“When I went in for the screening, I was not just complacent, I was even cocky,” he recalls. “For the last 10 years, I have had screenings every year, and none of them put me at high risk; this screening, however, revealed that I was in the 90th percentile for risk of heart disease.”
This surprising result could be true for many more South Asians—people who trace their origin to India, Pakistan, Nepal, Bangladesh, and Sri Lanka. According to the SAHC’s website, the risk of heart disease among South Asians is four times higher than for the rest of the population; South Asians suffer heart attacks at an earlier age, and have higher mortality rates after a heart attack. In California, Indians have the highest rates of hospitalization for coronary heart disease.
The SAHC has a concerted program to combat this higher risk among South Asians with advanced screening, patient education, lifestyle changes, and case management. The SAHC, located in the El Camino Hospital campus in Mountain View, has offered introductory screening for some participants like Saraf, but will open formally in April.
“People have known for some time now that a greater proportion of Indians have heart disease and at an earlier age,” says Dr. Padma Srinivasan, chair of the committee for patient education and physician relations at the SAHC.
She says that because many South Asians are vegetarian, family oriented, and generally non-smokers, the perception of risk is lower. But factors such as obesity, diabetes, metabolic syndrome (a pre-diabetic condition), smoking, family history of heart disease, stress, and lack of exercise can all trigger heart disease.
The cut-off parameters for South Asians are much lower than for the general population, and even small triggers—like being slightly overweight, or a slightly elevated cholesterol level—can put a person of South Asian origin at risk. The smaller frame of many South Asians could be one reason for this.
Though heart disease has often been perceived to affect mainly the working men in the family, it is not limited to them, says Srinivasan. Women are also at risk. Many Indian women wear saris and lehengas, which appear elegant, but also hide any tendency towards obesity.
“If the husband is working hard, then the wife is working harder,” says Srinivasan. “And she is also stressed out because she is lonely. She needs to gain the knowledge to serve healthy food and take good care of her family. That is why patient education is very important.”
It was the education of his health risks, and the knowledge to combat it, that was offered to Saraf when Dr. Cesar Molina conducted his screening. Molina has treated many South Asians, and he is also a lipid specialist. After volunteering for the last year-and-a-half for the center, he has come on board as its medical director.
“Lipoprotein (a) levels are higher in the South Asian population, and may be an important risk factor explaining the higher incidence of heart disease,” says Molina. “We have identified the South Asian population to be at higher risk for diabetes mellitus, metabolic syndrome (a significant precursor for heart disease), and coronary heart disease.”
Compared to the general American population, South Asians have lower incidence of obesity, tobacco usage, and high blood pressure, yet have a fourfold incidence of coronary or ischemic heart disease, says Molina. This is possibly due to various genetic differences in conjunction with environmental factors such as a high simple-carbohydrate diet and more sedentary lifestyles.
He points out that when the doctors at the SAHC reviewed medical data from the Kaiser Hospitals in Northern California, they found that a greater percentage of the South Asian population were admitted for heart disease and were much younger than the general patient population. The percentage of South Asian users of El Camino Hospital is only 3 percent, but they account for 6 percent of the heart attacks in the emergency room.
This is not the case for immigrants only, who may be more affluent and stressed out than their counterparts in India. Heart disease is a serious health issue in India as well. Studies show that the incidence of heart disease doubles among urban population samples when compared to rural areas.
That was why, when an increased number of South Asians showed up in their user database, and Jon Friedenberg, president of the El Camino Hospital Foundation, approached Dr. Prasanna Menon, a gynecologist with El Camino Hospital, to suggest a particular health issue for the South Asian population that the hospital should focus on, she zeroed in on heart disease. Menon has many South Asian patients and she had heard a number of them mention that their husbands, mostly young men who are vegetarian, non-smokers, and also exercise regularly, suffer from heart disease.
She researched this topic and contacted Dr. Enas A. Enas, author of the seminal book on this issue, How to Beat the Heart Disease Epidemic Among South Asians. Enas met with the doctors at El Camino Hospital and gave a presentation on the issue, which sparked off interest among doctors and community leaders in the Bay Area. The momentum gradually built up and is now culminating with the opening of the SAHC.
“Our main goal is to spread awareness on this issue; for instance, women are very often under-diagnosed,” says Menon, who chairs the Program and Executive Committee for the SAHC. “Regular lipid testing is not enough and may, in fact, falsely look good. That is why we recommend advanced lipid panel testing. Once the patient is aware, he or she can research family history and if needed, insist on getting the appropriate tests done.”
The center offers more than testing facilities. Ashish Mathur, executive director of the center talks about their two-pronged approach. The hospital aims to arm patients who come in for a screening with appropriate knowledge, and also educate physicians about special risks for South Asians and to treat them aggressively.
“I look at this as the program which can affect the largest number of people—people who need real help earlier,” says Mathur.
