Why diabetes and heart disease can arrive earlier and at a lower weight for Indian Australians

As at 30 June 2025, 971,020 people living in Australia were born in India. That made India the largest overseas-born group in the country for the first time on record, just ahead of England on 970,950, according to the Australian Bureau of Statistics. Nepal-born residents numbered 213,580 and Sri Lanka-born 184,800.

Almost none of those people will have read the line in Australia’s main heart disease guideline that applies specifically to them.

What the Australian guideline actually says

The 2023 Australian guideline for assessing and managing cardiovascular disease risk was led by the Heart Foundation on behalf of the Australian Chronic Disease Prevention Alliance, which also includes the Stroke Foundation, Diabetes Australia and Kidney Health Australia. It contains this recommendation:

“In people whose estimated CVD risk is close to the threshold for a higher risk category, consider reclassifying estimated CVD risk to a higher risk category for the following groups: Māori people, Pacific Islander people, people of South Asian ethnicity (Indian, Pakistani, Bangladeshi, Sri Lankan, Nepali, Bhutanese or Maldivian ethnicities).”

This matters because of how the calculation works. The Australian CVD risk calculator takes age, sex at birth, smoking status, systolic blood pressure, total cholesterol to HDL ratio, CVD medicines, diabetes status, and optionally postcode and atrial fibrillation history. Ethnicity is not one of its inputs. It sits outside the equation, as a judgement call the GP is meant to make afterwards. If nobody raises it, it does not get made.

The guideline sets assessment at ages 45 to 79 for the general population, 35 to 79 for people with diabetes, and 30 to 79 for First Nations people. For First Nations people aged 18 to 29 it recommends assessing individual risk factors rather than calculating a risk score. A Heart Health Check is a Medicare-rebated consultation of at least 20 minutes, claimable once per patient in a 12-month period under items 699 and 177.

The waist number AUSDRISK changes

Australia does apply a lower measurement threshold to people of Asian descent, though it sits in the diabetes tools rather than the heart ones.

AUSDRISK, the Australian Type 2 Diabetes Risk Assessment Tool published by the federal Department of Health, Disability and Ageing, scores waist circumference on two different scales. For people of Asian or Aboriginal or Torres Strait Islander descent, the lowest-risk band is under 90cm for men and under 80cm for women. For everyone else it is under 102cm for men and under 88cm for women. The tool also awards two points for being born in “Asia (including the Indian sub-continent), Middle East, North Africa, Southern Europe”. A total score of 12 or more is high risk, and the tool advises seeing a doctor about a fasting blood glucose test.

That is a 12cm difference for men and an 8cm difference for women, and it is the concrete number to bring to an appointment.

BMI is messier. The Heart Foundation’s waist guidance gives 94cm for men and 80cm for women, then notes waist circumference is “less accurate” for “Aboriginal and Torres Strait Islander peoples, South Asian, Chinese and Japanese adults” without publishing alternative figures. Healthdirect similarly lists South Asian people among groups for whom BMI is “less accurate”, again with no substitute numbers.

One Australian program does put a figure on it. The Life! program, run by Diabetes Victoria with Victorian Government support, accepts referrals at AUSDRISK 12 or above with a BMI of 25 or above, and its referral form states that “if customer self-identifies as being of Asian background a BMI ≥ 23 kg/m2 is accepted”. In the United Kingdom, screening guidance uses 23 for increased risk and 27.5 for high risk. Australia has no equivalent national BMI cut-off.

What is understood about the mechanism, and what is not

The most cited synthesis comes from the United Kingdom. Naveed Sattar and Jason Gill of the University of Glasgow, writing in The Lancet Diabetes & Endocrinology in 2015, described South Asians as typically developing type 2 diabetes “5-10 years earlier and at a lower body mass index” than white Europeans.

Their central explanation is the adipose tissue overflow hypothesis: that South Asians have a lower capacity to store fat in the safest place, just under the skin, so it spills earlier into more harmful places including around the organs and in the liver. Alongside that sit higher percentage body fat, more deep subcutaneous and visceral fat, lower lean mass and lower cardiorespiratory fitness at a given weight.

The authors are careful about what is not settled. They report that adjusting for fitness differences between South Asian and white European men reduced the excess insulin resistance by more than two-thirds, which points at fitness rather than fate. On genetics they write that there is “currently no clear evidence for genetic factors making a major contribution”, though epigenetic factors may play a role. On liver and pancreatic fat they say further studies are needed. Beta cell evidence rests on indirect measures.

So: fat distribution and fitness are well supported. A single South Asian diabetes gene is not established, and anyone claiming otherwise is ahead of the evidence.

The healthy migrant picture, and why it can mislead

Aggregate Australian numbers make Indian Australians look healthy. AIHW analysis of 2021 Census data found India-born Australians reported one or more long-term health conditions at 19 per cent, against 36 per cent for Australian-born people, ranking fifth lowest among the 20 most common overseas countries of birth.

Clinical Professor Smita Shah of the University of Sydney’s Faculty of Medicine and Health told Indian Link in February 2023: “At first glance these numbers do look impressive, no doubt. But I cannot refrain from offering a hint of caution. It is well-known that as a community we are prone to cardiovascular diseases and diabetes, and obesity as we age. These are common conditions I’m seeing in my own professional capacity at Western Sydney where I work. And I’m seeing them increase.”

