Impact of migration on coronary heart disease risk factors: comparison of Gujaratis in Britain and their contemporaries in villages of origin in India

South Asians are Under-Represented in a Clinic Treating Atrial Fibrillation in a Multicultural City in the UK

The Leeds rapid access atrial fibrillation (AF) clinic was set up to streamline and standardise management of patients with newly diagnosed AF. Anecdotal evidence suggests that there is under-representation of south Asians in these clinics.All patient attendances between June 2007 and June 2011 were documented and combined with ethnicity data from patient administration records. Local population demographics for 2009 were obtained from the office of national statistics. This was used to estimate the expected prevalence of AF across the different ethnic groups in Leeds taking age into account. One thousand two hundred and ten patients were referred. The study sample included 992 patients, and the number of south Asians attending was 88% less than expected (Chi squared analysis; p<0.0001). These results suggest that there is an under-representation of south Asians in a large centre that serves a cosmopolitan population. Potential reasons for this discrepancy including barriers to accessing treatment for this population or a lower prevalence of AF in south Asians due to an as yet unidentified genetic factor.

Prevalence, risk factors and complications associated with type 2 diabetes in migrant South Asians

It is estimated that type 2 diabetes (T2D) currently affects about 246 million people worldwide, with South Asians, especially Indians, having both the largest number of cases and the fastest growing prevalence. South Asian ethnicity has been identified as a major risk factor for the development of T2D with central adiposity, insulin resistance and an unfavourable lipid profile being identified as predominant signals of alarm. Leading databases, including Web of Science, Medline, PubMed and Science Direct, were consulted and manual searches were conducted for cited references in leading diabetes-related journals. In all, 152 articles were included for the final assessment reported in this review. Genetic predisposition, central adiposity and unfavourable lifestyle, including physical inactivity and an unhealthy diet, were associated with the prevalence of T2D in migrant South Asians. 'Westernization', acculturation, socio-economic factors and lack of knowledge about the disease have also been identified as contributors to the development of T2D in this population. Higher prevalence of T2D in migrant South Asians may not be entirely attributed to genetic predisposition; hence, ethnicity and associated modifiable risk factors need further investigation. Preventive measures and appropriate interventions are currently limited by the lack of ethnic-specific cut-off points for anthropometric and biological markers, as well as by the absence of reliable methods for dietary and physical activity assessment. This article describes the prevalence rate, risk factors and complications associated with T2D in migrant South Asians living in different countries.

Migrating husbands and changing cardiovascular risk factors in the wife: a cross sectional study in Asian Indian women

OBJECTIVE

The authors studied the influence of migration of husband on cardiovascular risk factors in Asian Indian women.

METHODS

Population-based studies in women aged 35-70 years were performed in four urban and five rural locations. 4608 (rural 2604 and urban 2004) of the targeted 8000 (57%) were enrolled. Demographic details, lifestyle factors, anthropometry, fasting glucose and cholesterol were measured. Multivariate logistic and quadratic regression was performed to compare influence of migration and its duration on prevalence of risk factors.

RESULTS

Details of migration were available in 4573 women (rural 2267, rural-urban migrants 455, urban 1552 and urban-rural migrants 299). Majority were married, and illiteracy was high. Median (interquartile) duration of residence in urban locations among rural-urban migrants was 9 (4-18) years and in rural areas for urban-rural migrants 23 (18-30) years. In rural, rural-urban migrants, urban and urban-rural migrants, age-adjusted prevalence (%) of risk factors was tobacco use 41.9, 22.7, 18.8 and 38.1; sedentary lifestyle 69.7, 82.0, 79.9 and 74.6; high-fat diet 33.3, 54.2, 66.1 and 61.1; overweight 21.3, 42.7, 46.3 and 29.7; large waist 8.5, 38.5, 29.2 and 29.2; hypertension 30.4, 49.4, 47.7 and 38.4; hypercholesterolaemia 14.4, 31.3, 26.6 and 9.1 and diabetes 3.9, 15.8, 14.9 and 8.4, respectively (p<0.001). In rural-urban migrants, there was a significant correlation of duration of migration with waist size, waist-to-hip ratio and systolic blood pressure (quadratic regression, p<0.001). Association of risk factors with migration remained significant, though attenuated, after adjustment for socioeconomic, lifestyle and obesity variables (logistic regression, p<0.01).

CONCLUSIONS

Compared with rural women, rural-urban migrants and urban have significantly greater cardiometabolic risk factors. Prevalence is lower in urban-rural migrants. There is significant correlation of duration of migration with obesity and blood pressure. Differences are attenuated after adjusting for social and lifestyle variables.

Diabetes Health, Residence & Metabolism in Asians: the DHRMA study, research into foods from the Indian subcontinent - a blinded, randomised, placebo controlled trial

Background

Coronary heart disease (CHD) is highly prevalent amongst the South Asian communities in Britain. The reasons for this excess CHD risk are multifactorial, but in part relate to a susceptibility to diabetes mellitus - where the aberrant metabolism of non-esterified fatty acids (NEFA) and glucose are likely to underpin vascular disease in this population. Dietary intervention is an important and first line approach to manage increased CHD risk. However, there is limited information on the impact of the South Asian diet on CHD risk.

Methods/Design

The Diabetes Health, Residence & Metabolism in Asians (DHRMA) study is a blinded, randomised, placebo controlled trial that analyses the efficacy of reduced glycaemic index (GI) staples of the South Asian diet, in relation to cardio-metabolic risk factors that are commonly perturbed amongst South Asian populations - primarily glucose, fatty acid and lipoprotein metabolism and central adiposity. Using a 10-week dietary intervention study, 50 healthy South Asians will be randomised to receive either a DHRMA (reduced GI) supply of chapatti (bread), stone ground, high protein wheat flour and white basmati rice (high bran, unpolished) or commercially available (leading brand) versions chapatti wheat flour and basmati rice. Volunteers will be asked to complete a 75g oral glucose tolerance test at baseline and at 10-weeks follow-up, where blood metabolites and hormones, blood pressure and anthropometry will also be assessed in a standardised manner.

Discussion

It is anticipated that the information collected from this study help develop healthy diet options specific (but not exclusive) for South Asian ethnic communities.

Trial registration

Current Controlled Trials ISRCTN02839188

Is there a divergence in time trends in the prevalence of impaired glucose tolerance and diabetes? A systematic review in South Asian populations

OBJECTIVE

Recently, diabetes prevalence has increased in South Asians making it a global public health priority. There are suggestions that pre-diabetes, including impaired glucose tolerance (IGT), may not be increasing. We conducted a systematic review to explore the paradox. Research Design and Methods We searched electronic databases from inception to June 2009 for cross-sectional studies providing prevalence of pre-diabetes (using WHO criteria) in South Asian adult populations. Two reviewers independently screened articles, performed data extraction, quality appraisal and study classification with any discrepancies resolved by consensus. Repeated cross-sectional studies, categorized by pre-specified criteria, were used for the primary analysis, supplemented by analysis of comparable and all studies.

RESULTS

In total, 79 cross-sectional data sets (from 69 published studies) were identified resulting in the inclusion of 179 408 people. Four sets of repeated cross-sectional studies, conducted in Chennai, rural Tamil Nadu, Mauritius and Singapore (n = 30,399), provided time trend information. Three of them showed an increase in diabetes prevalence (P < 0.001) whereas IGT fell in two (P < 0.05), and was stable in the remainder. A similar pattern was seen among three other sets of comparable studies (n = 58,820) and in scatterplots of all 79 data sets.

CONCLUSION

This novel systematic review is the first to assess secular trends of pre-diabetes in any population. The data show diabetes prevalence is rising, whereas IGT prevalence is stable or falling. Explanations include: recent environmental or lifestyle changes favouring an increased rate of conversion from IGT to diabetes, or a cohort effect with improving maternal and infant nutrition resulting in reduced IGT with a fall in diabetes to follow.

Ethnic Groups as Migrant Groups: Improving Understanding of Links Between Ethnicity/Race and Risk of Type 2 Diabetes and Associated Conditions

Most members of minority ethnic/racial groups in affluent western societies are recent immigrants or immediate descendants thereof. The health implications of ethnic groups also being migrant groups are important but often not fully explored. Research demonstrating developmental influences on the risk of type 2 diabetes and associated conditions suggests that migrants will differ in disease risk compared with the general population. It also leads us to expect intergenerational differences in disease risk within many minority ethnic/racial groups. Differences in health behaviors between ethnic/racial groups are also expected to change over time following migration, including across generations, but do not necessarily follow a simple model of acculturation. Understanding the ways in which the biosocial heritage of migrant groups interacts over the long term with migrants' new environments is central to understanding differences in disease risk that are identified as ethnic or racial and also highlights heterogeneity in risk within ethnic groups.

