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Read about MASALA in the New York Times

Read about MASALA in the New York Times

Why Do South Asians Have Such High Rates of Heart Disease?

PDF of the article.

“We all have someone in our first-degree circle that has either died suddenly or had premature cardiovascular disease,” said one researcher.

By Anahad OʼConnor

Feb. 12, 2019

Mahendra Agrawal never imagined he would have a heart attack. He followed a vegetarian diet, exercised regularly and maintained a healthy weight. His blood pressure and cholesterol levels were normal.

But when Mr. Agrawal experienced shortness of breath in June 2013, his wife urged him to go to a hospital. There, tests revealed that Mr. Agrawal, who was 63 at the time, had two obstructed coronary arteries choking off blood flow to his heart, requiring multiple stents to open them.

“I’m a pretty active guy and I eat very healthy, my wife makes sure of that,” said Mr. Agrawal, who lives in San Jose and worked in the electronics industry. “It makes me wonder why this happened to me.”

Despite his good habits, there was one important risk factor Mr. Agrawal could not control: his South Asian ancestry. Heart disease is the leading killer of adults nationwide, and South Asians, the second fastest-growing ethnic group in America, have a higher death rate from the disease than any other ethnic group. People of South Asian descent, which includes countries like India, Pakistan, Bangladesh, Nepal, Sri Lanka, Bhutan and the Maldives, have four times the risk of heart disease compared to the general population, and they develop the disease up to a decade earlier.

“Every South Asian has a very common experience unfortunately, and it’s that we all have someone in our first-degree circle that has either died suddenly or had premature cardiovascular disease,” said Dr. Abha Khandelwal, a cardiologist at the Stanford South Asian Translational Heart Initiative.

Experts are only now beginning to uncover why rates of heart disease are so high in this group. For the last seven years, a team of researchers at the University of California, San Francisco and Northwestern University has followed more than 900 South Asians in Chicago and the Bay Area. Their ongoing study, known as Masala, for Mediators of Atherosclerosis in South Asians Living in America, has found that South Asians tend to develop high blood pressure, high triglycerides, abnormal cholesterol and Type 2 diabetes at lower body weights than other groups. South Asian men are also prone to high levels of coronary artery calcium, a marker of atherosclerosis that can be an early harbinger of future heart attacks and strokes.

“South Asians represent almost 20 to 25 percent of the world’s population, and this is a major public health problem in this huge population,” said Dr. Alka Kanaya, a professor of medicine at U.C.S.F. and one of the Masala principal investigators. Born in Mumbai and raised in California, Dr. Kanaya was inspired to launch the Masala project after seeing many of her friends and family members die from heart disease at relatively young ages.

In November, the American Heart Association and other medical groups issued updated cholesterol guidelines that, for the first time, urged doctors to consider ethnicity when determining a patient’s cardiovascular risk and treatment options. Citing studies by the Masala researchers, the guidelines identified South Asians as a “high risk” group and “stronger candidates” for statin medications when other risk factors are present.

Some of the most striking findings to come out of Masala relate to body composition. Using CT scans, Dr. Kanaya and her colleagues found that South Asians have a greater tendency to store body fat in places where it shouldn’t be, like the liver, abdomen and muscles. Fat that accumulates in these areas, known as visceral or ectopic fat, causes greater metabolic damage than fat that is stored just underneath the skin, known as subcutaneous fat.

Studies show that at a normal body weight — generally considered a body mass index, or B.M.I., below 25 — people of any Asian ancestry, including those who are Chinese, Filipino and Japanese, have a greater likelihood of carrying this dangerous type of fat.

Despite having lower obesity rates than whites, Asian-Americans have twice the prevalence of Type 2 diabetes, which promotes heart attacks and strokes.

Heart risks tended to be greatest in South Asians, the Masala researchers found. In one recent study, in the Annals of Internal Medicine, they found that 44 percent of the normal weight South Asians they examined had two or more metabolic abnormalities, like high blood sugar, high triglycerides, hypertension or low HDL cholesterol, compared to just 21 percent of whites who were normal weight.

The Masala researchers also found that using the standard cutoff point to screen for diabetes, a B.M.I. of 25 or greater, would cause doctors to overlook up to a third of South Asians who have the disease. “Many of them may never get to that B.M.I. and they will have had diabetes for years,” Dr. Kanaya said.

The findings helped prompt the American Diabetes Association to issue updated guidelines in 2015 that lowered their screening threshold for diabetes, to a B.M.I. of 23 for Asian-Americans. A public awareness campaign, organized by the National Council of Asian Pacific Islander Physicians, called Screen at 23 has drawn attention to the issue, and a.t least three states, including California, Massachusetts and Hawaii, have enacted policies to promote more aggressive health screenings of Asian-Americans. Representative Pramila Jayapal of Washington, the first Indian-American woman to serve in the House, recently introduced a bill to provide more funding for South Asian heart health awareness and research.

Most of the participants in the Masala study are first-generation immigrants, and the researchers found that their cultural practices also impact their disease rates. Cardiovascular risks tended to be highest in two groups: those who maintained very strong ties to traditional South Asian religious, cultural and dietary customs, and those who vigorously — embraced a Western lifestyle. Those with lower risk are what the researchers call bicultural, maintaining some aspects of traditional South Asian culture while also adopting some healthy Western habits.

