Monday, March 23, 2015

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. 


  1. Dear Nupur,

    as so often, your words are an inspiration.

    Last year I lost 50 kg through intermittent fasting (fasting every second day) which worked beautifully for me. For the past two years I have also been exercising regularly (by running 8 km three times a week and working with - very light - weights).

    Two moths ago my husband went low carb and I was VERY sceptical. I felt that eating almost no carbs was depriving myself of my favourite foods etc. And, yes, at the beginning it was very hard. I honestly felt that not eating anything for a day was easier (!!!) than eating low carb.

    But after a couple of days the miracle happened: I felt better, healthier, stronger and more energetic and those constant carb/sugar cravings stopped (well, I still have them occasionally, but they are definitely manageable).

    I lost some more kilos and am now finally as slim as I can and should be. I feel better and I now know that I am doing the right thing - especially since in my family too there is a history of diabetes.

    Keep doing the good work and all the best from Austria, Europe,


    1. Bee- that's absolutely wonderful! Thanks for this nice note. Good for you for making all those changes in your life, and for enjoying excellent results. When you feel healthier and more energetic, it is the furthest thing from being deprived.

  2. Hi Nupur,
    What a wonderful and detailed post. I really want to know your take on beans and lentils. It seems the Paleo crowd and high protein crowd avoids it like plague due to high carb count.

    1. Vini- I do eat beans and lentils, and in fact they are my preferred source of proteins and fiber and carbs. I eat a relatively lower carb diet, not a no-carb diet and it seems to work fine for me.

  3. Thank you for reviewing the book for us, I am enjoying these posts and learning so much. I have also experienced positive change just like you since I have made changes in my diet and exercise, I have my dinner pretty early around 4:30-5:00pm but don't feel hungry at all until next day 7am when I have my breakfast. I am currently vacationing in Utah for a few days and breaking all the rules but I know I will get back and get on with it as soon as I am back. I need new clothes too and I can't wait to shop for summer soon. :-)

    - Priti

    1. Enjoy your vacation!! The nice thing about making these lifelong changes is that one can take breaks and then get back to the routine- no harm done.

  4. That's an amazing change Nupur, way to go! I'd love to hear all the changes you made, how you eat, and how you do NOT get hungry past 6! I'm trying to change how we eat as a family too, and while some things have come pretty easily - a lot of the other changes I want to incorporate seem ridiculously impossible!

    1. Meena- in a nutshell- at every meal, I try and see how I can switch out/reduce the major source of carbs. For instance, instead of eating a burrito, I skip the tortilla/wrap and instead eat the burrito filling with extra veggies in a bowl. Instead of eating rice, dal, subzi, raita, I simply omit the rice and eat more of the veggies, or I sprinkle a tablespoon or two of rice on the dal (reducing the rice to this small amount instead of 1/2 cup or whatever I ate before. I've posted recipes in the past few months noting down some of the substitutions I'm doing.

      In many people, carbs lead to hunger and cravings for more carbs (there's a biochemical explanation for why this happens, involving insulin and hunger hormones). So cutting the carbs has led to me simply being not as hungry.

      I'm curious- What changes are you thinking of that seem impossible?

  5. Jhakaas! :) So happy for you. Admire your positive spirit and gung-ho attitude about this endeavor. Good luck!

    1. Thanks- it has been easy to stay positive because I've been lucky and seeing good results.

  6. Nupur, Thanks so much for a great book review for people like me who come to your blog for tips. Can you provide some information on how to lose fat if you are 'skinny fat'? So for e.g. I am not overweight at all (probably slightly underweight), but I know from my blood tests etc that I don't have the 'perfect' numbers for HB1AC and other markers. I also have diabetes in the family. What should people like me eat to not lose weight, but lose fat and build muscle? Does the book provide any advise? Thanks again. Meera

    1. Meera- Yes, the book does address this in great detail and is worth reading. And the short answer from the book is: cut down excess carbs by removing sweets from your diet and minimizing rice, pasta, noodles, bread, chapatis etc. And eat lots of vegetables (raw and cooked). Don't be afraid to eat good fats- that's not what is causing the body fat.

    2. Thanks, Nupur. Only problem I see is that eating veggie diet and good fats does not build muscle. Protein is needed for that. Plant protein sources such as lentils do not have a lot of protein. That leaves animal protein (which some say is actually not good). Just today there is a nytimes article by Dean Ornish ( So it is a little challenging to figure out how to gain weight and muscle (or atleast not lose weight and gain muscle)!
      I will read the book as you suggested. - Meera

    3. And I say that it is a total myth that plant protein does not build muscle. What is the evidence for that?

      In my case, I should say that I'm a lacto-ovo vegetarian and do eat eggs and some dairy. But there are many people who thrive (and are even professional athletes) on a completely plant based diet. Check out this article:

      My personal belief is that people are free to eat whatever they like, but they should be live under such mistaken beliefs like plant protein being inferior.

