COPE Presents: "Prevention of ASCVD in South Asians: Impact of Diet Modification

and Physical Activity as Primary Intervention"

Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA

December 11, 2019

Moderator: Lisa Diewald, MS, RD, LDN

Presenter: Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA

Lisa:

Good afternoon. Welcome to our December webinar for health professionals. We're so

glad you've joined us for this hour of learning, followed by some discussion.

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Villanova Webinar 1: Today we are honored to welcome Geeta Sikand for a presentation

entitled, "Prevention of ASCVD in South Asians: Impact of Diet Modification and Physical

Activity as Primary Intervention".

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Villanova Webinar 1: Individuals of South Asian ancestry, the second fastest growing ethnic

group in America,

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Villanova Webinar 1: have a higher death rate from heart disease than any other ethnic group

and four times the risk of heart disease compared with the general population.

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Villanova Webinar 1: In addition, South Asians are up to six times more likely to develop type

two diabetes.

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Villanova Webinar 1: For this reason, it's imperative that health professionals become familiar

with South Asian lifestyle and dietary practices so that they may provide effective counseling

and care for this population.

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Villanova Webinar 1: My name is Lisa Diewald and I am the program manager for the

MacDonald Center for Obesity Prevention and Education at

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Villanova Webinar 1: Villanova University's

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Villanova Webinar 1: Fitzpatrick College of Nursing.

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Villanova Webinar 1: I have the pleasure of being the moderator for

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Villanova Webinar 1: today's program.

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Villanova Webinar 1: Villanova is home to the first College of Nursing in the country devoted

exclusively

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Villanova Webinar 1: to obesity prevention and education. As the bottom of the slide illustrates,

COPE's goals are to enhance nursing education in topics related to nutrition, obesity prevention

and health promotion strategies,

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Villanova Webinar 1: to provide continuing education programs such as this webinar on obesity

and obesity-related diseases for health professionals and educators, and finally to participate in

research to expand and improve evidence-based approaches for obesity prevention and

education in the community.

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Villanova Webinar 1: Before we begin the presentation, I would just like to remind our listeners

that PDFs of today's PowerPoint slides are posted on the COPE website at villanova.edu/COPE.

After going to COPE's website, simply click on the webinar description page for this month's

webinar.

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Villanova Webinar 1: Please use the question and answer box on your screen to submit

questions for our speaker. All questions will be answered as time permits at the end of the

program.

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Villanova Webinar 1: The expected length of the webinar is one hour. The session, along with

the transcript will be recorded and placed on the COPE website within the next week.

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Villanova Webinar 1: If you used your phone to call into the webinar today and want CE credit

for attending the webinar, please take a moment afterwards to email us at COPE@villanova.edu

and provide your name, so that we can send you your CE certificate.

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Villanova Webinar 1: The objectives for today's webinar are to describe the impact of Western

acculturation on the dietary patterns of South Asians, to explain the impact of diet and lifestyle

modifications on ASCVD risk in South Asians,

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Villanova Webinar 1: and lastly, to review the South Asian diet and lifestyle goals and

resources to help practitioners implement culturally tailored AHA/ACC recommended heart

healthy dietary patterns.

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Villanova Webinar 1: Villanova University College of Nursing is accredited as a provider of

continuing nursing education by the American Nurses Credentialing Center Commission on

Accreditation.

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Villanova Webinar 1: Villanova University College of Nursing continuing education, COPE, is

also a continuing professional education CPE accredited provider with the Commission on

Dietetic

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Villanova Webinar 1: Registration.

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Villanova Webinar 1: And we have just one special announcement. We're pleased to announce

an onsite conference at Villanova on Friday, March 6 entitled, "Nutrition Future Forward: Are

We Ready for Out of the Box Thinking?".

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Villanova Webinar 1: This conference will cover topics such as digestive wellness, culinary

literacy, preventing metabolic adaptation during weight loss, and the potential health and

nutrition implications of cannabis use and avoidant food restrictive intake disorder.

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Villanova Webinar 1: Continuing education credits are available so simply go to

villanova.edu/COPE for details and registration information.

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Villanova Webinar 1: Our webinar this month awards one contact hour for nurses, and one

CPEU for dietitians and DTRs. The suggested CDR learning need codes are 3020, 5160,5370

and 6000, and the CDR level of this webinar is 2.

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Villanova Webinar 1: Next I have the privilege of introducing our speaker for today's webinar.

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Villanova Webinar 1: Geeta Sikand is a registered dietitian nutritionist, clinical lipid specialist,

certified diabetes educator, fellow of the National Lipid Association, and fellow of the

American Academy of Nutrition and Dietetics.

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Villanova Webinar 1: She is director of nutrition at University of California Irvine preventive

cardiology program, as well as associate clinical professor of medicine and cardiology at the

University of California Irvine School of Medicine.

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Villanova Webinar 1: Geeta Sikand earned her masters and baccalaureate degrees in nutrition

and dietetics from California State University in Long Beach, California. She's authored

multiple scientific publications and book chapters on the nutritional management of lipids,

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Villanova Webinar 1: diabetes and obesity, and is the recipient of numerous awards including

most recently the 2019 Academy of Nutrition and Dietetics Medallion award.

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Villanova Webinar 1: Geeta Sikand was the lead author recently on the clinical and cost benefit

of medical nutrition therapy by registered dietitian nutritionists for management of

dyslipidemia: a systematic review and meta analysis

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Villanova Webinar 1: .