This discrepancy plays out in their dietary behaviors. Almost 40 percent of Masala participants are vegetarian, a common practice in India that is widely regarded in the West as heart healthy. But vegetarians who eat traditional South Asian foods like fried snacks, sweetened beverages and high-fat dairy products were found to have worse cardiovascular health than those who eat what the researchers call a “prudent” diet with more fruits, vegetables, nuts, beans and whole grains (and, for nonvegetarians, fish and chicken). People who eat a Western style diet with red and processed meat, alcohol, refined carbohydrates and few fruits and vegetables were also found to have more metabolic risk factors.

Dr. Namratha Kandula, a Masala investigator at Northwestern, said she hopes to study the children of the Masala participants next because they tend to influence their parents’ health and lifestyle habits, and the researchers want to understand whether health risks in second-generation South Asians are similar or not. But for now, some experts say their goal is to increase outreach to South Asians who may be at high risk and neglecting their health.

“As a South Asian Bay Area resident, I see that we focus a lot on success and academic achievements in our families,” said Dr. Khandelwal at Stanford. “But we don’t necessarily look at our health success, and your health is something that you can’t easily get back.”

Anahad OʼConnor is a staff reporter covering health, science, nutrition and other topics. He is also a bestselling author of consumer health books such as “Never Shower in a Thunderstorm” and “The 10 Things You Need to Eat.”

House Resolution 3592: support South Asian Heart Health


Please write to your State Representative in support of the South Asian Heart Health Awareness and Research Act of 2017, HR 3592.   

This  bill will promote recognition of the high risk of heart disease seen in our growing South Asian population, and develop treatment strategies that ultimately will save lives.  The federal government’s investment in research and prevention of heart disease, especially in the highest risk groups, will reduce long-term utilization of health care dollars.  Through previous and ongoing research supported by the NIH, we have already learned the following: 

  • South Asians living in the U.S. have on average 4x higher risk for heart disease compared to the general population.

  • Heart disease presents in South Asians at younger ages (5--10 years earlier) compared to other groups, with heart attacks often occurring before age 50.

  • The proportion of death due to heart disease is significantly higher in South Asians compared to other race/ethnic groups, especially at younger ages.

  • Research has shown that, through early screening for heart disease and risk factors, along with development of culturally tailored prevention programs, heart disease risk in the South Asian population can be lowered, saving lives while also significantly reducing health care costs.


SPECIFICALLY, this bill will:

  1. Create South Asian Heart Health Promotion Grants at the Centers for Disease Control to develop a clearinghouse and web portal of information on South Asian heart health, develop culturally appropriate materials to promote heart health in the South Asian community, and provide grants to work with community groups involved in South Asian heart health promotion;

  2. Authorize grants through NIH to conduct research on cardiovascular disease and other heart ailments among South Asian populations living in the United States;

  3. Authorize grants through USDA’s extramural science granting agency, the National Institute of Food and Agriculture, for the promotion of South Asian heart health nutrition; and

  4. Include a Sense of Congress that U.S. medical schools should include as part of their nutrition curriculum, a focus on South Asian diet and ways to achieve optimal nutrition in these populations.

If you support the bill, please use the information below to reach out to your representative and ask them to support HR 3592.




  1. Go to the link to find your representative. You can enter your home zip code to find your representative. After you find your representative, you can click on their name to go to their website. On the website, go to the “Contact” tab and find the phone number to their office.

  2. You can call your representative during normal business hours and talk to a staff member. Please mention that you are a resident and provide them with your contact information and state that you are calling to support the South Asian Heart Health Awareness and Research Act of 2017, HR 3592. If you would like you can mention any specific personal reason why you would like to support this bill. Below is an example for your reference.

“I am calling to support HR 3592. I am a xx year old South Asian female and this bill affects me and my family members personally. I know of friends and family members affected by heart disease and this bill will help create awareness about this important health issue.


Sample letter if you are a physician or health professional

Sample letter if you are a constituent

How do our social networks influence our health?

Many of us recognize that family, friends, peers, and coworkers play an important role in our lives. For a long time, health care has focused mostly on individuals, without considering how the people around us might influence our health and health behaviors. But now, there is growing interest in the power of social connectedness, the importance of social support, and the influences individuals have on one another’s behavior.


Social network analysis is a useful tool to study relationships and the flow of information between individuals, groups, and organizations.  This may be especially important for South Asians, who place great importance on their family and community.  In the MASALA study, we are studying the connections between social networks and the MASALA study participants’ diet, physical activity, weight, physical and mental health.  MASALA is the first study to investigate how social networks influence health in the South Asian community.  Understanding the social lives and relationships of South Asians and how they are linked to health can help inform more effective health behavior programs for our community. 

We recently published two papers on social networks in MASALA. We found that South Asians have a relatively large social networks, consisting mostly of family members and individuals who are also South Asian. Social networks that were more dense (when network members know each other), emotionally closer, and were comprised mostly of family were more likely to talk about health with each other. 

In a second paper, we looked at whether the body size of network members was associated with the MASALA participants’ perception of a “healthy” body size. We found that if the network members had larger body sizes, then the MASALA participant thought of larger body sizes as “healthy.” As a next step, we will look at whether these perceptions about healthy body size and the network members’ body size are associated with weight gain in MASALA participants.

Learn more about how social networks influence South Asians’ health by reading two papers that were recently published in peer reviewed scientific journals.

Social network body size is associated with body size norms of South Asian adults

Personal social networks and organizational affiliation of South Asians in the United States