[00:00:00] Shireen: Podcasting from Dallas, Texas. I am Shireen and this is the 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 2 diabetes and heart disease. We hope to share a unique perspective and a culturally relevant approach to managing these chronic conditions with you each week.

[00:00:33] Shireen: Dr. Sharan Rai and Dr. Shilpa Bhupathiraju are co authors of the article, A South Asian Mediterranean Style Diet is Associated with Favorable Adiposity Measures and Lower Diabetes Risk. In this episode, we will discuss exactly what this diet is and how it can prevent or even treat diet related chronic conditions.

[00:00:55] Shireen: We also discussed the role of cultural foods, something very important to Yumlish’s mission and how these foods in the community surrounding them can help assist in the journey to a sustainable, healthy lifestyle. Stay tuned. Dr. Shilpa Bhupathiraju is an assistant professor in medicine and nutrition at Harvard Medical School and Harvard T.

[00:01:20] Shireen: H. Chan School of Public Health and an associate epidemiologist at Brigham and Women’s Hospital, Boston. Her research focuses on dietary and lifestyle predictors of cardiometabolic disease. Dr. Sharan Rai is a postdoctoral fellow at Massachusetts General Hospital. She recently completed her PhD in population health sciences at the Harvard T.

[00:01:44] Shireen: H. Chan School of Public Health. Welcome both of you. 

[00:01:48] Dr. Rai: Thanks so much for having us. 

[00:01:48] Dr. Bhupathiraju: Thanks for having us. 

[00:01:50] Shireen: An absolute pleasure. I do want to go ahead and dive right in and ask each of you, starting with you, Dr. Rai, could you tell us a little bit more about your journey into the field of nutrition? 

[00:02:01] Dr. Rai: Yeah, absolutely.

[00:02:02] Dr. Rai: So my name is Sharan and I’m a recent PhD grad from the Harvard Chan School of Public Health. I had started my early grad studies, so going way back as a master’s student, looking at gout onset and cost trends using insurance claims data. And when I was writing my master’s thesis, I found that I was a lot more interested in sort of the why behind these rising trends and these healthcare costs of gout in this case.

[00:02:26] Dr. Rai: And as it turned out, both diet and adiposity were very important risk factors for gout, which is what led me down the path to look more closely at how we can leverage these factors to potentially prevent the disease. And so that was the direction that I decided to pivot and pursue full time in my PhD.

[00:02:42] Dr. Rai: And so from there, one thing led to another. And over the course of my PhD, I was fortunate to expand my horizon and look at additional conditions like diabetes, which we’ll talk about today. 

[00:02:52] Shireen: Lovely. Same question over to you, Dr. Bhupathiraju 

[00:02:55] Dr. Bhupathiraju: yeah. So my path was more circuitous compared to Sharan’s.

[00:02:59] Dr. Bhupathiraju: Growing up in India, the two career options that were presented to me were to either become a doctor, which my family’s full of doctors or an engineer. I didn’t want to do both of them. Um, so I was kind of a rebel, went into home economics just to, you know, break the mold and I really got interested in nutrition.

[00:03:19] Dr. Bhupathiraju: It really spoke to me. Applied for my Master’s in Human Nutrition at Iowa State. Worked on a clinical trial there. I’m looking at how soy affects bone health. And then as I was working on my Master’s, really got interested in epidemiology. And then applied to Tufts for my PhD. Got my PhD in nutritional epidemiology.

[00:03:42] Dr. Bhupathiraju: And then moved down the street for a postdoc at Harvard and the rest is history. And I’m a faculty member there now. 

[00:03:48] Shireen: Now, going into our next question, Dr. Rai, this question is for you. Now, we’ve all heard of the Mediterranean diet, right, but you collaborated on a study focusing on a South Asian Mediterranean style diet.

[00:04:02] Shireen: Can you tell us what kind of diet is this and what really drew you to this specific diet? 

[00:04:07] Dr. Rai: Yeah, definitely. This was a paper that we worked on a couple of years ago. It was actually born out of a course that I took at the Chan School as a student that Shilpa was teaching. So that’s how we met. So the Mediterranean diet in its form that you’ve probably heard of is a diet that is primarily plant based and it includes foods like whole grains, olive oil, fruits, vegetables, beans, other legumes and nuts, and then other foods like animal protein are eaten in smaller quantities with preferred animal protein sources typically being fish and seafood.

[00:04:37] Dr. Rai: And so it has proven health benefits for a number of conditions and people, they tend to really enjoy this eating pattern and they find it sustainable over the longterm. You know, it is enjoyable, but unfortunately there hasn’t been as much research on a Mediterranean style diet among more diverse populations.

