Lifestyle Choices Fuel Epidemics of Diabetes and Cardiovascular Disease Among Asian Indians

A School-based survey among adolescents on Dietary pattern, Exercise, and Knowledge of Cardiovascular risk factors (ADEK) Study

Background. Cardiovascular disease is a global emerging problem and its risk starts in children and adolescents. Adolescents have modifiable cardiovascular risk factors that have been found globally, and nationally, and early intervention programs may be able to lower these risks for both individuals and populations. Accurate risk factor evaluation at the individual level is crucial in this situation for the prevention of cardiovascular disease. Objective. The study aimed to investigate cardiovascular disease knowledge and to determine physical activity, and dietary patterns among school-going adolescents in Arakkonam, Tamil Nadu, India. Methods. A school-based cross-sectional survey was conducted to assess cardiovascular disease knowledge among 500 adolescents aged 10-18 from public schools. The study period was from September 2021 to February 2022. The measurement taken on anthropometrics such as height, weight, body mass index, and bio-physiological measurement as blood pressure, structured questionnaire assessed for knowledge, dietary questionnaire assessed previous week food consumption which the investigator developed, and physical activity standard questionnaire assessed the past week’s exercise level. Data were analyzed using IBM Statistical Package for Social Sciences version 20. Results. The mean study population age was 13.7±1.7, 53% were boys, and 47% were girls. Factors like age 16-18 years (p=0.01), site of residence from urban (p=0.001), education of teenagers (p=0.01), and family history of cardiovascular disease (p=0.001) are significantly correlated with the level of knowledge score, with better-educated adolescents having fair knowledge score than others. Level of knowledge score and demographic traits are associated with physical activity, such as 16 to 18 years (p=0.03), living in an urban region (p=0.03), being in a joint household (p=0.001), adolescents who are at higher secondary (p=0.02), and having a family history contribute more to cardiovascular disease (p=0.001) than other variables. Mean days eating diets were egg (4.18±2.27), vegetables (3.92±0.93), milk products (3.85±1.87), fried foods (3.75±1.25), toffees, and chocolates (3.35±1.81) all had higher percentages of consumed foods than others. Conclusion: There is a risk of cardiovascular disease higher among adolescents. Still a need for school-based primordial preventive educational approaches needed to improve to curb this burden.

Leading causes of death in Asian Indians in the United States (2005–2017)

Objective

Asian Indians are among the fastest growing United States (US) ethnic subgroups. We characterized mortality trends for leading causes of death among foreign-born and US-born Asian Indians in the US between 2005–2017.

Study design and setting

Using US standardized death certificate data, we examined leading causes of death in 73,470 Asian Indians and 20,496,189 non-Hispanic whites (NHWs) across age, gender, and nativity. For each cause, we report age-standardized mortality rates (AMR), longitudinal trends, and absolute percent change (APC).

Results

We found that Asian Indians’ leading causes of death were heart disease (28% mortality males; 24% females) and cancer (18% males; 22% females). Foreign-born Asian Indians had higher all-cause AMR compared to US-born (AMR 271 foreign-born, CI 263–280; 175.8 US-born, CI 140–221; p<0.05), while Asian Indian all-cause AMR was lower than that of NHWs (AMR 271 Indian, CI 263–278; 754.4 NHW, CI 753.3–755.5; p<0.05). All-cause AMR increased for foreign-born Asian Indians over time, while decreasing for US-born Asian Indians and NHWs.

Conclusions

Foreign-born Asian Indians were 2.2 times more likely to die of heart disease and 1.6 times more likely to die of cancer. Asian Indian male AMR was 49% greater than female on average, although AMR was consistently lower for Asian Indians when compared to NHWs.

Cardiovascular disease in diabetes, beyond glucose

Despite the decades-old knowledge that diabetes mellitus is a major risk factor for cardiovascular disease, the reasons for this association are only partially understood. While this association is true for both type 1 and type 2 diabetes, different pathophysiological processes may be responsible. Lipids and other risk factors are indeed important, whereas the role of glucose is less clear. This lack of clarity stems from clinical trials that do not unambiguously show that intensive glycemic control reduces cardiovascular events. Animal models have provided mechanisms that link diabetes to increased atherosclerosis, and evidence consistent with the importance of factors beyond hyperglycemia has emerged. We review clinical, pathological, and animal studies exploring the pathogenesis of atherosclerosis in humans living with diabetes and in mouse models of diabetes. An increased effort to identify risk factors beyond glucose is now needed to prevent the increased cardiovascular disease risk associated with diabetes.

