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This episode was produced by Nikitha (Nikki) Sheth, hosted by Nikitha (Nikki) Sheth, edited by Grace Kim, and graphic by Callista Wu.

 

00:00 Introduction

01:25 Dr. Shah’s journey into cardiology and South Asian health research

05:06 Introduction to the MASALA study

08:40 Moving beyond “why” in research

17:03 Personal connection to MASALA and community engagement

25:26 Understanding stress and its impact on health behaviors

30:39 Dietary recommendations and nuances

36:19 Common health misconceptions in the South Asian community

44:20 Advice for South Asian medical students

50:02 Closing remarks 

 

00:00 Introduction

Nikitha: Hi everyone, welcome to APAMSA White Coats and Rice’s new series South Asian Health in Lens, or SAHIL, where we delve into critical topics in South Asian health ranging from advocacy to cultural competency with distinguished healthcare leaders. My name is Nikitha Sheth, first-year medical student and third year in the University of Missouri Kansas City’s six-year BA/MD program, and the current vice president of UMKC APAMSA and member of the South Asian Committee here at National APAMSA. And I’ll be your host for our SAHIL series.

For today’s SAHIL episode, we’ll be speaking with Dr. Nilay Shah, who is an Assistant Professor of Cardiology, Preventative Medicine, and Medical Social Sciences at Northwestern University Feinberg School of Medicine and serves as Principal Investigator of the Mediators of Atherosclerosis in South Asians Living in America, known as MASALA, Second Generation Study. Recognized for his contributions to clinical advancement and cardiovascular disease prevention, Dr. Shah applies his expertise to shed light on cardiovascular health and social determinants of health. Let’s welcome Dr. Shah. Thank you so much today for joining us, Dr. Shah. It truly means a lot to me and to APAMSA for you to take the time to talk about your experience with MASALA, which we will delve into, but also just how you’ve been a proponent for South Asian health, both cardio-metabolic, cardiovascular. I do appreciate you coming in today and talking about all of these important topics.

Dr. Shah: It’s my pleasure. I appreciate the opportunity and I’m glad to have this conversation.

01:25 Dr. Shah’s journey into cardiology and South Asian health research

Nikitha: Yeah, so we’ll just dive right in. I wanted to ask if you could just talk a bit about yourself to start off with and more about your journey and how it’s led you to become the leader you are today in medicine and especially being the principal investigator of the MASALA second gen study.

Dr. Shah: Well, that’s very kind of you and I appreciate the recognition. So I am currently a faculty member at the Northwestern University Feinberg School of Medicine in Chicago. I’m a practicing preventive and general cardiologist, and I spend most of my time on public health and prevention related research with a focus on understanding and intervening to address disparities in cardiovascular health and cardiometabolic outcomes experienced by populations that experience excess cardiovascular disease, one of which, of course, is the South Asian community and several other Asian American communities.

So this area of interest, I think, really started for me, like probably many people who are listening, with the experience of what their community went through as they were growing up. In my community, I grew up in the Chicago metropolitan area. And in the Indian American community in Chicago, as I was moving from middle school to high school and into college, the stories of people experiencing cardiovascular disease and its risk factors just became more and more frequent. People had heart attacks, people needed bypass surgeries, people needed stents. A lot of people experienced diabetes and some of the challenges with managing diabetes. It was such a common story. And so that was the context of what I had in mind when I went through my formal education as an undergraduate and into medical school.

And as a medical student, I started to gain experience in some of the research methods that I would come to find as foundational to the research that I do now. And actually, I should say, before that, I took a year, a detour, and I spent a year at the NIH working on research in neuroepidemiological outcomes with the National Institute on Aging. And that’s actually where the foundation of my research method training started. It was a lab that focused a lot on population level data. And it was my first foray into epidemiology and biostatistics, which would come to really set the stage for all of the research I’ve done since then. So after that year, I was a medical student and I concurrently studied public health and then went kind of through a more traditional route of training. I finished medical school and did a residency in internal medicine, followed by a fellowship in cardiovascular disease.

And then that’s where I really differentiated into a research-focused faculty member. And this area of interest really started by still having this experience of my community in mind. And every time I met a patient who was a young adult South Asian experiencing cardiovascular disease, the question always became why. Why is this happening in our community? Why is it always a young adult South Asian person when a young person comes in with ST elevation MI? Of course not always, but it was so frequently people from our community that it was compelling to try to understand the reasons for that disproportionate burden. And by the time I was in clinical training as a resident, I had had the opportunity to formally study epidemiology and biostatistics. And I realized that I could use and apply that research methodological training to answering questions about this excess burden of cardiovascular and cardiometabolic disease that was occurring in the South Asian community. And that’s really where my interest in this area of research started.

