South Asian background and heart health

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Your ethnic origin can increase your risk of heart and circulatory disease and diabetes. Dr Sandy Gupta, consultant cardiologist at Whipps Cross and Barts Health NHS Trust, explains to senior cardiac nurse Christopher Allen.

Does South Asian background affect heart risk?

We’ve known for more than 50 years that the risk of coronary heart disease (CHD) is up to 50 per cent higher in first-generation South Asians than in the white European population in the UK. The sad thing is, it’s still a problem, despite us knowing this for so long.

What do we mean by South Asian background?

We’re talking about people of the Indian subcontinent (India, Pakistan, Bangladesh and Sri Lanka) living in the UK. Even within the South Asian group, there are differences in risk. Those at highest risk are the Bangladeshi population, followed by Pakistanis, Indians and Sri Lankans – but even Sri Lankans may be at higher risk than white Caucasians.

What is the reason for this increase in risk?

It is partly to do with body shape and diabetes. South Asians mainly develop central obesity (fat around the middle). Extra fat, particularly on the middle, increases insulin resistance (meaning you must produce more insulin to stabilise blood sugar, among other processes) and therefore risk of developing type 2 diabetes. For this reason, the waist circumference indicating increased risk is lower for a South Asian person than a white European.

Diabetes increases your risk of CHD and of having a heart attack. It is also linked to high levels of triglycerides and low levels of HDL (‘good’) cholesterol.

South Asians are diagnosed with type 2 diabetes at a much younger age, and at higher rates (rates are at least twice as high in South Asian communities as in the general population). It’s often a silent condition, so a diagnosis may come years after onset, when blood glucose levels have been unstable for some time and have already caused harm to the body.

Lifestyle factors may play a role, but part of it is genetic. A school playground study showed that children of South Asian background aged 10–14 had early markers of insulin resistance – a precursor to type 2 diabetes. Environmental factors such as a poor diet or smoking increase this genetic risk.

Does a traditional South Asian diet increase risk?

In South Asian culture, there are often family functions where it’s easy to graze

The components of a South Asian diet are healthy, such as lentils, vegetables and oily fish. But traditionally, many foods are fried. This means they’re higher in energy [calories], which can contribute to weight gain.

Traditional fats such as ghee are high in saturated fat, which is linked to raised LDL cholesterol levels. Salt is also a big issue and, over time, a high-salt diet
is associated with high blood pressure.

Some typically South Asian snacks, such as samosas (made with deep-fried pastry), are very unhealthy. In South Asian culture, there are often large gatherings and family functions, where exposure to these foods is frequent and it’s easy to graze and not realise how many calories you’re eating. Culturally, it may also be seen as rude to turn down food someone has prepared for you.

It’s important, however, not to ‘ban’ any foods. Recognise what is a ‘luxury’ item that should be eaten rarely, and what is a healthy item that can be enjoyed regularly. Dietary changes shouldn’t be viewed as a punishment, but be conscious of portion sizes and preparation methods.

What about exercise?

Studies suggest South Asians, especially women, do less physical activity. Many factors influence this. Some South Asian women may be reluctant to attend a mixedsex gym or go swimming because of religious beliefs. They should be supported in finding activities they feel comfortable taking part in, such as walking, group dancing or single-sex exercise classes.

It’s not just the South Asian population though – many people in the UK miss targets for physical activity. It’s important to build activity into your daily routine, for example getting off the bus a stop earlier or going for a walk at lunchtime. Breaking activities into manageable chunks (of 10 minutes or more) can make it much easier to achieve your target of at least 150 minutes a week.

Are there other factors?

Many South Asian communities are in areas of deprivation. This can increase risk of developing CHD, for many complex reasons. For example, in deprived areas people are often on lower incomes and may have less access to healthier foods. The highest death rates occur in Bangladeshi communities in east London, which has many pockets of deprivation. Compared with the white British population, Bangladeshi populations in the UK are more likely to report poor oral health, work part-time, suffer infant mortality, and live in overcrowded households.

Rates of cigarette and tobacco chewing are also higher in Bangladeshi communities. Shisha smoking is popular among some South Asian groups. Flavoured shisha can be misleading for younger people who don’t realise it is often tobacco-based.

Does this increased risk apply to people of South Asian background born in the UK?

Yes, evidence shows risk factors in young South Asians are often more prevalent than in young white Europeans. Even among children born and raised in the UK, South Asian heritage not only genetically means they’re at higher risk of CHD, but family surroundings also play a major role in influencing lifestyle habits.

Do people of mixed ethnic origin have raised risk?

At present, not enough time has passed for studies of these groups to answer this question with certainty.

Meet the expert: Dr Sandy Gupta

Dr Sandy Gupta is a Consultant Cardiologist at Whipps Cross and St Bartholomew’s Hospital. Dr Gupta was awarded a BHF research fellowship to explore the relationship between inflammation and heart disease.

Over the last 15 years, Dr Gupta has also remained passionate about dedicating his free time to raising awareness of heart disease, in particular in South Asian communities. To do so, he has worked with major committees, acting as Chairman of the BHF Strategy Group on Cardiovascular Health and Ethnicity and a member of the BHF Prevention and Care Committee. Dr Gupta has been actively involved in national BHF campaigns including our heart attack awareness campaign and helping to promote our physical activity campaign, encouraging South Asian communities to get their 30 minutes a day. He has also delivered lectures in more than 70 countries and given around 80 voluntary talks in communities and schools to raise awareness of heart disease.

He says: “To me, being a Consultant Cardiologist is a privilege and professionally rewarding…and still is! My 15-plus years of voluntary activities with the BHF have added a unique dimension to my vocation. Whether through committee work, community talks or campaigns, the opportunities to contribute have been so fulfilling. This has been made especially smooth and seamless by working with the highly motivated and talented BHF Team. They certainly know how to get the important messages of heart health across at every level.”

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