A new study provides powerful evidence of what’s sometimes called “the South Asian paradox”: People of South Asian backgrounds tend to live healthier lifestyles than other racial and ethnic groups in America, but are at greater risk of cardiac and metabolic health problems as they age.
Published in the Journal of the American Heart Association, the study shows that lifestyle alone does not explain that risk, and that wealth doesn’t always mean better health. While many South Asians in the U.S., particularly Asian Indians, are middle-class professionals, that status doesn’t shield them from risks shaped long before adulthood.
The findings may help South Asian families better understand their health risks, including when to seek earlier screening than recommended for the general population.
The research also challenges a longstanding belief in American health care that chronic disease is primarily the result of individual choices, an idea that predates the Make America Healthy Again (MAHA) movement by decades.
A South Asian “paradox”
This long-term study of 2,700 adults, led by a Northwestern University team, aims to paint a clearer picture of middle-aged South Asians’ cardiovascular risk compared with other racial and ethnic groups.
To do so, it drew on data from two cohort studies, based on in-person health exams and questionnaires:
- MASALA (Mediators of Atherosclerosis in South Asians Living in America), the first long-term study of South Asian cardiovascular health, and
- MESA (Multi-Ethnic Study of Atherosclerosis), which followed white, Black, Hispanic and Chinese participants.
Researchers found that even when South Asians had lower body mass index (BMI) and reported healthier habits, their metabolic health was worse.
“We were very surprised,” said Dr. Namratha R. Kandula, who leads MASALA. “We thought that if they develop these risk factors at an earlier age compared to other groups, then they would also have a poor diet, less exercise and things like that.”
It’s a finding that reinforces what health care professionals who work with the South Asian community in New York City and around the country have long seen.
“All through my life, I had aunties and uncles who were dying at very young ages,” said Dr. Nadia Islam, a professor and director of translational research partnerships at New York University’s Grossman School of Medicine, whose family was among the first Bangladeshi immigrants in Dallas, Texas. “Then, when I came to public health, I didn’t see them or their stories or their data reflected in the literature.”
This American Heart Month, here’s what else to know about the study and why it matters for your heart health.
Study design and findings
Who: Adults ages 45 to 55, largely immigrants, with heritage from Bangladesh, India, Pakistan, Nepal and Sri Lanka.
Compared to: Adults of the same age who are white, Black, Hispanic and Chinese.
Reported Behaviors: South Asians largely reported healthier diets, lower alcohol use and similar exercise habits.
But researchers found:
- Both South Asian men and women were much more likely to have prediabetes than any other group.
- By 45, South Asian men had higher rates of hypertension than white, Latino and Chinese men.
- By 45, they also had higher levels of cholesterol and/or triglycerides than Black men.
- By 55, South Asian men and women were twice as likely as white peers to develop diabetes.
Why cardiovascular profiles differ
Although the study did not examine underlying causes, prior research suggests several explanations beyond current lifestyle.
- Early infections: Frequent childhood infections may trigger inflammation and metabolic changes similar to those seen in adults at risk of cardiovascular disease. South Asia has one of the world’s highest burdens of early-childhood infectious disease. People raised there — especially in rural areas — are more likely to have experienced multiple serious infections than peers in higher-income countries.
- Early exposure to poor nutrition, pesticides or toxins can affect health decades later. A 2019 study of South Asian immigrants also found links between abnormal blood sugar, diabetes and high levels of pesticides — including DDT and its byproduct DDE — which linger in the body for decades. While the U.S. banned DDT in 1972, India continues to produce and use it to control malaria, making immigrants from the Indian subcontinent more likely to have been exposed. The study found that MASALA participants had median DDT levels up to eight times higher than the general U.S. population.
- Genetic predisposition to visceral fat: South Asians tend to carry more visceral fat — around the liver, pancreas and heart — even at lower BMIs. This internal fat is linked to inflammation, insulin resistance and plaque buildup.
A 2015 MASALA/MESA study found that, compared with other groups, South Asians had:
- more liver fat and fat around the heart and between muscles
- less lean mass
- lower levels of a hormone that protects blood vessels
- higher levels of a hormone tied to inflammation and insulin resistance
- Chronic stress: Many South Asian immigrants face layered pressures, including anxiety over immigration status, financial precarity, job instability, crowded housing and multigenerational caregiving, according to Dr. Islam.
While such stressors aren’t unique to this immigrant community, they compound an already elevated cardiovascular risk. South Asians are predisposed to store more visceral fat, and chronic stress can disrupt how the body processes it.
In Bangladeshi and Pakistani communities in New York City, many work long hours in low-wage, informal service jobs such as taxi driving or restaurant work, often without benefits, Dr. Islam says. And for these predominantly Muslim groups, heightened anti-Muslim sentiment over the past two decades has added yet another persistent source of stress.
Why this matters
Knowing about these factors does not mean “that people don’t have any control over what happens to them beyond their early life,” Dr. Kandula said. Lifestyle habits remain important and can delay disease or improve management.
But understanding that early-life exposures may program the body in ways that appear decades later explains why South Asians need earlier screening, she said.
What and who gets missed
Dr. Kandula says clinicians should consider that people with this heritage:
- may have normal BMI but still face high risk. People and their doctors should consider their family background and history of cardiovascular factors.
- screening for diabetes and hypertension should begin in people’s 20s and early 30s.
- women have a high risk for gestational diabetes and need continued care postpartum. Otherwise, they could be at risk later in life for cardiovascular and cardiometabolic complications.
Overall, doctors often overlook South Asians’ higher cardiovascular risk because the community has historically lacked representation in research.
“We’re always hearing things like, ‘Oh, it’s just about diet, it’s because they’re not doing exercise,’ ” Dr. Kandula said. “But this tells you that this is why we need actual long-term data and studies.”
Culturally tailored outreach and education about these factors in South Asian communities, Dr. Islam says, also means engaging trusted homegrown leaders “like auntie who lives down the block.”
Food, she adds, plays a key role in promoting health, but runs deeper: “Food in immigrant communities, it’s everything,” Dr. Islam said, calling it a source of cultural pride, identity, belonging and security that can help buffer stress.
For Dr. Islam, who leads a team of community health workers, promoting culturally appropriate messaging on food and other health issues can make all the difference.
Meanwhile, MASALA has expanded. A New York City site opened in 2021 at NYU Langone, where Dr. Islam is leading the new cohort. To better address their underrepresentation in the largely Asian Indian original 2010 cohort, NYC researchers recruited only Pakistani and Bangladeshi immigrants.
This post has been updated to reflect that the MASALA site in NYC is no longer recruiting for this period.
