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

Recalibration of Framingham risk for a local population of Sri Lanka

BACKGROUND

Cardiovascular Diseases (CVD) account for the highest number of deaths and disability globally and within Sri Lanka. A CVD risk prediction tool is a simple means of early identification of high-risk groups which is a cost-effective preventive strategy, especially for resource-poor countries. Distribution of risk factor levels varies in different regions even within the same country, thus a common risk estimation tool for the country may give false local predictions. Since there are few published data related to Sri Lanka the aim of this study was to recalibrate the Framingham equation according to the local risk factor profile of a population in the Kurunegala region in Sri Lanka.

METHOD

A cross-sectional study was conducted with the participation of 1 102 persons from the Kurunegala Regional Director of Health Services area and the data was collected using an interviewer-administered questionnaire, anthropometric, blood pressure, and biochemical measurements. CVD risk was estimated using Framingham original and recalibrated CVD risk assessment methods. Current CVD mortality and morbidity data and the recalibration method conducted by the method described by Wilson and colleagues were used for calculations.

RESULTS

Original and recalibrated Framingham CVD risk scores predicted 55.5% (N = 612) and 62.3% (N = 687) to be having less than 10% CVD risk respectively. Further, the original and recalibrated CVD Risk Scores predicted 2.2% (N = 24) and 1.8% (N = 20) to be having CVD risk more than 40% respectively.

CONCLUSION

These findings show an over prediction of the CVD risk with the original Framingham risk calculations which signifies the importance of development of a region-specific risk prediction tool using local risk factor data in Sri Lanka which will prevent unnecessary expenditure to manage people without risk of CVD.

Post-Migration Changes in Dietary Patterns and Physical Activity among Adult Foreign Residents in Niigata Prefecture, Japan: A Mixed-Methods Study

The migrant population of Japan is gradually increasing, but it is not well known how and why diet and physical activity (PA) change post-migration. Therefore, this study used a mixed-method approach to investigate the changes in dietary patterns and PA through a web- and paper-based survey (n = 128) and understand the contextual factors for those changes through semi-structured interviews (n = 21). Descriptive and thematic analyses of quantitative and qualitative data were conducted, respectively. The majority of survey (57.8%) and interview (66.7%) participants were female, and the mean duration of stay in Japan was 5 and 3.6 years, respectively. The survey revealed an increased consumption of foods attached to Japanese culture, frozen and microwavable food, and a reduced consumption of fruits. We identified environmental (availability, accessibility, and affordability of foods; food safety and diet-related information; and climate), individual (living status; post-migration lifestyle; and food preferences and limitations), or socio-cultural (relationships with Japanese people; cultural differences; and religious influences) factors that impact diet changes. Language proficiency and the duration of stay shape dietary behaviors. Determinants of PA changes were climate, lifestyle, and the influence of Japanese culture. In conclusion, immigrants in Japan experience post-migration diet and PA changes, and this study adds knowledge about how and why such changes occur.

Metabolic Syndrome and Chronic Disease Risk in South Asian Immigrants: A Review of Prevalence, Factors, and Interventions

South Asians (SAs) are among the fastest-growing ethnic groups in the U.S. Metabolic syndrome (MetS) is a condition that is characterized by multiple health factors that increase the risk for chronic diseases, such as cardiovascular disease (CVD) and diabetes. MetS prevalence among SA immigrants ranges from 27-47% in multiple cross-sectional studies using different diagnostic criteria, which is generally higher compared to other populations in the receiving country. Both genetic and environmental factors are attributed to this increased prevalence. Limited intervention studies have shown effective management of MetS conditions within the SA population. This review reports MetS prevalence in SAs residing in non-native countries, identifies contributing factors, and discusses ways to develop effective community-based strategies for health promotion targeting MetS among SA immigrants. There is a need for more consistently evaluated longitudinal studies to facilitate the development of directed public health policy and education to address chronic diseases in the SA immigrant community.