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Villanova Webinar 1: published in the journal [inaudible].

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Villanova Webinar 1: While we are preparing for Geeta Sikand's presentation to begin, I just

wanted to mention that neither the presenter, nor the planners of this webinar, have any

disclosures to report.

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Villanova Webinar 1: Accredited status does not imply endorsement by Villanova University,

COPE, or the American Nurses Credentialing Center of any commercial products or medical

nutrition advice displayed in conjunction with an activity.

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Villanova Webinar 1: And with that, I welcome Geeta Sikand to our COPE webinar program

and I will turn things over to her for her presentation. Welcome, you know, we are so glad that

you are here with us today.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: Thank you very much, Lisa for the kind

introduction and for setting the stage for my presentation. I'm very pleased to be here.

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Trying to move my slides forward.

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Maybe you want to turn the remote to me?

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: Ah ha, okay, now we're on. Okay, so let's

start with our very first slide today, which is who are South Asians? And what countries do they

come from that reside in the United States? So as we can see in this slide,

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: 84% come from India and the remaining

from Pakistan, Nepal, Bangladesh, Sri Lanka, and even Maldives. So moving forward,

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: let's look at some facts from the WHO on

South Asians. CHD strikes South Asians at an earlier age, almost 33% earlier and with a higher

mortality rate than other demographics.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: Furthermore, 50% of all heart attacks in

Indian men occur under the years of 50 years of age, and 25% of all heart attacks occur under

40 years of age.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: India accounts for approximately 60% of

the world's heart disease burden, despite less than 20% of the world's population.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: It is also considered the world's capital

for diabetes. For example, Hyderabad, India, which is a very high tech town or city, 20% of the

entire adult population there is diabetic.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: So moving forward, let's take a look at

what the most recent ACC/AHA 2018 cholesterol management guidelines had to say about

South Asian ancestry.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: And as you can see, as you go down the

bullet points to the one in yellow font, it says high risk ethnicities, example South Asian

ancestry. So even the ACC/AHA 2018 guidelines have acknowledged

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: that being of South Asian ancestry is an

enhanced risk factor. Moving forward, here's the background that South Asians basically tend

to be relatively lower body weight in terms of BMI,

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: but more central abdominal obesity and a

higher diabetes rate. Some of this is linked to the fetal hypothesis theory, which says that they

develop insulin resistance earlier because of the history of famines from a long time ago. So it's

like a survival mechanism

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: because they were undergoing famines

and they were very underweight at the time. So again, higher diabetes rate, higher risk of early

heart disease and very little population-based data in the US and absolutely no longitudinal

studies worldwide.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: So in this slide again, it reiterates that it

is relatively lower BMI, but more central abdominal obesity.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: The lower BMI cut point for overweight

in South Asians was recently lowered from 24.9, which is for the general population, to 23.0

due to early insulin resistance and high diabetes rates

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: and high risk of early heart disease. And

in this slide, we can see that when we compared Asians in general, all Asians, this is not only

South Asians, but all Asians, to blacks and Caucasians, you can see that the visceral,

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: the intra-abdominal depot for fat is much

higher in the Asians, as compared to blacks and Caucasians.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: So, the MASALA and the MESA were

the two big studies that examined different ethnic populations and compared them to other

populations such as the Caucasians.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: So they looked and examined and found

that there was a discordance between the tenure CVD risk estimates using the ACC/AHA 2013

estimator,

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: and the coronary artery calcium in South

Asian individuals when compared with other racial ethnic groups.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: So when we look at the next slide here,

we'll talk about now the impact of acculturation on incident CVD in South Asians.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: So, two to three fold higher risk of

incident CVD in non-adherers to heart healthy behaviors has been noticed

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: As you can see here in this study just

published in 2017 by Parackal and colleagues, those who consumed fewer fruits and vegetables

by migrating to the US

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: as a result of acculturation, who had a

sedentary lifestyle, who were smokers and also had excessive alcohol use had a two to three

fold higher risk of incident CVD.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: In this slide, we can see the connection or

the association between

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: the impact of acculturation in South

Asians and ASCVD risk. Here, the first bullet point where we see that there was an increased

intake of animal protein, fried snacks, sweets and high fat dairy products, it lead to increased

insulin resistance and reduced HDL cholesterol.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: Adherence to a traditional Indian dietary

pattern plus Western dietary pattern led to increase in obesity because of a higher consumption

of calories as well as hypertension.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: And adherence to a straight western style

dietary pattern, because now they were in the US., maybe they were students in a university and

were strictly on the western diet, it led to an increased risk for the metabolic syndrome.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: So now we're going to look at the South

Asian dietary patterns and how they vary by region and religion. But there are some common

factors in the diet,

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: despite the region and religion

differences. And those are that all consume high amounts of saturated fat and refined carbs,

such as ghee, which is clarified butter, butter, whole milk, cream,

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: shortening, fried foods, coconut oil,

potatoes, white rice, pizza and repeat use of cooking oil in deep fried savory snacks, which they

consume a lot off.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: And, you know, they hate to throw away

the oil so they'll keep one reusing it until it's gone. And there is a sugar sweetened beverages

increase as well.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: So is there a single South Asian dietary

pattern? In this slide you can see four different patterns from four different parts of India.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: And you can see that all of them have

some commonalities, which is a high intake of saturated fats and refined carbs. You can see the

white rice there

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: but in the other slides you can also see

the fried foods, the somosas, and you can see the rice again in the lower slide, and also with the,

what we call as a dosa, which is a little better because it's rice, but it's also got some lentils in it.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: So let's look at what happens based on-

there's vegetarian Indians or South Asians, and there's non-vegetarian Indians or South Asians.