Cardiovascular Risk Prediction using JBS3 Tool: A Kerala based Study

Background:

Accuracy of Joint British Society calculator3 (JBS3) cardiovascular (CV) risk assessment tool may vary across the Indian states, which is not verified in south Indian, Kerala based population.

Objectives:

To evaluate the traditional risk factors (TRFs) based CV risk estimation done in Kerala based population.

Methods:

This cross-sectional study uses details of 977 subjects aged between 30 and 80 years, recorded from the medical archives of clinical locations at Ernakulum district, in Kerala. The risk categories used are Low (<7.5%), Intermediate (≥7.5% and <20%), and High (≥20%) 10-year risk classifications. The lifetime classifications are Low lifetime (≤39%) and High lifetime (≥40%) are used. The study evaluated using statistical analysis; the Chi-square test was used for dependent and categorical CV risk variable comparisons. A multivariate ordinal logistic regression analysis for the 10-year risk and odds logistic regression analysis for the lifetime risk model identified the significant risk variables.

Results:

The mean age of the study population is 52.56±11.43 years. With 39.1% in low, 25.0% in intermediate, and 35.9% has high 10-year risk. Low lifetime risk with 41.1%, the high lifetime risk has 58.9% subjects. The intermediate 10-year risk category shows the highest reclassifications to High lifetime risk. The Hosmer-Lemeshow goodness-of-fit statistics indicates a good model fit.

Conclusion:

Timely interventions using risk predictions can aid in appropriate therapeutic and lifestyle modifications useful for primary prevention. Precaution to avoid short-term incidences and reclassifications to a high lifetime risk can reduce the CVD related mortality rates.

Cardiovascular Risk Reduction With Icosapent Ethyl: A Systematic Literature Review

Cardiovascular disease is the leading cause of death in the United States of America due to elevated triglyceride levels. High triglyceride levels lead to higher risks of ischemic events. There are multiple pieces of research and analyses on statin therapy and its ability to reduce the prevalence of heart complications. Heart ailments can reduce through the use of icosapent ethyl in the form of statin therapy. This literature review will explain the reduction of cardiovascular risks with icosapent ethyl. Though some genetic conditions can cause some of these ailments, the rest of the predisposing conditions revolve around cholesterol, lipoproteins, and triglycerides.

Betel Quid Health Risks of Insulin Resistance Diseases in Poor Young South Asian Native and Immigrant Populations

Betel quid, traditionally prepared with areca nut, betel leaf, and slaked lime, has been consumed for thousands of years, mainly in the form of chewing. Originally used for cultural, medicinal, and ceremonial purposes mainly in South Asian countries, its use has recently spread across the globe due to its psychoactive, euphoric, and aphrodisiac properties. Now it is widely used as a social lubricant and source of financial profit. Unfortunately, the profit motive has led to high rates of habitual consumption with eventual conversion to addiction among young girls and boys. Moreover, the worrisome practice of including tobacco in quid preparations has grown, particularly among pregnant women. Major health concerns include increased rates of malignancy, oral pathology, and cardiovascular, hepatic, fertility, metabolic, and neuropsychiatric disorders. Metabolic disorders and insulin resistance disease states such as type 2 diabetes, obesity, and metabolic syndrome contribute to cognitive decline and neurodegeneration. Mechanistically, the constituents of areca nut/betel quid are metabolized to N-nitroso compounds, i.e., nitrosamines, which are carcinogenic at high doses and cause insulin resistance following chronic low-level exposures. From an epidemiological perspective, the rising tide of insulin resistance diseases including obesity, diabetes, and dementias that now disproportionately burden poor countries has been propagated by rapid commercialization and enhanced access to betel quid. Public health measures are needed to impose socially and ethically responsible barriers to yet another cause of global health disparity.

