And therefore, they gain weight much more easily, and then develop diabetes and hypertension. Diabetes (see also NIH Guidelines) …
Asian Americans and Heart Disease:
Heart Disease has always been a public health problem People are living
longer An ever-increasing number suffer from one form of heart disease or
another The World Health Organization estimated that 12 million deaths
were related to cardiovascular diseases in 1992 One half of all deaths in
developed countries like the USA were from heart disease In developing
nations too, the increase in coronary heart disease is reaching epidemic
proportions India and China, which together account for over 50 of the
earths population, account for 45 to 5 million deaths from heart disease
every year And that doesnt count the sufferers who do not die, but live
with complications and restrictions imposed by their disease Determining
the unique risk factors for CVD among these groups is critical in order to
develop tailored strategies for the prevention of CVD Coronary artery
disease CAD is a major public health problem facing Asian Americans,
particularly South Asians and to complicate further, it cant be explained
by conventional risk factors
A case in point that strengthens my view is the following recent studies:
1 British Heart Foundation statistics
show that the death rate from
coronary heart disease is 46 higher in South Asian men than the UK
population as a whole, for women it is 51 higher
2 Anand and her colleagues at McMaster University in Hamilton studied
985 South Asians, Europeans and Chinese in three Canadian cities to
determine whether ethnic background had any impact on the risk of
heart disease The study found a higher risk of cardiovascular disease
was linked to a condition called carotid atherosclerosis
Atherosclerosis is the progressive narrowing and hardening of the
arteries It can occur as a result of ageing but also as a result of
high cholesterol, high blood pressure, smoking, and diabetes It is
regarded as a major cause of heart disease When it affects the
carotid artery, which carries blood from the heart to the brain, it
can lead to stroke This condition was much more common among South
Asians than among Europeans and Chinese The researchers suggested
that the variations between ethnic groups might be caused by
differences in the way the disease develops They added, however, that
it could also be due to
other undiscovered factors - diet is thought
to play a significant role
3 Dr Gupta and colleagues in Canada examined medical records of about
3,413 South Asian and European patients with coronary artery disease
who underwent angiography at the Trillium Health Centre in Mississauga
and the Rouge Valley Health System in Scarborough between April, 1999,
and March, 2000 Coronary angiography is a diagnostic/treatment
procedure that uses an inserted catheter to visualize the interior of
blood vessels Ethnicity was determined by self-reporting and name
analysis This study showed that every segment of the three major
arteries of the heart in South Asian patients were more seriously
diseased than in Canadians of European descent When the data were re-
examined to focus on women the results were even more disturbing
This type of life-threatening coronary anatomy was found to be twice
as often in South Asian group of women compared to the European
women, says Dr Gupta There was no significant difference between
South Asian Canadians and European Canadians in the known risk factors
for heart
disease - obesity, high blood pressure, elevated cholesterol
levels or family history Smoking, a powerful risk factor was much
less common in South Asians
Potential risk factors:
The risk factors are two kinds The first kind, one cant do much about
includes factors like gender, age, ethnicity, genetics and geographic
location
Coronary artery disease is 25 times more likely in men than
women
Heart attacks occur in 97 of women between 65 and 69 years
of age, but in 179 of those older than 85
African - Americans have a higher heart disease risk than
whites, and the incidence also varies among Hispanics, Asians
and other races
The second kind is, one can modify through diet and exercise
Risk factors more common to Asian Americans - South Asians:
Coronary artery disease CAD 40 higher in Indian Asians compared to
European whites Balarajan, 1991 The burden of CAD is twofold
higher in Indian Asian men compared to Europeans
Diabetes is 38 times higher than that in Europeans McKeigue et al,
1991
60 risk of CAD due to insulin resistance McKeigue
et al, 1993
Six-month mortality death rate after acute myocardial infarction
heart attacks is two-fold higher in Indian Asians compared to
Europeans, despite similar therapy Wilkinson et al,, 1996
An estimated 7 million people in the UK have metabolic syndrome and are
therefore at greater risk of stroke, heart attack and diabetes Deadly
Quartet of Syndrome X Kooner et al,1998; Reaven 1988 is identified by