Assessment of ideal cardiovascular health metrics in refugees, East of Iran

Background

In 2013, there was an estimation of greater than 4.5 million Afghan refugees who had migrated to the least developed countries. Over one million are legally registered in Iran. We assessed the heart health status as described by the American Heart Association (AHA) in the Afghan refugee populace.

Methods

This cross-sectional survey was carried out on 1,634 Afghan refugees, including 746 males (45.7%) and 888 females (54.3%), selected through a convenience sampling method in 2016. The American Heart Association's seven cardiovascular health metrics were evaluated to specify the status of heart health in Afghan refugees. Differences with age and sex were analyzed using the χ² test.

Results

Only one (0.1%) participant met the ideal for all seven cardiovascular health metrics. No significant differences were found between women and men in meeting the ideal criteria for more than five cardiovascular health metrics. As age increased, the proportion of refugees who met the ideal for more than five cardiovascular health metrics declined.

Conclusions

Refugees were not meeting the ideal cardiovascular health for some of the assessed metrics. Intervention to improve and monitor heart health in Afghan refugees is needed.

Epidemiology and the Magnitude of Coronary Artery Disease and Acute Coronary Syndrome: A Narrative Review

BACKGROUND

Coronary Artery Disease (CAD) is the foremost single cause of mortality and loss of Disability Adjusted Life Years (DALYs) globally. A large percentage of this burden is found in low and middle income countries. This accounts for nearly 7 million deaths and 129 million DALYs annually and is a huge global economic burden.

OBJECTIVE

To review epidemiological data of coronary artery disease and acute coronary syndrome in low, middle and high income countries.

METHODS

Keyword searches of Medline, ISI, IBSS and Google Scholar databases. Manual search of other relevant journals and reference lists of primary articles.

RESULTS

Review of the results of studies reveals the absolute global and regional trends of the CAD and the importance and contribution of CAD for global health. Data demonstrates which region or countries have the highest and lowest age-standardized DALY rates and what factors might explain these patterns. Results also show differences among the determinants of CAD, government policies, clinical practice and public health measures across the various regions of world.

CONCLUSION

CAD mortality and prevalence vary among countries. Estimation of the true prevalence of CAD in the population is complex. A significant number of countries have not provided data, the estimation of the exact figures for epidemiological data is a barrier. The incidence of CAD continues to fall in developed countries over the last few decades and this may be due to both effective treatment of the acute phase and improved primary and secondary preventive measures. Developing countries show considerable variability in the incidence of CAD. The globalization of the Western diet and increased sedentary lifestyle will have a dramatic influence on the progressive increase in the incidence of CAD in these countries.

Comparison of Cardiovascular Risk Factors among Somalis Living in Norway and Somaliland

Objective: We aimed to assess and compare cardiovascular disease (CVD) risk factors and predict the future risk of CVD among Somalis living in Norway and Somaliland. Method: We included participants (20–69 years) from two cross-sectional studies among Somalis living in Oslo (n = 212) and Hargeisa (n = 1098). Demographic data, history of CVD, smoking, alcohol consumption, anthropometric measures, blood pressure, fasting serum glucose, and lipid profiles were collected. The predicted 10-year risk of CVD was calculated using Framingham risk score models. Results: In women, systolic and diastolic blood pressure were significantly higher in Hargeisa compared to Oslo (p < 0.001), whereas no significant differences were seen in men. The ratio of total cholesterol to high-density lipoprotein (HDL) cholesterol was significantly higher in Hargeisa compared to Oslo among both men (4.4 versus 3.9, p = 0.001) and women (4.1 versus 3.3, p < 0.001). Compared to women, men had higher Framingham risk scores, but there were no significant differences in Framingham risk scores between Somalis in Oslo and Hargeisa. Conclusion: In spite of the high body mass index (BMI) in Oslo, most CVD risk factors were higher among Somali women living in Hargeisa compared to those in Oslo, with similar patterns suggested in men. However, the predicted CVD risks based on Framingham models were not different between the locations.