05:06 Introduction to the MASALA study

Dr. Shah: So when I finished my medicine residency and became a cardiology fellow, I was fortunate to match at the fellowship program at Northwestern in Chicago. And that, as your listeners may know, is one of the sites of the MASALA Research Program. So MASALA being the Mediators of Atherosclerosis in South Asians Living in America study. It’s a community-based cohort study that started in 2010 and recruited participants from two sites, one in the San Francisco Bay area at UCSF and one in the Chicago metropolitan area at Northwestern. And I was able to begin my collaboration with the MASALA Research Program as a fellow at Northwestern and developed several research projects that through which I was able to apply my prior experience in epidemiological methods and coding of statistics and statistical programming.

That led to kind of a decision that I wanted to steer my career to be a heavily research-focused career. So after I finished my clinical training, I did a two-year postdoctoral fellowship funded by an NIH F32 grant, focused on understanding some of the social network mechanisms and how they influence cardiovascular health in the South Asian community. And that was in the MASALA Research Program. And that really kind of set the ball rolling for a series of grants and research experiences that really deepened my interest in this area. This whole research program that I’m now working on and leading started with my community and it started with my experience in adolescence and into young adulthood. Because so many people in my community, in our community, have experienced heart disease, it was really compelling to try to understand the prevention aspect. And so that’s really kind of where this whole thing started. And it’s a bit about my journey.

Nikitha: That is truly an amazing journey of yours to see how you’re growing up in the Chicago suburbs and being surrounded by South Asians and the type of health struggles they have faced when it comes to early onset, especially when you talked about seeing young South Asian patients today with MI and other problems. So it’s truly amazing to see how you’re able to apply your previous experiences into your values today and why research is so critical in these aspects, especially in preventative care and understanding the why. So I completely resonated with that story because from my perspective, I’ve also grown up in the Chicago suburbs and coming from a more diverse community, we had a more Asian minority. And so I felt more compelled to advocate and think about Asian health and contribute to that in my community, as well as absorbing other cultures as well. And so to hear your experience about seeing those other people’s struggles and that aspect of their health, it means a lot because it shows that empathetic perspective that I think is also critical in medicine where people are telling you or you’re just simply by observing, seeing the different trends and to have that tied into research, I think the question of why and having that innate curiosity, that’s something that I share with you because wondering the reason why we see these health trends, it’s not simply treating the patient or just seeing these situations and saying, okay, there’s not much we can do about it. By digging further and understanding why is this happening, what trends do we see in certain underrepresented communities can give us a much more open-minded perspective that we can directly integrate into patient care. So that’s a truly amazing journey. I appreciate you sharing that.

08:40 Moving beyond “why” in research

Dr. Shah: Yeah, of course. And I appreciate your reflections as well, because I think a lot of people, a lot of people in our community have had a very similar experience. And I meet trainees who are South Asian and Asian American identifying all the time. And when I share my experience in the community in which I grew up and my journey, I think a lot of people hear a lot of echoes to their own experience. And so it actually is helpful and important to know that my experience was not actually unique and it lends a lot of credence to the importance of the work we’re trying to do.

And I would say that as a researcher, and I imagine I’ll be wearing my researcher hat for a lot of this conversation, one of the things I’ve learned is to move beyond why as a researcher. Because the first question was why, just as you alluded to, why were these trends happening? But I’ve learned that as a researcher, there’s so much more that comes after digging into this question. You know, when you have a sense of why, the next question is what do you do about it? And not only what you do about it, but how do you do it? And is what you do actually effectively going to move the needle to improving health and health outcomes for communities that you’re partnering with for your research? So there’s quite a bit of work to be done in this space, but it certainly did start with trying to answer the question why.

Nikitha: Yes, absolutely. I completely agree that why is kind of that starting point and to know how you’re going to go from there once you’re digging, but how are you going to apply that? So that clinical application is what makes this all worthwhile because the whole point is to improve the quality of patient care or make patients feel more seen and represented and find ways to make them directly impacted by these findings. So that’s absolutely, I agree with that. And so leading into that, so you talked about your experience kind of getting into MASALA and now being a prominent leader in that study. So I want to ask a little bit more about your experience, about how you recently led the MASALA second gen study and how patients would typically get involved in the MASALA study and kind of the significance of joining a study so that people who are listening can understand kind of the reason why people may want to participate in these and kind of the benefits that we can gain from it?

Dr. Shah: Yeah, that’s a great question. I think it actually has several different types of answers, one of which is for the trainees who may be listening with respect to how one might get involved or lead similar work for their own communities or get a research career off the ground. And the other, I think, is more from the community and patient perspective and how they might get involved. And maybe the third bit is what we do with the information that we get and what it means to be a research participant.

