Filipino, Vietnamese, Korean, or Japanese, if they are included at all in trials based in the U.S. and internationally, are usually lumped into a single Asian category. And when they are not represented or are underrepresented in clinical trials, it really limits our ability to understand whether the interventions we develop are actually applicable for the diverse population that we take care of. You know, this isn't about biological differences between groups.

If a patient who is Asian is having an ST-elevation MI, we're not trying to say that their heart attack is biologically different than the heart attack that's experienced by a person who identifies as black or white. What we are trying to say is that the disparities in outcomes seem to be because of differences in things like quality of care and barriers and access to care and cultural factors and norms about the approach to Western medicine or adhering to recommendations or a whole host of other social risk factors. But it's really important that we are making sure that we're accounting for some of these differences when we do clinical trials so that we can best make sure that the evidence we generate is implemented appropriately for the diversity of the population we take care of.

And so, to that point, my recommendation would be that I think it's incumbent on any of us as clinical researchers, and especially those of us who are trialists and run clinical trials to make sure that the participant samples of these studies is representative of the demographics of the population for whom we want the recommendations from this trial to apply. Or in other words, if we want to take the evidence that's generated from a clinical trial and translate it to patient care, we have to make sure that the samples of participants that are included in those trials reflect the diversity of the populations from which those samples are derived. Or, put even more simply, clinical trials need to represent the population of the United States and the world. They aren't doing that yet.

My recommendation, kind of my personal recommendation, would be that it's incumbent on the researcher to make sure that their sample is appropriately representative. It's no one else's responsibility. It certainly isn't the community's responsibility. As academics and as people who run clinical research studies, we really need to take it upon ourselves to bear that responsibility to make sure that our studies are representative.

Melanie Cole, MS: Dr. Shah, you said the most interesting thing. So, we hear about barriers. It's a big topic right now, maybe not talked about enough with different ethnic groups. And when we think of the barriers to accessing healthcare services, achieving health literacy, particularly for the Asian American community with limited English proficiency, but you said a most fascinating thing. You said as far as cultural differences and Western medicine. Now, when we think of all the different diverse groups in this country, as you mentioned, the one group that really is newer in that way to Western medicine would be the Asian American community. And do you feel that because Eastern medicine as it was, which we now look at as a form of complementary alternative, might be one of the barriers to the desire to access healthcare and then leading to the steps we're talking about

Dr. Nilay Shah: Yeah. You know, that's a really insightful observation. And I think you're right, the diverse Asian American population is perhaps, as you say, newer to the concepts of Western medicine. There were concepts and conceptualizations for how to address health and take care of people that are Eastern, that come from Asian and other regions, that have considerably predated the way that we think about taking care of patients here in the United States and in so-called Western countries.

And although some of these philosophies exist under the umbrella of complementary and alternative medicine. I suspect, and I often wonder whether there's an opportunity for some of these approaches to be, not only considered kind of on a level field, but also rigorously tested to understand what works, because there's a lot of wisdom in all of those thousands of years that perhaps we, as a collective, not any one individual or clinic or health system, but as a collective, we as practitioners of Western medicine, maybe don't give enough weight to, that we really ought to be, providing more respect for.

And, you know, when I take care of patients who identify as Asian and I'm making recommendations based on Western medical principles or norms, I try to make an effort to understand not only that individual patients' kind of perceptions of my recommendations and their own confidence or self-efficacy and feeling like they can and would and want to adhere to those recommendations, but also kind of their own conceptualizations of health and reasons for disease and what they think might work.

Because there are often questions related to access to care and adherence to recommendations that don't have to do with things like socioeconomic position or being able to access a clinician to receive care, but may have to do more with people's own conceptualization of health and their adherence to traditional medical practices that may have some evidence that we just don't yet well understand.

Melanie Cole, MS: A certain amount of skepticism.

Dr. Nilay Shah: I think that's true. I think that there is a prevailing skepticism amongst clinicians here in our practice environment. And I think the potential benefit of incorporating some of these Eastern philosophies of medical practice and patient care would not only help respect the patient's own approach to their own health and help Increase their adherence to recommendations we might provide, but there may also be benefits that we are underrecognizing through these well-established modes of care.

