CASE 20

Sunil Guha

A 32-year-old South Asian Indian man with metabolic syndrome

Fran Burke, MS, RD,1 and Lisa Hark, PhD, RD2

Educational Objectives

TACCT Domains: 1, 2, 4

Case Summary, Questions and Answers

Sunil Guha is a 32-year-old Asian Indian man who is seen in the Preventive Cardiology Clinic for a consultation. He has referred himself because he is concerned about his family history of premature heart disease (his father had his first myocardial infarction at 45), and he is seeking ways in which he can prevent this from happening to him. He has been living in the U.S. for the past 11 years since he came over for college. He is an engineer, recently married, and is planning to start a family in the near future. His parents still live in India, and he visits them a few times a year. He brings his lab results with him to the visit, which he obtained while visiting his primary care physician (PCP) a few months ago. He states that he does not want to take medication and prefers to focus on changing his diet and lifestyle. Mr. Guha’s results are as follows:

1 Is Mr. Guha at higher risk of heart disease compared with the general population, and how does his ethnic background affect his risk?

Yes, Mr. Guha is at greater risk for coronary heart disease (CHD) because he has several cardiac risk factors, including a family history of premature heart disease and metabolic syndrome. Mr. Guha is diagnosed with metabolic syndrome because he meets three of the four criteria: increased waist circumference (WC), borderline elevated blood pressure, elevated blood sugar, and elevated triglyceride levels (shown in Table 20.2).

Asian Indians are at higher risk for CHD, which occurs about 5 to 10 years earlier than in other populations. The increased risk appears to be due to the higher rates of metabolic syndrome, insulin resistance, and diabetes. Healthy, normal weight Asian Indians are more likely to have insulin resistance compared with age- and BMI-matched whites. Furthermore, insulin resistance in Asian Indians manifests at an earlier age. Conventional criteria from the Adult Treatment Panel (ATP) III underestimates the prevalence of metabolic syndrome by 25% to 50% in Asian Indians, because this ethnic group develops metabolic abnormalities at a lower BMI and WC than other ethnic groups. Therefore, several national and international organizations have recommended using the International Diabetes Federation (IDF) definition, which has developed ethnic- and gender-specific criteria using WC criteria for central obesity as a mandatory component (Table 20.3).

Table 20.1 Mr. Guha’s Lab Results

Visit 1 Desirable
Blood pressure 135/85 mm Hg <130/80
Fasting blood glucose 100 mg/dL <99
Fasting triglyceride 210 mg/dL <150
HDL-C 40 mg/dL >40
LDL-C (direct measure) 116 mg/dL <130
Total cholesterol 190 mg/dL <200
Height 5¢6²
Weight 167 lbs
Body Mass Index (BMI) 27 <25
Waist circumference (WC) 36² <35*

*based on International Diabetes Foundation definition, http://www.idf.org.

Table 20.2 Diagnosing Metabolic Syndrome: three or more of the five criteria

Source: Adult Treatment Panel (ATP) III Guidelines, NCEP 2001 Report.

Abdominal obesity Waist circumference
Men >40 inches
Women >35 inches
Pre-Hypertension BP ≥130/≥85 mm Hg
Glucose intolerance FBG ≥110 mg/dL
High triglycerides ≥150 mg/dL
Low HDL-C Men <40 mg/dL
Women <50 mg/dL

Most studies indicate that the average BMI of Asian Indians increases with urbanization and migration but is still less than that seen in whites, Mexican Americans, and blacks. Mr. Guha’s BMI is 27 inches and his WC is 36 inches. He meets the IDF criteria for increased WC, in addition to having an elevated blood pressure and triglyceride level at his first visit. Therefore, he should be treated with aggressive lifestyle management.

Table 20.3 Ethnic and gender WC criteria for central obesity

Source: International Diabetes Federation.

Men (inches) Women (inches)
European
Sub-Sahara Africa >37 >32
Middle eastern
South Asian
South/Central American >35 >32
Japanese    
Chinese    

2 What other laboratory values would be helpful in determining treatment recommendations for this patient?

In addition to a comprehensive metabolic and lipid panel, Mr. Guha should also be tested for lipoprotein [Lp(a)] and apolipoprotein B. Asian Indians often present with a dyslipidemia that is characterized by high serum levels of apolipoprotein B, Lp(a), and triglycerides and low levels of apolipoprotein A1 and high-density lipoprotein cholesterol (HDL-C). An elevated apolipoprotein B level is a stronger risk factor for CAD than low-density lipoprotein cholesterol (LDL-C) and is found in one-third of Asian Indians.