Prevalence of Multimorbidity among Asian Indian, Chinese, and Non-Hispanic White Adults in the United States

Asian Americans are the fastest-growing minority group in the United States, yet little is known about their multimorbidity. This study examined the association of Asian Indians, Chinese and non-Hispanic whites (NHWs) to multimorbidity, defined as the concurrent presence of two or more chronic conditions in the same individual. We used a cross-sectional design with data from the National Health Interview Survey (2012–2017) of Asian Indians, Chinese, and NHWs (N = 132,666). Logistic regressions were used to examine the adjusted association of race/ethnicity to multimorbidity. There were 1.9% Asian Indians, 1.8% Chinese, and 96.3% NHWs. In unadjusted analyses (p < 0.001), 17.1% Asian Indians, 17.9% Chinese, and 39.0% NHWs had multimorbidity. Among the dyads, high cholesterol and hypertension were the most common combination of chronic conditions among Asian Indians (32.4%), Chinese (41.0%), and NHWs (20.6%). Asian Indians (AOR = 0.73, 95% CI = (0.61, 0.89)) and Chinese (AOR = 0.63, 95% CI = (0.53, 0.75)) were less likely to have multimorbidity compared to NHWs, after controlling for age, sex, and other risk factors. However, Asian Indians and Chinese were more likely to have high cholesterol and hypertension, risk factors for diabetes and heart disease.

Healthy Weight and Obesity Prevention: JACC Health Promotion Series

Overweight and obesity have reached epidemic levels in the United States and worldwide, and this has contributed to substantial cardiovascular and other health risks. However, controversy exists concerning the causes of obesity and effective modalities for its prevention and treatment. There is also controversy related to the concept of metabolically healthy obesity phenotype, the "obesity paradox," and on the importance of fitness to protect individuals who are overweight or obese from cardiovascular diseases. In this state-of-the-art review, the authors focus on "healthy weight" with the emphasis on the pathophysiologic effects of weight gain on the cardiovascular system; mechanistic/triggering factors; and the role of preventive actions through personal, education/environment, and societal/authoritative factors, as well as factors to provide guidance for caregivers of health promotion. Additionally, the authors briefly review metabolically healthy obesity, the obesity paradox, and issues beyond lifestyle consideration for weight loss with medications and bariatric surgery.

Hormonal and metabolic substrate status in response to exercise in men of different phenotype

OBJECTIVES

The present study verified the effect of moderate-to-high-intensity aerobic exercise on the endocrine response profile and adipose tissue in young healthy men with different phenotype characteristics.

DESIGN

Eighteen men were divided into three experimental groups with defined body components and specific physical fitness: Endurance phenotype - EP (n = 6; low body mass; low fat content; aerobic endurance trained), Athletic phenotype - AP (n = 6; high body mass; low fat content, resistance trained), Obesity phenotype - OP (n = 6; high body mass; high fat content, untrained).

METHODS

The participants performed an progressive exercise protocol on a treadmill (30% VO2max, 50% VO2max, 70% VO2max), separated by 45 s of passive rest for blood collection.

RESULTS

Plasma glucose oxidation increased in relation to exercise intensity, but to a greater extent in the AP group. The free fatty acids' plasma level decreased with a rise in exercise intensity, but with different kinetics in particular phenotypes. Plasma growth hormone increased after the cessation of exercise and was significantly higher in all groups 45 min into recovery compared to resting values. Plasma insulin decreased during exercise in all groups, but in the OP, the decrease was blunted.

CONCLUSIONS

The results indicate that the rate of lipolysis, hormonal and metabolic response to aerobic exercise depends on the individuals' phenotype. Thus, exercise type, duration and intensity have to be strictly individualized in relation to phenotype in order to reach optimal metabolic benefits.

Age-and-sex stratified prevalence of atrial fibrillation in rural Western India: Results of SMART-India, a population-based screening study

BACKGROUND

Early detection of Atrial Fibrillation (AF) is a public health priority across the globe because AF-related strokes are preventable. Despite an ongoing stroke epidemic in India, a public health strategy for AF screening and treatment is missing because the epidemiology of AF in India remains poorly defined.

METHODS

This population-based study used mobile technology to derive age and sex-stratified AF prevalence by screening 7 participants in each of six age and sex strata (age 40-55, 56-65, 65+, and male and female) from 50 villages (2100 participants). A health worker from each village used a handheld digital electrocardiogram (iECG) device (Kardia) to screen for AF on 3 separate days, and administered a questionnaire. All abnormal (AF or unclassified) iECGs were reviewed by the Indian cardiologist and AF determination confirmed by a US-based cardiac electrophysiologist.

RESULTS

Of the 2100 individuals enrolled, iECGs were collected from 2074 participants (98.8%) and 1947 (92.7%) participants responded to the questionnaire. AF was identified in 33 participants (1.6%), two-thirds on the first iECG. AF prevalence was higher among males (2.3% vs 1.0%, p = 0.03) and in older people (0.6%, 0.9%, 2.1%, 5.6%; p < 0.01).

