Understanding South Asian Immigrant Health Perspective to Combat Cardiovascular Disease Prevalence

Authored by: Amina Khan

Art by: Eileen Cho

“As a primary care physician, I would see young South Asians coming in who’d had a heart attack,” said Dr. Kandula, founder of the Mediators of Atherosclerosis in South Asians Living in America (MASALA) study (Abbasi, 2022). Interestingly, Kandula and other researchers found that people of South Asian ancestry did not necessarily fit the typical risk factor profile. Individuals of South Asian background (from India, Pakistan, the Maldives, Nepal, Bangladesh, Bhutan, and Sri Lanka) who migrate to North America or Europe have an elevated risk for cardiovascular disease (CVD) compared to non-Hispanic White and other Asian-American groups. Understanding the unique health beliefs possessed by South Asian Americans regarding CVD is key in delivering culturally competent preventive healthcare, educating communities, and combating this disparity. Although current research focuses on lifestyle factors, genetic predispositions, and barriers to healthcare access, this review will analyze how social, historical, and cultural beliefs influence the everyday lives of South Asian Americans and CVD prevalence. 

South Asian Americans experience disproportionately higher cardiovascular morbidity and mortality from CVD. South Asian adults also have a higher prevalence of cardiovascular risk factors type II diabetes and hypertriglyceridemia, and greater levels of ectopic fat compared with non-Hispanic White adults (Reddy, 2022). Fortunately, it is possible to combat increased disease prevalence through the lens of modifiable risk factors by taking preventive health measures. A key reason for this disparity is thought to be due to ineffective patient-provider interactions because messages are not being delivered in a way that accounts for South Asian patients’ beliefs, social network, and habits (Patel, 2014). Recognizing these cultural differences is essential in effective healthcare delivery. 

For many immigrant South Asian communities, utilizing advice from medical professionals on lifestyle changes conflicts with their own cultural practices, especially in regards to dietary patterns. South Asian dishes include unique blends of ingredients that are essential in their diet as they have been passed down in familial recipes for generations. One perception is that because earlier ancestors did not experience CVD, these dishes do not contribute to risk factors such as hyperlipidemia. Another perception among vegetarian individuals is that meat is believed to be unhealthy, and the absence of such helps protect against the development of CVD (Patel, 2014). Overall, South Asians tend to consume less fruit and vegetables and intake higher carbohydrate levels compared to other ethnic and racial groups in the US, leading to acquisition of obesity, diabetes, insulin resistance, and other metabolic disorders (Jayawardena, 2020). 

Furthermore, lower levels of physical activity observed among South Asian patients are independently associated with the increased risk of CVD (Volgman, 2018). One study analyzed the health attitudes and beliefs regarding CVD risk factors among Bangladeshi immigrants residing in Queens, New York, using a CVD risk factor knowledge instrument. It was found that Bangladeshi participants were more likely to mention diet and cholesterol as risk factors and less likely to mention lack of exercise, being overweight, and smoking as risk factors (Patel, 2017). The lack of emphasis on exercise for health can stem from cultural attitudes originating in the South Asian subcontinent, and as a result, South Asian 

communities are less likely to engage in organized sports. As South Asian immigrants move to new communities, this can also lead them to be less likely to begin an exercise program following the advice of a healthcare provider (Patel, 2011). 

Fortunately, a Canadian study which evaluated various immigrant groups found that physical activity increased with time relative to immigration, with the largest difference found in South Asian immigrant groups (Patel, 2011). Furthermore, the expected roles of women in South Asian households may act as a barrier to physical activity. One study assessed interviews with South Asian women who stated that the majority of familial responsibilities were assigned to women as a part of cultural and social practices, leading to lack of time for exercise (Patel, 2011). Furthermore, South Asian culture also emphasizes physical separation between men and women and modesty. Thus, many Muslim South Asian women encounter additional barriers to physical activity, such as not being able to enroll in dual-gender exercise programs or utilize gym facilities (Patel, 2011). 

Lastly, it is equally important to acknowledge that South Asia is home to multicultural, multi-linguistic, and multi-religious regions, holding a vast abundance of diversity and traditions. While this review does not account for all of the beliefs held by communities across South Asia, it seeks to understand a few of the barriers in CVD risk reduction and provide healthcare providers in the US with an insight into these beliefs as a way to promote cultural humility and better patient-provider relationships. Future research and interventions should account for these perceptions and social influences to successfully mitigate the high CVD prevalence by improving dietary habits and physical activity levels in immigrant South Asian communities within the US. 

References:

1. Abbasi, J. Masala Study Probes Why People With South Asian Ancestry Have Increased Cardiovascular Disease Risks. (2022). Jama Network. 328(6):511-514. doi:10.1001/jama.2022.11417.

2. Reddy, N., Kaushal, V., Kanaya, A., Kandula, N., Gujral, U., Shah, N. (2021). Cardiovascular Risk factor profiles in North and South Indian and Pakistani Americans: The MASALA Study. American Heart Journal, Vol. 244, 2022, pp. 14–18, https://doi.org/10.1016/j.ahj.2021.10.115. 

3. Patel, Mihir, et al. “Attitudes and Beliefs Regarding Cardiovascular Risk Factors among Bangladeshi Immigrants in the US.” Journal of Immigrant and Minority Health, U.S. National Library of Medicine, Oct. 2014, www.ncbi.nlm.nih.gov/pmc/articles/PMC4666506/. 

4. Patel, Mihir, et al. “Barriers to lifestyle behavioral change in migrant South Asian populations.” Journal of Immigrant and Minority Health, vol. 14, no. 5, 17 Dec. 2011, pp. 774–785, https://doi.org/10.1007/s10903-011-9550-x. 

5. Ramaswamy, Padmavathy, et al. “Health beliefs regarding cardiovascular disease risk and risk reduction in South Asian immigrants: An integrative review.” Journal of Transcultural Nursing, vol. 31, no. 1, 8 Apr. 2019, pp. 76–86, https://doi.org/10.1177/1043659619839114. 

6. Volgman, A., Palaniappan, L., Aggarwal, N., Gupta, M., Khandelwal, A., Krishnan, A., Lichtman, J., Laxmi, M., Patel, H., Shah, K., Shah, S., Watson, K., (2018). Atherosclerotic Cardiovascular Disease in South Asians in the United States: Epidemiology, Risk Factors, and Treatments: A scientific statement from the American Heart Association. Circulation, vol. 138, no. 5, 2018, https://doi.org/10.1161/cir.0000000000000600. 

7. Patel, Mihir, Carla Boutin-Foster, et al. “Understanding of cardiovascular disease risk factors among Bangladeshi immigrants in New York City.” Ethnicity & Health, vol. 24, no. 4, July 2017, pp. 432–442, https://doi.org/10.1080/13557858.2017.1346191.