Diabetes & Cardiovascular Disease Risk Factors among South Asians Compared to other Ethnic Groups

Dr. Alka Kanaya talked about Diabetes and cardiovascular disease risk factors in multi-ethnic groups comparison studies, at a joint event hosted by  www.eppicglobal.org and  www.bio2devicegroup.org .  Dr. Kanaya is Professor of Medicine, Epidemiology, and Biostatistics at UCSF and a principal investigator in Mediators of Atherosclerosis in South Asians Living in America or MASALA study, for short.  Primary objective of the study was to research and understand the high incidence of diabetes and CHD among people of South Asian origin.

Kanaya first shared information on South Asians (will be referred here as SA) and then discussed the study results in the context of multi ethnic comparison.  Currently there are 3.4 M people from South Asia living in the US.  It is the second fastest growing racial/ ethnic minority in the US.  They constitute 20% of all Asians and 75% of them are foreign born.  Although there is little organized medical data on SAs, overall they have relatively lower body weight (BMI), have more central abdominal obesity, and experience higher rates of diabetes and indicate high risk of early heart disease.

MASALA study began in March, 2010 and constitutes a total sample of 906 people, between the ages of 40 and 84.  People with prior history of any cardiovascular disease, those in active cancer treatments, those planning to move out of the area in the next 5 years, and nursing home residents, were excluded.  Data collected included weight, height, waist, seated BP, Ankle-brachial index (ABI predicts the sevearity of PAD, peripheral artery disease), 2 hour OGTT (oral glucose tolerance test), abdominal CT, and several blood tests and extremely detailed questionnaires regarding family history and information about personal habits like alcohol, smoking, sleep, diet and exercise.

Results from MASALA study were compared to results on almost all similar measures with Whites, Latinos, African-Americans and Chinese populations in ongoing MESA study.  See the websites of MESA (www.mesa.nhlbi.org) and MASALA (www.masalastudy.org) studies to see many interesting details on several patterns that emerged.  Kanaya specifically discussed some patterns among South Asians when compared with other ethnic groups.

When adjusted by sex and age, South Asians had significantly high rates of hypertension.  However, there weren’t major or alarming differences in cholesterol.  One of the reasons could be that South Asians were overall more educated, from higher socio-economic background, and were more likely to be using statins and other cholesterol lowering drugs

Most alarming differences were observed in diabetes and pre-diabetes levels.  Almost 30% of men and almost 15% of South Asian women had Diabetes Mellitus, versus 20% or lower among other groups of men, and 13% or lower among other groups of women.  Nearly 37% of SA men and 29% of SA women had IFG (impaired fasting glucose indicative of pre-diabetes), compared to 20% or less for men and 13% or less for women from other groups.  When adjusted for many indicators including age, sex, cholesterol, triglycerides, hypertension etc., South Asians were significantly more likely to have type 2 diabetes.

When adjusted for age, sex, BMI, and waist and excluding those on diabetes meds, this high incidence of Diabetes Mellitus among South Asians seemed to be associated with higher levels of insulin resistance, lower pancreatic B-cell function, and (as confirmed by abdominal CT data) high amount of body fat around abdominal regions and in the liver.

Mercat de la Boqueria, fruits & vegetables (Photo credit: Wikipedia)

Among lifestyle factors, the high rates of DM (Diabetes Mellitus) among SA was attributed to poor diet with less fruits and vegetables and more Western diet (including pizza, pasta etc.), sweets, refined grains, and consumption of high animal based protein in the diet and low levels of exercise.  Considering that even on a relatively leaner body, South Asians carry more fat, the study concluded that guidelines for BMI should be lower for people of South Asian origin.

The study concluded that 75% of South Asians were overweight or obese using the recommended BMI cut-points in Asians.  Compared to other racial/ ethnic groups, South Asians were from higher socio economic status, had low smoking rates, and low to moderate alcohol use.  They also indicated very low physical activity, higher diabetes prevalence (specially among men), second highest prevalence of high blood pressure, and men have more coronary calcium than other groups.

A yoga class. (Photo credit: Wikipedia)

Some of the recommendations for South Asians from the study were, to know the risk factors, work towards ideal BMI goal (less than 23 kg/m2 for SA), remember waist size matters more than BMI, walk at least 30 minutes a day 5 days a week, avoid a diet high in animal protein and refined carbs, and then something interesting – do Yoga!

Kanaya also shared results from her PRYSMS study that assigned subjects with metabolic syndrome into two groups, one practicing Restorative Yoga (included lot of lying down and relaxing poses) and other, Stretching Exercises.  In 6 months, both groups improved their PA and calorie intake.  Favorable changes in the stretching group included, lowered triglycerides and improved mental health.  Restorative yoga group reduced and sustained weight loss and weight girth loss but not visceral fat area.  Finally, only yoga group indicated reduction of fasting glucose and overall favorable metabolic changes in the yoga group included lowering of fasting insulin, glucose, HbA1c and HDL.