[00:04:54] Dr. Rai: And so this was a gap that we really wanted to fill. And South Asians are particularly prone to heart disease and diabetes. And so they were a population that were of particular interest to us. And so our goal with this paper was basically To incorporate traditional South Asian foods that were measured among folks enrolled in this cohort called the Masala Cohort using a unique food frequency questionnaire.

[00:05:16] Dr. Rai: And basically, in constructing this Mediterranean diet, we were able to put it together into this framework of what is usually described as a Mediterranean diet. And this was something that was really important to us because we want folks from all cultures to see their foods represented in dietary recommendations and show that these frameworks are really adaptable and can be applied to all types of foods, not just foods that we’re potentially eating very common here in the US.

[00:05:41] Dr. Rai: And that’s something that we’ll come back to. in a little bit. 

[00:05:44] Shireen: Exactly. Speaking of those types of foods, actually, my next question is going to be for Dr. Bhupathiraju. How does a South Asian Mediterranean style diet really differ from what Americans would commonly identify as what we know the Mediterranean diet?

[00:05:58] Dr. Bhupathiraju: Yeah, I think some components do differ and some components remain the same, you know, fruits and vegetables. They’re very rich in a vegetarian dietary pattern, you know, 40 percent of South Asians are vegetarians. So that’s common. The types of oils that they consume, you know, a lot of South Asians don’t consume olive oil.

[00:06:18] Dr. Bhupathiraju: but they consume a lot of seed oils like sesame oil or mustard seed oil, which are have similar health benefits. Whole grains again, the staple of many South Asians is either rice or whole wheat. So again, you know, differentiating between the carbohydrate quality there, which is, could be very different from what Americans consume.

[00:06:38] Dr. Bhupathiraju: One thing South Asians consume and Americans don’t consume a lot of are legumes, right? Like eating your dhal, eating your veggies. So other than that, I think most components are very similar. A South Asian diet, you know, typically also does not consume as much red meat. And the way it’s consumed typically as a side rather than as a main dish, which is what we know in a more American or a Mediterranean style diet.

[00:07:06] Dr. Bhupathiraju: So those are the big differences between A South Asian style Mediterranean diet and what we typically know as a Mediterranean diet. But the underlying principles are very much the same. 

[00:07:17] Shireen: And, you know, even as we say South Asian style diet, I myself am South Asian. So this really, you know, strongly resonates with me.

[00:07:24] Shireen: But even within that, there’s so much diversity in food and the culture as well. How do you even account for those variances within a broad South Asian style diet? 

[00:07:36] Dr. Bhupathiraju: So again, you know, I think we’re going back to the principles of what underlies Mediterranean diet. What do we consume? What do we treat as legumes, right?

[00:07:46] Dr. Bhupathiraju: So, for South Asians, those are the dhals. What do we consume as protein or lean protein? It could be most of the protein South Asians consume is actually plant protein, which is good. But we Again, consume a lot of poultry, which is different when you’re looking at the sources of protein in American versus South Asian.

[00:08:07] Dr. Bhupathiraju: Fruits and vegetables are pretty similar. Of course, there are many vegetables that are, you know, unique to South Asia that are not as commonly consumed, but the health benefits are very similar. And we see a lot of when you’re replacing sort of the more harmful red meat with vegetables, you see protective effects and that is the same for South Asians as well.

[00:08:28] Shireen: Very interesting. Dr. Rai, over to you. What did you find out about in this study? Can you share a little bit more? 

[00:08:35] Dr. Rai: Yeah, absolutely. . . So in the study, we looked at certain measures cross sectionally, and then we also looked at the odds of developing type 2 diabetes over time. So by leveraging consecutive cycles of these data, so participants who did their baseline visit and then came back in the future for follow up.

[00:08:53] Dr. Rai: In terms of the cross sectional analysis, so looking at folks at baseline who were enrolled in the study, we did find that higher adherence to our South Asian Mediterranean style diet score was associated with favorable measures. of adiposity, including one particular pericardial fat volume. So we were a bit spoiled in the study where we had access to some very cool variables and very cool measures of adiposity, which is something that I hadn’t worked with before.

[00:09:18] Dr. Rai: And indeed we did find that Greater intake of this style of diet was inversely associated with these measures. And then also excitingly, when we looked at the data over time, we found that greater adherence to this diet was associated with a lower odds of developing type 2 diabetes. And given that that was one of the main motivations of undertaking the study was because South Asians do have this greater risk of diabetes over time compared with .

[00:09:42] Dr. Rai: other members of the population. That was a really exciting finding in our study. 

