IMPROVING SOUTH ASIAN
HEALTH
By
Ronesh Sinha, M.D.
Palo Alto Medical Foundation
© Copyright 2000-2009 Palo Alto Medical Foundation
(PAMF). All rights reserved. No part of this presentation
may be reproduced, stored in a retrieval system,
transmitted or retransmitted, in any form or by any
means, electronic, mechanical, photocopying, recording
or otherwise, without the prior written permission of
PAMF.
This presentation is designed to provide information with
respect to the subject matters addressed. Nothing
contained in any presentation is to be construed as
medical advice or a substitute for professional medical
care. If such advice or care is desired, the services of a
professional should be sought.
Talk Objectives
„ Understand
why South Asians are at high
risk for diabetes and heart disease
„ Identify major risk factors for diabetes and
heart disease risk
„ What simple changes can help reduce
diabetes and heart disease risk
„ Explore common exercise and nutrition
myths
Staggering South Asian Stats
„ Highest
coronary artery disease rates
worldwide
„ 50%
of heart attacks occur at age<55 and
25% at age <40
„ India
has the highest prevalence of
diabetes in the world
Why Are South Asians at High Risk?
Genes
„ South
Asians have inherited high risk genes
(will discuss later)
„ Family
history of heart disease, diabetes,
high cholesterol and/or high blood pressure
may mean you are at risk
„ Your
high risk genes may be passed to your
children
Lifestyle:
South Asian Pyramid of Priorities
FAMILY
ACADEMICS/CAREER
SOCIAL/CULTURAL/RELIGION
(NUTRITION AND PHYSICAL ACTIVITY?)
Older Face of Heart Disease
New Face of Heart Disease
Who Are South Asians?
„ India
„ Pakistan
„ Bangladesh
„ Sri
Lanka
„ Bhutan
„ Maldives
„ Nepal
4 CRITICAL QUESTIONS?
1.What’s my size?
2.What’s my cholesterol profile?
3.What’s my blood pressure?
4.Am I insulin resistant (fasting blood sugar and
other factors)?
Case Study
„ Vinod
is a 34 year old Indian software
engineer
„ He is vegetarian
„ He has never smoked
„ He gets no exercise
„ He has high levels of job stress
Vinod’s Numbers
Vinod’s
Results
Normal
Total Cholesterol
190
Not important
LDL
108
<100 (varies;will discuss)
HDL
32
>40 (males)
>50 (females)
Triglycerides
250
<150
Fasting Blood Sugar
109
<100
normal
100-125 prediabetes
126>/= diabetes
Blood Pressure
130/90
<130/80
Waist/Hip Ratio
1.2
<0.95 (males)
<0.90(females)
1.WHAT’S MY SIZE?
Standard BMI Table
Body Mass Index Target for South Asians is lower.
Aim for less than 23 kg/m2
Healthy
Overweight
Obese
Waist To Hip Ratio(WHR)
„ Superior
to BMI as an index of heart
attack risk
„ More constant among various ethnicities
„ Reflective of abdominal obesity
Waist-to-Hip Ratio
Male
0.95 or
below
0.99-1.0
>1.0
Female
0.90 or
below
0.91-0.95
>0.95
Risk
Normal
Moderate
High
Vinod’s Body Size
„ BMI
is 24 with a WHR of 1.2
„ Not
particularly overweight, but most of
his obesity is central (belly fat)
„ Belly
fat is “active fat”
Dangers of Belly Fat
The Y‐Y Paradox: Limitations of BMI as Measure of Adiposity Across Populations
BMI:
22.3
Yajnik CS, Yudkin JS. Lancet, 2004; 363:163.
Identical BMIs
22.3
Body 9.1% fat: 21.2%
Big difference in body fat
South Asian Body Size Resources
„www.pamf.org/southasian/healthy/screening/bodysize.html
„South
Asian adjusted BMI calculator; Waist-to-hip ratio
2.WHAT’S MY CHOLESTEROL
PROFILE?