And if you look here, the non-vegetarians usually

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: consume excessive animal products and

they are associated with obesity and dyslipidemia. There are the vegetarians, and the South

Asian vegetarians are usually lacto.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: They have a dyslipidemia, overweight

and ASCVD. So again, this is as a result of consuming excessive calories, refined carbs,

saturated fats from high fat dairy, such as ghee butter, whole milk, cream

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: as well as coconut oil because a lot of

them believe that coconut oil is very healthy, but because of the high saturated fat in coconut

oil, which is associated with high LDL cholesterol, we need to educate them on not using it if

they have issues with high LDL.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: So this was a great study, it was called

the MASALA study and as you know MASALA in Hindi means spices,

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: so the acronym was really great and they

say that a good acronym is going to lead to the success of the study. So this one was the

Mediators of Atherosclerosis in South Asians Living in America by Kanaya and colleagues.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: And in this study they looked at South

Asians between the ages of 40 to 84 years, 900 participants, only South Asians.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: The sites were in UC San Francisco and

northwestern Chicago and they had also done a pilot study back in 2006, and this study was

conducted between 2010 and 2013.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: And they compared this to the MESA

study which looked at other ethnic groups, not Indians, but the non-Indian Asians. And what

they found is that when they were comparing, they were very interesting findings and so I'm

going to share those with you now.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: So here's what they found- that the major

lifestyle contributors to ASCVD in South Asians was the atherogenic diet, lack of physical

activity.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: 75% of South Asians are overweight, as

we discussed earlier, the pattern that they eat is both their traditional as well as the Western and

this leads to excessive caloric intake.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: And then the diabetes prevalence is high,

as we said, 23% which is twice that of age and adiposity matched Chinese Americans, and that

was in the MESA study,

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: and quadruple of non-Hispanic whites,

which was only 6%. So, as we move forward here, we can also see that South Asians had much

lower exercise rates as you can see in this slide as compared to whites, as compared to African

Americans, Latinos, as well as Chinese.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: Okay, let me just move back to this slide.

Okay. So in this slide, we can see that three major dietary patterns emerged from the MASALA

study that the South Asians were following.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: There was one pattern where they had

very high animal protein. And then the second pattern was either traditional vegetarian diet,

which again is

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: as I mentioned earlier, is high in fried

snacks, wheats, high fat dairy products. And

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: the other part of the second pattern 2B

was a mixed pattern, which is the 2A plus a Western diet, which was again then very high in

high fat dairy, pizza, potatoes, fast foods,

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: and sweetened beverages. And the third

pattern was fruits, vegetables, nuts and legumes, kind of a heart healthy pattern.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: And what they found is that the first two

patterns, the high animal protein diet pattern, and the fried snacks, sweets, and high fat dairy

diet patterns were both linked with higher BMI, higher waist circumference, higher total LDL

cholesterol, lower HDL and higher insulin resistance.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: The fruits, vegetables, nuts and legumes

dietary pattern, they noticed that it was a lower rate of hypertension, fewer risk factors for

ASCVD, diabetes, stroke and metabolic syndrome.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: So the summary of changes in South

Asian dietary patterns upon acculturation in the West were a decrease in beans, lentils, fruits

and vegetables,

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: an increase in potatoes, dairy, oil, meat

and fish, an increase in fast foods due to increased frequency of eating out,

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: an increase in rich traditional foods,

example refined carbs, sweet snacks prepared with ghee, coconut oil, butter and shortening, and

an increase in western desserts as well as snacks.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: Ice cream is every South Asians favorite

snack at bedtime.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: Okay. So in this slide, I want to share

with you that the global burden of disease study that was done in 2010 showed

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: there was a low fruit and vegetable

consumption. This was the top risk factor for the causing the greatest loss of health worldwide.

And as we just talked earlier from the MASALA study, we noticed that fruits and vegetable

intake has gone down as a result of acculturation

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: And this slide, we can see that fruits and

vegetables are very rich in flavonoids, so they reduce oxidative stress, anti-inflammatory,

prevent thrombus formation,

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: improve endothelium function, and

improve lipids, blood pressure and glycemia. This was a paper I published with my colleagues,

Dr. Penny Kris-Etherton

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: in the current cardiology reports in 2015

where we examined the role of fruits and vegetables and other functional foods in the

prevention of both heart disease and diabetes.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: So in this slide now, we're going to look

at what are the low glycemic load carbs that are rich in flavonoids that we want to encourage

our South Asians to go back to, which they may have stopped eating as a result of acculturation.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: And these are the chickpeas, the yellow

split peas, beans, lentils.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: As you can see in this slide, all kinds of

beans and lentils are there. But the fact is if they're not eating them anymore then that's not a

good thing.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: So again, moving forward, traditional

whole grain, low glycemic load carbs include bulgar, barley, millet, which is similar to ragi

flour which you will find in most South Asian stores,

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: whole oats, whole wheat, brown or wild

rice, quinoa, whole rye. So that would be a big change for South Asians to switch them from

white rice to brown and wild rice. So that's an area we could focus on in our counseling, as well

as the use of these other whole grains.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: One more thing I want to mention in the

whole grains is, as you can see in the lower part of the slide, the bran, the endosperm and the

germ all have their own contribution. So all of those are included when we consider that we are

using a whole grain.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: Okay, so how do they help

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: with reducing the incidence of ASCVD?