Diabetes Mellitus/Insulin Resistance Baliga et al,, 1995, Hypertension,
Central Abdominal Obesity and Hyperlipidemia
Other general risk factors are smoking, hypertension, above normal Body-
Mass Index BMI total cholesterol and apolipoprotein-B However, in UK
based Indians, total cholesterol and Apolipoprotein-B were found to be
higher than non-migrant Asians
Diabetes mellitus:
There is increased prevalence of non-insulin diabetes mellitus in Indian
Asians It could be attributed to genetic factors and acquired from
westernization
Insulin Resistance:
Insulin resistance is characterized by raised plasma insulin, glucose
intolerance, increased triglycerides, decreased HDL good cholesterol and
central obesity These factors are found to be more prevalent in
Indian
Asians than Europeans McKeigue et al, 1993 It could be attributed to
genetic factors and acquired from westernization
Raised serum Lp a lipoprotein:
Lpa concentrations seem to be genetic in nature as it is found to be
uniquely higher in Asians in India than European whites Bhatnagar et al,
1995 Asian Indians tested above threshold levels 30 mg/dl for Lpa for
the development of CAD constitute about 30 compared to 19 Caucasians and
8 Mexican Americans It is genetically determined, so it runs in
families It is a powerful independent risk factor for premature fatty
deposition atherosclerosis and thrombosis clotting in the blood
vessels It is also responsible for the high failure rate of balloon
angioplasty and bypass surgery Raised serum Lp a and low-density
cholesterol LDL is associated with a 9-fold increase in risk of CAD Seed
et al, 1990 Raised plasma Insulin, decreased physical activity and
increase in central obesity is thought to be due to adopting western
lifestyles
Obesity:
Waist circumference Men 102 cm or 40 in, and Women 88 cm or 35 in,
decreased HDL-cholesterol Men 40 mg/dL and, Women 50 mg/dL and
increased triglycerides 150 mg/dl are thought to attributed
to
Westernized lifestyle rather than genetic
Smoking:
Has been found to be major risk factor in non-migrant Indians Pais et al,
1996 while smoking, hypertension and hypercholesterolemia are generally
lower in migrant Indian Asians than Europeans This suggests that other
factors also contribute to excess mortality in coronary artery disease
C-Reactive Protein:
C-Reactive Protein is a non-specific marker of inflammation C-Reactive
Protein concentrations are higher in healthy Indian Asians than in European
whites and are accounted for by greater central obesity and insulin
resistance in Indian Asians Chambers et al, 2001 These results suggest
that inflammation may contribute to increased risk of CAD in Indian Asians
Homocysteine:
Elevated levels cause twice as much CAD levels in Indian Asians compared to
Europeans Chambers et al, 2000
Genetics:
Cd36 gene deficiency also known as Fatty Acid Translocase Aitman 2001
Dominant negative mutations in human Peroxisome proliferators activated
receptor gamma or PPAR gamma associated with severe insulin resistance,
diabetes mellitus and hypertension Barraso et al, 1999
Diet:
Excessive use of clarified butter Ghee is found to be risk factor
in
South Asian diet Lancet 1987
Women:
In pre-menopausal women, polycystic ovarian disease is associated with
insulin resistance and coronary artery disease South Asian women with
polycystic ovarian disease are therefore more susceptible to insulin
resistance and coronary artery disease Dunaif et al, 1987 The risk in
post-menopausal women was found to be similar to men South Asian women
have higher waist circumference 87 cm compared to white women 79 cm
Lean et al, 2001
Stress:
British Heart Foundation is currently funding research to examine why South
Asians in the UK have a high incidence of heart disease Researchers have
long suspected that stress plays a role in the development of heart
conditions Now a team at University College London says their study of 183
men provides the first conclusive biological evidence of a link between
stress and metabolic syndrome - a condition thought to be a precursor to
coronary heart disease
The study examined the biological, rather than the physical, effects of
stress in civil servants aged between 45 and 63 The team monitored changes
to the mens nervous system and their production of certain stress
hormones They also measured the mens
risk factors for coronary heart
disease, and variations in heart rates and cardiac activity
Researchers also questioned the men about their jobs, such as position,
levels of control and responsibility, and lifestyles including eating
habits and exercise levels
Results showed that men with metabolic syndrome produced more stress
hormones, had abnormal heart rates, and were more obese than the control
group Job strain was one of the factors seen to partly explain the
increased production of the stress hormones associated with metabolic
syndrome and which combined with obesity to affect heart activity Although
this is not concrete proof that stress causes the metabolic syndrome or