How well does social variation mirror secular change in prevalence of cardiovascular risk factors in a country in transition?

OBJECTIVES

The social and cultural transition among the Inuit in Greenland over the last generations has in ecological studies been linked to changes in cardiovascular risk factors. To permit analyses at the individual level, we propose a categorization of participants in a cross-sectional study according to their relative position in the process of social change.

METHODS

Data was included from two cross-sectional population surveys in 1993-1994 (N = 1,580) and 2005-2009 (N = 2,834). Socioeconomic factors, mental health, health behavior, obesity, blood lipids, blood pressure, and prevalence of diabetes were compared between the surveys and among groups at various degree of social change defined from current residence, job, and education. General linear models and logistic regression analysis were applied.

RESULTS

Most outcome variables showed statistically significant difference between the two studies indicating secular change, and for most the gradient in the ranked social groups was in agreement with the observed secular change. This included housing conditions, wealth, diet, smoking, alcohol, physical activity, obesity, and for women also non-HDL cholesterol and hypertension. Anxiety and depression increased over time but decreased with social group for women. Prevalence of type 2 diabetes has increased, but we found no differences among social groups. Serum triglyceride and for men non-HDL cholesterol and hypertension showed inconsistent results.

CONCLUSIONS

For a majority of the examined cardiovascular risk factors, social population groups defined from cross-sectional data adequately mirror secular change.

Cardiovascular disease by diabetes status in five ethnic minority groups compared to ethnic Norwegians

Background

The population in Norway has become multi-ethnic due to migration from Asia and Africa over the recent decades. The aim of the present study was to explore differences in the self-reported prevalence of cardiovascular disease (CVD) and associated risk factors by diabetes status in five ethnic minority groups compared to ethnic Norwegians.

Methods

Pooled data from three population-based cross-sectional studies conducted in Oslo between 2000 and 2002 was used. Of 54,473 invited individuals 24,749 (45.4%) participated. The participants self-reported health status, underwent a clinical examination and blood samples were drawn. A total of 17,854 individuals aged 30 to 61 years born in Norway, Sri-Lanka, Pakistan, Iran, Vietnam or Turkey were included in the study. Chi-square tests, one-way ANOVAs, ANCOVAs, multiple and logistic regression were used.

Results

Age- and gender-standardized prevalence of self-reported CVD varied between 5.8% and 8.2% for the ethnic minority groups, compared to 2.9% among ethnic Norwegians (p < 0.001). Prevalence of self-reported diabetes varied from 3.0% to 15.0% for the ethnic minority groups versus 1.8% for ethnic Norwegians (p < 0.001). Among individuals without diabetes, the CVD prevalence was 6.0% versus 2.6% for ethnic minorities and Norwegians, respectively (p < 0.001). Corresponding CVD prevalence rates among individuals with diabetes were 15.3% vs. 12.6% (p = 0.364). For individuals without diabetes, the odds ratio (OR) for CVD in the ethnic minority groups remained significantly higher (range 1.5-2.6) than ethnic Norwegians (p < 0.05), after adjustment for age, gender, education, employment, and body height, except for Turkish individuals. Regardless of diabetes status, obesity and physical inactivity were prevalent in the majority of ethnic minority groups, whereas systolic- and diastolic- blood pressures were higher in Norwegians. In nearly all ethnic groups, individuals with diabetes had higher triglycerides, waist-to-hip ratio (WHR), and body mass index compared to individuals without diabetes. Age, diabetes, hypertension, hypercholesterolemia, and WHR were significant predictors of CVD in both ethnic Norwegians and ethnic minorities, but significant ethnic differences were found for age, diabetes, and hypercholesterolemia.

Conclusions

Ethnic differences in the prevalence of CVD were prominent for individuals without diabetes. Primary CVD prevention including identification of undiagnosed diabetes should be prioritized for ethnic minorities without known diabetes.

Dietary intake and rural-urban migration in India: a cross-sectional study

Background

Migration from rural areas of India contributes to urbanisation and lifestyle change, and dietary changes may increase the risk of obesity and chronic diseases. We tested the hypothesis that rural-to-urban migrants have different macronutrient and food group intake to rural non-migrants, and that migrants have a diet more similar to urban non-migrants.

Methods and findings

The diets of migrants of rural origin, their rural dwelling sibs, and those of urban origin together with their urban dwelling sibs were assessed by an interviewer-administered semi-quantitative food frequency questionnaire. A total of 6,509 participants were included. Median energy intake in the rural, migrant and urban groups was 2731, 3078, and 3224 kcal respectively for men, and 2153, 2504, and 2644 kcal for women (p<0.001). A similar trend was seen for overall intake of fat, protein and carbohydrates (p<0.001), though differences in the proportion of energy from these nutrients were <2%. Migrant and urban participants reported up to 80% higher fruit and vegetable intake than rural participants (p<0.001), and up to 35% higher sugar intake (p<0.001). Meat and dairy intake were higher in migrant and urban participants than rural participants (p<0.001), but varied by region. Sibling-pair analyses confirmed these results. There was no evidence of associations with time in urban area.

Conclusions

Rural to urban migration appears to be associated with both positive (higher fruit and vegetables intake) and negative (higher energy and fat intake) dietary changes. These changes may be of relevance to cardiovascular health and warrant public health interventions.

Dietary differences between elderly Iranians living in Sweden and Iran a cross-sectional comparative study

BACKGROUND

During the last decades, global migration has increased and many immigrant groups have a higher prevalence than the native born population of several cardiovascular disease risk factors, including poor dietary habits. However, it is uncertain if dietary habits in immigrant populations reflect dietary habits in their country of origin or if the current diet is a consequence of the migration and possible change of dietary habits. The aim of this study was to examine possible dietary differences between elderly Iranians living in Stockholm, Sweden with elderly Iranians living in Tehran, Iran, taking into account sex, age, marital status, and education.

METHODS

Dietary intakes were assessed by semi--quantitative food frequency questionnaire in a cross-sectional study of 121 Iranians living in Stockholm and 52 Iranians living in Tehran, aged 60-80. Differences in dietary habits between the two groups was analysed by bootstrapped regression analyses with 1000 replications.

RESULTS

Iranians living in Sweden had significantly higher intake of protein, total fat, fiber than Iranians living in Iran, but lower consumption of carbohydrates. The observed differences in intake of macronutrients were reflected in consumed amount of all food items, which were higher among Iranians living in Iran with the exception of bread and grain consumption which was lower.

CONCLUSIONS

There are general differences in dietary habits between Iranians living in Iran and Iranians living in Sweden. Parts of observed differences in dietary habits may reflect a favourable adoption process to the Swedish dietary habits after migration. Meanwhile other differences are point of concern in light of the high prevalence of overweight, among Iranians living in Sweden and can have unfavourable impact in particular in the context of cardiovascular health.

Assessment of follow-up, and the completeness and accuracy of cancer case ascertainment in three areas of India

BACKGROUND

A prospective study of diet and cancer has not been conducted in India; consequently, little is known regarding follow-up rates or the completeness and accuracy of cancer case ascertainment.

METHODS

We assessed follow-up in the India Health Study (IHS; 4671 participants aged 35-69 residing in New Delhi, Mumbai, or Trivandrum). We evaluated the impact of medical care access and relocation, re-contacted the IHS participants to estimate follow-up rates, and conducted separate studies of cancer cases to evaluate registry coverage (604 cases in Trivandrum) and the accuracy of self- and proxy-reporting (1600 cases in New Delhi and Trivandrum).

RESULTS

Over 97% of people reported seeing a doctor and 85% had lived in their current residence for over six years. The 2-year follow-up rate was 91% for Trivandrum and 53% for New Delhi. No cancer cases were missed among public institutions participating in the surveillance program in Trivandrum during 2003-2004; but there are likely to be unmatched cases (ranging from 5 to 13% of total cases) from private hospitals in the Trivandrum registry, as there are no mandatory reporting requirements. Vital status was obtained for 36% of cancer cases in New Delhi as compared to 78% in Trivandrum after a period of 4 years.

CONCLUSIONS

A prospective cohort study of cancer may be feasible in some centers in India with active follow-up to supplement registry data. Inclusion of cancers diagnosed at private institutions, unique identifiers for individuals, and computerized medical information would likely improve cancer registries.