Well, they decrease inflammation,

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: they decrease CRP, fibrinogen and other

inflammatory markers, they lower insulin resistance by lowering fasting blood sugar and A1C,

and they improved lipid profiles.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: And as a result of that, they lower CAD

risk anywhere from 20 to 30%, as well as progression to diabetes. And of course the high fiber

in there, promote satiety.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: A lot of times people wonder if you go

vegan or vegetarian can you get enough protein? And South Asians wonder about that too. So

it's good to know and to explain to them

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: that beans can be a wonderful source of

protein, so are lentils, so are nuts and seeds. And many of them are switching to the

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: high meat diet because they think that

their vegetarian cuisine is not giving them adequate protein. And then we can also incorporate

the other items listed here in their diet as well if they're willing to give it a try.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: Okay, my second objective was to

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: learn the impact of diet and lifestyle

modification on ASCVD risk factors in South Asians, and as I mentioned,

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: there's very little population-based data

in the United States. There is some in UK and Australia but again, no longitudinal studies

worldwide. So there's a few studies, and I will share those with you now.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: This study, there's two studies here, the

impact of diet and exercise intervention. The first one was a 16 week study, non-randomized

trial in Chicago in women with pre-diabetes.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: And the intervention was healthy diet,

plus twice weekly exercise intervention. And the BMI in these subjects improved significantly.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: And the second study was eight weeks

RCT in San Francisco Bay Area. It was called the CURE-D study.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: Women with type two diabetes, the

intervention was twice weekly culturally relevant exercise, so they were invited to Bollywood

dancing and you know how South Asians love their Bollywood dancing. So it was a very

successful study and it improved body mass index and A1C.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: In the next slide, we can see another

study called the SAHELI study. This was done in Chicago. This was a little longer study, six

months,

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: and the focus was on a healthy diet in

group sessions, and this was also a culturally relevant healthy diet. So again, great

improvements in weight status, A1C, physical activity and stress management skills.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: Another study that involved both diet and

exercise intervention in South Asians with pre-diabetes.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: So in this one, a three month study in the

San Francisco Bay Area, overweight women with insulin resistance. The intervention was low

calorie,

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: relatively low carb dietary pattern. And

again, significant improvement in BMI, insulin sensitivity, and CVD risk factors.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: And the second study was a six months,

New York community-based study. They went to the temples and they actually

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: recruited subjects from there and the

intervention was done in the temples. And these were adults with pre-diabetes. And the

intervention was a healthy diet, exercise and stress management as well.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: And again, significant improvements in

BMI, blood pressure, blood glucose, cholesterol along with food habits and exercise.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: My final objective is to help you

understand diet and lifestyle goals, and practical resources to help practitioners, such as

yourself, implement culturally relevant AHA/ACC recommended heart healthy dietary patterns

in South Asians. For this, let's first look at the 2019 AHA/ACC

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: prevention guidelines for adults. Now the

guidelines are the same, whether it's South Asians or not. So as you can see here, emphasis on

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: plant-based foods, lean protein and fish,

limit foods high in saturated fats and cholesterol, limit or minimize trans fat, sodium (salt),

processed meats, refined carbs and sweetened beverages.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: And to be physically active most days of

the week, which was defined by these guidelines as 150 minutes per week of moderate exercise,

such as brisk walking, or 75 minutes a week for high intensity, such as jogging.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: Now, if we want to look at that, as I said,

it's the same guiding principles. So we want to be able to implement

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: with culturally and ethnically relevant

and personal food preferences, the same DASH dietary pattern, the healthy Mediterranean style

dietary pattern, or a healthy vegetarian/vegan dietary pattern.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: So how would we go about doing that?

Well, there are some great resources out there for you. There is a member interest group in the

Academy of Nutrition and

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: Dietetics, and we designed a special

handout using the Indian carbohydrate counting tools.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: It so it's called, "Ready, Set, Start

Counting", and this is for the management of diabetes for Asian Indians or South Asians. There

is also Indian diet healthy plate.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: And again, you can find registered

dietitians by going to the website I have here for you, and dietitians are trained to be culturally

competent, that's part of our training

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: so I would hope that you would refer

your patients to registered dietitians

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: so they can access these tools and

therefore use them in the South Asian patients. This is an example of the Indian diet healthy

plate from the Academy of Nutrition and Dietetics.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: And as you can see here, they have

shown both a healthy vegetarian plate and also a healthy non-vegetarian plate.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: OK, so moving on, this was a wonderful

article by Linda Van Horn and colleagues and it was published in Circulation 2016

