Heterogeneity of coronary heart disease risk factors in Indian, Pakistani, Bangladeshi, and European origin populations: cross sectional study

Factors facilitating and hindering South Asian immigrant adults from engaging in exercise and physical activity - a qualitative systematic review

BACKGROUND

Exercise and physical activity are key components of management in patients with rheumatic musculoskeletal diseases (RMD), but people of the South Asian communities have a lower level of engagement with these activities compared to their Caucasian counterparts. The aim of this qualitative systematic review was to determine the barriers and facilitators of exercise and physical activity in South Asian communities who have migrated and live in western countries, particularly in those who have RMD.

METHODS

Qualitative studies, published in English between 1999 and 2021 and including evaluation of barriers and/or facilitators to exercise or physical activity behaviour in people of South Asian adult communities who have migrated and/or lived in western countries were identified from Embase, MEDLINE, CINAHL, PsycINFO, Google Scholar and manual searches. The studies were appraised using the CASP checklist. Inductive thematic synthesis was used to identify common and global themes.

RESULTS

A total of 32 studies that discussed barriers and facilitators of physical activity in South Asian communities who have migrated and lived in western countries were used for this review but there were no studies identified that focussed specifically on those with RMD. Following appraisal of the reporting of the studies, 30 studies were included in the pooling of the results. The facilitators and barriers to physical activities were broadly categorized into 'extrinsic' and 'intrinsic' factors. Extrinsic factors such as 'opportunity' included environmental factors such as weather and safety; socioeconomic factors such as education, language and literacy, and support in the form of social, psychological and resources. Intrinsic factors included cultural factors, such as life stages and family influence, beliefs and knowledge, which impacted attitudes and skills.

CONCLUSIONS

This review has synthesised evidence of barriers or facilitators and identified potentially modifiable factors influencing physical activity and exercise engagement, which could form the basis of evidence-based interventions to promote participation in healthy behaviour change. Provision of a safe, comfortable and culturally acceptable environment together with culturally-aligned cognitive strategies to facilitate acquisition of exercise-efficacy skills could help engagement.

REGISTRATION

The systematic review was registered on PROSPERO, registration no. 289,235.

The utility of coronary artery calcium scoring to enhance cardiovascular risk assessment for South Asian adults

South Asian individuals represent a highly diverse population and are one of the fastest growing ethnic groups in the United States. This population has a high prevalence of traditional and non-traditional cardiovascular disease (CVD) risk factors and a disproportionately high prevalence of coronary heart disease. To reflect this, current national society guidelines have designated South Asian ancestry as a "risk enhancing factor" which may be used to guide initiation or intensification of statin therapy. However, current methods of assessing cardiovascular risk in South Asian adults may not adequately capture the true risk in this diverse population. Coronary artery calcium (CAC) scoring provides a reliable, reproducible, and highly personalized method to provide CVD risk assessment and inform subsequent pharmacotherapy recommendations, if indicated. This review describes the utility of CAC scoring for South Asian individuals.

Ambulatory blood pressure levels in individuals with uncontrolled clinic hypertension across Bangladesh, Pakistan, and Sri Lanka

Hypertension is a leading risk factor for cardiovascular disease in South Asia. The authors aimed to assess the cross-country differences in 24-h ambulatory, daytime, and nighttime systolic blood pressure (SBP) among rural population with uncontrolled clinic hypertension in Bangladesh, Pakistan, and Sri Lanka. The authors studied patients with uncontrolled clinic hypertension (clinic BP ≥ 140/90 mmHg) who underwent ambulatory blood pressure monitoring (ABPM) during the baseline assessment as part of a community-based trial. The authors compared the distribution of ABPM profiles of patients across the three countries, specifically evaluating ambulatory SBP levels with multivariable models that adjusted for patient characteristics. Among the 382 patients (mean age, 58.3 years; 64.7% women), 56.5% exhibited ambulatory hypertension (24-h ambulatory BP ≥ 130/80 mmHg), with wide variation across countries: 72.6% (Bangladesh), 50.0% (Pakistan), and 51.0% (Sri Lanka; P < .05). Compared to Sri Lanka, adjusted mean 24-h ambulatory, daytime, and nighttime SBP were higher by 12.24 mmHg (95% CI 4.28-20.20), 11.96 mmHg (3.87-20.06), and 12.76 mmHg (4.51-21.01) in Bangladesh, separately. However, no significant differences were observed between Pakistan and Sri Lanka (P > .05). Additionally, clinic SBP was significantly associated with 24-h ambulatory (mean 0.38, 95% CI 0.28-0.47), daytime (0.37, 0.27-0.47), and nighttime SBP (0.40, 0.29-0.50) per 1 mmHg increase. The authors observed substantial cross-country differences in the distribution of ABPM profiles among patients with uncontrolled clinic hypertension in rural South Asia. The authors findings indicated the need to incorporate 24-h BP monitoring to mitigate cardiovascular risk, particularly in Bangladesh.

Diabetes mellitus and obesity among South Asians with ischemic stroke across three countries

BACKGROUND

Diabetes mellitus and central obesity are more common among South Asian populations than among White British people. This study explores the differences in diabetes and obesity in South Asians with stroke living in the United Kingdom, India, and Qatar compared with White British stroke patients.

METHODS

The study included the UK, Indian, and Qatari arms of the ongoing large Bio-Repository of DNA in Stroke (BRAINS) international prospective hospital-based study for South Asian stroke. BRAINS includes 4580 South Asian and White British recruits from UK, Indian, and Qatar sites with first-ever ischemic stroke.

RESULTS

The study population comprises 1751 White British (WB) UK residents, 1165 British South Asians (BSA), 1096 South Asians in India (ISA), and 568 South Asians in Qatar (QSA). ISA, BSA, and QSA South Asians suffered from higher prevalence of diabetes compared with WB by 14.5% (ISA: 95% confidence interval (CI) = 18.6-33.0, p < 0.001), 31.7% (BSA: 95% CI = 35.1-50.2, p < 0.001), and 32.7% (QSA: 95% CI = 28.1-37.3, p < 0.001), respectively. Although WB had the highest prevalence of body mass index (BMI) above 27 kg/m2 compared with South Asian patients (37% vs 21%, p < 0.001), South Asian patients had a higher waist circumference than WB (94.8 cm vs 90.8 cm, p < 0.001). Adjusting for traditional stroke risk factors, ISA, BSA, and QSA continued to display an increased risk of diabetes compared with WB by 3.28 (95% CI: 2.53-4.25, p < 0.001), 3.61 (95% CI: 2.90-4.51, p < 0.001), and 5.24 (95% CI: 3.93-7.00, p < 0.001), respectively.

CONCLUSION

South Asian ischemic stroke patients living in Britain and Qatar have a near 3.5-fold risk of diabetes compared with White British stroke patients. Their body composition may partly help explain that increased risk. These findings have important implications for public health policymakers in nations with large South Asian populations.

A Culturally Adapted Diet and Physical Activity Text Message Intervention to Prevent Type 2 Diabetes Mellitus for Women of Pakistani Origin Living in Scotland: Formative Study

BACKGROUND

Individuals of South Asian origin are at an increased risk of developing type 2 diabetes mellitus (T2DM) compared with other ethnic minority groups. Therefore, there is a need to develop interventions to address, and reduce, this heightened risk.

OBJECTIVE

We undertook formative work to develop a culturally adapted diet and physical activity text message intervention to prevent T2DM for women of Pakistani origin living in Scotland.

METHODS

We used a stepwise approach that was informed by the Six Steps in Quality Intervention Development framework, which consisted of gathering evidence through literature review and focus groups (step 1), developing a program theory for the intervention (step 2), and finally developing the content of the text messages and an accompanying delivery plan (step 3).

RESULTS

In step 1, we reviewed 12 articles and identified 3 key themes describing factors impacting on diet and physical activity in the context of T2DM prevention: knowledge on ways to prevent T2DM through diet and physical activity; cultural, social, and gender norms; and perceived level of control and sense of inevitability over developing T2DM. The key themes that emerged from the 3 focus groups with a total of 25 women were the need for interventions to provide "friendly encouragement," "companionship," and a "focus on the individual" and also for the text messages to "set achievable goals" and include "information on cooking healthy meals." We combined the findings of the focus groups and literature review to create 13 guiding principles for culturally adapting the text messages. In step 2, we developed a program theory, which specified the main determinants of change that our text messages should aim to enhance: knowledge and skills, sense of control, goal setting and planning behavior, peer support, and norms and beliefs guiding behavior. In step 3, we used both the intervention program theory and guiding principles to develop a set of 73 text messages aimed at supporting a healthy diet and 65 text messages supporting increasing physical activity.

CONCLUSIONS

We present a theory-based approach to develop a culturally adapted diet and physical activity text message intervention to prevent T2DM for women of Pakistani origin living in Scotland. This study outlines an approach that may also be applicable to the development of interventions for other ethnic minority populations in diverse settings. There is now a need to build on this formative work and undertake a feasibility trial of a text message-based diet and physical activity intervention to prevent T2DM for women of Pakistani origin living in Scotland.

Utility of paclitaxel-coated balloons for the treatment of infrainguinal disease in the Asian population - 24-month outcome data from the BIOLUX P-III Global Registry 24-month Asian outcomes of BIOLUX P-III

BACKGROUND

Results from the BIOLUX P-III registry have demonstrated favourable outcomes of Passeo-18 Lux™ (Biotronik®, Buelach, Switzerland) drug-coated balloon in treating obstructive infrainguinal peripheral artery disease, but it has not been established if Asians would benefit to the same extent as non-Asians.