I’ll be brief about this first part, but for any trainees who are interested in starting a research career, I’ll very briefly share how that occurred. So as you alluded to, I am the principal investigator of the MASALA Second Generation Study. And to give you just a little more detail, the MASALA Second Generation Study is a cohort of young adult South Asians and the main eligibility criteria for participation in this cohort is that their parent participated in the original MASALA study. So it’s an offspring cohort. We enrolled the young adult children of original MASALA study participants with the overall goal of trying to understand what are the characteristics of the early development of poor cardio metabolic health in this community? What are the reasons why people are starting to develop high blood pressure and high cholesterol? And what are the underlying factors that drive the development of diabetes at a young age?

The reason I was interested in this young adult community in the South Asian population was because epidemiologically we know that people on average experience heart disease at a younger age compared with other groups. And so I was interested in understanding what was going on in young adulthood that we might actually see as an intervention point to help promote health and prevent this trajectory to heart disease.

Dr. Shah: And so the MASALA second generation study so far and to date has been funded by a K award from the National Institutes of Health. If you don’t know, a K award is meant as a training grant. And so it’s a mentored research award. You apply as the principal investigator, but you have to apply under the mentorship of a more senior level investigator. I was lucky that the principal investigator of the original MASALA study at Northwestern, Dr. Namrata Kandula agreed to be my mentor for this, and so I applied for the grant, but she helped prepare this NIH grant and she had quite a bit more experience applying for NIH funding. And so we wrote this grant and it was luckily funded. And so we had funding to start the MASALA Second Generation Study.

From about 2023 to just earlier this year, early 2025, we enrolled a pilot cohort of this offspring study. And the idea is that we eventually will hope to expand to enrolling as many of the adult children of original MASALA study participants as we can. The first stage only enrolled about 120 participants, but it provides us really valuable preliminary data to apply for greater funding, a greater pool of funding for research. And it was amazing. The offspring participants were so activated and engaged to participate. And I think it’s because their parents participated in and encouraged them to join the research study. You know, research has this, participating in research has this really amazing ability to make people more aware of health and what contributes to health and what might threaten health. And the MASALA participants are no exception.

A lot of them came to participate in the MASALA study without a lot of knowledge about heart disease or what the risk factors are, how to prevent heart disease. And simply by participating, having their risk factors checked, getting health education information through their participation, a lot of them were compelled to learn more and spread information about not only the research study, but information about health to their social context, including their children. So we were fortunate to develop this as an offspring study because it really made enrollment and recruitment into the study a lot easier.

Dr. Shah: This is a bit of a tangent or I suppose a bit of an aside, but the point to those of you interested in a research career is that so much of developing a research career does depend on the ability to obtain funding for your research. And we are in a bit of a challenging environment right now. To address your question a little more directly, Nikitha, we are not currently enrolling participants into any of the MASALA research programs at the moment because of where the funding environment is. That being said, the PI of the second generation study and the three PIs of the main MASALA parent study are all actively working on securing funding so that the MASALA research program can continue.

Institutions like the NIH recognize the importance of the MASALA study. That certainly has been our impression through all of the conversations we’ve had. You know, we’re all confident that the funding will eventually come through and the MASALA Research Program will continue because there’s a lot more insights to be gained and especially from a cohort study perspective as the cohort of individuals passes through time and grows older there are important questions to be asked beyond cardiovascular disease risk that are important with respect to aging in the South Asian community. So understanding things like risk factors for cancer and cancer health outcomes, risk factors for cognitive impairment and dementia. There isn’t a lot of population-based data to understand what the experience of some of these conditions are like in the South Asian community. And so, MASALA actually stands to be a really important resource to move even beyond cardiovascular disease and understanding health overall and the risk for a wide range of diseases in the South Asian community.

17:03 Personal connection to MASALA and community engagement

Nikitha: Yeah, I do appreciate your honest perspective, especially on that funding aspect and how you can adapt and kind of work around things and see how things can change over time and go from there. And so when you talked about the first and second gen and how second gen was the offspring from first and how it seemed that they were more motivated to partake in the second generation, mainly because their parents were involved and they’re getting their risk factors checked. So there is some benefit in participating. And I personally also had family who are community members that partook in the MASALA study. So from my own personal perspective, I could see my grandma, my dad taking part in going to a nearby facility and getting these things checked. And as a young South Asian child, it was truly moving for me to be able to see that there are programs out there that truly cared for our community and how it’s been ongoing. It’s a longitudinal type of thing where each generation is cared for and checked with the intent of looking into not only cardio metabolic health, like you talked about, but expanding it to other foundational aspects of South Asian health. So it is truly incredible what MASALA does. And I think it’s important that people understand the values behind it because it is a truly moving program.

