Book Synopsis: The South Asian Health Solution

The South Asian Health Solution: A Culturally Tailored Guide to Lose Fat, Increase Energy and Avoid Disease by Ronesh Sinha, MD.

I found this book via the South Asian group on the forums of Ravelry (the knitting website). There was a discussion on diet and fitness and someone mentioned the author so I looked up the book. I bought a copy to read and pass along to my parents.

The author is a physician and his practice in Silicon Valley, California, treats many South Asian patients. The central premise of this book is that South Asians are suffering from an alarming epidemic of chronic diseases fueled by eating an extremely high amount of carbohydrates, and that these diseases can be prevented by changing the diet and exercising more. Here is a chapter by chapter synopsis of the book.

Inflammation and Insulin: The Real Culprits
This chapter opens with a question: Why are South Asians at such a high risk for diabetes and heart disease? And goes on to provide an answer: Excess insulin is the underlying thread that weaves together virtually every chronic ailment currently afflicting South Asians...Along with insulin resistance, chronic inflammation has emerged as a powerful threat to health and longevity.

Sinha goes on to explain the effects of excess insulin and how these in turn lead to chronic inflammation: high blood pressure, abnormal cholesterol and obesity, especially stubborn belly fat.

Insulin resistance is so common in South Asians that I now assume all South Asians are to some degree insulin resistant until proven otherwise...Most of the South Asians who appear slim are likely "skinny-fat". Their fat lurks under the surface, blanketing their liver and other internal organs. 

How can a person know if they have insulin resistance and if they are at a high risk for metabolic disorders? Sinha describes a set of measurements that he calls the metabolic 6-pack. Not meeting the metabolic 6 pack numbers is an indication of high risk for chronic illnesses like diabetes and heart disease. One of the numbers can be measured at home (waist circumference) and the rest would need a check-up and blood work at a doctor's office (triglycerides, HDL cholesterol, blood pressure, fasting blood glucose, HbA1C and hs-CRP). Sinha suggests that instead of obsessing over weight and BMI, tracking these numbers and keeping them where they should be is a better and more achievable indicator of keeping insulin and inflammation in check. Sinha also lists other clues that point to a person being insulin resistant, including a family history of diabetes, a history of gestational diabetes, a history of PCOS and a history of exceptional difficulty losing weight.

The next part of the chapter explores why South Asians have this strong tendency for insulin resistance, and mentions genetic and evolutionary factors (the genetic variations that promoted survival during feast-famine cycles and mitochondrial adaptations to a tropical climate) and cultural and lifestyle factors, including the tendency to be sedentary and the abundance of carbohydrates in the diet.

Despite the role of genes and evolution, you will be amazed by the resiliency and potential of the South Asian body to overcome years of abuse and transform into a leaner, more energetic, insulin sensitive, fat-burning machine within just a few months. 

Cholesterol and Heart Disease
Here Sinha states that the conventional wisdom on the mechanisms and risk factors for heart disease is flawed. As a result of the cholesterol fixation, we now have a population that is grossly overtreated with statin medications and undertreated with proper lifestyle changes. Sinha suggests focusing on triglyceride levels (instead of total cholesterol) and keeping them low.

The standard risk calculators for heart disease and stroke are based on outdated studies and on Caucasian patients. They end up underestimating risk in South Asians by ignoring key markers like high triglycerides, prediabetic blood sugar levels and abdominal obesity.

Blood Pressure: The Pressure is Killing Me
High blood pressure is called a "silent killer" because most patients with dangerously high blood pressure may have no symptoms at all. But even a mildly elevated blood pressure has a cumulative toxic effect on virtually every organ of the body.

Although sodium (salt) does play a role, especially in the form of processed foods, the balance of sodium and potassium is far more important in the battle against high blood pressure....Plant-based sources rich in potassium include spinach, broccoli, avocados, oranges, nuts and seeds.

This chapter looks at the causes of high blood pressure and ways to control it.

Your Body: Width Over Weight
This chapter looks at body fat. We used to think fat cells were just inert storage containers that took excess calories from our foods and stored them. We now know that fat cells have a different impact on your body depending on their location. 

If we were to look at peripheral fat (fat in the arms and legs) under a microscope, there's not much going on. But belly fat/ abdominal fat cells are now classified as an actual endocrine hormone because they produce so many inflammatory hormones.

The two primary defining features of the typical South Asian physique (regardless of gender) are excess belly fat and the relative absence of muscles, especially in the arms and legs. Insufficient muscle mass has consequences beyond mere looks- it worsens insulin resistance, results in bone and joint problems, greater chance of sports injuries (due to lack of core strength and general flexibility) and difficulty with weight loss.