CONCLUSIONS

The prevalence of AF observed in our population-based sample is comparable to rates found in studies from North America and Western Europe and increases similarly with age. AF screening using village health workers in rural India is feasible and presents an opportunity for a strategy to address the stroke epidemic in India through primary prevention.

The association of religious affiliation with cholesterol levels among South Asians: the Mediators of Atherosclerosis in South Asians Living in America study

Background

South Asians have disproportionately high rates of cardiovascular disease. Dyslipidemia, a contributing factor, may be influenced by lifestyle, which can vary by religious beliefs. Little is known about South Asian religions and associations with dyslipidemia.

Methods

Cross-sectional analyses of the MASALA study (n = 889). We examined the associations between religious affiliation and cholesterol levels using multivariate linear regression models. We determined whether smoking, alcohol use, physical activity, and dietary pattern mediated these associations.

Results

Mean LDL was 112 ± 32 mg/dL, median HDL was 48 mg/dL (IQR:40–57), and median triglycerides was 118 mg/dL (IQR:88–157). Muslims had higher LDL and triglycerides, and lower HDL, while participants with no religious affiliation had lower LDL and higher HDL. The difference in HDL between Muslims and those with no religious affiliation was partly explained by alcohol consumption.

Conclusions

Religion-specific tailoring of interventions designed to promote healthy lifestyle to reduce cholesterol among South Asians may be useful.

Coffee for Cardioprotection and Longevity

Coffee, a complex brew containing hundreds of biologically active compounds, exerts potent effects on long-term human health. Recently, a plethora of studies have been published focusing on health outcomes associated with coffee intake. An inverse association between coffee consumption and all-cause mortality has been seen consistently in large prospective studies. Habitual coffee consumption is also associated with lower risks for cardiovascular (CV) death and a variety of adverse CV outcomes, including coronary heart disease (CHD), congestive heart failure (HF), and stroke; coffee's effects on arrhythmias and hypertension are neutral. Coffee consumption is associated with improvements in some CV risk factors, including type 2 diabetes (T2D), depression, and obesity. Chronic coffee consumption also appears to protect against some neurodegenerative diseases, and is associated with improved asthma control, and lower risks for liver disease and cancer. Habitual intake of 3 to 4 cups of coffee appears to be safe and is associated with the most robust beneficial effects. However, most of the studies regarding coffee's health effects are based on observational data, with very few randomized controlled trials. Furthermore, the possible benefits of coffee drinking must be weighed against potential risks, which are generally due to its high caffeine content, including anxiety, insomnia, headaches, tremulousness, and palpitations. Coffee may also increase risk of fracture in women, and when consumed in pregnancy coffee increases risk for low birth weight and preterm labor.

Fructose-induced inflammation and increased cortisol: A new mechanism for how sugar induces visceral adiposity

Traditionally, the leading hypothesis regarding the development of obesity involves caloric imbalance, whereby the amount of calories consumed exceeds the amount of calories burned which causes obesity. Another hypothesis for why we get fat has surfaced in the last decade which is the idea that the overconsumption of added sugars and refined carbohydrates induce insulin resistance and high insulin levels causing obesity. While insulin is a fat-storing hormone, this hypothesis does not explain visceral adiposity, or why certain people are found to have fat stored in and around their organs. We propose a new mechanism for body fattening, particular visceral adiposity. This hypothesis involves the overconsumption of fructose, which leads to inflammation in all cells that metabolize it rapidly. When fructose is metabolized in subcutaneous adipocytes, the subsequent inflammation leads to an increase in intracellular cortisol in order to help squelch the inflammation. Unfortunately, the increase in intracellular cortisol leads to an increased flux of fatty acids out of the subcutaneous adipocytes allowing more substrate for fat storage into visceral fat tissue. Moreover fructose-induced inflammation in the liver also leads to increased intracellular cortisol via an upregulation of 11-B hydroxysteroid dehydrogenase type 1 causing increased fat storage in the liver (i.e., fatty liver). In essence, the fructose-induced inflammatory cortisol response causes "thin on the outside, fat on the inside" (TOFI). Furthermore, fructose in the brain, either from fructose uptake via the blood brain barrier or endogenous formation from glucose via the polyol pathway stimulates an increased release of cortisol causing hepatic gluconeogenesis leading to overall insulin resistance and further body fattening. This review paper will discuss in detail the hypothesis that fructose-induced inflammation and cortisol activation causes visceral adiposity.