Dr. Shah: Yeah, you know, that’s a really important point, because there are many, many cohorts of individuals that exist in the U.S. that are focused on understanding risk factors for cardiovascular disease. But this is the only one that includes and focuses on South Asian communities. And so the process by which the MASALA program started wasn’t simply adapting the infrastructure of a research program to enroll participants, but there was a lot of community engagement, conversations and partnerships with community members and adaptation of data collection instruments and the approach for recruiting and having people participate that really made the MASALA program as successful as it is.

And that credit, I think, goes to the original PIs, Dr. Alka Kanaya, Dr. Namrata Kandula, their teams at UCSF and Northwestern and the most recent site of MASALA, which is at NYU led by Dr. Nadia Islam and Dr. Naheed Ahmed. These researchers have put a lot of time into making sure that the research program not only helps us understand health and disease in the South Asian community, but that the program is aligned with the preferences and what is important to members of the South Asian community. So this is kind of more of a collaborative effort than simply being driven by researchers at an academic medical center. And so that’s a lot of where I think the values of the MASALA program come from, which is, I think, what you alluded to.

Nikitha: I agree that the collaboration that you can see with MASALA is, I believe, one of its strongest aspects because of that cross-institutional collaboration. You’re able to find data from multiple prominent cities and compare it. And it just shows a more unified approach towards a central goal of promoting health care and patient care in the Asian and the South Asian community across multiple age groups. So I do agree that that’s a very strong aspect of MASALA that should be commended.

Dr. Shah: Yeah, it’s been great. And I hope it’ll continue.

Nikitha: Yes, absolutely. So delving into the actual findings and your research experiences with MASALA and the types of things that have been discovered, you recently published an article on the effects of chronic stress on cardiovascular health, which highlights how elevated chronic stress could negatively impact cardiovascular health. So considering this key data point, what are some lifestyle choices that South Asian Americans can consider to promote their heart health?

Dr. Shah: Yeah, this was a particularly interesting study and I’m glad that you brought it to this conversation. And I think I find it particularly interesting because it was driven a lot by what we learned about the lived experience of being South Asian in the US, which is we and other researchers in the MASALA program have thought about what are the mechanisms that influence health behaviors in the South Asian community. And that kind of question was posed to community partners and members of South Asian communities. And one of the themes that emerged was that there was a strong belief that the experience of stress affected people’s health.

Now I’m guessing that doesn’t surprise anybody, but I think that it was a motivating factor to investigate how the experience of stress was related to cardiovascular health and cardiovascular health behaviors. So as you stated, this particular analysis of MASALA data showed that experiencing higher levels of chronic stress was associated with worse cardiovascular health in a cross-sectional analysis. And although this particular analysis didn’t delve into the question more specifically, my hypothesis would be that a lot of that association could potentially be explained by how stress influences health behaviors.

Now in the MASALA program, there wasn’t a lot of, for example, smoking behaviors. The prevalence of smoking was low in the MASALA participant sample. But one could imagine how more experience of stress might influence people’s smoking behaviors. Certainly the experience of stress might influence the quality of one’s dietary pattern. Absolutely, the experience of stress might influence the individual’s participation in exercise and physical activity. But there may also be some underlying biological mechanisms through which stress influences overall health, either through inflammatory pathways, being the one that comes to mind more immediately.

Dr. Shah: And so my advice, I think, with respect to this study is that if stress is particularly associated with worse cardiovascular health and cardiovascular risk factors in people who are South Asian, then I think that the approach would be to identify the stress mitigation techniques that work for you, work for you as an individual, which may help support more favorable health behaviors. And in the South Asian community, some of the things we’ve learned about stress and stress behaviors, stress-related behaviors, or I should say stress alleviating behaviors, can include things like mindfulness and yoga, can include things like spending time with social network members. And that avenue of intervention to mitigate the potential consequences of stress could lead to better and more favorable cardiovascular health behaviors and more downstream overall better cardiovascular health.

These are avenues that I think are of interest to potentially develop and test interventions to improve cardiovascular health. And I think a lot of the focus has been on mitigating the effects of stress rather than mitigating the stress itself. You know, when I meet patients in the clinic, I have to acknowledge that it’s not really feasible to eliminate the sources of stress altogether. People have to work, people have to go to school, people, there are stressors in people’s lives that are not really modifiable. So I think a lot of the conversation with respect to stress mitigation is moving from removing the source of stress when it’s not always feasible towards how best to mitigate the experience of stress.

