Cardiovascular health in migrants: current status and issues for prevention. A collaborative multidisciplinary task force report

The role of pre-existing left-sided valvular heart disease in the prognosis of patients with acute myocardial infarction

Acute myocardial infarction (AMI) and valvular heart disease (VHD) are the leading causes of cardiovascular morbidity and mortality. The epidemiology of VHD has changed in recent decades with an aging population, increasing risk factors for cardiovascular disease and migration, all of which have a significant implifications for healthcare systems. Due to common pathophysiological mechanisms and risk factors, AMI and VHD often coexist. These patients have more complicated clinical characteristics, in-hospital course and outcomes, and are less likely to receive guideline-directed therapy. Because of the reciprocal negative pathophysiological influence, these patients need to be referred to VHD specialists and further discussed within the Heart team to assess the need for earlier intervention. Since the results of the number of studies show that one third of the patients are referred to the heart teams either too early or too late, there is a need to better define the communication networks between the treating physicians, including internists, general practitioners, outpatient cardiologists and heart teams, after the discharge of patients with pre-existing VHD and AMI.

Hypertension in Pregnancy Among Immigrant and Swedish Women: A Cohort Study of All Pregnant Women in Sweden

BACKGROUND

Little is known about risks of hypertensive disorders of pregnancy in both first- and second-generation immigrant women in Europe and other Western countries; such knowledge may help elucidate the influence of genetic versus social factors on such risks. We aimed to study both first- and second-generation immigrant women for the presence of all types of hypertension (preexisting hypertension, gestational hypertension, preeclampsia, and eclampsia) during pregnancy.

METHODS AND RESULTS

A cohort study was conducted using data derived from the Swedish National Birth Register, the National Patient Register, and the Total Population Register. We used Cox regression analysis to compute hazard ratios (HRs) and 99% CIs while adjusting for sociodemographic factors and comorbidities. The first-generation study included a total of 1 084 212 deliveries and 68 311 hypertension cases, and the second-generation study included 989 986 deliveries and 67 505 hypertension cases. The fully adjusted HR (with 99% CI) for hypertension in pregnancy among first-generation immigrant women was 0.69 (0.66-0.72), and among second-generation immigrant women, it was 0.88 (0.86-0.91), compared with Swedish-born women with 2 Swedish-born parents. Women born in Finland or with parent(s) from Finland had higher risks, with fully adjusted HRs (99% CIs) of 1.30 (1.18-1.43) and 1.12 (1.07-1.17), respectively.

CONCLUSIONS

Both first- and second-generation immigrant women had overall lower risks of hypertension in pregnancy compared with other Swedish women. However, the risk reduction was less pronounced in second-generation compared with first-generation immigrant women, suggesting that environmental factors in Sweden may have an important influence on risk of hypertension during pregnancy.

Uptake and effectiveness of a primary cardiovascular prevention program in an underserved multiethnic urban community

BACKGROUND AND AIMS

Cardiometabolic risk is increased among disadvantaged people and ethnic minorities. Paradoxically, their uptake of primary cardiovascular prevention is relatively low. New strategies are needed to tackle this public health problem. Aims of this study were to assess the uptake (as well as its determinants) and effectiveness of a primary cardiovascular prevention program for communities devised to facilitate access of disadvantaged and inclusion of ethnic minorities in addition to providing a state-of-the-art interdisciplinary personalized care.

METHODS AND RESULTS

Single center, hospital-based, open study. All the residents in an underserved multiethnic urban community aged 40-65 years (n = 1646, 43.6% immigrants) were proactively invited by post mail to participate in a cardiovascular prevention program and different approaches were adopted to promote accessibility and inclusiveness. Program uptake was 23% and individual features independently associated with program uptake were status of immigrant (OR [CI 95%]: 3.6 [2.6-5.1]), higher educational level (3.6 [2.8-4.7]), and female gender (1.6 [1.2-2.1]). Retention was 82% at 6 months and 69% at 12 months. A predefined outcome of global cardiovascular risk improvement at 12 months in subjects with glycaemia >126 mg/dl, LDL-C >115 mg/dl, systolic blood pressure ≥140 mmHg or BMI >28 at baseline was reached in 35%, 33%, 37% and 7% of the patients, respectively. 20% of smokers quitted and significant favorable changes were reported in diet quality, anxiety, depression and physical activity.

