Shireen: Podcasting from Dallas, Texas. I am Shireen, and this is a Yumlish podcast. Yumlish is working to empower you to take charge of your health through diet and exercise and reduce the risk of chronic conditions Like type two diabetes and heart disease. We hope to share a unique perspective and a culturally relevant approach to managing these chronic conditions.

Shireen: In today’s episode, we will be talking with Dr. Alka Kanaya about obesity and diabetes, specifically the correlation between fatty liver, to obesity, to diabetes, and then heart disease, as well as her research focused on the South Asian community. 

Shireen: Dr. Alka Kanaya is a primary care doctor and a clinical researcher at UCSF. She has focused her research on understanding why there’s a high risk of diabetes and heart disease among South Asians. Welcome, Dr. Kanaya. 

Dr. Kanaya: Thank you for having me. 

Shireen: An absolute pleasure having you on Dr. Kanaya. Starting things out, can you tell us a little bit more about yourself and what led you to focus more, on the South Asian community?

Dr. Kanaya: Yeah, so being South Asian myself, [and] being an Indian immigrant, I just saw, lots of my family members, lots of people in my extended family and friends circle, being affected by diabetes at very young ages, and also having lots of complications from diabetes, including heart disease. And this is something that no one really had good answers [as] to why. And, being a primary care doctor, seeing patients, as well, who were afflicted with pretty severe forms of diabetes early in life, it’s pretty startling to me. It made me feel like, you know, this is definitely something that deserves more attention and there wasn’t a whole lot of research being done proactively prospectively among South Asians. So that was pretty much, a nice, way for me to think about spending time and energy and most of my career working in this.

Shireen: I certainly appreciate that I’m [of] South Asian descent myself, and those are some questions that I’ve carried with me over the years certainly. I wanna take it back a couple of steps and really get to the basics first. First, help us understand how being overweight, [or] obese really increase the chance of someone becoming a diabetic or a person with diabetes.

Dr. Kanaya: Yeah. So, we use very rough tools to measure weight. We use, you know, a weighing scale and use height. And in the clinic setting, we measure, something, a calculated measure of weight and kilograms over height and meter squares called BMI, body mass index and it’s a rough marker for, having excess body fat in your body and, uh, what we know about people who are overweight or obese on the BMI spectrum is that, that the more overweight or obese someone is, the higher the risk of diabetes and heart disease. The underlying reason is thought to be because there is excess body fat. And, the body fat can cause problems metabolically by, fat itself can secrete hormones that can be adverse to health, and it could be where the fat is, could be in unhealthy places in the body. So using a surrogate marker like BMI just gives you a rough idea of people who may be at higher risk of developing certain diseases.

Shireen: And so with that, we know that obesity; diabetes have both increased over the past several years now. What do you believe are some of the factors attributing to the prevalence of this disease and just the growth overall?

Dr. Kanaya: Yeah, I mean, I think, a lot has been said and thought about this. I don’t think it’s one cause I think it’s multifactorial, it’s multi-level it’s societal factors you know community factors, it’s interpersonal factors and it’s individual factors. So individual factors could be that we are exercising less, we are more sedentary, and we are consuming more calories that come from foods that may be ultra-processed or high in calories higher than what we need to maintain fitness and good health. Other factors related to community and structural factors can be the food environment that we live in or the, environments that can be less suitable for exercise or for eating well, and that is if you’re living in an area that doesn’t have fresh fruits or other access to, you know, wholesome whole grains and other plant-based foods and all you have is cheap, available fast foods, you’re more likely to consume those foods if you have limited resources. And so that could be a structural factor that’s related. It could be the stress levels in our life we know from some studies people who get poor sleep because of stress or working too many jobs and they’re doing shift work.