And in the South Asian context, especially among older or immigrant South Asians, leaning heavily on their cultural experience, whether that is through different types of mindfulness and meditation, which can sometimes be part of people’s South Asian cultures and cultural practices and identity. Religiosity is sometimes a mechanism of alleviating the experience of stress. These are potential ways that the experience of stress could be mitigated to improve cardiovascular health.

25:26 Understanding stress and its impact on health behaviors

Nikitha: I appreciate you highlighting the nuance that comes with it because, just like you said, when you hear that stress can cause cardiovascular problems, that is not necessarily as surprising on a surface level. But I do agree that it’s really important to understand, like you were talking about, the nuance behind how stress itself may not go away, but how that can influence a day-to-day routine or someone’s habits and how they allow the stress to affect different aspects of their lives, which then can subsequently impact their cardiovascular health. So I do agree that the importance of finding ways to mitigate your stress and kind of focusing on the mental health aspect as well in the South Asian community, but also in general, finding ways to allow the stress to still exist since it’s not easy to eliminate it altogether, just as you said, but to work with it and allow for, like you said, mindfulness or yoga, which I think are some things I’ve noticed to be more popular in like South Asian community members that I’ve interacted with. Ways that you can kind of cope with the situation without having to feel any pressure to eliminate it because sometimes they will remain. But it’s how you can find ways to work with it and incorporate more mindful routines that can promote your heart health altogether.

Dr. Shah: I think that’s right. I think given this audience of people who are either clinicians or clinicians in training, I think actually one of the lessons I took away that people may find compelling is that when we do research like the MASALA program, we’re looking at a population or we’re looking at a community and we’re looking at trends within that community. But I think it’s really important to make clear the distinction between patterns that are observed within a community and what somebody might actually experience at the individual level. So although this research, studying this analysis from the MASALA data set, which includes nearly, I think about 1200 participants, showed us that the higher experience of stress was associated with worse cardiovascular health, that was among 1200 participants on average.

It’s important, I think, as a clinician to really meet your patients where they are at. And so if you’re sitting in front of a patient who identifies as a South Asian ethnicity, like Indian or Pakistani or whatever they may be, I think starting with open-ended questions and trying to understand an individual person’s experience of stress and what may or may not work for them to mitigate that experience is really the key to start. Being guided by some of these community and population level data is an important and great place to start. You know, again, I think we all really understand that everybody experiences stress differently and different kind of external inputs differently. So we can learn a lot from population level data and community level data, but we should also be mindful about making sure that we’re taking care of the person in front of us.

Nikitha: I completely agree. I think being able to apply the information that is found in research studies, so having informed care is really crucial, but to just look at the patient in front of you and let them explain everything that’s going on and just like you said, meet them where they’re at is so critical in order to become an empathetic physician and to find that intersection between your knowledge in research findings, but also applying that in a way that directly impacts the patient that you’re seeing with their specific concerns. So not to impose any other new ideas on them, but to understand what their values are, what their chief concern may be, and to use your knowledge to help them specifically of what they may desire, where they’re at.

Dr. Shah: Yeah, that’s exactly right. And I would imagine anybody going through clinical training will increasingly find that this approach will make sure that they retain their empathy and their patients find the advice given to be useful.

Nikitha: Yeah. And leading into that, so as you’re experiencing preventative medicine specifically, so based on your in-depth background on preventative medicine, are there particular universal pieces of advice that you would recommend to most South Asian patients based on what you’ve seen and experienced?

Dr. Shah: Yeah, that’s a great question. I get asked that question quite often, actually. And it’s because I think patients are actually increasingly aware of the research work that I do. I will often have self referrals to my clinic of people who are aware that I conduct research on South Asian communities or with South Asian communities to try to understand patterns of health and disease. And they’ll come to my clinic asking, well, what have you learned and what should I do?

And the reality is this, so far, most of what we should be doing is already known. We already know that we should be eating a healthful diet. We already know that we should be exercising regularly. We already know that we shouldn’t smoke or vape. We already know that we should get a good amount of sleep, and we already know that we should be checking things like blood pressure, cholesterol, and blood sugar. These things are universal to being a human being. What we don’t know is what are effective strategies to improve health behaviors in people who are South Asian, and what are the motivating incentives that may help people change and adhere to behavior change that would help set them up for healthful behaviors throughout their life course.