METHODS

A subgroup analysis was performed on the 24-month data comparing the Asian cohort (AC) to non-Asian cohort (NAC).

RESULTS

AC included 49 patients with 77 lesions. AC was significantly younger (65.6 vs 70.3 years, p < 0.05), had more diabetes (87.8% vs 45.3%, p < 0.05), and was more likely to present with CLTI (73.5% vs 35.3%, p < 0.001) compared to NAC. They had significantly longer mean target lesions (115 vs 86.9 mm, p = 0.006), and received significantly higher paclitaxel doses (10.7 vs 7.2 mg, p = 0.0005). Device, technical and procedural successes were 125/125(100%), 95/97(97.5%) and 45/49(91.8%), respectively. There was no significant difference in target lesion revascularization rates between groups (10.5% vs 12%, p = 0.91). However, the AC had more major adverse events (30.2% vs 16.1%, p = 0.001), amputations (26.3% vs 6.2%, p < 0.05) and mortality (37.9% vs 10.6%, p < 0.05) at 24 months.

CONCLUSION

Passeo-18 Lux™ use was efficacious in Asians, but was associated with higher adverse events, amputations and mortality rates, likely attributable to poorer patient comorbidities and more extensive PAD.

Risk Factor Interactions, Non-High-Density Lipoprotein Cholesterol to Apolipoprotein B Ratio, and Severity of Coronary Arteriosclerosis in South Asian Individuals: An Observational Cohort Study

Background South Asian individuals are at higher risk for arteriosclerotic cardiovascular disease and diabetes. The factors associated with arteriosclerotic cardiovascular disease severity and their interactions are unknown. Methods and Results This is a retrospective cohort study of the first 1162 South Asian participants enrolled in the South Asian Heart Center's AIM to Prevent Program who completed noncontrast coronary computed tomography scans. Using machine-learning algorithms, we identified and modeled the interaction of predictor variables with coronary artery calcification (CAC) severity in South Asian individuals. Anthropometric, laboratory, demographic, and lifestyle predictor variables were analyzed using continuous boosted regression trees to model the relationship with and in between predictor variables and CAC. Participants with CAC were older, predominately men, had smoking history, had personal histories of diabetes, hypertension, and hypercholesterolemia, and had family histories of coronary artery disease. Insulin, body mass index, blood pressure, fasting blood sugar, hemoglobin A1c, and waist-to-height ratio were associated with CAC but not low-density lipoprotein cholesterol or lipoprotein (a). The arteriosclerotic cardiovascular disease score failed to classify individuals. Only age, body mass index, non-high-density lipoprotein cholesterol/apolipoprotein B ratio, smoking risk, fasting blood sugar, and diastolic blood pressure were predictive, explaining 30.3% of CAC severity. A non-high-density lipoprotein cholesterol/apolipoprotein B ratio of 1.4 or less markedly increased coronary calcification. Conclusions Our findings highlight factors associated with dysmetabolism and cholesterol-depleted non-high-density lipoprotein cholesterol particles with coronary arteriosclerosis, possibly explaining the dual epidemics of diabetes and arteriosclerotic cardiovascular disease in this population. Markers of glucose dysmetabolism and the non-high-density lipoprotein cholesterol to apolipoprotein B ratio should become the focus of assessment for cardiovascular risk in South Asian individuals, with prevention strategies directed at improving glucose metabolic health.

Identification and Management of Atherosclerotic Cardiovascular Disease Risk in South Asian Populations in the U.S

South Asians (SAs, individuals with ancestry from Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka) are among the fastest growing ethnic subgroups in the United States. SAs typically experience a high prevalence of diabetes, abdominal obesity, and hypertension, among other cardiovascular disease risk factors, which are often under recognized and undermanaged. The excess coronary heart disease risk in this growing population must be critically assessed and managed with culturally appropriate preventive services. Accordingly, this scientific document prepared by a multidisciplinary group of clinicians and investigators in cardiology, internal medicine, pharmacy, and SA-centric researchers describes key characteristics of traditional and nontraditional cardiovascular disease risk factors, compares and contrasts available risk assessment tools, discusses the role of blood-based biomarkers and coronary artery calcium to enhance risk assessment and prevention strategies, and provides evidenced-based approaches and interventions that may reduce coronary heart disease disparities in this higher-risk population.

Differential Associations of Cystatin C Versus Creatinine-Based Kidney Function With Risks of Cardiovascular Event and Mortality Among South Asian Individuals in the UK Biobank

Background South Asian individuals have increased cardiovascular disease and mortality risks. Reliance on creatinine- rather than cystatin C-based estimated glomerular filtration rate (eGFRcys) may underestimate the cardiovascular disease risk associated with chronic kidney disease. Methods and Results Among 7738 South Asian UK BioBank participants without prevalent heart failure (HF) or atherosclerotic cardiovascular disease, we investigated associations of 4 eGFRcys and creatinine-based estimated glomerular filtration rate categories (<45, 45-59, 60-89, and ≥90 mL/min per 1.73 m2) with risks of all-cause mortality, incident HF, and incident atherosclerotic cardiovascular disease. The mean age was 53±8 years; 4085 (53%) were women. Compared with creatinine, cystatin C identified triple the number of participants with estimated glomerular filtration <45 (n=35 versus n=113) and 6 times the number with estimated glomerular filtration 45 to 59 (n=80 versus n=481). After multivariable adjustment, the eGFRcys 45 to 59 category was associated with higher risks of mortality (hazard ratio [HR], 2.38 [95% CI, 1.55-3.65]) and incident HF (sub-HR [sHR], 1.87 [95% CI, 1.09-3.22]) versus the eGFRcys ≥90 category; the creatinine-based estimated glomerular filtration rate 45 to 59 category had no significant associations with outcomes. Of the 7623 participants with creatinine-based estimated glomerular filtration rate ≥60, 498 (6.5%) were reclassified into eGFRcys <60 categories. Participants who were reclassified as having eGFRcys <45 had higher risks of mortality (HR, 4.88 [95% CI, 2.56-9.31]), incident HF (sHR, 4.96 [95% CI, 2.21-11.16]), and incident atherosclerotic cardiovascular disease (sHR, 2.29 [95% CI, 1.14-4.61]) versus those with eGFRcys ≥90; those reclassified as having eGFRcys 45 to 59 had double the mortality risk (HR, 2.25 [95% CI, 1.45-3.51]). Conclusions Among South Asian individuals, cystatin C identified a high-risk chronic kidney disease population that was not detected by creatinine and enhanced estimated glomerular filtration rate-based risk stratification for mortality, incident HF, and incident atherosclerotic cardiovascular disease.

Ischaemic stroke in South Asians: The BRAINS study

BACKGROUND AND PURPOSE

Studies on stroke in South Asian populations are sparse. The aim of this study was to compare differences in age of onset of ischaemic stroke in South Asian patients living in the United Kingdom and South Asian patients living in India versus White British stroke patients.

METHODS

We studied the UK and Indian arms of the ongoing BRAINS study, an international prospective hospital-based study of South Asian stroke patients. The BRAINS study includes 4038 South Asian and White British patients with first-ever ischaemic stroke, recruited from sites in the United Kingdom and India.

RESULTS

Of the included patients, 1126 were South Asians living in India (ISA), while 1176 were British South Asian (BSA) and 1736 were White British (WB) UK residents. Patients in the ISA and BSA groups experienced stroke 19.5 years and 7.2 years earlier than their WB counterparts, respectively (mean [interquartile range] age: BSA 64.3 [22] years vs. ISA 52.0 [18] years vs. WB 71.5 [19] years; p < 0.001). Patients in the BSA group had higher rates of hypertension, diabetes mellitus and hypercholesterolaemia than those in the ISA and WB groups. After adjustment for traditional stroke risk factors, an earlier age of stroke onset of 18.9 years (p < 0.001) and 8.9 years (p < 0.001) was still observed in the ISA and BSA groups, respectively. In multivariable stepwise linear regression analysis, ethnicity accounted for 24.7% of the variance in early age onset.

CONCLUSION

Patients in the BSA and ISA groups experienced ischaemic stroke approximately 9 and 19 years earlier, respectively, than their WB counterparts. Ethnicity is an independent predictor of early age of stroke onset. Our study has considerable implications for public health policymakers in countries with sizable South Asian populations.

Outcome of Femoral Angioplasty/Stenting Procedures in Different Ethnic Groups in England: A Retrospective Analysis of Hospital Episode Statistics and Review of Literature

PURPOSE

Various studies, mainly from North America, report worse outcomes in ethnic minority populations submitted to revascularization for peripheral arterial disease (PAD). Limited nationwide data in relation to ethnicity are available from Europe.

OBJECTIVE

The objective of the study is to compare the outcomes of femoral angioplasty/stenting procedures among different ethnic groups in England during the 10-year period from 2006 to 2015.

MATERIALS AND METHODS

The "Hospital Episode Statistics" database has been searched using International Classification of Diseases, Tenth Revision (ICD-10) codes to identify all cases of femoral angioplasty or stenting from English NHS Hospitals between January 1, 2006, and December 31, 2015. Subsequent mortality, second open or endovascular infrainguinal procedures, and major amputations on the same side within 2 years after the first procedure have been recorded. Patients were broadly categorized according to ethnicity as whites, Asians, and blacks. Chi-square test was used to demonstrate significant differences among ethnic groups and odds ratios (ORs) were calculated using white ethnic group as reference.