CONCLUSION

Access inequalities to effective prevention may be counteracted, but increasing global uptake requires further upstream sensitization and awareness actions. REGISTERED IN CLINICALTRIALS.GOV: NCT03129165.

The contribution of obesity to the population burden of high metabolic cardiovascular risk among different ethnic groups. The HELIUS study

BACKGROUND

The burden of cardiovascular risk is distributed unequally between ethnic groups. It is uncertain to what extent this is attributable to ethnic differences in general and abdominal obesity. Therefore, we studied the contribution of general and abdominal obesity to metabolic cardiovascular risk among different ethnic groups.

METHODS

We used data of 21 411 participants of Dutch, South-Asian Surinamese, African-Surinamese, Ghanaian, Turkish or Moroccan origin in Healthy Life in an Urban Setting (Amsterdam, the Netherlands). Obesity was defined using body-mass-index (general) or waist-to-height-ratio (abdominal). High metabolic risk was defined as having at least two of the following: triglycerides ≥1.7 mmol/l, fasting glucose ≥5.6 mmol/l, blood pressure ≥130 mmHg systolic and/or ≥85 mmHg diastolic and high-density lipoprotein cholesterol <1.03 mmol/l (men) or <1.29 mmol/l (women).

RESULTS

Among ethnic minority men, age-adjusted prevalence rates of high metabolic risk ranged from 32 to 59% vs. 33% among Dutch men. Contributions of general obesity to high metabolic risk ranged from 7.1 to 17.8%, vs. 10.1% among Dutch men, whereas contributions of abdominal obesity ranged from 52.1 to 92.3%, vs. 53.9% among Dutch men. Among ethnic minority women, age-adjusted prevalence rates of high metabolic risk ranged from 24 to 35% vs. 12% among Dutch women. Contributions of general obesity ranged from 14.6 to 41.8%, vs. 20% among Dutch women, whereas contributions of abdominal obesity ranged from 68.0 to 92.8%, vs. 72.1% among Dutch women.

CONCLUSIONS

Obesity, especially abdominal obesity, contributes significantly to the prevalence of high metabolic cardiovascular risk. Results suggest that this contribution varies substantially between ethnic groups, which helps explain ethnic differences in cardiovascular risk.

Blood pressure and fasting glucose changes in male migrants waiting for an asylum decision in Italy. A pilot study

BACKGROUND

The Central Mediterranean route from Libya to Italy has been for years the major port of entry from Africa to Europe. However, information on the early effects of permanence in Italy on cardiovascular risk factors is limited. Therefore, the association between length of stay in Italy and blood pressure or blood glucose was explored in young asylum seekers.

METHODS

Cross-sectional study performed on male asylum seekers (aged 18-40 years), hosted for 0-30 months in Prato, Italy. Blood pressure and blood glucose, measured with validated instruments, were classified according to European Society of Hypertension and American Diabetes Association guidelines respectively. The relationship of quartiles of months of stay in Italy (independent variable) with blood pressure and fasting glucose was investigated with multivariate linear regression adjusted for years of age, world area of origin, education level, travel duration in months, smoking habit, alcohol use, body mass index, triglycerides.

RESULTS

On average, the 217 asylum seekers lived in Italy for 8.4 months (95% CI 7.5-9.3; range 0-30 months). At multivariate adjusted linear regression analysis, quartiles of months in Italy were associated with a forward shift in the blood pressure categories of the European Society of Hypertension (B = 0.396; 95% CI 0.190 to 0.602) and in the categories fasting glucose levels of the American Diabetes Association (B = 0.450; 95% CI 0.023 to 0.876).

CONCLUSIONS

When considering the importance of high blood pressure and type 2 diabetes for ethnic minorities living in Europe, changes of cardiovascular risk factors in the new environment probably need more attention.

Cardiovascular diseases and their risk factors among Syrian refugees in Turkey

BACKGROUND

Information on the world distribution of cardiovascular disease and its risk factors in refugees/migrants is not available at the same rate for all countries or for different ethnic and socioeconomic groups. Today, Syria's humanitarian catastrophe has become a public health concern, which cannot be ignored.