High Levels of Cardiovascular Risk Factors among Pakistanis in Norway Compared to Pakistanis in Pakistan

Objectives. Previous studies have shown that the Norwegian-Pakistanis had considerably higher prevalence for diabetes and obesity compared to Norwegians. We studied the additional risk of obesity, dyslipidemia, and hypertension among Pakistanis in Norway compared to Pakistanis living in Pakistan. Method. 770 Norwegian-Pakistani adults (53.9% men and 46.1% women) born in Pakistan from two surveys conducted in Norway between 2000 and 2002 were compared with a sample of 1230 individuals (29.1% men and 70.9% women) that participated in a survey in Pakistan in 2006. Results. Both populations had similar height, but Norwegian-Pakistanis had considerably higher mean weight. Of the Norwegian-Pakistanis, 56% of the males and 40% of the females had a BMI above 25 kg/m(2), as opposed to 30% and 56% in Pakistan, for males and females, respectively. Norwegian-Pakistanis had higher total cholesterol. Conclusion. Obesity and an unfavourable lipid profile were widely prevalent in both populations; the highest level was recorded amongst those living in Norway. The increased risk for obesity and dyslipidemia may be ascribed to change of lifestyle after migration.

South Asian ethnicity as a risk factor for major adverse cardiovascular events after renal transplantation

BACKGROUND AND OBJECTIVES

South Asians (SAs) comprise 25% of all Canadian visible minorities. SAs constitute a group at high risk for cardiovascular disease in the general population, but the risk in SA kidney transplant recipients has never been studied.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

In a cohort study of 864 kidney recipients transplanted from 1998 to 2007 and followed to June 2009, we identified risk factors including ethnicity associated with major cardiac events (MACEs, a composite of nonfatal myocardial infarction, coronary intervention, and cardiac death) within and beyond 3 months after transplant. Kaplan-Meier methodology and multivariate Cox regression analysis were used to determine risk factors for MACEs.

RESULTS

There was no difference among SAs (n = 139), whites (n = 550), blacks (n = 65), or East Asians (n = 110) in baseline risk, including pre-existing cardiac disease. Post-transplant MACE rate in SAs was 4.4/100 patient-years compared with 1.31, 1.16, and 1.61/100 patient-years in whites, blacks, and East Asians, respectively (P < 0.0001 versus each). SA ethnicity independently predicted MACEs along with age, male gender, diabetes, systolic BP, and prior cardiac disease. SAs also experienced more MACEs within 3 months after transplant compared with whites (P < 0.0001), blacks (P = 0.04), and East Asians (P = 0.006). However, graft and patient survival was similar to other groups.

CONCLUSIONS

SA ethnicity is an independent risk factor for post-transplant cardiac events. Further study of this high-risk group is warranted.

Health status of refugees settled in Alberta: changes since arrival

OBJECTIVE

This paper sought to examine which pre- and post-migration factors might be associated with changes in refugees' health status.

METHODS

Using linear regression, the associations between pre- and post-migration factors and changes in self-rated mental and physical health status were examined in 525 refugees from the 1998 Settlement Experiences of Refugees in Alberta study.

RESULTS

Having spent time in a refugee camp and having held professional/managerial jobs in one's home country were associated with a greater decline in mental health status since arrival in Canada. Having completed a university degree in one's home country was associated with a greater decline in physical health status. Being employed was associated with greater improvements in mental health status. Perceived economic hardship was associated with greater declines in physical health status. A higher number of settlement services received during the first year in Canada was associated with greater improvements in both mental and physical health status. Longer residence in Canada was associated with greater declines in physical health status but not in mental health status.

CONCLUSION

While little can be done to alter refugees' pre-migration experiences, public policies can affect many post-migration experiences in order to mitigate the negative health consequences associated with resettlement. Results of this study point to the need for continued provision of settlement services to assist refugees with job training, labour market access, and credential recognition, as well as counseling for refugees who experienced the trauma of living in a refugee camp.

Ethnic-specific differences in abdominal subcutaneous adipose tissue compartments

South Asians have a higher prevalence of cardiovascular disease (CVD) than Europeans. Studies have identified distinct subcompartments of subcutaneous adipose tissue (SAT) that provide insight into the relationship between abdominal obesity and metabolic risk factors in different ethnic groups. Our objective was to determine the relationship between SAT compartments and fat-free mass (FFM) between South Asian and European cohorts, and between men and women. Healthy Europeans and South Asians (n = 408) were assessed for FFM via dual energy X-ray absorptiometry, and SAT areas by computed tomography (CT). SAT was subdivided into superficial subcutaneous abdominal adipose tissue (SSAT) and deep subcutaneous abdominal adipose tissue (DSAT). Linear regression analyses were performed using DSAT and SSAT as separate dependent variables and FFM and ethnicity as primary independent variables adjusting for age, gender, income, education, and smoking status. Results showed that South Asian men had significantly higher amounts of DSAT (median 187.65 cm(2) vs. 145.15 cm(2), P < 0.001), SSAT (median 92.0 cm(2) vs. 76.1 cm(2), P = 0.046), and body fat mass (BFM) (25.1 kg vs. 22.6 kg, P = 0.049) than European men. In a fully adjusted model, South Asians showed significantly greater DSAT at any FFM than Europeans. Women had more SSAT at any given FFM than men and less DSAT at any given FFM than men, irrespective of ethnic background. In conclusion, South Asians had more DSAT than Europeans and men had relatively more DSAT than women. These data suggest that specific fat depots are influenced by ethnicity and gender; therefore, could provide insight into the relationship between ethnicity, gender and subsequent risk for CVD.

Comparison of cardiovascular risk factors between Sri Lankans living in Kandy and Oslo

Background

South Asians living in western countries are known to have unfavourable cardiovascular risk profiles. Studies indicate migrants are worse off when compared to those living in country of origin. The purpose of this study was to compare selected cardiovascular risk factors between migrant Sri Lankans living in Oslo, Norway and Urban dwellers from Kandy, Sri Lanka.

Methods

Data on non fasting serum lipids, blood pressure, anthropometrics and socio demographics of Sri Lankan Tamils from two almost similar population based cross sectional studies in Oslo, Norway between 2000 and 2002 (1145 participants) and Kandy, Sri Lanka in 2005 (233 participants) were compared. Combined data were analyzed using linear regression analyses.

Results

Men and women in Oslo had higher HDL cholesterol. Men and women from Kandy had higher Total/HDL cholesterol ratios. Mean waist circumference and body mass index was higher in Oslo. Smoking among men was low (19.2% Oslo, 13.1% Kandy, P = 0.16). None of the women smoked. Mean systolic and diastolic blood pressure was significantly higher in Kandy than in Oslo.

Conclusions

Our comparison showed unexpected differences in risk factors between Sri Lankan migrants living in Oslo and those living in Kandy Sri Lanka. Sri Lankans in Oslo had favorable lipid profiles and blood pressure levels despite being more obese.

Ethnic difference in patients with type 2 diabetes mellitus in inter-East Asian populations: a systematic review and meta-analysis focusing on gene polymorphism

BACKGROUND

We previously reported that the fasting serum insulin level was significantly lower in Japanese patients than in Korean and Chinese patients, and showed evidence that a difference in the dietary component would be one of the most influential factors for the ethnic difference. However, it is well known that type 2 diabetes mellitus (T2DM) results from the interaction between genetic predispositions and environmental risk factors. Therefore, we investigated ethnic differences by focusing on gene polymorphism, possibly related to T2DM in Japanese, Korean, and Chinese subjects.

METHODS

Data sources included MEDLINE and EMBASE between January 2001 and October 2008. We conducted a search for articles containing minor allele frequency (MAF) in the gene polymorphisms of peroxisome proliferator-activated receptor-γ (PPARG), inward-rectifying potassium channel Kir6.2 (KCNJ11), Calpain 10 (CAPN10), and transcription factor 7-like 2 (TCF7L2). The pooled odds ratio was calculated by using a fixed-effects model with the Mantel-Haenszel method after confirming statistical evidence of homogeneity across the ethnicities using the Breslow-Day test.

RESULTS

The Breslow-Day test revealed that there were no statistically significant differences between ethnicities in pooled odds ratios for the gene polymorphisms in PPARG (P = 0.828), KCNJ11 (P = 0.194), CAPN10 (P = 0.090), and TCF7L2 (P = 0.376). Also, pooled odds ratios of each gene polymorphism in East Asians were 0.645 for PPARG (P = 0.000), 1.168 for KCNJ11 (P = 0.000), 0.967 for CAPN10 (P = 0.759), and 1.386 for TCF7L2 (P = 0.000).

CONCLUSION

The results of this study and our previous studies suggest that behavioral and environmental risk factors have a more significant impact on ethnic difference in East Asian patients with T2DM compared with genetic predispositions.

Apolipoproteins in diabetes dyslipidaemia in South Asians with young adult-onset diabetes: distribution, associations and patterns

Background

Apolipoproteins B (apoB) and AI (apoAI) are strong predictors of cardiovascular disease (CVD). We describe apolipoprotein distributions and their associations with lipids and diabetes subtype in diabetic young adult South Asians.