We know that sleep is very highly associated with craving centers and Satya centers in the brain and in the gut, and people can, you know, eat, foods that may be less healthy when they’re under periods of stress or deprived of sleep. There [are] many factors I can’t say it’s only because we are not exercising as much that, that’s kind of ridiculous. But, it’s just multiple factors that have shown this steady rise in the rates of overweight and obesity around the world. It’s not unique to developed countries or the United States seems to be leading the pack in terms of [the] amount of obesity. We have the proportion of our, residents in the US that have obesity, but all states and all countries are seeing this increased number in terms of overweight, obesity, and diabetes, unfortunately.

Shireen: You mentioned earlier you mentioned about BMI and how that’s that’s sort of the measure through which is loosely tied across different ethnicities, different age groups, all of that body composition, and what we know in terms of fatty liver. Now, little is known about why that is. Excess weight goes into these wrong places, at leads to diabetes and even heart disease. Can you help us walk us through that journey of like, how does that have an impact all the way into heart disease and diabetes? 

Dr.Kanaya: These are really good questions. They’re actually some, really important questions that, our team and others are working really hard to understand and disentangle. So what we know is, there’s some really nice new studies that have been done that look at the genetic risk of where we put fat and it looks like there, there are genes that do determine if you store fat mostly under the skin, so that’s the subcutaneous fat that you can pinch under your skin, or if the fat is more likely to go around the abdomen or in the different organs where it shouldn’t be like in muscle and in the liver and around these abdominal organs.

There was a nice study that was just done about a month ago, came from the UK Biobank where they have hundreds of thousands of people that they have genetic data on, and they have, body composition data by MRI scans, and they categorize people into having a pear-shaped body, which is more fat around the gluteal femoral, the buttocks, and the, lower body, and then upper body fat so people more like apples with more fat around their abdomen the places where you really don’t wanna have of fat and what they found was there are genetic polymorphisms these are variants in the genetic DNA code that seem to really link strongly into where body fat is put in in people.

And so what we’ve seen in South Asians is that there’s a higher predisposition of putting fat in the liver around the organs in the central area, the apple body shape is much more predominant in men and women of South Asian backgrounds. I do think that we will find eventually, as we get more genetic data in South Asians, that there, there is some genetic underpinnings of where we put fat and we know that you know, the fat doesn’t go there unless there’s an excess of body fat. If we were to gain weight, unfortunately, our weight gain would go in these wrong places. How does liver fat lead to these things? This is a really hot area of research right now. There are many theories about what happens. The liver is like the key metabolic organ that helps to make cholesterol. Our bodies need cholesterol to live because cholesterol’s in the cell walls of every cell. The liver makes cholesterol so that our cells can turn over and make new cells but the liver can also, cause problems with how much cholesterol is being made and also, how much, the glucose is being used in the liver and in other tissues.

When there is fat where it shouldn’t be in the liver. It can disrupt these processes and lead to more of the abnormal cholesterol levels as well as more insulin resistance so that the message of insulin is not being heard, by the liver and that’s not, allowing the normal metabolism to happen which can lead to diabetes. Now, how does this lead to heart disease? I think it’s, still being worked out, but my theory and a lot of people’s theories are it works slowly through, disrupting the normal amounts of cholesterol that, are made by the liver and also, by disrupting this glucose process to cause both of these problems to occur, and those problems eventually lead to heart disease. It’s not a direct link to heart disease, it’s indirect through these other factors that, and inflammation factors may be disrupted, clotting factors, maybe disrupted. I mean, in the most severe form of fatty liver, there can be, you know, unfortunately like cirrhosis of the liver, which can really disrupt, a lot of the processies of the liver.

Shireen: I do wanna switch back now, Dr. Kanaya, to some of the research work that you’re doing specifically within the study and the program that you’re doing there. First, can you tell us a little bit about that program and what even initiated your research, and how far you’ve gotten with that?

Dr. Kanaya: Yeah, so we’ve been conducting the Masala study since 2010. It started out as a study that was being done at my, institution, UC, San Francisco. And my co-PI is Dr. Numi Kadula, and she’s at Northwestern University in Chicago. Both of our sites enrolled about 450- 500 people. We had 900 people in this cohort, and we’ve been following these people now for 12 years. We’re actually, seeing them back right now in a third exam visit. But we also have been fortunate to be able to get new grant funding to add a new site. So just last year, we added a new site for Masala at NYU in New York City to add another 1,150 participants. And we are really focusing on getting more diversity in the South Asians who are in the study. We hope by next year or by the end of 2023, we will have a total of 2300 people in the study, and about, a thousand will be from Indian backgrounds.