RESULTS

A total number of 70 887 femoral endovascular procedures were recorded in patients from the 3 ethnic groups. Two-year mortality in whites, Asians, and blacks was 18.3%, 22.1%, and 19.5% (p<0.001); rates of second endovascular procedure were 12.1%, 13.1%, and 13.5% (p=0.24); rates of open infrainguinal procedure were 5.6%, 4.5%, and 8.0% (p<0.001); and rates of major amputation were 4.8%, 4.1%, and 7.0% (p<0.001), respectively. Mortality was higher in Asians (OR=1.26, 95% confidence interval [CI]=1.10-1.45, p<0.01) compared with whites. On the contrary, blacks underwent more open arterial operations (OR=1.48, 95% CI=1.19-1.83, p<0.01) and more amputations (OR=1.49, 95% CI=1.18-1.87, p<0.01). There were no significant differences in the rates of second endovascular procedures.

CONCLUSION

Two-year mortality after femoral angioplasty/stenting is higher in Asians, whereas risk of limb loss is higher in blacks compared with whites. Reasons of these ethnic differences in outcomes following femoral endovascular procedures for PAD merit further study.

Comparison of the modified Singapore myocardial infarction registry risk score with GRACE 2.0 in predicting 1-year acute myocardial infarction outcomes

Risk stratification plays a key role in identifying acute myocardial infarction (AMI) patients at higher risk of mortality. However, current AMI risk scores such as the Global Registry of Acute Coronary Events (GRACE) score were derived from predominantly Caucasian populations and may not be applicable to Asian populations. We previously developed an AMI risk score from the national-level Singapore Myocardial Infarction Registry (SMIR) confined to ST-segment elevation myocardial infarction (STEMI) patients and did not include non-STEMI (NSTEMI) patients. Here, we derived a modified SMIR risk score for both STEMI and NSTEMI patients and compared its performance to the GRACE 2.0 score for predicting 1-year all-cause mortality in our multi-ethnic population. The most significant predictor of 1-year all-cause mortality in our population using the GRACE 2.0 score was cardiopulmonary resuscitation on admission (adjusted hazards ratio [HR] 6.50), while the most significant predictor using the SMIR score was age 80–89 years (adjusted HR 7.78). Although the variables used in the GRACE 2.0 score and SMIR score were not exactly the same, the c-statistics for 1-year all-cause mortality were similar between the two scores (GRACE 2.0 0.841 and SMIR 0.865). In conclusion, we have shown that in a multi-ethnic Asian AMI population undergoing PCI, the SMIR score performed as well as the GRACE 2.0 score.

Burden of cardiovascular risk factors and disease in five Asian groups in Catalonia: a disaggregated, population-based analysis of 121 000 first-generation Asian immigrants

AIMS

To evaluate the burden of cardiovascular risk factors and disease (CVD) among five Asian groups living in Catalonia (Spain): Indian, Pakistani, Bangladeshi, Filipino, and Chinese.

METHODS AND RESULTS

Retrospective cohort study using the Catalan Health Surveillance System database including 42 488 Pakistanis, 40 745 Chinese, 21 705 Indians, 9544 Filipinos, and 6907 Bangladeshis; and 5.3 million native individuals ('locals'). We estimated the age-adjusted prevalence (as of 31 December 2019) and incidence (during 2019) of diabetes, hypertension, hyperlipidaemia, obesity, tobacco use, coronary heart disease (CHD), cerebrovascular disease, atrial fibrillation, and heart failure (HF). Bangladeshis had the highest prevalence of diabetes (17.4% men, 22.6% women) followed by Pakistanis. Bangladeshis also had the highest prevalence of hyperlipidaemia (23.6% men, 18.3% women), hypertension among women (24%), and incident tobacco use among men. Pakistani women had the highest prevalence of obesity (28%). For CHD, Bangladeshi men had the highest prevalence (7.3%), followed by Pakistanis (6.3%); and Pakistanis had the highest prevalence among women (3.2%). For HF, the prevalence in Pakistani and Bangladeshi women was more than twice that of locals. Indians had the lowest prevalence of diabetes across South Asians, and of CHD across South Asian men, while the prevalence of CHD among Indian women was twice that of local women (2.6% vs. 1.3%). Filipinos had the highest prevalence of hypertension among men (21.8%). Chinese men and women had the lowest prevalence of risk factors and CVD.

CONCLUSIONS

In Catalonia, preventive interventions adapted to the risk profile of different Asian immigrant groups are needed, particularly for Bangladeshis and Pakistanis.

Device-worn measures of sedentary time and physical activity in South Asian adults at high risk for type 2 diabetes in Metro-Vancouver, Canada

Background

South Asians have high incidence of chronic disease. Physical activity (PA) and sedentary time are modifiable risk factors for chronic disease but their assessment in South Asians has been primarily based on self-report. This study presents directly-measured PA and sedentary time in South Asian adults in Canada.

Methods

A subset of 100 South Asian participants from a larger study who were identified at being at a higher risk for type 2 diabetes wore Actical accelerometers for 7 days. Anthropometric measures were taken and socio-demographic factors including age, income, education level, years since immigration, presence of children under the age of 12 years in the household and employment status were self-reported.

Results

Ninety-one participants (mean age 65.6 years) provided valid accelerometer data. Participants accumulated mean 673.5 (95% CI: 656.6, 691.0) min/day sedentary time, 130.5 (95% CI: 117.3, 145.3) min/day light PA (LPA) and 2.3 (95% CI: 1.3, 4.2) min/day moderate-to-vigorous PA (MVPA). For sedentary time and LPA, sex and BMI explained 51% of variability. For MVPA, BMI, season of assessment and employment status explained 23% variability with those who were employed accumulating significantly higher mean min/day of MVPA compared to those who were unemployed; (5.8, 95% CI: 1.5, 21.7) vs (1.5, 95% CI: 5.3, 20.0) respectively.

Conclusion

High sedentary time, and low MVPA indicates the need to focus health promotion efforts on shifting sedentary time into LPA while trying to increase MVPA. Future studies need to be based on larger, representative samples of South Asians.

Differences in total and regional body fat and their association with BMI in UK-born White and South Asian children: findings from the Born in Bradford birth cohort

Background: Body mass index (BMI) is commonly used as a proxy to determine excess adiposity, though this may underestimate fat mass (FM) in individuals of South Asian (SA) heritage. SA tend to have greater central adiposity than white people, which is associated with a higher risk of cardiometabolic disease. In this cross-sectional study, we aimed to determine the differences in total and regional FM using Dual-energy X-ray absorptiometry (DXA), and to see if any differences in FM varied by BMI category in UK-born white and SA children aged ~9 years. Methods: Anthropometric measurements and DXA scans were undertaken from 225 white and 269 SA children from the Born in Bradford cohort study. Linear regression was used to assess ethnic differences in total body fat percent and total and regional FM. Results: Although mean BMI was similar, compared to white children, the proportion of SA children who were overweight or obese was ~10% higher, and the proportion with > 35% total body fat (TBF) was 22% and 16% higher in boys and girls respectively. Mean TBF% was greater in SA children compared to white children in the same BMI category. Fat mass index (FMI) was higher in all body regions in SA children in all BMI categories; as was total and truncal FMI in healthy and overweight, but not obese, SA children. Conclusions: Greater TBF% and total and regional FM in SA children suggests they may be at greater risk of future cardiometabolic disease at a BMI level below the obesity threshold. However, our sample size was small, and results may be influenced by selection bias and confounding; our findings need to be replicated in a larger study.

A narrative review of the biopsychosocial and health characteristics of Asian Indians in the United States: Clinical and research implications for neuropsychological functioning

Objective: The prevailing scientific literature aggregates Asians living in America into one omnibus category and thus can problematically result in a subpar and at times inaccurate understanding of health, social and cultural factors necessary for competent and informed medical care. Method: A literature search was conducted by cultural experts familiar with Asian Indian culture with a focus on immigrants from this community living in the US. Database using search engines was sought in the following domains: immigration patterns, prevalence for key medical and neurological conditions commonly associated with cognitive dysfunction, psychiatric/psychological needs in the community, some preliminary neuropsychological testing considerations while working with this community, and treatment considerations that could affect adherence and efficacy of outcomes. Articles were selected from 2000 to the most recent date, with emphasis on compiling information from review papers and meta-analysis from the past decade. Conclusions: Asian Indians living in the US are distinct from the larger Asian American community. Immigration trends underscore that Asian Indians have a bimodal distribution of wealth. Regarding medical conditions, a key and highly concerning finding is the higher prevalence of cardiovascular risk factors, especially in young males. The lack of non-existent cognitive data in this community is glaring and should serve as an impetus for conducting high-priority research in this community. Preliminary neuropsychological testing considerations are discussed from a practical perspective with emphasis on multilingualism and region of origin. Finally, treatment considerations include understanding attitudes and beliefs regarding traditional medicine.