One wonders if very determined focus on material wealth goes with more stress.  In any case, it shows once again that stress relief is a key for improved health.  This was a fascinating talk and was followed by Q&A and animated discussion.

Post – US 2012 Elections – a mandate to create true inclusion

Post – US 2012 Elections – a mandate to create true inclusion

As a corporate trainer in “diversity and inclusion to effectively achieve global business objectives”, I was heartened to see the results of the current presidential elections, in the US, which seemed to be a clear mandate for the belief in the slogan, “diversity pays”. However, many challenges are obvious, not only for the President but for us as a nation. Diversity from afar is mysterious and attractive, but up close, it is challenging and mystifying. Let us prepare to meet the challenges.

We must put our own house in order

That means, we must have clarity of vision and values and make informed choices, in alignment with these values. While his opponent flip-flopped on issues, President Obama remained true to the issues he holds dear. In an interview with Diane Sawyer, four years ago, he said, “The only thing you carry into this office is a moral compass. If you start making decisions based on what’s convenient at the time, then you would be lost”. Moral compass of values of diversity and inclusion must continue to be our guide as we put our house in order.

We must recognize the need to be broadly inclusive and find common ground and communication platform that is not narrow and limiting. We cannot choose diversity and inclusion, when it is convenient. For instance, we must reach out to older while men, understand issues of concern to them, and recognize the diversity within this group, even as we oppose the singularly older while male vision for our future. How do we do this? Even as we tout the “diversity pays” mantra, we must not be derisive of the many contributions of this group on whose hard work and broad shoulders the country was built. President Obama must reach across the aisle and make more determined bipartisan efforts to understand the concerns, fears, and issues important to those who are not socially very far to the right.

Maine and Maryland passed landmark legislation that enables gay and lesbian people to marry. But this same proposition was defeated in the last election, in California. How hypocritical it would be for our decidedly blue state to celebrate victory on the platform of diversity and on more enlightened view of immigration, while continue to discriminate against gay/ lesbian population? Attitudes are shifting, however, and it is imperative that we continue this trend and California jumps on board. A similar ballot measure in Washington state is pending, and in Minnesota, voters rejected a measure that would have banned same-sex marriage. Additionally, Wisconsin elected America’s first openly lesbian senator, Democrat Tammy Baldwin, and President Obama became the first president to openly support same-sex marriage, and get re-elected. As a resident of California, I will say once again, we must continue on this path and ensure absolutely the same rights for gay and lesbian couples, everywhere, as straight couples.

The Latino community is steadily growing and it is amply clear that the politicians may neglect this fact, at their own peril. Businesses have long recognized the contributions of immigrants from various backgrounds. But in politics, we have been slower to accept this new perspective, holding on to the antiquated notion that America is for white people, even as the face of America has become more and more a blend of red, yellow, black, brown, and white. This nation of immigrants must continue to embrace people of various ethnicities and backgrounds, even as we focus on making the nation secure from terrorism. We can and must achieve both those objectives and recognize that immigrants want to be as safe and secure here as non——— well, aren’t most of us immigrants or the descendents of immigrants? Additionally, we must recognize the many issues sadly still stacked against African-Americans. I was glad that we had Mitt Romney, a Mormon, running for the highest office, in the nation. We must continue to respect and welcome all faiths and move away from theTea Party conservative agenda that frequently promotes issues, under the umbrella of faith, which pit one faith against another.

Once and for all, it has become clear that women are a force to be reckoned with. They showed it in the ballots, jumping out of the “binders”. Why would we entertain a discussion regarding whether insurance may or may not pay for contraception, when in fact, insurance has been paying for years for Viagra? Obviously this was an issue in the minds of men. But 1.5M women in the US take birth control pills for reasons other than preventing pregnancy and over half a million women who take these pills have never had sex. Additionally, it is estimated that 47 million women will now be able to get preventative services that they previously could not. This is excellent. We need more widespread education on the health impact, away from ideology based battles over contraception coverage and abortion choice.