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: on recommended dietary patterns to

achieve adherence to the AHA/ACC guidelines and basically evidence-based dietary

recommendations to facilitate adherence

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: to the AHA/ACC guidelines is what this

whole paper is about. And it also helps to achieve AHA's 2020 strategic impact goals.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: It also provides guidance for achieving

adherence to a heart-healthy dietary pattern

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: and accommodate personal, cultural, and

ethnic food choices. So I would hope that you would turn to that paper, it's absolutely a great

paper.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: And again populations worldwide should

follow the same guiding principles for a heart-healthy dietary pattern to achieve the AHA 2020

goals.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: And again, implementation is the key and

should be based on personal, socio-economic, cultural, ethnic and regional food preferences.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: And to enhance acculturation by

substituting heart-healthy ingredients in recipes for traditional foods. So for example, when we

were talking about the use of coconut oil or ghee or butter,

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: we can talk to the South Asian patients

about substituting with a heart-healthy oil or non-tropical vegetable oil would be the

recommendation for them.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: But with nutritional goals for optimizing

lipids and reducing ASCVD risk factors, again, those are the same, whether it's South Asian or

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: not. So, as you can see here, it should be

culturally tailored, personalized cardioprotective dietary pattern.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: It should emphasize plant-based foods, it

should achieve 5% to 10% weight loss if they're overweight, reduce saturated fat,

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: dietary cholesterol, reduce added sugars,

increase viscous fiber, and when we looked at those whole grains we saw there was oat, there

was bulgar, there was barley, there was

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: the ragi flower. So there's a lot of

different products that can be used to increase viscous fiber in the diet. And then use of plant

sterols and stanols. Okay.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: Again, high recidivism rate was noted in

subjects who tried to follow eating plans that were different from their usual dietary pattern. So

it's really, really important that we

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: make the diet counseling culturally

relevant.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: Culturally tailored cardioprotective

dietary and exercise interventions lead to improved BMI, A1C, insulin sensitivity and physical

activity. And I showed you this study earlier and there it is again in this quick summary.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: And then multiple personalized sessions

with a dietitian. In over 5,700 subjects from 13 countries led to improved LDL cholesterol,

triglycerides,

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: BMI and A1C. And this was our study,

so I'm very pleased to share with you this study. And our study question was that in outpatient

adults,

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: what is the effectiveness and cost benefit

of medical nutrition therapy provided by a registered dietitian for management of dyslipidemia?

And in this study,

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: it was the selection was done based on

research so PubMed, Medline, worldcat.org, we used all of that. Inclusion criteria was English

language publications, adults over 18,

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: and the medical nutrition therapy had to

be provided by a registered dietitian in an outpatient setting. And we looked at all the papers

that were published between January 2003 and October 2014

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: and there had to be at least 10 or more

subjects in the study with at least 65% completion rate.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: And at least one outcome measure of

dyslipidemia. So this is a quick summary of the study findings. So as you can see here in the

first part,

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: it was face to face counseling by the

registered dietitian, and we looked at both cardio-metabolic risk factors outcomes and also

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: cost saving outcomes. And so there was a

total of 34 primary studies, which resulted in 5,704 subjects and there were 10 RCTs as part of

the 34 studies.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: And if you look at the results you can see

how the total cholesterol, LDL, triglycerides, A1C and body mass index went down

significantly.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: And HDL went up, cost savings went up.

It was like $1,456 per year per person and quality of life here is increased 10.78 years, so very

significant findings of the study.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: And so this is the forest plot of the LDL

cholesterol, comparing the intervention and controls. And in this study for LDL, I want you to

see

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: that when you look at the zero, anything

that's left of the zero shows that intervention worked- the medical nutrition therapy by the

dietitian worked. So you can see that in all these studies, LDL cholesterol went down

significantly.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: This study we looked at the triglycerides.

And again, you can see that most of the studies are on the left of the zero, which shows

intervention work.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: And the next slide, you can see same

thing with A1C. All the studies on the left of the zero showing that diet counseling or medical

nutrition therapy by the registered dietitian was very effective.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: In this one we looked at weight, body

mass index, and again, you can see that all the studies are on the left, except one is right at the

zero and you can see again that it shows that intervention was effective as compared to controls.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: So the highlights of this study were that

dietitian intervention with 5,704 subjects lead to improved LDL, triglycerides, A1C, body mass

index,

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: and quality adjusted life years as well as

reduce the need for lipid lowering medications. And that multiple individual sessions with

dietitians were clinically and cost beneficial.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: Benefits were also reported when

dietitians were part of a multidisciplinary healthcare team.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: Like the program where I work, we have

an exercise physiologist, we have a dietitian, and we have a preventive cardiologist.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: And the patient see all three of us back to

back when they come into the clinic. They come for eight sessions over 16 weeks, so twice a

month.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: And then we graduate them to a program

where now they come monthly for their maintenance visits. And we're getting very good

outcomes as you can see from here also. So what are my takeaways for you?

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: First one is culturally tailored counseling

for a personalized cardioprotective dietary pattern, weight loss of just 3% to 5% of body weight

can lead to significant outcomes.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: Reduced intake of saturated fat, under

7%. So if you have a vegan who's using, for example, say coconut oil,

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: if it is within 7% of their calories, it's

fine. Because now if they're vegan, they're not using anything else from the animal fat group.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: So, but, you still need to take a look at it

because it would be like two tablespoons a day of coconut oil would meet that goal for

somebody who's on a 2,000 calorie diet.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: And then less than 200 milligrams of

dietary cholesterol a day, reduced intake of added sugars, 5 to 10 grams per day of viscous fiber

and two grams per day of phytosterols. Culturally relevant multiple visits with the dietitian for

diet and lifestyle counseling.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: So in summary, emphasize a plant-based

diet with vegetables, fruits, whole grains, legumes, non-tropical vegetable oils, unsalted nuts,

most people eat salted nuts so that's something to check.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: Non-fat dairy products and poultry and

fish for the omnivores, and to limit sweets, sugar sweetened beverages, fruit juices, salty or

highly processed foods and fatty red meat or processed meat.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: And again, to provide culturally

appropriate counseling by a healthcare team- include a registered dietitian,

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: exercise specialist and stress

management counselor, because in South Asians there's also a lot of stress from the

acculturation

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: and raising children in a different society

as compared to the society they grew up in. So there's a lot of issues that are psychosocial in

this population as well.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: I wanted to give you the resources.