indeed heart disease, we are certainly closer to proving it But
researchers were also reassured to find that the biological effects of
stress were at least partly reversible in men who reduced their risk
factors, such as losing weight or who had their blood pressure lowered The
link between stress and heart disease is still unclear, but this study is
significant as it helps us to understand more about the relationship
between the conditions
Myocardial Infarction Heart Attacks:
Six-month mortality death rate
after acute MI is 2-fold higher in Indian
Asians compared to Europeans This increased mortality has been attributed
to a higher prevalence of diabetes
South Asians show a higher predisposition to adult onset diabetes, a major
risk factor However, when a statistical analysis was performed to correct
for the difference in diabetic disease, the rates of coronary disease were
still much higher among the South Asians
Postulated mechanisms include Thrifty Gene Hypothesis Neel 1962 The gene
pool is relatively constant over the past 100 to 200 years although the
environment and lifestyle has changed Asians like other ethnic groups may
have the thrifty genes This gene or group of genes enabled them
during centuries of living as hunters or farmers to survive on relatively
small amounts of food, thereby being able to survive periods of drought and
famine But the new generation lives in a society where food is not only
readily available but is high-calorie, high-fat food In addition the
current desk jobs do not require as many calories as hunting or farming or
other activities that were required to eek out an existence in the past
And therefore, they gain weight much more easily, and then
develop diabetes
and hypertension
Some of the reasons for decline in heart disease in other parts of the
world:
Though not measurable directly, the cost of treating heart disease in
American women alone was estimated to be around 300 billion dollars in
1998 Over the past two decades, there has been a significant decline in
the incidence of heart disease In Japan and Australia, 50-60 decline in
heart attacks has been recorded since 1980
The causes for this decline are related to:
Decreasing modifiable risk factors - smoking, cholesterol, exercise
Better treatment facilities for heart attacks and strokes
Emphasis on primary prevention rather than treatment
How to modify heart disease risk profile? See also NIH guidelines
There isnt anything one can do about being born male, growing older or the
color of ones skin But there are other things that can be done to reduce
heart disease risk
Eating a healthy diet, exercising regularly, maintaining a healthy body
weight, stress reduction and not smoking, are important for everyone but
especially for this group
Risk factor assessment
Should begin at age 20 years
Pulse to exclude atrial fibrillation, blood
pressure, fasting
cholesterol, blood glucose, and other risk factors should be assessed
every year
Calculate your risk every month: Risk calculator
Exercise:
Benefits of regular exercise see also NIH Guidelines
Improves heart and lungs
Decreases resting blood pressure
Decreases body fat
Decreases total and LDL cholesterol bad cholesterol
Raises HDL cholesterol good cholesterol
Increases energy level
Increases tolerance to stress and depression
Controls or prevents the development of diabetes
Decreases risk of orthopedic injury
Guidelines for Safe Exercise
Frequency - 3-5 times a week
Duration - 20-60 minutes
Intensity how hard - within your target heart rate
Calculating Your Target Heart Rate
1 220 - age MHR maximum heart rate
2 MHR x 06 _____ this is the low end of your target HR
3 MHR x 08 _____ this is the upper end of your target HR
Example:
If you are 40 years old, your MHR is 220 - 40 180
180 x 06 108
180 x 08 144
Therefore, your Target Heart Rate is between 108 and 144 beats per minute
Physical activity:
The goal of physical activity to improve both metabolic fitness
and
circulatory fitness Exercise improves insulin sensitivity
Moderate-intensity physical activity such as walking, cycling and swimming
so that at least 100 kcal/h is expended daily–e,g brisk walk 30 min
every day
Weight loss see also NIH guidelines
The goal of treatment is to reduce central obesity
Aim for ideal body weight body mass index 185-23 kg/sq m Are your
overweight? Calculate your BMI
Aim for a waist: hip ratio 10 in men and 085 in women
Weight loss improves insulin sensitivity
UK Indians Asians consume as much fat as Europeans but twice as much as non-
migrants
Weigh yourself everyday and measure waist:hip ratio daily
Reduce daily calorie intake by 500 Kcal
Reduce fat intake to 21 of total energy intake
Diabetes see also NIH Guidelines
The goal of therapy is to achieve optimal blood sugar levels: Plasma
glucose 110 mg/dL and Hb A1c 7
Cholesterol Profile see also NIH guidelines
The goal is to aim for a lipid profile similar to non-migrant rural Indian