METHODS

A search was conducted across PubMed and Google Scholar for papers on cardiovascular diseases among refugees/migrants worldwide with a focus on Syrian in Turkey.

RESULTS

The total number of papers identified through the database searches and from reference lists was 486. Of these, 62 were found to be relevant after further screening. A further 42 papers were considered not eligible after full-text, language and data assessments, resulting in a final 20 papers included in the qualitative analysis. These studies discussed several major themes: cardiovascular diseases and their risk factors among refugees/migrants, the effects of changing living conditions on refugees/migrants, the effects of psychological and socioeconomic factors, and the prevention and treatment of cardiovascular diseases in refugees/migrants. The risk of cardiovascular disease varied by country of origin, country of destination, and duration of residence. The findings suggest that cardiovascular diseases and their risk factors are increased for Syrian refugees in Turkey.

CONCLUSION

Raising awareness, prevention, early detection, and good management as well as monitoring and reporting of risk factors are the key components to controlling cardiovascular diseases in refugees. Further studies and greater acquisition of survey data are urgently needed.

Immigration Emergency in Italy: The Impact of Socioeconomic Status on Blood Pressure Levels and Control

INTRODUCTION

Nowadays there are more than 5 millions of immigrants (8.3% of general adult population) in Italy.

AIM

To evaluate the potential impact of immigration and the possession of a permanent residence on blood pressure (BP) levels and control in a low income population of immigrants from different countries.

METHODS

We evaluated clinical characteristics and social status of adult individuals with known diagnosis of hypertension afferent to the Poliambulatorio della Caritas Diocesana in Rome, Italy, between 2010-2016. Subjects were stratified according to their macro-areas of origin (Europe, Asia, Africa, South-America), housing (with or without house), and immigration status (presence or absence of residence permit). BP levels were measured in three consecutive visits according to recommendations from current European Guidelines.

RESULTS

From an overall population sample of 9827 adult individuals, we initially identified 994 patients with a diagnosis of hypertension (10.1%), among whom 536 (5.4%) had valid BP data. Among these, 50.6% came from Europe, 21.6% from Africa, 24.1% from Asia, and 3.7% from South-America. They were predominantly male (54.7%), middle aged (42.8 ± 12.1 years at arrival and 51.6 ± 10.6 years at first visit) and untreated (72.8%) individuals with baseline systolic/diastolic BP levels of 156.9 ± 22.2/97.3 ± 12.4 mmHg). BP levels remained higher in homeless than in housed people at both visit 2 (150.0 ± 21.8/92.6 ± 12.9 mmHg vs. 142.9 ± 19.3/89.9 ± 11.6 mmHg; P < 0.001) and visit 3 (147.9 ± 22.2/91.7 ± 12.5 mmHg vs. 141.8 ± 19.4/89.2 ± 12.0 mmHg; P = 0.013). We also observed reductions of both systolic and diastolic BP levels compared to baseline values in immigrants stratified according to residence permit, although without relevant differences among groups.

CONCLUSIONS

Beyond conventional risk factors, socio-economic issues, including lack of residence permit or habitation, may affect BP levels and control in frail populations of immigrants, which have been marginally considered before.

Exploring the Health Care Challenges and Health Care Needs of Arabic-Speaking Immigrants with Cardiovascular Disease in Australia

The Arabic-speaking immigrant group, which makes up the fourth largest language group in Australia, has a high prevalence of cardiovascular disease. The objective of this study was to explore the health care challenges and needs of Arabic-speaking immigrants with cardiovascular disease (CVD), using a comparative approach with English-speaking patients with CVD as the comparable group. Methods: Participants were recruited from community settings in Melbourne, Australia. Face-to-face semi-structured individual interviews were conducted at the recruitment sites. All interviews were audio-taped, transcribed, and coded thematically. Results: 29 participants with CVD were recruited; 15 Arabic-speaking and 14 English-speaking. Arabic-speaking immigrants, and to a lesser extent English-speaking patients with CVD may have specific health care challenges and needs. Arabic-speaking immigrants’ health care needs include: effective health care provider (HCP)-patient communication, accessible care, participation in decision-making, and empowerment. English-speaking participants viewed these needs as important for CVD management. However, only a few English-speaking participants cited these needs as unmet health care needs. Conclusion: This study suggests that Arabic-speaking immigrants with CVD may have unique needs including the need for privacy, effective HCP-patient communication that takes into account patients’ limited English proficiency, and pharmacist-physician collaboration. Therefore, there may be a need to identify a health care model that can address these patients’ health care challenges and needs. This, in turn, may improve their disease management and health outcomes.

