Just as the term "Asian American" encompasses a vast number of people and cultures, the idea of an "Asian diet" oversimplifies differences in what they eat, a new report on heart health says.
Understanding those differences is important for the United States' fastest-growing ethnic group and the professionals who tend to their health, says the American Heart Association scientific statement, published Monday in the journal Circulation.
Dr. Tak Kwan, who led the team of experts who wrote the report, said its main goal was to highlight the distinct risks of heart disease and diabetes in different Asian American subgroups. Failing to separate Asian American subgroups may result in overestimating or underestimating their risk of Type 2 diabetes and cardiovascular disease, according to the report.
"We cannot just say Asian Americans are all the same," said Kwan, chief of cardiology at Lenox Hill Greenwich Village hospital in New York City. "We should not generalize."
The report's section on diet offers a flavorful emphasis to that message.
Dr. Latha Palaniappan, vice chair of the report's writing committee, said misconceptions about Asian diets can be traced to older studies that looked at preferences in Japan. Those findings were then extrapolated to the whole of Asia, said Palaniappan, a professor of medicine at Stanford University in California and founder of the school's Center for Asian Health Research and Education.
"But as we have evolved our understanding of Asian diets and Asian culture, we realize that there are major differences in this wide geographical base," which accounts for 60% of the world's population, she said. "So there's a lot of territory and also a lot of differences in terms of culinary practices."
Broadly speaking, the report says, Asian diets have many healthy aspects, including the use of soybeans, unsweetened tea, and fresh fruits and vegetables.
Kwan, who also is a clinical professor of medicine at Northwell Health, said the diets also share some weaknesses. They don't emphasize dietary fiber, he said, and focus heavily on white rice and rice products, which means a lot of refined carbohydrates. Managing carbohydrates is important for controlling Type 2 diabetes, and a diet rich in dietary fiber can help protect against several illnesses, including heart disease.
But geography brings variety. So the report divides preferences into three regions:
– Southeast Asia (Cambodia, Vietnam, Thailand, Indonesia, Laos, Malaysia and Singapore), where the diet "incorporates the balance of grilling, stir-frying, braising and deep-frying." Dishes often call for coconut milk, fish sauce, shrimp paste and meat broth.
– South Asia (India, Pakistan, Sri Lanka, Nepal, Bangladesh and Burma), where vegetarians are common, but deep-frying is popular among people who eat meat. Rice is used in dishes such as dosa (a fermented crepe) and vada (a type of fritter), and flour is the basis of naan and roti flatbreads.
– Northeast Asia (China, Taiwan, Japan and Korea), where soy and soy-based protein are popular, and white rice is "an integral part of each meal."
Among the dietary weaknesses by region, diets from Southeast and South Asia lack fresh fruit and get unhealthy fat from cooking oils such as coconut oil, while Southeast and Northeast diets get high levels of sodium from condiments such as soy sauce, although regional favorites differ. (Sambal, a chile paste, is a staple in Indonesia, while sweet and savory hoisin would be more common in China.)
Palaniappan said more research is needed to show how those preferences connect with variations in heart health risk. But the report also emphasizes how those risk levels differ for groups in the U.S.
Kwan noted that as a whole, Asian American adults have a higher risk of developing Type 2 diabetes compared to non-Hispanic white adults. But East Asians (people with ancestry from China, Japan or Korea) have a lower risk than people from South Asia (which includes people from India, Pakistan, Sri Lanka, Bangladesh, Nepal and Bhutan).
Similarly, Chinese and Japanese Americans are at lower risk than their white counterparts of developing coronary artery disease. But its prevalence in South Asians is four times higher than in white people – and six times that of Chinese people.
To combat such issues, the report offers region-specific guidance on making healthy dietary changes.
For the South Asian diet, that might include adding more vegetables to stews. In the Northeast, it suggests seasoning with fresh herbs and spices to cut sodium. For the Southeast, that includes switching to low-fat coconut milk or a nondairy alternative, and switching from coconut oil to something with lower saturated fat and higher polyunsaturated and monounsaturated fat. (Healthier choices include vegetable, canola, corn, olive and peanut oils, according to the AHA.)
Across the board, the report suggests replacing white rice with whole-grain products and brown rice. Palaniappan said that can actually mean a return to foods that predate the Green Revolution of the mid-20th century, which emphasized processed, refined grains such as white rice and refined wheat flour over ancient whole grains.
Of course, "we can't just assume by a person's race or ethnicity what their diet is," Palaniappan said. But the report says culturally tailored screenings would help U.S. health care professionals.
That's especially important for immigrant groups, Palaniappan said, who tend to overeat foods that remind them of home, especially around traditional festivals.
Palaniappan has seen what happens when diets are evaluated without taking someone's background into account. Patients often are asked to complete food questionnaires that are tailored to a typical U.S. diet.
Her Asian patients were going to nutritionists and being told to not eat foods such as hamburgers, fries or mayonnaise. "The patients would say, 'Oh, well, I don't eat those things anyway.' And they would go back to eating their samosa (fried pastries stuffed with anything from meat to chocolate), jalebi (a syrupy dessert) and fried foods and not connecting that those, also, were not healthy for their heart or their blood vessels."
The point, Palaniappan said, is not that everyone needs to switch to a Mediterranean diet, a benchmark for healthy eating, but to help people apply the science backing healthy diets to their own cultures.
Kwan said examining Asian subgroups separately is crucial not only to better understand how differences affect the risk of Type 2 diabetes and cardiovascular disease, but also to learn how health care professionals may manage and provide culturally appropriate care and support to those looking to adopt healthier eating habits. This may start by connecting with a registered dietitian who understands where they come from and the food they eat. A local community center or clinic might be a good place to ask, Kwan said.
He and Palaniappan agreed that more needs to be done to consider the needs and diversity of Asian American people at every level of the research process. Census data show Asian Americans make up more than 7% of the U.S. population. They are expected to be the nation's largest immigrant group by mid-century, according to population projections from the Pew Research Center.
"Asian subgroups are diverse, and very little is known about atherosclerotic cardiovascular disease in these diverse groups," Palaniappan said.