There's the paper by Linda Van Horn. There's my paper,

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: "Preventing Heart Disease in Asian

Indians" and this is free. You just click on the link and the book will come up, which is the

American Association of Physicians from India book on guide to nutrition, health and diabetes

and I have a whole chapter there on

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: preventing heart disease in Asian

Indians. And the third one, as you can see is the Palaniappan study, which is also the MASALA

study findings

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: summarized in there. And then this is my

favorite, favorite handout to give you. I hope you all are familiar with the National Lipid

Association, they have a website,

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: lipid.org and the CMLT part of it stands

for clinical lifestyle modification tool kit, and I'm the co-chair of the nutrition and

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: lifestyle work group. And what we did is

we developed a lot of handouts and these are free. You don't have to be a member even to

download these handouts.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: And you can get the heart healthy eating

South Asian/Indian style, you can get a handout on the DASH, Mediterranean, vegetarian,

vegan

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: and many, many more. You will be

surprised when you go to that website, and they are beautiful colored printouts. You just have

to print them and share them with your

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: South Asian patients, and also with the

other patients that you see, because these are also very valuable for everybody. So with that, I

want to thank you, but I also want to say that at the end of the day, food and culture does bring

people together. Thank you very much for your attention.

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Villanova Webinar 1: Thank you, Geeta for this excellent presentation.

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Villanova Webinar 1: You so eloquently illustrated, not just the clinical benefit and the cost

benefit and brought those two concepts together, but you also provided us with a treasure trove

of

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Villanova Webinar 1: resources that will be so helpful to us in working with patients of South

Asian ancestry. So thank you very, very much.

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Villanova Webinar 1: Before we get to our questions, I did want to mention that everyone who

has completed the webinar will be emailed a link to the evaluation within a week.

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Villanova Webinar 1: The email will be sent to the email address you use to register for the

webinar.

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Villanova Webinar 1: Evaluation expires in three weeks so please complete it as soon as you

can just to be sure you receive your CE certificate promptly.

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Villanova Webinar 1: Once the evaluation is completed, the CE certificate will be emailed

separately within two business days. So remember, also if you phoned into the webinar today

please email us at COPE@villanova.edu and provide your name, so we can provide you with

your CE certificate

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Villanova Webinar 1: Next month's webinar, actually the first webinar of the 2020 year is

entitled "The Ketogenic Diet for Obesity and Diabetes".

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Villanova Webinar 1: We will be exploring basically the ketogenic diet risks, benefits and

alternatives presented presented by Shivam Joshi

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Villanova Webinar 1: who is a physician and clinical assistant professor at the Department of

Medicine at the NYU School of Medicine. That will be presented

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Villanova Webinar 1: Wednesday, January 22, 2020 from 12 to 1pm Eastern Standard Time. So

if you are working with patients who are using the ketogenic diet or you have been using the

ketogenic diet with your patients, be sure to tune in for this webinar for the latest research on

the risks, benefits and alternatives.

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Villanova Webinar 1: Okay. And with that, we're going to open up the floor for questions. We

have several questions to

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Villanova Webinar 1: get started with.

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Villanova Webinar 1: So I guess it's good for us to understand as dietetic and nursing and

medical professionals,

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Villanova Webinar 1: first of all, what's the cultural perception of obesity in the South Asian

population? Some populations embrace

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Villanova Webinar 1: obesity in terms of it being very culturally accepted and women or men

who are too thin are considered, you know, not healthy. So can you just give us an example of-

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Villanova Webinar 1: an understanding, a better understanding of what the cultural perception

is so we can enter our, you know, counseling sessions with a better understanding.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: So the coaching perception of obesity in

the South Asians is the same. They all want to be slim.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: .

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: But

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: some people struggle more with it than

others. For example, if you went to India and you looked at any website for matrimony, you'll

find that they all advertise fair, slim, tall.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: So that is really not an issue. And now in

the middle age and postmenopausal women, for example, people are more accepting that they're

overweight.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: But at the same time, now they know that

it's not a good thing for them. So I think the perception would be the same. At one time it was

okay, that if you were postmenopausal and you were overweight, it was fine, but not anymore

with all the education and all.

Okay. All right.

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Villanova Webinar 1: And this is a question that I I saw on your slide. So this is a question from

me, you indicated that the lower cut off of BMI was 23

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Villanova Webinar 1: for South Asians because of their high, you know, insulin resistance and

risk factors and so forth, does that also mean that on the other end of the scale the healthy BMI

on the other end is it lower than 18.5 or

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Villanova Webinar 1: is that the same?

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: No, that's the same. They only changed

this one number. Yeah.

Okay, great.

Great question.

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Villanova Webinar 1: So,then these are the plethora of different questions- are there differences

in the types of coconut oil that are traditionally used by South Asians and the kind that's

typically seen in, you know, Western supermarkets?