Impact of Immigration on Body Mass Index and Blood Pressure Among Adolescent Males and Females: A Nationwide Study

Immigration from one cultural milieu to another has been associated with a greater risk for incident cardio-metabolic morbidity among adults. In this nationwide, population-based, cross-sectional study of data recorded from 1992 to 2016, we assessed the association between body mass index and blood pressure levels among adolescent immigrants, aged 16 to 19 years, of Ethiopian origin, and their secular trend of overweight and obesity. Adolescents of Ethiopian origin were classified as Israeli-born (n=16 153) or immigrants (N=23 487), with stratification by age at immigration. Adolescents whose fathers were at least 3 generations in Israel (n=277 789) served as a comparative group. Hypertensive-range blood pressure values adjusted for age, sex, and height served as outcome. Among adolescents of Ethiopian origin, overweight and obesity (body mass index ≥85th percentile), increased by 2.5 and 4-fold in males and females, respectively, during the study period, compared with a 1.5-fold increase among native Israeli-born males and females. The odds for hypertensive-range measurements increased with the length of residence in Israel: 7.3%, 10.6%, and 14.4% among males who immigrated at ages 12 to 19, 6 to 11.9, and 0 to 5.9 years, respectively; and 11.5%, 16.7%, and 19.3%, respectively, among females. Israeli-born Ethiopians had a significantly higher risk for hypertensive-range measurements at any body mass index level compared with native Israeli-born examinees, after adjusting for sociodemographic factors and health status. In conclusion, among Ethiopian Israeli adolescents, abnormal blood pressure correlates directly with the time-lapse since immigration. Immigrant populations require targeted surveillance and appropriate intervention.

Ethnic inequalities in acute myocardial infarction hospitalization rates among young and middle-aged adults in Northern Italy: high risk for South Asians

The knowledge of ethnic-specific health needs is now essential to design effective health services and population-based prevention strategies. However, data on migrant populations living in Southern Europe are limited. The study is designed to investigate ethnic inequalities in hospitalization for acute myocardial infarction (AMI) in the Veneto region (Italy). Hospital admissions for AMI in Veneto for the whole resident population aged 20-59 years during 2008-2013 were studied. Age and gender-specific AMI hospitalization rates for immigrant groups (classified by country of origin according to the United Nations geoscheme) and Italians were calculated. The indirect standardization method was used to estimate standardized hospitalization ratios (SHR) for each immigrant group, with rates of Italian residents as a reference. Overall, 8200 AMI events were retrieved, 648 among immigrants. The highest risk of AMI is seen in South Asians males (SHR 4.2, 95% CI 3.6-4.9) and females (SHR 2.5, 95% CI 1.4-4.5). AMI rates in South Asian males sharply increase in the 30-39 years age class. Other immigrant subgroups (Eastern Europe, North Africa, Sub-Saharan Africa, other Asian countries, Central-South America, high-income countries) displayed age- and gender-adjusted hospitalization rates similar to the native population. Present findings stress the urgent need for implementation of ethnic-specific health policies in Italy. The awareness about the high cardiovascular risk in subjects from South Asia must be increased among general practitioners and immigrant communities.

Diverging patterns of cardiovascular diseases across immigrant groups in Northern Italy

BACKGROUND

Only fragmentary data are available on the burden of non-communicable diseases among immigrants in Europe, mostly limited to mortality by cause. Aim of the study is to investigate the prevalence of cardiovascular diseases across different immigrant groups in the Veneto Region (North-Eastern Italy).

METHODS

The resident population aged 20-59 was classified according to country of citizenship. The Adjusted Clinical Groups System was adopted to identify selected cardiovascular conditions by linkage of Hospital Discharge Records, Emergency Room visits, Chronic disease registry for copayment exemptions, the Home care database, and drugs reimbursed by the Regional Health Service. Age standardized prevalence rates were compared across population groups, and rate ratios (RR) with 95% confidence intervals (CI) were computed taking the Italian population as reference.