High Prevalence of Overweight/Obesity in Urban Sri Lanka: Findings from the Colombo Urban Study

BACKGROUND

South Asian countries face a double burden of malnutrition characterized by high prevalence of underweight, overweight, and obesity. Understanding the distribution of this public health problem is important to tailor targeted interventions for communities. The objective of the current study was to find out the prevalence of obesity in urban Sri Lanka and to identify sociodemographic factors associated with it.

METHODS

Adult males and females residing in an urban government division of the Colombo District in Sri Lanka were included in this study (Colombo Urban Study). Stratified simple random sampling was used to select a sample of 463 from the total population. Sociodemographic data using an interviewer-administered questionnaire, anthropometric measurements, and serum samples were obtained for investigations.

RESULTS

When the global BMI cutoffs were applied, the community prevalences of underweight, normal weight, overweight, and obesity were 7.7%, 39.6%, 37.0%, and 15.8%, respectively. When the Asian BMI cutoffs were applied, the respective prevalences were 7.7%, 26.8%, 34.3%, and 31.2%. The community prevalence for abdominal obesity was 58.1% when using Asian cutoffs. Females had a higher prevalence of both obesity and abdominal obesity. There was an ethnic difference in obesity rates with Moors having the highest rates (65.5%) followed by Sinhalese (52.3%) and Tamils (40.2%). The highest obesity prevalence was observed in the most educated group. Multiple regression analysis showed that high BMI was associated with female gender and family history of hypertension. Serum LDL negatively associated with BMI while the strength of this relationship was impacted by serum HBA1c levels. Finally, serum triglyceride level showed positive association with BMI, and the effect was more marked in Moors compared to Sinhalese.

CONCLUSION

Two-thirds of adults in the studied urban population were overweight or obese. This highlights the urgent need for interventions to curb this epidemic. The gender, ethnic differences in obesity, its associations with educational status, and the interactions with metabolic comorbidities indicate that these interventions may need to be targeted towards different groups in the population.

Aging and obesity are associated with undiagnosed hypertension in a cohort of males in the Central Province of Sri Lanka: a cross-sectional descriptive study

BACKGROUND

Lifestyle factors associated with hypertension (HT) in South Asian populations are relatively unknown. The objective of the current study was to investigate the prevalence rates of undiagnosed HT and factors associated with it in a cohort of males from the Central Province of Sri Lanka.

METHODS

The study group consisted of 2462 males (mean age 31 years, range: 16-72 years) who underwent a routine medical examination at the National Transport Medical Institute, Kandy, Sri Lanka. Participants with previously diagnosed heart disease, diabetes, hypertension or other chronic illnesses were excluded from this study. Dietary and other lifestyle factors were studied using validated self-administered questionnaires. Body Mass Index (BMI) cut-off values for Asians were used to categorize the subjects according to weight status. The association of individual dietary and lifestyle patterns with HT was assessed by fitting into binary logistic regression models.

RESULTS

The mean systolic (SBP) and diastolic blood pressures (DBP) of the individuals were 125.9 mmHg and 80.5 mmHg, respectively. The prevalence rate of undiagnosed HT was 31.7%. Both SBP and DBP showed significant positive correlations with age, weight, BMI and waist circumference. After adjusting for potential confounders, HT was associated with older age (p = 0.001) and increased weight status (p < 0.001) with trends of association for level of education (p = 0.058). Level of income, alcohol consumption, sleeping hours, smoking, physical activity level, ethnic difference, consumption of fruits, fish, meat, dairy, sweets or fried snacks were not significantly associated with HT. Obese males were 92.1% [odds ratio: 1.9 (1.4-2.7)] more likely to be hypertensive compared to normal weight males.