30:39 Dietary recommendations and nuances

Dr. Shah: There are some insights we’ve gained through the MASALA Research Program and other studies that have been conducted, primarily led, again, by my mentor, Dr. Kandula here at Northwestern, that would help address these. To be more specific about your first question or your original question: eating a healthful, a largely plant-based diet that is rich in fruits and vegetables and whole grains and low-fat dairy, moderating the quantity that you eat, having regular physical activity and exercise, not smoking, not vaping. These are universal recommendations. There’s a reason that clinical guidelines exist and it’s because we know that these things work and they work for everyone.

The nuances are how you achieve that. What is it that you can do in different communities that may have different life experiences to achieve these overall goals with respect to health behaviors? If that makes sense. One of the things that I find particularly compelling is the experience I think that is fairly common in South Asian communities that it’s a very social community. It’s very communalistic as opposed to other communities that may have a more individualistic spirit. And some of my mentors worked in the MASALA research program showed that the social networks in South Asian communities are particularly strong. And by social networks, I don’t mean electronic social network or social media. I mean, the network of people with whom you have social contact, very strong, very family centered, very much multi-generational and very much supportive of other people within the social network through a lot of different mechanisms of support, things like emotional support, just being kind of conveying support through one’s actions and words or instrumental support.

Examples of that can be things like driving a family member to the doctor’s office or working with somebody in your social network to kind of improve health behaviors together, like partnering with a friend or a family member and deciding to exercise more, exercise together. The potential role of social contacts and social support, I think, is particularly strong in the South Asian community. And so I’ve actually leveraged some of that in my clinical practice and in some of my research by trying to leverage these kind of strong social network structures and health behavior change. There are some active studies in development that leverage these principles.

But in my clinical practice, if I have a patient who’s South Asian who is making recommendations to make diet modifications or increase physical activity, I often will enlist the help of a support partner, whether it’s a spouse or a child or a friend who may be willing to help a patient do that at the same time. One example I can think of is a patient who came in who had previously experienced a heart attack, had a coronary bypass surgery, completed cardiac rehabilitation, but after completing the cardiac rehab program, their exercise participation was starting to fall off a little bit. And so I asked the patient to come into the clinic with their spouse. And together we came up with a plan that they both would start to exercise more regularly. And you know, it helped that the spouse was interested in doing so too, but the fact that they were willing to do that together, I mean, things as simple as going on walks together helped this patient be more active because they had somebody there providing support.

Now I’ll be clear, this approach is not necessarily limited to the South Asian community or being South Asian, but I do think that it’s a particularly effective approach for people who are South Asian and I’ve started to incorporate that more into behavior change. So the short of all of that is the things that we know work, work. And we have a lot of evidence to provide those universal recommendations to people who are South Asian or are not South Asian. But the nuances and the reason that our research program exists is trying to implement those recommendations in the South Asian community.

Nikitha: That is really interesting actually how you talked about, so there’s already measures out there that we know work, but I really appreciated how you talked about leveraging the values that you’ve noticed and are aware of, such as that social community and network aspect of South Asian communities. I think that’s a really mindful approach when it comes to being a physician and how you utilize that to help your patients be more motivated to promote their health, like with your patient for exercising. And even from my own personal experience, I would often see community members who are South Asian do things together or when you have a family function, there will be a lot of people of multiple generations that are living together or they will ask you how you’re doing with genuine interest. And it just shows that very social aspect in the culture. So I think utilizing that when it comes to patient care and keeping multiple family members in the loop, if the main patient is comfortable with that, of course, and finding ways to incorporate multiple people involved so that the patient is more motivated to keep doing activities that promote heart health or other aspects of their health. I think it’s a really unique but also mindful approach that people should definitely keep in mind and I know I will.

36:19 Common health misconceptions in the South Asian community

Nikitha: So going into our next question, based on your research findings and interactions with South Asian patients, so keep building off of that idea, what have you found to be more common misunderstandings about health?

Dr. Shah: Yeah, that’s a particularly interesting question. And I think that we’re increasingly learning that there do seem to be, so there certainly do seem to be misconceptions. And they seem to be a little bit generational, meaning in the older South Asian community, predominantly those who are immigrants. And I’m really kind of thinking about that community of people who are South Asian who immigrated in that wave of immigration between the 1970s and the 1980s. There certainly are misconceptions about health. And I think that they are very deeply rooted and I think they’re very deeply rooted in things like culture.

I think about even conversations with my own family and they’ll share a belief about something that should be eaten or some way to practice some kind of healthful approach to their lives. And they do that because number one, that’s kind of what they were taught to do or told to do. And nobody can remember where that advice came from, but it was just kind of more of like a, I mean, I don’t want to say lore, but it’s more just kind of like a norm of the community that this is how things are done. And so this is the way we’ll do it. And that often, I mean, I think about that a lot when people think about what they should be eating and what is considered healthy to eat. And of course, that kind of, those kind of norms and that experience experiences so much onslaught of information from things like social media.

