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heart
Coronary
disease
Paul
Matthew
Heart
Foundation
of
University
College
1989,
Community
Gower Street,
Submitted
with
Iv,
MFCM
Department
66-72
a*evatmis
McKeigue
MA MSc MB BChir
British
in --Coukh Asians
for
the
Research
Medicine
and Middlesex
London
degree
amendments
Fellow
of
April
Hospital
Medical
School
WC1E 6EA
PhD in
the
1990
(10"
BIBL.
IL
LONDIN
UNIV
University
of
London,
September
Acknowledgements
by a Wellcome
I was supported
The British
Study
Research
way in
described
the epidemiology
differences
fruitful.
The literature
heart
review
Denise
and Suraiya
publicity.
Pierpoint,
and others.
Lipid
consultants.
and insulin
analyses
in
Stanford
grateful
to
the
Lyons
the
Harry
Tetleý,
ideas
in
collaboration
in
the assistance
with
for
analyses
were
organized
management
conclusion
Davey
Smith.
2
and the
were supervised
acted
Free
as
fatty
Chen.
of
CAV, Quaker
for
their
cooperation.
with
and
acid
Lucas
discussions
with
Tracey
Mattock
by Ami Laws and Ida
I owe much to
with
in the East
analyses
by Martin
Collins.
Catering
help
their
to
patients
Study was planned
Jarrett
undertaken
and workforces
Airways
their
of Jane Ferrie,
Keen and John
of
to the general
analyses
Risk
Harry
by Andrea
Keen and George
Lipid
the assistance
were
of
and Wendy Middlemass
and Coronary
analyses
has been
at the Department
I am grateful
by Karen Lyall
Despite
relationship
in close
College,
with
and British
the
investigate
to
me
in South Asians.
was prepared
Rahman.
The Diabetes
Turner.
Medical
Marmot who was my
encouraged
our working
by Dawn Barnes.
analyses
Bela Shah and undertaken
glucose
Michael
with
disease
Medical
London Study were undertaken
serum insulin
and awarded
and Coronary
by the
supported
for
East
London
Mosque
Trust
the
to
and
fatty
The plasma lipid
acid composition
be studied,
by Peter
is
in East London who gave permission
practitioners
Study
London
The Diabetes
Syndercombe Court
London Hospital
Daphne Cottier
London
was completed.
work
The East London Study was undertaken
with
Haematology,
1988.
of approach,
George Miller.
collaboration
October
Clinical
Foundation.
of coronary
occasional
with
the
work and first
this
this
East
supported
here were planned
throughout
in
Fellowship
when most of
west
and by the
Council
supervisor
from
Fellowship
now under
The studies
1988,
Foundation
Heart
me a Research
Risk
1983 to
from
Epidemiology
Training
I am
Oats,
For
Ami Laws,
Preface
This
thesis
describes
a programme of work which
began to assemble
first
heart
coronary
disease
on the analysis
us to plan
during
1985-86.
a new hypothesis
From the
at the end of
planning
a larger
in April
and May 1988;
progress
(September
study
together
material
final
not a single
not
follow
instead
study
the usual
describes
Michael
Marmot
London.
This
study
I was able
hypothesis
this
A pilot
for
this
we began
was completed
began in June 1988 and is still
of the pilot
study,
final
a
discussion
literature.
in
the
work
a continuing
form of review,
the programme as it
programme of work,
methods,
happened.
3
results
in
and their
of the main study, are described.
from the main study to bring the
results
with
led
to formulate
planning
other
but
of
London which was undertaken
To test
The results
and closed
with
1986.
the main study
1989).
date,
to
up
in east
in west London.
have added some preliminary
thesis
in north-west
of this
results
the epidemiology
of
and to work with
of Gujaratis
of Bangladeshis
to the
review
in South Asians
of a survey
a study
application
a systematic
began in 1984, when I
I
draws
this
which
Because it
covers
the thesis does
and discussion
but
Abstract
South
Asian
of
people
where
high coronary heart disease
In countries
unexpectedly
South Asian
men and women compared with
is shared by Gujarati
CHD mortality
high
from Pakistan
Muslims
and Bangladesh.
populations
are unexplained
cholesterol
dietary
or
To test
or
The results
undertaken.
Asians
with
compared
in
by differences
the
high prevalence
CD
Bangladeshis.
of
CHD rates
of smoking,
blood
and
in these
pressure,
plasma
the
in
high
blood
low plasma
serum
of
or
South
be explained
cannot
plasma
haemostatic
HDL cholesterol
activity
and high
a glucose
load
was identified
in
after
diabetes
non-insulin-dependent
CHD
in
CHD rates
pressure
levels
insulin
high
London was
east
population
disturbance
a
of
the
underlie
study
of
of
lipoprotein
activity,
might
that
distributions
high
levels,
triglyceride
Sikhs
The high
British
native
A pattern
supported.
Punjabi
in
In England
groups.
ethnic
Hindus,
a population
The hypothesis
cholesterol.
was not
metabolism
confirmed
the
other
haemostatic
of
Asians,
South
have been recorded
rates
intake.
carbohydrate
in
mortality
fat
disturbances
whether
metabolism
by levels
have settled,
origin
and
On the basis
it
findings
these
and a review of other recent work
of
disturbances
(i) insulin
these
that:
underlies
resistance
(ii)
in
this
Bangladeshis;
metabolism
and carbohydrate
is
suggested
of
lipoprotein
resistance
(iii)
and
overseas;
populations
for
the high
insulin
that
role
of
is a possible
CHD and diabetes
in South Asian
underlying
in these
is described.
this
a syndrome of metabolic
in Bangladeshis,
first
identified
This
is
in South Asians.
obesity
pattern
insulin
prevention
associated
with
These findings
in South Asian
4
communities.
to
related
is present
also
tendency
to the
in CHD and suggest
resistance
The
Preliminary
a striking
point
mechanism
populations.
disturbances
and Punjabis.
for
it
to test
study
resistance,
aetiological
strategies
rates
confirm
Gujaratis
central
of both
large
a
of
planning
results
is a general
to insulin
tendency
possible
in
to
Table
of Contents
Page
1. Review
of
2.
The East
London
3.
Discussion
of
4.
Planning
5.
Pilot
6.
Preliminary
7.
Conclusion
the
Study
in
Diabetes
the
East
and Coronary
Finchley
results
1985.,
09
27
......................................
methods
in
study
London
Risk
Study
Study
A-
tables
Appendix
B-
figures
in
the
..............
55
the
Diabetes
and Coronary
Risk
sample
Appendix
D-
references
size
and Coronary
calculations
67
94
144
..........................................
Diabetes
study
71
...........................................
C-
47
....................................
of
Appendix
37
.............
.................................................
Appendix
1
up to
epidemiology
Risk
Study
.........................
.......................................
5
...........
148
150
151
List
Tables
of
Page
Review
of
epidemiology
in
Table
1-
CHD mortality
Table
2-
Mortality
Table
3-
Serum cholesterol
in
South
Table
4-
Serum cholesterol
in
South
Table
5-
Diabetes
East
London
in
South
Asians
overseas
boroughs,
London
in
prevalence
1979-83
94
..............
95
...............
Asia
.....................
Asians overseas
South
Asians
96
97
..........
98
.................
Study
for
Table
6-
Sample
Table
7-
Alcohol
Table
8-
Response
Table
9-
Numbers
Table
10 -
Cigarettes
Table
11 -
Alcohol
Table
12 -
CHD risk
Table
13 -
Height
Table
14 -
Weight
Table
15 -
Table
16 -
Table
17 -
Table
18 -
.............................................
Body mass index
....................................
blood
Systolic
pressure
........
blood
Diastolic
pressure
...........................
fibrinogen
Plasma
..................................
Table
19 -
Factor
Table
20 -
Fatty
Table
21 -
Prevalence
Table
22 -
Insulin-glucose
Table
23 -
Insulin-glucose
Table
24 -
Percent
Table
25 -
Correlations
between
Table
26 -
Correlations
between
size
consumption
rate
London
East
Study
categories
99
...................
100
......................
101
.......................................
by
attending
smoked
by
sex
sex
and
and
ethnic
pattern
consumption
factors
age,
by
sex
ethnicity
102
.........
category
.......
104
........................
and
ethnicity
105
..............
106
.............................................
VIIc
acid
........................................
lipids
of
composition
of
total
diabetes
107
108
109
110
111
112
640.0
..............
..............................
by sampling
time
ratio
cholesterol
115
.............
as HDL ...................
measurements:
measurements:
6
113
114
.............................
ratio
103
116
117
men .............
118
women ...........
119
Page
Pilot
studv
Table
27
Age distribution
Table
28
Anthropometric
Table
29
Metabolic
Table
30
Obesity
indices
against
fasting
Table
31
Obesity
indices
against
2-hour
Table
32
Correlations
based
on all
Table
33 - Correlations
based
on Europeans
Table
34 - Principal
Preliminary
in Finchley
results
of
in
participants
pilot
study
........................
by ethnic
group ................
variables
component
the
of
insulin
insulin
groups
analysis
Diabetes
of
..........
and Coronary
.......
Risk
Table
36 - Anthropometric
measurements ........................
by age and ethnic
37 - Obesity
group ....................
by
38 - Metabolic
group ................
ethnic
variables
Table
39 - CHD risk
Table
40 - Prevalence
Table
41 - Age-standardized
Table
42 - Univariate
Table
43 - Multivariate
Table
44 - Glucose
45 - Glucose
factors
of
participants
by social
of
prevalence
of
comparison
comparison
diabetes
of
intolerance
by tertiles
of
intolerance
by tertiles
of
131
group .....
and IGT ....
133
and BMI...
135
ratio
waist-hip
130
132
ratio
waist-hip
129
group..
and ethnic
by age and ethnic
diabetes
128
...................
class
127
Study
Table
of
125
126
...............
correlations
123
124
.............
combined
only
12''
............
35 - Age distribution
Table
121
measurements
Table
Table
....
120
134
and BMI. 136
WER and BMI
.....
WHR and BMI .....
137
138
Conclusion
Table
46
Plasma triglyceride
Table
47
Mortality
Table
48
San Antonio
Table
49
Framingham Study:
Table
50
Plasma cholesterol
Pimas
compared with
of
Study:
and Whites ... 139
140
US Whites .........
and HDL in Blacks
and Anglos
Mexicans
compared ....
141
142
in
and
women
men
risk
... .
143
in South Asians in the UK .......
factors
7
List
of
Figures
Page
Figure
1-
Ethnic
Figure
2-
Total
Figure
3-
Triglycerides
Figure
4-
Waist-hip
in
Figure
5-
the
of
Tower
and HDL cholesterol
and insulin
ratio
Diabetes
Mean serum
in
Figure
the
composition
insulin
Diabetes
6 - The insulin
Hamlets
in
East
................
London Study
in
East
London
distributions
by ethnic
and Coronary
Risk
by tertiles
of
and Coronary
Risk
resistance
syndrome
8
Study
Study
.....
.....
145
146
group
............
waist-hip
Study
144
ratio
............
.. ..................
147
148
149
1.
Epidemiology
heart
coronary
of
disease
in
South
Asians:
up to
review
1985
2 Introduction
heart
Coronary
disease
(CHD) rates
to be particularly
the world
A basis
subcontinent.
This
review
the extent
disease
for
preventive
for
Indian
new hypotheses and possibilities
the term 'South Asian' is used to denote
excess,
review
Those who migrated
subcontinent.
Partition,
and their
descendants,
'Indian'.
Migration
from India,
describe
generally
Pakistan,
themselves
as
to the United
of the subcontinent:
those
in
from
originating
region.
2.1 The Indian
Indian
diaspor
have migrated
people
modern history
colonial
(from
Fiji
Indian
of
system of
creation
Indian
of
1838),
(from
Madras.
for
recruiting
leaving
and Bihar,
Punjab
and North-West
mostly
Dravidian
Pradesh.
Hindus
with
Indians
people
particularly
in 18341,2.
(from
indentured
(from
1877),
The main agencies
labourers
were in Calcutta
came mainly
from
Bengal,
numbers
smaller
the West Indies
1896).
Calcutta
through
1834),
Settlements
of the
led to the
This
(from
the Straits
and
from the United
Orissa,
Oudh,
through Madras were
Those emigrating
from Madras State (now Tamilnadu) and Andhra
exceeded Muslims
travelled
from the beginning
in Mauritius
1860),
The
many centuries.
Provinces.
South had been converted
initiative,
labour
1879) and East Africa
Indians
Provinces
indentured
(from
dates
emigration
for
lands
to other
communities
Natal
responsible
Other
before
and Bangladesh
Kingdom has occurred mainly since the partition
is generally
the UK the term 'Asian'
used for
this
epidemic.
of excess CHD rates in South Asians,
knowledge about the pathogenesis
of the
this
In this
from the
communities
the evidence
to which existing
prevention.
in these
strategies
of the causes of this
understanding
examines
can account
origin
high
for
depends upon adequate
have been noted in several parts of
in people originating
from the Indian
by about
before
to Christianity
through
9 to 1, and many from the
the British
to East and Central
their
departure.
Empire on their
Africa.
own
Many of these
Presidency
Bombay
from
Gujarat,
and
and professionals
came
entrepreneurs
labour system was banned by the Viceroy in 1917 but
Goa. The indentured
9
Review
a steady
migration
continued
the
until
independence
in
East
to
Britain
from
the
a peak
around
were
to
and reached
introduction
in
move to
India,
Indian
1954.
fell
then
or North
Migrants
restrictions3.
America.
1960
after
following
sharply
Indians
of
increased
subcontinent
East
With
numbers
Europe
has
in
arrive
large
changes,
1966-67,
immigration
of
bans
political
forced
to
continued
legislative
of
and subsequent
Africa
Migration
enactment
migrants
families
and their
professionals
Indian
since.
ever
Africa
traders,
of
the
from
to Britain
Gujarat
Most had been agricultural
and Punjab came from rural
areas4.
literacy
or manual workers but their
rate was higher than that of the
from Pakistan and Bangladesh were from
Migrants
general population.
than those from the north of India.
poorer circumstances
2.2 Coronary
heart
The earliest
report
in
this
in
a series
of
in
artery
times
higher
death
rates
in 1954-57 were four
Though
in
in
CHD mortality
both
1978 in
Indian
males
Singapore
groups,
a threefold
In Uganda 43 percent
deaths
Indians
compared
Prevalence
with
undertaken
seven
the
over
higher
times
in
excess
other
CHD - defined
involvement
-
1950-54
years
was
Age-standardized
in Indians
has more than
1)
with
of
myocardial
Chinese5.
than
(Table
overseas
19575.
disease
9568 autopsies
all
in
CHD rates
Singapore
as coronary
study
in Indians
rates
high
of
from
was
groups
ethnic
disease
than Chinese.
doubled
Indians
CHD
between
compared
1957 and
Chinese
with
remains6.
1956-58
years
the
African
was 49 percent
Africa,
above
that
for
in
Indian
was similar
the
1968-197/7
the
rate
percent
above
rate
for
for
USA and UK at
this
infarction
men of
in
and European
Indian
time.
In
around
Fiji
in
men at
during
this
time
1955-578.
but
increased
15-64
twice
non-
30-69
aged
women
descent
during
while
to be almost
Indian
men aged
Europeans9:
disease
was said
European
women of
for
heart
coronary
disease
the
the
1970-73,
over
to
estimated
45
rates
myocardial
hospital
be
to
admissions of
much commoner among
was noted
National
Indian descent than those of Melanesian descentiO.
data
mortality
heart
the
the
in
men in Kampala
Asian
CHD mortality
South
Mortality
the
Uganda
of
population
existent'.
as due to
certified
were
In
years
of
among South
disease
Melanesians,
for
1971-80
to be about
though
only
showed age-specific
three
times
higher
72% of deaths
mortality
in Indians
were medically
10
from
than
certified".
ischaemic
in
Review
In Trinidad,
where about
descent,
prevalence
the
groups
for
ratio
in
major
Indians
55-69
ages
from
heart
disease
a total
urban
coronary
a survey
versus
ot'her
years.
In
of
Q waves
ethnic
a more recent
disease
descent,
was 2.6
of mixed descent,
with
in
of
age-adjusted
CHD),
Indians,
2.1
in
differen't,
in
The odds
35-54
ages
1-1,1-2)
and 1.3
in
mortality
comparison
death
of
with
Europeans,
at
this
risk
sex difference
no significant
ethnic
codes
relative
in
Ind. -Lan
communitY12.
at
analysis
(mostly
is of
(Minnesota
was 3.8
groups
1977 and 1985,
cardiovascular
African
of the population
electrocardiographic
between
community
of
in
was assessed
30 percent
adults
and 0.3
in
of
adults
in relative
risk
estimates13.
In Britain
high
CHD rates
time
of the
1971 Census.
East
London
borough
over
the
borough
during
1970-72
years
Bangladeshi:
of
In a community
Tower
in
was 3114.
the
South
Analysis
same period
from the
on death
certificates
had high
(PMRs) were
coronary
CHD mortality
120 for
all
heart
disease.
proportional
general
The social
of
women
developing
Analysis
of
born
Asians
these
England
ratios
ratios
were
of CHD
gradient
class
surnames
in Africa
mortality
women, although
population
men and 128 for
from other
migrants
(SMRs) for
ratios
men and all
the
in
the
for
rates:
mortality
England and Wales
119 for
of
South
deaths.
numbers of
were recorded
males in the
all
mortality
ethnic
based on small
seen
for
that
men and 163 for
in the
register
events
for
data
subcontinent
In contrast
showed
attack
from the rate
the rates
at the
observed
men, predominantly
standardized
taking
had low SMRs for
heart
Asian-born
Indian
10015.
as
respectively
were first
40 coronary
of national
showed
women aged 20-69 years,
countries
Hamlets,
the number expected
CHD in migrants
also
in South Asians
and Wales
was absent
in South Asians.
It
is
not
to
possible
different
regions
from the
Gujaratis,
Punjabis,
percent
analyses
coronary
excess
of
of
National
separate
of South Asia
immigrants
PMRs for
calculate
Indian
heart
disease
myocardial
Health
migrants
but surnames on death
and Muslims:
in the years
infarctions
Service
from
certificates
of
have been used to distinguish
subcontinent
Southerners
rates
for
in
hospital
11
all
four
1975-7,716.
