Despite smoking less, being leaner and mostly vegetarian, Indian immigrants are up to four times more prone to heart ailments compared to other demographic groups. Here’s an eye-opening explanation of why that is so, and what we can
do about it.
Drop in at any Indian social gathering and
almost inevitably the chatter will drift towards cholesterol numbers and the threat of oil, ghee, and sugar in
our diets. We watch our calories and take pride in
spreading butter substitutes on our toast hoping to
stay healthy and lean. Statistically, we eat less meat, smoke less, and are leaner than the average Westerner. Shouldn’t we be a heart healthy community?
Strangely, no. The surprising news is that in spite
of these “healthy” parameters, studies1 from Canada,
U.S., and the United Kingdom have shown high rates of
heart disease among south Asian communities compared
to other immigrant populations. In the book Coronary
Artery Disease, the authors noted that:
“The CAD rates among overseas Asian Indians worldwide
are 50% to 400% higher than people of other ethnic origins
irrespective of gender, religion, or social class.”
Paradoxical, isn’t it? Here are some more alarming
statistics:
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• A northern California study on 13,000 participants
over a period of 7 years also found out that
Indians had the highest rates of hospitalizations
from coronary artery disease (CAD) compared to
other immigrant populations (Figure 1, above).
• The median age of first heart attack in Indians is
53 years, 10 years earlier than Westerners.
• The incidence of CAD in young Indians (under 50
years) is about 12% -16%, higher than any other
ethnic group.
• About 5% -10% of heart attacks occur in Indian
men and women younger than 40 years.
Two prominent factors, amongst other health
and lifestyle considerations, could hold the answer to
the puzzle of high incidence heart ailments and the
relative young age of Indians succumbing to them: an
overdriven carb/insulin metabolism and the stress of
social dislocation.
According to ChartsBin, a web based data-visualization service, Indians top the world in carbohydrate consumption, second only to the Republic of Congo. A whopping 71% of our calorie intake comes from carbs, with protein content at only 10% and fat at 19%.
Indians top the world in carbohydrate consumption
A typical Indian meal features chappati (or paratha)
along with rice, some vegetables (perhaps with potatoes)
and lentil or beans. Since a high percentage of
Indians are vegetarians, meat consumption is low. As
one may observe, the biggest calorie component in
our diet comes from carbohydrates—more specifically,
from easily digested carbohydrates found in wheat,
rice, and potatoes.
According to ChartsBin (http://chartsbin.com/view/1162), a web based data-visualization service,
Indians top the world in carbohydrate consumption,
second only to the Republic of Congo. A whopping 71%
of our calorie intake comes from carbs, with protein
content at only 10% and fat at 19% .
So how does a carb-rich diet impact our metabolism?
Carbohydrates—long chains of sugar molecules
whose prime purpose is to supply energy—break down
into simple sugars in the gut, and are then absorbed
in our blood. This causes a rise in the level of blood
sugar. Excess blood sugar sticks to lipids and proteins
to form Advanced Glycation End-products (AGE) that
are responsible for systemic inflammation and oxidation
in our bodies, leading to heart disease, Type II
diabetes, osteoarthritis, age related dementia, and
certain forms of cancer.
Excess sugar in blood is undesirable. To regulate its
levels, our pancreas secretes insulin. Insulin plays the
sugar cop by signaling the liver to convert the excess
sugar into fat molecules—those tiny villains we know
as triglycerides. These triglycerides are then transported
to their final storage location inside fat cells. And
that’s how we gain weight.
When blood sugar rises rapidly from a carb-rich
meal, the pancreas overproduces insulin. After the
excess sugar is stored away as fat, the leftover insulin
keeps working to store the remaining blood sugar. This
causes a sharp drop in your sugar level leaving you low
on energy and craving another high-carb fix.
Over time, due to these insulin spikes and sugar
crashes, the fat cells become resistant to insulin action,
just as we become immune to traffic noise if we live by
a highway. As a result, even more insulin is needed to
do the same job. At this point, a person is said to have
developed insulin resistance or metabolic syndrome:
their insulin and sugar levels are simultaneously high.