And I am of the opinion that social media has actually deteriorated people’s understanding of health because not necessarily because people are putting bad information out there, although there’s concerns that like anybody can get on social media and provide information that isn’t evidence-based. But because there’s so much information people I think have information overload and don’t really know where to turn for actual accurate information.

Dr. Shah: So you posed the question, what are some of the misconceptions? I think one of the ones that I see most often is this idea that being vegetarian automatically translates to eating a healthful diet. And, you know, maybe those of us who are in clinical training or are clinicians readily recognize that that’s not true. But for somebody who’s never really thought about heart health or really thought about their health behaviors as it pertains to how it might influence things like diabetes or cholesterol or blood pressure or their risk for heart disease, I commonly kind of get the response when I ask about people’s eating patterns and eating habits, I commonly get the response, oh, I’m not worried about my dietary pattern. I eat pretty healthy and I ask them about it and they say, well, I’m vegetarian.

And then you start asking about what types of foods they’re eating. And of course, they’re invariably includes foods that one would probably not consider healthy. I mean, things that are fried in high in saturated fat, consuming high fat dairy products, a large amount of carbohydrates. And that’s one of the challenges I think of being vegetarian is that when you replace animal-based products with plant-based products, often what’s replaced is, or what is replaced is replaced with a high amount of simple and refined carbohydrates and sugars. And so it actually takes a lot of deliberate and slow health education to convey that vegetarianism and a healthful dietary pattern are not necessarily equivalent. And in many ways, a lot of people, especially the older immigrant South Asian community, in their mind, there’s an equivalency between being vegetarian and eating healthfully.

Dr. Shah: It’s a big challenge in clinical practice, I think, because most of us do not have nearly the amount of time that we’d like to have to take a really comprehensive dietary history and understand people’s diet patterns. And that is coupled with the fact that there is very little information available about, at least in the US context, how to make a South Asian dietary pattern healthy. I see like one-off examples. Here’s a recipe of a typical South Asian style dish, and this is a modification you could make to make it healthy. But short of following people to the grocery store, standing in their kitchen as they prepare food, or joining them as they go to a restaurant, it’s incredibly difficult to understand what people are eating and how to make modifications for health.

That’s coupled with the fact that there’s very little expertise available for people who are trained in nutrition and dietetics to refer people to. I mean, I know of just a very small number of people who are South Asian themselves and are trained as nutritionists and provide these kind of recommendations in a formal clinical setting to patients. That is a resource that is very scarce and it’s something I would love to be able to refer patients to so they can have a very extended and detailed conversation about understanding their dietary pattern where they’re starting and modifications that could be made to improve dietary pattern. It’s a big gap, I think, in our clinical care system, certainly for people who are South Asian, but probably for the entire diversity of the communities that live in the U.S.

And it’s important, I think, because when we look at the quality of people’s overall cardiovascular health, by far and away, by far and away, their diet pattern is the worst component of their cardiovascular health. You know, people participate in exercise, people take medications for their cholesterol or blood pressure, or they have kind of manage that through their other exercise and physical activity behaviors. But by far and away, people’s diet quality tends to be the worst component of their overall heart health and the most important avenue for change for cardiovascular disease prevention. But we have so little understanding and so little time in front of a patient of where patients are starting and how to counsel them appropriately and in an effective way.

So, you started this question about misconceptions and I think a lot of them that I’ve heard of in my own clinical practice and my research focus around healthy eating and dietary patterns.

Nikitha: I appreciate you discussing that in that level of detail because it’s very helpful to know that on a surface level when you hear that it’s about diet, people can understand that yes, a healthy diet is important, but how you delved into the how of multifaceted complexity this is where now in this day and age we have social media and the pros and cons of that, a con being that so many sources of content and information can kind of dilute what could potentially be the more accurate information for target audiences and coupling that with a physician or a trainee’s limited time with a patient to truly understand what their diet may look like on a day-to-day basis or where they may be lacking in certain nutrition and vitamins. And on top of that, patients who believe that just being vegetarian itself may be a more healthy approach, it’s really helpful to know that that in some patients could lead to more simple carbs being utilized instead of other aspects to substitute for animal products and things like that. So to understand that when you go a few levels more deep, there’s so many different factors that could be contributing to this, but overall to understand each one and keep that in mind when you approach patients is very helpful to know.

Dr. Shah: Yeah, it’s not easy. It’s important, but it’s not easy.

Nikitha: Yes, absolutely.