Methods

In 995 subjects with diabetes, we measured fasting total cholesterol (TC), high-density lipoprotein cholesterol (HDLC), triglycerides (TG), apoB and apoAI, glycosylated haemoglobin (HbA1c) and glutamic acid decarboxylase antibodies (GADA). Low-density lipoprotein cholesterol (LDLC) and non-HDLC (NHDLC) were calculated. We compared values in subjects aged 15–50 y from the United States National Health and Nutrition Examination Survey (NHANES).

Results

Median age and duration of diabetes were 38 (range 14–45) and 4 (0–24) y. Men had significantly higher TC, TG, NHDLC, TC/HDLC, apoB/AI and NHDLC/apoB, and lower apoAI than women. Compared with the reference group, patients with type 1 diabetes had lower TG, apoB:apoAI and HDLC:apoAI, and higher HDLC and apoAI. Patients with type 2 diabetes had higher TG, TC, LDLC, NHDLC, TC:HDL, apoB, apoAI and apoB:apoAI, and lower HDLC, LDLC:apoB and HDLC:apoAI. Among patients with type 2 diabetes, 54% had high apoB (>1.2 g/L) and 33% also had high TG (>1.5 mmol/L). Measures of obesity (body mass index and waist circumference) were weakly correlated with lipid and apoprotein parameters, suggesting a modest contribution to dyslipidaemia.

Conclusions

A large proportion of young adult Sri Lankan patients with type 2 diabetes has a low LDLC:apoB and high apoB and/or TG, suggesting that these patients are at increased risk of CVD.

Folate status of Ghanaian populations in London and Accra

Migration to the UK is associated with higher incidence of stroke in African populations. A low folate status has been associated with increased risk of stroke, likely to be mediated through raised plasma homocysteine concentrations. We conducted a cross-sectional study to compare blood folate and homocysteine concentrations in eighty healthy Ghanaian migrants living in London matched by sex, age and occupation to 160 individuals from an urban population in Accra, Ghana. Folate intake was determined using three 24 h recalls. Fasting blood samples were collected for the determination of serum and erythrocyte folate and plasma homocysteine concentrations and the methylenetetrahydrofolate reductase (MTHFR) 677C → T polymorphism. Reported mean folate intake was 20 % lower in London compared with Accra (P < 0·001). However, serum folate was 44 % higher, erythrocyte folate 30 % higher and plasma homocysteine was 26 % lower in subjects from London compared with those from Accra (P < 0·001). These differences persisted after adjusting for confounders including the MTHFR 677C → T mutation, which was rare in both populations. Although there were no associations between dietary folate intake and blood folates (P>0·05), folic acid supplement use, which was more prevalent in London than Accra (25 and 10 %, respectively,P = 0·004) was associated with erythrocyte folate in both populations (P < 0·01). The main predictors of plasma homocysteine concentrations were erythrocyte folate and male sex (P < 0·001). Findings from the present study suggest that migration from Ghana to the UK results in improvement of biomarkers of folate status despite the fact that reported dietary intake of folate was apparently lower in subjects from London.

Triglycerides and small dense low density lipoprotein in the discrimination of coronary heart disease risk in South Asian populations

INTRODUCTION

Coronary heart disease (CHD) is exceptionally prevalent amongst globally dispersed migrant groups originating from the Indian subcontinent, but the contribution of dyslipidaemia to their increased risk remains poorly defined.

METHODS

Fasting lipids and lipoproteins, apolipoproteins (Apo), low density lipoprotein (LDL) diameter and oxidised LDL were measured amongst rural Indians in India (n=294) and their migrant contemporaries in the UK (n=242). The performance of qualitative and quantitative measures of lipid metabolism were compared in the discrimination of WHO defined metabolic risk and raised Framingham CHD risk scores (>15%) using Receiver Operating Characteristic (ROC) curves.

RESULTS

LDL diameter was correlated with triglycerides (R(2)=0.12, P<0.001) and with high density lipoprotein (HDL) cholesterol levels (R(2)=0.15, P<0.001) in both groups. Migrants had less small dense LDL (95% CI: 12.5-14.2%) vs. rural Indians (15.7-17.2, P<0.05). On ROC analysis, triglycerides were the only consistent discriminators of metabolic and CHD risk scores (all P< or =0.001). Apo B was also a strong indicator of raised CHD risk scores. Irrespective of site, individuals with raised triglycerides also had higher total cholesterol and Apo B, denser LDL, lower HDL and more oxidised LDL (all P< or =0.01).

DISCUSSION

Fasting triglycerides reflect both qualitative and quantitative aspects of lipid metabolism, and are a comprehensive discriminator of CHD risk in this South Asian population.

How dietary intake methodology is adapted for use in European immigrant population groups - a review

Immigrants comprise a noteworthy segment of the European population whose numbers are increasing. Research on the dietary habits of immigrants is critical for correctly providing diet counselling and implementing effective interventions. The aim of the present study was to identify the presently used methods and adaptations required for measuring dietary intake in European immigrant groups. A comprehensive review strategy included a structured MEDLINE search, related references and key expert consultations. The review targeted adults from non-European union (European union-15 countries) ethnic groups having the largest populations in Europe. As studies evaluating nutrient intake were scarce, papers evaluating intake at the level of foods were included. Forty-six papers were selected. Although Eastern Europe, Turkey, Africa (North, Sub-Saharan and Afro-Caribbean), Asia and Latin America represented the most numerous immigrant groups, papers on dietary intake were not available for all populations. Interview-administered FFQ and repeated 24 hour recalls were the most frequently applied instruments. Inclusion of ethnic foods and quantification of specific portion sizes of traditional foods and dishes in assessment tools as well as food composition databases were commonly identified problems. For FFQ, food list elaboration required particular consideration to reflect key ethnic foods and relative contribution to nutrient intake. Extra efforts were observed to overcome cultural barriers to study participation. Evaluating dietary intake of immigrant populations requires special attention to various methodological aspects (sampling, recruiting, instruments used, method of administration, food composition database, acculturation, etc.) so as to adequately address the range of socio-cultural factors inherent in these nutritionally at risk target groups.

DHA status of vegetarians

BACKGROUND

Docosahexaenoic acid (22:6n-3; DHA) is absent from vegan diets and present in limited amounts in vegetarian diets.

OBJECTIVE

To review DHA status in vegetarians and vegans.

DESIGN

To identify published studies and review their findings.

RESULTS

Dietary analyses show that vegan diets are devoid of DHA and vegetarian diets that included dairy food and eggs only provide about 0.02 g DHA/d. Vegetarian and especially vegan diets supply more linoleic acid (18:2n-6) than omnivore diets. The intake of alpha-linolenic acid (18:3n-3) also tends to be similar or greater but depends on culinary oils used. The proportions of DHA in plasma, blood cells, breast milk, and tissues are substantially lower in vegans and vegetarians compared with omnivores. The lower proportions of DHA are accompanied by correspondingly higher proportions of the long-chain derivatives of linoleic acid, indicating that the capacity to synthesize long-chain polyunsaturated fatty acids is not limited. Short-term dietary supplementation with alpha-linolenic acid increases the proportion of eicosapentaenoic acid (20:5n-3) but does not increase the proportion of DHA in blood lipids. Small amounts of preformed DHA (as low as 200mg) result in a large increase in the proportion of DHA in blood lipids in vegetarians and vegans. There is no evidence of adverse effects on health or cognitive function with lower DHA intake in vegetarians.

CONCLUSIONS

Preformed DHA in the diet of omnivores explains the relatively higher proportion of this fatty acid in blood and tissue lipids compared with vegetarians. The pathophysiological significance of this difference remains to be determined.

Younger age of escalation of cardiovascular risk factors in Asian Indian subjects

Background

Cardiovascular risk factors start early, track through the young age and manifest in middle age in most societies. We conducted epidemiological studies to determine prevalence and age-specific trends in cardiovascular risk factors among adolescent and young urban Asian Indians.

Methods

Population based epidemiological studies to identify cardiovascular risk factors were performed in North India in 1999–2002. We evaluated major risk factors-smoking or tobacco use, obesity, truncal obesity, hypertension, dysglycemia and dyslipidemia using pre-specified definitions in 2051 subjects (male 1009, female 1042) aged 15–39 years of age. Age-stratified analyses were performed and significance of trends determined using regression analyses for numerical variables and Χ² test for trend for categorical variables. Logistic regression was used to identify univariate and multivariate odds ratios (OR) for correlation of age and risk factors.