[00:09:46] Shireen: And, you know, it’s interesting that you mentioned that. In fact, I was looking at some data the other day, which was to say that South Asians have one of the highest prevalences of diabetes, which is so interesting. And yet you find portions that have like a pure vegetarian diet.

[00:10:02] Shireen: And yet you see this high sort of prevalence of diabetes across the population. How would you even, or at least for me, how would you help me reconcile sort of that disparity across this region? 

[00:10:15] Dr. Rai: Shilpa, do you mind if I actually volley this one over to you? I know that you’ve done some work like specifically that looks at.

[00:10:20] Dr. Rai: plant based dietary quality in the same population. 

[00:10:23] Dr. Bhupathiraju: Yeah, sure, and I’m happy to take this. You know, the classic example I give when people talk about plant based diets is Coke is plant based. Right, which is not very healthy, and then you have your vegetables, which are also plant based, which are very healthy.

[00:10:41] Dr. Bhupathiraju: So, I think the quality of what you’re consuming is very important. We’ve seen a lot of work saying, well, you know, we’re vegetarian. So we’re protected from all of this risk, which isn’t necessarily true. If you look at what South Asians are consuming now, it’s, you know, very ultra processed foods, a lot of eating out, white rice, and even when eating out, you know, it’s the constant frying generates trans fat within the oil.

[00:11:12] Dr. Bhupathiraju: And the vegetables lose their protective properties. So, being vegetarian alone isn’t enough. It’s the type of vegetarianism you have. If you’re consuming a lot of white rice with fried vegetables and downing it with some sugary beverages, that’s vegetarianism, but it isn’t very cardioprotective compared to you’re eating your dhals with vegetables, with whole grains, either in the form of, uh, Brown rice or other whole grains and limiting your intake of these added sugars.

[00:11:50] Dr. Bhupathiraju: Those have very different effects in the sense that they’re very cardioprotective. And this is especially important for South Asians because like I said, 40 percent identify as being vegetarian, but the quality of their diets vary hugely. And that can have a huge effect. 

[00:12:12] Shireen: That’s so interesting. So what you’re saying is the nutrient.

[00:12:15] Shireen: Dense foods that where the focus needs to be and then how the food is also cooked that has an impact on that. Over to you, Dr. Rai, how do you think cultural or ethnic particularities could influence nutrition overall? You know, your work touched on a lack of integration of cultural foods into conventional dietary advice.

[00:12:35] Shireen: What has been the impact of this and what can be done moving forward? 

[00:12:39] Dr. Rai: Yeah, I think this is a really important question and this is something that we tried to give a lot of attention to in the discussion of our paper. So, there have been consensus reports that have been published that discuss how it is important to integrate cultural factors so that we can do a better job of individualizing nutrition therapy for adults who have diabetes or are at risk of diabetes.

[00:13:02] Dr. Rai: So, this is definitely something that is known in the field. With respect to the Mediterranean diet, the majority of the research, like I said before, has been conducted among mostly white populations living in Europe and the U. S. And that was what we had tried to address by integrating foods that are consumed by different ethnic groups.

[00:13:21] Dr. Rai: When we dug into the literature, what we found was that, you know, there was a wealth of qualitative literature that detailed sort of the negative messaging that South Asians, Receive about their diet when they’re being counseled by a dietitian when they’re at risk of potentially developing diabetes Or maybe they have already developed diabetes and they’re often advised by their providers whether their physician or a dietitian That they should stop eating their traditional diets and they had been in a Using words like this drove their belief that their foods from their culture are quote unquote damaging.

[00:13:56] Dr. Rai: And we saw this across multiple studies with participants from multiple countries. There was just this negative messaging that’s occurring about these foods. And I think, you know, if you’ve scrolled social media, you probably know exactly what I’m talking about. And so these participants noted that they were often told to stop eating these foods completely.

[00:14:15] Dr. Rai: Which they would also describe as being seen as unrealistic because a lot of the times their foods are strongly tied to their cultural identity. And that is rightfully important to these people. You know, we looked at a couple studies in the UK, a couple studies among Canadians that we were able to found.

[00:14:31] Dr. Rai: And these people did describe a close relationship between how they eat and their identity. And they said that, You know, even though they were told that this was potentially a quote unquote damaging diet, they were unlikely to avoid eating the foods that they were used to. And so I think when you put all this together, that really underscores how important it is to study and, more importantly, integrate these culturally specific foods into your dietary recommendations.