RESULTS

The prevalence of diabetes was higher across all immigrant groups compared to Italians. Specific risk patterns could be identified associated to different ethnicities: South Asian immigrants were at very high risk of diabetes, dyslipidemia, and ischemic heart disease (males RR 2.3, CI 1.9-2.8; females RR 2.0, CI 1.2-3.5). Immigrants from Africa were affected by high rates of hypertension, cerebrovascular diseases, and heart failure, with a more pronounced unfavorable profile among females (hypertension RR 3.0, CI 2.6-3.3; cerebrovascular diseases RR 1.7, CI 1.1-2.7).

CONCLUSIONS

Wide differences in the prevalence of cardiovascular diseases could be detected across immigrant groups. These findings represent a first step towards systematic chronic disease surveillance by ethnicity, a fundamental tool for shaping culturally-tailored prevention strategies.

The CAPITAL study (CArdiovascular Prevention wIth Telecardiology in ApuLia): preliminary results

BACKGROUND

The CArdiovascular Prevention wIth Telecardiology in ApuLia (CAPITAL) study aimed to investigate the prevalence of cardiovascular risk factors, the status of cardiovascular prevention, and the compliance to international scientific societies' guidelines on cardiovascular prevention in a Mediterranean region.

METHODS

The CAPITAL study was based on the assessment of cardiovascular risk and compliance to guidelines on cardiovascular prevention, and on an electrocardiogram screening with remote telemedicine support performed in pharmacies of Apulia (Italy); the study was expected to enroll 10 000 consecutive patients accessing their usual pharmacy.

RESULTS

In the first 1000 patients enrolled, 16% were smokers, 9% diabetic, 26% hypertensive, 43% overweight, and 23% obese; 37% of the patients treated with antihypertensive drugs did not achieve the target levels, regardless of the number of antihypertensive drugs given, and 60% of subjects treated with lipid-lowering drugs did not achieve the target levels.Twenty-two per cent of the patients subjected to the lipid-lowering drugs did not check their cholesterol levels in the past 12 months, and 21% of those taking antihypertensive drugs did not check their blood pressure levels.Left ventricular hypertrophy was detected at electrocardiogram examination in 3.4% of the cases, and in 2.6% of the patients with unknown hypertension: 52% of the hypertensive patients were not checked with an electrocardiogram in the past 12 months, 44% of the diabetic patients, and 44% of subjects treated with lipid-lowering drugs.

CONCLUSIONS

The awareness, therapy, and control of cardiovascular risk factors in a Mediterranean real-world population are unsatisfactory. There is a large scope of an improvement in the control of cardiovascular risk factors. Telemedicine support and pharmacy-based assessment may be helpful in implementing strategies aimed at the improvement of cardiovascular prevention.

New findings on type 2 diabetes in first-generation Chinese migrants settled in Italy: Chinese in Prato (CHIP) cross-sectional survey

BACKGROUND

Chinese people are one of the fastest growing immigrant populations in Europe, and their health has become a key issue to host nations. Although type 2 diabetes (T2DM) is a big burden among migrant populations, data on Chinese immigrants in Europe are limited.

METHODS

A cross-sectional survey was performed in 2014, adopting principles of community-based participatory research to investigate T2DM, diagnosed by the American Diabetes Association fasting criteria, in Chinese first-generation migrants aged 16 to 59 years settled in Prato (Italy). Association with different factors was investigated using logistic regression.

RESULTS

Of the 1608 participants, 177 had T2DM (11.0%), 119 being newly diagnosed (7.4%). Among subjects with diabetes, 58 (32.8%) were aware of the disease; among subjects with diabetes aware of their condition, 46 (79%) were treated with glucose lowering drugs. Age-standardized (World Health Organization 2001 population) prevalence of T2DM was 9.6% (95% CI 9.1 to 10.2%), being 12.0% (95% CI 11.0 to 12.9%) in men, and 7.8% (95% CI 7.1 to 8.4%) in women. At adjusted logistic regression, diabetes was associated with hypertension, current smoking, adiposity indices (waist circumference, waist-to-hip ratio, waist-to-height ratio, and body mass index), and high triglycerides. T2DM, adiposity indices, and high triglycerides were not associated with duration of stay in Italy.