CONCLUSIONS

Undiagnosed HT is prevalent at an alarming rate among adult males in the Central Province of Sri Lanka. Its association with age and BMI (weight status) highlights the importance of routine screening for HT as well as interventions targeted at reducing obesity to curb the rise of this modifiable cardiovascular disease risk factor.

Lifestyle factors associated with obesity in a cohort of males in the central province of Sri Lanka: a cross-sectional descriptive study

BACKGROUND

Obesity has become a global epidemic. The prevalence of obesity has also increased in the South Asian region in the last decade. However, dietary and lifestyle factors associated with obesity in Sri Lankan adults are unclear. The objective of the current study was to investigate the association of dietary and lifestyle patterns with overweight and obesity in a cohort of males from the Central Province of Sri Lanka.

METHODS

A total of 2469 males aged between 16 and 72 years ([Formula: see text]) were included in the study. The sample comprised individuals who presented for a routine medical examination at the National Transport Medical Institute, Kandy, Sri Lanka. The Body Mass Index (BMI) cutoff values for Asians were used to categorize the participants into four groups as underweight, normal weight, overweight or obese. The data on dietary and lifestyle patterns such as level of physical activity, smoking, alcohol consumption, sleeping hours and other socio demographic data were obtained using validated self-administered questionnaires. Multinomial logistic regression model was fitted to assess the associations of individual lifestyle patterns with overweight and obesity.

RESULTS

The mean BMI of the study group was 22.7 kg m^-2 and prevalence rates of overweight and obesity were 31.8 and 12.3%, respectively. Mean waist circumference of the participants was 78.6 cm with 17.1% of them being centrally obese. After adjusting for potential confounders, weight status was associated with older age (P < 0.0001), ethnicity (P = 0.0033) and higher income (P = 0.0006). While higher physical activity showed a trend for being associated with lower odds of being obese (odds ratio: 0.898 - confidence interval: 0.744-1.084), alcohol intake, consumption of fruits, level of education, sleeping hours, smoking, consumption of fish, meat, dairy, sweets or fried snacks were not significantly associated with the weight status.

CONCLUSION

The high prevalence rates of overweight and obesity in working-age males is a threatening sign for Sri Lanka. Since the prevalence rate is higher in certain ethnic groups and higher-income groups, targeted interventions for these groups may be necessary.

Lipoprotein(a) and lipid profiles of patients awaiting coronary artery bypass graft; a cross sectional study

Background

Lipoprotein(a) (Lp(a)) excess is an independent risk factor of coronary artery disease (CAD) and have shown wide ethnic variations. Further, lipid parameters used in the assessment and management of risk factors for CAD may not reflect accurately the disease or severity if the patients are on pharmacological interventions when compared to Lp(a). Lp(a) levels of Sri Lankan CAD patients awaiting coronary artery bypass graft are not documented.

Methods

A cross sectional study was carried out with patients (n = 102) awaiting coronary artery bypass graft at a tertiary healthcare institution in Sri Lanka. Lp(a) was determined by immunoturbidimetric method (Konelab 20XT) and information on risk factors collected using a standardized questionnaire. The severity of CAD was determined by Gensini score. Lipid parameters and pharmacological treatment data were obtained from the Medical Records. Data were analysed using independent sample t-test, Pearson and Spearman tests respectively.

Results

Total cholesterol (TC), LDL cholesterol (LDLc) and HDL cholesterol (HDLc) of the total study sample (average ± SD) were, 150 ± 36 mg/dL, 92 ± 36 mg/dL and 34 ± 9 mg/dL respectively with no significant difference irrespective of being on pharmacological treatment or not. All lipid parameters were significantly high (p < 0.05) in females. The average Lp(a) was 50 ± 38 (SD) mg/dL with no significant difference in males or females independent of being on treatment (50 ± 39 mg/dL) or not (49 ± 39 mg/dL) and above the cut off value (30 mg/dL).