  7. Thanks for the concise review! Makes me want to read the book.
    This is so awesome that you have lost 11 lbs in a short time! I also notice that when I cut our processed food and make sure every meal I eat is cooked at home, I do better in terms of maintaining my weight.
    Would you mind sharing what a regular day of meas look like for you? I would love to get some practical ideas. TIA!

    1. Sangeetha- I'll try to take some notes and pics over the next few days so I can share what my daily meals look like.

  8. Inspiring post as always! One of the changes we have made recently is to eat more of veggies and fruits. And the thing that helps with this for me is if I visit the farmers market every weekend. Seeing the fresh produce definitely makes me want to eat it. So, we have been more diligent about spending some time at the local farmers market instead of making quick weekday stops at the supermarket. Also, Another new thing I am planning to try out this week is to replace breakfast with a smoothie. I did this today and made a green smoothie with lots of greens, fruits, an avocado and almond milk. And I was satiated for the next 3-4 hours till lunch time. Do you have any ideas for low carb breakfast? What do you generally tend to eat in the mornings?

    1. Neha- we've signed up for a CSA box (our first year doing it) and I'm getting boxes of veggies every two weeks, that's been great for making me eat more greens in particular.

      I tend to eat the same breakfast almost every morning: half an avocado plus one egg.

  9. Thanks Nupur for reviewing and sharing the details with us. Can you please share the details on what all you eat on a day or your menu for a day?

    1. Sandhiya- I'll definitely try and post some of my daily meals in the next week or two.

  10. Nupur, as always a brilliant post, one that is informative, insightful and inspirational. You are doing a sort of “social service” by writing these posts.
    I don’t add dressing to my salad, as I add avocado, chopped walnuts, a few shreds of cheese, beans, mushrooms sauted in a tiny amount of extra virgin olive oil to the base of plenty of salad greens, red capsicum, grated carrot, cucumber, steamed green beans, a bit of juicy fruit like grapes, nectarines in summer

    1. Shubha- Thanks :) "social service" or not, I feel like diabetes/chronic disease is a huge elephant in the room for many of us, we don't much like talking about it and would like to go on living as usual, but it is a conversation and change that needs to happen. Your salad sounds hearty and delicious!

  11. Thanks for the great review. And what an inspiration you are. I have two questions
    - what do you eat for breakfast? After snacks, breakfast is my other carb downfall.
    - how do you adjust the meals for kids?

    1. Rainee- I eat half an avocado and one egg for breakfast.

      My kid eats what we eat, so I usually don't make anything special for her. Kids don't need excess carbs any more than adults do.

      But yes, I keep have bread in the freezer so I can occasionally make her a small grilled cheese sandwich when I'm only eating a big salad for dinner, say.

  12. Forgot to sign my comment.

    - Rainee

  13. Thank you so much for the review Nupur. I'm going to go ahead and read this book asap as managing my mum's diet on a day to day basis whilst trying to convert her from her former carb(rice and chapatis) rich diet to healthier plant kingdom options is more a challenge than I'd realised. But to her and my surprise in a few short weeks of dietary changes and despite surgery for cancer her fatigue and the side effects she had due to diabetic neuropathy have ease up.


    1. Deepa- That's a very positive sign that she's feeling less fatigue and less neuropathy! Change is hard, and I can only guess that it is even harder for an older adult who has decades of habits to undo. But kudos to her and you for trying so hard.

  14. Nupur, thanks for the detailed review. You deserve more credit than the authors of the books - for spreading the word and writing an unbiased review - very selfless of you. I would see it as a kind act of charity/ giving to the society.
    The 'being force fed sweets by loving relatives' strikes a chord with me. I found relatives being offended/ hurt when I tried to say no to sweets when I visited them. In fact, this time when I visited India, I noticed a bigger issue. All small town mithai shops have come up with 'sugar free' versions of their sweets - and people trust them and buy/gift them - with all good intentions. Whenever I asked the mithai shop guy what sweetener has been added here instead of sugar - I never got a clear answer. I wish I could do something about people eating these sugar free sweets with some mystery sweeteners. Add to it, I noticed this sense of entitlement - if I can't eat a single square of good old Kaju Katli, I can/ should eat four of these mystery sweets! Hope food ingredient labels are made mandatory soon. - Mansi

    1. Mansi- I've seen exactly the same thing with sugar-free sweets- their ingredients are a total mystery and people take the "sugar-free" label as a free pass. I've also heard people say, "Have the mithai and just take some extra insulin, no big deal". Diabetes is more common than the common cold which makes people forget what a truly horrible disease it is.

  15. I'm struggling to eat sensibly. A mostly plant based diet is what worked so well for me in the past, constant long term guests and a general loss of control has landed me in a mess. I am so inspired by your post today and 11 pounds is a lot to lose in a few short weeks. Well done!


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