Differences in total and regional body fat and their association with BMI in UK-born White and South Asian children: findings from the Born in Bradford birth cohort

Background: Body mass index (BMI) is commonly used as a proxy to determine excess adiposity, though this may underestimate fat mass (FM) in individuals of South Asian (SA) heritage. SA tend to have greater central adiposity than white people, which is associated with a higher risk of cardiometabolic disease. In this cross-sectional study, we aimed to determine the differences in total and regional FM using Dual-energy X-ray absorptiometry (DXA), and to see if any differences in FM varied by BMI category in UK-born white and SA children aged ~9 years. Methods: Anthropometric measurements and DXA scans were undertaken from 225 white and 269 SA children from the Born in Bradford cohort study. Linear regression was used to assess ethnic differences in total body fat percent and total and regional FM. Results: Although mean BMI was similar, compared to white children, the proportion of SA children who were overweight or obese was ~20% higher, and the proportion with > 35% total body fat (TBF) was 22% and 16% higher in boys and girls respectively. Mean TBF% was greater in SA children compared to white children in the same BMI category. Fat mass index (FMI) was higher in all body regions in SA children in all BMI categories; as was total and truncal FMI in healthy and overweight, but not obese, SA children.. Conclusions: Greater TBF% and total and regional FM in SA children suggests they may be at greater risk of future cardiometabolic disease at a BMI level below the obesity threshold. However, our sample size was small, and results may be influenced by selection bias and confounding; our findings need to be replicated in a larger study.

Ethnic minority status as social determinant for COVID-19 infection, hospitalisation, severity, ICU admission and deaths in the early phase of the pandemic: a meta-analysis

Introduction

Early literature on the COVID-19 pandemic indicated striking ethnic inequalities in SARS-CoV-2-related outcomes. This systematic review and meta-analysis aimed to describe the presence and magnitude of associations between ethnic groups and COVID-19-related outcomes.

Methods

PubMed and Embase were searched from December 2019 through September 2020. Studies reporting extractable data (ie, crude numbers, and unadjusted or adjusted risk/ORs) by ethnic group on any of the five studied outcomes: confirmed COVID-19 infection in the general population, hospitalisation among infected patients, and disease severity, intensive care unit (ICU) admission and mortality among hospitalised patients with SARS-CoV-2 infection, were included using standardised electronic data extraction forms. We pooled data from published studies using random-effects meta-analysis.

Results

58 studies were included from seven countries in four continents, mostly retrospective cohort studies, covering a total of almost 10 million individuals from the first wave until the summer of 2020. The risk of diagnosed SARS-CoV-2 infection was higher in most ethnic minority groups than their White counterparts in North American and Europe with the differences remaining in the US ethnic minorities after adjustment for confounders and explanatory factors. Among people with confirmed infection, African-Americans and Hispanic-Americans were also more likely than White-Americans to be hospitalised with SARS-CoV-2 infection. No increased risk of COVID-19 outcomes (ie, severe disease, ICU admission and death) was found among ethnic minority patients once hospitalised, except for a higher risk of death among ethnic minorities in Brazil.

Conclusion

The risk of SARS-CoV-2 diagnosis was higher in most ethnic minorities, but once hospitalised, no clear inequalities exist in COVID-19 outcomes except for the high risk of death in ethnic minorities in Brazil. The findings highlight the necessity to tackle disparities in social determinants of health, preventative opportunities and delay in healthcare use. Ethnic minorities should specifically be considered in policies mitigating negative impacts of the pandemic.

PROSPERO registration number

CRD42020180085.

Heterogeneity in cardio-metabolic risk factors and atherosclerotic cardiovascular disease among Asian groups in the United States

OBJECTIVE

The Asian American population in the U.S. comprises various, ethnically diverse subgroups. Traditionally, this population has been studied as a single, aggregated group, potentially masking differences in risk among subgroups. Analyses using disaggregated data can help better characterize the health needs of different Asian subpopulations and inform targeted, effective public health interventions. We assessed the prevalence of cardiovascular disease (CVD) risk factors and atherosclerotic CVD (ASCVD) and their associations with socioeconomic factors among Chinese, Asian Indian, Filipino and Other Asian subjects, compared with non-Hispanic White (NHW) subjects in the U.S.

METHODS

: Cross-sectional study using data from 298,286 adults from the National Health Interview Survey (NHIS) from 2007 to 2018. We utilized chi-squared tests to compare characteristics across subgroups. Weighted proportions and unadjusted and adjusted logistic regression models were utilized to examine the associations between Asian subgroups, self-reported CVD risk factors and self-reported ASCVD, as well as between socioeconomic factors within each Asian subgroup.

RESULTS

: Asian Indian subjects had the highest prevalence of diabetes (12.5%), while Filipino subjects had the highest prevalence of hyperlipidemia (27.7%), hypertension (29.8%) and obesity (19.8%). Despite this, the prevalence of self-reported ASCVD was lower in all Asian groups compared with NHWs. Chinese subjects had the lowest odds of having each of the CVD risk factors assessed.

CONCLUSION

: We found considerable heterogeneity in the distribution of risk factors as well as ASCVD among Asian subgroups in the US. Compared with health system or community-based reports, the prevalence of risk factors and ASCVD may be underestimated in some Asian NHIS subgroups. There is an urgent need for efforts to improve recruitment of Asian participants of heterogeneous socioeconomic backgrounds in national surveys, as well as to perform a thorough assessment of risk factors and disease in this population, not relying solely on self-report.

Quantifying and Understanding the Higher Risk of Atherosclerotic Cardiovascular Disease Among South Asian Individuals: Results From the UK Biobank Prospective Cohort Study

BACKGROUND

Individuals of South Asian ancestry represent 23% of the global population, corresponding to 1.8 billion people, and have substantially higher risk of atherosclerotic cardiovascular disease compared with most other ethnicities. US practice guidelines now recognize South Asian ancestry as an important risk-enhancing factor. The magnitude of enhanced risk within the context of contemporary clinical care, the extent to which it is captured by existing risk estimators, and its potential mechanisms warrant additional study.

METHODS

Within the UK Biobank prospective cohort study, 8124 middle-aged participants of South Asian ancestry and 449 349 participants of European ancestry who were free of atherosclerotic cardiovascular disease at the time of enrollment were examined. The relationship of ancestry to risk of incident atherosclerotic cardiovascular disease-defined as myocardial infarction, coronary revascularization, or ischemic stroke-was assessed with Cox proportional hazards regression, along with examination of a broad range of clinical, anthropometric, and lifestyle mediators.

RESULTS

The mean age at study enrollment was 57 years, and 202 405 (44%) were male. Over a median follow-up of 11 years, 554 of 8124 (6.8%) individuals of South Asian ancestry experienced an atherosclerotic cardiovascular disease event compared with 19 756 of 449 349 (4.4%) individuals of European ancestry, corresponding to an adjusted hazard ratio of 2.03 (95% CI, 1.86-2.22; P<0.001). This higher relative risk was largely consistent across a range of age, sex, and clinical subgroups. Despite the >2-fold higher observed risk, the predicted 10-year risk of cardiovascular disease according to the American Heart Association/American College of Cardiology Pooled Cohort equations and QRISK3 equations was nearly identical for individuals of South Asian and European ancestry. Adjustment for a broad range of clinical, anthropometric, and lifestyle risk factors led to only modest attenuation of the observed hazard ratio to 1.45 (95% CI, 1.28-1.65, P<0.001). Assessment of variance explained by 18 candidate risk factors suggested greater importance of hypertension, diabetes, and central adiposity in South Asian individuals.

CONCLUSIONS

Within a large prospective study, South Asian individuals had substantially higher risk of atherosclerotic cardiovascular disease compared with individuals of European ancestry, and this risk was not captured by the Pooled Cohort Equations.

Cardio-metabolic outcomes in South Asians compared to White Europeans in the United Kingdom: a matched controlled population-based cohort study

BACKGROUND

There appears to be an inequality in the risk of cardio-metabolic disease between those from a South Asian (SA) background when compared to those of White Europeans (WE) descendance, however, this association has not been explored in a large European cohort. This population-based open retrospective cohort explores the incidence of cardio-metabolic disease in those without pre-existing cardiometabolic disease taken from a large UK primary care database from 1st January 2007 to 31st December 2017.

METHODS

A retrospective open cohort matched population-based study using The Health Improvement Network (THIN) database. The outcomes of this study were the incidences of cardio-metabolic events (type 2 diabetes mellitus, hypertension, ischemic heart disease, stroke, heart failure, and atrial fibrillation).

RESULTS

A total of 94,870 SA patients were matched with 189,740 WE patients. SA were at an increased risk of developing: T2DM (adjusted hazard ratio (aHR) 3.1; 95% CI 2.97-3.23); HTN (1.34; 95% CI: 1.29-1.39); ischaemic heart disease (IHD) (1.81; 95% CI: 1.68-1.93) and heart failure (HF) (1.11; 95% CI: 1.003-1.24). However, they were at a lower risk of atrial fibrillation (AF) (0.53; 95% CI: 0.48-0.59) when compared to WE. Of those of SA origin, the Bangladeshi community were at the greatest risk of T2DM, HTN, IHD and HF, but were at the lowest risk of AF in when compared to Indians and Pakistanis.

CONCLUSION

Considering the high risk of cardio-metabolic diseases in the SA cohort, differential public health measures should be considered in these patients to reduce their risk of disease, which may be furthered tailored depending on their country of origin.

Delivering a childhood obesity prevention intervention using Islamic religious settings in the UK: What is most important to the stakeholders?