44:20 Advice for South Asian medical students

Nikitha: And so I guess this leads into kind of the final parts of our episode today. And so looking back on your experiences as a South Asian medical student, what advice would you give to current South Asian medical students as they’re navigating this period of their lives?

Dr. Shah: Well, that’s an interesting question. And looking back on my own experience, I think that my identity as an Indian American largely manifested through my clinical training in the type of work that I did, meaning the type of research that I was interested in pursuing and the directions I was going with developing my career. But I certainly must acknowledge that many, if not most people who identify as South Asian who are going through clinical training, this may not necessarily be their area of clinical interest. They may have an interest in it because it’s their community or it’s also how they identify. But I can imagine that there are many people whose research or clinical interests may be, don’t focus specifically on the South Asian community.

And I think that my advice kind of has to be the same because whether or not your identity as somebody who’s South Asian influences kind of the direction that your career goes in, I think the advice is universal, which is be flexible and be open to new opportunities. I think a lot of the opportunities and directions that I have chosen to pursue came trying to be as open as possible to the possibility that an opportunity that has arisen that may kind of change the trajectory of my career development is worth considering. I didn’t go into medical school planning to be a heavily research-focused academic faculty member. And I didn’t even go into medical school thinking that I was going to be a cardiologist.

You know, as a medical student, I really kind of bounced back and forth between different potential clinical training paths. I was interested in internal medicine for a while. I was interested in pediatrics. I thought about neurology for a while. You know, when I started medical school, I thought I wanted to do emergency medicine. I mean, I was so, it was kind of all over the place. And ultimately I did decide to do internal medicine, but it was because I think, you know, I went through my clinical training and I went through it with no preconceived expectation that I should necessarily pursue a particular path. And I think that’s actually why maybe my mind changed so much is because every time I had a new experience and it was something that I enjoyed, I started thinking about this potential career path.

And I imagine that there are students that are out here who know exactly what they want to do. And if that is you, that is spectacular. By all means, pursue your passion and your interest. But if you’re not sure, if you’re like me and you’re not sure, then be as flexible as you can. It’s advice that was given to me by one of my very first mentors in medical school and I’ve carried it with me to this day. He said, you know, a lot of potential different deviations off your path will present themselves. And just because it’s a deviation doesn’t mean that it’s not the right path for you. And so I’ve really tried to be as flexible as I can in my own career development. And it’s what led to me ultimately deciding to do a residency in medicine and train in cardiology and decide to do a research postdoctoral fellowship and stay in academia.

I think that’s maybe the most important advice that I could give anybody training in clinical medicine because it can be, it certainly is a time consuming path and it can be an unpredictable path. But if you are here as a medical student, you’ve already kind of done the work and thought about the direction you want your career to go in a general sense, but there’s so many more opportunities and you know, training in medicine is an incredibly versatile path. And so just be open to potential opportunities that may arise.

Nikitha: I think that is truly honest and very true advice, at least from my experiences so far. So I do appreciate your honesty and how you may not know right away what you want to do, but keeping an open mindset even now currently as a student, as you go on into your career, it opens up for so many opportunities to allow you to grow as a person, a researcher, if that’s what someone is interested, or just as a physician in general, but as your role in healthcare, it really creates a more cultivated mindset that you can apply to patient care as well as personal growth. So I think that is truly wonderful advice and also to channel your interests. So similar to you, I also have interest in cardiology but also neurology and it’s just a lot of different things that I like to expose myself to and I also have passions for research because I like to delve further into unanswered questions but also apply that to clinical settings. So it’s really nice to see how someone who has kept that open mind and channeled so many different interests and kept that drive going to pursue the research and the fellowships that you have done to see where you are today is very inspiring for medical students like myself.

Dr. Shah: Well, if any component of what I’ve done can be inspiring, I’m grateful to have had the opportunity to be in this position. So I appreciate that.

50:02 Closing remarks

Nikitha: Yeah, of course. And that was my last question for today. So I do appreciate you taking the time today, Dr. Shah, to kind of highlight so many important aspects from MASALA itself to your journey to where you are today, as well as research findings. It’s all very fundamental and critical information for people who are listening so that they can incorporate that into their mindset as they grow as if it’s just community members or if they’re medical students or even healthcare professionals. It provides a lot of honest and crucial perspectives that people should be aware about when it comes to South Asian health. So thank you.

Dr. Shah: It was my pleasure. I appreciate the opportunity to share and this was really a terrific conversation. So I hope anybody who’s listening really thinks about the direction they want to go and moves confidently in that direction.

Nikitha: To our listeners, we hope you enjoyed today’s episode and learn more about the beauty and nuance that is South Asian health in America. Don’t forget to tune into the rest of our series and until next time, take care. Thank you.