Asians who have a low risk for CAD Total cholesterol levels should not
exceed 200 mg/dL
LDL cholesterol bad cholesterol should not exceed 100 mg/dL
Triglycerides should not exceed 150 mg/dL
HDL cholesterol good
cholesterol should exceed 60 mg/dL
Medications: See NIH Website
Statins should be used to treat hypercholesterolemia and mild
triglyceridemia
Statins Fibrates should be used for though with severely increased plasma
triglycerdies or very low HDL cholesterol
Hypertension see NIH guidelines
The goal is not to exceed blood pressures seen in non-migrant Indian
Asians, ie, 130/80 mm Hg Medications: see NIH Website
Thiazide diuretics interfere with blood glucose control, increase total
cholesterol and decrease HDL cholesterol good cholesterol–therefore,
avoiding thiazides to diuretics may be relevant to Indian Asians
Smoking see also NIH guidelines
The goal of therapy is smoking cessation
Smoking cessation has been shown to reduce coronary artery disease by 25
Homocysteine:
The goal of therapy is to reduce plasma homocysteine to less than 10
mol/L
Patients with homocysteine levels above 11 mol/L should benefit from folic
acid 5 mg every day
Family Relatives:
The goal is to identify first degree relatives eg, brothers, sisters,
children and parents of patients for risk factors particularly lipid
profile, blood pressure, smoking, central obesity, insulin resistance,
diabetes,
homocysteine etc
Diet:
A Mediterranean-style diet may help reduce the risk of coronary artery
disease in Asian people, especially those living in western nations,
according to new research
A study by Indian and Israeli researchers recent issue of The Lancet,
included 1,000 people with a history of health problems associated with
CAD, including angina, heart attack and diabetes Half the people were
given a Mediterranean-style diet that included whole grains, fruits,
vegetables, walnuts and almonds That diet is rich in alpha-linolenic acid,
believed to benefit the heart The other half of the people in the study,
the control group, ate a conventional Asian diet At the end of two years,
the group given the special diet had doubled their daily intake of alpha-
linolenic acid The study group had half the number of sudden cardiac death
cases and non-fatal heart attacks compared to the control group
Stress reduction in whatever way or form For example, Yoga, Ta-ichi etc,
appropriate and suitable to the individual in question
In conclusion, among Asian Americans, South Asians have a certain mix of
genes that increase their risk of developing diabetes and premature
coronary disease, but
those genes only exert a negative effect when exposed
to a certain mix of environmental factors Economic transition,
urbanization, industrialization and globalization bring about lifestyle
changes that promote heart disease The wrong environment appears to be
conventional ones such as tobacco use, physical inactivity and unhealthy
diet
Life expectancy in developing countries is rising sharply, and people are
exposed to these risk factors for longer periods
Newly emerging CVD risk factors like low birth weight, folate deficiency
and infestations are also more frequent among the poorest in low and middle-
income counties
Diet cannot be the singular factor as there is no such thing as a singular
South Asian diet South Asia is four different countries, more than 20
different cultures and radically different diets However, one aspect that
is common to this group is a predominantly carbohydrate rich and relatively
low protein diet coupled with a sedentary lifestyle with little or no
physical activity exercise
It is extremely important that people of South Asian heritage be aware they
face a greater risk of adult onset diabetes and heart disease, that they
must be investigated for
these conditions earlier, and that they be treated
appropriately
Prevention, early detection and treatment of heart disease among this high-
risk population could save many lives Similar studies are needed among
other ethnic populations of APIA
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1 Ad Hoc Committee on Health Literacy for the Council on Scientific
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American Heart Association in 1995
6 Barroso, M Gurnell, V E F Crowley, et al, Dominant negative
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in human PPAR associated with severe insulin resistance,
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siblings in India Lancet 1995;345:405-9 PubMed
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and European Men Lancet 2000;355:523-7 PubMed
9 Chambers JC, Eda S, Bassett P, Karim Y et al, C-Reactive Protein,
insulin resistance, central obesity, and coronary heart disease in
Indian Asians from the United Kingdoms compared with European Whites
Circulation 2001;104:145 PubMed
10 Davi G, Catalano I, Averna M, Notarbartalo A et al, Thrombaxane
biosynthesis and platelet function in type II diabetes mellitus N
Engl J Med 1990;322:1769-74