Visceral fat—the fat surrounding your vital organs
(liver, stomach, gall bladder, etc.) as opposed to subcutaneous
fat that’s just beneath the skin—is exposed
to a higher flow of blood and also has higher number
of insulin receptors. Hence, any excess blood sugar
is most likely stored in this area. Visceral fat is also a
rich source of many inflammatory molecules that are
transported directly into the liver for circulation around
the body, contributing to systemic inflammation
which is the cause of many of today’s lifestyle diseases.
Metabolic syndrome, when left untreated, leads to
Type II diabetes, where the pancreas completely ceases
to produce insulin.
The second distinctive cause, which is not specific
to Indians only, that contributes to weight gain is eating
pattern. Most people eat a light, quick breakfast before
rushing to work, followed by a comparatively heavier
lunch. Dinner being a family ritual is the day’s biggest
meal, followed by dessert.
What makes Indians, again, more susceptible, is,
generally speaking, dinner in an Indian home is eaten
just an hour or two before going to bed when activity
levels are winding down. So how does this eating
pattern affect our metabolism?
At this point it helps to understand two concepts:
Basal Metabolic Rate (BMR) and Activity Thermogenesis
(AT). BMR is the minimum amount of energy
required to sustain vital body functions. This is the
energy you burn even when resting or sleeping, so
it’s also called resting metabolic rate (RMR). The
activity thermogenesis is the amount of energy
you burn doing daily activities, everything from
brushing your teeth to washing your hands to exercising.
Your daily calorie expenditure is a combination
of BMR and AT. While BMR stays more or less
constant throughout the day, AT expenditure depends
on what you are doing at any given time. For
most people, AT is
highest in the morning
and tapers off by
the end of the day.
Figure 2. Blood glucose response to a typical eating pattern.
Figure 2 shows
the relationship between
daily eating
patterns and the resulting
blood sugar
levels through a typical
day. In the first
‘breakfast triangle’
the blood sugar spikes
slightly but as it’s
well below the AT
expenditure, the excess
sugar gets used
up. The moderately
larger ‘lunch triangle’ has a small red apex representing
excess unused blood sugar beyond AT
expenditure, which gets stored as fat. In the largest
‘dinner triangle’ the prominent red apex represents
all excess blood sugar beyond the AT expenditure
that is stored as fat.
Indians are known
to eat a late dinner,
leaving very little time
between it and sleeping
time. Eating a big
meal precisely when
the body’s Activity
Thermogenesis (see
figure 2) takes a dip is
a recipe for overdriving
the carb/insulin metabolism
that causes
heart ailments.
From this triangle, it’s apparent that the later you
eat dinner, the more the big triangle moves to the
right pushing more of the area beyond the AT curve
into fat storage zone.
Combine a high-carb diet and this eating pattern
and you get fat gain leading to insulin resistance and
eventually, metabolic syndrome.
The current Coronary Heart Disease (CHD) metrics
like total cholesterol, BMI, fat intake, etc., don’t capture
the true risk of developing heart disease. Medical
researchers are realizing that better predictors of
CHD risk are:
1) Triglyceride levels
2) Fasting glucose levels and
3) Waist to hip ratio (which captures visceral
obesity, as opposed to BMI).
These are the exact three metrics Indians fail,
which makes us susceptible to CHD. And all three of
them point to a single cause: an overdriven carb insulin
metabolism. Add to this a lack of sufficient exercise,
and is it any wonder that even young Indians
are susceptible to heart ailments?
This brings us to the second aspect that predisposes
immigrant Indians to heart disease—the stress
of social dislocation!
Subliminal stress among immigrant communities
is a potential killer
The term “Stress kills” has actual physical significance.
However, the body copes reasonably well to
the garden variety daily stress of modern living—a
looming deadline, bill payments, taxes, negotiating
crazy traffic, and scrambling to compress ever more
activities into our
waking hours.