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: Great question. Yeah, coconut oil, you'll

find the extra virgin again coconut oil, which has not been processed.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: And then there's the processed, you

know, the refined coconut oil, but either one is high in saturated fat because of the lauric acid

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: and the lauric acid does not bypass the

portal circulation, so the body processes that just like it does saturated fats.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: A lot of people are purporting that it's an

MCT, medium chain triglycerides, so it's not going to go in that pathway. But that's not the

case, it does and 60% of the saturated fat in

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: coconut oil is lauric acid. And it can lead

to hyperchylomicronemia and high LDL cholesterol, depending on the genetic makeup of the

person.

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Villanova Webinar 1: Okay. Thank you for clarifying that. So let's say you have

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Villanova Webinar 1: someone who is used to using a lot of coconut oil, if you were doing a

counseling session, would you recommend that they eliminate it altogether or just use a tiny bit

of it to get the flavor?

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Villanova Webinar 1: Because we know that it's that flavor that often captures interest. So what

would you recommend?

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: Great question. And again, that same

thing applies to key oil, also coconut oil, because these are the two foods that that are high in

saturated fat that

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: Indian South Asians love to use because

they do add flavor. And so when anything that's a flavor enhancer is going to be very important.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: So like I mentioned during my

presentation, also, you look at their diet and you look at the overall diet in terms of saturated fat

consumption. And if they're cooking in

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: basically in a non-tropical oil, vegetable

oil,

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: then you know their saturated fat intake

is not so high. And if they're not using a lot of high fat dairy products, sometimes they'll make

their yogurt in whole milk and then their saturated fat will be up from that as well.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: So then you can look at and see, as a

percent of their calories, can they use a tablespoon or two tablespoons per day of

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: the saturated fat source which is the

coconut oil or the ghee? And they will be very happy just with that, with the little bit that they

can use rather than take it all away.

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Villanova Webinar 1: You gave us an excellent explanation and description of the types of

foods in the South Asian diet and Western diet that have been problematic. So obviously the

type of foods that are consumed is an issue.

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Villanova Webinar 1: This may be a silly question, but is portion control an issue as well?

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Villanova Webinar 1: Is it common for people to go back two or three times for rice or is it

more they scooped themselves out a large portion to begin with and that's it? So are we to be

speaking as much as we would normally speak about portion control as we would about types

of foods?

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: Absolutely. And this is not a silly

question, because the overall, even like a standard portion of rice for the South Asians would be

a

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: cup, cup and a half cooked amount, not

half a cup. That would be their serving and then they'll still have two tiers that are Indian, we

call them roti or chipati.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: They have that in addition. So one thing

we teach them is eat one or the other because it's hard to keep your carbs down when you're

using both in the same meal.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: Or we just teach them carb counting and

then they can have a little bit of both. But usually, you know, the lentils are very soupy and they

tend to mix that with the rice and eat or they'll dip their

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: chipati or roti pieces into the lentils and

eat so they need something to scoop up that lentil

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: or to wet their rice with it.

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Villanova Webinar 1: Which it actually brings me to a question about you indicated that there

are fewer beans and lentils and fruits and vegetables in general being consumed. Is this simply

because so many other options compete?

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Villanova Webinar 1: Or is it more that the in the United States that types of beans and lentils

and so forth, you know, the canned products or what have you, are not what is typically used?

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: Well.

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Villanova Webinar 1: What are the obstacles?

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: No, it's not that they're not available,

lentils, beans are all available in their dried forms, which is how

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: South Asians cook them, they buy them

dry and they soak them overnight and then they either pressure cook them or use the instapot,

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: or just boil them with their onions,

tomatoes, garlic, all the seasonings. So that's not even an issue. It's really not the access to the

beans and lentils, but it's the availability of more

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Villanova Webinar 1: options like ice cream and

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Villanova Webinar 1: pizza.

So its more the competitive

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Villanova Webinar 1: foods you have certainly mentioned,

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Villanova Webinar 1: the ice cream at night and so

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forth.

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Villanova Webinar 1: Yeah, it's

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: like every Indian homes favorite dessert

is ice cream.

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Villanova Webinar 1: I thought it was interesting when you said that there's a somewhat of a

misconception in some individuals that, you know, perhaps their diet, if their

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Villanova Webinar 1: very healthy vegan diet is not high enough, or their vegetarian diet is not

high enough in protein, and you said that it's important to correct that

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Villanova Webinar 1: misconception. How do you go about correcting that? How do you

approach that conversation in a way that

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Villanova Webinar 1: you know-.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: One thing is you show them on their

typical eating day what they're getting, you know their usual food intake. How many grams of

protein are they getting and are they meeting their needs?

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: And then you also, like that slide I

showed it had all the grams of protein listed, give them a handout, say, look, you're eating

vegetarian, but you're getting enough protein.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: And here's how you calculate it. So, give

them the tools. They are very into being educated so that won't be an issue. They love to be

educated.

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Villanova Webinar 1: And then often in my counseling sessions when I'm working with South

Asian families, you may see

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Villanova Webinar 1: families coming together for the counseling session or, at least, you

know, husband and wife, or father and daughter or mother and daughter, and so forth.