Ten per cent of the childhood population in the UK are of South Asian (SA) origin. Within this population, over 40% are living with overweight or obesity. The majority of SA children are Muslim and attend Islamic religious settings (IRS) daily after school. Because of their reach and influence, IRS may be an appropriate channel for obesity prevention initiatives. We conducted 20 in-depth interviews with parents of children attending IRS, 20 with Islamic leaders, and 3 focus group discussions with 26 managers and workers of IRS in Bradford and Birmingham. Topic guides were developed, interviews and focus group discussions were audio-recorded, transcribed, and analysed thematically. Muslim parents, Islamic leaders and IRS staff were supportive of the delivery of obesity prevention interventions for children using IRS. Participants identified important components of an intervention including: Prophet Muhammad (PBUH) as a role model for healthy lifestyle; healthy diet, physical activity, and organisational behaviour change within IRS. Participants suggested that Islamic narrative on healthy diet and physical fitness could increase delivery uptake. Staff showed willingness to conduct physical activity sessions for boys and girls. Barriers for the intervention delivery were poor funding systems and time constraints for staff. All participant groups thought that it would be possible to deliver a childhood obesity prevention intervention. Interventions should be co-designed, culturally and religiously sensitive and combine the scientific guidelines on healthy living with Islamic narrative on importance of healthy diet consumption and physical activity.

Differences in total and regional body fat and their association with BMI in UK-born White and South Asian children: findings from the Born in Bradford birth cohort

Background: Body mass index (BMI) is commonly used as a proxy to determine excess adiposity, though this may underestimate fat mass (FM) in individuals of South Asian (SA) heritage. SA tend to have greater central adiposity than white people, which is associated with a higher risk of cardiometabolic disease. In this cross-sectional study, we aimed to determine the differences in total and regional FM using Dual-energy X-ray absorptiometry (DXA), and to see if any differences in FM varied by BMI category in UK-born white and SA children aged ~9 years. Methods: Anthropometric measurements and DXA scans were undertaken from 225 white and 269 SA children from the Born in Bradford cohort study. Linear regression was used to assess ethnic differences in total body fat percent and total and regional FM. Results: Although the mean BMI was similar, compared to white children, the proportion of SA children who were overweight or obese was ~20% higher, they had a median of 2kg more total FM, and the proportion with > 35% total body fat (TBF) was 22% and 16% higher in boys and girls respectively. Mean TBF% was greater in each BMI category, as was truncal, android and gynoid FM, with the greatest differences between ethnic groups observed in the healthy and overweight categories. Conclusions: Greater TBF% and total and regional FM in the healthy- and overweight BMI categories observed in SA children suggests they may be at greater risk of future cardiometabolic disease at a BMI level below obesity threshold. However, our sample size was small, and results may be influenced by selection bias and confounding; our findings need to be replicated in a larger study.

Diabetes and COVID-19: Diseases of racial, social and glucose intolerance

Diabetes and coronavirus disease 2019 (COVID-19) are worldwide pandemics that have had a major impact on public health throughout the globe. Risk factors for developing diabetes and having adverse outcomes of COVID-19 appear to be similar; metabolic factors (such as obesity), non-White ethnicity and poorer socioeconomic status appear to be risk factors for both. Diabetes and COVID-19 have a significant effect on populations adversely affected by health inequality. Whilst we hope that COVID-19 will be mitigated by widespread use of vaccines, no such prospect exists for mitigating the pandemic of diabetes. In this brief opinion review, I compare risk factors for diabetes and adverse outcomes of COVID-19 and argue that tackling health and social inequality is likely to play a major role in solving the global diabetes pandemic and improve outcomes of COVID-19.

Cardiovascular Risk Calculators and their Applicability to South Asians

BACKGROUND

Estimation of absolute cardiovascular disease (CVD) risk and tailoring therapies according to the estimated risk is a fundamental concept in the primary prevention of CVD is assessed in this study. Numerous CVD risk scores are currently available for use in various populations but unfortunately, none exist for South Asians who have much higher CVD risk as compared to their western counterparts.

METHODS

A literature search was done using PubMed and Google search engines to prepare a narrative review on this topic.

RESULTS

Various currently available CVD risk scores and their pros and cons are summarized. The studies performed in native as well as migrant South Asians evaluating the accuracy of these risk scores for estimation of CVD risk are also summarized. The findings of these studies have generally been inconsistent, but it appears that the British risk scores (e.g. QRISK versions) may be more accurate because of inclusion of migrant South Asians in the derivation of these risk scores. However, the lack of any prospective study precludes our ability to draw any firm conclusions. Finally, the potential solution to these challenges, including the role of recalibration and subclinical atherosclerosis imaging, is also discussed.

CONCLUSION

This review highlights the need to develop large, representative, prospectively followed databases of South Asians providing information on various CVD risk factors and their contribution to incident CVD. Such databases will not only allow the development of validated CVD risk scores for South Asians but will also enable application of machine-learning approaches to provide personalized solutions to CVD risk assessment and management in these populations.

Driver versus navigator causation in biology: the case of insulin and fasting glucose

BACKGROUND

In biomedicine, inferring causal relation from experimental intervention or perturbation is believed to be a more reliable approach than inferring causation from cross-sectional correlation. However, we point out here that even in interventional inference there are logical traps. In homeostatic systems, causality in a steady state can be qualitatively different from that in a perturbed state. On a broader scale there is a need to differentiate driver causality from navigator causality. A driver is essential for reaching a destination but may not have any role in deciding the destination. A navigator on the other hand has a role in deciding the destination and the path but may not be able to drive the system to the destination. The failure to differentiate between types of causalities is likely to have resulted into many misinterpretations in physiology and biomedicine.

METHODS

We illustrate this by critically re-examining a specific case of the causal role of insulin in glucose homeostasis using five different approaches (1) Systematic review of tissue specific insulin receptor knock-outs, (2) Systematic review of insulin suppression and insulin enhancement experiments, (3) Differentiating steady state and post-meal state glucose levels in streptozotocin treated rats in primary experiments, (4) Mathematical and theoretical considerations and (5) Glucose-insulin relationship in human epidemiological data.

RESULTS

All the approaches converge on the inference that although insulin action hastens the return to a steady state after a glucose load, there is no evidence that insulin action determines the steady state level of glucose. Insulin, unlike the popular belief in medicine, appears to be a driver but not a navigator for steady state glucose level. It is quite likely therefore that the current line of clinical action in the field of type 2 diabetes has limited success largely because it is based on a misinterpretation of glucose-insulin relationship. The insulin-glucose example suggests that we may have to carefully re-examine causal inferences from perturbation experiments and set up revised norms for experimental design for causal inference.

Cardiovascular risk assessment in South and Middle-East Asians living in the Western countries

Nearly a quarter of the world population lives in the South Asian region (India, Pakistan, Bangladesh, Sri Lanka, Nepal, Bhutan, and the Maldives). Due to rapid demographic and epidemiological transition in these countries, the burden of non-communicable diseases is growing, which is a serious public health concern. Particularly, the prevalence of pre-diabetes, diabetes and atherosclerotic cardiovascular disease (CVD) is increasing. South Asians living in the West have also substantially higher risk of CVD and mortality compared with white Europeans and Americans. Further, as a result of global displacement over the past three decades, Middle-Eastern immigrants now represent the largest group of non-European immigrants in Northern Europe. This vulnerable population has been less studied. Hence, the aim of the present review was to address cardiovascular risk assessment in South Asians (primarily people from India, Pakistan and Bangladesh), and Middle-East Asians living in Western countries compared with whites (Caucasians) and present results from some major intervention studies. A systematic search was conducted in PubMed to identify major cardiovascular health studies of South Asian and Middle-Eastern populations living in the West, relevant for this review. Results indicated an increased risk of CVD. In conclusion, both South Asian and Middle-Eastern populations living in the West carry significantly higher risk of diabetes and CVD compared with native white Europeans. Lifestyle interventions have been shown to have beneficial effects in terms of reduction in the risk of diabetes by increasing insulin sensitivity, weight loss as well as better glycemic and lipid control.

One Size Does Not Fit All: Diabetes Prevalence Among Immigrants of the South Asian Diaspora

The risk of diabetes is higher in South Asians compared to the general population. As a result of migration during the twentieth-century postindependence, the South Asian diaspora is incredibly vast. We examined the diabetes prevalence between groups of the South Asian diaspora based on their distinct migration patterns. Population-based health care and immigration administrative data were used to compare crude and standardized diabetes prevalence between immigrants from nine regions of the South Asian diaspora and the non-immigrant population. Diabetes prevalence across groups were also stratified by gender. There were 199,003 South Asian immigrants; 33,882 (crude prevalence of 17.0%) of whom had a diagnosis of diabetes. The nine subgroups varied significantly in the prevalence of diabetes after adjusting for age, sex and income: Sri Lanka 24.3%, Pakistan 22.2%, Fiji 21.5%, Bangladesh 20.7%, the Caribbean 20.4%, India 16.0%, East Africa 13.8%, South Africa 10.8%, and the Middle East 9.6% in comparison to the non-immigrant population 17.8%. Higher prevalence was evident among men compared with women in each subgroup with the exception of Pakistan. Diabetes prevalence is not uniform among South Asians. Our findings highlight potential impacts of their unique migration histories on the risk and burden of diabetes, and move beyond a one size fits all approach in the South Asian population of Ontario to develop targeted interventions.

Cultural adaptation of an existing children's weight management programme: the CHANGE intervention and feasibility RCT

BACKGROUND

Excess weight in children is a continuing health issue. Community-based children's weight management programmes have had some effect in promoting weight loss. Families from minority ethnic communities are less likely to complete these programmes but, to date, no programmes have been culturally adapted to address this.

OBJECTIVES

We aimed to (1) culturally adapt an existing weight management programme for children aged 4-11 years and their families to make it more suited to Pakistani and Bangladeshi communities but inclusive of all families and (2) evaluate the adapted programme to assess its feasibility and acceptability, as well as the feasibility of methods, for a future full-scale trial.