They were born and immigrated from India or have roots to India. And about 600- 700 will be from Bangladesh, and another 600-700 will be from Pakistan. We’re really happy to have more diversity in the South Asians who are represented in the study. And this is a group of adults who are healthy community-dwelling adults between ages 40 and 85 who volunteered to be in our study. We asked the people who joined our study could not already have existing heart disease cuz we’re trying to figure out factors that lead to someone developing heart disease. We are following them every year we call and email people to follow up on their health. What has changed, what’s new? What are they doing differently? And then if they ever do get diagnosed with heart disease or a stroke, or have any kind of procedures on their heart; We ask them about that and we try to, you know, determine what factors we had measured in them may have been causally related to them having a future stroke or heart problem. 

Shireen: I find this so fascinating one of the things, and, you know that has always intrigued me is that we always talk about communities of color being disproportionately impacted by diabetes, heart disease, all the top chronic conditions. What I’m seeing and hearing from what you’re mentioning is really to look beyond, well, what is it about the communities of color? Like just being a person of color doesn’t make you more likely to get diabetes. There has to be something else to the story here. And what I’m hearing you say is more of that unraveling of like, what is it within that that makes it in fact more predisposed to the, to the study. Any comments on that?

Dr. Kanaya: Yeah, absolutely. That’s where we’re going is looking at lots of levels of factors. Structural factors, cultural factors, interpersonal factors, family factors, and individual factors that may be leading to someone developing diabetes. We’ve been following this initial group of 900 people for years and what we did when we saw them back at our second visit we were able to determine who had developed diabetes in those first five years, and about 50 people had developed diabetes and then we were able to link factors from, you know, the first time we saw them to the second time to say; Well, what factors determined? And we found that people who had the highest amount of fat in their liver were more likely to develop diabetes. And we found that there’s certain aspects of their diet, people consuming less healthy plant-based foods were more likely to develop diabetes. That’s what we’re trying to do, is really understand, the causative factors that lead to new development of disease so that we can intervene. That’s the point of this study, is to find what are the modifiable factors that lead to disease so that we can, uh, help our communities, you know, thrive and do better and avoid those risk factors.

Shireen: You mentioned something interesting about diet that I want to, I wanna peel back a little bit more on, including dietary plans in general as well. What are the three main dietary plans within Masala [study] that you know, that you’ve seen, that you’ve, that you’ve recommended, perhaps? Also, can you speak specifically to plant-based diets we’re hearing a lot of that, but what does it, what does it really mean? 

Dr. Kanaya: Yeah, when we, measured diet in Masala [study], we used a very long questionnaire called a Food frequency Questionnaire that was developed in South Asians in Canada. It’s not perfect. None of these tools are perfect, but it’s pretty good. It had 163 items of different types of foods that South Asians eat. Now, you know how different our diets can be depending on what part of South Asia we may have grown up in or our family comes from where we live now, you know, so we had lots of different types of food items, and what we did is we put all that data together. We found that there were three main dietary patterns that our participants were eating. And this is a majority of the days they were eating. The one pattern was more of a western animal-based diet. So, a lot more meat products a little bit higher in coffee consumption, a little bit higher in alcohol consumption in that diet. A second dietary pattern was one that was more of a traditional South Asian diet, and that one had a lot more fried foods and high-fat dairy products, and snacks, types of foods. That you can think of as the, you know, more traditional plant-based some plant-based, but also some meat in that diet as well.