CONCLUSIONS

The high prevalence of T2DM among first-generation Chinese immigrants in Europe stresses the need for specific health programs for T2DM early diagnosis, treatment, and prevention. There is an urgent need for policies to support this group because current policies will produce major social and economic costs. Copyright © 2016 John Wiley & Sons, Ltd.

Health literacy: the missing link in improving the health of Somali immigrant women in Oslo

Background

Existing studies report a positive association between inadequate health literacy and immigrant’s adverse health outcomes. Despite substantial research on this topic among immigrants, little is known about the level of health literacy among Somali women in Europe, and particularly in Norway.

Methods

A cross sectional study using respondent driven sampling was conducted in Oslo, Norway. A sample of 302 Somali women, 25 years and older, was interviewed using the short version of the European Health Literacy Questionnaire. Data was analysed using logistic regression.

Results

Findings revealed that 71 % of Somali women in Oslo lack the ability to obtain, understand and act upon health information and services, and to make appropriate health decisions. Being unemployed (OR 3.66, CI 1.08–12.3) and socially less integrated (OR 8.17, CI 1.21–54.8) were independent predictors of an inadequate health literacy among Somali women.

Conclusions

Enhanced health literacy will most likely increase the chance to better health outcomes for immigrants, thereby moving towards health equity in the Norwegian society. Therefore, policies and programs are required to focus and improve health literacy of immigrant communities.

The prevalence of diabetes, hypertension and obesity among immigrants from East Africa and the former Soviet Union: a retrospective comparative 30-year cohort study

Background

Previous studies have reported an increasing prevalence of metabolic abnormalities in immigrants who moved from low-cardiovascular-risk regions to Western countries, but little is known about time trends following immigration.

Methods

A retrospective cohort study of immigrants from Ethiopia in east Africa (EAI), the former Soviet Union (FSUI) and native-born Israelis (NBI) over a 35-year period. EAI were divided into three groups by date of immigration. Associations between ethnicity, age, sex and metabolic risk factors were assessed using logistic regression models.

Results

The study included 58,901 individuals (20,768 EAI, 20,507 FSUI, and 17,626 NBI). The multivariate odds ratios (OR) for diabetes were 2.4 (95 % CI 2.1–2.6), 2.1 (95 % CI 1.9–2.2) and 1.5 (95 % CI 1.3–1.7), respectively, for the three waves of EAI immigrations (P < 0.001 for trend) and 1.1 (95 % CI 0.9–1.2) for FSUI. For hypertension, the corresponding ORs were 1.8 (95 % CI 1.6–1.9), 1.4 (95 % CI 1.3–1.5), and 1.1 (95 % CI 0.9–1.2), respectively (P < 0.001) for EAI, and 2.1 (95 % CI 1.9–2.2) for FSUI. For obesity the ORs were −0.5 (95 % CI 0.4–0.6), 0.5 (95 % CI 0.4–0.6), and 0.3 (95 % CI 0.2–0.3), respectively (P < 0.001) for EAI, and 1.2 (95 % CI 1.1–1.3) for FSUI. The prevalence of diabetes in NBI with a BMI of 30 was identical to a BMI of 23.4 for EAI and 28.9 for FSUI.

Conclusions

The prevalence of diabetes and hypertension was higher in EAI and increased over the years, despite a lower prevalence of obesity. It exceeded the prevalence rates in NBI.

Lifestyle interventions in preventing new type 2 diabetes in Asian populations

The aim of this study was to review current evidence on interventional studies aimed at the prevention of type 2 diabetes in Asian population with lifestyle interventions. Prevalence of type 2 diabetes sharply increased in most Asian countries during the last decades. This issue has now also relevant implication for Europe where different surveys are also consistently revealing an higher prevalence of type 2 diabetes and other and major CVD risk factors among subjects originating from Asian Countries than in the native population. Nutrition and lifestyle transition seem to play a role in disclosing the predisposition for the development of type 2 diabetes and great interest is now shown toward the possibility to intervene with lifestyle intervention on at risk populations. A meta-analysis of Randomized Controlled Trials showed that lifestyle interventions are highly effective also in the Asian population. All studies were, however, conducted with an individual approach based on the identification of high-risk individuals. When ethnic minority groups have to be addressed, an approach directed to the community rather than to the individual might, however, be more effective. This review reinforces the importance for policy-makers to consider the involvement of the whole community of minority immigrant groups with lifestyle intervention programs.