DESIGN

In phase I, a cultural adaptation of a programme that was informed by formative research and guided by two theoretical frameworks was undertaken and in phase II this adapted programme was delivered in a cluster-randomised feasibility study (for which the clusters were the standard and adapted children's weight management programmes).

SETTING

Birmingham: a large, ethnically diverse UK city.

PARTICIPANTS

In phase I, Pakistani and Bangladeshi parents of children with excess weight, and, in phase II, children aged 4-11 years who have excess weight and their families.

INTERVENTIONS

A culturally adapted children's weight management programme, comprising six sessions, which was delivered to children and parents, targeting diet and physical activity and incorporating behaviour change techniques, was developed in phase I and delivered in the intervention arm to 16 groups in phase II. The eight groups in the comparator arm received the standard (unadapted) children's weight management programme.

MAIN OUTCOME MEASURES

The primary outcome was the proportion of Pakistani and Bangladeshi families completing (attending ≥ 60% of) the adapted programme. Secondary outcomes included the proportion of all families completing the adapted programme, the feasibility of delivery of the programme, the programme's acceptability to participants, the feasibility of trial processes and the feasibility of collection of outcome and cost data.

RESULTS

The proportion of Pakistani and Bangladeshi families and all families completing the adapted programme was 78.8% [95% confidence interval (CI) 64.8% to 88.2%] and 76.3% (95% CI 67.0% to 83.6%), respectively. The programme was feasible to deliver with some refinements and was well received. Ninety-two families participated in outcome data collection. Data collection was mostly feasible, but participant burden was high. Data collection on the cost of programme delivery was feasible, but costs to families were more challenging to capture. There was high attrition over the 6-month follow-up period (35%) and differential attrition in the two study arms (29% and 52% in the intervention and comparator arms, respectively).

LIMITATIONS

The study was not designed to address the issue of low participant uptake of children's weight management programmes. The design of a future trial may include individual randomisation and a 'minimal intervention' arm, the acceptability of which has not been evaluated in this study.

CONCLUSIONS

The theoretically informed, culturally adapted children's weight management programme was highly acceptable to children and families of all ethnicities. Consideration should be given to a future trial to evaluate clinical effectiveness and cost-effectiveness of the adapted programme, but the design of a future trial would need to address the logistics of data collection, participant burden and study attrition.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN81798055.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 33. See the NIHR Journals Library website for further project information. Kate Jolly is part-funded by the Collaboration for Leadership in Applied Health Research and Care West Midlands.

Comprehensive laboratory reference intervals for routine biochemical markers and pro-oxidant-antioxidant balance (PAB) in male adults

Background

Reference values of biochemical markers are influenced by various parameters including age, sex, region, and lifestyle. Hence, we aimed to determine age‐ and BMI‐specific reference intervals (RIs) for important clinical biomarkers in a healthy adult male population from northeastern Iran. This is also the first study to investigate reference values for pro‐oxidant‐antioxidant balance (PAB).

Methods

Seven hundred and twenty (720) healthy men, aged 20‐60 years, were recruited from Sarakhs in the northeast region of Iran. Reference values for lipid profiles (total cholesterol, triglyceride, HDL‐C and LDL‐C), fasting blood glucose, inflammatory factors (hs‐CRP and PAB), minerals (zinc and copper), uric acid, and blood pressure were measured and statistically analyzed to establish accurate age‐ and BMI‐specific RIs in alignment with CLSI Ep28‐A3 guidelines.

Results

RIs for lipid profiles, inflammatory factors, minerals, and uric acid required no age partitioning with the exception of fasting blood glucose and blood pressure, which demonstrated significantly higher values in subjects aged 50 years and older. Among these biomarkers, only uric acid, blood pressure, and triglycerides demonstrated statistically significant increases in reference value concentrations with increasing BMI.

Conclusion

In this study, age‐ and BMI‐specific RIs for several biochemical markers were determined in healthy adult Iranian men. Partitioning by age and BMI was only required for a few analytes with most demonstrating no statistically significant changes with these covariates. These data can be useful to monitor various diseases in male adults with varying BMI in this region and others.

Effectiveness of a Cultural Stroke Prevention Program in the United States-South Asian Health Awareness About Stroke (SAHAS)

There are few stroke education programs focused on the South Asian population in the United States. The South Asian Health Awareness about Stroke (SAHAS) program was developed to provide culturally appropriate stroke education to South Asians from 2014 to 2017. Participants recruited for the SAHAS program were educated through a uniquely developed, culturally-specific, educational presentation. Each participant was asked to complete identical educational questionnaires both before (pre-) and after (post-) the intervention, which were then scored and evaluated. Overall, the 357 participants who completed the SAHAS program had a significant, modest 9% improvement in questionnaire score (p < 0.0001). After adjusting for confounders, those ≤ 60 years had a 2.9-point greater increase in score than those > 60 (p < 0.0001). Having programs targeted and developed for specific minority groups with an emphasis on familial commitment and active participation may aid in raising awareness and reducing the elevated adverse stroke outcomes in South Asians.

Objective measurement of physical activity and sedentary behavior among South Asian adults: A systematic review

Background

South Asians are one of the fastest growing ethnic groups in western countries with a high incidence of chronic diseases like metabolic syndrome and cardiovascular disease occurring at younger ages and lower body weight compared with white Europeans. Physically active lifestyle and reduced sedentary time are modifiable risk factors that can decrease burden of chronic diseases. Population-level surveys based on self-report show South Asians engage in low levels of physical activity. Because of known limitations with self-report data, we aimed to synthesize available evidence to generate a physical activity /sedentary time profile of South Asians from studies using accelerometry.

Methods

We systematically searched Medline, EMBASE, CINAHL, PsycINFO, and SportDiscus. We included studies applying accelerometry to measure physical activity /sedentary time under free-living. Studies with an exclusive focus on drugs or including participants with health conditions/physical disability, and special populations (athletes/pregnant women) were excluded. Two authors independently adjudicated inclusion of citations at title/abstract and full text. We applied a standardized data abstraction form to extract relevant data. We evaluated methodological quality using Newcastle Ottawa Quality Assessment Scale. Due to variability and inconsistencies in measurement and reporting of physical activity /sedentary time, we only provide a narrative synthesis.

Findings

We identified only 14 studies(n = 1,338). Despite using similar accelerometry assumptions, we noted variability in reported outcomes for physical activity and sedentary time. Sedentary time ranged from 482(98) to 587 min/day. Mean light physical activity ranged from 211.69(67. 38) to 574(227) min/day. Moderate to vigorous physical activity among South Asian women ranged from 17–41 min/day and among men, 32–43 min/day.

Conclusion

South Asians exhibited higher levels of physical activity when compared to the Canadian population level survey but not when compared to the American population level survey. Overall, fewer studies, and small sample sizes led to considerable variability limiting any effective comparisons. Results highlight the importance of conducting methodologically robust studies based on random sampling to advance the field, and to capture true levels of sedentary time and physical activity in the South Asian population.

Socio-economic and reproductive concomitants of abdominal adiposity and hypertension: A study on Bengali-speaking Hindu women of Habra, North 24 Parganas, West Bengal, India

Obesity and hypertension have become a global epidemic among the women, especially as they experience additional stressful events compared to men. The epidemiology of these two metabolic disorders is regulated by various biological, socio-economic, reproductive and lifestyle factors related to women. However, inconsistency in the nature and magnitude of the effects of these traits indicates exploring the areas where little emphasis has been given. In this context, the present study attempted to determine the effect of socio-economic and reproductive traits on hypertension and abdominal adiposity among women living in the North 24 Parganas district of West Bengal, India. Data on socio-demographic and reproductive traits were collected from 319 adult women from both rural and urban sectors of Habra block I. Anthropometric measurements and Blood pressure levels were measured following standard protocols. Results highlighted that the prevalence of obese individuals and hypertensive individuals were 73.4 and 50.5 per cent respectively. Women with low income (OR=0.51) were at lower risk and post-menopausal women (OR=1.71) were at higher risk of developing abdominal adiposity. The risk of developing hypertension increased with higher educational attainment (OR=2.43). Post-menopausal women (OR=0.46) and shifting workers (OR=0.40) were at lower risk of developing hypertension. The risk also decreased with increased age (OR=0.96). Present study revealed that menopause is a significant event to predict abdominal adiposity and hypertension among Bengali-speaking Hindu women.

Development of a Culturally Tailored Motivational Interviewing-Based Intervention to Improve Medication Adherence in South Asian Patients

BACKGROUND

South Asians (SAs) are among the fastest growing ethnic population in Western countries and have a higher risk of cardiovascular diseases relative to the general population. SAs living in Canada also have poorer adherence to medical regimens for treating cardiovascular disease, relative to other ethnic groups. Motivational interviewing (MI) maybe effective in improving health-related behaviour change in patients; however, the research is nascent on the effectiveness of MI in SAs and may also require cultural adaptation.

AIM

To develop a culturally tailored MI-based intervention to improve medication adherence in hypertensive SA patients living in Canada.

METHODS

Previous literature about medication adherence in SAs was reviewed, along with transcripts and responses to open-ended survey questions from our previous studies with SAs, to draft an MI intervention manual. The manual received extensive feedback from the study team, SA community members and health-care providers who work with SA patients. The feedback was used to refine the manual and make it culturally tailored and relevant to SA hypertensive patients living in Canada.

RESULTS

A culturally tailored MI-based manual which we called a "motivational communication manual" was developed to support a study focused on improving medication adherence in SA hypertensive patients. The development process, components (eg, being culturally sensitive, family involvement, providing education about medications, reminders, etc.) and cultural nuances included in the manual are described in this paper.