South
Asians
admission
groups
had high
A 40 to 50
was found
data
for
in
Review
Leicester
during
clinical
at
197/7-7817
presentation
angiography
patients
do not
differ
that
diabetes
except
Plasma
patients'9120.
British
native
National
data
Asian
by country
60 percent
higher
for
England
and Wales
Unless
South
from
mortality
Wales
The diminished
The high
in
South
of
birth
for
the
Asian
Asian
in
than
Asian
heart
increased
disease
the
average
by
shared
and Pakistaii.
Asians
in
the
decade
over
fitness
f or
was 40
unrepresentative,
among South
25 percent
selection
is
Bangladesh
2 are
Table
than
mortality
Punjab,
with
1979-83
in
each borough
the
around
London boroughs
high
This
in
by about
of
in
Gujarat,
populations
for
period
CHD mortality
Asians
2)23.
from
effects
CHD rates
for
selected
subcontinent,
Britain
heart
2.3 Coronary
Though
there
Indian
in
incidence
England
and
1971-81.
for
may account
Indian
admissions
surveys
and the
were
some of
of
disease
other
USA and South
the
of
sections
usually
have
been
may
groups
migrant
Africa
-
- correspond
is
It
disease
heart
1970-712 were
Africa
origin.
of
coronary
likely
in
exist
the
from
population
Indian
which
subcontinent
data
population-based
Pakistan
hospitals
and the
or
from
rates
practice24
mortality
on coronary
Hospital
Bangladesh.
have been
1958-62
have
in
urban
common
CHD is
that
report
CHD prevalence
East
certain
in the Indian
to
results
from
are
in
drawn.
railwaymen
ascertained
in
and Wales
migrants
exodus
countries
those
between
railway
England
Poland,
of
in
clinicians
India,
seen
their
rates
no satisfactory
are
CHD were
in
least
at
to
migrants
high
the
rates
in
immigrants:
recent
Ireland,
recorded
that
Asians
although
Scotland,
rates
therefore
in
The high
from
the
of
fitness,
an exception.
those
South
finding
an unexpected
for
British
increase.
this
to
(Table
coronary
have
must
lower
show that
among South
originating
the
South
Tfie
disease
of
and native
is
but data
available
populations
to
communities
Asian
more common in
cholesterol
Census are not yet
South
is
South
1980-8218.
distribution
anatomical
between
during
patients21,22.
mortality
large
CHD and the
of
London
and north-west
admission
reported
but
or
rates
only
electrocardiographically-documented
were
not
standardized
been conducted
have been compared with
12
those
in
northern
of a survey
for
age25.
India26,27
Two
9
in Tecumseh,
Review
USA28.
In Chandigarh,
30 years
and over
community
1000)
of
aged
40-59
numbers
of
Despite
populations.
in
CHD rates
to
in
exist
rural
the
explanation
which
South
Asians
several
2.4.1
Smoking
Cigarette
in
In
was less
in
77 smoking
lower
data
in
in
general
2.4.2
to
.
increased
rural
The
findings
suggest
have
been
may
groups
rates
explain
in
than
were
Asian
South
the
in
the
Melanesian
than
lower
show
Britain
with
in
from
sexes
an early
Studies
factors
have been
CHD rates
them it
between
to
was possible
others.
Asian
Indians
in
than
of
than
Asian
European
women32.
smoking
in
rates
of
in
Africans
but
between
these
Africa
European
National
South
smoking
two
men who had ever
South
In
unusual
20
or
smoked
men who
mortality
men3l.
but
men overseas
proportion
South
the
another,
mechanism.
proportion
difference
Fiji
higher
lower
suggest
Trinidad
the
a survey
rates
in
in one
Asians
known CHD risk
by reviewing
and to
In
Indian
South
both
in
risk
common among South
is
in
same as that
of
higher
day
was
a
failed
groups
be the
countries:
hypotheses
more cigarettes
13
5 in
much lower
that
CHD mortality
ethnic
several
smoking
high
distribution
the
women13,18,29,30.
habit
but
in men
between
India
northern
per
21
on
cases).
these
cases,
may be a common underlying
and other
reject
(rate
in South Asians
of
compared
from
reported
time,
necessarily
there
that
age suggests
have
USA at
this
(based
comparison
of
in
of
distribution
world-wide
numbers
populations
factors
risk
need not
community
the
small
village
1-1,1-2)
codes
on 22 cases),
Tecumseh
a4-d
areas,
2.4 Coronary
Though
urban
in
those
the
(based
few for
too
women were
a total
The prevalence
(Minnesota
and 26 in
2030 adults
Haryana
rural
study,
Chandigarh
3
on
cases),
in
for
Q waves
38
in
was
cases
in
while
age was included
years
(based
similar
examined,
electrocardiographic
Haryana
that
were
this
of
of Punjab and Haryana,
capital
during
1975-
but
men
much
household
men than
Asian
smoked
surveýin
population33,
Hypertensio
is
Hypertension
common in
subcontinent34,35.
found
was
to
be less
In
urban
a survey
common in
and rural
in
populations
Durban,
Indians
than
13
South
in
Africa,
Africans
in
the
Indian
hypertens'On
or
Europeans,
the
Rev i ew
though
the design
Guyana, blood
Indians:
not
a similar
which
prevalence
and lower
origin,
cardiovascular
men with
9.6
descent.
Europeans,
Fiji,
31
men
who had migrated
industrial
5.1
Higher
to
between
hypertension
in
England
in
South
do not
pressures
in
found
for
account
high
the
Age-adjusted
in
Indians
those
mixed
in
Indian
similar
in
and
Punjabi
women
a study
of
an
in blood
Levels
workers40.
CHD rates
compared
of
no differences
British
and native
had
among Trinidadian
in
were
of
and mixed
were
the
Birmingham
descent
in
recorded
39
home countr. ý,
but
pressures
than
Asian
and 1.1
in
body size
descent38.
person-years)
Africans
blood
European
of
African
of
larger
of Indian
130 mmHg was 11.3
mean systolic
population
pressure
below
pressures
In
Melanesian
adults
by the
those
In
men and women than
adults
to
(deaths/1000
mortality
in
In Trinidad,
than
rates
systolic
in African
hypertension
of
differences36.
observer
be explained
could
descent3,.
of African
for
control
were higher
pressures
differences
adults
with
did
South
of
Asians
overseas.
2.4.3
Serum ýcholesterol
A high
factor
a
necessary
scale4l.
Values
of
India,
but
3)42-53.
above
high
Comparisons
of
are difficult
(Table
higher
than
in
ethnic
other
with
since
frequently
are
in Indians
but not
4)7,18,53-55
groups
of
(Table
to interpret
techniques
urban
parts
groups
tend to be higher
Mean concentrations
for
in various
socio-economic
and laboratory
in the subcontinent
than
status
lower
and
type
of CHD on a mass
a population
socio-economic
this
is considered
have been reported
level
this
procedures
sampling
in
occurrence
in the middle
not
necessarily
the
or
at
not comparable.
overseas
for
relatively
population
in excess of 5.2 mmol/l,
serum cholesterol,
average
groups
concentration
lower
CHD rates.
45-69
for
1980s
years was
In the early
men aged
mean serum cholesterol
Apart from a 1959
5.5 mmol/l in the USA and 6.3 mmol/1 in Britain56,57study
of
Uganda7,
South
Asian
no group
men attending
originating
in
general
the
Indian
practitioners
subcontinent
in
Kampala,
has been
to
have
or
similar
to
concentration
cholesterol
serum
mean
a
reported
LDL
Trinidad,
(Table
In
4).
cholesterol
British
serum
that
men
of
above
concentrations
but
Fiji,
this
did
0.3
were
not
plasma total
account
mmol/l
for
cholesterol
higher
the difference
levels
in African
men55
13.
In
in CHD mortalitý,
in Indian
were 0.3
14
than
mmol/l
higher
in Indian
Review
in
than
Melanesian
the
could
explain
these
two ethnic
of
Gujarati
this
2.4.4
Dietary
the
low
low average
high
to
saturated
intakes
recall
are
high
in
dietary
food
employees
the
inventories18
and high
polyunsaturated
lipids
low:
these
suggested
Ghee,
fatty
that
prepared
traditionally
12 percent
prepared
were not
acids
they
against
protect
by heating
sterols
Indian
suggested
dietary
intakes
Authority,
in Indians
intakes60,
the
for
value
to
British
predicted
the
most of
levels
of
the
in
high
the
be expected
levels
and
in
a
in plasma
w3 series
and it
origin
fat
the
with
was similar
acids
Gujaratis
saturated
to
by
were
has been
atherosclerosis.
cooking.
in ghee obtained
the
off
water,
One analysis
from commercial
is
has shown that
and home-
these
form
in
the
compounds
oxides:
of cholesterol
sources were
Since there is evidence from
butter6l.
found in ordinary
that
cholesterol
studies
62, the
presence of
cholestero,
animal
in
those
one using
compared
marine
to drive
butter
used in North
of the
of
mainly
are
Asian
are
Port
of
In two studies,
intakes
polyunsaturated
diets
of total
As would
fatty
the
that
as a proportion
accounted
Gujaratis.
dietary
population,
long-chain
of
of
acid
of
low dietary
intake
low or
exist
weighed
intakes
fat
are
intermediate
was close
Linoleic
intake
vegetarian
mainly
fat
Total
population.
fat
have
to
cholesterol
plasma
formula18.
Keys
British
found
holds,
overseas
South
Singapore
the
of
and the other
were
data
in Chinese,
polyunsaturated
Average
the
was highest
London
north-west
from
intake
with
an assessment
and lowest
average.
striking
Asians
intakes
survey
In
South
overseas
59
in Malays
fat
Polyunsaturated
.
in all three groups.
was similar
intakes
cholesterol
serum cholesterol58
The only
fat
in
plasma
between
particularly
comparison
mean total
household
is
in
and cholesterol
London.
528 male
in
found
fat
detailed
which
and north-west
intake
size
CHD mortality23.
average
levels
and US populations.
for
populations
fat
this
of
in CHD mortality
and Harrow18
diet
relating
fat
European
24-hour
difference
Brent
cholesterol
that
polyunsaturated
Singapore
a difference
fat
either
North
twofold
has exceptionally
group
that
unlikely
The relatively
groups.
relatively
imply
more than
Keys equation
the
is
men and women in
since
If
it
men:
as a possible
than
pure
atherogenic
more
are
oxides
these compounds in ghee has been
high
of
cause
CHD rates
15
in South Asians
in
Review
Britain
and Trinidad6l.
cholesterol
is
oxidation
Trinidad
the
South
that
Asians
high
levels
levels
Asians
are
and have been
compared
with
predictors
fully
explain
higher
found
fairly
the
Indian
communitY55.
have
reported
to
than
general
the
is
There
populations'
2.4.5
Diabetes
it
In urban
to
to
which
extent
may be separately
and impaired
affluent
and obese74,75.
excess
of
diabetes
Saigon
in
191376.
in
Similar
Trinidad78,
Malaysia77,
and England83.
Prevalence
two British
recent
criteria90
surveys
with
surveys
with
are
for
basis
of
and high
factors
are
antiquity
in
European
of
in the middle-aged,
the first
Indians
ethnic
Singapore8o,
from
shown
published
in
Table
a 50g glucose
Surinam82
in
surveys
5 together
Committee's
16
from
Fiji8l,
1980 WHOExpert
load,
of an
was from
come more recently
comparison88,89.
using
report
groups
To allow
studies
levels
and triglyceride
Both
disease
a
other
have
estimates
based on the
earlier
is
Africa79,
populationsl3,77,81,84-87
been
tolerance
Among overseas
South
not
this
low HDL cholesterol
as prevalent
reports
in
on the
in
mmol/1)
did
triglyceride
distinguish
mellitus
comparison
age-
levels
have also
HDL cholesterol
and
South
men (0.9
adults
States
diabetes
glucose
diabetes
Indian
atherogenic.
non-insulin-dependent
in
and triglyceride
and higher
difficult
64,65
Trinidad,
in Indian
United
between
has
long been recognised
and
India
from
is
the
Non-insulin-dependent
Asian
the
association
levels
with
-3
to
in
HDL cholesterol
70,71
population
data
triglyceride
CHD deaths
of
CHD
in
These differences
lower
so that
epidemiologic
Africans.
migrants
an inverse
levels64,72
associated
excess
it
high
the
consistently
groups.
other
in
than
for
CHD risk
of
mean HDL cholesterol
concentrations
and women (1.2 mmol/1) were 0.1 mmol/l lower
40 percent
in
communication):
(HDL) cholestero,
adjusted
were
of
levels
high-density-lipoprotein
studies
overseas
personal
can account
and triglyceride
of
presence
world.
triglyceride66-69
of
prospective
the
the
confirm
Use of ghee among Indians
hypothesis
this
around
Plasma HDL cholesterol
Low plasma
to
was uncommon (GJ Miller,
therefore
in
have failed
63.
in ghee
products
survey
unlikely
rates
Others
South
with
comparison
diagnostic
prevalence
data
of
Rev i ew
figures
based on comparable
been extracted
from the earlier
The low prevalence
in
Orissa
India
rates
197184 are
in
distribution
in striking
in
rates
diabetic
were
prevalence
of
criteria
diabetes
in
in
Indian
(measured
5.
Table
men than
this
of
tenfold
in
urban
age
and rural
from
possible
the
and 0.5% in
rural
In
sur-, -ey the
the
Fiji
Melanesian
as triceps
in urban
by differences
age is
Cuttack
urban
have
Badachana
higher
men was not
thickness)
skinfold
or
activity9l.
physical
Preliminary
analyses
that
suggested
cardiovascular
between
these
The European
to
easier
Africans
death
in
part
mellitus
this
this
study
in
Britain.
of
the
risks
Indian
of
3.4
did
CHD in
Indians
in
in CHD rates
this92.
comparisons
mellitus
not
lowest
the
range
of
mortality
4.2-4.6
and 0 in
Africans
be
more
that
above
the
would
explain
mortality
cardiovascular
Indians,
descent,
to confirm
similar
in
was
glucose
of
of cardiovascular
in Trinidad:
descent
study
and European
failed
follow-up
risk
fasting
in
relative
analysis
Diabetes
age-adjusted
6.7
was
Trinidad
was small:
excess
mixed
the
the difference
explain
longer
in
men of
A more recent
men whose
stratum
person-years)
might
with
in
and men of
were
similar
were
groups13.
perform
in
data
adjusted
group
a small
and in
of
and mortality
morbidity
follow-up
the
diabetesage- and
diabetes
and that
rates
by the
by obesity
explained
2% in
for
of
findings
that
Comparison
10 years
over
data:
Orissa
published
can be accounted
individuals
all
glucose
data are given.
77
in 1966
and in
to later
is unlikely
criteria.
blood
where sufficient
contrast
It
diagnostic
2-hour
in East Pakistan
reported
prevalence
or
for
values
studies
and overseasl3,81,86,87.
difference
than
cut-off
mmol/l
(deaths/1000
men of
mixed
descent.
Quantitative
consideration
and CHD mortality
intolerance
for
an entire
glucose
between plasma glucose
to be a threshold
and there
elevation
of CHD risk,
2-hour
at a
year
follow-up
study
to examine
age-adjusted
appears
this
level
glucose
for
to the WHOcriterion
The largest
prevalence
The relationship
is non-linear
impaired
17
of
and
for
approximatelý,
glucose
was the Whitehall
CHD mortality
CHD risk
elevated
markedly
high
by
a
explained
suggests
mortality
equivalent
that
is not easily
population
intolerance.
between glucose
of the relationship
tolerance93-96
Study93,94:
0
10at
in men in the top 5 percent
of
Review
2-hour
the
blood
were known diabetics,
implies
that
glucose
intolerance
this
the
overseas
would
A 30 percent
6 percent
mortality,
it
unlikely
that
is
tolerance
Indians
in
Melanesians
high
a
likely
more
has pointed
Fiji.
out,
diabetes
there
have
appears
duration
of
diabetes97.
diabetes
in
South
disturbance
Socio-economic
economic
eventually
South
Asians
between
in
CHD risk
30 percent
of
rather
a 23 percent
only
basis
On this
of
Indians
between
glucose
CHD death
in
with
compared
plasma
causal and it is
97.
determinants
As Jarrett
tolerance
prevalence
suggests
the
to CHD
and non-insulinCHD death,
of
risk
between
glucose
plasma
increased
CHD mortality
and
and the
non-insulin-dependent
of
presence
of
an underlying
first
the
metabolism.
to
to
appear
into
spread
commonest in those
Some writers
statusq8ý99.
instead
status
and then
becoming
Asians
be directly
The high
CHD has tended
groups,
in
and
relating
glucose
South
age,
risk
relationship
gradient
high
and impaired
relative
and
CHD mortalitN,.
equal.
diabetes
to
an equally
Asians
yield
common underlying
of carbohydrate
Historically
the
be no relationship
to
would
being
of
unlikely
impaired
carry
for
Singapore
any case
is
risk
factors
risk
in
a biological
dependent
this
Chinese
both
mortality
but
in
in middle
the
ill
intolerance
total
of
intolerance
double
6 percent
an exceptionally
elevation
to
attributable
glucose
tolerance
glucose
a threefold
In
lacking:
even
explain
that
is
betweeen
prevalence
and CHD mortality
glucose
2.4.6
would
other
with
compared
about
then
population
alone
could
is
-
glucose
of
the
total
excess
fraction
a modest
Whitehall,
of
are
relationship
only
prevalence
6 percent
than
which
and impaired
produce
as in
CHD deaths
populations
diabetes
of
all
1 percent who
93.
This
of the cohort
in the rest
aetiologic
this
across
and in a further
that
of
the
If
holds
prevalence
was twice
proportion
population.
mortality
distribution,
glucose
Britain
and low
the
of
lowest
the
population,
socio-economic
the high CHD mortality
explained
by the
of
association
The absence
statuslOO.
socio-economic
socio-
more affluent
of
rest
that
have suggested
may be partly
in
of
a
in
England
Asians
South
and
in
CHD
among
mortality
social
class gradient
is
It
difficult
to
similarly
Wales makes this notion
sustain.
high
CHD
the
deprivation
in terms of economic
impossible
to explain
rates
of
Indians
the economically
compared with
dominant
group.