Prevalence and association of metabolic syndrome and vitamin D deficiency among postmenopausal women in a rural block of West Bengal, India

Background

Prevalence of metabolic syndrome (MS) and vitamin D deficiency was reported among postmenopausal women (PMW) in India. However, no report is available regarding the association of MS and 25-hydroxyvitamin D [25(OH)D] among PMW in India. This study aimed to find out the prevalence of MS and 25(OH)D status as well as their association among rural PMW of West Bengal, India.

Materials and methods

This cross-sectional study was conducted among 222 randomly selected rural PMW in Singur Block, West Bengal, India. Serum 25(OH)D, Blood pressure (BP), waist circumference (WC), fasting blood glucose (FBG), triglycerides (TG) and high density lipoprotein cholesterol (HDL-C) were measured using standard procedures. MS was defined as per International Diabetes Federation, 2005 (for Asian-Indians) criteria. Statistical tests were done using SPSS software.

Results

Prevalence of metabolic syndrome was 46%. 51% and 19% PMW were vitamin D insufficient and deficient, respectively. 22% and 53% women having MS were vitamin D insufficient and deficient, respectively. Among the PMW, 21% and 47% with WC≥80cm; 22% and 62% with FBG≥110mg/dl; 21% and 54% with TG≥150mg/dl; 23% and 51% with HDL-C<50mg/dl, 15% and 55% with BP≥130/85mm of Hg were vitamin D insufficient and deficient, respectively. Significant statistical association between FBG and 25(OH)D status existed (p = 0.01). Significant positive correlation between WC and 25(OH)D level (p = 0.004) and significant negative correlation between FBG and 25(OH)D level observed (p = 0.02). WC was the only statistically significant predictor of the dependent variable. Odds of non-sufficient 25(OH)D level increased with decrease in WC.

Conclusion

High prevalence of MS as well as vitamin D insufficiency and deficiency existed among PMW of Singur block, West Bengal, India. 25(OH)D had significant inverse and direct relationship with FBG and WC. Low 25(OH)D may be one of the potential risk factors for developing MS in PMW or vice-versa.

Insulin Therapy Increases Cardiovascular Risk in Type 2 Diabetes

Insulin therapy increased cardiovascular (CV) risk and mortality among type 2 diabetes (T2D) patients in several recently reported clinical outcomes trials. To assess whether this association is causative or coincidental, PubMed searches were used to query the effects of insulin therapy for T2D on CV health and longevity from large-scale outcomes trials, meta-analyses, and patient registry studies, as well as basic research on insulin's direct and pleiotropic actions. Although several old studies provided conflicting results, the majority of large observational studies show strong dose-dependent associations for injected insulin with increased CV risk and worsened mortality. Insulin clearly causes weight gain, recurrent hypoglycemia, and, other potential adverse effects, including iatrogenic hyperinsulinemia. This over-insulinization with use of injected insulin predisposes to inflammation, atherosclerosis, hypertension, dyslipidemia, heart failure (HF), and arrhythmias. These associations support the findings of large-scale evaluations that strongly suggest that insulin therapy has a poorer short- and long-term safety profile than that found to many other anti-T2D therapies. The potential adverse effects of insulin therapy should be weighed against proven CV benefits noted for select other therapies for T2D as reported in recent large randomized controlled trials.

Cardiovascular risk in an HIV-infected population in India

OBJECTIVE

To characterise prevalence of traditional cardiovascular disease (CVD) risk factors, assess CVD risk and examine the effect of simulated interventions on CVD risk among HIV-infected Asian Indians.

METHODS

Cross-sectional data between September 2015 and July 2016 wer used to describe the prevalence of CVD risk factors. Five risk scores (Framingham, Data Collection on Adverse Effects of Anti-HIV Drugs Study (D:A:D), Atherosclerotic Cardiovascular, QRISK2 and Ramathibodi-Electricity Generating Authority of Thailand were used to estimate CVD risk. The effect of seven sensitivity analyses: smoking prevention; diabetes prevention; optimal blood pressure and dyslipidaemia control (total cholesterol, high-density lipoprotein (HDL)); CD4 augmentation and a combination of the scenarios on the median cumulative D:A:D CVD scores were assessed.