Conclusions

Despite pharmacological interventions 27 % of the study population had high LDLc and majority low HDLc. Mean Lp(a) was in excess irrespective of risk factors or being on treatment or not and is confirmed as an independent, potential marker for assessing the susceptibility for CAD especially in those with other intermediate risk factors but considered non-hyperlipidemic by conventional methods.

The impact of migration on body weight: a review

Immigrants may be more vulnerable to obesity as a result of the immigration process. The aim of this article is to summarize current knowledge about the impact of immigration on body mass index (BMI). A systematic review was performed in accordance with PRISMA guidelines through a database search of scientific articles (last updated in August 2014). Thirty-nine articles were included and assessed. Results varied according to ethnic background, country of origin and host country. A consistent positive association between BMI and time since immigration was found among Hispanic, European and African immigrants. Less than half of the studies observed a positive association among Asian immigrants. The quality of the majority of the studies assessed was poor, reflecting a need to improve methodology and concept definition. Immigration appears to have a deteriorative effect on BMI. Underlying causes may include changes in nutrition and physical activity, psychological and social factors, and genetic susceptibility and these aspects should be included as moderator variables in future studies.

Immigration, ethnicity, and avoidable mortality in Canada, 1991-2006

OBJECTIVE

Avoidable mortality is a well-recognized, but less studied indicator of the performance of the health system. First, the study seeks to establish whether immigrants overall and selected foreign-born ethnic groups (Western Europeans, South Asians, Chinese, and Filipinos) have an advantage over nonimmigrants in avoidable mortality. Second, it assesses the effect of sociodemographic and socioeconomic factors on any observed differences by duration of residence.

DESIGN

Deaths grouped by cause of death and by behavioral risk factors, namely smoking-related and alcohol-related, were derived from the 1991 Canadian Census Cohort: Mortality and Cancer Follow-up. The analysis estimated age-standardized mortality rates (ASMRs), rate ratios, and rate differences and also fitted hazard regression models for the overall Canadian-born population and for selected foreign-born ethnicities by sex. Predictors were assessed at baseline.

RESULTS

Compared to the Canadian-born persons, foreign-born men and women had lower ASMRs for overall avoidable mortality and also for selected causes of avoidable mortality. The only exception to this overall trend was for ischemic heart disease among South Asian women. Except for the order of prominence, the three leading causes of death for nonimmigrant and immigrant men and women overall were ischemic heart diseases, smoking-related diseases, and neoplasms. A similar pattern was observed among the ethnic groups, except for circulatory heart diseases replacing ischemic heart diseases and smoking-related diseases among Chinese and Filipino women, respectively. In the hazard regression analysis, the risk of avoidable mortality was lower for immigrants overall and selected ethnicities irrespective of the duration in Canada compared to nonimmigrants. These differences persisted even with adjustment for sociodemographic and socioeconomic factors.

CONCLUSION

Immigrants overall and the selected ethnicities enjoy an advantage over nonimmigrants in avoidable mortality. However, for certain causes of death especially ischemic heart disease mortality among South Asian women, immigrants appeared worse-off than nonimmigrants. The results suggest differential access to and use of health services, differences in protective health-related behavior, and the healthy immigrant effect.

Differences in Predicted Cardiovascular Risk in Sinhalese and Tamils in Sri Lanka Compared With Sri Lankans in Norway

Using data from 3 cross-sectional studies, the authors compared the estimated risk of cardiovascular diseases between migrant Sri Lankans in Oslo, Norway, and Tamils and Sinhalese in Kandy, Sri Lanka. The authors found that Sri Lankans in Oslo had significantly lower Framingham coronary heart disease (CHD) risk. Among men, the prevalence with estimated 10-year risk of a CHD event ≥10% was 20.6% in Oslo, 31.1% in Kandy Tamils, and 44.2% in Kandy Sinhalese. The corresponding figures in women were 10.4% in Oslo, 19.2% in Tamils, and 14.9% in Sinhalese. Risk of fatal cardiovascular disease estimated by the SCORE model showed a similar pattern. The Oslo group had a higher body mass index (BMI), but the differences were observed in all BMI categories. In conclusion, despite a lower BMI, Tamils and Sinhalese in Sri Lanka had higher estimated cardiovascular risk compared with Sri Lankans in Norway, mainly because of poorer lipid profiles.