Cholesterol
„ Know
all of your numbers, not just the
total cholesterol
„ LDL
is the bad cholesterol (“Lousy”)
„ HDL
is the good cholesterol (“Healthy”)
„ Triglycerides
are a type of fat in the blood
„ HDL-
“Healthy” cholesterol
„ LDL- “Lousy” or “Lazy” cholesterol
LDL Target Levels
Risk Profile
Recommended
Target
South Asian w/o Risk
Factors
LDL<130
South Asian w/Risks
LDL<100
Diabetics
LDL<100
History of heart attack, LDL<70
stroke or arterial
disease
Risk Factors
„
Age: greater than or equal to 45 in men and 55 in
women
Smoking
Family History: coronary heart disease in a first degree
male family member age less than 55 and female less
than 65 (sibling, parent or child)
High Blood Pressure: greater than or equal to 140/90 or
if you are taking medications for blood pressure
HDL less than 40 for males and less than 50 for females
„
Vinod has one of the above risk factors (HDL of 32)
„
„
„
„
Vinod’s Target LDL Level
Vinod’s LDL is 109
Risk Profile
Recommended
Target
South Asian w/o Risk
Factors
LDL<130
South Asian w/Risks
LDL<100
Diabetics
LDL<100
History of heart attack, LDL<70
stroke or arterial
disease
Resources for Lowering LDL
www.pamf.org/southasian/video/ldl.html
HDL (“Healthy” Cholesterol)
„ South
„ Men
Asians commonly have low HDL
should aim for an HDL above 40
„ Women
„ Exercise
should aim for an HDL above 50
and proper nutrition can help
raise HDL levels
HDL Resources
www.pamf.org/southasian/video/hdl.html
Triglycerides
„
Your triglycerides should be less than 150
„
South Asians tend to have high triglycerides
„
Regular exercise and weight loss can reduce
triglycerides
„
Reducing refined carbs and alcohol intake can
reduce triglycerides (will discuss later)
Resources for High Triglycerides
„www.pamf.org/southasian/video/tri.html
Typical South Asian Cholesterol
Profile
„
High triglycerides
„
Low HDL
„
LDL may be slightly high or normal
„
Total cholesterol may be less than 200
„
Lipoprotein (a) may be elevated
Total Cholesterol to HDL Ratio
„
Total cholesterol is not an accurate indicator of
heart attack risk
„
Total cholesterol to HDL ratio is better
„
Aim for ratio of 4.0 or less
„
Example-if your total cholesterol is 200 and your
HDL is 40, then your ratio is 200/40=5
Vinod’s Cholesterol
Cholesterol Tests
Vinod’s
Results
Target Level
Total cholesterol (TC) 190
Not important
LDL
108
<100
HDL
32
>40
Triglycerides
250
<150
TC/HDL Ratio
190/32=5.9
<4.0
Advanced Lipid Tests Necessary?
„ VAP,
Berkeley Heart Lab, etc.
„ In most cases unnecessary
„ Commonly used as “tiebreaker tests”
„ Consider Lp(a) if family history of early
heart disease
„ Although LDL levels may be normal, may
be pattern B (small,dense)
South Asian Resources
„ For
more information on interpreting South
Asian cholesterol results:
www.pamf.org/southasian/video/cholesterol.html
Improving Cholesterol in South
Asians
„ Refer
to following for comprehensive
information on lowering cholesterol:
www.pamf.org/southasian/healthy/screening/choleste
rol.html
3.WHAT’S MY BLOOD
PRESSURE?
Define Blood Pressure
„ Systolic(Top
Number)-pressure in your
arteries after your heart contracts
„ Diastolic(Bottom
Number)-pressure in
your arteries while your heart relaxes
Hypertension Stages
Monitoring You Blood Pressure
„
Home monitoring is a must
„
Arm cuff by Omron or A&D ($30-40)
„
Cuff must be large enough for your arm
„
Check at different times of day
„
Take home recordings to your doctor
Managing High Blood Pressure
„
Lose weight
„
Aerobic and resistance exercise
„
DASH (Dietary Approaches to Stopping
Hypertension) style diet
„
Refer to PRANA website for South Asian specific
information
DASH Pyramid
Hidden Salt
„
Not more than 2300 mg
sodium daily
„
1 tsp contains 2000mg of
sodium
„
Allow up to 500-600mg
sodium per meal
High Salt Indian Foods
Read all food labels for salt/sodium content:
„ Pickles and chutneys
„ Sauces and ketchups
„ Papadums and Indian snack foods
„ Nut mixes
„ Canned, packaged and preserved foods
„ Assume all restaurant foods are high in salt,
especially Indian, Asian and Mexican cuisines
Salt Substitutes
„
„
„
„
„
Spices and herbs
Lemon juice
Flavored vinegars
Potassium Chloride substitutes
Salt-free seasoning blends: Mrs.Dash has
15 different no-salt productswww.mrsdash.com/products/index.aspx
Vinod’s Blood Pressure
„ Average
blood pressure has been 130/90
over last 4 office visits
„ Defined
as prehypertension
High Blood Pressure Resources
Short video:
http://www.pamf.org/southasian/video/high_blood_pressure.html
Text:
www.pamf.org/southasian/healthy/screening/bloodpressure.html
4.AM I INSULIN RESISTANT?
