When we first launched the South Asian Heart Center at El Camino Hospital, we thought that our greatest challenge lay in raising awareness among South Asians of the four times greater risk of heart disease they face.  

That’s no longer the problem. 

There’s growing awareness that 60 percent of the worldwide burden of heart disease falls on South Asians. In fact, nearly everyone has had a close family member fall prey to the disease—it’s so prevalent that it is often taken for granted as an inevitable fact of being South Asian. 

We now realize that South Asians know they have a higher risk; they just don’t know what to do about it. 

The real awareness problem may be in the physician community.  Primary care doctors and cardiologists typically are applying the commonly used Framingham formula developed using mostly individuals of European descent outside of Boston to risk-stratify their patients. This inevitably leads them to underestimate the risk in South Asians and overestimate the risk in some other populations, such as in the Chinese.  In the physician office, if the patient is of normal weight with normal blood pressure and total cholesterol and a presumably healthy vegetarian diet, why would anyone suspect heart disease?  Yet given this population’s unique risk factors, we now know that we need to look further. For South Asians, coronary artery disease can lead to heart attacks at a much earlier age with 50% of heart attacks occurring before age 55 and 12% before the age of 40.  This is sobering, particularly when in the ER they lack many of the classical risk factors associated with heart disease. 

Why is the heart disease risk in South Asians so frequently overlooked? For one thing, it appears that there are genetic factors that make conventional screening inadequate.  An important risk factor appears to be their below-average level of protective HDL2b cholesterol and high levels of lipoprotein (a) –despite a normal level of total cholesterol. These two abnormalities may have a genetic basis.  Unless we screen specifically for them they will go unnoticed and untreated.

In additional to genetic factors, certain cultural and lifestyle factors magnify the South Asian heart disease risk. There is a shortage of protective behavioral factors. Like most chronic disease, coronary artery disease has both genetic and behavioral risk factors.  It is polygenic—which means that not just one, but many genes are involved in its development. But as we often tell South Asian Heart Center participants, “Genetics load the gun, but lifestyle pulls the trigger.” Only 27% of South Asians consume vegetables and or fruits daily as compared to 45% in other populations. And if you have very low good HDL cholesterol and high triglycerides, a diet high in carbohydrates and very little exercise will activate one or more genes that accentuate that anomaly and increase the risk of heart disease. More exercise and a lower simple carbohydrate diet may keep those genes from triggering heart disease. You can’t change your genes, but you can change their expression.  You can turn them on and off.

No matter how high your risk, lifestyle modification (and medication when appropriate) can effectively reduce heart disease risk. That’s important to know, because the typical lifestyle of a South Asian includes a deadly combination of carbohydrates and fat-rich foods and very little exercise. Regardless of whether they live in urban or rural communities, most South Asians’ lifestyles tend to be quite sedentary. Sports and athletics play a relatively minor role, so from childhood on, most South Asians have never developed the habit of regular exercise. Only 6% of South Asians exercise regularly as compared to 26% in other populations. And contrary to popular perception, the traditional South Asian diet, which derives most of its calories from grain-based and fried foods isn’t any healthier than most meat-based diets. 

At the South Asian Heart Center, we attempt to decrease the risk of heart disease on three fronts.  The first is education: helping individuals understand their unique risk profile.  We evaluate blood work, family history, lifestyle and diet. Then we refer those at highest risk back to their physician for medical evaluation. 

The next step is to develop a personalized plan to lower risk.  Participants are helped to develop realistic diet and exercise plans that make sense within a cultural context. A South Asian dietician will recommend culturally appropriate diet modifications that still allow them to enjoy beloved and familiar foods—made with healthier ingredients and cooking methods.  An exercise physiologist will help them develop a suitable exercise plan. Transcendental meditation is recommended to reduce stress.

The third step is to provide encouragement and coaching for a full year to ensure follow-through with the lifestyle recommendations.  Several recent studies have underlined how important coaching is to goal achievement when compared to usual care or advice. Our heart health coaches help participants develop healthy habits and overcome potential obstacles to healthy eating, exercise and stress reduction.  

