Heart disease remains the leading cause of death worldwide, but for people of South Asian ancestry, including those from India, Pakistan, Bangladesh, Sri Lanka, and Nepal, the risk is often higher and develops at younger ages than in many other populations. In fact, South Asians are more likely to experience a heart attack on average 5 to 10 years earlier than in other ethnic groups, even when traditional risk factors appear well controlled.
One of the biggest misconceptions is that a normal body weight automatically means a healthy heart. For many South Asians, this is simply not the case.
Research has shown that South Asians tend to develop more visceral fat, the fat stored around internal organs, even at lower body mass index (BMI). Unlike the fat just beneath the skin, visceral fat is metabolically active and contributes to insulin resistance, inflammation, elevated triglycerides, lower HDL cholesterol, and an increased risk of type 2 diabetes and cardiovascular disease. This pattern has sometimes been described as being "thin outside, fat inside," highlighting that outward appearance does not always reflect underlying metabolic health.
Genetics also play an important role. Elevated lipoprotein(a) (Lp(a)), is more common among South Asians and represents an inherited cholesterol particle that can significantly increase the risk of heart attack, stroke, and even aortic valve disease. Because Lp(a) is largely determined by genetics and is not really affected by diet or exercise, current guidelines recommend measuring it at least once during adulthood, particularly in individuals with a family history of premature cardiovascular disease.
Traditional cholesterol testing may not tell the whole story. While LDL cholesterol remains an important treatment target, additional markers such as apolipoprotein B (ApoB) can provide a more accurate estimate of the total number of cholesterol-containing particles capable of entering the artery wall and contributing to plaque formation. In some South Asians, ApoB may be elevated despite an LDL cholesterol level that appears pretty normal.
Lifestyle continues to be the foundation of prevention. A heart-healthy diet rich in vegetables, beans, lentils, fruits, whole grains, nuts, and lean sources of protein remains very important. Many traditional South Asian foods can fit into a healthy dietary pattern when prepared with less saturated fat, smaller portions of refined carbohydrates, and greater emphasis on fiber and protein. Regular physical activity is equally important. Current guideline recommendations include at least 150 minutes of moderate-intensity exercise each week, along with two or more days of resistance training to help improve insulin sensitivity and preserve muscle mass.
Beyond diet and exercise, stress is also considered an important part of elevated cardiovascular risk in this population. Chronic psychological stress, long work hours, caregiving responsibilities, and cultural pressures are common experiences within many South Asian communities and can contribute to hypertension, poor sleep, unhealthy coping behaviors, and increased cardiovascular risk. Addressing stress through regular exercise, adequate sleep, mindfulness practices, social support, and when appropriate, professional mental health care, should be viewed as an important part of cardiovascular prevention rather than an afterthought.
Early screening is particularly important for South Asians because cardiovascular disease often develops before symptoms appear. Blood pressure, cholesterol, blood sugar, and waist circumference should be monitored regularly. In select individuals, additional testing such as coronary artery calcium (CAC) scoring can help identify silent atherosclerosis and refine treatment decisions before a heart attack or stroke occurs.
The encouraging news is that heart disease is not inevitable. Although South Asians may inherit a higher baseline risk, many of the factors that drive cardiovascular disease can be identified early and managed effectively. Combining healthy lifestyle habits with appropriate screening and individualized medical care offers a powerful opportunity to reduce risk and improve long-term health.
Awareness is the first step. By recognizing that South Asian cardiovascular risk often extends beyond what traditional measurements reveal, individuals and healthcare providers can work together to detect disease earlier, intervene sooner, and help prevent future cardiovascular events.
References:
Volgman AS, Palaniappan LS, Aggarwal NT, et al.
Atherosclerotic Cardiovascular Disease in South Asians in the United States: Epidemiology, Risk Factors, and Treatments: A Scientific Statement From the American Heart Association.
Circulation. 2018;138:e1-e34.
Shah NS, Xi K, Kapphahn KI, et al.
Cardiovascular and Cerebrovascular Disease Mortality Across Asian American Subgroups.
Circulation: Cardiovascular Quality and Outcomes. 2022.
Kanaya AM, Kandula NR, Herrington D, et al.
The Mediators of Atherosclerosis in South Asians Living in America (MASALA) Study: Objectives, Methods, and Cohort Description.
Clinical Cardiology. 2013;36:713-720.
About the author:
Dr. Ambreen Mohamed is a board-certified non-invasive cardiologist and head of medical education at Heartbeat Health. She specializes in advanced cardiac imaging, with subspecialty training in cardiac MRI and structural cardiac imaging, and is a Fellow of the American College of Cardiology active in its Women in Cardiology section and California chapter leadership.