[00:14:54] Dr. Rai: Because if folks are tied to them and don’t want to stop eating them, you need to find a way to work within that framework and make sure that these populations are included in your dietary interventions. Does that answer? Yeah, I feel like that was, it went on. No, 

[00:15:08] Shireen: we’re good. I think that certainly does.

[00:15:10] Shireen: You know, building on what we were talking about just a second ago, and this question for you, Dr. Bhupathiraju, we talked about diabetes, the prevalence of diabetes. I’d also like to peel back a little bit more to really understand the whole scope of other common sort of . diet related chronic diseases that are prevalent within the South Asian community.

[00:15:30] Shireen: And again, if you can help us align with how diet influences the prevalence of that disease as well. 

[00:15:36] Dr. Bhupathiraju: Yeah, my research focuses on cardiometabolic diseases and, you know, all cardiometabolic diseases, which include not only type 2 diabetes, but also cardiovascular disease, which is a combination of, you know, myocardial infarction or what we know as heart attacks and stroke are pretty high.

[00:15:56] Dr. Bhupathiraju: And the South Asian population, not only are they high, individuals of South Asian ancestry actually experience the onset of these conditions at a much younger age. And this is why prevention is so important and it’s important to start at a much, much earlier age. Sharan did talk about, you know, these really interesting findings with pericardial fat.

[00:16:19] Dr. Bhupathiraju: And one of the things we’ve noticed all along is that which isn’t easily measured as fatty liver, right? Other measures of visceral fat or the fat that’s, you know, just not around your waist, but in other organs. One big one is NAFLD or non alcoholic fatty liver disease. And that’s something we’ve seen very strong within all our studies among South Asians.

[00:16:47] Dr. Bhupathiraju: And if you take You know, a random sample of 30 year old South Asians, and you do CT scans on them, you’ll see that they have fatty liver, a good proportion have fatty liver. And the only modifiable risk factor for fatty liver is diet fatty liver is a huge risk factor for type 2 diabetes, for heart disease, for all other cardiometabolic conditions.

[00:17:15] Dr. Bhupathiraju: So fatty liver is something that’s gaining more attention right now. It’s not as easily measured in a doctor’s office, but we do know that it’s an important mediator for some of these more hard endpoints like heart attacks or strokes or even type 2 diabetes. 

[00:17:34] Shireen: You know, building on that, Dr. Bhupathiraju,, are there any cultural rituals, practices, and I’m smiling as I say this because I already know part of the answer because it’s quite prevalent in my own household, but are there any cultural rituals or practices related to food preparations and consumption within the South Asian community that you find particularly meaningful or impactful to what you just mentioned?

[00:17:57] Dr. Bhupathiraju: You know, as I reflect back on my own childhood and my family back home, using those traditional oils, the seed oils, sesame oil, for example, It’s in Tamil, it’s called Nallanai, which Nalla means good and, you know, it means good oil. So your ancestors knew these oils were good for you. And I remember my grandmother, you know, going to the mill close by, bringing these oils that were, Hand, pressed from hand, and they just have a really great fatty acid profile, you know.

[00:18:36] Dr. Bhupathiraju: Using traditional oils, I think that’s one thing, you know, using spices. Turmeric, there’s been a lot of literature on turmeric having anti cancer properties, but you know, if you look at What, and it does make it sense in terms of it being protective. It’s rich in polyphenols. It has anti inflammatory properties and again, you know, growing up in India, just, you know, I remember my great grandmother, she lived to over a hundred, just hand pounding rice and eating that.

[00:19:12] Dr. Bhupathiraju: So there’s a lot of talk about ultra processed foods now. So going back to what you’re, you know, Grandparents or great grandparents did, you know, minimally processed, hand pounded, eating at home, consuming oils from seeds and nuts like peanut oil again, which is not only cheap, but it’s also very healthy and flavorful.

[00:19:36] Dr. Bhupathiraju: I think some of those practices are really important and we do need to go back to those. 

[00:19:42] Shireen: And that is so interesting, right? It is about taking away sort of the demonization of foods because that’s not the problem because our ancestors clearly did it. Like you’re, you know, you mentioned your family member who lived over a hundred years old.

[00:19:54] Shireen: I mean, how amazing is that? It’s really this drive toward ultra processed, convenient, you know, sort of eating some of those things that are having really this problem. profound impact specifically within the South Asian community. Just building on that, Dr. Bhupathiraju,, you know, the work that we do at Yumlish, it’s all about tying sort of what you eat to the culture and not demonizing it and not taking away that demonization of foods to make it like, this is what you cannot eat because there’s sort of this very tunnel vision around what is a good food or good diet, right?