What was not mentioned by either candidate, in any of the discussions, was the issue of poverty and increasing class divide. Most of the data below is taken from the Atlantic magazine, September, 2011 issue. According to one poll, the richest 1 percent households in America earn as much as the bottom 60% put together and the rich 1% possess as much wealth as the bottom 90%. Recovery has increased the divide. According to Gallup, while the daily consumer spending was completely flat for majority of Americans, between May 2009 to May 2010, among those Americans earning more than $90,000 a year, the spending rose by 16%. This is a country built on an ability to pursue the dream, work hard, and be rewarded for it. We should not begrudge those who do just that. However, when the playing field is not leveled then it becomes a whole another story. Many millionaires and billionaires including Gates and Buffett are now speaking out against the outrageousness of the system where the odds are increasingly favoring money’s ability to attract money. Buffett, famously appeared with his secretary who reportedly paid higher taxes, while Buffett was able to use tax loop holes. We have to bridge this divide and level the playing field so that hard work can once again be valued and people find the incentive to pursue their dreams. The looming tax cliff, at the end of the year, when Bush era tax cuts expire, will test us on our readiness to understand and confront this class divide, while trying to reach a bipartisan agreement on the issue.

It would be morally repugnant if we send some of our citizens in harm’s way, to guard our interests and when they return from wars, they find themselves left behind in the daily struggles of life, including jobs, shelter, and medical care. We have to ensure that our vetetans get the care and all the help they so rightly deserve. Even as we ensure care and comfort of our vets, we must also not adopt a cavalier attitude towards infants and other innocent civilians killed by our drones. These are contradictions we must balance.

Globally, we cannot continue to be singularly Israel focused. Middle East is a big region. There are other nations with other agendas and issues. For instance, (if we peek into history), on account of thoughtless actions of powerful nations, Palestinian people have endured immense suffering. As a powerful nation, we cannot continue to be partially blind and one-sided. Similarly, we cannot be bashing China or India, which are powerful forces, simply given the sheer size of the population. But if we consider their determination, the motivation to strive and do better, their global recognition and increasing clout than we will have to learn to work with these nations as well as other emerging economies and even guide them to become better world citizens, even as we focus on growing jobs at home, keeping them from being outsourced, and protecting our interests. Similarly, we must pass legislation to protect the environment and join the good world citizens club.

Does this mean that we become more partisan?
No. Having clarity around values means that we do not embrace inclusion only when it is convenient but truly become inclusive and broaden the base. The results have indicated that changing face of the nation is closely tied to changing perceptions around gay issues, around environment, around women’s issues and so on. Embracing diversity will be an assurance to all that their issues will be heard.

Managing waste and running an efficient Government
Conservatives who are extremely far to the right, may never find anything to their liking in this dialog of diversity and inclusion. Their agenda per se, may be perhaps exclusive and derogatory towards women, discriminatory towards gays and lesbians and demeaning towards immigrants. But such extreme conservatives are diminishing steadily in numbers. However, we have a whole base of fiscal conservatives, whose issues need to be heard. Many of them have concerns over inefficiency of the Government and concerns over managing waste. We can do a better job here. We have seen two different faces of FEMA. During Katrina, FEMA was arrogant, primarily operating as a cop to control looting and lawlessness, rather than a disaster relief organization. During Sandy, we saw a different face of FEMA, an efficient, speedy disaster relief organization, reaching in real time to the help of the people. Now that the campaigning is over, we can acknowledge that no one would endorse the FEMA of Katrina but we could barely do without the FEMA during Sandy. The change in FEMA was partly on account of the lessons learned, during Katrina. It has become evident that during disaster, people come to each other’s help, rather than focus on looting, for instance. However additionally, FEMA was different, during Sandy, because of the clear mandate under the expert leadership of Governor Christie. Further, Governor Christie was able to operate at full capacity and better efficiency because of clear channels of communication with the President.

What prompted me to write this article

President Obama’s clarity of vision won us this extremely viciously fought election. But many challenges lie ahead. I implore the party that fought on the platform of diversity, to not be selectively inclusive, but truly broaden the base and the platform. If we will be selectively inclusive than we will erode the base in another cleverly fought campaign or be caught in a gridlock where our victory will ring hollow. We can meet the same fate as the Republican Party, leaving people disillusioned. Simon Schama, a British Historian, analyzed the reasons behind the defeat of the Republican party. And he says, “What bit the dust on Tuesday was the world of denial in which Republicans have immured themselves ever since the rise of the Tea Party in 2009. This is a universe in which the financial crash was caused by over-regulation; one in which, despite years of brutal drought and violent weather patterns, climate change is a liberal hoax; a country that can correct a vast structural deficit without ever raising additional revenue, while expanding the military budget beyond anything sought by the Pentagon; a belief system in which Mr Obama was the source of all economic ills rather than the steward of the most intractable crisis since the Depression. The mantra was that a business executive would, simply by virtue of that fact, effect a magical rejuvenation of the staggering American economy.” The denial of changing reality caught them unawares. Let it not surprise and shock us. Let us capture this vision of the changing future and ride the wave to a better tomorrow.