This chapter has a section on "skinny-fat", the phenomenon where a person may have a normal body size, even be underweight, and yet have plenty of fat stored around the organs and invading the liver. The medical term for this is "metabolically obese, normal weight" which describes a person who has metabolic evidence of obesity (for instance, with blood tests showing fatty liver disease) even though their weight falls within the normal range. Whether you are skinny-fat or fat-fat, you need to lose fat and add muscle.

Studies show that insulin resistance and heart disease occur at a lower BMI (body mass index) for South Asians, so we should be evaluating ourselves based on an Asian-adjusted BMI scale, where the healthy range is 18.5 to 23. But BMI is only one measure of health, and measuring abdominal obesity is arguably more important. Using a simple tape measure, we can measure waist circumference (the goal is less than 35 inches for men and less than 31 inches for women) and hip circumference, and calculate the waist to hip ratio (should be less than 0.85 for women and less than 0.9 for men). Sinha emphasizes that these numbers are guidelines (to make progress towards) and not absolute goals.

The South Asian Struggle with Fat and Weight Loss
Sinha attributes weight loss struggles to myths, including the myth of eating low-fat, high-carb foods to lose weight, and the myth that exercise alone can help you lose weight. Eating greater portions of the right foods will control your weight more effectively than eating smaller portions of the wrong foods. This chapter is a detailed discussion of the role of carbohydrates and fat in weight gain and weight loss.

The good news is that once you reduce your dietary carbs and insulin levels, you will free up years of stored fat deposits for use as energy. Significant changes can occur within a few short weeks of carb reduction, such as a drop in weight, a reduction in food cravings, and an increase in energy. 

CARBS Approach to Burning Fat
This whole chapter is devoted to the idea of drastically reducing carbs in the diet. Sinha uses the acronym CARBS to identify what he calls fat-promoting carbs, where C=chapatis (and other flatbreads and bread in general), A= aloo (potatoes and starchy vegetables), R=rice (and other grains), B=beans (and lentils and other legumes) and S= sugar (including sweet foods and beverages).

Net carbs in any food= Total grams carb - Total grams fiber. Bargain foods are the ones with low net carbs and lots of nutrients and expensive foods are the ones with high net carbs and little nutrition. Sinha suggests that a daily diet of 100 grams of net carbs is generally the zone at which fat burning is activated.

The rest of this chapter has plenty of tips on what foods to eat more of and what foods to avoid, and strategies to cut carbs while eating a satisfying diet. Sinha especially emphasizes eating more vegetables, in the form of salads, smoothies, soups, snacks, sauces and as a substitute for grains.

Exercise: An Enjoyable Approach to Fitness and Strength
Sinha explores three reasons why South Asians tend to not enjoy exercise: (1) A high carb diet results in excess insulin which in turn causes a chronic state of fatigue by shunting fuel from food into the fat cells and into muscle and liver glycogen but having none available in the bloodstream to burn for energy, (2) Sedentary influences in culture and upbringing which place academic success way above sports and activity and (3) Exercise aversion because exercise recommendations feel too overwhelming or exercise is assumed to be painful and a burden.

He recommends first changing the diet to increase energy levels and starting slowly by moving a little more during the day, and choosing a physical activity to enjoy (enjoy being the critical word) for 30 minutes a week- like a hike with a friend, walk with a neighbor, dance or yoga class or sport like tennis or cricket.

The benefits of exercise are listed- and there are many. There is a discussion of the benefits of standing and walking and cutting back on the time spent sitting down. Then the author suggests a fitness plan with exercises (some based on yoga) that can be done anywhere, tips on walking for health and how to fit exercise into a busy schedule.

Recharge! An Approach to Energy and Stress Management
This chapter deals with the problem of fatigue. It does not have to be accepted as an inevitable part of hectic modern life. Sinha lists what he calls 5 S-factors that are major contributors to fatigue and ways to manage them:
(1) Stress, often experienced as rapid breathing, heart palpitations, poor mood, headaches and a disrupted digestion. Suggested ways to manage stress are yoga, pranayama (breath control), meditation, music and spending time in nature.
(2) Sugar and starches, which against a background of insulin resistance, result in food being stored as fat instead of being utilized as energy. The suggestion is to pay attention to your energy levels after different types of meals and make changes to what you eat.
(3) Sleep- lack of quality sleep has serious consequences. The suggestions for good sleep include having a consistent sleep schedule and restricting light.
(4) Substances- Caffeine and alcohol should be consumed in moderation.
(5) Sedentary lifestyle.
Sinha also lists medical conditions that can cause persistent fatigue (even when all the factors above are corrected), such as thyroid disorders, depression, anemia and sleep disorders.