Insulin Resistance
„ Fat
and muscle cells “resist” insulin’s
action
„ Excess blood sugar therefore cannot
enter cells
„ Leads to further increase insulin
release
„ Excess insulin is “toxic” to our body
„ Insulin resistance means a higher risk
of diabetes and heart disease.
Insulin Sensitivity
Insulin Resistance
Effects of Insulin Resistance
Pancreas pumps out more insulin
Excess amount of insulin in your bloodstream
“Insulin toxicity”
Insulin Effect #1: Fat storage
„ Obesity,
particularly central obesity
(belly fat)
Insulin Effect #2: High blood
pressure
„ Excess
insulin causes salt and water
retention
„ Excess
insulin leads to blood vessel
constriction
„ 50
percent of individuals with
hypertension are insulin resistant
Insulin Effect #3: Cholesterol
„ High
triglycerides: >150 mg/dl
and/or
„ Low
HDL: <40 mg/dl for males
<50 mg/dl for females
Some Risk Factors for Insulin
Resistance
„
„
„
„
„
Obesity, particularly central obesity
Family history of type 2 diabetes or insulin
resistance
High blood pressure: 50% are insulin resistant
Gestational diabetes (during pregnancy)
Ethnic groups-South Asians, Southeast Asians,
Native Americans, African American women
How To Measure Insulin
Resistance?
„ Measure
your fasting blood sugar
„A
level above 100 suggests “pre-diabetes.”
„A
level above 125 defines diabetes.
Why Insulin Resistance Is Killing
Us?
Computer Age:
Present day
Paleolithic Man:
Millions of yrs ago
Neolithic Man:
10,000 yrs ago
DNA
Vinod’s Blood Sugar
„ Fasting
Blood Sugar of 109
„ Prediabetes
by definition
Improving Insulin Resistance
„ Losing
15 pounds or 5-10 percent loss in
body weight can dramatically improve
insulin resistance
„ Regular
exercise three to four times per
week for at least 30 minutes can improve
insulin sensitivity, triglycerides and HDL.
Diabetes/Prediabetes Resources
for South Asians
„
„
www.pamf.org/southasian/video/prediabetes.html
www.pamf.org/southasian/video/diabetes.html
What happened to Vinod?
Vinod presented to Stanford ER with crushing
chest pain and was diagnosed with a heart attack
due to a blocked coronary artery.
„
He had emergency angioplasty which helped
bypass his blocked artery
„
Under the Radar
„ Normal
LDL: 108
„ Prehypertension: BP of 130/90
„ Prediabetes: Blood sugar of 109
„ Non-smoker
„ Vegetarian diet
„ BMI of 24: Normal by non-South Asian range
„ Age-34: Too young to have heart attack?
The South Asian Diet
Half plate-Fruits/Vegetables
Whole Grains
•Whole wheat couscous,
quinoa, brown rice,
whole wheat chapattis
Meat/Protein
¼ plate-whole grain ¼ plate-meat or
(1-2 chapattis:size of protein
CD)
•Skinless poultry, trim fat
off meat. Lentils, beans
(garbanzos,kidney beans,
etc), and tofu are good
sources of vegetarian
protein.
Carbs: The Center of The South
Asian Diet
Glycemic Index(GI)
„
Helps distinguish healthy and unhealthy carbs
„
Measures how quickly a certain food raises your
blood sugar
„
A high GI food quickly raises your blood sugar
levels
Glycemic Index(cont.)