The same AIHW dataset shows the split. On age-standardised figures, Bangladesh-born Australians had the highest prevalence of both diabetes and heart disease at 12 per cent and 4.6 per cent. Pakistan-born residents also recorded 4.6 per cent for heart disease and Sri Lanka-born 3.9 per cent, against 3.6 per cent for Australian-born people.

Trend data from the Baker Heart and Diabetes Institute points the same way. Professor Dianna Magliano and colleagues, publishing in the Medical Journal of Australia in October 2024, found type 2 diabetes incidence fell across Australia between 2010 and 2019, but rose from 2011 to 2019 among people born in Asia, North Africa and the Middle East, and the Pacific Islands. Among South Asian-born Australians the rates were 8.28 new cases per 1,000 per year in men and 6.28 in women. Magliano’s conclusion was that “we therefore need multifaceted approaches for preventing type 2 diabetes that take into account differences in the risk”.

Food is more complicated than eating less rice

The international evidence on rice is real but narrower than the headlines. The PURE study, published in Diabetes Care in 2020 and covering 132,373 people across 21 countries over a mean 9.5 years, found a hazard ratio of 1.20 for eating 450g or more of white rice a day compared with under 150g, rising to 1.61 in South Asia. In China the association was not significant at 1.04. That variation is the point: the same food behaves differently in different overall diets.

Vegetarian eating carries its own trap. A meal of white rice, potato, refined-flour roti and sweetened chai contains no meat and still delivers a heavy, fast carbohydrate load. Vegetarian is a description of what is absent, not a measure of glycaemic quality.

Australian research adds texture. A University of Sydney qualitative study published in Public Health Nutrition in 2025, with 21 South Asian migrants aged 18 to 35 in Sydney, found people cooking traditional food at home while eating Western and multicultural food out, cutting oil, adding salads and reducing rice portions, but also leaning on frozen meals and takeaway because, as one put it, “our traditional foods take a lot of time in cooking”. Participants named food prices and community expectations about eating generously at gatherings as real constraints. A cross-sectional study of 129 South and South-East Asian migrants in greater Sydney, published in 2022, found 45.7 per cent routinely added extra salt and 75.2 per cent regularly ate fried, oily or fast food.

Movement, and what gets in the way

A Deakin University study published in BMC Public Health in 2021 interviewed 21 Indian migrants in Melbourne about physical activity. Participants described it holistically, one saying: “Physical activity means the overall development of a person … mentally as well as physically.” Women described gendered constraints, with one saying: “You come from a certain class or a certain caste, where women are expected to do traditional roles. So, a mother is just a mother, and her role is defined.” The same participant went on to describe a woman who “has got to cook” and “look after the family”, and who is “not somebody who is encouraged to take up any hobbies”. The researchers argued practitioners should work with these varying perspectives rather than applying standardised Western definitions.

That has a practical edge. Given Sattar and Gill’s finding on fitness, activity is one of the more useful levers available, and advice that ignores who does the cooking, the caring and the second shift will not be taken up.

What to ask your GP

This is general information, not medical advice. Everything below is attributed to a named Australian body, and your own circumstances need a conversation with your GP.

• Ask for a Heart Health Check and, if your risk lands near a threshold, ask directly whether the South Asian reclassification recommendation in the 2023 Australian guideline applies to you. The Heart Foundation sets eligibility at 45 to 79, or 35 to 79 if you have diabetes.
• Ask which waist scale is being used. The Department of Health’s AUSDRISK tool applies under 90cm for men and under 80cm for women of Asian descent, not the 102cm and 88cm figures.
• Ask about AUSDRISK. The RACGP recommends adults over 40 be assessed with a validated tool every three years, and names South Asian background among high-risk groups. A score of 12 or more prompts a fasting blood glucose test.
• Ask about the standard checks: blood pressure, total cholesterol to HDL ratio, blood glucose or HbA1c, and kidney function through eGFR and urine albumin to creatinine ratio, which the 2023 guideline lists among reclassification factors.
• If you have had gestational diabetes, raise it. The AIHW reports women born in Southern and Central Asia are more likely to be diagnosed with gestational diabetes than Australian-born women, and it is a recognised marker of later type 2 risk.
• Diabetes Australia names “Indian subcontinent” cultural background among risk factors you cannot change, and lists age over 40, family history, gestational diabetes and polycystic ovary syndrome alongside it.

The NDSS, administered by Diabetes Australia, publishes translated diabetes material in Hindi, Punjabi, Tamil, Urdu and Bengali.

What this does and does not mean

None of this is a verdict. The INTERHEART analysis published in JAMA in 2007 found South Asians had their first heart attack at a mean age of 53.0 years compared with 58.8 in other countries, and then found that nine modifiable risk factors explained 85.8 per cent of heart attack risk in South Asians. The gap sat almost entirely in things that can be measured and changed.

The Australian figures carry the same message. Type 2 diabetes incidence is falling nationally. Up to 500,000 Australians are estimated to have undiagnosed type 2 diabetes, and Diabetes Australia chief executive Justine Cain has spoken publicly about stigma, noting that “nobody chooses diabetes”. Cardiovascular disease causes around one in four deaths in Australia, roughly 120 people a day.

An earlier appointment, a waist measured against the right scale, and one direct question about reclassification are small acts. For a community that now makes up Australia’s largest overseas-born group, they are worth asking for.

*This article is general information only and is not medical advice. It does not take account of your personal circumstances. Speak to your GP or a qualified health professional before making decisions about screening, medication, diet or exercise.*