Then the third was more of a prudent diet, which was fresh fruits and vegetables lots of whole grains, and low-fat dairy products. And there was some meat in that as well, but it was more of the low fat, meat fish, poultry. These three patterns emerged as like very, you know, different, and ⅓ of our cohort was eating the, you know, animal protein diet ⅓ were eating that traditional diet and ⅓ were eating the more you know prudent fresh fruits and veggies diet. What we found when we just did, you know, a cross-sectional study, a snapshot in time, was the people that were eating the Western diet and that traditional diet had a higher risk of having more metabolic problems. So, the people eating the western diet had a higher BMI, [and] more waist circumference measures more weight around their belly. 

The people eating that traditional South Asian diet had higher blood pressure and had higher measures of insulin resistance and cholesterol problems. The ones eating the more prudent diet had the best kind of profile overall. And so when we follow these people over time and looked to see who developed diabetes, we probed a little bit more beyond the patterns to say; Well, we know that people generally eat some sort of plant-based foods. Whether or not you’re eating an animal diet predominantly, there’s still some plant-based foods in what you eat. Researchers at Harvard helped us with this analysis where they took our data and they developed a healthy plant-based pattern and an unhealthy plant-based pattern. 

The foods that go in the healthy plant-based are things like, you know fresh fruits and vegetables that are not very starchy. The more starchy plant-based foods like potatoes and rice go into the unhealthier plant-based pattern. Sugar goes into the image. Sugar comes from a plant as well, and that can go into the unhealthy. Processed foods, juices, fruit- juices go into the unhealthy. They made a kind of a different type of analysis looking at healthy plant-based foods and unhealthy plant-based foods and then they looked at who developed diabetes five years later. It turned out the people eating the, healthy plant-based foods were much less likely, significantly less likely to develop diabetes. So we can say with a little bit more confidence now cause we have some prospective data showing that this healthy plant-based diet seems to help protect people from developing diabetes. That’s where we need to be moving. That doesn’t mean you need to completely stop eating meats. Like I said, you know as long as you’re improving the number and how much of the healthy plant-based foods you’re eating, then that’s better for you.

Shireen: And I really like that you broke it down into the healthy versus unhealthy plant-based, just because you could have chips all day long. You can be snacking on a bunch of those types of foods and still be in the plant-based category, but it’s not helping anyone. It’s, you know, yeah. As you’re looking at sort of some of the diet, and I find this very interesting because you’re one, you’re splitting it into that healthy versus unhealthy, and you’re actually able to see the impact of that and follow sort of how people are doing with that over time as well. My next question for you is more around, understanding. So with the Masala program and the study that you are doing, where do you see it going next? Or what do you hope for it to do?

Dr. Kanaya: Yeah. We are seeing people back in the third exam visits right now. So these are the original thousand people are being invited back and we’ve seen about 300 people already. We are measuring heart function. We are looking at how their heart is, um, contracting. By ultrasounds of the heart, we’re asking them to do a six-minute walk to look at their, you know, overall functional status, their exercise capacity with the walking. What we’re trying to figure out is we know that there’s a lot of diabetes. We know there’s a lot of high blood pressure in this group. We’ve already, you know, seen that as we’ve, uh, gotten to know them over time and we’ve only seen things kind of worsen as people age as they do in all populations. What we’re trying to understand now; Is how can we better identify people who are having problems with early heart failure, which is a very hard thing to diagnose clinically. I’m a primary care doctor. We generally don’t diagnose people with heart failure until they have like full-blown, really severe symptoms and their heart’s really not functioning well. We often miss people who are really early onset of heart failure because they’re very subtle symptoms and we’re trying to pick up on those subtle symptoms in how we’re doing these tests. 

Because there are ways to help also prevent people from developing more advanced heart failure by diet and exercise and lifestyle. That’s always the mainstay. But also there are new medications that can help people, forestall developing heart failure. I think this is our new kind of pathway to understanding early heart failure, so we can help to define how people can be, diagnosed with that at an earlier stage. The next place where we’re going is actually looking at brain health. So we’re writing grants right now to do cognitive function testing of our masala participants, to look at how people are doing as they age. There’s very little known about dementia rates in South Asians. In my own family and while observing my parents and grandparents and their friends, I am seeing a lot more people as we age and live in this country, have problems with relatives and friends and family developing dementia, and very little is known about this and how much dementia is there.