[00:20:26] Shireen: What role does community , family gatherings really play in maintaining cultural food traditions, and how can these gatherings be really leveraged in a way to promote healthier eating habits? I know, for instance, when we have our own family gatherings, there is Mitai, which it’s just dessert and just as packed with a lot of sugar.

[00:20:49] Shireen: But how do you begin to start having these conversations at the dinner table, at family gatherings to move toward this more healthier way, less ultra processed foods, more healthier way of eating? 

[00:21:00] Dr. Bhupathiraju: Yeah, you know, that’s a tough one. I would say do what your grandmother did. Again, if you go to any South Asian, you know, event, whether it be Diwali dinner or a wedding or, you know, It’s like the family coming together to cook meals together.

[00:21:18] Dr. Bhupathiraju: You see, there’s like a group, you know, there’s cutting vegetables. And I think that community is so important. Not only for preserving your culture, but also for promoting good nutrition and health. And you know, some of the matais and everything, I’m very familiar with those. You know, they, you can’t have a gathering without matais.

[00:21:38] Dr. Bhupathiraju: I would say that’s just more recent, right? Again, thinking about what my great grandmother did. It’s, again, she would make these peanut balls with jaggery. It’s a healthier snack, it’s a healthier dessert, but it’s not the matai that we know. It’s the refined flour that’s fried in oil and then you mix it with ghee and tons of sugar.

[00:22:06] Dr. Bhupathiraju: But what I do want to say is that while holding on to your culture, I think there is a space for promoting good nutrition, going back to your roots and remembering that minimally processed foods It can be healthier and when consumed once in a while in these gatherings, it’s okay not have making it a daily habit.

[00:22:29] Shireen: That’s incredibly helpful. I, you know, I kind of reflect on what you just said as well as I think there was also an access challenge back then, right? Just where we’ve come from, sort of the scarcity of all of those options, even if you wanted to indulge, you couldn’t quite afford to, or couldn’t quite get access to those foods in the way that we do today.

[00:22:47] Shireen: So I will. Big old smile on my face thinking about some of those stories and how it sort of connects into even sort of this idea around doing well, right? So when you’re doing well, you have access to these things and it almost emphasizes that point around, oh, you’ve made it or you’re doing well, or I have Coke in my pantry now.

[00:23:06] Shireen: You know, but a generation or two before we didn’t, right? So I think those are the types of things as well that I feel underlies some of this, but how interesting. And I feel like this conversation can certainly go on for another half hour here, but we are toward the end of the episode at this point, Dr.

[00:23:22] Shireen: Rai starting with you, how can our listeners connect with you and learn more about the work that you are doing? Dr. Rai 

[00:23:27] Dr. Rai: So I’m happy to share my email and you can put it into the episode notes if that’s helpful to folks if they want to get in touch. I can also put in a plug for the Harvard School of Public Health’s NutritionSource website.

[00:23:38] Dr. Rai: I don’t know the web address offhand, but I can give it to you for the show notes. And also if you just Google Harvard T. H. Chan School of Public Health NutritionSource, it’ll take you directly to the website. And it’s a fabulous resource with Tons of nutrition information based on, you know, the latest research that’s happening and, uh, viewers might find it very helpful.

[00:23:56] Shireen: Same question for you, Dr. Bhupathiraju 

[00:23:58] Dr. Bhupathiraju: yeah, I completely echo what Sharan is talking about the nutrition source. That’s one of the most listed websites for Harvard. If you put my name, my email address does Bob up, and I’m happy to connect with anyone 

[00:24:12] Shireen: lovely at this point. I want to thank both of you for your time here and just walking us through this journey of the South Asian diet, how it has evolved over time, where we are today and sort of what are those things that we should have top of mind.

[00:24:25] Shireen: So again, This episode was certainly be dear to my heart just for that reason. And to our listeners, thank you so much for tuning into another episode of the Yumlish podcast. Head over to our social media and answer this quick question. How has culture and community played a role in your health journey?

[00:24:41] Shireen: Whatever community you come from. So again, head over to our social media. Find this podcast post, comment below to tell us how has culture and community played a role in your health journey. You can find us at Yumlish on Facebook and on Instagram. We’ll continue the conversation there with that Dr. Rai, Dr.

[00:24:59] Shireen: Bhupathiraju. Thank you so very much for your time. Thank you so 

[00:25:02] Dr. Bhupathiraju: much. Thanks for having 

[00:25:03] Shireen: us. Thank you for listening to the Yumlish podcast. Make sure to follow us on social media at Yumlish underscore 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.

[00:25:25] Shireen: You can also visit our website, Yumlish. com. For more recipes, 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.

[00:25:50] Shireen: Stay well.

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