cv risk factors in south asians of canada
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CV Risk Factors in South Asians of Canada. Sonia Anand McMaster University Feb 21, 2013. North America. Europe. Asia. Middle East. Africa. Australia. South and Central America. Excess Coronary Heart Disease in South Asian Migrants. Mortality for CHD and Cancer Age 35 – 74 (1979-1993). - PowerPoint PPT PresentationTRANSCRIPT
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CV Risk Factors in South Asians of Canada
Sonia AnandMcMaster University
Feb 21, 2013
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North America
Australia
Africa
AsiaEurope
Middle East
South and Central America
Excess Coronary Heart Disease in South Asian Migrants
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Mortality for CHD and CancerAge 35 – 74(1979-1993)
0
20
40
60
80
100
120
140
160
CH
D &
Can
cer M
orta
lity
.. Ra
te/1
00,0
00
South Asian Chinese European
CHDCancer
Sheth T et al, CMAJ 1999
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South Asian 7%
Black 4%
Other 9%
White 75%Statistics Canada, 2006
Ethnic Profile in Ontario
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Changes in Risk Factors with Migration
51.6
19.4
9.3
1.8
13.5 16.8
6.6
23.519
1
19.1
25.226.3
0
5
10
15
20
25
30
0
10
20
30
40
50
60
Rurual India Urban India Canada
BMI
% R
isk
Fact
or
Smoke
DM
HTN
BMI
36 lbs42 lbs
n=972 n=342n=775
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1. Weight gain 2. pre-Diabetes 3. Diabetes 4. Heart Disease
Evolution of risk factors in South Asians
• Lipids• Blood Pressure
5.? Some Cancers
6
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Metabolic Syndrome Phenotype: A Cluster of Metabolic Abnormalities
• Abdominal Adiposity
• Dysglycemia• HDL Cholesterol• Triglycerides• +/- Elevated BP
Associated with a significant increase in type 2 diabetes and CHD
Visceral Adipose Tissue
Subcutaneous Adipose Tissue
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Age-Adjusted Prevalence of Metabolic Syndrome in Canada
45.4
26.8
15.9
28.8 28.325.2
14.37.1
41.3
23.4
05
101520253035404550
Overall Chinese Euro SouthAsian
Aboriginal
WomenMen
Age-AdjustedAnand et al Circulation 2003
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0.5 1 2 4 8 16OR (99% CI)
INTERHEART: MS and MI by Region
Region % Contr OR (99% CI) PAR (99% CI)
Overall 26.1 2.69 (2.48,2.92) 29.2 ( 27.1, 31.3)
W Europe 16.7 3.86 (2.61,5.70) 36.0 ( 27.5, 45.4)
C/E Europe 32.0 1.82 (1.46,2.26) 20.4 ( 14.3, 28.2)
Middle E/Egypt 35.7 2.53 (2.08,3.08) 34.8 ( 29.1, 41.1)
Africa 24.6 4.02 (2.76,5.86) 41.7 ( 32.6, 51.4)South Asia 26.9 2.72 (2.18,3.39) 31.6 ( 25.9, 37.9)
China /H.K. 13.9 2.27 (1.89,2.73) 15.1 ( 12.1, 18.7)
S.E. Asia/Japan 22.4 5.59 (4.22,7.41) 50.0 ( 43.5, 56.6)
Aust/N. Z. 26.4 2.20 (1.30,3.72) 22.0 ( 10.5, 40.3)
South Am./Mex. 36.3 2.74 (2.18,3.44) 40.3 ( 33.1, 47.9)
North Am 27.4 2.30 (0.97,5.47) 21.5 ( 5.5, 56.3)
Mente et al JACC
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Summary of Risk Factors
• 1) Increased body fat• 2) Tendancy toward central adiposity• 3) Visceral Fat excess• 4) Fatty liver• 5) Low HDL, High LDL, High TRGS• 6) Increased Diabetes• 7) Smoking is lower
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Summary of Presentation, Diagnosis, and Treatment
• Presentation time to hospital with chest pain symptoms is later in SA
• Management of acute coronary syndromes is similar
• Case fatality rate is similar • Long-term morbidity, mortality appears
similar• Lower attendance at Cardiac Rehab
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Pregnancy and Early Childhood
Adult Metabolic Syndrome
Interventions to Change Health
Behaviours
Individual
Community Level
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SouTh Asian BiRth CohorTEarly Life Determinants
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“Thin-fat” baby
• Newborns, relatively small at birth (BW < 2.9 kg) reported to have greater subscapular skin fold thickness, which is shown to correlate well with truncal obesity
• This adiposity tracks to 4 years of age• An increase of BMI of 1 SD from 2 to 12
years of age, increased the odds ratio for disease (IGT / DM) by 1.36. in young adults
Krishnaveni GV, Hill JC, Veena SR, Fall CHD. Indian Pediatr 2005; 42: 527-538New Eng J Med 2004; 350: 865-875.