CONCLUSION

This is the first culturally tailored MI-based intervention manual that has been developed with the aim of improving medication adherence in hypertensive SA patients and that includes direct feedback from SA community members. Use of this manual may improve the accessibility and adoption of MI-based practices in improving health behaviours in SAs living in Canada as well as encourage further research studies and clinical trials with SA patients.

Ethnic Differences in Functional Limitations by Age Across the Adult Life Course

Background

Despite compelling evidence from the United States of ethnic inequalities in physical functioning and ethnic differences in risk factors for poor physical functioning, very little is known about ethnic differences in the United Kingdom. Furthermore, the life stage at which these ethnic differentials are first observed has not been examined.

Methods

Using cross-sectional data from Wave 1 of the UK Household Longitudinal Study (UKHLS), we compared self-reported physical functioning among 35,816 White British, 4,450 South Asian and 2,512 African Caribbean men and women across different stages of adulthood (young adulthood, early middle age, late middle age, older age). Regression analyses examined ethnic differences in functional limitations, with adjustment for socioeconomic and clinical covariates. Ethnicity by sex and ethnicity by age-group interactions were examined, and subgroup heterogeneity was explored.

Results

Compared with White British adults over the age of 60, older South Asian men and women reported higher odds of functional limitations (odds ratio [OR] 2.77 [95% confidence interval {CI}: 2.00–3.89] and OR 3.99 [2.61–6.10], respectively); these ethnic differentials were observed as early as young adulthood. Young African Caribbean men had lower odds of functional limitations than White British men (OR 0.56 [0.34–0.94]), yet African Caribbean women reported higher odds of functional limitations in older age (OR 1.84 [1.21–2.79]).

Conclusions

There is an elevated risk of functional limitations relating to ethnicity, even in young adulthood where the impact on future health and socioeconomic position is considerable. When planning and delivering health care services to reduce ethnic inequalities in functional health, the intersectionality with age and sex should be considered.

Elevated Lipoprotein A in South Asians and the Associated Risk of Cardiovascular Disease: A Systematic Review

BACKGROUND

South Asians have a premature risk of cardiovascular disease and increased lipoprotein A which enhances their risk.

METHODS

This systematic review evaluates the role of elevated lipoprotein A in cardiovascular disease risk for South Asians. It discusses the pathophysiology, clinical studies, and treatment of elevated lipoprotein A using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses method.

RESULTS

A total of 72 articles was incorporated which consisted of clinical studies, case-control and cohort studies, meta-analysis, reviews, and editorials. Cardiovascular disease and myocardial infarction occurs prematurely in South Asians, which is further enhanced with an elevated lipoprotein A.

CONCLUSIONS

South Asians with an elevated lipoprotein A have an increased risk of coronary artery disease so they should have early enactment of lifestyle modification and aggressive medical management.

The relationship of acculturation to cardiovascular disease risk factors among U.S. South Asians: Findings from the MASALA study

AIM

We investigated the association between acculturation strategies and cardiometabolic risk among South Asian (SA) immigrants in the US.

METHODS

In this cross-sectional analysis of data from 849 SA participants in the Mediators of Atherosclerosis in SAs Living in America (MASALA), we performed multidimensional measures of acculturation to categorize the participants into three acculturation classes: separation (preference for SA culture), assimilation (preference for US culture), and integration (similar preference for both cultures). Differences in glycemic indices, blood pressure, lipid parameters and body composition by acculturation strategy were examined.

RESULTS

Women in the integration class had the lowest prevalence of diabetes (16.4%), prediabetes (29.7%), fasting and 2-h glucose compared to women in the separation class with the highest prevalence of diabetes (29.3%), prediabetes (31.5%), fasting and 2-h glucose and 2-hr insulin (all p < 0.05). Women in the assimilation class had significantly lower triglycerides, BMI, and waist circumference and higher HDL compared to women in the separation class after adjusting for age, study site, and years in the US. After additionally accounting for socioeconomic/lifestyle factors, women in the assimilation class had significantly lower triglyceride and higher HDL levels compared to women in the separation class (p < 0.01). There was no significant association between acculturation strategies and cardiometabolic risk in SA men.

CONCLUSION

SA women who employed an assimilation or integration strategy had a more favorable cardiometabolic profile compared to women using a separation strategy. Future research should investigate the behavioral and psychosocial pathways linking acculturation strategies with cardiometabolic health to inform preventive interventions among SAs living in America.

Elucidation of the novel role of ethnicity and diabetes in poorer outcomes after cardiac surgery in a multiethnic Southeast Asian cohort

BACKGROUND

Although diabetes is associated with ethnicity and worse cardiac surgery outcomes, no research has been done to study the effect of both diabetes and ethnicity on cardiac surgery outcomes in a multiethnic Southeast Asian cohort. Hence, this study aimed to delineate the association of ethnicity on outcomes after cardiac surgery among diabetics in a multiethnic Southeast Asian population.

METHODS

Perioperative data from 3008 adult patients undergoing elective cardiac surgery from 2008 to 2011 at the two main heart centers in Singapore was analyzed prospectively, and confirmatory analysis was conducted with the generalized structural equation model.

RESULTS

Diabetes was significantly associated with postoperative acute kidney injury (AKI) and postoperative hyperglycemia. Postoperative AKI, Malay ethnicity, and blood transfusion were associated with postoperative dialysis. Postoperative AKI and blood transfusion were also associated with postoperative arrhythmias. In turn, postoperative dialysis and arrhythmias increased the odds of 30-day mortality by 7.7- and 18-fold, respectively.

CONCLUSIONS

This study identified that diabetes is directly associated with postoperative hyperglycemia and AKI, and indirectly associated with arrhythmias and 30-day mortality. Further, we showed that ethnicity not only affects the prevalence of diabetes, but also postoperative diabetes-related outcomes.

The Burden of Atherosclerotic Cardiovascular Disease in South Asians Residing in Canada: A Reflection From the South Asian Heart Alliance

South Asians (SAs), originating from the Indian subcontinent (India, Pakistan, Sri Lanka, Bangladesh, Nepal, and Bhutan), represent one quarter of the global population and are the largest visible minority in Canada. SAs experience the highest rates of coronary artery disease in Canada. Although conventional cardiovascular risk factors remain predictive in SA, the excess risk is not fully explained by these risk factors alone. Abdominal obesity, metabolic syndrome, and insulin resistance likely contribute a greater risk in SAs than in other populations. The South Asian Heart Alliance has been recently formed to investigate and recommend the best strategies for the prevention of cardiometabolic disease in SAs in Canada. This topic review represents a comprehensive overview of the magnitude of cardiovascular disease in SAs in Canada, with a review of conventional and novel risk markers in the SA population. Both primary and secondary prevention strategies are suggested and when possible, adapted specifically for the SA population. The need for SAs and their healthcare professionals to be more aware of the problem and potential solutions, along with the need for population-specific research, is highlighted.

A scoping review and systematic mapping of health promotion interventions associated with obesity in Islamic religious settings in the UK

Islamic religious settings (IRS) may be useful places to implement obesity interventions for Muslims. However, little is known about the level and nature of such activity in these settings. We searched bibliographic databases and grey literature, and requested grey information from Muslim organizations, local councils, and mosques in 13 selected areas in the United Kingdom. Thirty-five interventions were identified; most were poorly described and not evaluated. Twenty-seven interventions focused on physical activity behaviours, four on diet behaviours, one on both behaviours, and seven addressed long-term conditions associated with obesity. Most interventions were led by volunteers from the congregation/faith leaders and were funded through donations from congregants or charity organizations. The evidence suggests that health promotion interventions in IRS have a relatively high reach. Obesity interventions are commonly delivered in UK IRS. Most target physical activity behaviours, are instigated and led by volunteers from the congregation or faith leaders, receive no public funding, and are only recorded in people's memories. High-quality evaluations of well-specified interventions in this context are needed. We suggest that the methods used in this review, including the learning around positionality of researchers, could be adopted by other researchers as a way to locate opportunities for effective community-level interventions.

Heterogeneity/granularity in ethnicity classifications project: the need for refining assessment of health status

BACKGROUND

Identifying ethnic inequalities in health requires data with sufficiently 'granular' (fine detailed) classifications of ethnicity to capture sub-group variation in healthcare use, risk factors and health behaviors. The Robert Wood Johnson Foundation (RWJF), in the USA, commissioned us to explore granular approaches to ethnicity data collection outside of the USA, commencing with the European Union.

METHODS

We examined official data sources (population censuses/registers) within the EU-28 to determine the granularity of their approach to ethnicity. When ethnic information was not available, related variables were sought (e.g. country of birth).

RESULTS

Within the EU-28, we found 55% of countries collected data on ethnicity. However, only 26% of these countries (England, Wales, Northern Ireland, Scotland, Republic of Ireland, Hungary, Poland and Slovakia) had a granular approach, with half of these being within the UK. Estonia, Lithuania, Croatia, Bulgaria, Republic of Cyprus and Slovenia collected one to six categories. A 'write-in' option only was found in Latvia, Romania and the Czech Republic. Forty-five percent of countries did not collect ethnicity data but collected other related variables.

CONCLUSIONS

(i) Although there is reasonable attention to the diversity of ethnic groups in data collection, a granular approach does not predominate within EU-28 classifications. (ii) Where ethnicity is collected, it is conceptualized in different ways and diverse terminology is used. (iii) A write-in option provides the most granular approach. (iv) Almost half of the countries did not collect data on ethnicity, but did collect related variables that could be used as a proxy.