Focus on migrants with type 2 diabetes mellitus in European Countries

The prevalence of type 2 diabetes mellitus, one of the major causes of morbility and mortality in Europe, is increasing in all European countries. Diabetes is not distributed equally among all population groups, as higher incidence, appearance of complications, and different mortality rates have been observed among migrants and the native population. These differences may be due to genetic profiles, lifestyle, and utilization of the health care system in different ways. Taking into account that the quantity of migrants is nowadays increasing, mainly in the southern part of Europe, the knowledge of diabetes in migrants through a better collection of data is necessary, considering that few limited epidemiological studies have evaluated the importance of this problem in EU countries. A special effort in developing a comprehensive management for native and immigrant populations in order to prevent and cure diabetes should be mandatory. This activity could be helpful to limit the incidence of future diabetes complications and to avoid the consequent burden of the health care system along with a control on its costs. It is clear that diabetes complication prevention is essential for long-term sustainability of the health care system.

Cardiovascular diseases and risk factors among Chinese immigrants

The aim of this study is to identify the prevalence of cardiovascular disease (CVD) and major CVD risk factors, including diabetes, hypertension, dyslipidemia, obesity and smoking among Chinese immigrants by a systematic review of studies from various countries. PubMed and the China National Knowledge Infrastructure databases were searched for studies of the prevalence of major CVDs and risk factors, and of CVD mortality among Chinese immigrants. The search identified 386 papers, 16 of which met the inclusion criteria for this review. In mainland China, there is a pattern of high stroke prevalence but low coronary heart disease (CHD) prevalence. Among Chinese immigrants, there is a much lower prevalence and mortality of stroke, but a higher prevalence and mortality of CHD, even though these are lower than the rates in immigrants of other ethnicities in the host country. The prevalence of CVD risk factors is also markedly different in immigrants. Compared with mainland Chinese, Chinese immigrants have a higher prevalence of diabetes and hypertension, higher serum cholesterol, poorer dietary patterns, and higher prevalence of obesity and smoking. Thus, the epidemiological pattern of CVD among Chinese immigrants changes compared with resident mainland Chinese. The less healthy environmental factor after immigration may be a major trigger in the adverse CVD status of Chinese immigrants. It is important for policy-makers to pay more attention to specific minority immigrant groups, and to implement more effective preventive measures to improve the health of immigrant populations.

Diabetes in migrants and ethnic minorities in a changing World

On a worldwide scale, the total number of migrants exceeds 200 million and is not expected to reduce, fuelled by the economic crisis, terrorism and wars, generating increasing clinical and administrative problems to National Health Systems. Chronic non-communicable diseases (NCD), and specifically diabetes, are on the front-line, due to the high number of cases at risk, duration and cost of diseases, and availability of effective measures of prevention and treatment. We reviewed the documents of International Agencies on migration and performed a PubMed search of existing literature, focusing on the differences in the prevalence of diabetes between migrants and native people, the prevalence of NCD in migrants vs rates in the countries of origin, diabetes convergence, risk of diabetes progression and standard of care in migrants. Even in universalistic healthcare systems, differences in socioeconomic status and barriers generated by the present culture of biomedicine make high-risk ethnic minorities under-treated and not protected against inequalities. Underutilization of drugs and primary care services in specific ethnic groups are far from being money-saving, and might produce higher hospitalization rates due to disease progression and complications. Efforts should be made to favor screening and treatment programs, to adapt education programs to specific cultures, and to develop community partnerships.

Prevalence of diabetes across different immigrant groups in North-eastern Italy

BACKGROUND AND AIMS

Type 2 diabetes, one of the most important non-communicable diseases, represents a major health problem worldwide. Immigrants may contribute relevantly to the increase in diabetes. The aim of the study was to investigate variability in diabetes prevalence across different immigrant groups in the Veneto Region (northeastern Italy).