Several studies report a strong association between Lp(a) levels and CHD risk. Lp(a) is a modified form of LDL-C. It represents a class of LDL-C particles that have apolipoprotein B-100 linked to apolipoprotein A. Lp(a) is structurally similar to plasminogen but has no thrombolytic activity. Excess Lp(a) may promote atherosclerosis by increasing LDL oxidation and smooth muscle cell proliferation and by impairing endothelium-dependent vasodilation. Plasma Lp(a) levels are determined primarily by genetic factors that regulate production by the liver. Screening for Lp(a) is recommended for patients with a strong family history of premature CHD, as in Mr. Guha’s case. Lp(a) measurement is useful for identifying highrisk individuals and families who may be at higher risk than what might be suggested by mildly elevated total or LDL-C levels. These patients may benefit from earlier pharmacotherapy in conjunction with diet and lifestyle changes.

The optimal level of Lp(a) should be less than 20 mg/dL. Research shows that the risk of CAD is two- to fourfold higher when the levels of Lp(a) are above 30 to 40 mg/dL. This risk also increases when an Lp(a) level greater than 50 mg/dL is accompanied by elevated cholesterol levels. Recent studies have indicated that CAD risk is much greater when elevated Lp(a) levels are accompanied by low HDL-C versus high LDL-C levels.

Mr. Guha’s Lp(a) results are 61 mg/dL and aggressive therapy is warranted, but he states that he does not want to take medication and prefers to focus on changing his diet and lifestyle. He is referred to a registered dietitian who determines that he is a vegetarian and his diet includes white rice, legumes, and whole milk dairy products. He has been eating a combination of American and Indian foods since he began living in the United States 11 years ago. He states that he tries to watch what he eats and only eats one meal per day with no snacks.

3 How does Mr. Guha’s ethnic background affect his dietary habits and lifestyle?

Nutrition interventions for the prevention and treatment of CAD need to be compatible with an individual’s cultural values and beliefs. Developing nutrition interventions that target people from diverse backgrounds presents a variety of challenges. Health professionals must recognize the importance of specific foods within cultures and of ethnosocial influences on food choices. However, generalizations about food patterns should not be made solely on the basis of race, ethnicity, or geographic origin because food-choice diversity is common within all cultural and racial groups. The U.S. is a melting pot of cultures. Interventions are most effective when focused on each individual’s unique dietary history and background, without making assumptions about food habits on the basis of cultural or racial identity. Factors such as where you live may influence the availability of ethnic foods, and issues of acculturation play a huge role in the food selection of all people.

Asian Indians often follow a vegetarian diet for both cultural and religious reasons. Rice and wheat are staples of the Indian diet, whereas fruit and vegetable intakes are low. Many vegetarian foods and baked goods are prepared with coconut and palm oils, butter, ghee (clarified butter), vanaspathi (hydrogenated fat), and coconut milk, all of which are very high in saturated and trans fats.

It is important to question Mr. Guha about the types of fats that he and his family use when preparing Indian dishes at home. His saturated fat intake should be less than 7% of his total calorie intake. Asian Indians in India consume relatively more carbohydrates (~60% to 67% of energy intake) compared with Asian Indians living in the U.S. (~56% to 58% of energy intake). High carbohydrate intake is associated with elevated triglyceride levels. Low dietary intake and low plasma levels of omega-3 fatty acids in Asian Indians have been reported in several studies.

Asian Indians have been shown to be less physically active compared with other ethnic groups. It is culturally unacceptable for Muslin women to participate in leisure time physical activity. Mr. Guha currently leads a very sedentary lifestyle. Sedentary Asian Indians are more likely to have higher BMI values, triglyceride levels, and blood pressure. Physical activity patterns in Asian Indians warrant further investigation because a sedentary lifestyle could be an important risk factor for the insulin resistance seen in this population.

Whoever prepares meals for this family should be included in the counseling session with the dietitian.

The dietitian prescribes a low saturated fat diet and a regular exercise program, both of which are supported by the physician. Mr. Guha says he will return for follow-up in 3 months; however, he does not. He returns to the Preventive Cardiology Clinic 3 years later. His father died of heart disease the previous year. He also states that his mother, who has diabetes, has been living with his family since last year and now does most of the cooking. He reports that he has been very busy with work and his new 1-year-old baby and rarely finds time to exercise.

4 What is the best approach to take with this patient who has not followed up as recommended?

Initially patients may express the desire to change lifestyle habits and appear motivated to improve their overall health but may find it challenging to make permanent dietary changes. When patients do not return for their follow-up visit, it typically means that they have not followed the medical nutrition prescription that was outlined for them.