What proves more
detrimental, particularly
to immigrant
communities, is the
subliminal stress working
at a deeper level
of consciousness: the
stress of social dislocation
(being in a foreign
land), cultural alienation,
socioeconomic
problems, depression,
and anxiety are all
examples of subliminal
pressures that lead
to chronic stress.
Like immigrant Indians, Japanese immigrants
living in the U.S. have higher mortality from heart
disease compared to those living in Japan. Traditionally,
the Japanese were believed to have superior
genetics with respect to heart disease (since Japan
has the most number of centenarians alive) but this
advantage seems to disappear when they start living
abroad, even when they follow their traditional diets.
This phenomenon has been found to apply to
immigrants worldwide. A 1990 study of Indian immigrants
living in Singapore, compared to their Malay
counterparts, found that, compared to the Malays,
the immigrant Indians smoked less, had lower
blood pressure and cholesterol, and yet their mortality
was higher.
An Australian meta-analysis2 of 23 immigrant
population studies sought an answer to the very
vital question: is being an immigrant a heart disease
risk factor? The conclusion:
“Higher prevalence of cardiovascular disease was found
among Middle Eastern, South Asian, and some European
immigrants.”
In another remarkable study3 done in London,
364 participants were divided into two groups. One
group comprised first generation immigrants living
in London and the other group, their siblings living in
Punjab. This eliminated any genetic/hereditary factors
from corrupting the results. It was found that the
London immigrants had higher BMI, blood pressure,
and insulin resistance compared to their siblings in
India, putting them at a higher risk of heart disease.
Stress impacts our health in a profound way. The
human body reacts to stress by releasing two distinct
hormones, adrenalin and cortisol. Adrenalin induces
the primal ‘fight-or flight’ response in us during times
of impending calamity. This raises the heart rate and
blood pressure. The liver shoots out blood
sugar to power the brain for a quick response.
But this type of momentary stress
doesn’t harm our long term health.
The other type of stress, which is what
concerns us here, is the chronic and subliminal
kind that cause the release of the second stress
hormone, cortisol. Cortisol works very much like
adrenalin but over longer time frames. In a normal
healthy person the primary role of cortisol is
to fine tune changes in the body that occur as a response
to stress. Such changes include among others,
blood sugar levels, blood pressure, and anti-inflammatory
action. Cortisol levels peak a few hours
after waking up and then again in the evening and
stay low throughout most of the night. However, in
a person with chronic stress, cortisol levels remain
high all day leading to a range of health problems
including high blood pressure, increased blood clotting
factors, triglycerides, and insulin resistance.
Specifically, cortisol increases blood sugar levels.
However, since the excess sugar remains unutilized,
it gets stored as abdominal fat, which medical research
associates with heart disease and increased
levels of ‘bad cholesterol’ (LDL).
Studies have shown that as cortisol levels rise so
does the level of ghrelin, the hunger hormone, giving
rise to hunger pangs. This causes the stressed
individual to indulge in comfort eating. And as we
all know, the best comfort foods for the brain are
also high in sugar and fat.
Essentially, elevated levels of cortisol add to the
harm caused by a carbohydrate rich diet—a double
jeopardy for heart disease!
How to counter this vicious cycle?
Is there a way out of this double whammy to
which Indians are particularly susceptible? And can
it be done without resorting to the conventional
route of regulating cholesterol, hypertension, and
blood sugar through medication?
Yes, indeed. Adopting simple lifestyle and diet
modifications can reduce our likelihood of getting
heart disease. The two main goals in this health
regimen are:
A) Insulin management through diet and lifestyle
Insulin management centers on the fact that
our blood sugar levels have to be regulated throughout
the day because that is what drives fat gain and
production of AGE free radicals. Clearly, the production
of this storage hormone has to be minimized.