11 Dunaif A, Segal K, Futterweit W, Bobrjanksky A Profound peripheral
insulin resistance, independent of obesity, in polycystic ovary
syndrome Diabetes 1989;38:1165-1174 PubMed
12 Ghee, cholesterol and heart disease Lancet
1987;148568:144-4
13 Gupta, M 2001 Canadian Cardiovascular Congress, Halifax, Nova
Scotia
14 Kooner JS, Baliga RR, Wilding J et al, Abdominal obesity, impaired
non-esterified fatty acid suppression, and insulin-mediated glucose
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myocardial infarction Arterioscler Thromb Vasc 1998;18:1021-6 PubMed
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16 McKeigue PM, Ferrie JE, Pierpoint T, Marmot MG Association of early-
onset coronary heart disease in South Asian men with glucose
intolerance and hyperinsulinemia Circulation 1993;87:152-161 PubMed
17 McKeigue PM, Shah B, Marmot MG Relation of central obesity, and
insulin resistance with high diabetes prevalence and cardiovascular
risk in South Asians Lancet 1991;337:382-386
18 McKeigue PM, Ferrie JE, Pierpoint T, Marmot MG Association of
early-
onset coronary heart disease in South Asian men with glucose
intolerance and hyperinsulinemia Circulation 1993;87:152-161 PubMed
19 New Initiatives to reduce health disparities, National Institutes of
Health NIH News Release, Nov19, 2002 For more information, see
wwwnihgov/ninr
20 Neel JV Diabetes mellitus: A thrifty genotype rendered detrimental
by progress? Am J Hum Genet 1962:14:353-62 Cross Reference
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Clin Invest, 1996;98:2094-2099 PubMed
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disease Diabetes 1988;37:1595-607 PubMed
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lipoprotein a concentration and apolipoprotein a phenotype to
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study Lancet 1996;348:358-63
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literacy with diabetes outcomes JAMA 2002;288:475-482 PubMed
26 Sleight P and ISIS-2 investigators: Second International Study of
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27 US Census, 2000
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Other resources:
1 RICADIA Risk Intervention in Coronary Artery Disease in Asian-
Indians Study Purushotham, K et al, Cholesterol, Genetics and
Heart Disease Institute, Berkeley Heart Lab This is an important
project aimed at preventing premature heart disease, disability and
deaths associated with CAD For individual and family screening
living in the San Diego, CA area, contact 619-229-1995 or fax 619-229-
1109 during regular hours
2 Dr BR Baliga, Department of Medicine, University of Michigan
Medical School Contact Tel 734-764-7440
3 Indian Foods: AAPIs Guide to nutrition, health and Diabetes, American
Association of Physicians of Indian Origin AAPI, Oakbrook Terrace,
IL
4 British Heart Foundation BHF, London, England wwwbhforguk
5 Heart and Stroke Foundation of Canada, Contact No 513-569-4361
ext318
Table 2 Growth rate of US Population based on Racial/ethnic
classification
|Racial/Ethnic Group |Growth Rate, |Growth Rate, |
| |1980-1990 |1990-2000 |
|Whites |409 |508 |
|Blacks |1198 |1526 |
|American Indians |3544 |1442 |
|Latinos/Hispanics |5302 |3942 |
|Asian Americans |9613 |6324 |
|Asian Ethnic |Growth Rate |Growth Rate | of Asian American |
|Group |1980-1990 |1990-2000 |Popul |
|Chinese |1041 |475 |237 |
|Filipino |816 |303 |181 |
|Asian Indian |1256 |1134 |164 |
|Vietnamese |1253 |892 |110 |
|Korean |1348 |351 |105 |
|Japanese |209 |-94 |78 |
Table 3 Growth Rates of within major Asian American ethnic groups
Table 4 Asian Americans, distribution by geographic location in USA
|Metropolitan Area |Asian American | of Total
|
| |Popul |Population |
|Los Angeles |1,799,000 |114 |
|New York |1,343,000 |67 |
|San Francisco |1,279,000 |188 |
|Honolulu |566,000 |649 |
|Washington |373,000 |51 |
|DC-Baltimore | | |
|Chicago |367,000 |42 |
Table 1 Distribution of Asian Americans in USA
|Ethnic |Asian alone |Asian at |Total |
|Group | |least One |Population, |
| | |Other Race |Alone or in |
| | |ie, |Any |
| | |Filipino-Whit|Combination |
| | |e | |
| |Single |Two or More | | |
| |Ethnicity |Asian | | |
| | |Ethnicities | | |
| |
|ie, | | |
| | |Chinese-Vietna| | |
| | |mese | | |
|Chinese |2,314,537 |130,826 |289,478 |2,734,841 |
|Filipino |1,850,314 |57,811 |456,690 |2,364,815 |
|Asian |1,678,765 |40,013 |180,821 |1,899,599 |
|Indian | | | | |
|Korean |1,076,872 |22,550 |129,005 |1,228,427 |
|Vietnamese |1,122,528 |47,144 |54,064 |1,223,736 |
|Japanese |796,700 |55,537 |296,695 |1,148,932 |
|Cambodian |171,937 |11,832 |22,283 |206,052 |
|Pakistani |153,533 |11,095 |39,681 |204,309 |
|Laotian |168,707 |10,396 |19,100 |198,203 |
|Hmong |169,428 |5,284 |11,598 |186,310 |
|Thai |112,989 |7,929 |29,365 |150,293 |
|Taiwanese |118,048 |14,096 |12,651 |144,795 |
|Indonesian |39,757 |4,429 |18,887 |63,073 |
|Bangladeshi|41,280
|5,625 |10,507 |57,412 |
Source:acadmed.org.my
