Cardiovascular Disease among South Asian Immigrants in the United States - Implications for Behavioral Medicine

Biswadeep Dhar, PhD, MEd, MS^1,2,3,; Deepika Laddu, PhD⁴; Benjamin Brown MD, MPH⁵ & the Cardiovascular Health SIG

Cardiovascular disease (CVD), which broadly includes coronary heart disease, heart failure, stroke, and hypertension, is estimated to affect 48.6% (127.9 million) of adults in the United States (U.S.) with costs adding up to over $400 billion per year.¹ Despite being preventable through risk factor reduction, CVD claims more lives each year than all cancer types and chronic lower respiratory diseases combined, and currently accounts for the largest proportion of total U.S. health expenditures.¹ Certain racial and ethnic disparities in the prevalence of CVD are well described. Total CVD is observed in 59% of Black men and women, 52% of Hispanic men, and 37% of Hispanic women, compared to 51% among non-Hispanic White men and 45% of non-Hispanic White women.¹ However, the South Asian (SA) population is one distinct ethnic group that is often overlooked in U.S. CVD prevalence and clinical reporting. SA individuals descend from countries within the Indian subcontinent (e.g., Bangladesh, Bhutan, India, the Maldives, Nepal, Pakistan, and Sri Lanka) and is one of the fastest growing ethnic groups in the U.S.^2,3 SAs in the U.S. are disproportionately affected by a higher burden of premature and aggressive CVD, particularly ischemic heart disease.^3-5 In addition, SAs have higher CVD-related mortality rates compared to other racial or ethnic groups, including other Asian groups. For example, the proportional mortality rate from ischemic disease was found to be the highest among Asian Indian men (1.43), when compared to Filipino men (1.15).^3,6 Not surprisingly, the higher risk of CVD in SAs can be largely attributed to an increased prevalence of known risk factors, such as diabetes and metabolic syndrome.³ 

Cardiovascular risk behaviors and risk factors among South Asians

While the burden of poor cardiovascular health and its association with greater CVD risk among SA immigrants is well-documented,^7,8 the rates of this health issue in SA populations, until recently, has received inadequate attention. Investigators of the MASALA (Mediators of Atherosclerosis in South Asians Living in America) study evaluated cardiovascular health among middle-aged SA American adults by applying the American Heart Association (AHA) Life’s Essentials 8 (LE8). The LE8 is a comprehensive scoring methodology that incorporates a variety of CVD risk domains.⁹ Overall, the MASALA study showed that SA immigrants commonly demonstrate suboptimal cardiovascular health, with an overall LE8 score of 64.4 points (0 to 100), and the majority of participants (~87% of n=1,164) present with low (0-49) or intermediate (50-79) LE8 scores.⁷ Of the distinct LE8 components, diet quality faired the poorest with 66% of SAs demonstrating low scores. Other components that had a relatively higher percentage of participants with low scores included blood pressure (24%) and fasting glucose (22%). Further, higher LE8 scores were associated with better psychosocial health and more favorable social determinants of health, such as high household income, educational attainment, safe neighborhood environment, preferential immigration status, and supportive socio-cultural factors— data which aligns with findings among other U.S. subpopulations.¹ Reasons for cardiovascular health disparities among SAs in the U.S. are unclear and it is possible that these disparities are linked to differences in access to quality and affordable healthcare.^3,10

While a large body of evidence demonstrates the strong association between body mass index (BMI) and cardiometabolic disorders, it is important to note that the risk of CVD is prevalent among SA immigrants even in the absence of overweight or obesity.¹¹ BMI is inherently limited, as it fails to differentiate between fat and lean tissue, and it does not consider the distribution of body fat in various areas, such as abdominal visceral fat, intermuscular fat, hepatic fat, and pericardial fat. Studies have shown that these fat differentials are more pronounced in SA adults compared to other racial and ethnic groups in the U.S.³ Additionally, genetic, and physiological factors, such as biological predisposition and environmental variability resulting from migration and acculturation play a significant role in the pathophysiology of CVD, as well as abdominal obesity, metabolic syndrome, and type 2 diabetes in SA immigrants.³

Implications for Behavioral Medicine

One important implication in research is to separate the distinct SA ethnic groups in research with evidence-based interventions. Culturally tailored interventions are effective in chronic disease management to mitigate the risk of CVD, as observed in diabetes care management among SA ethnic groups.¹² Culturally relevant studies on SAs also indicate that higher intake of healthy plant–based foods is linked to lower risks of cardiometabolic syndromes.¹³

It is important that healthcare systems and their providers recognize the increased burden of CVD risk and disease among SAs. Improved health behaviors such as eating a healthy plant-based diet, increasing physical activity, avoiding harmful addictive substances, and getting sufficient sleep should be emphasized to nullify the elevated chronic disease risks among SAs. Behavioral medicine has both policy implications and the ability to expand the impact of future interventions to bring improved health and well-being outcomes to the growing SA patient population.

Affiliations

1. Department of Human Ecology, University of Maryland, Eastern Shore, Princess Anne, MD, USA
2. Department of Family, Youth and Community Sciences, University of Florida, Gainesville, FL, USA
3. Division of Health, Research and Evaluation, University of Illinois College of Medicine Rockford, IL, USA
4. Arbor Research Collaborative for Health, Ann Arbor, MI
5. Department of Family and Preventive Medicine, University of Utah, Salt Lake City, UT, USA

References

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