Assessment of cardiovascular disease risk in South asian populations

Although South Asian populations have high cardiovascular disease (CVD) burden in the world, their patterns of individual CVD risk factors have not been fully studied. None of the available algorithms/scores to assess CVD risk have originated from these populations. To explore the relevance of CVD risk scores for these populations, literature search and qualitative synthesis of available evidence were performed. South Asians usually have higher levels of both “classical” and nontraditional CVD risk factors and experience these at a younger age. There are marked variations in risk profiles between South Asian populations. More than 100 risk algorithms are currently available, with varying risk factors. However, no available algorithm has included all important risk factors that underlie CVD in these populations. The future challenge is either to appropriately calibrate current risk algorithms or ideally to develop new risk algorithms that include variables that provide an accurate estimate of CVD risk.

Differences in Selected Lifestyle Risk Factors for Cardiovascular Disease Between Sri Lankans in Oslo, Norway, and in Kandy, Sri Lanka

Sri Lankans in Oslo have previously been shown to have lower risk of cardiovascular disease compared with those in Kandy, Sri Lanka. Here we present lifestyle risk factors for cardiovascular diseases: frequency and type of fat consumed, frequency of fruit and vegetable intake, alcohol consumption, and leisure time physical activity between 1145 Sri Lankans living in Oslo and 678 Tamils and Sinhalese Sri Lankans living in Kandy as possible explanatory factors for the differences observed. Those in Oslo were consuming healthier fats and reported higher levels of physical activity but frequency of vegetable and fruit consumption was lower. Alcohol consumption among women was negligible. Type of fats consumed might be protective for Oslo group compared with predominantly saturated fat diet in Kandy. Higher leisure time physical activity may also be protective for the Oslo group. Higher frequency of consumption of vegetables and fruits may be beneficial in Kandy.

Changes in dietary habits after migration and consequences for health: a focus on South Asians in Europe

BACKGROUND

Immigrants from low-income countries comprise an increasing proportion of the population in Europe. Higher prevalence of obesity and nutrition related diseases, such as type 2 diabetes (T2D) and cardiovascular disease (CVD) is found in some immigrant groups, especially in South Asians.

AIM

To review dietary changes after migration and discuss the implication for health and prevention among immigrants from low-income countries to Europe, with a special focus on South Asians.

METHOD

Systematic searches in PubMed were performed to identify relevant high quality review articles and primary research papers. The searches were limited to major immigrant groups in Europe, including those from South Asia (India, Pakistan, Bangladesh, Sri Lanka). Articles in English from 1990 and onwards from Europe were included. For health implications, recent review articles and studies of particular relevance to dietary changes among South Asian migrants in Europe were chosen.

RESULTS

Most studies report on dietary changes and health consequences in South Asians. The picture of dietary change is complex, depending on a variety of factors related to country of origin, urban/rural residence, socio-economic and cultural factors and situation in host country. However, the main dietary trend after migration is a substantial increase in energy and fat intake, a reduction in carbohydrates and a switch from whole grains and pulses to more refined sources of carbohydrates, resulting in a low intake of fiber. The data also indicate an increase in intake of meat and dairy foods. Some groups have also reduced their vegetable intake. The findings suggest that these dietary changes may all have contributed to higher risk of obesity, T2D and CVD. IMPLICATIONS FOR PREVENTION: A first priority in prevention should be adoption of a low-energy density - high fiber diet, rich in whole grains and grain products, as well as fruits, vegetables and pulses. Furthermore, avoidance of energy dense and hyperprocessed foods is an important preventive measure.

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

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