Melanesians
in Fiji,
More relevant
18
where Indians
to understanding
are
the
Review
high
CHD risk
South
in
hypothesis
is
and by the
relationship
mortality
are
for
Early
high
2.4.7
The failure
of
to
European
of
infant
short
interest
to
and cardiovascular
is
South
Asians
from
in
less
data
for
in
existing
explanation
Afro-Caribbeans
since
developed
South
the
examine
be a sufficient
Britain,
CHD
and subsequent
mortality
to
unlikely
to CHD101
stature
mortality
is
this
populations
No similar
be of
CHD risk
have
regions
and
low CHD
in
between
for
in
The theoretical
to
construction.
depend
on theoretical
Measurement
modello-'.
but
straightforward
in
which
they
of
they
are
were
theory
of
work
this
line
concepts
this
of
thesis,
inquiry.
factors
might
This
in
be applied
the
to
factors
developed.
19
in
embodied
and the
difficult
be
may
by epidemiologists
their
and do not
operationally
examples
low-level
usually
in
psychosocial
defined
are
scores106
these
are
Asians.
frameworks:
network
social
the
developed
constructs
in CHD mortality
psychosocial
psychosocial
level
the
Low-level
behaviour'05,
of
stress
psychosocial
according
heavily
South
basis
about
and CHD
Epidemiologists
consider
how these
examining
and serum cholesterol
differences
neglecting
ideas
current
CHD rates
2.4.7.1
of
for
have been
acculturation
when presenting
writer,
CHD before
high
to
in
Asians
that
ideas
service'01.
reluctance
reviews
explain
classified
between
civil
South
speculation
pressure
and for
the
criticized
the
The concepts
in
their
the
briefly
to
Similar
blood
relationship
grades
similarly
of
the
CHD in
of
has led
Japanese-Americans103
explanations'04:
aetiology
factors
risk
may be responsible'00.
for
indicted
section
excess
why smoking,
employment
has been
the
risk
explain
account
prevalence
for
account
stress
to
advanced
to
factors
established
psychosocial
setting
the
that
rates15.
Psycho-social
terms
For
relationship
would
height
in
hypothesis
cohorts'02.
deprivation
CHD rates
mortality
often
it
have
who
migrated
others
fail
birth
between
datasets.
life.
early
between
available:
relationship
may be the
by the
supported
different
of
Asians
Asians
deprivation
to
related
in
are
job
Karasek
constructs
to
Type A
is
apply
strain
relatively
outside
the
Review
Examples
higher-level
of
learned
helplessness'09.
theory.
constructs
non-human
pathophysiologic
based
constructs:
for
social
is
drive,
developed
to
predict
CHD incidence
study
terms
in
the
to
reversal
of
higher-level
of
a population
high
with
by postulating
that
the
quality
to
2.4.7.3
than
the
Social
Several
is
contacts
have mentioned
reports
separate
factors
such
social
stress:
measures of
- which
they
believe
group
pattern:
with
the
quartile111,112,114-116.
risk
follow-up
support
frequency
low
a
this
association
of
other
buffer
individual
the
would be more generalizable
fewest
mortality
social
(In
the
or
usually
the
lowest
the
shape
study
develop
support
CHD even
however discloses
is
Gothenburg
20
and predict
CHD risk
contacts,
is
against
of social
studies
risk
model
need to
- quality
construct
these
behavioural
theoretical
have emphasized
social
CHD as a
with
The underlying
the
of
A few of
holds
independent
relationships
excess
are
disease.
that
the high-level
non-
even when they
mortality106,111-115.
proponents
was with
be diagnosed
with
is
to
factors
high
it
failed
Psychosocial
Review of the prospective
more stronglY108.
a consistent
the
appeared to
105.
factors
A
association
shown that
as smoking1061111.
supportive
psychosocial
have
and that
category
of
and social
studies
associated
original
Earlý,
syndrome
longer
CHD will
that
history
natural
networks
other
with
- was
men in California.
the
mortality"O.
chance
prospective
the
that
with
the
affect
influence
same cohort
appears
CHD rather
of
and impatience
in
observed
stud. y showed that
the
by aggressiveness,
deadlines
with
independently
of
it
this:
confirm
the
in
across
linked
explain
- characterized
a pattern
a prospective
subsequent
better
on an underlying
deficient.
summarize
of
that
to
and
simple
be directly
and to
CHD rates
preoccupation
results
not
have
support108
be generalizable
to
assumed
possible
Type A behaviour
of
competitive
likely
do not
constructs
high
social
Type A behaviour
The construct
fatal
is
of
some extent
can be explained
scores
support
2.4.7.2
It
instance,
network
to
populations,
on low-level
quality
constructs
are
pathways.
predictions
are
and depend
High-level
human and even
of
These
definitions
operational
social
constructs
in
concentrated
of
the
do
Rev i ew
between
relationship
)
reported'13.
demonstrated
Although
the
influenced
failed
to
is
association
constructs
to
necessary
to
does
This
neglected.
increased
cause
can be explained
at
This
assumed.
concept
support
ill-health
group
with
who are
in
of
social
morbidity
and mortality,
a simpler
level
to
differences
than
between
without
a
then
not
are
likely
is
and physically
that
isolation
the
most workers
the
the
contacts
social
but
same
support,
fewest
health
the
isolation,
relationships
mean that
for
If
social
and
had been
using
social
poor
necessarily
implications
study
increasing
with
networks
index
network
and social
the
has
social
a gradient114.
of
quality
not
Alameda
a subsequent
the
many individuals
contain
not
it:
explain
County
social
existence
mortality
about
in
between
the
results:
between
simply
was not
study
of
the
confirm
and mortality
relationship
mortality
decreasing
of
complex
original
construction
by the
gradient
the
dose-response
a
mortalltyl06,
index
influences
social
application
association
field
this
in
the
of
does
social
in
as argued
populations,
have
Section
1.5.7.6.
2.4.7.4
Work environment
for
More
CHD117,118.
patterns
are those
latitudel07.
been
which
In
CHD risk.
participants'
demanding was associated
after
for
matching
of
rating
with
fourfold
a
low personal
with
discretion
direction
in
the
same
were
studies
of
characteristics
exposures
of
monotonous
with
relative
infarction.
unsatisfying
necessarily
Swedish
men in
with
their
used
of
work
to
and psychologically
death
CHD
of
to
1.2
for
learn
on the
the
new things
hospital
with
are consistent
though
classify
the
Karasek's
in
as
21
psychosocial
occupational
as
rated
were
admission
associated
with
myocardial
a modest effect
relationship
model.
risks
reach significance.
Occupations
cohorts120,121,
environments,
be as specific
survey
data
occupations
around
These results
not
national
few opportunities
risks
but did
of
in 1968 and
Surveys
risk
relative
in
two cohorts
of
smoking119.
and current
low
intellectual
freedom
and
schedule
associated
Two further
as hectic
hypothesis
this
study
of Living
jobs
their
work
stressful
The relati-ve
education
have
to test
case-control
Level
that
demands and low decision
have attempted
a nested
factor
risk
as a possible
has proposed
combine excessive
Swedish men based on the national
1974,
implicated
Karasek
recently
Three studies
to
relation
long
has
Job dissatisfaction
may not
of
Review
2.4.7.5
Psychosocial
From the
most
brief
review
consistently
populations
are
CHD rates
South
British
in
between
in
South
the
in
Asians
native
British
this.
In
psychological
the
with
in
scores
British
2.4.7.6
Conclusions
low-level
applying
social
isolation
data.
It
levels
of
is
the
possible,
higher-level
than
to
high
environment,
however,
constructs
the native
to
in
South
in
which
population.
22
manual
levels
expect
Asians
in
than
do not
the
support
fewer
this
is
Psychological
migration.
to
in
those
that
possible
in
the
standard
a different
developed:
uncertainty.
factors
psychosocial
of
in South
Western
fit
do not
formulate
CHD
residents123;
similar
as
psychosocial
reported
CHD rates
developed
of
available
this
role
environment.
mostly
were originally
resolve
to
predominantly
morbidity
they
possible
the
who work
we would
course
of
which
constructs
and work
of stress
for
of
explanations
were
psychological
needed
about
is
It
that
are
studies
Pyschosocial
terms
from
setting
qualitative
immigrants
detect
on work
urban
at
selection
of
Pakistani
to
British
native
population124.
questionnaires
cultural
than
effects
fail
data
class
patterns
based
in
that
native
a social
difficult
immigrants
Indian
survey
symptoms
to be higher
The limited
the
make it
CHD mortality,
high
suggest
occupational
levels
experiencing
also
population.
a population
consistent
trades.
excess
in
of
who are
of
explaining
have even higher
and catering
morbidity
do not
London,
London,
cause
data
of
east
are
in
Asians
businessmen,
Neither
than
CHD rates
north-west
in
Britain
to
psychological
native
men in
clothing
sufficient
symptom
high
the
Bangladeshis
than
stress
of
for
South
CHD mortality,
and self-employed
mortality
workers
high
European
part
Asians
diversity
and the
who share
Gujarati
professionals
South
in
in
exposures
dissatisfaction.
Survey
The absence
explanations
instance,
Britain.
psychosocial
CHD risk
a substantial
more common in
CHD mortality,
groups
construct
If
in
population122.
gradient
For
Asians
is
and job
play
the
increased
with
to
that
appears
isolation
likely
isolation
social
it
above
social
is
in
in South Asians
associated
factors
these
factors
populations,
the
explanatory
South
Asians
Asians
based
such
on
as
epidemiological
hypotheses
are
under
Such explanations
in
greater
would
Review
have
to
specify
Asians,
such
Two such
as
new
low-level
the
effects
hypotheses,
constructs
Indian
of
have
which
of
stress
family
been
structure
of
or
proposed
informally,
association
between
South
to
specific
racism.
are
examined
here.
On the
is
and mortality
it
is
demands
to
are
family
Asian
migrants,
however,
based
ties
South
simply
an effect
in
of
irrelevant.
pathological
duties
and
responsibilities
South
the
are
low CHD rates
predict
in
and excessive
above,
constructs
supposed
available,
Asian
relationships
is
networks
CHD rates
in
as suggested
on the
social
support
high
ties
CHD rates
to
would
their
who escape
for
quality-of-support
a hypothesis
any case,
emotional
maladaptive
support
then
of
family
close
with
If
social
isolation,
social
the
associated
of
quality
an explanation
that
on individuals.
relationship
the
construct
by postulating
communities
inverse
the
related
to
possible
Asians
South
that
assumption
In
effects
of
first-generation
to
the
preceding
generation.
has been placed
Emphasis
tension
with
racial
risk
among South
to
not
instance,
racism
is
there
native
British
population
United
States.
Adverse
to
Britain
but
Indian
established
Pacific
finally
in
no other
Blacks
psychoso cial
risk
South
in
as those
such
high
for
in
to
South
Asian
CHD rates
Caribbean
the
the
with
Whites
adaptation
of
the
CHD risk.
compared
with
in
evidence
increased
first-generation
account
immigrants
Asian
compared
CHD
of
with
effects
cannot
high
the
epidemiological
associated
in
in
culture
in Afro-Caribbeans
in
communities
stressors
that
terms
that
assuming
of
to
inability
the
the
the
host
migrants
in
long-
and
factors
psychosocial
hypothesis
as an explanation
act
through
provides
for
a weak basis
a plausible
differences
23
mechanisms.
alternative
in
for
even psychosocial
responsible:
physiological
class
is
mediators
are
in disease
differences
explain
known physiological
presumably
deprivation
stress
or
host
associated
regions.
I note
rates
is
there
factors
these
the
stress
The existence
generally
to
psychosocial
against
no excess
may contribute
culture
to
directed
is
of
Britain'00.
however
doubt:
that
suggest
For
in
Asians
racism
in
role
and adaptation
institutionalized
UK is
on the
to
The early
psychosocial
CHD mortalitý-102.
A
Rev iew
follow-up
failed
study
to
the
confirm
found
and CHD risk
125
Japanese-Americans
Further
in
acculturation
studies
which
relate
independent
an earlier
in
advances
factors
psychosocial
between
relationship
cross-sectional
field
this
to
of
study
may come through
pathophysiological
mediators.
2.4.8
Genetic
inheritance
factor
Any environmental
disease
all
invoked
in South Asian
the main ethnic
and in their
descendants
population126.
This
in CHD rates
determined.
In contrast
communities
Indian
country,
descent
from the
suggesting
that
studies
compared with other
factors129.
by environmental
coronary
different
genetic
many generations
groups
ethnic
in
prevalence
factors
in the same
may be important.
have suggested
that
genetically
to be explained
is that
explanations
entirely
high diabetes
and
by
originating
populations
heart disease rates are shared
be
to
genetically
Asia,
South
supposed
are
who
regions of
dissimilar.
the
for
for
is unlikely
groups
Asians
One difficulty
than genetically
of non-insulinof the epidemiology
in South
that the high prevalence
have concluded
diabetes
longest
overseas
rather
in European populations
is strongly
groups,
between-population
case genetic
Most reviewers
determined127,128.
dependent
rates
in this
diabetes
non-insulin-dependent
in other
migrant
that
overseas
settled
sexes and
in the host
diabetes
and
CHD mortality
to diverge
and twin
Sibling
are environmentally
to both
settled
to those
to converge
has led to the view that
differences
continue
tend
In other
in those
of the
must be common to
subcontinent,
migration.
after
in the USA, CHD rates
such as Japanese
of
Indian
of the
generations
several
persist
rates
around the world
populations
groups
the high
to explain
European
Indo-European
anthropologists
of the
language
and Dravidian
(Aryan)
19th century
assumed that
found
groups,
from
in
to different
corresponded
respectively,
and southern
northern
'race'
has
underpinned
Aryan
subsequently
9races9130:
the notion of an
This
Lanka.
Sri
to present-day
Germany
Nazi
from
ideologies
racist
have
few
modern
used
by
the
which
studies
is
not supported
assumption
between
distances
groups
within
genetic
to
compare
genetics
quantitative
India
India
Using
with
alleles
the distances
of
between
the vitamin
Indians
D binding
and other
protein
24
populations131,132.
to calculate
genetic
Review
distances,
close
A similar
study
Singapore
Indians,
the
Asian
and Madras
from
Malays
groups
genetically
were
This
groups132-
found
between
South
linguistic
origins
has been exaggerated
genetic
identified.
consistently
genotype
under
high
in
risk
of
The evidence
high
mechanism
the
must
three
and distant
from
genetic
and Dravidian
both
groups
disease
(other
originate
smoking
disturbance
a possible
the
populations
of
not
Asians
course
such
transition
genotype'
in
final
the
basis
for
mean that
the
the
dietary
of
fat
intake,
were unlikely
to
explain
levels
pressure
high
explain
change.
and that
overseas,
for
to
'thrifty
a genetic
of
to
a recent
detail
more
in
that
blood
and
diabetic
exposed
this
of
considered
would
ha-ve been
has been suggested
scarcity
by environmental
Three
risk.
Fibrinogen
disturbance
a
found
of
to
haemostatic
of
for
contender
had been
cholesterol
South
for
advantage
in
diabetes
have
who
undergone
Asians
preventable
in
in-dependent
those
than
some other
hypotheses
tentative
formulated:
mechanism were
atherosclerosis.
(ii)
is
be responsible
an underlying
levels
food
of review
here
suggested
reviewed
CHD rates
strongest
non- insul
heart
The identification
South
cholesterol,
plasma
or
condition
Asians
CHD in
2.5 Conclusion
(i)
the
supposed
Aryan
of
The application
thesis.
this
coronary
generations
South
was not
condition
the
of
earlier
to
of
section
for
the
and that
for
of
affluence133.
relative
explanation
the
populations
A selective
conditions
prevalence
conditions
high
markers
hyperlipidaemia)
to
related
to
that
a common gene pool.
No specific
the
Asian
Sinhalese,
each other
that
suggests
be geneticallý131
populations
Punjabis,
similarly
to
close
difference
from
in
to
Pacific
or
allotypes
and Chinese
found
were
Asian
other
immunoglobulin
of
Asian
east
Delhi
distinct
and markedly
South
in
populations
predict
CHD in
lipoprotein
and elevated
to
an alternative
factor
and
triglyceride
the
lipid
pathway
seemed
hypothesis
of
VII
coagulant
activity
the
Northwick
Park
metabolism,
levels
25
this
activity:
causing
without
(VIIc)
Studý-134.
low HDL
elevated
plasma
Review
cholesterol,
(iii)
basis
the
on
suggested
disturbance
a
of carbohydrate
of non-insulin-dependent
of the findings
in Trinidad12.
metabolism
causing
diabetes
and increased
risk
a study
of Bangladeshis
high
prevalence
of
atherosclerosis.
To test
these
hypotheses
described
in the next
Gujaratis
in Brent
grouP60.
The results
of these studies
be discussed
together.
1985 will
section,
was undertaken29:
was simultaneously
undertaken
and other
26
in East London,
study of
a similar
Park
by the Northwick
work published
since
3. Coronary
3.1
in Bangladeshis
in East London
Introduction
Since
the survey
of Gujarati
to the
no clues
South Asians
borough
from
morbidity
the
in
average
data
Mortality
Asian
men:
Tower
Hamlets
2)23.
from
for
there
for
1979-83
north-west
mortality
in
disease
in
rate
factors
haemostatic
South
were
which
risk
in
investigate
to
in
Asians
measured
and glucose
activity
during
deaths
in
South
Asian
high
(Table
heart
by other
risk
especially
study,
earlier
in
findings
coronary
be explained
could
the
the
the
in
40 years
whether
a Muslim
whether
Britain
in South
to be estimated
group
determine
to
men compared
14
1970-7/2
women aged over
this
be replicated
not
Asian-born
recorded
Asian
first,
were:
could
South
High
Bangladesh.
show an excess of coronary
few South
and second,
population;
in
London
is made up
population
of
in
rates
in the east
region
was first
too
The objectives
London
disease
district
were
coronary
Sylhet
disease
heart
investigation
the
heart
this
London18 had yielded
where the South Asian
Muslims
coronary
in north-west
the high
the next
of Tower Hamlets,
of
Hindus
for
reasons
we undertook
predominantly
to
factors
risk
intolerance.