Low GI - less than 55
Intermediate GI - between 56 and 69
High GI - higher than 70
Glycemic Index(cont.)
Low GI - less than 55
Medium GI - between 56 and 69
High GI - higher than 70
High Glycemic Index Carbs
“Bad Carbs”
Simple Rule Of Thumb:
„
Restrict White Foods-white breads (naan,puris),
white rice, potatoes and sugar
„
White Substitutes-whole wheat breads/rotis,
brown rice, sweet potatoes and non-starchy
vegetables
Risks of High GI Foods
„ Increase
triglycerides
„ Increase
abdominal fat
„ Raise
blood sugar
„ Make
you hungrier
How Do Carbs Increase
Triglycerides?
„ By
increasing insulin release
„ Insulin
„ Eating
stores fat as triglycerides
high glycemic carbohydrates can
raise triglycerides as much as eating a
fatty meal!!
Fats and Oils
Healthy Fats
„ Monounsaturated
„ Polyunsaturated
„ Above
fats
Fats
Fats: Omega-3s
should replace saturated and trans
MUFA Sources
„ Oils:
olive oil, canola oil and peanut oil
„ Nuts:
hazelnuts, almonds, brazil nuts,
cashews and peanuts/peanut butter
„ Seeds:
sesame and pumpkin seeds
„ Avocados
What Are Omega-3s?
„ These
„2
are the healthy oils found in fish
main types: abbreviated DHA & EPA
„ Omega
3s can be consumed by eating fish
or taking fish oil capsules
„ Other
sources: flaxseed, walnuts, spinach
Benefits of Fish Oil
„ Helps
reduce triglycerides
„ May
reduce death from heart attack
„ May
reduce arthritis pain (unproven)
„ May
help with memory (unproven)
Fish Oil Capsules
„
Discuss with your doctor before taking
„
DHA and EPA are the Omega-3s found in fish
and fish oil capsules
„
Need 1g (1,000mg) for heart protective effects
„
Need at least 3g (3,000mg) of Omega-3s to
lower triglycerides
Read The Label
Serving Size2 Capsules
600mg total
Omega-3s in 2
capsules
More on Fish Oil
„
www.pamf.org/southasian/healthy/fishoil.html
Key Point About Fats
„ Healthy
and unhealthy fats have the same
amount of calories
„ Excess
weight increases the risk of
metabolic syndrome and heart disease.
„ The
key to a healthy diet is moderation.
South Asian Nutrition Resources
www.pamf.org/prana/nutrition/
Your Children
„ Your
high risk genes may be passed to
your children
„ Sedentary parents tend to raise sedentary
children
„ Healthy eating habits should start as early
as possible
„ Refer to the children’s section of the
PRANA website
South Asian Children’s
Resources
www.pamf.org/southasian/healthy/children/pyra
mid.html
The New South Asian Pyramid of
Priorities
HEALTH
FAMILY
ACADEMICS/CAREER/RELIGION/SOCIAL
PRANA Website
www.pamf.org/prana
„
Most comprehensive South Asian health resource on the
web
„
Wide range of health topics
„
Extensive nutrition information and healthy South Asian
recipes
„
Audio lectures in English and Hindi
„
Infant and children’s section
PRANA Website
Subscribe to our monthy newsletter
South Asian Services
„
South Asian consult service-spend 60 min
with a specialist in South Asian health. Can be
referred by your doctor: 650-330-4523. Can
request Dr. Sinha if you wish to see him.
„
Employer Lectures-Dr.Sinha has an entire
wellness lecture series that includes South Asian
specific topics. Call 650-934-8613 and ask for
Sarah to schedule talks at your workplace.
„
Employer services: online South Asian
wellness program for companies (being piloted at
Cisco). Contact Sarah (above) for more info.
