Cardiometabolic Risk in South Asians: Advanced Assessment

An earlier article described the South Asian metabolic phenotype: more body fat, visceral fat and liver fat at a given BMI, less muscle and greater insulin resistance. This article focuses on advanced assessment of cardiometabolic risk in people of South Asian ancestry, wherever they live. The aim is to identify risk that standard approaches may miss, without assuming that every individual fits the population pattern.

The scale of the problem

Coronary heart disease tends to occur earlier in South Asian populations, often before the age of 50, and is more often extensive at diagnosis. Type 2 diabetes develops at younger ages and lower body weight. Studies of South Asian communities in North America and Europe have found higher rates of coronary disease and diabetes than in populations of European ancestry, even after accounting for traditional risk factors. Heart failure, stroke and chronic kidney disease are also relevant.

Why standard calculators can fall short

Many cardiovascular risk calculators were developed in populations with few South Asian participants. Some, such as QRISK3 used in the United Kingdom, include ethnicity and have been calibrated for South Asian groups. Others do not include ethnicity, and studies suggest they may underestimate risk in South Asian individuals. American guidelines list South Asian ancestry as a risk enhancing factor that should push treatment decisions towards more intensive prevention when risk is borderline or intermediate.

A lipid profile with a characteristic shape

The typical South Asian lipid pattern, reflecting insulin resistance, includes raised triglycerides, low HDL cholesterol and small dense LDL particles, with LDL cholesterol that may appear only moderately raised. In this setting, apoB and non HDL cholesterol better reflect atherogenic burden. Lipoprotein(a) levels are higher on average in some South Asian populations, adding inherited risk that standard lipids do not show.

Advanced assessment

Prevention priorities

• Earlier and more intensive risk factor management, particularly of blood pressure, LDL and apoB, and glucose.
• Muscle building: resistance exercise and adequate protein to address lower muscle mass.
• Carbohydrate quality and quantity: reducing refined grains and sugar, adjusting portions of rice and flatbreads, increasing legumes and vegetables, while keeping meals culturally familiar.
• Cooking fats: reducing deep frying and ghee in large amounts, and choosing unsaturated oils.
• Physical activity: addressing lower average activity levels, particularly in women and older adults, with culturally acceptable options.
• Sleep and stress, including the effects of work patterns and migration.
• Postpartum follow up after gestational diabetes.

Cultural and community considerations

South Asian communities are diverse in religion, language, diet and circumstances. Dietary advice should reflect the specific cuisine, whether vegetarian Gujarati, Punjabi, Bengali, Tamil, Pakistani or Sri Lankan, rather than generic recommendations. Family and community involvement often supports change. Religious fasting, festivals and hospitality customs need planning rather than prohibition. Language and health literacy should be considered in communication.

Avoiding stereotypes

Population risk does not determine individual risk. Many people of South Asian ancestry are metabolically healthy. The purpose of advanced assessment is to find hidden risk where it exists, not to assume it everywhere.

An illustrative case

A 42 year old man of Punjabi heritage living in Canada has a BMI of 25.5, a waist of 97 cm and no symptoms. His father had a heart attack at 48. His LDL cholesterol is 3.0 mmol/L, triglycerides 2.3 mmol/L and HDL 0.9 mmol/L. A calculator that does not include ethnicity estimates his 10 year risk as low. Further assessment finds an apoB of 1.2 g/L, a lipoprotein(a) of 150 nmol/L, an oral glucose tolerance test showing impaired glucose tolerance and a raised ALT with fatty liver on ultrasound. A coronary calcium score is 45.

His true risk is substantially higher than the calculator suggested. His doctor discusses lipid lowering treatment, and a plan addresses insulin resistance through dietary changes built on his family’s cooking, resistance and aerobic exercise and sleep. His siblings are offered lipoprotein(a) testing. A year later his apoB and liver tests have improved and his glucose tolerance has normalised.

Seeing hidden risk

Advanced assessment in South Asian patients combines population knowledge with individual measurement. Lower thresholds, earlier screening, apoB and lipoprotein(a), attention to fatty liver and sleep apnoea, and culturally tailored prevention allow practitioners to identify and reduce risk that standard approaches may leave unseen.