RESULTS

Of 402 enrolled, 56% were women, median age was 40 years (IQR: 35-45 years) and median time-updated CD4 counts were 378 cells/μL (IQR: 246-622). Fifty-five and 28% had ever been screened for hypertension and diabetes, respectively prior to enrolment. The prevalence of diabetes, hypertension, hypercholesterolaemia, low HDL, previous and current smokers were 9%, 22%, 20%, 39%, 14% and 4%, respectively. Thirty-six per cent had intermediate-to-high 5-year CVD risk by D:A:D estimates. Thirty-two per cent were eligible for statin therapy by American College of Cardiology/American Heart Association guidelines; 2% were currently on statins. In sensitivity analyses, diabetes prevention was associated with the highest reduction of CVD risk.

CONCLUSION

CVD at younger ages among Asian Indian people living with HIV appear to be an imminent risk for morbidity. Stepping up of preventive services including screening services and prescription of statins are important strategies that must be considered.

Exercise and eating habits among urban adolescents: a cross-sectional study in Kolkata, India

BACKGROUND

Unhealthy eating and lack of exercise during adolescence culminated into earlier onset and increasing burden of atherosclerotic cardiovascular diseases (CVDs) worldwide. Among urban Indian adolescents, prevalence of these risk factors of CVD seemed to be high, but data regarding their pattern and predictors was limited. To address this dearth of information, a survey was conducted among urban adolescent school-students in Kolkata, a highly populated metro city in eastern India.

METHODS

During January-June, 2014, 1755 students of 9th-grade were recruited through cluster (schools) random sampling. Informed consents from parents and assents from adolescents were collected. Information on socio-demographics, CVD-related knowledge and perception along with eating and exercise patterns were collected with an internally validated structured questionnaire. Descriptive and regression analyses were performed in SAS-9.3.2.

RESULTS

Among 1652 participants (response rate = 94.1%), about 44% had poor overall knowledge about CVD, 24% perceived themselves as overweight and 60% considered their general health as good. Only 18% perceived their future CVD-risk and 29% were engaged in regular moderate-to-vigorous exercise. While 55% skipped meals regularly, 90% frequently consumed street-foods and 54% demonstrated overall poor eating habits. Males were more likely to engage in moderate-to-vigorous exercise [adjusted odds ratio (AOR) = 3.40(95% confidence interval = 2.55-4.54)] while students of higher SES were less likely [AOR = 0.59(0.37-0.94)]. Males and those having good CVD-related knowledge were more likely to exercise at least 1 h/day [AOR = 7.77(4.61-13.07) and 2.90(1.46-5.78) respectively]. Those who perceived their future CVD-risk, skipped meals more [2.04(1.28-3.25)] while Males skipped them less [AOR = 0.62(0.42-0.93)]. Subjects from middle class ate street-foods less frequently [AOR = 0.45(0.24-0.85)]. Relatively older students and those belonging to higher SES were less likely to demonstrate good eating habits [AOR = 0.70(0.56-0.89) and 0.23(0.11-0.47) respectively]. A large knowledge-practice gap was evident as students with good CVD-related knowledge were less likely to have good eating habits [AOR = 0.55(0.32-0.94)].

CONCLUSIONS

CVD-related knowledge as well as eating and exercise habits were quite poor among adolescent school-students of Kolkata. Additionally, there was a large knowledge-practice gap. Multi-component educational interventions targeting behavioral betterment seemed necessary for these adolescents to improve their CVD-related knowledge, along with appropriate translation of knowledge into exercise and eating practices to minimize future risk of CVDs.

Lower Vitamin D Metabolites Levels Were Associated With Increased Coronary Artery Diseases in Type 2 Diabetes Patients in India