And by a better tomorrow, we mean not just a diverse landscape of tomorrow but rather through an emergence of shared prosperous diversity. For a better, more prosperous tomorrow, we must buy elements of the Republican vision. We cannot speak of a better tomorrow and not worry about the enormous debt we will be leaving our children. Mr. President, so popularly elected, will need to make some hard choices and we will have to support him. Mr. Obama will have to reach out to more reasonable and fiscally knowledgeable people across the aisle. We will have to start talking and listening. He will need to build a strong narrative outlining his concerns for the rising debt and how he will contain it as he assures us that prosperity will be created and it will be a spread out prosperity. The only way he will be able to get everyone to listen is if he is able to give solid assurances of how waste will be tracked and managed and how his Government will run more efficiently. We are a diverse nation and he will have to speak to us often and get the message to us in diverse ways, to reach us.

We have achieved something truly phenomenal by proving the pandits wrong, the pollsters wrong, and defying the money power. Now it is time to not be arrogant but be humble in our approach, for diversity itself will bring many challenges and opportunities to truly broaden our own perspectives and learn and grow and prosper together. Let us make this diverse landscape, a truly inclusive one.

The Scottsboro Boys – Play Review

How does one tell a deeply moving story which compels the whole society to soul search, through a musical?  Writers Fred Ebb and John Kander and Director Susan Stroman have achieved just that.  In the play, The Scottsboro Boys, they have given voice to each of the nine marginalized and disenfranchised Scottsboro Boys.  So meaningfully is the story told that indeed each one of them “matters”, and together they will continue to impact societal consciousness for a long time to come; perhaps as long as grave injustices occur, where one lie can destroy many innocent lives.

The Scottsboro Boys is the true story of nine African-American boys who were traveling through Alabama, in 1931 and were falsely accused of raping two white girls.  The hysteria which gripped the state might have ended in their summary execution at the hands of a lynch mob, but for the Governor of Alabama intervening and calling in the National Guard.  In the previous 50 years, at least 3,000 African Americans had suffered death by lynching.  A myth had gripped the nation that Negroes were lynched “because of their crimes against women”.  In the case of the Scottsboro boys, two impoverished white prostitutes who were known to consort with black men, when questioned by the Sheriff, falsely accused the boys of rape, in order to save themselves.  The nine boys felt fortunate that they did not face a lynching mob, only to be swiftly indicted in the subsequent trial, and sentenced to death by electric chair.  The youngest, 12 year old Eugene Williams, was forced to sleep near the electric chair until he had nightmares every night.  Samuel Leibowitz, a New Yorker employed by International Labor Defense, a legal arm of the Communist Party, took up their case, and over the next seven years,went through a series of appeals.  Despite the fact that the original accusers, the two white women, recanted their testimony, the doctor who had examined them testified to no evidence of rape, and there was not a shred of evidence supporting the guilty verdict, the all white jury rendered guilty verdicts in trial after trial.  Leibowitz persisted and secured the release of four of the young men and eventually four more.

Mass mobilizations around the world in response to the trials, raised the consciousness of the nation, and eventually led to the expanded right to counsel for all those who could receive jail time if convicted, and resulted in a court ruling that systematic exclusion of African Americans from the jury rolls violated the Equal Protection Clause of the Fourteenth Amendment.

The play is a moving tale of glimpse into a very unflattering piece of our national history. It also serves as a reminder that there are still those without a voice who are systematically marginalized and not afforded equal protection and justice.  This is a profound societal issue; how can it be portrayed in a short time and in a musical?  The staging and direction were simply superb.  Using a set of chairs, the actors tell their own story as they organize the chairs to make a train, create a holding room, build a jail cell, a court house, and a solitary confinement room.  In essence, the actors create their own set.  The casting was amazing.  Each and every single actor gave an excellent performance, their voices deep and resonating, and the music and words packed with meaning.  The lyrics are still humming in my head. In “Zat so” – when Haywood Patterson is taken in front of the Governor and his lawyer advises him to confess to the rape and be guaranteed leniency and a pardon, Patterson refuses and the Governor says, “Mr. Patterson. I don’t think you heard me correctly. You people sometimes don’t understand what you’ve been asked. It’s because you don’t listen. So let’s try this again.”

The most outstanding scene in the play was a superb shadow puppet show in the background, with Patterson singing, “You better make friends with the truth.” Tragically, Patterson refused to trade a false confession for his freedom and spent sixteen years in a harsh Alabama prison, before he escaped.  Later he was recaptured on another charge and died in prison.  The play does complete justice to the tragic and soul- wrenching tale of the nine Scottsboro boys.  If you see only one play this year, make this the one.  Click on the link to book your tickets – http://www.act-sf.org/1112/scottsboroboys/index.html .