Socioeconomic Determinants of Cardiovascular Diseases, Obesity, and Diabetes among Migrants in the United Kingdom: A Systematic Review

International Migration and Cardiovascular Health: Unraveling the Disease Burden Among Migrants to North America and Europe

Europe and North America are the 2 largest recipients of international migrants from low-resource regions in the world. Here, large differences in cardiovascular disease (CVD) morbidity and death exist between migrants and the host populations. This review discusses the CVD burden and its most important contributors among the largest migrant groups in Europe and North America as well as the consequences of migration to high-income countries on CVD diagnosis and therapy. The available evidence indicates that migrants in Europe and North America generally have a higher CVD risk compared with the host populations. Cardiometabolic, behavioral, and psychosocial factors are important contributors to their increased CVD risk. However, despite these common denominators, there are important ethnic differences in the propensity to develop CVD that relate to pre- and postmigration factors, such as socioeconomic status, cultural factors, lifestyle, psychosocial stress, access to health care and health care usage. Some of these pre- and postmigration environmental factors may interact with genetic (epigenetics) and microbial factors, which further influence their CVD risk. The limited number of prospective cohorts and clinical trials in migrant populations remains an important culprit for better understanding pathophysiological mechanism driving health differences and for developing ethnic-specific CVD risk prediction and care. Only by improved understanding of the complex interaction among human biology, migration-related factors, and sociocultural determinants of health influencing CVD risk will we be able to mitigate these differences and truly make inclusive personalized treatment possible.

Under-representation of ethnic and regional minorities in lipid-lowering randomized clinical trials: a systematic review and meta-analysis

AIMS

The efficacy of lipid-lowering therapies (LLT) amongst different ethnicities and regions remains unclear. We aimed to assess cardiovascular event reductions associated with LLT according to ethnicity and region in previously published randomized clinical trials (RCTs).

METHODS AND RESULTS

Medline, EMBASE, and Cochrane CENTRAL were searched for RCTs of statins, ezetimibe, or proprotein convertase subtilisin/kexin type 9 inhibitors comparing intensive vs. less-intensive low-density lipoprotein cholesterol (LDL-C) lowering. The primary endpoint was major adverse cardiovascular events (MACE) defined as the composite of cardiovascular mortality, myocardial infarction, stroke, and revascularization. Random-effects meta-analysis was used to pool risk ratios (RRs) with 95% confidence intervals (CI) adjusted per mmol/L reduction in LDL-C. Fifty-three trials with 329 897 participants were included. Amongst participants, 39.5% were from Europe, 16.0% from North America, 9.0% from Japan, 2.8% from Australasia, 1.8% from South America, 1.1% from Asia, 0.6% from South Africa, and 29.2% were unspecified. Amongst trials reporting ethnicities, there were 60.3% White, 20.2% Japanese, 9.4% Asian, 5.5% Black, and 4.7% Latin American. There was reduction in MACE with LLT in regions including Australasia (RR 0.75, 95% CI 0.67-0.85), North America (RR 0.75, 95% CI 0.69-0.83), Europe (RR 0.78, 95% CI 0.71-0.86), and Japan (RR 0.73, 95% CI 0.63-0.85) and in Black ethnicity (RR 0.55, 95% CI 0.37-0.82). Head-to-head comparisons between regions and ethnicities revealed no significant differences in MACE reduction.

CONCLUSION

Despite under-representation in clinical trials, regional and ethnic minority groups such as Australasia and Blacks appear to derive at least as much cardiovascular benefit from LLT.

Assessing community readiness for overweight and obesity prevention among Ghanaian immigrants living in Greater Manchester, England

Aim

This study assesses community readiness to prevent overweight/obesity among Ghanaian immigrants in Greater Manchester, England.

Subject and method

The Community Readiness Model (CRM) was applied using a semi-structured interview tool with 13 key informants (religious and other key community members) addressing five readiness dimensions. A maximum of 9 points per dimension (from 1 = no awareness to 9 = high level of community ownership), was assigned, alongside qualitative textual thematic analysis.