Does it work?  Having launched in 2006, we don’t yet have enough data to draw absolute conclusions.   We do know from other studies that lifestyle modification works to reduce and even to reverse coronary artery disease.  Because program participation is so important, the fact that 50% of our participants stick with their heart health coach— a much better rate that would be predicted from other studies—is a strong indicator that we are making a difference. 

As a cardiologist, that gratifies me, but my goal is much bigger.  When we started the Center, we set out to raise awareness of the epidemic, followed by screening for risk factors and the presence of asymptomatic coronary arteriosclerosis, followed by physician education. Now, we are gearing up our research program to try to identify the cause of premature coronary artery disease in this population.  

The South Asian Heart Center is a gift to the local South Asian community from South Asian donors and the El Camino Hospital Foundation, but what we learn and achieve here may have an impact throughout the world.  Where once we were the only nonprofit center tackling this crisis, we’re now seeing other organizations emulate our programs. That’s one of the best outcomes we could achieve.

Here’s a story which featured in the South Asian Heart Center’s health column. It narrates a conversation with a South Asian heart attack patient, who requested that his real name not be revealed. Read on…

Jagdeep Shah (not his real name) learned how important it is to maintain a healthy lifestyle after surviving a heart attack at age 43.  Here is his story:

When did you realize you had heart disease?

Not until I had a heart attack.  My parents are diabetic and both had had bypasses, but what I worried about was becoming a diabetic.  I had a terrible diet and was overweight but going to the gym regularly. One cold day in January 2006 I came home from the gym feeling very uncomfortable—so much so that my wife wanted to call 911. I convinced her I wanted to drive to the hospital instead.  It was terrible; we sat there waiting two hours even though they took my blood pressure when I came in and it was 180.  

What happened at the hospital?

My jaw started to hurt and my arm was going numb.  I was in real pain, but no one at the ER seemed very concerned. Finally, a physician looked at me, and thought I might just have a bad toothache.  But they decided to take a look at my heart.  All of a sudden, everyone was gathered around the heart monitor—they saw I was having a heart attack!  Luckily for me, that night Dr. Molina was on call and came immediately.  He did angioplasty, found a clot on the right side and put in a stent.  It was a miracle for me; he said that if the clot had been on the other side I might not have survived.

How did this change your life?

I was 43. When I had my heart attack my cholesterol was 164, but my LDL was over 100 and my HDL was very low.  Had I known it mattered I would have done the Berkeley HeartLab advanced lipid screening—but I didn’t—and there I was with a heart attack.

When I woke up from the heart attack, I changed my life completely. I started to eat healthy—I used to eat deep fried samosas—now I measure everything out, I eat brown rice. There’s no resemblance between how I eat now and how I ate before.  I don’t go out to restaurants as much. I lost the excess weight in two months and exercise and meditation are part of my life. 

The heart attack has had a big impact on my life.  I always have to carry a vial of nitro glycerin with me, when I’m walking, when I’m working out, and even when I’m sleeping. I know I can take it if I need it, but I’ve never had to take it—it’s more about dealing with the fear.  I worry about overdoing it, but Dr. Molina told me that as long as I can breathe through my nose, I’m fine.  If I need to breathe through my mouth then I need to slow down. 

What is the program you follow?

Dr. Molina is my doctor and architect of the program I follow. He also is the medical director of the South Asian Heart Center, so my program is very similar to theirs. I see the same dietician and follow the same therapeutic lifestyle change principles that they do.

Were the changes difficult to make?

Not really. Following the program requires mental strength.  Some things are repetitious--eating nuts over and over again, for instance--but it’s good for you.  Once in awhile I see myself breaking the rules, but not often.  The one thing I should do more of is green veggies.

Do you think your primary care doctor was aware that as a South Asian, you were at greater risk of a heart attack?

I’m not sure.  I never had the Berkeley HeartLab advanced lipids screening test, which is necessary to identify my real risk.  Since I was so young, it isn’t in the guidelines to do this test, so he probably thought that he could wait until I was 50. I know now that you need to get it done much earlier.

(Dr. Cesar Molina is a member of Heart and Vascular Associates in Mountain View, California, where he is Medical Director of the South Asian Heart Center at El Camino Hospital.)