What can we do to prevent dementia? The US literature has actually shown that Asians have very low dementia compared to other groups. But actually, we don’t think so because of our own observations and because there’s so much diabetes and heart disease, and those are risk factors for dementia. So how can that be possible that we would be protected from developing dementia? That’s kind of the next frontier, is understanding aging, wellness, [and] brain health in masala participants as they age.

Shireen: I truly applaud you for the work that you’re doing, Dr. Kanaya, cuz there’s so much wrapped in truly what you were saying. Also to your point of Asians not having as much dementia, I think even when we are seeing Asians, there’s a lot of variety there. Even within that group, there’s a South Asian population, which you mentioned earlier. There’s a lot of different groups there that as much as we sort of get bundled together to be like; Oh, all the Indian folks and the Bangladeshi folks, like everyone can convene the South Asian people, but there’s still so much variety in the types of foods we eat, our lifestyle, all of that. I truly appreciate you sort of peeling back the layers and understanding what those differences are and really honing in, on what those factors truly are. So can’t wait to see more of this as it progresses. With that, we are toward the end of the episode. Dr. Kanaya would love to learn at this point, or for our listeners to learn better yet how they can connect with you and just learn more about your work and stay updated with the Masala study as well

Dr. Kanaya: Yeah, no, reach out for sure. But we have a website that we update weekly with, new papers, new findings, [and] new information. We post blogs on that website. We have a healthy resources page, which talks about healthy plant-based foods. If you’re trying to do keto, we actually have South Asian foods that are keto and plant-based that you can look at, and we’ve kind of curated lots of sites to add to that. So that’s masalastudy.org, check out our website. We have a pretty active Twitter following. So follow us at Masalaunderlyingstudy. And then Facebook, we’re not as active on the Facebook app, but that is another place that you can connect with us and our team.

Shireen: Lovely. Before I do let you go, I do have one last question for you. Why did you pick the word masala for this? 

Dr. Kanaya: It was an early morning idea that popped into my head in 2006. I mean, I think it’s nice to have an acronym for a study that catches your eye and is something that’s easy to remember. Masala is a mixture of spices and all people from South Asia eat a mixture of spices in whatever type of exact, you know, the diet that they consume. And it’s a word that now is commonplace in the US and the UK cuz of chicken masala and channa masala, so even people who are not South Asians have heard the word masala. They may not understand that it means a mixture of spices. But, I think it was just really relevant and it fit kinda what we were trying to do is not, and so people think it’s only a food-based study. It’s not just a food-based study. It’s much broader than food but Masala brings us all together. 

Shireen: Mm-hmm. Oh, I love that. Masala brings us all together and I’m totally snapping that up. Love it. Thank you so much Dr. Kanaya, for your time here today. So our listeners, head over to our social media, head over to our Facebook, our Instagram pages. Get over there, find this podcast post, and answer a quick question; How are you managing diabetes in your life? So again, find this podcast post, get into the comment sections, um, for this post, and at the bottom of it, answer this quick question. Dr. Kanaya, I thank you so very much. It was an absolute pleasure having you on.

Dr. Kanaya: Thank you so much for inviting me. 

Shireen: And thank you everyone for tuning in. Thank you for listening to the Yumlish Podcast. Make sure to follow us on social media at Yumlish_ on Instagram and Twitter and at Yumlish on Facebook and LinkedIn for tips about managing your diabetes and other chronic conditions, and to chat and connect with us about your journey and perspective. You can also visit our website, yumlish.com for more recipes, and advice, and to get involved with all of the exciting opportunities Yumlish has to offer. If you like this week’s show, make sure to subscribe so you can hear more from us every time we post. Thank you again, and we’ll see you next time. Remember, your health always comes first. Stay well.

Connect with Dr. Kanaya:

• Website
• Twitter
• Facebook

Additional resources:

• Masala Study