METHODS AND RESULTS

Diabetic subjects on January 2013 were identified by record linkage of hospital discharge records, drug prescriptions, and exemptions from medical charges for diabetes. Immigrant groups were identified based on citizenship. Age-standardized prevalence rates were obtained for residents aged 20-59 years by the direct method, taking the whole regional population as reference. Prevalence rate ratios (RR) with 95% Confidence Intervals (CI) were computed with respect to Italian citizens. Among residents aged 20-59 years, 45280 Italian and 7782 foreign subjects affected by diabetes were identified. Prevalence rates were highest among immigrants from South-East Asia, RR 4.9 (CI 4.7-5.1) among males, and 7.6 (7.2-8.1) among females, followed by residents from both North and Sub-Saharan Africa. Citizens from Eastern Europe (the largest immigrant group) showed rates similar to Italians. Most South-Asian patients aged 20-39 years were not insulin-treated, suggesting a very high risk of early onset type 2 diabetes in this ethnic group.

CONCLUSION

Large variations in diabetes prevalence by ethnicity should prompt tailored strategies for primary prevention, diabetes screening, and disease control. An increased demand for prevention and health care in selected population groups should guide appropriate resource allocation.

Causes of mortality across different immigrant groups in Northeastern Italy

Background. Despite massive immigration towards Southern Europe in the last two decades, data on mortality by cause among immigrants in Italy are scarce. The aim of this study was to investigate mortality from all and from specific causes of death among immigrants residing in the Veneto Region (Northeastern Italy). Methods. Mortality records for the period 2008-2013 were extracted from the regional archive of causes of death, whereas population data were obtained from the 2011 Italian census. Immigrants were grouped by area of provenience based on the information on country of citizenship available both in mortality and census data. Standardized Mortality Ratios (SMR) with 95% Confidence Intervals (CI) were computed for the period 2008-2013 in subjects aged 20-59 years, with rates of Italian citizens as a reference. Results. Overall mortality was reduced both in male (SMR 0.86, CI [0.80-0.92]) and female immigrants (SMR 0.72, CI [0.65-0.78]), although an increased risk was observed for subjects from Sub-Saharan Africa. Significantly raised SMR for circulatory diseases were found among Sub-Saharan Africans and Southern Asians in both genders. Sub-Saharan Africans experienced a higher risk of death, especially from cerebrovascular diseases: SMR 4.78 (CI [2.67-7.89]) and SMR 6.09 (CI [1.96-14.2]) in males and females, respectively. Among Southern Asians, the increase in mortality from ischemic heart diseases reached statistical significance in males (SMR 2.53, CI [1.42-4.18]). In spite of a lower risk of death for all neoplasms combined, mortality from cancer of cervix uteri was increased among immigrants (SMR 2.61, CI [1.35-4.56]), as well as for other cancer sites in selected immigrant groups. A raised mortality was found for infectious diseases in Sub-Saharan Africans (both genders), and for transport accidents among females from Eastern Europe. Conclusion. Our study showed great variations in mortality by cause and area of provenience among immigrants resident in the Veneto Region and highlighted specific health issues that should be addressed through tailored efforts in chronic diseases prevention.

Need for better blood pressure measurement in developing countries to improve prevention of cardiovascular disease

Hypertension is now the foremost cause of disability and is responsible for the highest percentage of attributable death among risk factors. These global changes are mainly due to the increase in the prevalence of hypertension in most low- and middle-income countries (LMICs) as a consequence of relevant socioeconomic changes occurring during the last decades. Implementation of global prevention efforts urgently needs to be accelerated because of the increasing incidence of haemorrhagic stroke, renal failure, and hypertensive heart disease in developing countries. Blood pressure (BP) measurement has different implications in epidemiological studies performed in low-resource settings. First, the frequency of blood pressure measurement is a simple but reliable indicator of access to healthcare in epidemiological studies, which may disclose the favourable effects of urbanization; the opportunity to have BP measured increases hypertension awareness, facilitates drug treatment, and leads to better achievement of BP control. Second, BP measurement is a key element in cardiovascular risk stratification, focusing solely on the preferred strategy in low-resource settings where costs of biochemical tests might be less sustainable. Third, the issue of obtaining reliable estimation of BP values is crucial to achieve sound data on the burden of hypertension in LMICs, and some aspects of BP measurement, such as the use of reliable automated devices, the number of measurements/visits to achieve a consistent diagnosis of hypertension, and the possible confounding effect of environmental factors, must be closely considered.