3.2 Methods
3.2.1
Sampling
literature93,134,135
From existing
distribution
between
difference
differences
Fieldwork
Asian
(postal
general
ethical
male
to a 20 percent
rise
coronary
heart
80 men in
detect
to
sufficient
size
disease
each ethnic
such
(Table
group
was obtained.
approval
1986.
between June 1985 and April
live
half
in the western
Most South
borough
the
of
three
of
one
practices
as the
would give
sample
be about
Hamlets
Tower
of
districts
further
of a
chosen
to
was undertaken
residents
in
A targ et
was estimated
Local
that
two populations
was estimated.
mortality
6).
of each risk
factor
in the
difference
of
the size
with
El and E2) and are registered
The lists
in this area.
of these three
two practices
sampling
with
frame
native
mostly
(Figure
1).
British
A sample
of
from
excluding
practice,
1949
each
chosen
1920 and
was
homeless
those
with mental
for
the
and
hostels
single
27
and
practices
patients
were
born
men
between
residents
handicap,
in
recent
London
East
illness,
psychiatric
the
minimize
proportion
1981 or
since
Bangladesh
approximately
practices
year
birth
of
early
stages
South
Asian
a means of
chosen
of
between
In
Bangladeshi
the
practice
whether
subject
was sent
557 subjects
the
addresses
in
to
hospital.
take
it
and
part
interviewed
Respondents
were
demographic
items,
invited
to
smoking,
the
attend
measurement
blood
and
interviewed
in
without
to
fast
before
giving
size
diabetes
of
overnight
before
the
time
a final
was reached
respondents
is
of
their
booking.
stage
response
for
men but
shown
in
to
Table
the
of
last
the
as
women was
four
months
of
included
at
by age,
this
sex and
Most
not
9.
for
There
28
were
history,
blood
for
8).
and
pressure
were
Those
English.
drink
it
drink
attended
66% (Table
women.
to
were
including
75g
glucose
a
then
unfit
be resident.
subjects
subjects
253 participants
and one was
and medical
in
other
interviews
to
College
Of
medically
12.308
Bangladeshi
appointment
of
invitation.
a questionnaire
given
rate
ascertain
2 had died
believed
those
non-Asian
were
to
3 were
contact
Medical
Hospital
participate.
173 had moved to
consumption
alcohol
and most
history
a
of
visited
unknown,
home with
sampling.
Bengali
to
unsatisfactory
a further
58 refused,
81% from
at
London
because
part:
them to
were
issue
or
possible
of
rate
the
who were married
stratification
sent,
district
was not
In
age range.
1940 were
inviting
were
381 remaining,
a response
completed:
a letter
was correct
Of the
by
was stratified
was random.
and to
outside
either
the
in
before
was received
the
In
was made up predominantly
and the
whom letters
to
The
ensure
A sample
practices
no reply
which
sample
proved
women.
the
exclusions
procedure
address
Asian
to
respondents.
take
this
whose list
sampling
from
the
the
to
consulted
resident.
to
35 years
To
returning
be still
the
invited
of
before
across
women born
only
from
Each eligible
Addresses
four
one practice
residents,
Apart
stage.
from
had
who
not
and non-Asian
and wives
South
those
adjusted
registers
also
husbands
older
independently
fieldwork.
Asian
women aged over
were
advanced
to
were
disease.
other
immunization
practice
of
study,
sampling
for
an even distribution
respondents
difference
age
addresses,
had age-sex
give
the
of
or
as unlikely
each
numbers
which
to
wrong
also,
from
equal
malignancy
attended
excluded
sampled
three
of
last
who
were
proportions
terminal
Study
for
and asked
11 hours
examination,
The target
Age distribution
few Bangladeshi
of
sample
the
women aged
East
45 or older
than
younger
London
Study
54: a result
than
demographic
the unusual
of
of the population
in the later
and the restriction
fieldwork
of the Bangladeshi
sample to women born before
structure
stages
the
1940.
Blood
pressure
was measured
after
subjects
had been
measurements
sample
load
the
3.2.2
Laboratory
time
reported
Fibrinogen
method.
by a gravimetric
determination
Brozovic
et
in liquid
blood
using
fresh
in
citrated
plasma
cold
by a manual
plasma
for
samples
were
factor
thawed at 37*C and
Factor
activation.
method
based
plasma
on that
in
V11
of
doubling
brain
CaC12 and 1 in 32 rabbit
from
prepared
oxalated
plasma was
deficient
Factor-VII
Plasma
analyser.
nitrogen,
to avoid
and in whole
specimens
Immuno AG 100% reference
using
a1137
VC
for up to 48
at
by heparin-manganese
Citrated
method136.
was assayed
thromboplastin.
bovine
2 hours
specimen by the glucose
oxalate
from 1/10 to 1/360,0.025M
dilutions
to
was kept
concentrations
were stored
activity
coagulant
who had been
those
it.
in a centrifugal
at room temperature
maintained
venous
as possible
in these
cholesterol
fluoride
was measured on a
measured
VII
as nearly
all
A single
in
was separated
plasma was measured enzymatically
oxidase
(PM).
determinations
lipoprotein
precipitation;
glucose
minutes:
253 attenders:
the
consuming
cholesterol
High-density
chloride
five
observer
was timed
of
for
sphygmomanometer
analyses
EDTA plasma for
hours.
this
a random-zero
quietly
247
on
of
was obtained
after
sitting
with
by
made
a single
were
gi, ven a glucose
twice
of
Lechnes
the
and
of
method
of
a modification137
Deutsch138.
Fatty
of
in
the
seen
last
thin-layer
silica
is
not
to Folch's
phosphatidyl
ester,
were the
internal
gel
using
transesterified
separated
programming)
(Pye
Unicam
Lipids
Lipid
standards.
under
esters
were prepared
the conditions
204 Gas Chromatograph
on an open
packed
glass
classes
Sphingomyelin
column
29
those
from 1
of
(Sigma
by
were separated
directlý,
is excluded
used140.
with
of
derivatives
and triacylglycerol
choline
University
were extracted
Heptadecanoin
method139.
sodium methoxide.
by the
on a random subsample
fieldwork.
Methyl
chromatography.
was measured
Unit
Research
months of
six
ml plasma according
Chemicals)
plasma
Cardiovascular
Edinburgh
cholesterol
of
composition
acid
lipids
Methyl
on
since
esters
it
were
temperature
(4 mm ID x 1.5M)
using
10%
East
SP2330 (Supelco)
time
retention
Supelco)
layer
with
(Tribal
different
lipid
measurements
II,
Trevector).
the
classes
determination
of
from
2.0
acids
levels
of
study
samples.
variation
of
3.6% and from
to
in
3.2.3 Statistical
analyses
.
All those of South Asian origin
to as Bangladeshi
and all other
0.6
stored
the
repeated
5.0% for
to
linoleic
and percent
In
the
acid
serum were measured
by a double
consistent
Alcohol
mortality14,23.
participants,
7)142.
Index
Participants
diabetic
local
are excluded
is
morbidity
defined
were
in
the General
used
as diabetic
from the data
if
and
according
Household
Survey
had been
they
was 11 mmol/1 or
plasma glucose
post-load
this
group:
of
categories
were classified
or their
Known diabetics
to the non-Asian
consumption
to the Quantity-Frequency
in the group referred
including
three Afro-
used in analyses
the groupings
with
diagnosed
have been included
have been assigned
Caribbeans,
more.
(Sigma and
mixtures
techniquel4l.
antibody
(Table
the
with
coefficients
fatty
total
Insulin
respectively.
ester
thinand silver
nitrate
by a computing
were integrated
A plasma pool was used for quality
coincidentally
ranged
methyl
was based on
by mass spectrometry
Peak areas
and analysed
Identification
phase.
to standard
respect
chromatography.
control
Study
as stationary
and confirmed
integrator
London
for
plasma insulin
and
In
since they did not fast or receive a glucose load.
between ethnic groups, data have been analysed
for differences
testing
least-squares
linear
for
model. Age was
separately
men and women using a
levels
three
to the
treated
corresponding
with
variable
as a categoric
triglycerides
age groups
predicted
in the model when all
Other
values.
were treated
covariates
as continuous
were log-transformed
for the
to SI units
age group,
small
55-69
years.
and
35-44,45-54
data
for
for
Adjusted
are held
covariates
means are the values
at their
mean
insulin
index,
body
triglycerides
and
mass
insulin
Triglyceride
and
values
variables.
these
tabulations.
analyses
In figures
women are given
numbers of Bangladeshi
but have been transformed
for
only
and tables
means by
two age bands because of
women at the extremes
30
giving
back
of the age range.
-
London
East
Study
3.3 Results
,
3.3.1 Questionnaires
,
89 percent of Bangladeshi
to social
III
classes
men and 80 percent
manual or IV by the Registrar-General's
classification143.17
of Bangladeshi
en,
full-time
received
percent
Bangladeshi
women had never
Bangladeshi
men were married
them in the UK.
with
non-Asian
cigarette
53 percent
smokers,
daily
93 percent
from alcohol
abstainers
2 percent
living
wives
men and 20 percent
of
were Muslim
Although
most Bangladeshi
men were
of Bangladeshi
men smoked more than
of non-Asian men (Table
34 percent
Bangladeshi
men and all
(Table
had their
of
of South Asians
compared with
of Bangladeshi
98 percent
education.
two-thirds
of
97 percent
23 percent
only
men and 64 percent
of Bangladeshi
were from Sylhet.
15 cigarettes
10).
but only
men were unemployed.
and 91 percent
men belonged
of non-Asian
11).
74 percent
women were
of Bangladeshi
men but
of Bangladeshi
women attended the mosque at least once a
Bangladeshi
from social networks
week.
women appeared to be isolated
93 percent stated that they had no social
their
outside
own families:
only
contact
with
3.3.2
non-Asians.
of
this
low
The most
high-density
lipoprotein
variables
2)
measured
for
was true
16),
and serum
of
acids
the
plasma
24).
body
Bangladeshis
than
were
w3 series
use of
between
fish
ethnic
in
Bangladeshis
in
3).
ratio
non-Asians
Bangladeshi
in
2),
plasma
in
cooking.
VII
coagulant
31
lipids
were
in
triglycerides
than
in
the
of
pressure
(Figure
fatty
essential
and the
were
of
lower
in
fatty
acids
consistent
levels
activity
in
non-Asians:
blood
acid)
Levels
of
than
triglycerides
Bangladeshis,
Fibrinogen
half
age and several
of
lipids
than
about
Bangladeshis
plasma
20).
for
plasma
systolic
linoleic
(Table
higher
factor
and
15),
The proportion
(predominantly
slightly
groups
(Table
(Figure
(Figure
w6 series
in
lower
in
mass index
Bangladeshis
The percentage
non-Asians.
with
between
cholesterol
insulin
in
and high
cholesterol
marked
in
differences
striking
2 and 3)
Figures
accounted
The relationship
less
was
polý, unsaturated/saturated
the
index
mass
as HDL was also
cholesterol
(Table
non-Asians
(Table
body
men and women compared
plasma
this
for
Adjusting
12-27,
10 mmHg lower
were
pressures
week.
(Tables
findings
difference.
Bangladeshi
total
blood
systolic
in
the
in an average
laboratory
and
Clinical
Average
friend
a close
did
not
(VIIc)
with
differ
was
of
the
East
lower
markedly
VIIc
levels
analysis
correlated
higher
times
between
in
not
men (Tables
non-Asian
plasma
did
but
cholesterol
fully
explain
than
twice
as high
the
18 and 19).
in
a regression
difference
ethnic
persists
Asians
(Table
within
each
ethnic
levels
were
correlated
high-density
Serum insulin
was also
higher
levels
were
(Tables
group
with
for
correlated
Insulin
cholesterol:
between
in
and triglyceride
difference
Bangladeshis
insulin
23).
body mass index
correlated
the
some of
This
in non-
than
with
and inversely
each other
differences
load were
a glucose
in Bangladeshis
25 and 26).
cholesterol
by the
after
(Figure 2).
as in non-Asians
for time of sampling (Table
ratio
lipoprotein
accounted
levels
controlling
Insulin
lipoprotein
men and women:
in non-Asians
(Table 21).
Two-thirds
diagnosed:
this proportion
did not differ
after
22).
in Bangladeshi
rate
in Bangladeshis
The insulin/glucose
density
the
groups.
ethnic
20 percent
exceeded
were already
difference
with
in
high-
and non-Asians
was
and triglycerides.
Discussion
3.4.1
This
South
Cholesterol,
study
in
to
linearly
of
Asian
plasma
total
measurements
ratio
in
Bangladeshis.
Bangladeshis
in
in
made
If
average
than
in
the
this
study,
that
values
non-Asians,
of
from
it
of
value
for
a
and
holds
(2S-P)
the
of
the
saturated
both
in
be
lower
must
low
relatively
no direct
P/S ratios
and the
follows
32
Asian
dietary
low polyunsaturated/saturated
dietary
(2S-P)
South
in Brent60.
Keys equation
Though
the
cholesterol.
S and P are
where
account
Bangladeshis.
implies
lipids
the
to
non-Asians
cholesterol
were
If
populations,
in
between
among
serum cholesterol
average
obtained
energy
plasma
Gujaratis
of
(2S-P),
respectively.
than
plasma
the
disease
by elevated
study
to
dietary
and European
Bangladeshis
the
intakes
acid
heart
serum cholesterol
average
in
fatty
coronary
explained
not
related
total
fats
polyunsturated
in
in
of
excess
Keys equation58,
the
is
percentages
South
is
Britain
men was found
and European
population
the
that
difference
According
smoking and dietary
clotting,
confirms
Asians
A similar
in
with
cholesterol
of diabetes
of diabetics
3.4
than
levels.
Prevalence
about
Bangladeshi
were
plasma
in VIIc
three
in
London Study
that
are
ratio
also
low
P/S are
average
dietary
in
lower
LIýCnL-)'L9 ,
London Study
tasL
fat
saturated
high
relatively
years
that
These conclusions
Total
fat
this
group
have biased
the sample;
disease
factor
this
rates
implicated
strongly
VIIc:
they
were
levels
Europeans
in
Gujaratis
and Europeans,
European
low
and a
high
cannot
Asian
3.4.2
to
and markedly
varables
fibrinogen
in
techniques
between
and
in
and in
Brent6o
South
Asians
Bangladeshi
and
in
was similar
activity
lower
as
high
the
explain
CHD are
differ
not
was estimated
The haemostatic
for
VIIc
men than
of
smokers
Asian
in
very
dietary
coronary
explain
w6 series
in
levels
high
in
men recorded
the
of
plasma
Hindus
disease
the
national
for
insulin
rate
of
levels
in
lipids
of
ratio
pattern
Bangladeshis
and in
a
contrast
While
includes
smoking
to
may contribute
which
the
polyunsaturated
men in east
Bangladeshi
mortality
of
London.
north-west
from
London18
north-west
The low
polyunsaturated/saturated
heart
men differs
among Bangladeshi
sample33.
the
London,
they
other
South
groups.
Evidence
The associations
between
hyperinsulinaemia
following
low high-density
lipoprotein
these
did
which may
individuals.
Asians.
by similar
representative
acids
the
of
rates
nationally
with
intake
fail
factors
Factor
study.
proportion
smoking
fatty
either
South
in
men.
The high
low
measured
to speak English
sedentary
also
as risk
Fibrinogen
study.
for
high
There are
findings:
the men
of these
ability
activity
in
based
report,
on
144
men in east London
to be unusually
mean energy
level
based on plasma lipid
population.
the validity
and their
haemostatic
heart
British
of their
an unlikely
in
Differences
most
doubting
diet.
traditional
of an earlier
were reported
the native
on the basis
3400 kcal/day,
coronary
and P/S ratios
for
reasons
a less
12 Bangladeshi
of
The
men aged under 45
of Bangladeshis,
to those
opposite
compared with
were selected
of Bangladeshi
the diets
of the diets
intakes
in Bangladeshis.
may be following
group
about
recording
several
this
directly
are
analyses,
be lower
plasma cholesterol
suggests
one-day
(S) must also
intake
factors
resistance
in
Bangladeshis
diabetes,
non-insulin-dependent
a glucose
are manifestations
load,
high
plasma triglyceride
in Bangladeshis
cholesterol
of a single
33
metabolic
suggest
disturbance.
and
that
These
associations
hyperinsulinaemia
poorly
have
also
from
One hypothesis
demonstration
measurements
Bangladeshis
levels
in
index,
which
Bangladeshis
in
were
for
average
size150.
closely
related
to
than
3.4.3
Similar
findings
of
similar
high
plasma
East
been
also
for
Pakistan
in body mass
may be
in
levels
are
in
measured
more
this
populations
of
and low HDL cholesterol
than
in South
pattern
diabetes
other
in
diabetes,
non-insulin-dependent
a general
in
1.3
the
this
in
Asians
is
sample
small
South
overseas
Asian
percent
in
reported
a
196477.
A-II
apoplipoprotein
pre-employment
were
0.1
but
men
studies
30 percent
were
were
lower
medical
mmol/l
the
lower
levels
ratio
in
Indian
South
than
In
Asian
of HDL to total
34
compared
and the
United
pattern.
In
higher
were
Asians
in
not
Indians
in
(mainly
cholesterol
in
than
In
and
Chinese
Brent,
with
Fiji
measured3l.