Optimal Health for South Asian Women
This chapter has a detailed discussion of polycystic ovarian syndrome (PCOS), which is a common hormonal disorder in women and even more common in South Asian women. There is also a section on gestational diabetes.

Sinha also talks about different reasons why women may have difficulty losing body fat. South Asian women often hit a weight loss plateau due to lack of strength training...The type of drastic cyclical dieting that many South Asian women periodically engage in- which often involves periods of severe caloric deprivation from exclusive juicing and Ayurvedic techniques- leads to a loss of not only fat but also precious lean muscle tissue.

Sinha has several suggestions, everything from dietary changes like reducing carbs further and eating more fat to checking one's thyroid and intermittent fasting.

Building a Healthier Future for the South Asian Child
Sinha's wife is a pediatrician whose practice sees many South Asian kids. This chapter addresses many common concerns that parents come to her with- about kids who are too skinny, refuse to eat fruits and vegetables, and so on. This chapter has pretty much common sense advice on the importance of sleep, restricting screen time and how physical fitness is correlated with academic performance.

Anti-Aging and Improving the Health of the Elderly
This chapter again has pretty much common sense advice on dietary guidelines, exercise, mental stimulation and stress reduction for optimizing health in seniors.

Achieving Your Goals
This chapter has tips for setting realistic goals and changing habits for life- in terms of nutrition (eg. cutting out one problem food like sodas or sweets), activity (eg. sitting less) and stress/sleep (eg. no screen time in the final hour before bedtime). If you've reduced your daily carbohydrate intake from 400 grams to 100 grams and this modification is proving too difficult, then approach in a more step-by-step fashion. Reduce carbohydrate intake in 100 gram increments with each passing month. Stay positive at all times, and realize that some change is better than no change.

Sinha suggests building a "health team" which includes not only medical professionals like doctors and nutritionists but also one's family, workplace and community (social circle, place of worship etc). He has some suggestions, for instance, to create healthier social gatherings that focus not on elaborate food but other activities, such as meeting for a hike or for movie night.

Day after day, I greet kind, intelligent, hard-working South Asian folks pursuing the American Dream, only to receive the bad news, or very bad news, that I often must dispense...the vast majority of my work includes battling against cultural forces that create diet- and lifestyle- related health conditions and disease. 

The final part of the book has case stories, recipes and a list of resources.

What I liked about this book:
1. Sinha writes from a place of deep sincerity and compassion. It is obvious that his motivation is to inform and help, and sort of put himself out of business.
2. There is an abundance of specific tips in this book for changing diet and lifestyle. And the tips are based on common sense, simple changes that any ordinary person could do.
3. Sinha does hit on the major cultural norms that hold us back (eg. being force fed sweets by loving relatives), and this book would be relatable to many South Asians.
4. It is important to know where you stand as far as health and wellness goes. The book has a series of numbers which you and your doctor can keep track of, to know how well you're doing. I found this very practical and helpful.

Things I did not like as much:
1. The writing could have been better edited to be less wordy and repetitive.
2. The book is very Paleo-diet focused, so there are things in here that make me roll my eyes, like the whole "wheat belly" thing and cautions about eating soy and enthusiastic support for eating grass-fed meat while warning that legumes contain anti-nutrients. As usual, I'm taking away some good ideas from this book, and ignoring some others.

I can say for myself that even before I read this book, I'd started to make some of the same changes that the book suggests, and they are working beautifully for me. I have a family history of diabetes and a personal history of gestational diabetes, and I know from a DEXA scan that I am skinny fat. I've cut down moderately on carbs about 3 months ago, replacing them with lots of raw and cooked vegetables. This is not about being in dieting mode. If you're feeling hungry and deprived, you're doing it wrong. I'm nourishing myself very well, and also living quite normally, in that I go and eat at parties and restaurants and social events once or twice a week.

Since I made these changes a few short weeks ago, I've lost 11 lbs, I've lost inches off my waist (I really need to buy pants in a smaller size), and I'm feeling motivated and energized to exercise more than I have my whole entire life. I don't feel hunger pangs every couple of hours and I'm not constantly foraging for snacks. I eat dinner at 6 PM and don't eat a thing for the next 12-14 hours. I can't tell you how surprised I am at all this.

When you see it working for you, you know it is not a fad. This is how I want to live for the rest of my life. And right after I finish writing this post, I'm calling my primary care physician to schedule a check-up and blood-work so I can track some of the numbers, like HbA1C. To anyone who's thinking of making these changes, just start. Small changes can surprise you with good results.