Results

In males and females respectively, smoking or tobacco use was observed in 200 (11.8%) and 18 (1.4%), overweight or obesity (body mass index, BMI ≥ 25 kg/m²) in 12.4% and 14.3%, high waist-hip ratio, WHR (males > 0.9, females > 0.8) in 15% and 32.3%, hypertension in 5.6% and 3.1%, high LDL cholesterol (≥ 130 mg/dl) in 9.4% and 8.9%, low HDL cholesterol (<40 mg/dl males, <50 mg/dl females) in 16.2% and 49.7%, hypertriglyceridemia (≥ 150 mg/dl) in 9.7% and 6%, diabetes in 1.0% and 0.4% and the metabolic syndrome in 3.4% and 3.6%. Significantly increasing trends with age for indices of obesity (BMI, waist, WHR), glycemia (fasting glucose, metabolic syndrome) and lipids (cholesterol, LDL cholesterol, HDL cholesterol) were observed (p for trend < 0.01). At age 15–19 years the prevalence (%) of risk factors in males and females, respectively, was overweight/obesity in 7.6, 8.8; high WHR 4.9, 14.4; hypertension 2.3, 0.3; high LDL cholesterol 2.4, 3.2; high triglycerides 3.0, 3.2; low HDL cholesterol 8.0, 45.3; high total:HDL ratio 3.7, 4.7, diabetes 0.0 and metabolic syndrome in 0.0, 0.2 percent. At age groups 20–29 years in males and females, ORs were, for smoking 5.3, 1.0; obesity 1.6, 0.8; truncal obesity 4.5, 3.1; hypertension 2.6, 4.8; high LDL cholesterol 6.4, 1.8; high triglycerides 3.7, 0.9; low HDL cholesterol 2.4, 0.8; high total:HDL cholesterol 1.6, 1.0; diabetes 4.0, 1.0; and metabolic syndrome 37.7, 5.7 (p < 0.05 for some). At age 30–39, ORs were- smoking 16.0, 6.3; overweight 7.1, 11.3; truncal obesity 21.1, 17.2; hypertension 13.0, 64.0; high LDL cholesterol 27.4, 19.5; high triglycerides 24.2, 10.0; low HDL cholesterol 15.8, 14.1; high total:HDL cholesterol 37.9, 6.10; diabetes 50.7, 17.4; and metabolic syndrome 168.5, 146.2 (p < 0.01 for all parameters). Multivariate adjustment for BMI, waist size and WHR in men and women aged 30–39 years resulted in attenuation of ORs for hypertension and dyslipidemias.

Conclusion

Low prevalence of multiple cardiovascular risk factors (smoking, hypertension, dyslipidemias, diabetes and metabolic syndrome) in adolescents and rapid escalation of these risk factors by age of 30–39 years is noted in urban Asian Indians. Interventions should focus on these individuals.

Ischemic Stroke in South Asians

Background and Purpose— Within the United Kingdom, mortality from stroke is higher among South Asians compared to European whites. The reasons for this excess cerebrovascular risk in South Asians remain unclear. The aim of this review is to present a comprehensive and systematic overview of the available literature relating to ischemic stroke among South Asian populations identifying distinct features of stroke epidemiology in this group.

Summary of Review— A high frequency of lacunar strokes is a familiar pattern among South Asians, which suggests a greater prevalence of small-vessel disease in South Asians. This may be a consequence of abnormal metabolic and glycemic processes. In addition, stroke mortality among South Asians appears to be explained by glycemic status, which is an independent predictor of long-term stroke mortality. Within India, there is a perceptible rural–urban gradient in stroke prevalence, underlying the dangers of the rapid transition in socioeconomic circumstances seen across the Indian subcontinent.

Conclusions— This review emphasizes the importance of further research into ischemic stroke for South Asians given their higher cardiovascular disease burden and necessity for targeted healthcare approaches.

Statin therapy in South Asians-facts and future

South Asians have higher overall burden of coronary heart disease. South Asian migrants suffer from more severe and fatal coronary heart disease at younger age despite similar risk factors compared with local population. Elevated blood cholesterol contributes to atherosclerosis and heart disease and is one of the primary modifiable risk factor for these conditions. Since the discovery of a fungal metabolite that inhibits 3-hydroxy-3methyl-glutaryl-coenzyme A reductase, statins have emerged rapidly as the global leader in medical therapeutics designed to lower low-density lipoprotein cholesterol and had reduced mortality and morbidity from coronary heart disease when used for primary or secondary prevention. Despite the considerable burden imposed by cardiovascular disease, South Asians remain inadequately targeted for risk-reduction strategies, including screening and treatment for dyslipidemia.

Migration and health in Italy: a multiethnic adult sample

BACKGROUND

Immigration to Italy has increased drastically, but there is a paucity of data on the health of these immigrant populations and the need to improve their health care. Therefore, we analyzed a multiethnic immigrant population in Bologna (northern Italy) to identify the risk factors for health. This anthropometric study was part of a multiregional project "Health Assistance and Monitoring for Indigent Italian Citizens and Immigrants" funded by the Italian Ministry of Health.

METHODS

The sample consisted of 401 adult immigrants from southeastern Europe (Kosovars, Gypsies, or Roma) and four extra European countries (Senegalese, Moroccans, Tunisians, and Pakistanis). Ethnic ancestry was self-reported. Anthropometric (height, weight, and waist circumference) and blood pressure data were collected during the survey.

RESULTS

The prevalence of overweight (and obesity) exceeded 50% in Moroccans and Kosovars of both sexes and in male Roma. The ethnic heterogeneity was associated with different patterns of obesity: the highest prevalence of abdominal obesity was in Moroccan and Kosovar women and in male Kosovars and Gypsies. The highest prevalence of hypertension (more than 20%) was in Senegalese, Kosovar, and Gypsy males.

CONCLUSIONS

Some of the immigrant subsamples had a high prevalence of obesity, which is associated with morbidity. Our findings on the relationships between the anthropometric traits and the blood pressure suggest different cardiovascular disease risk profiles in the ethnic groups (higher for Kosovars and Roma) and an urgent need for preventive measures.

Ethnicity and peripheral artery disease

Peripheral arterial disease (PAD) is an important healthcare problem and is an indicator of widespread atherosclerosis in other vascular territories, such as the cerebral and coronary circulations. PAD is associated with considerable morbidity and mortality. Most population-based studies investigating PAD prevalence and risk factors for its development and progression have been based on predominantly White ethnic groups. Much less is known about the characteristics of this disease in other ethnic groups. Understanding the epidemiology of PAD amongst ethnic minority groups is relevant, given that the population of minority ethnic groups in countries such as the United Kingdom rose by 53% between 1991 and 2001 and is expected to rise further in the future. This article aims to provide an overview of possible pathophysiological differences between ethnic groups for PAD, focussing predominantly on South Asians (people originating from India, Bangladesh and Pakistan) and Blacks (people of Black Caribbean and Black African descent) as these groups comprise the majority of all ethnic minorities in the United Kingdom.

Genetic and environmental factors in human osteoporosis from Sub-Saharan to Mediterranean areas

The aim of this study was to determine the prevalence of known gene polymorphisms associated with osteoporosis in postmenopausal normal women from Burkina Faso and Sicily, compared to postmenopausal Sicilian women with osteoporosis, and to establish the weight of environmental factors in the mechanism of osteoporosis. Bone mass density (BMD) was measured by phalangeal quantitative ultrasound (QUS) in Burkinabe woman and by the dual X-ray absorptiometry at the femoral neck in Sicilian women. The polymorphisms of the vitamin D receptor (VDR) gene, estrogen receptor (ESR) gene, calcitonin receptor (CTR) gene and COL1A1 collagen gene were characterized by PCR. The social characteristics of studied women were evaluated by a specific questionnaire. The observed percentages of single specific polymorphisms did not differ from that expected with exception of VDR B allele and ESR X and P allele in Burkinabe and Sicilian women, respectively. Association analyses and multivariate two-step regression model of social and molecular parameters, demonstrated that in comparison to the VDR, ESR, CTR polymorphisms, physical activities and healthy diet, associated with outdoor work are the best favourable prognostic factors for osteoporosis. A diet rich in calcium, other minerals and vitamin D in association with physical activity represents the most effective way to maintain not only a healthy bone structure but also an acceptable BMD. This is particularly true for Sub-Saharan women.

Ethnic difference in inter-East Asian subjects with normal glucose tolerance and impaired glucose regulation: a systematic review and meta-analysis focusing on fasting serum insulin

AIMS

To investigate ethnic difference by focusing on fasting serum insulin (FSI) in inter-East Asian subjects with normal glucose tolerance (NGT) and impaired glucose regulation (IGR).

METHODS

Data sources included MEDLINE and EMBASE between 2001 and 2007. We conducted a search for articles containing mean or geometric mean values of FSI in East Asian subjects with NGT, IGR, or type 2 diabetes (T2DM). The Monte Carlo method was used for simulation of the mean and standard deviation of individual measures in each ethnic group; calculation of the median ratio and 95% confidence interval of individual measures between ethnic groups.