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LBW persists in South Asian babies in UK
• X- sectional data record linkage 2005 – 2006 n=861,654 births of white, or South Asians
• 1st generation: Born in Indian subcontinent
• 2nd generation: Born in England/Wales
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Singleton Birth Weights
N = 772,128 1st Generation 2nd Generation
White Mean = 3457g
Bangladesh Mean = 3074g 13,261Mean = 3084g
3,015Mean = 3026g
Indian Mean = 3089g 15,733Mean = 3105g
11,368Mean = 3062g
Pakistani Mean = 3130g 28,566Mean = 3148g
17,583Mean = 3097g
Leon, J Epidemiol Community Health 2012;66:544-61
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Birth Weight by Maternal Region of Birth (Canada and South Asia only). Ontario, 2002-2006 Combined
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Risk of Gestational Diabetes Mellitus in Association with Maternal Place of Birth
Canad
ian-B
orn
Indus
trializ
ed N
ation
s
Sub S
ahara
n Afric
a
Carribe
an
East A
sia
South
Asia0
1
2
3
4 Country of Birth
a Odds ratios were adjusted for maternal age (continuous in years), number of livebirths, multifetal pregnancy, place of residence, neighborhood income quintile, and fiscal year of delivery. b Reference category.
Epidemiology: November 2011 – Volume 22 – Issue 6 – pp 879-880.
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Rel
ativ
e R
isk
of
DM
, obe
sity
, CVD
Low HighBirth Weight Higher Risk with
LOW Birth Weight
Higher Risk with HIGH Birth
Weight
• Placental insufficiency • Maternal undernutrition• Hypoxia (smoking, anemia,
altitude) • Genetics
• Maternal diabetes • Obesity• Excess gestational
weight gain • Genetics
Both low birth weight and high birth are associated with long-term metabolic disease risk for offspring
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Diverse Environments
250 Mothers/Babies
250 Mothers/Babies
1000 Mothers/Babies
Rural India Urban India Urban Canada
DIETARY DIFFERENCES (WEIGHT GAIN)
ACCESS to PRIMARY CARE
PSYCHSOCIAL SRESS, SOCIAL SUPPORT
GENETIC/EPIGENETIC FACTORS20
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Birthweight among GA > 37 weeks
START FAMILY (EC)3.15
3.2
3.25
3.3
3.35
3.4
3.45
3.5
3.55
3.6
Series 1
In singleton newborns with a gestational age >=37 weeks
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START: Is thin fat phenotype Observed in Canada?
South Asian FAMILY (EC)2.6
2.7
2.8
2.9
3
3.1
3.2
3.3
3.4
%fat/kg BW
%fat/kg BW
In singleton newborns with a gestational age >=37 weeks
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Epigenetic
• Maternal Exposures linked to DNA methylation in offspring:– Smoking– Depression– Under or over nutrition
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Regions of Genome associated with Birth Weight
• Development and morphagenesis • Cell Cycle/Cell division• Metabolism and biosynthesis• Not imprinted regions or housekeeping
genes• 60% methylation discordance between
heavy and light birth weight babies
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Explanations
• 1) Genetic- Transgenerational, DNA inherited
• 2) EpiGenetic – Transgenerational, inherited, non-DNA
• 3) Cultural: Diet deficiency or imbalance• 4) Other: Brown fat, telomere length
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What can we do to prevent Metabolic Syndrome in about the South Asian population in Canada?
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SAHARA Project
A multi-media based intervention aiming to provide culturally tailored health messaging and feedback to participants with the goal of reducing their cardiac risk score over a 6-month period.
http://www.youtube.com/watch?v=SwZdUSmWBpo
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Screening Cohort• 320 Men and women of South Asian ancestry • Permanent residents of Ontario/BC• ≥30 years• Access to email, cell phone with text messaging
capability, or a smart phone• No previous MI, CABG, Stroke
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Study Outcomes
• Primary outcome: change in IHRS after 1 year• Secondary outcomes:
• Change in components of risk score - blood pressure, HbA1c, waist to hip ratio, and apolipoproteins B and A
• Difference in clinical events between the intervention and control groups at the end of the study
• Rate of change in IHRS over time
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INTERHEART Modifiable Risk Score Report
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Genetic Risk Score Report
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Community or Contextual Factors and Future Interventions
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Social Networks
• 12,000 people tracked for 32 yrs• Social networks play a powerful role in
determining weight gain• If spouse or brother is overweight –1.40x
would be overweight• Friends had the most powerful influence 1.5-
2.0x - “kind of social contagion” • Think about typical S. Asian social networks-
centered around eating, not around moving• Older cultural beliefs must change to prevent
weight gain
Kristakis NEJM 2007
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Social Networks 2008; 30: 330-342.
Obesity in a Facebook Network
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Population & high risk individualized strategy for the Prevention of CVD
GOAL
Type of Strategy
Examples
Determinants of Risk Behaviours in a
Population
Interventions with a Socio-Economic &
Political Focus
• Taxing Tobacco• Subsidizing healthy
foods• Health Education• Promote Physical
Activity
Individuals with Risk Factors for
CVD
Interventions with a
Preventive Focus
• Identifying & treating individuals with high cholesterol or hypertension
• Smoking cessation in a smoker
Individuals with Manifest CVD
Interventions with a Clinical
Focus
• Lipid Lowering• Aspirin• Beta blockers• ACE-inhibitors• Appropriate revascularization
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October 30, 2008
A PolyPill for all?
AspirinStatinThiazideBBACE - I