From a gender perspective, Mr. Guha may follow a sex role belief that women cook and men eat, therefore imparting him with an adopted powerlessness about food that his mother and wife prepare. Being aware of this would be important in developing an effective behavior charge program for Mr. Guha.

Bringing patients back frequently for follow-up visits and asking them to complete food and activity records is a good behavioral tool to keep patients on track. The best way to discuss these issues with Mr. Guha is to explain where he is in terms of his CHD risk, where he needs to be to lower his risk, and how we can achieve this together. This provides a supportive, nonjudgmental approach. It is important to inform Mr. Guha that you appreciate him returning for follow-up, rather than confronting him with your disappointment that he has not come back for 3 years.

Vital signs and labs are obtained (see Table 20.4). Mr. Guha returns 1 week later to discuss his lab results.

Table 20.4 Mr. Guha’s lab results

Visit 1: Visit 2: (3 years later)
Blood pressure 135/85 mm Hg 150/86 mm Hg
Fasting blood glucose 100 mg/dL 122 mg/dL
Fasting triglyceride 210 mg/dL 250 mg/dL
HDL-C 40 mg/dL 35 mg/dL
LDL-C 116 mg/dL 152 mg/dL
Total cholesterol 190 mg/dL 230 mg/dL
Height 5¢6² 5¢6²
Weight 167 lbs 182 lbs
BMI (kg/m2) 27 29
WC 36² 39²
Lp(a) 61 68

5 What is the most appropriate next step in the management of this patient?

At this point, it is important to express concern about Mr. Guha’s increased weight as well as the significant increase in many of his lab values. Focus on the nonweight goals when counseling Mr. Guha. He should understand that he now meets all five of the ATP III criteria for metabolic syndrome and, because of his strong family history for premature CHD, he is at high risk for developing heart disease. In addition, because his mother has diabetes and his blood sugar is now elevated, he is also at risk of developing diabetes. Mr. Guha should therefore be aggressively treated with diet, exercise, and medication(s) to reduce his risk of heart disease and diabetes. Mr. Guha’s diet should be low in saturated and trans fats and restricted in total calories to achieve weight loss. Recommend that he substitute lower fat dairy products for those that are high in saturated fat, such as cheese and whole milk yogurt. The patient needs to increase his total and soluble fiber intake by substituting whole grain starches for the white bread and white rice he consumes daily.

The predominant cooking oil used in food preparation should be high in monounsaturated fat, such as olive or canola oil. In addition, Mr. Guha and his mom should be counseled to avoid frying, or use a limited amount of oil to sauté or stir fry foods, as oils are calorically dense, supplying 135 calories per tablespoon. Mr. Guha should be encouraged to increase his intake of fresh fruits and vegetables, which will help increase his fiber intake, decrease the energy density of his diet, and help him better manage his weight. Finally, Mr. Guha should be counseled to avoid drinking sugar-sweetened beverages, such as regular soda or fruit juice. These beverages, which provide refined sugars, contribute to increased calories and elevated triglyceride and glucose levels. Finally, Mr. Guha is recommended to begin a physical activity program three to four times a week for at least 30 minutes, which will aid in weight control and may help to improve HDL-C levels.

The physician starts Mr. Guha on several medications in addition to recommending lifestyle changes, which include an aspirin, antihypertensive agent, and an HMG CoA reductase inhibitor. ATP III details the means of assessing CHD risk and outlining LDL target goals, which for Mr. Guha, is less than 100 mg/dL. A follow-up appointment with the physician and registered dietitian is scheduled for 6 weeks to monitor changes in serum lipids, glucose, blood pressure, and weight and reassess medications.

6 What factors have contributed to the change in Mr. Guha’s risk factor profile?

By helping Mr. Guha reassess his life and identify factors that have contributed to his overall health, he is more likely to come to terms with his current health problems and begin to make lifestyle changes to prevent future events. It is very important that Mr. Guha maintain his cultural identity, especially related to his food intake and physical activity pattern, by providing culturally appropriate recommendations targeted to Asian Indian patients. These are the factors in Mr. Guha’s life:

Lifestyle: He has a full-time job and a new baby and states that he is very, very busy and does not have time to exercise. Mr. Guha would greatly benefit from a regular exercise program, so discussing how he can work in time to exercise or make exercise part of his everyday life is critical. Write him an exercise prescription and discuss his schedule and activities he enjoys. Suggest he purchase a pedometer to help quantify his activity, and discuss activities he enjoyed when he was more active. Encourage reducing sedentary activities, such as limiting television and taking stairs instead of elevators.