Melanie Cole, MS: So well-established. And I also was referring to the skepticism from the Asian American community toward Western medicine in the fact that they've been doing this thousands of years. And now, I think we are coming together more and doing what I've done for 35 years. I see more nutrition, meditation, spirituality, yoga coming in and specifically where cardiovascular health is concerned.

Dr. Nilay Shah: I think that's right. And I think it's really important to be said out loud that it's not an either or. I think it would not be correct to think about each of these ways of taking care of patients at being at odds of each other, but rather to use the term that we kind of fit it under this complementary approach, but rather not just complementary, but more of an equal approach where there's benefit to be derived from both. And I think that there's more work to be done to better understand the side of perhaps so-called non-Western medical approaches.

Melanie Cole, MS: And I think it's actually more exciting, Dr. Shah, because as we think of combining these all, as you say, complementary, putting everything together for a whole wellness, as we look at our populations, I think that we are all better off for all of these kinds of influences to come together and treat us as a whole group of humans. But off that topic now, the implications for patient care from the findings that we've been discussing here, what would you like other physicians to know about the effect of social factors on this cardiovascular health of the Asian American community and how we can better for our colleagues and for the professional healthcare community to reach out and get this looked at?

Dr. Nilay Shah: For as much time as I spend thinking about investigating the upstream social risk factors that influence health, the real question I think is how do we use this information to make sure that our patients have the opportunity for good health and we can support them. It's an active area of research. I suspect anybody who's a clinician who's listening to this recognizes that we are still working on figuring out how to effectively address social risk factors in clinical settings, because so much of what determines health happens outside of the 20 to 40 minutes we might each get to spend with a patient the clinic. Our patients spend almost all of their lives outside of that interaction that we have with them.

And so, part of the approach I think is for Asian American patients, or really any patient, is to get better at asking about people's social determinants and their social risk factors, and trying to better understand what the individual level barriers to health are. Not necessarily because an individual clinician has the right answer or has a solution, though I hope we move in that direction, that clinicians are able to help patients address and surmount their social risk factors, but at least to better understand what the barriers that the individual patient in front of you has, and how that might relate to their cultural values and norms and how their experiences of being an immigrant, for example, or language barriers might influence their access to care.

And speaking of that, I do think as health systems go, we really should be working towards making sure that we have clinicians with language and cultural expertise and experience, not only physicians, but also dieticians, exercise physiologists, nurses, anybody who cares for patients, so that our patients not only feel represented, but also feel seen and heard in their clinical care. And I hope that this field of research moves forward to seek avenues to surmount some of these social risk factors. Maybe not such a small thing, but one of the ways that I really try to do this in my own clinical practice is that when I know that a patient, for example, has language access barriers, I try to ask my clinical team to schedule an in-person interpreter in advance of these patient visits because especially for languages that are less well-represented, especially some of these Asian languages like Hindi or Mandarin Chinese or Vietnamese, a phone interpreter sometimes just isn't enough and really can put up a barrier between you and the patient you're talking to. So, I try as best I can to schedule in advance an in-person interpreter for these visits.

This is just one potential lever that somebody could pull to try to improve access to care and lower some of the barriers that our patients who identify as Asian might be experiencing. There are many more, I hope this is kind of an active area of work. And I see that being an active area of work in our health system and across the country, especially as the Asian American population grows. It's the fastest growing minoritized group in the United States. And I think that its needs are going to become more and more relevant to us as clinicians as time goes on.

Melanie Cole, MS: What a lively, enlightening, eye-opening discussion that we had here today, Dr. Shah. I thank you so much for bringing this to light. And there are so many questions still to be answered and it's complex. So, I hope other providers will reach out if they want to be involved and have more questions. And to refer your patient or for more information, please visit our website at breakthroughsforphysicians.nm.org/cardiovascular to get connected with one of our providers. That concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole. Thanks so much for joining us today.