A-I
apolipoprotein
screening152.
in
South
Trinidad12
HDL cholesterol,
of
in
show a similar
HDL cholesterol
plasma
levels
in
reported
levels
triglyceride
European
of
higher
much
More recent
Melanesians:
levels
insulin
different
groups
not
Asian
and low HDL cholesterol
have
States70,71.
for
in
triglycerides
Singapore
high
and HDL cholesterol
Triglycerides
Europeans
prevalence
resistance
the
insulin
triglyceride
prevalence
reported
but
survey
parallel
diabetes
index
this
deposition,
of
be part
to
populations13,81,86
comparable
the
by differences
between
South
other
prevalence
figure
the
fat
steady-state
but
Although
of
lipase149
insulin
that
populations
high
The 22 percent
to
infer
of
formation
requires
direction,
other
the
and high
explained
adiposity
body
by hepatic
levels.
opposite
in
appears
overseas.
plasma
not
In
removed
ratio
still
transfer
in
levels
is
that
results
resistance
to
and this
mass indexl5l.
hyperinsulinaemia,
High
were
upper
body
to
The combination
Bangladeshis
insulin
comparing
increased
and insulin
of
the
frame
study,
insulin
populations145-147:
synthesisl45,148
that
rapidly
reasonable
elevation
inappropriate
is
disposal
make it
the
is
insulin/glucose
elevated
other
by a mechanism
HDL particles
of
glucose
of
of
underlies
levels
HDL2 which
Definitive
in
reported
VLDL triglyceride
VLDL to
triglyceride-rich
findings
been
HDL cholesterol
understood72.
triglyceride
in
London Study
increases
lower
to
appears
East
men attending
HDL cholesterol
Gujarati)
did
than
not differ
in
East
between
significantly
higher
in
contrast
South
In the study
groups:
Asian
interval
It
is
than
in
in
other
the
the
for
therefore
were
not
in
study,
of
the
puzzling
(-0.15
to
of
is
mmol/1)
less
than
by chance
entirely
0.3
about
95% confidence
the
since
+0.15
Asian
sex difference
usual
is
in high-density
or the non-Asian
South
other
be explained
to
unlikely
Brent
the Asian
in
reported
difference
the
in either
group
the
was no sex difference
absence
non-Asian
men in
levels
populations.
levels
has been
Triglycerlde
European
cholesterol
this
measurement
groups60.
here there
populations18,43,52
in
Study
reported
while
mmol/l
these
findings
with
lipoprotein
London
or
this.
random
error.
I nsul in
In
South
insulin
Africa,
students'53,
levels
children154
European
origin.
compared
with
and nurses'55
high
Similarly
for
and
West London156
Indian
of
those
in
outpatients
DC15-1.
coronary heart disease rates
high-fat
diet,
Although the evidence relating
plasma cholesterol,
a
heart
disease
hypertension
the
to
of
occurrence
coronary
and smoking
3.4.4
Possible
strong,
Asians
high
do not
factors
these
account
for
the high
well-established
any attempt at explanation
factors.
Pathological
risk
evidence
the view
overseas:
insulin,
support
is
cholesterol
found
to
be an independent
it
association
risk
may also
lipoprotein
of
of
be mediated
these
of
mechanism of
high
overseaS29:
insulin
less
invoke
CHD in
plasma
three
effects
plasma
lipoprotein
insulin
either
directly
Some of
metabolism'58.
has been
prospective
or
the
diabetes
and non-insulin-dependent
with
CHD
by hyperinsulinaemia.
findings
rates
of
in South
rates
of elevated
Elevated
atherogenic
hypertension
On the basis
Asians
predictor
is
and epidemiological
high-density
low
and
may exert
disturbances
disease
must therefore
the combination
atherogenic64,158,159.
studies160-162:
through
that
triglycerides,
elevated
of
Indians
in
hospital
in
in
than
levels
in Washington,
vegetarians
for
mechanism
for
were higher
origin
insulin
post-load
have been reported
Europeans
load
a glucose
after
we suggested
of coronary
resistance
heart
a unitary
disease
diabetes
and
be
responsible
may
35
hypothesis
for
for
the
in South
East London Study
hyperinsulinaemia,
high
a
prevalence
pattern
effect
might
of
lipoprotein
to
reduce
exercise,
disease
of
lead
insulin
in
disturbances
secondary
insulin
accelerated
upon
the
If
resistance,
most
in South Asians:
atherogenesis
arterial
metabolism.
wall
or
the
hypothesis
such
as weight
effective
this
lipoprotein
diabetes.
non-insulin-dependent
to
be
the
may
of
means of
is considered
36
This
as a result
correct
a direct
of
disturbances
then
measures
and increased
reduction
preventing
further
and
metabolic
through
either
is
metabolism
coronary
in Sections
heart
4 and 7.
4. Discussion
The account
section
the
of
interpretation
This
methods
the
of
raise
discusses
in the East London Study
East
London
material
However
results.
issues
some wider
section
the
of
describing
on
concentrated
project
issues
of methodological
these
problems
encountered
to
the
planning
identify
themselves
cultural
characteristics.
as belonging
differences,
provide
hypotheses.
Apart
identifying
Migrant
of
the
work.
for
for
are
have
fundamental
reported
in
different
their
death
the
elucidate
differences:
demonstrated
of
rates
of
thus
studies
that
differences
in those
The post-war
influx
of
environment
to
these
risk
later
at
Britain
37
and
to age at
be
is 'set'
can
sclerosis
presents
have
States
have been
before
age 15
has been inferred
ages166:
in
childhood.
of exposures
to
rates
than genetic
rather
it
of
to
in cancer
from Europe to South Africa
is a consequence
immigrants
disease
international
countries
of multiple
rates
a result
can help
rates according
life
later
in
disease
of
who migrated
of
of
disease
low rates
low
to the United
are of environmental
who migrated
those
compared with
that the disease
countries
and Italian
just
Comparison
origin
By examining
in disease
the
that
and not
real
between these
rates
For instance,
determined.
view
of Japanese migrants
the age at which
migration
their
contribution
1126,164,165.
are
first-generation
French
of
the
practice15.
in
disease
supports
origin
certification
heart
ischaemic
and Wales
services.
of
of
mortality
and
groups,
differences
international
class
of social
high-risk
Studies
and
aetiological
studies
purpose,
uses163.
like
and test
and planning
low coronary
the
country
with
migrants
in health,
defining
intervention,
specific
England
to
for
useful
also
for
instance,
immigrants
to which people
of shared physical
differences
can be used to validate
migrants
reported
in
minorities?
a model in which to generate
pathways
studies
basis
the
on
Ethnic
from this
variation
cultural
origi,
the
future
possibilities
4.1 Why study the health of of migrants and ethnic
The term 'ethnic'
is used here to denote groupings
in
to
them.
resolving
rates:
previous
relevant
and the
problems
the
directly
the
relevant
in
Study
unrivalled
Discussion
for
opportunities
have large
immigrant
opportunities
it
as their
likely
are
rates
majority
first-generation
to study
Between these
offspring.
to change markedly.
lack
migrants
as well
disease
two generations
The young adults
formed
the
who
to the UK in the
of migrants
1950s and 60s are now entering
which make up the leading causes of death
age when the conditions
middle
is hampered by the
which have such coverage do not
To take full
advantage of these
communities.
British-born
in the
groups
the most disadvantaged
covering
countries
is necessary
different
of
such research
service
Scandinavian
while
the health
States
health
of a comprehensive
groups,
into
research
In the United
population.
of methodology
become common.
Accurate
and meaningful
to
epidemiological
It
is,
for
health
instance,
in
denominators
perinatal
data
denominator.
birth
of
heads
Force
the
for
Environment's
instance
'white'
as either
people
for
the
enough
to
or
one of
OPCS Labour
sample
the
for
giving
on country
of
the
of
who in
'white'167.
as
1981 Census
the
1991 Census,
the
'New
of
and Maltese
in
origin
British
were
which
have devised
population
'racial
by age at
of
the
individuals
A similar
these
their
classifies
Department
groups'.
breakdown
38
the
Sur-vey asks
None of
Survey.
Survey
Household
whereas
and Housing
seven
accurate
in
only
be a measure
themselves
'coloured'
Force
to
describe
OPCS General
Dwelling
National
themselves
assign
of
surveys
the
Without
awaited.
are
question,
value
a built-in
based
Cypriots
for
direct
of
statistics
includes
study
a pilot
of
intended
on ethnic
a question
an ethnic
own systems:
normally
results
government
it
though
Survey
include
to
abandoned:
included
of
on
to OPCS's category
origin'
is
This
statistics
also
Census
relate
(NCWP) ethnic
household.
population
Labour
area
and Pakistan
9non-white'
Attempts
small
to diabetes
from
rates
published
level
is
a local
of
be compiled:
calculate
only
to
medicine.
discrimination.
cannot
to
possible
at
identifying
community
related
group
fundamental
are
performance
Access
by ethnic
in
the
the
origin.
data
of
deaths
or
statistics
At present
Commonwealth
large
it
breakdowns
ethnic
used
is
practice
evaluate
ethnic
these
the
strokes
communities
minority
Census
to
and health
employment
ethnic
other
for
standardizing
housing,
the
difficult
preventing
health
collected
and to
research
service
without
to
routinely
system
surveys
small
to
use a
area
le,. -el.
is
Discussion
The construction
the Census,
of a standard
death
of considerable
from
which
were likely
possible
further
studies
high
This
causes.
in the social
measurement
of
long-term
is scarce.
It
is difficult
direct
to
so as
emphasis on
in cardiovascular
adopted
causal
of possible
where study
is excluded.
environment
than
rather
in South Asians
CHD rates
factors
was to identify
The purpose
to the point
sometimes
lead
a clear
and mortality,
has
been
widely
mechanisms
epidemiology,
would be
and physiological
metabolic
CHD incidence
the underlying
of
pathophysiologic
factors
to happen without
causes directly.
mechanisms for
Service
Health
in
ethnicity
in ev)idemiolog
on measuring
to predict
to study
recording
professionals.
measurements
concentrated
attempting
is unlikely
and other
4.2 Uses of metabolic
study
and the National
this
value:
for
classification
registration
researchers
This
of methodology
One reason
is that
diet
such as
the
is
exposures
diet
between
CHD
the
difficult.
The understanding
rests
and
relation
of
fat
intake
dietary
hypothetical
causes elevated
causal chain:
OD a
for
this
disease.
Direct
the
evidence
which causes
plasma cholesterol
CHD within
is of similar
power
statistical
low unless
there
between
CHD rates
evidence
observational
evidence
We considered
be too
obtain
weighed
resources
4.3 Choice
than
for
the
diet
low
literacy
or
records
intake
to
this
of
CHD provide
but
household
food
epidemiology.
decided
have made it
would
that
and the
cardiovascular
rate
variation
explain
demonstration
study
risk
is
population
predicts
cholesterol
as part
were available
of study
design
A case-control
Asians
central
survey
or
cholesterol,
dogma of
disease
and
diet
the
experimental
plasma
plasma
this
diet
a
difficult:
the
increases
that
fat
dietary
populations,
fat
dietary
increasing
of
between
intake
fat
between
measurements
repeated
are
of
an association
The ability
heterogeneous.
indirect
to
dietary
and
between measurements on
to the variation
in consequence the
occasions:
order
detect
between diet
an association
variation
different
on
the same individual
in
to detect
the
populations:
individuals
is
environmental
inventories
it
would
difficult
without
to
more
to us.
design
for
the aetiology
investigating
at an early
stage
was considered
it would have answered
First,
reasons.
39
but
eventually
in
South
CHD
of
for
two
rejected,
the wrong question.
We are
Discussion
seeking
to
whereas
case-control
associated
in
study
easily
or
samples,
the
which
are
and the
risk
but
results
the
dietary
of
of
question
chosen
was the
for
reasons
of
reason
only
oral
One
fat
subcutaneous
to
assess
fatty
acids
onset,
design
rates.
Study,
designed
was considered
deficiency
that
of
in
CHD risk
excess
of
randomly
to
possible
of
and low
can
of
variables
in
differences
then
British
established
this
in
possible
based
between
the
samples
men
the
of
two cities,
of
insulin
lipoprotein
resistance,
it
was
levels
on serum cholesterol
disturbances
acids,
type
of
factors
study
is
risk
factors
that
is
two populations
to
and
metabolism,
short
stature,
are
for
coronary
likely
heart
40
to
the
between
in
exceptional
of
any comparison
which
Comparisons
be attributed.
population
risk
populations
fatty
each of
of
Edinburgh-Stockholm
By comparing
small
relatively
different
fitness.
physical
of
in
study
differences
the
rates169.
an explanation
essential
for
reasons
new ones:
by the
the
about
having
two populations
out
The design
a correlational
was provided
CHD mortality
the
several
One limitation
this
factors
risk
reject
suggest
deficiency
for
made it
study
hypotheses
test
Asians:
between
investigate
from
chosen
South
levels
A model
distributions
in
rate
factor
to
to
cohort
had been done.
work
one available
in
Sweden
and
Scotland
and to
high
or
cross-sectional
more preliminary
simplest
the
disease
native
as use of
the
this
epidemiology
suggested
explain
and past
For
essential
This
to
symptoms
recent
of
we
diet,
as genotype.
of
intake
London'8
exposures
bias.
composition
infarction168.
a large
until
risk
comparing
rates
such
such
dietary
past
of
from
by disease
affected
the
cardiovascular
of
was unlikely
mounting
the
number
onset
exposures
measurement
factors
Asians.
The cost
of
past
in
populations
measurements,
free
a manner
north-west
acid
by the
been used
myocardial
linoleic
South
not
metabolic
characteristics
the
from
Second,
affected
between
relationship
populations.
- are
stable
has been
investigating
pressure,
in
between
for
used
blood
quantifiable
contraceptives
innovation
within
have
studies
methodology
in CHD rates
are
be assessed
cannot
case-control
to
-
factors
psychosocial
exposure
methods
disease
with
interested
are
difference
the
explain
of
that
disease
numerous
uncover
in disease
difference
South
several
large
a
Asians
of
- smoking,
and the
the
plasma
u1scussion
blood
cholesterol,
direction
opposite
and haemostatic
pressure
to
of methodology
difference
the
CHD rates.
in
break
the confounding
of these factors
isolate
for study whatever risk factors
Europeans.
fallacy':
limitation
false
inference
the
level
population
suicide
rates
necessarily
more
Another
likely
factors
within
to
suicide.
is
when
therefore
4.4 Problems
This
study
factors
for
fieldwork
under
fairly
differ
to
incomes
the
between
were
risk
populations
an explanatory
role.
learnt
problems:
sampling
frame,
response
rate,
tension
of racial
deprivation
social
and an adequate
conditions
not
well
use of an appropriate
from the community
acceptance
national
would
higher
with
hypothesizing
a number of special
population,
instance,
are
found
are
between
epidemiology
populations
thall
at the
associations
cardiovascular
in East London and lessons
the study
conducting
In
some basis
presented
affecting
gaining
such
those
country
CHD within
predict
characterized:
each
and to
'ecological
of
for
capita,
to
in South Asians
An association
per
is
exposures,
that
assumption
income
mean that
commit
other
are higher
individuals.
to
and national
which
there
apply
with
in the
The effect
is the possibility
that
differ
-
activity
and
in an inner-city
area.
4.4.1
The Bangladeshi
Men from the Sylhet
British
in Tower Hamlets
community
of East Pakistan
region
began
to settle
and
vessels
were recruited
as seamen on
in England in the mid-1950s.
In
found work in the catering
From the mid 1960s they began to bring
trade
London they
Britain:
control
this
Bengali
for
a Sylheti
are not
Bangladeshis
minorities
a recent
metropolitan
delayed
often
is sufficiently
dialect
speaker
form.
has no written
identified
recent
arrival
country,
different
from
understanding
in
Most Bangladeshis
in any language.
of all
they
the main ethnic
face have been reviewed
from the House of Commons Committee
report
by immigration
to have difficulty
disadvantaged
the
most
are
in Britain:
the difficulties
The Committee
problems:
literate
and it
their
continuing,
still
The Sylheti
interpreter
a Bengali
Britain
process
procedures.
standard
is
and garment manufacture.
families
to join them in
three
from
underlying
the
English,
poor command of
41
on Home Affairs170.
Bangladeshis'
the
causes of
peasant
rural
in
society
of
Sy1het
and discrimination.
to
a
It
Discussion
of
noted the consequent restriction
housing
scale
population,
has fomented
scarce
a complete
population
base
at
the
to
E2,
western
limit
the
likely
to
leave
for
the
remained
in
be less
the
in
At
of
other
possible.
to
necessary
record
that
in
sample
and therefore
frequently
was adopted.
folder
a
From each
health
of
frame
would
homes it
fieldwork
British
and which
residents
by immigrants
than
in
the
are
those
who
sample
were
few
with
colonization
beginning
El and
lies
population
the
was
districts
healthy
has a stable
the
with
hospital
British
have
distances
postal
inhabited
and
plasma
a site
Native
native
this
of
few
a
and only
this
study
a manual
was not
biased
had thicker
row of
from
sampling
in
those
towards
envelopes,
follows:
as
42
in
in
of
each
digit
two of
procedure
cramped
under
to
GP, subjects
was a source
registers
envelopes
the
can be excluded
it
In
advantages.
an approach
register,
problems
one practice
was selected
has several
invitation
age-sex
of
conduct
cabinets,
the
the
and less
population
In
The absence
difficulties.
at
in
which
just
was
practitioners'
because
is
in
lists
a near-complete
follow-up
and
cabinet
the
Asians
sample.
general
ineligible
ensure
of
South
and participants'
resident
the
of
by
be
a personal
can
made
subjects
different
However
To minimize
active
professionals
the
samples
population.
which
time
sampling
borough.
predominantly
Wapping,
by high-income
is
has
stock,
of
measurement
blood
those
Asian
Most
the
for
use
borough
ghettos
suburbs.
non-Europeans.
it
South
ideal
the
of
Hospital
economically
resident
The use of
Bengali
hatred.
racial
facilities.
to
the
of
of
in
up
the
between
on comparison
the
the
London
sample
half
most
to
taking
laboratory
decided
Hamlets
recommended
to
the
have
who
the
especially
of
Competition
rested
register
access
between
contains
study
Tower
necessitated
immediate
the
in
we were
fibrinogen
the
of
resident
technique
poor
frame
validity
non-Asians
made it
housing
housing
the
theory
the
of
for
Since
turned
growth
problem.
Sampling
area
neglect
Hamlets
rapid
housing
4.4.2
however
the
with
and the
an exceptional
communities
the
In Tower
borough
the
compounded
created
been
to
migration
of employment opportunities,
difficulties.
and educational
of
methodology
advance,
serious
the
practices
from
directly
To
conditions.
who consulted
a two-stage
drawer
of
procedure
the
(m) was selected
filing
from
a
Discussion
of methodology
random number table,
the distance
(m/10 x length of drawer)
was measured
from the front
of the drawer, and the envelope at this point lifted.