Studies of centenarians across the globe have
shown that they come from diverse backgrounds and
lifestyles and some have even been regular smokers and alcohol drinkers. One distinctive common denominator, though, stands out among them—they have well regulated insulin levels, and as a result, they are rarely obese. The best way to regulate insulin levels is
by keeping our blood sugar levels low. This can be
accomplished by adopting a few diet changes:
1. Reduce the consumption of easily digested carbs from refined flours, rice, potatoes, and sweets. Instead get your carbs from whole grains,
antioxidant and fiber rich vegetables, berries, nuts, seeds, lentils, etc. Fiber slows the absorption of sugar in blood, blunting the insulin
spike; you stay satiated longer and don’t get
ambushed by hunger pangs.
2. Nuts and seeds are also rich in monounsaturated fatty acids (MUFA), that bestow heart health benefits and could help reduce
belly fat. Make sure the nuts you eat are in raw form as roasting or frying them at high
temperatures renders the fatty acids toxic by forming free radicals.
3. Eat in accordance with your activity thermogenesis curve. Having a big breakfast, moderate lunch, and light dinner instead of the other
way around is the best way to avoid insulin
driven fat gain. Munch on snacks like almonds or a piece of fruit to keep hunger at bay. The saying “Eat breakfast like a king, lunch like a prince, and dinner like a pauper” goes a long way
towards minimizing our likelihood for fat gain.
4. Get your nutrition from wholesome, organic
produce at the local farmers market rather than depending on convenience dinners and processed foods from supermarket shelves that are loaded with harmful chemicals and genetically modified ingredients.
5. Increase your intake of healthy herbs and spices to fight oxidative damage. Many spices like turmeric, cloves, and cardamom, traditionally used in Indian cooking, are rich in antioxidants that help fight against oxidative damage and chronic inflammation that lead to heart disease.
Antioxidants have also been shown to increase
insulin sensitivity which helps with weight loss.
6. Daily mild to moderate paced walking. Walking has been shown to lower blood sugar for up to 24 hours after the activity.
7. Some form of weight bearing exercises (like pushups, body weight squats) 2-3 times a week. Weight bearing exercises build muscle which
is the preferred storage reserve for excess blood sugar (as glycogen). Building muscle makes
you more carb tolerant and helps regulate
sugar and insulin levels, not to mention other health benefits like release of testosterone
and growth hormone that helps prevent aging and osteoporosis.
B) Stress reduction:
Follow these simple tips to help you relax:
1. Practice breathing techniques (pranayama) to lower blood pressure and reduce cortisol levels.
2. Get 7-8 hours of restful sleep every night.
Sleep rejuvenates the body and helps normal-
ize cortisol levels.
3. Exercise and be active. Plenty of studies have shown the link between exercise and reduction in depression and anxiety. Exercise also releases endorphins or feel-good chemicals in the brain that induce a general sense of well-being. Don’t indulge in comfort eating in times of stress. Try to understand the root cause of your stress and eliminate or control it instead of burying yourself in comfort foods.
4. Change your attitude. A positive attitude goes a long way towards preventing stress hormones and heart disease. Watch a comedy movie once in a while and laugh as often as you can. Laughter seems to lower cortisol production and goes a long way towards protecting heart health (its true—laughter is the best medicine!)
Indians have a rich culinary heritage and wholesome lifestyle traditions. From potent herbs and
spices to colorful lentils and vegetables, our food is a powerful source of disease-fighting antioxidants
and health-promoting ingredients. Coming from the
land of Yoga and Ayurveda, Indian communities
worldwide should be examples of vibrant health. So
it is indeed a paradox that, sadly, we stand out for
our high rates of heart disease.
Reviving our historically healthful culinary
traditions and adopting the simple lifestyle changes outlined above will bestow robust health upon our communities, and free us from the clutches of most modern ailments. It’s time we challenged the ‘Indian paradox’—dil se!
Yogesh Verma is a health and fitness blogger (www.inutrifit.com) and a nutrition expert specializing in Indian diet.
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