‘Cultural competence’ key to reduce cardiometabolic risk among South Asian subgroups
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South Asian adults develop cardiovascular disease approximately a decade earlier than people of other ethnicities, and the multifactorial causes of premature risk show more preventive work is needed, according to a speaker.
South Asians make up about 25% of the world’s population, and their risk for CVD is double that of the national averages of the Western world, Martha Gulati, MD, MS, FACC, FAHA, FASPC, president-elect of the American Society for Preventive Cardiology, said during a presentation at the Heart in Diabetes CME Conference. Approximately 1 in 2 South Asian adults with normal weight have at least two risk factors for CVD compared with 1 in 5 white adults with normal weight, Gulati said. South Asian adults are also more likely to develop type 2 diabetes, hypertension, hypertriglyceridemia and high cholesterol at lower body weights compared with the general population, she said, though risk varies among South Asian subgroups. Currently, about 5 million South Asian adults live in the U.S.
“Not all South Asians are the same,” Gulati told Healio. “In the past, we used to talk about ‘Asians,’ in general. We have gotten a little bit better about being more specific. Even culturally, there are very different worlds. When we say, ‘South Asian,’ those of us who are cardiologists or endocrinologists should try to find out a little bit more about where exactly our patient comes from. Certainly, South Asian ancestry is a risk enhancer for CVD, based on 2019 guidelines. That is fair, but also the [American Heart Association] has emphasized that Asian subgroups must be evaluated separately. Indian vs. Pakistani vs. Bangladeshi are very different in terms of risk.”
Where is your patient from?
Risk for coronary artery disease is not uniform among South Asians; important differences exist between Indians, Pakistani, Bangladeshi and other South Asian adults for many coronary risk factors, Gulati said. Developing “cultural competence” is helpful to learn more about where a patient comes from, or where their parents are from, when assessing risk for cardiometabolic conditions.
“Part of what we are seeing is there are cultural differences — diet, differences in physical activity and tobacco use,” Gulati said. “There may also be genetic differences. Social determinants of health also determine who is more likely to develop type 2 diabetes or heart disease. Things like education, social class or diet type that is influenced more by income than a lack of awareness about eating healthy. It is not always a choice; sometimes it is about what is cheaper.”
Gulati said a better understanding of the underlying causes can help inform effective preventive interventions.
Risks for South Asian women
For South Asian women, there are also unique risks, particularly with pregnancy, Gulati said.
“Gestational diabetes occurs more often in South Asian women, and we know that gestational diabetes is a risk factor for future CV events,” Gulati said. “That is something South Asian women need to be aware of and something we as physicians need to be talking about and screening for when doing risk assessment, because gestational diabetes is considered a risk enhancer.”
Preeclampsia and risk for CVD also differ by race and ethnicity, Gulati said. In an analysis of hospital data from more than 11.3 million deliveries between 2016 and 2018 published in Hypertension, Gulati and colleagues showed that Asian and Pacific Islander women had 19% lower odds of preeclampsia than white women. However, risk for future CVD after developing preeclampsia was highest among South Asian adults compared with any other group, after adjustment for socioeconomic factors and comorbidities.
“For those of us who take care of these patients, we see CVD at younger and younger ages now than traditionally seen in other races or ethnicities,” Gulati said. “We have to do far more in terms of preventive efforts for this group.”
New data coming
The Mediators of Atherosclerosis in South Asians Living in America (MASALA) study, funded by the NIH, is the first longitudinal study of U.S. South Asians to understand what factors lead to CVD and guide prevention and treatment. The “wave A” cohort (2010-2018) included 1,164 participants (83% Indian). The “wave B” cohort (2021-2024) comprised 1,150 participants, including 600 Bangladeshi and 550 Pakistani participants.
“This wave will specifically look at Bangladeshi and Pakistani adults,” Gulati said. “That will give us a nice look at what we are seeing here in the United States and provide us even more information in the future.”
References:
The MASALA study. Available at: www.masalastudy.org. Accessed Sept. 8, 2021.
Minhas AS, et al. Hypertension. 2021;doi:10.1161/HYPERTENSIONAHA.121.17104.
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Gulati M. Cardiovascular disease in South Asians. Presented at: Heart in Diabetes Annual Meeting; Sept. 10-12, 2021 (hybrid meeting).
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