The next digit
(n) between 5 and 9 was
from the random number
selected
table and a further
n envelopes were counted from the lifted
envelope
towards
the back of the cabinet,
from this
This
point
between
practices
check
Wapping,
to correct
fewer
no longer
in
the
borough's
share
homeless
to
to
of
or
the
excluded:
had placed
that
generally
mobile
to
In this
householders
most were
those
record
in
to
necessary
envelope.
practice
records
helped
postcodes
and to exclude
study
suburbs
in
other
some
flats
of
received
extent
since
1982
were
that
letter
of
the Post Office
would no longer
by refuse.
be
Sending
would have been one way of ensuring
to those
in other
language
the
immunization
letters
and letters
surveys
Extended
After
the
of the stairwells
delivery
of
addresses.
we discovered
residents
state
London.
consulted
incorrect
that
chaotic
absence.
and typhoid
had not
they
movement of
and when subsequently
who had not
of
of
Bangladeshi
three
parts
for
cholera
proportion
and postmen might
two or
reason
subjects
of
and the
as sub-tenants
delivered
were
the
by the
hotels
to inform
future
has been exacerbated
common for
that
by recorded
in
inaccuracy
another
the
but
the
the
was for
stated
letters
were returned:
this.
of addresses
because of obstruction
invitations
all
in
were
reduced
notices
delivered
proved
add full
to
women.
Even in
clinical
recording
flat
In some blocks
invitation.
it
addresses
directories
is
be placed
Many respondents
out
it
attendance
this
of
though
born.
the
against
sample
Bangladeshi
birth
registers
one-third
became clear,
last
were
Hamlets
a single
Bangladesh
problem
whose
are
housing:
to
visits
they
population
families
to
which
postcode
Tower
British
native
in
the
stratify
existed.
records
the
of
age-sex
than
populations
address
dates
register
in the
mistakes
Inner-city
in the row
subject
when sampling
their
year
the
Use of
correct.
which
in
address
to
of
had compiled
which
Outside
the
was difficult
especially
uncertain
least
at
each
were
were
of
and it
age groups,
Many subjects
certain
eligible
onwards was chosen.
was time-consuming
evenly
The first
populations
barrier
we plan
resident
to do
between Bangladeshi
have made it
43
no longer
less
useful.
The recording
Discussion
of methodology
of patients'
phone numbers would have saved considerable
had done this.
practice
We hope
that
in
living
populations
first
census
any
in
extraneous
Family
help
in
removed
the
accuracy
initial
in
field
to
acceptable
the
local
displaying
slips,
The response
these
for
community
flats
rate
house calls
it
could
not
group
to conduct
this
study.
of
key
who are
individuals
Clergy
prayer
meetings
their
returned
read
English
either
depended
were sent
in batches
out
estates
on council
by the
were
to the estates
writer
in this
households.
all-male
indexed
grouped
by
by postcode
difficult:
was
by lettering
identifiable
or
on house-to-house
was accompanied
easier
and
appointment
would have been unacceptable
Maps at the entrances
buildings.
at
subjects
this
were anticipated
respondents171.
the addresses
addresses
longer
were no
doubtful
her
own to visit
on
woman
invitations
and
Finding
rate
help
the
interviewer
since
visits
a Muslim
To make house-to
sector.
in
are
fieldworkers
announcements
they
that
Our Bengali-speaking
on most of
postcode
being
may
letters.
to attempt
was not
reassure
Few Bangladeshi
of
progress,
who had attempted
and obtaining
with
on
rate
workers
to
transfer
duplicates
delivery
depends upon recruiting
help
than
rather
now in
if
records,
it
a separate
The
computers,
one
If
study.
on it
sample
response
community
mosque helped
problem
Bengali.
calls.
of other
will
posters.
the
address
and response
community
whose endorsement
to
records
this
as GP lists.
such
a satisfactory
surveys
the
the
only
study
taking
consider
and basing
of
in the Bangladeshi
Success
seriously
to
as in
conditions
made by recorded
checks
advice
be necessary
not
register
in obtaining
research
of
area
Community acceptance
and the
in
we would
Committee
and annual
Difficulties
will
unstable
population
improve
to
4.4.3
such
a small
Practitioner
it
work
be necessary
to
were
future
work:
many blocks
on the
walls
had faded
of
the
to
illegibility.
The final
stage
stage
appointments:
rate
In practice
and non-Asians.
interview
response
but
native
frequently
British
did
66%
of
Bangladeshis
failed
subjects
differ
not
at the
seldom refused
to turn
up to their
likely
more
were
44
between Bangladeshis
clinic
to refuse
at the
Discussion
interview
but
stage
Attendance
for
reluctant
been to invite
for
seldom failed
of Bangladeshi
sometimes
women to go out
of the
to make their
to take
wives
appointments.
low:
husbands were
The original
part.
in this
since
it
community
husbands and there
have biased the sample.
their
would not
13 wives
study
their
without
this
methodology
women was particularly
spouse pairs,
women so that
of
of Bangladeshi
is not customary
few single
are very
In the early
part
were interviewed,
respondents
had
plan
of
The age difference
whom 8 attended the clinic.
between wives and
husbands made it necessary to choose the
female
rest of the Bangladeshi
from general practitioners'
sample directly
lists:
51 were interviewed
37
A circular
from the local mosque endorsing the study
and
attended.
husbands but produced little
was sent to all non-attenders
and their
improvement.
Bangladeshi
men were frequently
concerned about the
quantity
of blood to be taken and this sometimes necessitated
lengthy
Bangladeshi
reassurance:
less
Several
concerned.
number of
research
to antenatal
women, accustomed
respondents
projects
bewilderment
expressed
were
at the
community by social
on their
conducted
clinics,
scientists.
4.4.4
Racial
Racial
tension
in East London is well-documented
tension
Native
common172.
expressed
local
Bangladeshi
To have publicized
the study
investigation
as an
of heart
difficult
to obtain
cooperation
examining
ethnic
to non-Asian
expressed
interest
inadvisable
for
with
British
differences
there
circumstances
staff
This
the evenings.
roadblocks
fieldworker
Additional
during
interview
those
is of course
as it
difficulties
the disturbances
initial
with
We also
respondents
considered
the other
few South Asians
who were
Physical
was necessary
safety
who
it
with
but
weakness
of the
to conduct
were encountered
45
invitation
for
was possible
a methodologic
resulting
of
interviews
any
of group comparisons
confounding
concern
later
in
population
the objective
to conduct
it
though
sometimes
would have made it
in the
of the study.
was no alternative.
was a particular
reason
discussed
was
respondents,
in English.
interviewer
it
our Bangladeshi
team to
this
are
frequently
in the general
was not mentioned
though
attacks
population,
in Bangladeshis
and for
in the purpose
two members of the
fluent
disease
differences
subjects
native
in conversation
respondents
of the
resentment
terms.
violent
British
and racial
with
in the
field
visits
in
police
from a newspaper dispute
iti
of methodology
i)lscussion
Wapping
at
this
the
concentrate
in
completed
4.5 Future
Including
necessary
the
the time
those
of all
MO.
we plan
it
can be
so that
summer months
to reduce
this
unit
help.
If
of
consequent saving
for working unsocial
to the
immediate
rates:
interviewer
it
Using an occupational
population
literacy
with
to
sampling
of
had not been such a problem
questionnaire
time
per
is
a high proportion
The use of a mobile trailer
have
helped
area of study could
such units
with
we
in this
and particularly
hours.
however equipping
the cost
study,
to be feasible
studies
cost.
a more stable
will
who worked on this
For large
have used a self-administered
response
surveys
plans
owner-occupiers
close
in
residence-based
daylight.
frame or studying
could
fieldwork
was about
subject
further
In
time.
study, with
less necessity
which parked
to improve
adequate
space,
is
to
not
a
centrifuge
run
running water, and power supplies
has
the
to
Lack of suitable
continued
study area
premises close
cheap.
investigation.
in our current
to cause difficulties
heating,
46
5. Insulin
resistance
and Europeans
Diabetes
the
-
5.1 Background
5.1.1
On the basis
design
for
South Asians
hypothesis
will
be available
definitive
results
South
high
in
in
at
least
CHD rates
influences
South
Central
The best
pattern
Modern interest
observations
of
the
Central
of
was associated
veins.
only
with
chance
if
the
little
research
the
of
prevention
on this
importance
fat
with
deposition
'mechanical'
These observations
of
CHD
even
body
mainly
with
insulin
In planning
that
who reported
mainly
on the
on the
hips
upper
part
with
and thighs
disorders
statistical
an
hypertension
disease,
was contrasted
circulatory
lacked
fat
back to the clinical
heart
This
body
detail.
in
work
this
coronary
47
associated
diabetes177.
and
deposition
diabetes178.
is
resistance
adiposity
1947
from
Vague
Jean
onwards,
of
- was associated
since
environmental
strongly
to review
-
in
carbohydrate.
dates
obesity
it,
for
insulin
CHD174-176
in regional
of
and more
resistance
prevent
to
point
is
obesity
both
of
of t.he
test
analyses
insulin
study
resistance
determinant
and non-insulin-dependent
fat
'gynoid'
obesity
-
varicose
data
prospective
Initial
group.
best
dietary
and
was necessary
pattern
body
is a large
relatively
existing
and predicts
it
has been
insulin
and
obesity
the new study
offer
activity
characterized
151,173,174.
resistance
I android'
There
physical
The only
resistance,
the
of
possible
how to
insulin
rates
of CHD.
cause
identify
to
pathway
populations:
pattern,
5.1.2
this
Asians.
to
the
high
and secondary
definitively
find
to
for
a specific
hyperinsulinaemia
and a comparison
related
are
upon
European
fat
will
objective
or
rates
both
from cross-sectional
follow-up.
be available
at
is
Asians,
high
hypothesis
this
both
A secondary
Study
is responsible
and, by causing
disturbances,
including
in South Asians
in East London we formulated
resistance
in South Asians
to test
Risk
disease
hyi)othesis
findings
insulin
lipoprotein
and Coronary
resistance
of our
hypothesis:
heart
of coronary
the L)roject
of
The insulin
diabetes
and risk
such
analysis
- which
as
and wc-re
rian
ignored
field
for
Kissebah's
from
between
central
from
of
hips
are
the
of
half
pattern
circumference
not
the
studies
of
were
reported
by
studies
were
diabetes
the
deposited
waist-thigh
Waist-hip
ratio
proportion
of
risk
body
total
affecting
of
strongly
with
sited
intra-
many of
the
fat
0
heart
coronary
by the
the
on the
waist-hip
by
trunk
or
ratio'82,
correlates
disease
predominantly
can be measured
obesity
below: -
deposition
with increased
176,177,181
associated
ratio176,180,
of
fat
adiposity,
and cardiovascular
fat
of
regional
summarized
disturbance
body:
central
is
risk
a pattern
the
or
of
thicknesses'81.
estimates
to
of
hypertension
This
this
in
Cohort
between
relationships
disease
specific
is
and thighs
(ii)
Clinical
and metabolism
174,179
Wisconsin
of metabolic
and upper
disease,
investigations
obesity
and cardiovasular
obesity
abdomen
1982 onwards.
Studý-
body fat pattern
and Paris
relating
to
177
176,180,181
diabetes
death
and cardiovascular
The associations
with
more formal
of
Milwaukee,
understanding
metabolism
Risk
Gothenburg
risk
Current
(i)
in
group
increased
reports
appearing
relationship
and Coronary
viabetes
many years:
began
reported
oi
skinfold
radiographic
abdominally183,184.
(iii)
Insulin
resistance
disturbances
(iv)
the
waist-hip
(,., i)
ratio
are
the
impaired
vein
glucose
increased
free
in
resulting
levels
from
fat
risk
of
acids
decreased
skeletal
with
developmental
a
pattern:
extraction
muscle186.
48
and insulin
or
176
and
has been
fat
by the
Alternatively
obesity
aberration
obesity
visceral
disturbance
a
on
high
disease
relationship
from
released
187
heart
central
causal
central
women with
coronary
insulin
be
may
explicable
risk
between
A direct
fatty
cause
uptake
disease
association
unknown.
indirect,
be
may
association
hormone
which
portal
of
body
179,185.
low
HDL cholestero,
and
triglyceride
in
metabolic
intolerance,
glucose
obesity:
cardiovascular
the
is
resistance
in
at
underlie
central
sex differences
of
postulated,
both
in
The mechanism
insulin
into
elevated
Sex differences
basis
with
associated
hyperinsulinaemia,
to
appears
cells
liver
or
the
resistance
of
sex
Plan
(vi)
The factors
factors
determining
are
identifiedl88.
not
associated
in
Physical
Increasing
effect
central
physical
to
returning
are
genetic
markers
in adult
unknown.
life.
Genetic
have been
determined
Elevated
and insulin
obesity
Study
pattern
presumably
and insulin
by exposure
levels
androgen
in
resistance
to
women but
levels,
which
have
to
lasts
for
a short-term
days
few
a
long-term
and a
after
in
effect
obesity
which also
hyperinsulinaemia
suggest
that
important
be
more
may
in
central
and reducing
two effects:
only
levels190,
activity
fat
resistance
appears
activity
previous
central
mobilizing
are
Risk
men'89.
activity
on insulin
fat
no specific
necessarily
witb
not
apparently
5.1.3
but
body
Sex differences
hormones,
sex
are
of
important
and Coronary
Diabetes
reduces
levels'91.
insulin
5.1.4
and insulin
Diet
Dietary
experiments
quantity
and type
to
appears
193
elevate
with
on subjects
dietary
of
levels
insulin
determining
resistance
carbohydrate
levels
insulin
dietary
fat192,193:
dietary
than
more than
equivalent
the
sucrose
quantities
of
starch
5.2 Objectives
(i)
high
(ii)
that
rates
that
obesity,
physical
to
hypotheses
The specific
hyperinsulinaemia
of
CHD in
the high
body fat
inactivity,
South
insulin
be tested
are: -
and glucose
intolerance
Asians
compared
levels,
in turn,
elevated
patterning,
and excess
sucrose.
0
'AIN.
responsible
Europeans.
to central
are related
levels,
fatty
free
acid
plasma
dietary
JO)NDI's.
slslý
with
are
49
for
Pian
5.3
Planning
5.3.1
the
in
this
men:
'Prevalent
sample
CHD' is
three
(Section
4.3.3),
Stud.,.
protocol
between
a 7.7
non-Asian
From local
about
- smoking,
is
analysis
ethnicity
pressure
expected
equivalent
relative
of
data
for
of
1.54
factors
and plasma
to
a relative
An occupation-based
ease
risk
disease
prevalent
sampling
of
obtaining
a population
likely
to
be healthier
than
necessarily
bias
relationship
to
containing
identified
in
Allowing
of
proportion
West London:
Oats.
Quaker
and
workforces
for
1.6
lower
score
associated
for
that
with
that
assuming
more,
parallels
risk
a multivariate
effect
or
mortality.
and the
specimens
those
in
population,
this
of
factors
prevalence
the
advantages:
Although
general
of
to
was therefore
high
a
outside
of
Appendix
relative
Asians
in
in
risk
easier
are
employment
does not
and their
disease.
As a result
40-64,
men aged
the
comparisons
plan
populations.
looking
the
and 2-hour
fasting
access
large
crude
-
has practical
frame
few
sites.
on a
Tetley
cholesterol
of
difference
shown in
the
of
90 percent
men and 5 percent
on which
an estimate
to
The initial
Ealing23
have
the
(calculation
for
CHD'
diagnosis
a medical
3000 men will
Asian
the
'probable
of
significance
CHD in
risk
yield
of
one of
frame
Sampling
relative
size
of
to
for
risk
questionnaire
level
mortality
blood
least
or
risk
adjusting
at
only
low.
women is
angina
prevalence
but
1.4
of
include
will
signs
percent
percent!
study
CHD in
of
presence
The sample
a5
main
electrocardiographic
men: a relative
C)194.
5.3.2
by the
positive
at
the
prevalence
defined
criteria:
detect
to
a minimum
the
infarction.
myocardial
power
to
size
age group
following
the
sampling
Risk
Sample size
To keep
is
the
of
and Coronary
Diabetes
ot
conduct
lengthy
of
the
enquiries
middle-aged
British
Together
Airways
these
entire
large
four
South
in
study
Asian
Catering,
workforces
workforces
men were
Nestle,
contained
No
Asian.
South
other
were
of whom about
difficulties
logistic
found:
expense and
were
half
Greater
70
percent
a
industrial
Lyons
about
1500
suitable
precluded
London.
response
rate,
50
this
leaves
us
with
only
about
Plan
1000 participants
decided
where
to
li-, ý,e.
sufficient
of
participants
to
be away from
work
for
7.30
for
blood
glucose
load.
Several
options
(ii)
there
make up
in
comparable
not
hours
considered:
socio-
fasting
the
day
on another
taken
two visits
sample,
travelling
time.
for
will
Even those
10 am, since
until
work
they
be made immediately
cannot
after
at
sample
bome,
as in
the
at
a glucose
each one
is
a 2-hour
only
and collecting
following
but
and 2-hour
leave
to
if
a
-
sample
load
plus
be able
difficulty:
a serious
a fasting
2j
about
fasting
a glucose
are
will
Southall.
presents
for
attend
were
collecting
sample
sample
am will
the
omitting
Southall,
protocol
and ECG recordings
pressure
following
in
we
participating
Greenford
participants
collection
a residential
have
booked
British
in
practices
four
the
from
Accordingly
test
tolerance
The use of
in
Studý
sample.
general
employed
Asians
the data
Planning
from
sample
native
South
to
status
Glucose
Asians
Risk
an industrial
sample
An additional
numbers
economic
5.3.3
South
the
of
and Coronary
from
available
add a residential
most
companies
Diabetes
of
London
study.
and the
2-hour
East
the
first
visit
load
taken
sample
at
home,
so that
brief.
relatively
take
to
for
those
unable
(iii)
weekends
at
sessions
screening
running
to
having
resources
sufficient
This necessitates
time off on weekdays.
lieu.
in
time
off
have
weekends
at
worked
be able to allow staff
who
By basing
homes,
attend
proved
including
the
field
holding
and
in
the
possible
both
home in the
station
occasional
morning
to
within
but
attain
fasting
intervening
were
few
minutes'
a
evening
sessions
to
prepared
and 2-hour
for
fast
response
an acceptable
samples.
period.
