The Susceptibility of South Asians to Cardiometabolic Disease as a Result of Starvation Adaptation Exacerbated During the Colonial Famines

South Asians, representing one quarter of the world's population, have disproportionally high rates of obesity and cardiometabolic disease thus resulting an epidemic health crisis.This crisis could be the consequence of epigenetic effects exacerbated during the colonial-era famines resulting in a unique starvation-adapted physiology.Due to evolutionary mismatch in circumstances of abundance, this starvation-adapted physiology can become harmful.Evidence for this starvation adaptation in South Asians includes high body fat and unfavorable adipokines; low lean body mass; lower resting energy expenditure (compounded by lack of brown adipose tissue); greater insulin resistance and insulin response; exaggerated lipemic response to fat and sugar intake; less capacity to handle an overabundance of food; lower fat burning (oxidative capacity) and VO2max during aerobic exercise; and energyconserving response to resistance exercise, as well as increased lipoprotein (a) levels.The Roma people, also of South Asian ancestry, may represent an interesting pre-colonial historical control.Physician and patient knowledge of this unique physiology in South Asians will promote a stronger physicianpatient relationship and foster compliance with treatment.