Research shows South Asians make up 60% of heart disease patients

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Munaf Patel is an active husband and father. He plays cricket, basketball and volleyball, and runs around with his young kids in the family's yard near the city's Far Northwest Side.

So when he had an "uneasy" feeling in his chest in September 2015, he took some aspirin and followed up with his doctor. He was concerned but didn't expect to hear what test results showed—at age 39, Patel was having a attack.

Despite the placement of a stent to unblock his artery, a quick recovery and watching what he ate, Patel had his second heart attack just eight months later.

"I was very active, and you don't think about it when you're young," he said. "At the age that I am at, you don't expect those things."

But a part of him knew to be vigilant about his health; Patel, who is Indian, has an extensive family history of heart disease that many South Asians share. His family represents the heightened risk carried by South Asians, who experts say are about four times more at risk for —the leading cause of death in the U.S.—than other groups, and are stricken at younger ages.

As a young boy, Patel lost his father, who died in his 40s after a heart attack. Several other close relatives have had heart attacks at young ages, and one needed a heart transplant.

Researchers continue to probe why it seems that, in the South Asian community, everyone knows someone who has had a heart attack. Experts say that while the group represents about a quarter of the world's population, it accounts for about 60% of heart disease patients.

The alarming risk has prompted researchers to study South Asians in the long-term Mediators of Atherosclerosis in South Asians Living in America study, known as Masala (meaning spice blend), in part because medical guidelines physicians historically use come from data derived from white men. Yet South Asians, researchers say, often do not show some of the typical signs of cardiovascular disease and need their own guidelines. Experts also say it's important to distinguish South Asians—those from India, Pakistan, Sri Lanka and other countries in the region—from other Asian groups because their risks differ.

This work has led to a shift in recommendations last year from the American Heart Association and other medical organizations, directing physicians to consider ethnicity when assessing patients' cardiac health. The move recognized that South Asian patients tend to carry lower levels of good cholesterol in their blood, among other health distinctions.

There's also an effort to educate South Asians about the risk they carry that might be surprising or go unnoticed, but possibly could be offset by diet and exercise. At Advocate Lutheran General Hospital's South Asian Cardiovascular Center, clinicians have amped up their efforts with a video series that provides heart healthy recipes and encourages sound lifestyle choices.

Dr. Shoeb Sitafalwalla, a cardiologist and medical director of the center, works with a team that treats South Asian patients and also goes into the community, spreading the word that and exercise could help offset their genetic predisposition. That includes regular visits to speak at churches, mosques, restaurants and grocery stores that sell ingredients used in South Asian recipes.

To expand its audience, the group created a video series, called "Dil Se," a Hindi phrase that means "from the heart." The first seven in the 25-video series launched over the past few months.

Sitafalwalla said that while South Asians likely have heard of this risk because of knowing others affected, it's not talked about enough.

"You talk about how your daughter got into law school," he said. "You don't talk about how your son just had a heart attack."

The advocacy work of the cardiovascular center "started as a grass-roots operation, going into communities ... taking our message of health and wellness," he added. "But we were limited in scale. There are 300,000 South Asians living in Illinois. We needed to find a way that could help us bring that message to a greater amount of people."

The team came up with the concept as a way to "interact with the community, especially where their eyes are most—their mobile phones," Sitafalwalla said. A grant from Boehringer Ingelheim Pharmaceuticals helped fund the project.

Some of the videos resemble rapid-fire cooking videos popular on social media, and include facts on wise food choices for those concerned about cholesterol or blood sugar. South Asians are also at a greater risk for diabetes, Sitafalwalla said.

Others tackle myths or home remedies Sitafalwalla said are common within South Asian communities, from drinking apple cider vinegar to unblock arteries to rubbing lemons on skin to get rid of dark spots on the skin—a sign of diabetes.

Dietitian Srisakthi Ramanathan said the video recipes for healthier versions of South Asian cuisine include a mock-up of a nutrition label for the dish. "That's hard to find in Indian recipes. That's a big gift."

During community demonstrations, Ramanathan said, she'll hear from South Asians that it's eye-opening to learn about the nutritional makeup of certain foods, as well as portion control, especially with oil.

South Asians have a cultural connection with oil, she said, as well as a desire not to waste it. "Even now, my mom will hide the oil because they don't want us to find it and throw it away."

"When you're entertaining or serving your family, adding more oil is considered a sign of generosity," added Sitafalwalla. "So when the pot of curry sits down on the table, if there isn't an oil slick you can see, it's not generous. What you don't realize is you're also being really generous in how you'll clog up their arteries."

But educating the community doesn't mean wiping away traditions, he said, and the team tries to be culturally sensitive. "All of the choices that we lay out ... are pragmatic ones. We're under no illusion that people are going to give up staple items that are culturally ingrained."

Given the inherited risk, eating right and exercising are especially important for South Asians, Sitafalwalla said, and it's important to learn from a young age, noting that 25% of heart attacks among South Asians occur before age 40, and half occur before 50.

Dr. Namratha Kandula, a Northwestern University researcher involved in the ongoing, long-range Masala study, said it's vital to better understand why the group has these risks "because they don't fit the typical pattern of someone at risk of heart attack and stroke."

South Asians are typically not overweight and do not use much tobacco, common risk factors for heart disease.

But through the ongoing study, researchers have learned the group has other risk factors, like high blood pressure, less lean muscle mass and a tendency to store fat in the liver and abdomen.

Kandula said there are also cultural differences, like not regularly exercising. Yet "exercise is very important because of the South Asian body type," she said.

"The goal isn't really to lose weight," but to build lean muscle, she said.

Kandula promotes this and other healthy concepts in another study she's leading: the South Asian Healthy Lifestyle Initiative, or Saheli (meaning friend), which helps participants change behaviors by incorporating exercise and healthy foods into their lives. The 16-week program, in its third year, works with community partners and so far has recruited more than 300 South Asian participants in the area. The goal is to reach about 550 in the next couple of years, Kandula said.

While members of the South Asian community are aware of these risks, they might be reluctant to discuss and seek guidance, Kandula said.

"Everyone knows somebody who has had a heart attack at a young age. It's very common," she said. "But how do you get support to help manage them? It's sort of your own problem."

Saheli study participant Ravi Natarajan, 48, of Naperville, enrolled in the study last fall after hearing about it at his temple. While Natarajan said he's "pretty healthy," his father had a at 68, and he also has had friends in their 30s experience heart attacks.

"I wanted to learn more about prevention," he said.

Through the study, he learned to keep food logs, received regular cholesterol and blood sugar checks, and talked about ways to manage stress. Natarajan said he now incorporates more fruit and healthy grains into his diet, and added strength training to his walking and running routine.

The result is lower cholesterol and he shed a few pounds, but Natarajan said he also has benefited from awareness of his risks, now leading a healthy life and setting an example for his sons.

"My sons are watching me," he said. "We cannot control ... some of the family history. What we can control is the exercise as well as the food habits."

Patel, now 43, said he's doing well and is fully recovered from his two heart attacks. He said he remains active and only indulges in fried shrimp and some of his other less nutritious favorites every once in a while.

He also tries to talk to others in his community about their shared risks, especially those hesitant to pay attention to markers like high blood pressure, or those who don't get regular doctor checkups.

"It can happen to anyone; it doesn't matter how old," Patel said. "You get worried about your family, your kids, yourself."


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