Stress: The death of his father and the stress at work have placed much pressure on Mr. Guha, which has caused him to eat more, exercise less, and avoid focusing on his own health. Ask him if he has ever paid attention to stress reduction and if he would be willing to try meditation, yoga, and massage therapy, as some may fit into his cultural belief systems.

Preparation of the family meals: Now that Mr. Guha’s mother is living with his family on a full-time basis, she is taking care of their child and cooking all their meals. As a result, he states that he has gained 15 pounds in the past few years. Mr. Guha’s BMI is 29, combined with an increased WC of 39 inches, significantly increases his risk of CHD. To help improve adherence, include his mother and wife as part of the conversation with the registered dietitian to ensure that she can still prepare and enjoy a healthier Indian cuisine. Refer to Table 20.4 for healthier versions of traditional Asian cuisine.

Table 20.5 Healthier versions of traditional Asian Indian cuisine

Source: Gans, K., Karmally W. Multicultural nutrition strategies: Asian-Indians. In: Carson J.S., Burke F.M., Hark L.A., eds. Cardiovascular Nutrition: Disease Management and Prevention. American Dietetic Association, Chicago, 2004.

Traditional food Healthier way of eating
Meat, poultry, fish, and eggs fried in ghee, butter, coconut oil, palm kernel oil, or hydrogenated fats and oils. Bake, roast, broil, grill, or oven-fry. Remove skin from chicken before eating. Fry with canola, olive, or corn oil instead. Limit to 1/4 cup of oil.
Legumes and vegetables prepared with oil, butter, cream yogurt to enhance flavor. Use almond paste or nonfat yogurt in place of cream and butter. Season with onion, garlic, spices, or low-sodium chicken broth to enhance flavor.
Rice (white) dishes or wheat (refined) preparations deep fried or prepared with large amounts of ghee, butter, and hydrogenated fats (vanaspati) containing trans fatty acids. Use brown rice and whole grain wheat. Boil or bake instead of frying. Fry with canola, olive, or corn oil or trans-free margarine instead of solid or hydrogenated fat. Limit to 1/4 cup of oil.
Whole milk/cheese/cream/yogurt used to prepare rice dishes, vegetables, desserts, and shakes. Yogurt cheese (panir) prepared with whole milk. Use low-fat or nonfat milk, milk powder, cheese, cream, yogurt, buttermilk, or soymilk instead.
Omelettes and desserts prepared with egg yolks. Substitute egg yolks with egg whites.
Snacks such as fried legumes “bhel.” Snack on fruits, rice cakes, and puddings made with low-fat milk instead. Use oat and whole wheat cereal to prepare savory snacks.
Salt used to enhance flavor. Use herbs (e.g. cilantro, mint) or spices (e.g. cumin, black pepper, cardamom, cinnamon) or flaxseed powder to enhance flavor.

References: Case 20

Enas E.A., Chacko V., Pazhoor S.G., Chennikkara H., Devarapalli H.P. Dyslipidemia in South Asian patients. Curr Atheroscler Rep 2007;9(5):367–74.

Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive summary of the third report of the national cholesterol education program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III). JAMA 2001;285:2486–97.

Gans K., Karmally W. Multicultural nutrition strategies. In: Carson J.S., Burke F.M, Hark L.A., eds.Cardiovascular Nutrition: Disease Management and Prevention. American Dietetic Association, Chicago, 2004.

Gupta R., Joshi P., Mohan V., Reddy K.S., Yusuf S. Epidemiology and causation of coronary heart disease and stroke in India. Heart 2008;94:16–26.

Hoogeveen R.C., Gambhir J.K., Gambhir D.S. Evaluation of Lp(a) and other independent risk factors for CHD in Asian-Indians and their USA counterparts. J Lipid Res 2001;42:631–8.

Joshi P., Islam S., Pais P., et al. Risk factors for early myocardial infarction in South Asians compared with individuals in other countries. JAMA 2007;297:286–94.

Minority Women’s Health. Available at: http://www.4woman.gov.

Misra A., Vikram N.K. Insulin resistance syndrome (metabolic syndrome) and obesity in Asian-Indians:evidence and implications. Nutrition 2004; 20:482–91.

Rajeshwari R., Nicklas T.A., Pownall H.J., Berenson G.S. Cardiovascular diseases-a major health risk in Asian-Indians. Nutr Res 2005;25:515–33.

von Eckardstein A., Schulte H., Cullen P. Lipoprotein(a) further increases the risk of coronary events in men with high global cardiovascular risk. J Am Coll Cardiol 2001;37:434–9.

1University of Pennsylvania School of Medicine, Philadelphia, PA, USA

2Jefferson Medical College, Philadelphia, PA, USA