RESULTS

Twenty-two articles fully met our pre-determined criteria and were included in the meta-analysis. Results of the meta-analysis revealed that FSI level is significantly lower in Japanese subjects with NGT, IGR, or T2DM than in Korean and Chinese subjects.

CONCLUSIONS

Ethnic difference in FSI level between East Asians was observed in not only T2DM patients but also subjects with NGT or IGR. The lower FSI level in Japanese subjects was accompanied by lower triglyceride level. These results suggest that ethnic difference in dietary habit was one of the most influential factors for the ethnic difference in FSI.

Lifestyle of Asian Indians with coronary heart disease: the Australian context

This paper aims to report lifestyle factors of Asian Indians in Australia in relation to coronary heart disease. This issue has not been previously explored in the Australian context. This study also seeks to identify factors that could inform health education and rehabilitation programs for migrant Asian Indians in Australia. The qualitative descriptive approach of constructivism was used for this study. Semi-structured, in-depth conversations were conducted with eight patients and five family members. Participants were at risk for coronary heart disease either due to unhealthy diet and/or lack of physical exercise and irregular health checks. Although lifestyle modifications were implemented by participants after the cardiac event; these changes were implemented inconsistently and without continuity. Knowledge of the beneficial effects of a healthy diet did not deter the participants from continuing to follow unhealthy dietary habits. The introduction of any exercise or physical activity by participants in this study lacked consistency. A positive aspect revealed from this study was the influence of culture and religious faith, which helped patients and family members to cope with the illness trajectory. The results of this study suggest that health education and rehabilitation programs need to be designed specifically for this high-risk group would be beneficial when initiated early in life and need to be targeted to the individual.

Ethnic difference in patients with type 2 diabetes mellitus in inter-East Asian populations: a systematic review and meta-analysis focusing on fasting serum insulin

AIMS

To investigate ethnic difference by focusing on fasting serum insulin (FSI) in inter-East Asian patients with type 2 diabetes.

METHODS

Data sources included MEDLINE and EMBASE between 2001 and 2006. We conducted a search for articles containing mean or geometric mean values of FSI in East Asian patients with type 2 diabetes. The Monte Carlo method was used for simulation of the mean and standard deviation of individual measures in each ethnic group; calculation of the median ratio and 95% confidence interval of individual measures between ethnic groups.

RESULTS

The initial search identified a total of 996 journal articles. After reviewing the titles and abstracts of these articles, 201 studies were selected for further screening and the complete papers on these studies were then reviewed in detail. Of these, seven articles fully met our pre-determined criteria and were included in the meta-analysis. Results of the meta-analysis revealed that FSI level is significantly lower in Japanese patients than in Korean and Chinese patients.

CONCLUSIONS

Results from our review of ethnic differences in dietary habit in the inter-East Asian population suggested that difference in dietary component was one of the most influential factors for the ethnic difference.

Waist circumference, metabolic syndrome and coronary artery disease in a Pakistani cohort

BACKGROUND

Metabolic syndrome (M-IRS) is common in Asians. This study investigated the relationship of two definitions of M-IRS to atherosclerosis in Indian Asians with suspected coronary arterial disease (CAD).

METHODS

400 patients with chest pain selected for the presence or absence of angiographic disease were recruited from a tertiary referral centre in Pakistan into a prospective case-control study. Patients were categorized by the National Cholesterol Education Program adult treatment panel 3 (NCEP) and International Diabetes Federation (IDF) definitions of the metabolic syndrome and the relationship of these to the presence of CAD and extent of atheroma burden was investigated.

RESULTS

M-IRS was present in 53% by IDF criteria and in 44% using the Asian criteria for NCEP. The 2 populations identified were only 69% concordant. No relationship existed between the presence of NCEP M-IRS and atheroma burden. In contrast, the presence of IDF M-IRS was associated with CAD (65 vs. 34%; RR=1.88; p<0.001) and angiographic disease burden (28 [0-224] vs. 0 (0-198); RR=1.83; p<0.001). This association persisted (beta=18.4; p<0.001) after correction for C-reactive protein (beta=8.67; p<0.001), lipoprotein (a) (beta=8.14; p=0.002), and estimated glomerular filtration rate (beta=-0.22; p=0.01). Differences in presumed underlying factors were found in the 2 populations identified by the definitions though both agreed on the separate weightings given to blood pressure and HDL-C/apolipoprotein A1.

CONCLUSIONS

The specific Asian IDF and NCEP definitions of M-IRS show limited concordance in Pakistanis. The IDF criteria in contrast to the NCEP criteria are associated with the presence of CAD even after allowing for other risk factors identified in this population.

Westernization of the Filipino population resident in Rome: obesity, diabetes and hypertension

BACKGROUND

Aims of the present study were to examine the anthropometrical and metabolic characteristics of the Filipino population migrant to the Southern European city of Rome, Italy.

METHODS

A cross-sectional study was carried out in the city of Rome. Three hundred thirty-five Filipinos (95 M/240 F, mean age: 44.0+/-9.8 years, mean residence in Italy: 12.9+/-6.3 years) were studied. Data were collected by standardized questionnaires; anthropometrical parameters, arterial pressure, and fasting capillary blood glucose (FCG) were measured.

RESULTS

Abdominal obesity was found in 52.5%, and BMI >or= 25 kg/m(2) in 44.5% of subjects. History of type 2 diabetes mellitus (T2DM) and hypertension were reported by 6.0 and 9.0% of subjects, respectively. Impaired fasting glucose was found in 13.1%, and FCG >or= 110 mg/dl in 18.5% of subjects. Altered systolic and/or diastolic blood pressure was found in 34.3% of subjects. About three-fourths of subjects were unaware of being diabetic and/or hypertensive. Years of Italy residence showed a direct significant correlation with the degree of changes in alimentary behaviours (rho=0.18, p=0.001), and with weight gain (rho=0.27, p<0.001). Multivariate analysis showed only age and waist circumference to be associated with both diabetes and hypertension.

CONCLUSIONS

In the present study, the first to examine the metabolic disorders in a migrant Filipino population resident in Rome, a high prevalence of obesity, diabetes, and hypertension was found. The alarming results emerging from this study should be seriously considered by public health practitioners and decision makers, and made known to the Filipinos resident in Europe.

Environmental risk factors for heart disease

In this review, we discuss current evidence linking environmental pollutants to cardiovascular disease (CVD). Extensive evidence indicates that environmental factors contribute to CVD risk, incidence, and severity. Migrant studies show that changes in the environment could substantially alter CVD risk in a genetically stable population. Additionally, CVD risk is affected by changes in nutritional and lifestyle choices. Recent studies in the field of environmental cardiology suggest that environmental toxins also influence CVD. Exposure to tobacco smoke is paradigmatic of such environmental risk and is strongly and positively associated with increased cardiovascular morbidity and mortality. In animal models of exposure, tobacco smoke induces endothelial dysfunction and prothrombotic responses and exacerbates atherogenesis and myocardial ischemic injury. Similar mechanism may be engaged by other pollutants or food constituents. Several large population-based studies indicate that exposure to fine or ultrafine particulate air pollution increases CVD morbidity and mortality, and the plausibility of this association is supported by data from animal studies. Exposure to other chemicals such as polyaromatic hydrocarbons, aldehydes, and metals has also been reported to elevate CVD risk by affecting atherogenesis, thrombosis, or blood pressure regulation. Maternal exposure to drugs, toxins, and infection has been linked with cardiac birth defects and premature CVD in later life. Collectively, the data support the notion that chronic environmental stress is an important determinant of CVD risk. Further work is required to assess the magnitude of this risk fully and to delineate specific mechanisms by which environmental toxins affect CVD.

Changing dietary habits of ethnic groups in Europe and implications for health

A systematic review of the literature suggests the dietary habits of some ethnic groups living in Europe are likely to become less healthy as individuals increase consumption of processed foods that are energy dense and contain high levels of fat, sugar, and salt. Such products often replace healthy dietary components of the native diet, such as fruits, vegetables, nuts, and grains. Mixed food habits are emerging mainly amongst younger people in the second and third generations, most likely due to acculturation and adoption of a Western lifestyle. Age and immigrant generation are the major factors accounting for changes in dietary habits, whilst income, level of education, dietary laws, religion, and food beliefs are also important factors. Obesity, cardiovascular disease, diabetes, and hypertension present major problems for the mainstream European population. However, the risk of chronic disease is reported to be higher in ethnic populations, particularly South Asians, African Caribbeans, and Mexicans.

Insulin resistance phenotypes and coronary artery disease in a native Pakistani cohort

OBJECTIVE

To determine the relationship between insulin resistance (IR) and atheroma burden in Pakistanis.

METHODS

A prospective case-control study of 400 patients selected for the presence/absence of angiographic disease. Coronary atheroma burden was quantified and IR and cardiovascular risk factors were measured.