Epidemiology, risk factors, and opportunities for prevention of cardiovascular disease in individuals of South Asian ethnicity living in Europe

South Asian (SA) individuals represent a large, growing population in a number of European countries. These individuals, particularly first-generation SA immigrants, are at higher risk of developing type 2 diabetes, atherogenic dyslipidaemia, and coronary heart disease than most other racial/ethnic groups living in Europe. SAs also have an increased risk of stroke compared to European-born individuals. Despite a large body of conclusive evidence, SA-specific cardiovascular health promotion and preventive interventions are currently scarce in most European countries, as well as at the European Union level. In this narrative review, we aim to increase awareness among clinicians and healthcare authorities of the public health importance of cardiovascular disease among SAs living in Europe, as well as the need for tailored interventions targeting this group - particularly, in countries where SA immigration is a recent phenomenon. To this purpose, we review key studies on the epidemiology and risk factors of cardiovascular disease in SAs living in the United Kingdom, Italy, Spain, Denmark, Norway, Sweden, and other European countries. Building on these, we discuss potential opportunities for multi-level, targeted, tailored cardiovascular prevention strategies. Because lifestyle interventions often face important cultural barriers in SAs, particularly for first-generation immigrants; we also discuss features that may help maximise the effectiveness of those interventions. Finally, we evaluate knowledge gaps, currently available risk stratification tools such as QRISK-3, and future directions in this important field.

Cultural adaptation of a children's weight management programme: Child weigHt mANaGement for Ethnically diverse communities (CHANGE) study

BACKGROUND

Childhood obesity prevalence continues to be at high levels in the United Kingdom (UK). South Asian children (mainly Pakistani and Bangladeshi origin) with excess adiposity are at particular risk from the cardiovascular consequences of obesity. Many community-based children's weight management programmes have been delivered in the UK, but none have been adapted for diverse cultural communities. The aim of the Child weigHt mANaGement for Ethnically diverse communities (CHANGE) study, was to culturally adapt an existing children's weight management programme for children aged 4-11 years so that the programme was more able to meet the needs of families from South Asian communities.

METHODS

The adaptation process was applied to First Steps, an evidence informed programme being delivered in Birmingham (a large, ethnically diverse city). A qualitative study was undertaken to obtain the views of South Asian parents of children with excess weight, who had fully or partially attended, or who had initially agreed but then declined to attend the First Steps programme. The resulting data were integrated with current research evidence and local programme information as part of a cultural adaptation process that was guided by two theoretical frameworks.

RESULTS

Interviews or focus groups with 31 parents in their preferred languages were undertaken. Themes arising from the data included the need for convenient timing of a programme in a close familiar location, support for those who do not speak English, the need to focus on health rather than weight, nutritional content that focuses on traditional and Western diets, more physical activity content, and support with parenting skills. The data were mapped to the Behaviour Change Wheel framework and Typology of Cultural Adaptation to develop an intervention programme outline. The research evidence and local programme information was then used in the detailed planning of the programme sessions.

CONCLUSIONS

The process of cultural adaptation of an existing children's weight management programme resulted in a theoretically underpinned programme that is culturally adapted at both the surface and deep structural levels.

TRIAL REGISTRATION

ISRCTN81798055 , registered: 13/05/2014.

Health Beliefs Regarding Cardiovascular Disease Risk and Risk Reduction in South Asian Immigrants: An Integrative Review

Introduction: The risk for cardiovascular disease (CVD) is higher in South Asians (SAs) than in other ethnic groups. The purpose of this review is to explore SAs' health beliefs regarding CVD risk and risk reduction behaviors including physical activity and healthy diet. Methodology: An integrative review was conducted to examine the peer-reviewed literature published before May 2017. Searches from PubMed, Scopus, and CINAHL yielded 1 mixed-method, 4 quantitative, and 14 qualitative studies. Results: Stress, lack of exercise, and high-fat diet were perceived as causes of CVD in most studies. Lack of time, sociocultural norms, and insufficient guidance from health care providers were perceived barriers to CVD risk reduction. Exercise and healthy diet were perceived to be beneficial in a few studies. Cues to action included information from community leaders and health care providers. Discussion: Understanding the unique health beliefs of SAs regarding CVD is important in planning and delivering culturally competent preventive and educational services.

ST-elevation myocardial infarction in a migrant population: a registry-based study of patient treatment and outcomes

BACKGROUND

Internationally, a growing number of studies has identified race-related disparities in the presentation, treatment and outcomes of patients with ST-elevation myocardial infarction (STEMI). With a large migrant population, Australia presents a unique microcosm in which to study the impact of migrant status and ethnicity in STEMI patients.

AIM

To investigate if first-generation migrants differed in presentation, treatment or outcomes following STEMI compared with the Australian-born population.

METHODS

We conducted a retrospective observational study using data from a clinician-initiated registry. The study involved 2154 patients who presented to 12 hospitals between 2004 and 2012. Our main outcome measures included time to reperfusion, 30-day mortality and complications.

RESULTS

Migrants (n = 1035, 48.8%) were more likely to be older (61 vs 58 years, P < 0.001), diabetic (29.3 vs 21.5%, P < 0.001) and have a prolonged symptom to door time (102 vs 91 min, P = 0.04). Despite lower rates of previous known ischaemic heart disease (22.5 vs 26.6%, P = 0.03), migrants had more diffuse disease (triple vessel or left main (3VD/LM): 29.8 vs 22.0%, P < 0.001) and higher troponin values (3.77 vs 3.22 μg/L, P = 0.01). We found no significant differences in hospital treatment times, intervention types or rates. Multivariate regression identified age, diabetes, female gender and multi-vessel disease as predictors of complications and death at 30 days.

CONCLUSIONS

Migrants had longer pre-hospital delays and exhibited different cardiovascular risk profiles than Australian-born patients but received comparable treatment in the acute hospital setting. Higher rates of diabetes and multi-vessel coronary artery disease were seen among migrant patients, indicating a relatively higher risk population.

Ethnic differences in sedentary behaviour in 6-8-year-old children during school terms and school holidays: a mixed methods study

BACKGROUND

Sedentary behaviour (SB) in childhood is a major public health concern. Little is known about ethnic differences in SB during school and holiday weeks among White British (WB) and South Asian (SA) children, which this study aims to address through investigating inclinometer measured SB and exploring reasons for child engagement in SB.

METHODS

A mixed methods study, comprising of a quantitative investigation with 160, 6-8 years old children and a qualitative study with a subsample of 18 children, six parents and eight teachers was undertaken. Children of WB and SA ethnicity in three schools were invited to wear inclinometers for seven school terms (summer/winter/spring) and seven holidays (winter/spring) days during July 2016-May 2017. Total SB, SB accumulated in bouts > 30 min and breaks in SB were explored using multivariate linear mixed effects models which adjusted for wear time, sex, deprivation, overweight status, season, term, weekday and school. Nine focus groups and two interviews were carried out using the Theoretical Domains Framework to explore SB perceptions among parents, teachers and children. Data were analysed using the Framework Approach.

RESULTS

104/160 children provided 836 valid days of data. Children spent on average eight hours of SB/day during term time and holidays, equating to 60% of their awake time, and had on average 111 SB breaks /day. SA children had 25 fewer SB breaks/ day when compared to WB (p < 0.001). Perceived reasons for engagement in SB included: boredom, enjoyment of screen activities (by children), parenting practices, curriculum pressures (by teachers), the need to sit down and learn, and child's preference for screen activities (by parents).

CONCLUSIONS

Children spent 60% of their awake time being sedentary, regardless of ethnicity or school term. There were no significant ethnic differences for any of the SB outcomes except for breaks in SB. Interventions aimed at reducing SB should consider involving parents and teachers and should focus on increasing breaks in SB, especially for SA children, who are at a higher risk of cardio metabolic ill health.

South Asians living in the UK and adherence to coronary heart disease medication: a mixed- method study

Background The prevalence of coronary heart disease amongst South Asian population in the UK is higher compared to the general population. Objective This study sought to investigate beliefs and experiences of South Asian patients regarding coronary heart disease and medication taking behaviour. Setting A London Heart Attack Centre. Methods This mixed method study is part of an original pilot randomised study on 71 patients involving a pharmacy-led intervention to improve medication adherence in coronary heart disease patients. South Asian patients from the randomised study took part in qualitative semi-structured telephone interviews. Both South Asian and non-South Asian patients completed the questionnaire about adherence and beliefs regarding medicines using Morisky Scale and the Belief About Medicines Questionnaire-Specific at 2 weeks, 3 and 6 months. Outcome Patients' beliefs about coronary heart disease and medication adherence. Results Seventeen South Asian patients and 54 non-South Asian patients took part. Qualitative data from 14 South Asian patients showed that while some attributed coronary heart disease to genetic, family history for their illness, others attributed it to their dietary patterns and 'god's will' and that little could be done to prevent further episodes of coronary heart disease. On the Belief About Medicines Questionnaire-Specific in South Asian patients, beliefs about necessity of medicines outweighed concerns. South Asian patients (n = 17) showed a similar pattern of adherence compared to non-Asian patients (n = 54). Adherence decreased with time in both populations, adherence measured by Morisky Scale. Conclusion South Asian patients in this study often attributed coronary heart disease to additional causes besides the known risk factors. Future studies on their understanding of the importance of cultural context in their attitudes to prevention and lived experience of the disease is warranted.