51
of
walk
Most
those
from
rate
participants'
who could
breakfast-time,
with
participants
a protocol
return
not
it
Plan
Questionnaire
background,
not
usually
and socio-economic
to
Indian
first
use of
religious
measure
socio-economic
at
status
availability
smoking,
Asian
frequencies
were
foods,
than
English
possible
participants;
age twelve
years,
questions
or
running
people
water
at
of
eating
residence,
home, and frequencies
at
of
number of
of
neighbourhood
places
tenure,
baths
of
South
of
usual
field
home and at
at
housing
occupation,
acculturation
the
on two other
cardiovascular
English
rather
observance
data
obtain
acculturation
and typical
language
include
to
in childhood.
status
developed
typical
of
to
in
measured
degree
the
surveys'02,103:
Items
Study
history,
medical
We wished
and occupation.
factors
risk
Risk
was designed
questionnaire
demographic
covering
alcohol,
and Coronary
items
The self-administered
items
Diabetes
of
To assess
worship.
per
father's
about
home, and
room at
home were
of
included.
Anthropometry
design
The
as
required
indices
disturbance.
of
objective
Devices
fat
adiposity,
The
development
the
pilot
Waist
conditions.
were
measurements
The choice
of
of
for
fat
these
pattern,
as too
waist
hip
and
in
abdominal
studies
abdominal
insulin
and
diameter
valid
and
metabolc
was a principal
which
to
levels
best
in
which
show this
fat
mass183.
the
resistance186,
supine
but
position,
52
in
on the
the
pilot
the
of
CHD from
trunk
of
is
the
association
we chose
study.
of
ratios
it
waist
results
predictions
highly
be
to
measurement
no agreed
two different
exist:
on the
subcutaneous
field
were essential
based
was
the
of
use under
as described
included,
measurements
Study,
slow
were obtained
measurements
anthropometric
181
that
been
has
it
Since
suggested
skinfolds
.
the
fat
that
intra-abdominal
causes
of
activity
obesity
and
measurements
ultrasonic
with
central
reproducible
measurements
circumferences
therefore
skinfold
Prospective
quick.
study.
hip
and
definitions
anatomic
of
and rejected
evaluated
were
regional
available
currently
were
Paris
total
of
that
measurements
to
basis
correlated
thigh
metabolic
between
include
of
to
sagittal
radiographic
with
intra-
Plan
Diet
Diabetes
of
and Coronary
Risk
Study
survev
We plan
to
in
participants
insulin
this
30 South
a further
7-day
of
sample
level
of
intake
lowest
serum
insulin
records
size
have
will
an 18 percent
or
the
power
difference
in
relationship
fat
of
and
together
quintiles
be invited
will
of
fat
of
of
with
the
to complete
a nutritionist.
to detect
in
total
the
A random subsample
highest
difference
of
from
energy
supervision
90 percent
a 15 percent
significance
the
each group
under
the
known diabetes,
men without
in
of
consumed.
and 25 from
subsamples
examine
percent
carbohydrate
the
diet
weighed
to
intake,
and 30 European
25 from
distribution
of
from
records
specifically
energy
and type
Asian
diet
weighed
study,
to
resistance
carbohydrate,
This
7-day
obtain
at
total
a5
percent
carbohydrate
intake
between
any two
groups.
Coding
and analysis
As in
of
the
Whitehall
one or
more of
Study93
the
1.3
,
following
9positive
Minnesota
-
4.1
4.4
-
S-T depression
5.1
5.3
-
T wave inversion
7.1
the
CHD' are
presence
codes:
data
cross-sectional
in
difference
prevalence
block
major
more restrictive:
Q waves
(1.1
(7.1).
block
branch
bundle
left
of
the
'probable
for
or
Analysis
by the
flattening
or
branch
bundle
Left
ECG criteria
or
defined
Q/QS waves
1.1
1.2)
ECG' is
of
will
include:
probable
-
CHD between
South
Asians
and Europeans.
(ii)
in
a multi'Variate
be accounted
(iii)
elevated
analysis,
the
for
by factors
of
relationship
free
fatty
acid
the
associated
insulin
levels,
extent
with
resistance
self-reported
diet.
53
to
which
insulin
to
this
difference
can
resistance.
central
physical
obesity,
activity
and
Plan
Including
crucial
South
identifying
to
collaborating
Institute
and rural
Asian
with
of
Medical
populations
Medical
Research.
between
our
of
Diabetes
populations
and Coronary
at
possibilities
Sciences
in
Delhi,
Use of
who are
risk
for
prevention.
methods
results.
54
the
at
Indian
will
All-India
survey
a similar
by the
is
We are
colleagues
supported
standardized
of
planning
Study
CHD and diabetes
low
Reddy and his
Dr KS
Risk
Council
allow
of
urban
for
comparison
6.
Pilot
in
Finchley
of
the
study
6.1 Objectives
The objectives
(i)
to
test
the
and in
study
for
the
(ii)
to
(iii)
of
determine
measuring
plasma
levels
2 hours
at
the
total
fat
the
in
was present
the
develop
body
whether
were:
of
to
particular
determine
to
study
practicability
measurement
Bangladeshis
pilot
accurate
in
the
main
techniques
and reproducible
pattern
hyperinsulinaemia
South
other
identified
Asian
compared
validity,
in
groups
fasting
with
HDL cholesterol
cholesterol,
after
be used
to
protocol
measurements,
of
and triglyceride
load.
a glucose
6.2 Methods
6.2.1
All
Data
collection,
men aged over
were
invited
were
226 participants:
respondents
their
first
administered
10.30
to
were
in
40 years
take
of
language
60 of
part:
the
South
Asian
an overnight
70 percent.
of
of
origin:
and 35 were
factory
323 names were
rate
a response
questionnaire
a. m. after
an engineering
these
for
and attended
fast.
55
North
South
screening
London
There
Asian.
47 of
42 spoke
Participants
Hindu.
in
the
Gujarati
completed
between
as
a self-
7.30
and
study
in Finchley
questionnaire
included:
Pilot
The self-administered
Medical
history:
history
Diet:
including
the
frequency
of
typical
Smoking:
diabetes,
of
hypertension
WHO chest
foods
animal
and typical
handrolled
cigarettes,
questionnaire
different
eating
Asian
pain
and CHD
products,
English
tobacco,
foods
pipe
and cigar
into
three
exercise,
and
smoking
Alcohol:
based
Exercise:
frequency
Demographic
items:
vigorous
exercise
supplemented
with
including
country
status
age twelve
father's
number
After
at the
consent
measured
twice
subscapular,
and
to
with
allow
coding
of
social
of
job
Karasek
scale
housing
and land
control
occupation,
of
persons
per
room.
the questionnaire
station
tenure,
was checked and
obtained.
with
electrocardiograph
Skinfolds
field
for
quietly
resting
respondent
at
years:
On arrival
of
sweat-
language
details
job
calorimetric
about
birth
of
first
and
of
a question
activitY196
together
basis
lists
literature'90,
the
inducing
demands
grouped
on the
in
parents,
Survey
moderate
measurements
sufficient
Economic
Household
activities
exercise,
class,
written
of
as light
both
Occupation:
on General
five
minutes
a random-zero
was recorded
were measured at the
supra-iliac,
sitting
blood
sphygomanometer.
according
following
and anterior
mid-thigh.
was
A 12-lead
to the Minnesota
sites:
56
pressure
biceps,
protocol.
triceps,
A Holtain
caliper
was
Pilot
in
study
Finchley
with readings taken 3 seconds after
the jaws.
Sagittal
releasing
diameter
of the abdomen at the level of the iliac
crests was measured in
used,
the
supine
position
M
was measured
as the smallest
and the
iliac
between
the costal
(ii)
and
crest,
as the circumference
iliac
of the greater
drawn to a tension
was measured in the standing
circumference
at a level
margin
halfway
in the mid-axillary
crest
was measured at the level
circumference
between the costal
circumference
1.5
measure
cm wide was used,
A tape
Waist
anthropometer.
and the
margin
Hip circumference
line.
trochanters.
600g.
of
at the level
position
Thigh
the
of
fold.
gluteal
a fasting
After
drink
a Holtain
with
blood
75g anhydrous
containing
5 minutes
instructed
and
starting
6.2.2
Laboratory
to
drink
to
after
dextrose
to
for
return
the
was given
participant
drink
under
blood
a second
supervision
a
over
2 hours
sample
it.
data
and
analyses
Plasma from the
immediately.
had been taken
sample
fluoride
processing
and the EDTA specimens were separated
for at least 1 hour to allow
specimen was left
specimens
The clotted
One EDTA specimen was
the serum.
the clot to form before separating
frozen on dry ice and the other specimens were kept at 4*C.
All
specimens
Hospital
the screening
at the end of
Cholesterol
precipitation.
in
method
determinations
cholesterol
undertaken
School
6.2.3
at
cholesterol
fatty
free
for
oxidase
and LDL
acids
measurements were
at -70'C:
Center,
Research
Clinical
by heparin/MnC12
Stanford
University
in
shown
Table
of Medicine.
Statistical
40 percent
the
were stored
General
the
analysis
Age distribution
Asian
analyser.
a centrifugal
by the
Plasma
was
method and serum insulin
was separated
was measured
at Guy's
Plasma glucose
session.
HDL cholesterol
Medicine
Metabolic
by the hexokinase
measured in a COBAS analyser
by radioimmunoassay.
for
to the Unit
were transferred
of
the
of
ratio
measurements
were
participants
was stratified
sample
Waist-hip
participants
this
participants
by ethnic
except
aged under
from
the
average
two measurements
57
but
for
were
50-64
and
of
the
27:
among South
To control
40-49
two age groups:
has been calculated
when these
50 years
66
percent.
was
proportion
into
is
group
age
years.
two waist
specifically
illilot
Known diabetics
compared.
insulin
levels
mass index,
adding
The values
skewness.
original
between
pressure,
term
analyses
receive
free
load.
levels
acid
to
necessary
Body
were
eliminate
have been transformed
tables
and
plasma
fatty
where
lipid
of
a glucose
insulin,
serum
and plasma
the
age group
measurements
Asians
A principal
summarizing
in
back
to
the
load,
linear
variables,
To control
variables.
the
for
tested
were
least-squares
as categoric
75g glucose
the
for
and Europeans
variance
and ethnicity
to
been adjusted
the
of
as continuous
relative
between
South
by analysis
significance
size
or
the
units.
Differences
with
from
fast
a constant
in
Finchley
excluded
not
glucose
plasma
log-transformed,
did
blood
skinfolds,
triglycerides,
are
they
since
in
study
models,
and other
for
the
effect
levels
insulin
post-load
of
body
ha-ve
height.
component
analysis
metabolic
measurements:
data
multivariate
was used
this
but
is
not
to
examine
technique
intended
intercorrelat
the
is
ions
for
useful
to distinguish
causal
relationships.
6.3 Results
6.3.1
(Table
Anthropometr
28)
men were on average
index
body
mass
men: mean
European
between
the
European
thicknesses
6.3.2
Fasting
men: the
ratios
circumference
pressures
suprailiac
in Section
is examined
different
groups.
did
Li_pids
Three measures of central
and the ratio
obesity
-
of sagittal
higher
in
South
Asian
were
circumference
differences
to
these
metabolism
of
relationship
between groups in waist-hip
6.3.4.
Differences
were not
were greater
between
different
was not significantly
skinfold
than
to hip
diameter
abdominal
than
two ethnic
skinfold,
subscapular
6
kg
lighter
and
5 cm shorter
South Asian
groups.
differ
not
(Table
plasma total
significant.
Anterior
thigh
skinfold
but
were not
arm skinfolds
men
blood
diastolic
and
systolic
in South Asian
Average
between South Asians
and Europeans
(Table
28).
29)
cholesterol,
HDL cholesterol
58
and triglycerides
were
not
different
significantly
sample.
total
cholesterol
did
between
fell
triglycerides
Asians:
on average
in
triglycerides
insulin
fasting
with
negatively
variables
(Table
29)
insulin
and
glucose levels
were not different
higher
were
with
model,
as
difference
ethnic
but
respectively,
to height
Waist-hip
with
of
to
at
about
hip
level
equally
circumference
levels
abdominal
than
ratios
diameter
and body mass index.
strongly
hip
denominator
as
with
with
thigh
was weaker
were
59
waist
insulin
more strongly
circumference
than
at
L4
The two waist
circumference.
associated
circumference,
diameter
abdominal
and sagittal
to
waist
smallest
for
were compared
adiposity
levels:
of
predictors
less direct
compared with
such as arm skinfolds
as ratio
expressed
were the strongest
levels,
insulin
predict
L3-L4
30 and 31)
intra-abdominal
relative
of
measures
were
Inclusion
significant.
remained
skinfolds
obesity,
measures of central
each
from 79% to 56%.
(Tables
levels
insulin
serum
2-bour
and
circumference
levels
differences
these
and trunk
ratio
ability
of
in
the
the
ethnic
reduced
models
skinfolds
49%
16%
levels
to
insulin
2-hour
and
and
insulin
and
Obesity
insulin
in South Asians
in predicted
with
serum insulin
for height reduced the ethnic
Adjusting
insulin
in fasting
difference
measures
were
and trunk
ratio
waist-hip
level,
levels
insulin
Fasting
related
significantly
height:
the slope
with
associated
in height.
in 2-hour
difference
fasting
groups but 2-
inversely
was
line was a 3% decrement
the regression
each 1 cm increment
Sagittal
the
levels
was not
insulin
but 2-hour
to
acid
were 79% higher
levels
insulin
Fasting
than Europeans.
Ratios
in
In a regression
of
South
but
skinfolds
between ethnic
in South Asians.
insulin
and 2-hour
22% higher
their
change
positiveiy
fatty
one-third
plasma
response.
hour levels
Three
about
free
in
by 3% in
rose
correlated
levels.
and fasting
explained
but
this
plasma
same period
and trunk
acid
this
of
The change
load
ratio
fatty
insulin
the
significant.
a glucose
change
in
Glucose
Fasting
6.3.4
Europeans
free
average
and direction
by 5% in
fasting
fasting
the
Over
waist-hip
dependent
6.3.3
to
size
and Europeans
Asians
groups.
levels,
of
triglyceride
the
was highly
response
inclusion
in
ethnic
difference
this
South
and 2 hours,
3%
fall:
was a
differ
not
Finchley
between
fasting
Between
small
in
study
Fliot
levels.
related
denominator.
as
circumferences
as a
Pilot
predictor
fasting
of
6.3.5
fatty
fatty
were
slightly
in
South
Asians
than
lower
to
fatty
measurements
were
after
a glucose
and 2-hour
fasting
of
when the
European
levels,
and systolic
blood
accounted
for
43 percent
6.4 Discussion
in
of
the
on the
second
factor
results
loaded
not
on blood
mainly
were not
typical
conducted
ethnic
of acculturation
in
London,
Gujaratis
of
groups.
was about
work elsewhere.
for
strong
first
factor,
higher
on fasting
between
differ
ethnic
be interpreted
British
studies
fitness:
this
selection
at which
and many skilled
workers
60
still
this
with
the socio-economic
men in this
workforce
work in non-
who generally
with
problem
The factory
to close
Native
and
of pilot-study
A serious
between
fatty
pressure.
of the Gujarati
manual occupations.
is
selection
populations
free
analysis
loaded
data on ethnic differences
These preliminary
should
(ii)
(i)
South
Asian
the
sample was small;
caution:
degree
and
triglyceride
were markedly
which
did
fatty
33).
on the
insulin,
factor,
free
two eigenvectors
Scores
hyperglycaemia,
and
levels
(Table
component
variation.
and serum
in
each
were equally
The first
34).
with
triglycerides
separately
a principal
(Table
obesity
scores
of
was considered
groups
on central
insulin,
(Table
matrix
2-hour
These correlations
examined
ethnic
fall
free
and
Fasting
pressure.
fasting
with
metabolic
correlated
insulin
all
The third
were
These
to fasting
a correlation
2-hour
including
acid
acids
other
levels.
obesity.
were
Asians:
fatty
Europeans.
of 2-hour
glucose
group
The correlations
loaded
free
correlated
central
in
was examined
with
load,
were
acid
2-hour
and
correlated
measures
status
and 2-hour
levels
free
of
acids
groups.
levels
in South Asians.
and with
fatty
acid
higher
other
free
29)
was significantly
Fasting
South
levels.
but the ratio
32).
in
insulin
significant
anthropometric
which
waist
were not
The relationship
levels
2-hour
to
than
stronger
higher
levels
acid
but
slightly
were
differences
(Table
acids
Finchley
levels
relationship
free
plasma
levels
acid
its
Free fatty
Fasting
insulin
in
circumferences
in
study
in employed
process
investigation
employees
employed
may differ
was
leaving
were
there
at the
to
time
Pilot
of
this
had
are likely
study
left:
immigrant
may have
been
Since
physical
such
differential
The results
fitness
that
first
of
insulin
diabetes,
not
tendency
difference
reach
in
Bangladeshis,
was too
those
who
mobility,
worker
in
effect'.
sensitivity,
lessen
to
the
in
obesity
present
South
of
are
consistent
to
related
overseas.
is associated
resistance
in South Asians.
the
and fasting
disturbances
Asians
in
also
comparisons
results
a
after
HDL cholesterol
metabolic
insulin
that
for
the
of
generally
is
small
significance,
a pattern
suggest
to central
in body fat
for
hyperinsulinaemia
to
differences
and
occurs
also
than
insulin
greater
with
tendency
sample
that
resistance
The results
the
the
hypothesis
our
'healthy
have been expected
would
fit
opportunities
reverse
associated
identified
did
triglycerides
and less
between groups.