He explains the procedure. For South Asians who come in for a screening, the SAHC will do a brief physical, a health-risk assessment, and advanced blood tests. Based on the combined results, the doctors will give their recommendations. The center will consult with the primary doctor, or if there is no primary care provider, refer the participant to a physician who is aware of the special needs of South Asians. The doctor will be given all the necessary information to create a special program for the patient.
Mathur mentions their system called MEDS, which focuses on medication, exercise, diet, and stress. The SAHC will follow through and make sure that the participants are adhering to the program, with an emphasis on cessation of smoking, weight loss, stress reduction, yoga, and diet. South Asians who do not show a risk profile will not have to follow MEDS, but will still get information, which will help them manage their health. As an example, for Saraf, who was in the high-risk category, the treatment was to combat all the factors that could be putting him at risk.
“Dr. Molina put me through an additional series of tests, spent over an hour evaluating my condition, carefully sifting through the data, and explained why I was at risk,” says Saraf. “But he also told me that I had come in with enough time, so that I could reverse the risk.”
Earlier, Saraf had tried some cholesterol medication as his cholesterol was slightly on the higher side, but had suffered from side effects. The dietician at Molina’s office talked to him about changing his diet (if he had been drinking orange juice earlier, he was asked to eat a whole orange instead), augmenting his exercise routine (exercise more often and increase the aerobic component), and adding meditation or yoga to his routine.
After his first screening in October 2005, Saraf went back for a follow-up in January 2006. They found that his good cholesterol had nearly doubled, and that the cholesterol particles were much better distributed, an important step in lowering his risk.
“The screening with the SAHC has certainly made me more aware of my health and what I need to do to keep healthy,” he says.
The cause of this elevated level of risk for heart disease for South Asians is not fully known yet. Saraf, who has been a career counselor and life coach for the past five years, counsels a number of South-Asian Americans about work-related issues. He believes that the genetic abnormality that puts South Asians at risk for heart disease is exacerbated by an additional factor—stress.
“I find that people from South Asia are not good at managing stress. They are mentally competitive and harbor a fear of failure, as they believe that if they fail, they would not be well regarded in the community,” he says.
Srinivasan agrees with Saraf, and confirms that the South Asian immigrant has higher stress and less time for exercise.
Though many of the triggers for heart disease are inherited tendencies, we can modify them by changing our lifestyle, says Srinivasan. She emphasizes that it is important to pass on this information to the next generation as well. “Our kids have the less-than-optimum gene and when unhealthy food is added to the mix, it puts them at double jeopardy,” she says.
Menon agrees that lifestyles today are inherently unhealthier, but does not see increased levels of affluence (and therefore increased levels of consumption of richer food), and less exercise as the simple link to this issue. She adds that there is a limit to what can be achieved with diet and exercise. If the physician is informed, then hopefully aggressive action can be taken with the appropriate medication.
PROGRAM TAILORED FOR SOUTH ASIANS
To ensure that more people are able to avail of this effort, Menon mentions that the SAHC is offering the screening at reduced rates by special arrangement with the laboratory that conducts the testing. Nutritionists who are aware of Indian vegetarian cooking, and how people from different parts of India eat, are also available at the SAHC.
Additionally, the SAHC is trying to identify appropriate exercise centers that offer discounted memberships to South Asians. Exercise, apart from being heart-friendly, releases endorphins and relieves stress, thus benefitting in multiple ways, says Menon.
Over time, it is believed that the data generated at the SAHC would also provide invaluable information about the potential causes of this risk. But for now, the SAHC is focusing on disseminating information. “I’m hopeful that awareness will help with the situation as I believe that as the community settled here grows older, the problem is only going to get worse,” says Menon.
“We have the talent, the interest, and the technology, and that is the reason we have been able to do so much so quickly,” says Molina. “It is my dream that the SAHC will become a premier center for South Asians not only in the Bay Area, but also for the entire state, as I see that the small seed which we planted has now grown into a tree.”
South Asian Heart Center, El Camino Hospital, 2400 Grant Rd., Mountain View. (650) 940-7242. To get screened, you can sign up through the SAHC website: www.southasianheartcenter.org
Priya Gopalakrishnan is a freelance writer and editor.
HOW TO BEAT THE HEART DISEASE EPIDEMIC AMONG SOUTH ASIANS: A Prevention and Management Guide for Asian Indians and their Doctors by Enas A. Enas, M.D., F.A.C.C., with Sudesh Kannan, Ph.D., Advanced Heart Lipid Clinic, 2005. Paperback, 350 pages, 56 figures, and 112 tables. www.cadiresearch.com
The concept and realization of South Asian Heart Center (SAHC) draws largely from the pioneering research of Dr. Enas A. Enas, director of the Coronary Artery Disease among Asian Indians (CADI) Research Foundation, and an SAHC advisory board member. Enas is the first cardiologist to publicly address and scientifically prove a three- to four-fold high rate of heart disease among Indians in the United States. His book tells you why. The book also tells you how you and your family—working with your physician—can prevent, manage, and even reverse this dangerous but treatable killer.