RESULTS

The patients were divided into two groups by QuickI score. Waist circumference (90 +/- 10 vs. 90 +/- 9 cm; p = 0.7) was similar but the groups differed in body mass index (26.5 +/- 3.7 vs. 24.2 +/- 3.5 kg/m(2); p < 0.001) and waist:hip ratio (0.94 +/- 0.09 vs. 0.90 +/- 0.06; p < 0.001). Lipid parameters showed similar high-density lipoprotein cholesterol (HDL-C) (0.77 +/- 0.23 vs. 0.82 +/- 0.22 mmol/l; p = 0.1) differences in triglycerides [1.32 (0.08-3.98) vs. 1.12 (0.37-3.61) mmol/l; p = 0.01], but no difference in low-density lipoprotein cholesterol (LDL-C) (2.75 +/- 1.00 vs. 2.90 +/- 0.94 mmol/l; p = 0.14). In insulin-resistant patients C-reactive protein (CRP) [6.8 (0.3-175.1) vs. 3.9 (0.2-57.9) mg/l: p < 0.001], sialic acid (82 +/- 14 vs. 77 +/- 15 mg/l; p < 0.001) aspartate transaminase [24 (7-171) vs. 21 (7-83) IU/l; p < 0.001] and gamma-glutamyl transferase [27 (8-482) vs. 21 (7-168) IU/l; p = 0.005] levels were increased. In insulin-resistant patients (n = 187), coronary artery disease (CAD) burden correlated (r = 0.55) with age (beta = 1.62; p < 0.001), HDL-C (beta = -53.2; p < 0.001), lipoprotein (a) (beta = 11.4; p = 0.007), smoking (beta = 7.98; p = 0.004), CRP (beta = 6.06; p = 0.03) and QuickI index (beta = -146; p = 0.04). In contrast in insulin-sensitive patients (n = 178) CAD burden (r = 0.46) correlated with LDL-C (beta = 10.0; p = 0.02), CRP (beta = 7.13; p = 0.03), HDL-C (beta = -38.1; p = 0.03), and weakly with age (beta = 0.73; p = 0.07) and smoking (beta = 5.52; p = 0.09).

CONCLUSIONS

Indian Asians show a dichotomous insulin-resistance phenotype. Atheroma is associated with low HDL-C and inflammation associated in all but LDL-C is a factor in the insulin sensitive in contrast to age and extent of IR in the insulin resistant.

Increased 5-year mortality in the migrant South Asian stroke patients with diabetes mellitus in the United Kingdom: the West Birmingham Stroke Project

BACKGROUND

Stroke is a major cause of premature mortality in Britain, but its burden is markedly greater amongst South Asians. Because of the paucity of data in this area, we investigated the magnitude and impact of risk from cardiovascular comorbidities on survival amongst South Asian stroke patients.

METHODS

We reviewed hospital case records of consecutive first in life time ischaemic stroke patients [self reported ethnicity and International Classification of Disease (ICD) 10th revision, codes 430-438] admitted to an inner city hospital in the UK between 1997 and 2001. In-hospital mortality data and CVD risk factors were analysed. Five-year mortality data was obtained from the National Health Tracing Services.

RESULTS

Of 1474 ischaemic stroke patients, 242 (16%) were South Asian of whom, 143 (59.1%) were male. The prevalence of hypertension was 70.2%, followed by diabetes 56.2%, hyperlipidaemia 7% and myocardial infarction 10.3%. At 5 years follow-up, 40.5% had died. Cumulative event-free survival at 5 years was significantly poorer in patients with diabetes (log-rank test, p=0.009). On Cox regression analysis, incorporating age, gender and other CVD risk factors, diabetes mellitus was an independent predictor of mortality odds ratio=1.65 (1.02-2.6, p=0.039). Hypertension and dyslipidaemia did not discriminate survival amongst South Asian patients.

CONCLUSION

Stroke mortality in South Asians is associated with presence of diabetes mellitus. This highlights the significance of early and intensive CVD risk modification strategies in ethnic minorities particularly in patients with diabetes. Further research is warranted in South Asians to examine the underlying basis and related pathophysiological abnormalities.

Widening access to cardiovascular healthcare: community screening among ethnic minorities in inner-city Britain - the Healthy Hearts Project

BACKGROUND

The burden of cardiovascular disease (CVD) in Britain is concentrated in inner-city areas such as Sandwell, which is home to a diverse multi-ethnic population. Current guidance for CVD risk screening is not established, nor are there specific details for ethnic minorities. Given the disparity in equitable healthcare for these groups, we developed a 'tailored' and systematic approach to CVD risk screening within communities of the Sandwell locality. The key anticipated outcomes were the numbers of participants from various ethnic backgrounds attending the health screening events and the prevalence of known and undiagnosed CVD risk within ethnic groups.

METHODS

Data was collected during 10 health screening events (September 2005 and July 2006), which included an assessment of raised blood pressure, overweight, hyperlipidaemia, impaired fasting glucose, smoking habit and the 10 year CVD risk score. Specific features of our approach included (i) community involvement, (ii) a clinician who could deliver immediate attention to adverse findings, and (iii) the use of an interpreter.

RESULTS

A total of 824 people from the Sandwell were included in this study (47% men, mean age 47.7 years) from community groups such as the Gujarati Indian, Punjabi Indian, European Caucasian, Yemeni, Pakistani and Bangladeshi. A total of 470 (57%) individuals were referred to their General Practitioner with a report of an increased CVD score - undetected high blood pressure in 120 (15%), undetected abnormal blood glucose in 70 (8%), undetected raised total cholesterol in 149 (18%), and CVD risk management review in 131 (16%).

CONCLUSION

Using this systematic and targeted approach, there was a clear demand for this service from people of various ethnic backgrounds, of whom, one in two needed review from primary or secondary healthcare. Further work is required to assess the accuracy and clinical benefits of this community health screening approach.

Migration and its impact on adiposity and type 2 diabetes

In this review, we discuss the impact of migration on the incidence and prevalence of obesity and type 2 diabetes mellitus (T2DM) in different ethnic groups and populations. We also analyze the determinants of such phenomena in view of the global increase in the migration and escalating prevalence of obesity and T2DM. The risk escalation of the obesity and T2DM followed a gradient, as migrants (Blacks, Hispanics, Chinese, South Asians, etc.) became more affluent and urbanized, indicating an important role of environmental factors. A stepwise increase in the prevalence of obesity in Blacks along the path of migration (5% in Nigeria, 23% in Jamaica, and 39% in the United States) is a classic example. Furthermore, South Asian migrants, who are particularly predisposed to develop insulin resistance and T2DM, showed nearly four times prevalence rates of T2DM than rural sedentee populations. Similar observations were also reported in intracountry migrants and resettled indigenous populations. The determinants were found to include nutrition transition, physical inactivity, gene-environment interaction, stress, and other factors such as ethnic susceptibility. However, certain contradictory trends were also seen in some migrant communities and have been explained by various phenomena such as healthy migrant effect, "salmon bias", and adherence to traditional diets. A review of the evidence suggests a critical role of environmental factors in conferring an increased risk of obesity and T2DM. The important contributory factors to this phenomenon were urbanization, mechanization, and changes in nutrition and lifestyle behaviors, but the role of stress and as yet unknown factors remain to be determined.

Raised leptin concentrations among South Asian patients with chronic heart failure

BACKGROUND

The disease presentation of chronic heart failure (CHF) is considered to progress with metabolic deterioration, underlined by changes in adipose associated hormones (adipocytokines). However, little is known about ethnic variations of adipocytokines amongst CHF patients, in particular South Asians, who are at an increased risk of CHF.

METHODS

Using a cross-sectional study, South Asians (n=106) and Caucasians (n=105) living in the UK were compared by CHF status. We investigated ethnic differences in adipocytokines (leptin, adiponectin, tumor necrosis factor (TNF)alpha), and their association with CHF. Patients with mild to moderate CHF were recruited from heart failure clinics (47 Caucasian, 54 South Asian), and compared to healthy controls. Metabolic parameters (including insulin resistance using HOMA modelling), echocardiography and brain natriuretic peptide (BNP) were measured amongst patients and healthy controls, and compared across and within ethnic groups.

RESULTS

Mean (log transformed) plasma leptin concentrations were highest amongst South Asian patients, being 5.25% (95%CI: 1.50-9.02) higher than Caucasian patients (P=0.007), and similarly raised with respect to controls (P< or =0.04). Indices of insulin resistance were higher amongst CHF patients compared with controls, with no ethnic variation. In addition to age, female gender and body-mass index, levels of leptin were also associated with South Asian ethnicity (P<0.001), insulin resistance (P=0.02), smoking habit (P=0.01) and HDL cholesterol (P=0.004). Levels of adiponectin showed no ethnic variation, but were associated with CHF and a previous history of myocardial infarction (P<0.001). On multivariate regression analysis of patients and healthy controls, CHF was independently associated with smoking habit, adiponectin and insulin resistance (all P<0.01).