The purpose of the present study was to measure six vitamin D metabolites and to find the association between vitamin D deficiency and coronary artery diseases in diabetes (T2DM_CAD). Four groups [control (n = 50), type 2 diabetes (T2DM, n = 71), coronary artery diseases (CAD, n = 28), T2DM_CAD (n = 38)] of total 187 subjects were included in the study. Six vitamin D metabolites (D₂, D₃, 25(OH)D₂, 25(OH)D₃, 1,25(OH)₂D₂, 1,25(OH)₂D₃), total 25(OH)D and total 1,25(OH)₂D were measured by UPLC/APCI/HRMS method in these subjects. Although all the vitamin D metabolites were significantly decreased in T2DM_CAD as compared to both control and T2DM subjects (p < 0.05), only two metabolites i.e., 25(OH)D₃ and total 25(OH)D were significantly (p < 0.05) decreased in the T2DM subjects as compared with the control subjects (p < 0.05). Vitamin D₃, 1,25(OH)₂D₂, 25(OH)D, and 1,25(OH)₂D levels were significantly decreased in T2DM_CAD subjects as compared with CAD subjects (p < 0.05). Further, multiple logistic regression analysis revealed that total 25(OH)D and total 1,25(OH)₂D can be used to predict T2DM (OR 0.82.95% CI 0.68-0.99; p = 0.0208) and T2DM with CAD (OR 0.460, 95% CI 0.242-0.874; p = 0.0177), respectively. Our data concludes that lower concentration of 1,25(OH)₂D is associated with type 2 diabetes coexisting with coronary artery diseases in South Indian subjects.

Cardiac Rehabilitation Delivery Model for Low-Resource Settings: An International Council of Cardiovascular Prevention and Rehabilitation Consensus Statement

Cardiovascular disease (CVD) is a global epidemic, which is largely preventable. Cardiac rehabilitation (CR) is demonstrated to be efficacious and cost-effective for secondary prevention in high-income countries. Given its affordability, CR should be more broadly implemented in middle-income countries as well. Hence, the International Council of Cardiovascular Prevention and Rehabilitation (ICCPR) convened a writing panel to recommend strategies to deliver all core CR components in low-resource settings, namely: (1) initial assessment, (2) lifestyle risk factor management (i.e., diet, tobacco, mental health), (3) medical risk factor management (lipids, blood pressure), (4) education for self-management; (5) return to work; and (6) outcome evaluation. Approaches to delivering these components in alternative, arguably lower-cost settings, such as the home, community and primary care, are provided. Recommendations on delivering each of these components where the most-responsible CR provider is a non-physician, such as an allied healthcare professional or community health care worker, are also provided.

Urbanized South Asians' susceptibility to coronary heart disease: The high-heat food preparation hypothesis

OBJECTIVE

Known risk factors do not fully explain the comparatively high susceptibility to coronary heart disease (CHD) in South Asians (Indian, Pakistani, Bangladeshi, and Sri Lankan populations in South Asia and overseas). The search for explanatory hypotheses and cofactors that raise susceptibility of South Asians to CHD continues. The aim of this study was to propose "the high-heat food preparation hypothesis," where neo-formed contaminants (NFCs) such as trans-fatty acids (TFAs) and advanced glycation end-products (AGEs) are the cofactors.

METHODS

We reviewed the actions of AGEs and TFAs, the burden of these products in tissues and blood in South Asians, the relationship between these products and CHD, the effects of preparing food and reheating oils at high temperatures on NFCs, and the foods and mode of preparation in South Asian and Chinese cuisines.

RESULTS

Animal and human studies show NFCs increase the risk for CHD. Evidence on the consumption and body burden of these products across ethnic groups is not available, and comparable data on the NFC content of the cuisine of South Asians and potential comparison populations (e.g., the Chinese with lower CHD rates) are limited. South Asians' cuisine is dominated by frying and roasting techniques that use high temperatures. South Asian foods have high TFA content primarily through the use of partially hydrogenated fats, reheated oils, and high-heat cooking. Reheating oils greatly increases the TFA content. In comparison, Chinese cuisine involves mostly braising, steaming, and boiling rather than frying.

CONCLUSION

We hypothesize that South Asians' susceptibility to CHD is partly attributable to high-heat treated foods producing high NFCs. Research to accrue direct evidence is proposed.

Obesity and Prevalence of Cardiovascular Diseases and Prognosis-The Obesity Paradox Updated

The prevalence and severity of obesity have increased in the United States and most of the Westernized World over recent decades, reaching worldwide epidemics. Since obesity worsens most of the cardiovascular disease (CVD) risk factors, not surprisingly, most CVDs, including hypertension, coronary heart disease, heart failure, and atrial fibrillation, are all increased in the setting of obesity. However, many studies and meta-analyses have demonstrated an obesity paradox with regards to prognosis in CVD patients, with often the overweight and mildly obese having a better prognosis than do their leaner counterparts with the same CVD. The implication for fitness to markedly alter the relationship between adiposity and prognosis and the potential impact of weight loss, in light of the obesity paradox, are all reviewed.