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Villanova Webinar 1: This is more of a question about the best counseling approach- is it best

to encourage

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Villanova Webinar 1: the whole family to come in if it's an individual issue? Or are there are

there times when it's best to discourage

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Villanova Webinar 1: the family coming in together? I find it personally, sometimes, I'm not

sure

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Villanova Webinar 1: which would be the best way to go? Is it best to

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Villanova Webinar 1: suggest sometimes that I that I talk to the father by himself, or I talk to

the mother by herself or I talk to the daughter by herself? Help me out with that in terms of

some guidelines and tips.

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Villanova Webinar 1: .

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: Take a look at their psychosocial

dynamics when they come as a couple and take a look at who's the cook. It's usually the wife in

your Indian families, South Asian families, the job description is very clear, the wife does the

cooking

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: and the guy does the earning. And then if

they both do any other then that's great, it's welcome, but this is very typical.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: So if the guy is the patient, the husband

is the patient, then you want the wife there because she's cooking and shopping for him. But if

the wife is the patient, then you may or may not want the husband there because the dynamics

might not be as good from the control perspective.

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Villanova Webinar 1: I guess that's what I'm, you know-.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: Right, right.

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Villanova Webinar 1: Okay. And I know that you are- we have a question here, we know

obviously you've shown us lots of research on the benefits.

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Villanova Webinar 1: I love the fact that you said, you know, 3% to 5% weight loss has shown

some some benefits. What's your thought about statin use? At what point should statins be

brought in?

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: And

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Villanova Webinar 1: in general, not maybe not even just for this population, but since you're a

clinical lipid specialist, what would you recommend there in terms of getting the-.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: The data on statins is very robust. And

there's the risk estimator that everyone is now using

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: to see the 10 year risk what that is. And

based on that, there are guidelines on the use of statins and those are in the 2018 cholesterol

management guidelines paper I talked about earlier in the presentation.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: And the lead author is Scott Grundy, and

these are the 2018 cholesterol management guidelines. So like I said, the data on statins is very

robust.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: Some patients tend to shy away from

medicines, they feel they can do it without the medications just by changing their diet and

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: lifestyle their exercise, but in many cases

they still need the statins so I would encourage that if that's what their practitioner and their

doctor, their PA, whoever has, you know, prescribed them.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: They really need to take that and we

must educate and work as a team on that. Now, if there's a patient who says, I have resistance to

statins, I can't tolerate it, I get muscle pains, then you may want to look at other options. I have

a whole

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: session I do just on that- what are your

nutraceutical options for patients who cannot tolerate statins, and I would be happy to do a

webinar on that in the future.

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Villanova Webinar 1: Thank you

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Villanova Webinar 1: very much. I may just take you up on that. It's a

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Villanova Webinar 1: fascinating topic.

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Villanova Webinar 1: Okay, the last question we have, tell us what the next steps are. Tell us

what your next, you know, what you envision in the next 10 to 20 years in terms of how

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Villanova Webinar 1: this all plays out. And what you'd like to see happen?

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: Yeah, this is an excellent question. We're

hoping for more research and as the co-chair of the South Asian work group for the National

Lipid Association,

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: we are writing a paper right now that

should be published in the next six months on

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: clinical guidelines consensus statement

from the National Lipid Association on South Asians, prevention of ASCVD in South Asians.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: And that will include also a nutrition and

lifestyle section, which I offered, but it also will talk about statins and all the other issues that

are there the whole picture. So, right now there is a bill in Congress to support

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: research for South Asians on ASCVD,

and it's supported very strongly by the American Heart Association and the National Lipid

Association and the

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: Diabetes Association, because there's a

lot of need for research in this population. As I said, there are no longitudinal studies

whatsoever. So we hope that this bill will pass and there will be funding assigned by the NIH to

do more studies in this population. So that's what

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Villanova Webinar 1: I envisioned.

That's what you envision, and that's a noble plan, a noble

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Villanova Webinar 1: dream there. I want to thank you so much for sharing such wonderfully

organized and

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Villanova Webinar 1: research presentation, but as well, thank you for providing those practical

tools. We can go to those different resources and we have plenty of great quality

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Villanova Webinar 1: handouts and so forth that we can use to really make our sessions much

more robust and that will make us, as professionals, much more credible to our to our

populations

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Villanova Webinar 1: of various ethnicities because we've taken the time to appreciate the

cultural differences and respond accordingly. So, thank you Geeta so much for a wonderful

presentation.

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Villanova Webinar 1: Lastly, I just wanted to let our listeners know that it's important to us that

our webinars benefit you and your clients and patients.

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Villanova Webinar 1: Our goal is to meet your educational needs to improve and enhance your

practice.

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Villanova Webinar 1: So in light of this, in addition to the brief CE survey you receive

immediately following the webinar,

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Villanova Webinar 1: you may also be emailed another short anonymous online survey in two

months, asking you to just kind of tell us how you use the information you learn today in your

practice.

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Villanova Webinar 1: That's very important to us to know that what you learn today could be

implemented tomorrow. These surveys are invaluable to us so that we can continue to provide

quality continuing education programs.

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Villanova Webinar 1: So with that, I thank Geeta Sikand again for her wonderful presentation. I

just like to encourage our participants to go to the COPE website, sign up for upcoming

webinars and please

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Villanova Webinar 1: look for your email that will contain the evaluation if you need a CE

certificate. We're so pleased to be able to continue to provide these free webinars and we look

forward to your input and comments and we hope you have a great day.

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Villanova Webinar 1: Thank you.

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Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA: Thank you, Lisa.