Common Exercise Myths
Myth #1: “I exercised today, so
now I can eat what I want”
Scenario
„ Saturday
evening you are meeting
friends for thai food
„ You
decide to work out in the
morning so you can enjoy dinner at
night: You do 30 minutes on the
elliptical machine
„ Average
calories burned=500
Thai Dinner
2 spring rolls=220 calories
„ 1 serving of Padh Thai=560 calories
„ 1 serving of Green curry chicken=470 calories
„ 1 cup of cooked white rice=240 calories
„ Thai iced tea-170 calories
_____________________________________
1,660 calories taken in
„
1,660-500 calories= 1160 calories net positive
(3500 calories~1 pound)
Lesson Learned
„ Exercise
does not give you the license to
eat without restrictions
„ If
you are trying to lose weight, exercise
must be balanced with a healthy diet
„ Pay
attention to portion sizes: Exercise
often contributes to “portion distortion”
Myth #2: “I exercised this morning, so
I don’t need to be active for the rest of
the day”
How Much Activity Do You
Need?
„
Human body not designed to be as
sedentary as we are today
„
30-60 min of daily exercise does not give
us license to sit for the rest of the day
„
Lower levels of constant activity are as
important as intense bursts of activity
Get Creative With Exercise
„ Park
further away
„ Take the stairs
„ Buy a Pedometer-aim for 10,000 steps a
day
„ Walk during your lunch hour
„ Turn your cell phone into a “walkie talkie”
„ Consider purchasing a heart rate monitor
Pedometers
„
„
„
„
„
Check your baseline number of daily steps
Less than 5,000 steps associated with
being overweight
More than 9,000 steps associated with
normal weight
Aim for goal of 10,000 steps daily
2,000 steps~1 mile
Myth #3: “I don’t have time to
exercise”
No Time To Exercise?
„
"Most of my workouts have to come
before my day starts…the main reason I
do it is just to clear my head and relieve
me of stress…there's always a trade-off
between sleep and working out. Usually I
get in about 45 minutes, six days a week.
I'll lift (weights) one day, do cardio the
next. I wish I was getting a 90-minute
workout," he added.”
WHO SAID THIS?
Interrupted Activity Counts!
„
Three ten minute walks can be as good as
one thirty minute walk
„
Take any opportunity to leave your chair
and add steps to your day
„
You can reduce your risk of heart disease,
stroke and death without breaking a sweat
Interval Training
„
„
„
„
Short bursts of intense exercise may be superior
for improving fitness and weight loss
One study of overweight women compared 20
min interval workouts on stationary cycle (12 sec
slow peddling followed by 8 sec intense sprints)
three times a week with those cycling at steady
pace for 40 minutes
After 4 months, interval training group lost 6
pounds of body fat and steady exercises lost less
than 2 pounds
Short bursts may increase catecholamine release
which stimulates fat breakdown
Schedule Exercise
Myth #4: “I’m just going to do cardio,
since lifting weights is a waste of time”
Include Resistance Training
„
More muscle mass reduces insulin
resistance
„
More muscle increases metabolism
„
More muscle can reduce injuries, repetitive
stress injuries and arthritis
„
Can be done at home (resistance bands,
weights, etc.)
Increased Muscle Improves Insulin
Resistance by Increasing Glut 4
A Few of My Closing Thoughts on Exercise
„
„
„
„
„
Go from “I don’t have time to exercise” to
“I’m not making time for exercise”
When you think you have the least time
for exercise is when you need it the most
I have never regretted a trip to the gym.
I have never met a patient who did not
benefit in some way from regular exercise
Try exercising before work for two weeks
and see if your mood and overall
performance improve
EXPLORING SOME COMMON
NUTRITION MYTHS
Myth #1: “Shrimp is evil”
„
„
„
„
„
„
Very low in fat and high in cholesterol
Raises bad (LDL) slightly and good (HDL)
cholesterol more
Overall is cholesterol neutral
Very low in calories
May have some heart healthy properties
Steam it, broil it or grill it with minimal
oil…don’t fry it!
Myth #2: “Eggs are bad for you”
„
„
„
„
„
„
High in cholesterol (200mg per egg) and all of it is in the
yolk
Does not raise blood cholesterol significantly
For most healthy people, 1 egg per day is fine
If you have heart disease or high cholesterol, limit to 2-3
egg yolks per week
Egg whites do not need to be limited
If you eat an egg, limit other sources of cholesterol that
day
Dietary Cholesterol
„
Dietary cholesterol does not always raise blood
cholesterol.