CONCLUSION

Metabolic abnormalities are present in CHF, which in turn, are influenced by ethnicity. The role of adipocytokines in CHF pathophysiology and prognosis merits further study.

Diet quality of North African migrants in France partly explains their lower prevalence of diet-related chronic conditions relative to their native French peers

Mediterranean migrant men living in France have lower mortality and morbidity than local-born populations for nutrition-related noncommunicable diseases (NR-NCD). We studied diet quality and its influence on NR-NCD in Tunisian migrants compared with 2 nonmigrant male groups: local-born French and nonmigrant Tunisians, using a retrospective cohort study. We performed quota sampling (n = 147) based on age and place of residence. Using logistic regression models, components of the Diet Quality Index-International (DQI-I) were tested as potential mediators for the effect of migration on overweight, hypertension, hypercholesterolemia, type-2 diabetes, and cardiovascular diseases (CVD). The total DQI-I score revealed good overall diet quality ( approximately 60/100) for all groups. Migrants scored higher than the French in variety, adequacy, and moderation and lower than Tunisians in overall balance. Migrants displayed a lower prevalence of overweight than French, lower prevalence of diabetes and CVD than Tunisians, and lower prevalence of hypertension and hypercholesterolemia than the 2 nonmigrant groups. No mediator was found for overweight. Diet adequacy, fruits, and vitamin C were mediators of the difference in hypercholesterolemia between migrants and French and the effect on hypertension was mediated by diet adequacy and fiber. Compared with Tunisians, the effect of migration on hypercholesterolemia was mediated by saturated fat. No mediator was found for hypertension, diabetes, or CVD. Despite increasing NR-NCD levels in both France and Tunisia, migrants appear to have conserved some healthy dietary characteristics that partly explain their difference in NR-NCD with local-born French, but other lifestyle factors may contribute to the favorable effect of migration.

Effects of white European, African Caribbean and South Asian ethnicity on homocysteine levels in patients with systolic heart failure

BACKGROUND

Patients with heart failure of any cause have elevated homocysteine compared to healthy controls. A number of studies in the UK and other western countries have documented higher levels of homocysteine among South Asian than among White European or African Caribbean subjects both in health and in disease, and have suggested that dietary deficiency of folate is the main cause for the difference.

METHODS

Plasma homocysteine, vitamin B(12), and folate levels were measured in a multiethnic UK heart failure clinic population (n=112), and compared to matched control subjects (n=131).

RESULTS

Plasma homocysteine levels were significantly higher in heart failure patients than controls (p<0.001), a result that was consistent across all ethnic groups. There was no difference in homocysteine levels by ethnic group in either patients (p=0.898) or controls (p=0.368). There was no significant difference in levels of folate or B(12) among patients or controls. Using a stepwise linear regression model, homocysteine levels in patients and controls were independently associated with age (p<0.001), vitamin B(12) (p<0.001), folate (p<0.001) and healthy control status (p<0.001), but not with gender, ethnicity, diabetes status, smoking status or BNP levels.

CONCLUSION

This study does not provide evidence of ethnic differences in homocysteine levels between White European, South Asian, and African Caribbean subjects with systolic heart failure. The lack of difference in levels of folate or B(12) among patients or controls, suggests that homocysteine levels - and differences previously seen between South Asians and other ethnic groups - may be driven by dietary factors.

Secular trends in the cardiovascular risk profile and mortality of stroke admissions in an inner city, multiethnic population in the United Kingdom (1997–2005)

Our objective was to study ethnic differences in the cardiovascular risk profile and mortality of stroke admissions to an inner city teaching hospital serving a multiethnic population in Birmingham, UK, over a 9-year period (1997-2005). Hospital case notes and registry data of 3083 patients admitted with a first onset stroke were reviewed. Secular trends in the prevalence of risk factors (hypertension, diabetes, hyperlipidaemia, atrial fibrillation and myocardial infarction), hospital admission rates and 30-day mortality among Afro-Caribbean, European Caucasian and South Asian ethnic groups were analysed. Between 1997 and 2005, there were 3083 first onset strokes, of whom 47.6% (1595) were men, 9.3% Afro-Caribbean, 57.8% European Caucasian and 15.1% South Asian. There was a significant trend towards a reduction in non-haemorrhagic stroke admissions over the study period (P<0.001), with no ethnic variation (P=0.07). Increases in hypertension and hyperlipidaemia were observed (P<0.001), whereas myocardial infarction showed a decline (P<0.001). Compared to other ethnic groups, South Asian patients were younger on admission (P<0.001), had more hyperlipidaemia (P<0.05) and poorer survival at 30 days (P=002). We conclude that cardiovascular risk profiles among patients admitted with non-haemorrhagic stroke have changed over the last decade. In particular, hyperlipidaemia has increased, especially among South Asians. The reduced decline in stroke admissions and 30-day survival of stroke in South Asians in recent years warrants further investigation and highlights the importance of a targeted health-care approach in the migrant ethnic minorities.

Visceral adipose tissue accumulation differs according to ethnic background: results of the Multicultural Community Health Assessment Trial (M-CHAT)

BACKGROUND

It was suggested that body fat distribution differs across ethnic groups, and this may be important when considering risk of disease. Previous studies have not adequately investigated differences in discrete regions of abdominal adiposity across ethnic groups.

OBJECTIVE

We compared the relation between abdominal adipose tissue and total body fat between persons living in Canada of Aboriginal, Chinese, and South Asian origin with persons of European origin.

DESIGN

Healthy Aboriginal, Chinese, European, and South Asian participants (n = 822) aged between 30 and 65 y were matched by sex, ethnicity, and body mass index (BMI; in kg/m(2)) range. Total abdominal adipose tissue (TAT), subcutaneous abdominal adipose tissue (SAT), visceral adipose tissue (VAT), total body fat mass, lifestyle, and demographics were assessed. Relations between BMI and total body fat, TAT, SAT, and VAT and between total body fat and TAT, SAT, and VAT were investigated.

RESULTS

BMI significantly underestimated VAT in all non-European groups. Throughout a range of total body fat mass, VAT was not significantly different between the Aboriginals and the Europeans. With total body fat >9.1 kg, Chinese participants had increasingly greater amounts of VAT than did the Europeans (P for interaction = 0.008). South Asians had less VAT with total body fat >37.4 kg but more VAT below that amount than did Europeans (P for interaction < 0.001).

CONCLUSION

Compared with Europeans, the Chinese and South Asian cohorts had a relatively greater amount of abdominal adipose tissue, and this difference was more pronounced with VAT. No significant differences were observed between the Aboriginals and the Europeans.

Increased carotid intima-media thickness in remote and urban Indigenous Australians: impact of diabetes and components of the metabolic syndrome

OBJECTIVE

Indigenous Australians have rates of cardiovascular (CVD) mortality some seven to 10-fold higher than non-Indigenous Australians aged 25-64 years. We aimed to evaluate the impact of type 2 diabetes and components of the metabolic syndrome on carotid intima-media thickness (CIMT) as a marker of cardiovascular risk in Indigenous Australians living in remote and urban environments and in Australians of European ancestry.

DESIGN, PATIENTS AND MEASUREMENTS

CIMT was measured by high-resolution B-mode ultrasound imaging of the common carotid artery in 119 remote Indigenous, 144 urban Indigenous and 122 urban European Australians with and without diabetes.

RESULTS

In nondiabetic participants, CIMT was lowest in Europeans (mean (SD) 0.64 mm (0.10)), higher in urban Indigenous Australians (0.67 mm (0.12)) and highest in remote Indigenous Australians (0.73 mm (0.15), P < 0.001). CIMT was higher with diabetes with the same pattern observed between populations: 0.73 mm, 0.79 mm and 0.82 mm, respectively (P < 0.001). Traditional risk factors (age, male gender, blood pressure and HbA1c) explained 35-45% of the variance of CIMT within each population group. However, differences in CIMT between population groups were maintained after adjustment for these cardiovascular risks plus cholesterol and smoking (P < 0.001). Factor analysis revealed that variables of the metabolic syndrome, together with smoking and elevated C-reactive protein (CRP) and urinary albumin-creatinine ratio (ACR), are likely to explain the higher CIMT in Indigenous Australians (and the urban-remote gradient). Unmeasured variables (genetic, psychosocial and socioeconomic) may also contribute to higher CIMT in these populations.

CONCLUSION

Glycaemic control and metabolic syndrome components contribute significantly to premature atherogenesis in Indigenous Australians and we recommend that therapy should be targeted accordingly.