Results

The mean readiness score indicated that the study population was in the “vague awareness stage” (3.08 ± 0.98). The highest score was observed for community knowledge of the issue (4.42 ± 0.99) which was in the pre-planning phase, followed by community climate (vague awareness; 3.58 ± 0.62). The lowest scores were seen for resources (denial/resistance; 2.70 ± 0.61) and knowledge of efforts (no awareness; 1.53 ± 0.44). Findings identified structural barriers, including poor living conditions as a result of poorly paid menial jobs and high workload, contributing to the adoption of unhealthy lifestyle behaviours. Socio-cultural factors such as fatalism, hereditary factors, and social status were associated with acceptance of overweight.

Conclusion

Despite recognising overweight/obesity as an important health issue in these communities, especially among women, it is not seen as a priority for targeting change. To help these communities to become more ready for interventions that tackle overweight/obesity, the focus should initially be to address the structural barriers identified, including reducing poverty, alongside designing interventions that work with these structural barriers, and thereafter focus on the socio-cultural factors.

Association of gestational diabetes mellitus with overall and type specific cardiovascular and cerebrovascular diseases: systematic review and meta-analysis

OBJECTIVE

To quantify the risk of overall and type specific cardiovascular and cerebrovascular diseases as well as venous thromboembolism in women with a history of gestational diabetes mellitus.

DESIGN

Systematic review and meta-analyses.

DATA SOURCES

PubMed, Embase, and the Cochrane Library from inception to 1 November 2021 and updated on 26 May 2022.

REVIEW METHODS

Observational studies reporting the association between gestational diabetes mellitus and incident cardiovascular and cerebrovascular diseases were eligible. Data, pooled by random effects models, are presented as risk ratios (95% confidence intervals). Certainty of evidence was appraised by the Grading of Recommendations, Assessment, Development, and Evaluations.

RESULTS

15 studies rated as moderate or serious risk of bias were included. Of 513 324 women with gestational diabetes mellitus, 9507 had cardiovascular and cerebrovascular disease. Of more than eight million control women without gestational diabetes, 78 895 had cardiovascular and cerebrovascular disease. Compared with women without gestational diabetes mellitus, women with a history of gestational diabetes mellitus showed a 45% increased risk of overall cardiovascular and cerebrovascular diseases (risk ratio 1.45, 95% confidence interval 1.36 to 1.53), 72% for cardiovascular diseases (1.72, 1.40 to 2.11), and 40% for cerebrovascular diseases (1.40, 1.29 to 1.51). Women with gestational diabetes mellitus showed increased risks of incident coronary artery diseases (1.40, 1.18 to 1.65), myocardial infarction (1.74, 1.37 to 2.20), heart failure (1.62, 1.29 to 2.05), angina pectoris (2.27, 1.79 to 2.87), cardiovascular procedures (1.87, 1.34 to 2.62), stroke (1.45, 1.29 to 1.63), and ischaemic stroke (1.49, 1.29 to 1.71). The risk of venous thromboembolism was observed to increase by 28% in women with previous gestational diabetes mellitus (1.28, 1.13 to 1.46). Subgroup analyses of cardiovascular and cerebrovascular disease outcomes stratified by study characteristics and adjustments showed significant differences by region (P=0.078), study design (P=0.02), source of data (P=0.005), and study quality (P=0.04), adjustment for smoking (P=0.03), body mass index (P=0.01), and socioeconomic status (P=0.006), and comorbidities (P=0.05). The risk of cardiovascular and cerebrovascular diseases was, however, attenuated but remained significant when restricted to women who did not develop subsequent overt diabetes (all gestational diabetes mellitus: 1.45, 1.33 to 1.59, gestational diabetes mellitus without subsequent diabetes: 1.09, 1.06 to 1.13). Certainty of evidence was judged as low or very low quality.

CONCLUSIONS

Gestational diabetes mellitus is associated with increased risks of overall and type specific cardiovascular and cerebrovascular diseases that cannot be solely attributed to conventional cardiovascular risk factors or subsequent diabetes.