„
Saturated fats and trans fats raise cholesterol
more than dietary cholesterol
„
Healthy diet: <300mg of cholesterol daily
„
Heart disease, diabetes or high LDL cholesterol,
then <200mg cholesterol
Myth #3: “Brown sugar is brown, so it must
be healthier”
„ Brown
sugar is not healthier
„ Brown
sugar=white sugar + molasses
„ Similar
glycemic index to white sugar
„ Message:
healthy
Not all “brown foods” are
Message: Not all brown foods
are healthy!
“Is honey healthier than sugar?”
„
„
„
„
„
„
„
Both made up of glucose and fructose
Honey is about 1.5 times sweeter than
sugar.
Honey has slightly lower glycemic index
Honey has more calories, but you end up
using less since it’s sweeter
Honey has vitamins and minerals
Sugar is much cheaper
Limit both if you are insulin resistant or
overweight
Myth #4: “Ghee is good for you”
„
„
„
„
„
„
Ghee is clarified butter (simmered butter with
water and milk fat removed)
Still a saturated fat
1 tbsp has 14 grams of fat
Avoid if you have high cholesterol (especially high
LDL) or heart disease
“Vegetable ghee” is even unhealthier since it is a
trans fat (hydrogenated vegetable oil). Commonly
used in restaurants since it is cheaper
If you must use, use smallest quantity possible
“What about coconut oil?”
„
„
„
„
„
Like ghee, many rumored, but unproven
benefits
It is a saturated fat, although not from
animals
One tablespoon contains nearly 120
calories and more than 13 grams of fat.
10 times more unhealthy saturated fat
than olive oil
If you must use, use smallest amounts of
extra virgin coconut oil
Butter versus Margarine
„
„
„
„
Butter and margarine are both high in fat
Butter has more saturated and/or trans fat
which raises LDL cholesterol
Soft or liquid margarines have less
saturated and trans fats. Choose these
over stick margarines and butter.
Select margarine with 0 grams of trans fat
Myth #5: “Rice krispies, corn flakes and
honey bunches of oats are all healthy”
Choosing Cereals
„
„
„
At least 6 grams of fiber per serving
Sugar should be less than 25 percent of calories unless
dried fruit is listed in first three ingredients.
1 gm of sugar has 4 cal
gm of sugar
4
cal/serving
100
Percent calories from sugar
Honey Bunches of Oats
(A South Asian Favorite)
„
„
„
„
„
„
Only 2 g of fiber
120 calories per serving
6 g of sugar
6 g X4/120 X100=20%
Sugar content acceptable,
but not enough fiber
If you can’t give it up, add
fiber powder, flaxseed, mix
in high fiber cereal and/or
add berries or other fruits
Myth #6: “I should start drinking alcohol to
improve my health”
„
„
„
„
„
„
Don’t start drinking to improve your health
Moderate drinking can reduce heart disease,
especially in middle age
Moderate drinking=1 daily drink for women and 2
daily drinks for men
1 drink=12 oz beer, 5 oz wine or 1.5 oz of hard
liquor
Heavy drinking increases blood pressure, liver
disease, cancer risk, accidents, etc.
You can drink purple grape juice to get all the
antioxidant effects of wine
Myth # 7: “Vegetarians are healthier”
„
Not necessarily the case, especially in South
Asians
„
Western vegetarian diet is healthier due to
emphasis on whole grains and high fiber foods
„
South Indians have higher incidence of heart
disease and diabetes than North Indians. Kerala
is the highest risk region of India
Which is Healthier?
Vegetarian Thali
Steak & Vegetables
Myth #8 “I’m eating healthy, but still not
losing weight”
„
„
Keep track of “BLTs” (bites, licks and tastes)
May add up to 1,000 extra “hidden calories”:
ƒ Standing at the refrigerator and grabbing a
piece of cheese.
ƒ Frequent visits to the cupboard or pantry
for crispy snacks or handfuls of nuts
ƒ Eating chips out of the bag while watching
TV or sitting at the computer.
ƒ Sampling baked goods and deli treats at the
grocery store.
ƒ Eating your kid’s leftovers
ƒ Sampling while cooking and baking
The End