Although
prevalence
with
is
confirm
Gujaratis.
fewer
by this
selection
load,
glucose
having
affected
differences
metabolic
Finchley
to have been older
workers,
less
in
study
with a
differences
of
The failure
to explain
more than a small part of the ethnic
in 2-hour insulin
levels
in this small sample suggests that
pattern
disturbance
in
is
the
the
not
metabolic
cause
of
either
central
body
fat
to
South Asians or the techniques
pattern
are too
used
measure
index
for
As
inaccurate
indirect.
too
comparing central
obesity
an
and
obesity
between
ethnic
groups,
it
body mass index:
Skinfold
type.
thicknesses
to give
definitive
a
insulin
resistance
strongest
mass index,
Europeans:
but are
be
may
needed
computed tomography
using
body frame
with
more directly
measure adiposity
studies
differences
in
to
the
to
ethnic
which
extent
answer
body
by
the
be
proportion
of
relative
explained
may
arm skinfolds
such as waist-thigh
to detect
distribution
trunk
two
the
the
skinfolds
sum of
and
ratio
dataset,
in
levels
this
insulin
of
predictors
Waist-hip
predicting
body fat
as
intra-abdominally.
sited
diameter
may confound
inaccurate:
notoriously
fat
waist-hip
is open to the same criticism
ratio
ratio.
is possible
better
be
measurements may
levels.
2-hour insulin
the differences
this
index
is
clearly
that
than waist
Comparisons
in adiposity
displacing
measures of central
and alternative
It
were the
sagittal
61
obesity
abdominal
circumference
for
body
index
mass
of
between South Asians
inappropriate
for
studies
body
fail
and
comparing
Pilot
between
obesity
Although
plasma
measured
outside
glucose,
triglyceride
0.38.
up to
surveys
In
with
to
for
account
insulin
are
In this
dataset
that
against
in
findings
that
One is
free
for
explanations
must
resistance
No population
and there
correlated
against
fatty
that
in
acids
both
of
lipolysis
the
effect
in
insulin
of
to
response
individuals197,198.
free
fatty
acids
the
hypothesis
despite
with
between fasting
higher
markedly
the
and 2
2-hour
the
main
hypothesis
are
study
that
between
will
for
in
central
this
obesity
constitute
free
elevated
responsible
obesity:
they
fatty
insulin
the
case
other
and insulin
be sought.
metabolic
with
acid
central
association
levels
cause
.
in
the
accompanies
including
survey
were
fatty
circulation
systemic
which
resistance
other
that
by skeletal
that
elevated
Europeans,
confirmed
are
evidence
the
than
in South Asians.
levels
compelling
with
is
insulin-resistant
in free
fall
in South Asians
these
acids
Two hypotheses
of
uptake
suppression
the hypothesis
percentage
insulin
If
have been
hyperinsulinaemia.
The
alternative
and
resistance
is
both
insulin
pathways
consistent
affects
resistance
smaller
hours
predictive
levels
levels
glucose
explanation
in
field
in fasting
free
the absence of an ethnic difference
difference
in fasting
insulin
levels
is
the
accompanying
acid
evidence
diminished
with
coefficients
of
sufficient
acid
by elevated
and the
with
resistance197,198.
blocking
disposal
correlate
conditions
have been advanced.
caused
The other
upon glucose
fatty
and insulin
circulation
they
usuallý
epidemiology.
free
association
is
the
may have
cardiovascular
and not
measurements,
even under
elevated
this
muscle186,199.
fatty
that
out60
labile
dataset
this
pressure
measurements
obesity
resistance
systemic
insulin
in
in
pointed
highly
are
ward,
and blood
acid
have
levels
acid
suggests
Finchley
as others
metabolic
studies
associated
the
the
fatty
laboratory
insulin
fatty
be useful
to
power
free
This
free
groups,
ethnic
in
study
and clinical
some unexpected
fasting
rather
fatty
free
acid
measurements
2-hour
findings.
than
2-hour
62
free
measurements
together
has been reported
levels
insulin
fatty
before
acid
levels,
and
Pilot
fasting
insulin
Systolic
fatty
levels
blood
levels
acid
this
underlie
correlation
be accounted
for
in
On the
hand,
hyperglycaemia
suggests
disturbances:
(i)
associated
(ii)
to
insulin
with
free
this
second
This
fatty
that
loading
are
maY
the
of
fatty
acids,
cannot
Elevated
associated
all
plasma
with
between
and 2 hours.
fatty
fasting
acids
fall
to
that
are
associated
a glucose
after
least
at
with
two factors
data.
underlying
associated
in
response
2-hour
free
to
fatty
fall
with
metabolic
central
load,
a glucose
obesity,
and weakly
acids,
strongly
and with
associated
of
elevated
with
in
triglycerides
may be the
to
response
mechanism
underlying
that
is
In
component
between
the
of
leads
with
glucose
analysis
South
hyperglycaemia
on
failure
to
hyperglycaemia
than
suggests
Asians
and free
free
2-hour
that
it
and Europeans:
fatty
63
with
insulin
resistance
free
to
fatty
acid
is
acid
suppress
to
fatty
acids.
the
levels,
The
insulin
second
does
to
be associated
appears
only
plasma
leading
increases
production
dataset
fasting
in
by changes
mediated
consistent
between
relationship
resistance
this
is
independently,
developed
hepatic
more strongly
differs
activity
low HDL
confirms
deficiency
though
acids,
hyperglycemia.
principal
load
free
hypertriglyceridaemia,
resistance
Insulin
When insulin
with
diastolic
and obesity
may be two distinct
acids,
intolerance
and glucose
free
from
free
triglycerides
hyperglycaemia
to
suggestion200
levels.
fasting
acids.
disturbance.
suggestion,
Reaven's
for
with
common factor.
free
analysis
elevated
fatty
load.
a glucose
between
a glucose
fasting
triglycerides
a tendency
fasting
inspection
fatty
-
in
rise
from
clear
triglycerides
the
there
apart
nervous
a single
after
elevated
that
a tendency
with
of
in
summarize
variable
HDL cholesterol
component
to
associated
associations
and a tendency
Principal
This
is
free
sympathetic
hyperinsulinaemia,
and a rise
are needed
the
terms
cholesterol,
load.
It
2 hours
acids
other
of
triglyceride,
obesity,
central
any other
effects
that
glucose,
fatty
with
association.
matrix
insulin,
free
than
fasting
than
rather
was more strongly
lipolytic
the
pressure:
Finchley
2-hour
with
pressure
in
study
resistance
component,
not
differ
Pilot
between
This
groups.
ethnic
when free
fatty
effect
hyperinsulinaemia
of
the
explain
South
acid
are
be tested
will
for
available
triglycerides
to
rise
more detail
main dataset.
the
upon VLDL triglyceride
of
in
The
synthesis145
maý
load
a glucose
after
in
Asians.
The appropriate
of
clear.
Adjustment
a standard
effect
to
adjustment
effects
the
Finchley
hypothesis
results
tendency
in
study
of
body
size
using
to adjust
since
height
is uncorrelated
with
post-load
size
the
insulin
the
with
fasting
insulin
levels
is
and groups
effects
of
load.
glucose
levels
the
when comparing
individuals
confounds
to
2-hour
body
between
weight
relative
height
association
load
glucose
for
body
make for
in this
obesitý-
with
The rationale
for
is that
analysis
insulin,
not
the inverse
the effect
measures only
of
body size.
relative
6.5 Modifications
finding
The unexpected
to
response
of
have
led
us to
both
and cholesterol
the main study
differences
ethnic
load
a glucose
triglycerides
for
to the protocol
in
continue
fasting
at
the
triglyceride
measuring
2
hours
and
for
the
main
study.
6.5.1
Questionnaire
Items
on the
frequency
discriminate
instance,
Initial
between
plans
were
without
English
by others
with
be used
approximately
abandoned
of
spouse
to
sample
as this
the
about
Items
and with
split
equal-sized
the
for
group
about
Asian
to
day.
South
with
Asian
the
a neighbourhood
also
were
difficult
use of
language
appeared
to
be acceptable
participants
groups.
64
two
rest
of
inhabited
to
first
into
for
Asians:
every
almost
difficulties
in
residence
children
South
dhal
questionnaire
caused
same ethnic
mistrust.
causing
ate
use a supplementary
Questions
workforce.
mainly
could
to
this
failed
South
and traditional
westernized
in
foods
Indian
typical
eating
of
Indians
all
respondents
the
design
use
rather
and
than
Pilot
Questions
found
be too
to
physical
vague
activity
Baecke
the
to
three
shortened
age twelve
years
distinguishing
check
describe
caused
questions
the
backgrounds
during
conditions
found
and
was
at
be useful
to
in
who had been
those
childhood;
in
conditions
Many participants
childhood.
from
it
main study
were
from
about
filled
socio-economic
but
were
modified
was poorly
for
about
exercise
and sport.
scale
offence
poorer
living
were unwilling
the
of
explanation
was necessary.
Anthropometry
to
was necessary
the
participant:
dictate
the
leaving
both
Accurate
biceps
most
into
was that
the
not just
dermis,
define
to
the
with
position
be large
should
to
switch,
of
to
measurements,
of
reproducibility
the
of
triceps
for
and
forwards
held
forearm
the
the
was adopted.
standardize:
the
rule
adopted
include
to
enough
subcutaneous tissue
disagreed
two
observers
where
higher
had
been
whose reading
this:
than
more
but not
to
The midline
palm
difficult
was
grasped
fold
in duplicate
remote
was essential
measurements.
skinfold
a semi-prone
of
forearm
the
of
difficult
fold
fieldworker
this
with
recorder
the
as
same sex
free.
hands
The size
a tape
the
for
was
method
efficient
measurements
and triceps
study
of
an anthropometrist
use
positioning
was found
main
Questions
during
and vigorous
time
participants:
with
from
objectives
leisure
The Karasek
sometimes
their
moderate
by more specific
other
items.
affluent
underlying
It
work,
those
relatively
6.5.2
of light,
questionnaire201.
to
Finchley
and replaced
at
time-consuming
to
study
frequency
about
in
the observer
fold.
taking
This
training
the measurement
a smaller
5Use
between
in
of
a
observers.
agreement
close
resulted
eventually
the
delay
was
3-second
calipers
of
release
than
after
a
second rather
better
this
with
agreement
gives
for
skinfolds:
recording
adopted
repeated
estimates
radiographic
Since
insulin
protocol
trunk
levels
the
biceps
to save time.
measurements
of subcutaneous
better
were
skinfolds
were also
fat
skinfold
Lateral,
abandoned.
(Peter
Jones,
than arm skinfolds
measurement
medial
65
of
as predictors
dropped
was
and posterior
Though these
unpublished).
from
thigh
measurements
the
skinfold
were
Pilot
obtained
found
successfully
it
difficult
thigh
anterior
lateral
limb
to
the
them without
obtain
measurement
Finchley
in
on policemen
supra-patellar
was obtained
skinfold
Prospective
Paris
discomfort.
causing
without
was added
Studylý",
The
difficulties,
as an extra
we
and a
measure
lower
of
fat.
Positioning
gluteal
in
study
fold
main study
circumference
the tape
to measure thigh
in the standing
the Stanford
with
knee
to a right
and
the
position
protocol
foot
circumference
was found
on a chair
angle.
66
level
to be awkward.
was used instead:
resting
at the
of the
For the
maximal thigh
both
bend
to
so as
hip
Preliminary
7.
results
Preliminary
This
results
section
Diabetes
the
the
of
presents
first
the
of
Diabetes
preliminary
714 men examined
and Coronary
in
and Coronary
analyses
the
Risk
main
the
of
Risk
study
findings
clinical
in west
study
Study
on
London.
7.1 Methods
have
been described
methods
Field
The sample was based on three
Quaker Oats,
Lyons Tetley,
40 on these
aged over
in detail
industrial
Airways
were invited
section.
in west London:
workforces
and British
sites
in the previous
Catering.
1013 men
All
to participate
and 714 were
The response rate did
a response rate of 70 percent.
between
differ
those with South Asian and those with non-Asian
not
language for 64 percent of the South Asian
names. Punjabi was the first
giving
examined,
participants:
77 percent
cholesterol
and triglyceride
samples:
HDL cholesterol
strength
of association
other
variables
of Punjabi-speakers
variable
This
linear
with
independent
of age;
for
allowed
linear
variable.
that
and second,
terms
in the
that
10-year
analysis
variables.
are
are
of non-linearity
to compare
by adding
explained
explained
of variance
in each variable
For
regression
detected
the effects
and
with
independent
the associations
The
group.
from this
variance
has been computed first
for
is added after
and second when one variable
separately,
each variable
terms
The percent
of associations.
and quadratic
and 2-hour
was performed
in a further
variable
the percentage
when using
the strength
fasting
each ethnic
The residuals
and quadratic
method ensures:
analysis
a regression
first,
within
separately
dependent
the
as
were then entered
Plasma total
was measured on the 2-hour sample only.
between waist-hip
body
ratio,
mass index
age group as a categoric
analysis
were measured on both
was estimated
dependent
each
were Sikhs.
the other.
7.2
Results
7.2.1
As in
the
different
pilot
between
tendency
striking
waist-thigh
than
(Tables
Anthropometry
in
ratio
European
study,
the
to
36 and 37)
mean body
two ethnic
central
groups.
obesity:
and abdominal
men.
index
mass
Comparison
trunk
diameter-hip
of
was not
South
Asian
men showed
waist-hip
skinfolds,
ratio
mean skinfold
67
sig-nificantly
were
ratio,
higher
markedly
thicknesses
a
in
the
rreilminary
two
resuits
ethnic
in
the
groups
shows clearly
two
ethnic
groups:
in
South
thicker
differ
between
Europeans.
(Figure
mmHg higher
and diastolic
in
men: adjusting
regression
model
group
there
any significant
in
than
for
European
body
Plasma ligids
Plasma total
South Asians:
of total
higher
there
in Europeans.
was correlated
7.2.3
diabetes
Age-standardized
(Table
in Europeans
also
higher
Fasting
41).
levels
in South Asians
2-hour
nor
insulin
7.2.4
(Tables
were
workers
39).
level
This
in
lower
in
in the percent
was 8 percent
in South Asians
load on
of a glucose
Between
groups.
fell
than
by 5% in European
change in triglycerides
39-41)
was 14.5% in South Asians
prevalence
Prevalence
impaired
of
2-hour
and
than Europeans
glucose
(Table
related
insulin
38).
to height
and 4.7%
tolerance
8.7% compared with
than Europeans:
was significantly
than
levels
Neither
was
4.1%.
were
fasting
or age in either
group.
Relationship
of obesity
42-45,
Figure
5)
of
insulin
The relationship
a
South
group
was 0.1 mmol/l
in the two ethnic
higher
20%
were
66% higher
ethnic
(Tables
in South Asians
insulin
the
in South Asians
the effect
study,
was a 2% rise.
levels.
insulin
there
and insulin
Glucose
lower
the mean triglyceride
fasting
with
in
(Table
ratio
was 17% higher
triglyceride
was different
men: in South Asians
in
skinfolds
and non-manual
ethnic difference
Mean fasting
triglyceride
As in the pilot
and 2 hours,
than
38)
as HDL.
plasma triglyceride
fasting
manual
Plasma HDL cholesterol
and mean 2-hour
Asian
ethnic
was no significant
cholesterol
one
was 4
in South
neither
or waist-hip
was 0.2 mmol/l
cholesterol
(Table 38).
in
between
mass index
(Table
but
in
almost
was higher
workers
group
nol
1 mmHg and 2 mmHg
to
manual
differences
pressure,
Europeans
of
did
pressure
and trunk
ratio
differences
these
blood
systolic
waist-hip
to
amounted
fat
were
thicker
were
was 3 mmHg higher
pressure
the
ratio
body
of
skinfolds
skinfolds
Average
Study
skinfolds
thigh
and anterior
4).
reduced
Asian
and supra-iliac
waist-hip
The proportion
respectively.
in blood
in
Risk
distribution
and supra-patellar
The difference
European
different
the
triceps
groups,
and Coronary
subscapular
Asians,
deviation
standard
7.2.2
Diabetes
the
ot
to
levels
insulin
levels
to waist-hip
68
and glucose
ratio
within
intolerance
each e'hnic
L
- --l.
Vfý -I-1.
-
Jý ýT
Preliminary
is
group
of
the
Figure
5.
results
in
shown
dependent
as
skinfolds
differences
predictor
Asians
was waist-hip
with
waist-hip
ratio
(diabetes
or
percent
and specificity
highest
tertile
45 percent
sensitivity
difference
in
index
7.3
of
draw
(i)
The syndrome
feature
(ii)
of
This
identified
the
syndrome
is
South
Asians.
obesity
body
to
disease,
is
to
adequate
distributions.
associated
is
for
analyse
it
factor
risk
Bangladeshis,
insulin
with
present
in
also
includes
pattern
low HDL cholesterol,
and
is
another
diabetes.
Hypertension
In
overweight
of
the
metabolic
central
ethnic
other
diabetes,
such
in
occurs
groups
as Pimas,
a group
to
central
with
this
who are
not
Europeans.
indices
Weight-for-height
of
with
to
contrast
of
tendency
a striking
with
distribution
fat
by comparison
measures
small
triglyceride,
plasma
prevalence
in
direct
in
associated
difference
risk
men this
syndrome.
and a high
at
too
heart
about
non-insulin-dependent
obesity
Asians
with
body
and
mass
ratio
study
is
size
The metabolic
high
in
(iii)
the
In European
main
disturbances
metabolic
and Gujaratis.
of
of
coronary
conclusions
of
first
rates
sample
prevalent
hyperinsulinaemia,
high
of
58
of
intolerance
glucose
waist-hip
results
the
stage
some preliminary
Punjabis
tertile
By comparison
specificity.
between
value
45).
identified
mass index
intolerance
a sensitivity
(Table
and 70 percent
with
resistance,
mass index
Preliminary
this
relationships
of
South
striking.
Discussion
at
73 percent
body
highest
men the
with
ethnic
as a
in
only
than
glucose
with
tolerance)
glucose
predictive
was less
Although
individuals
body
of
Asian
mass index
groups:
associated
Among South
identified
body
than
the
reduced
16% and 49%
to
ethnic
and trunk
ratio
levels
both
Stuýy
models
was stronger
in
Risk
waist-hip
regression
more strongly
levels.
impaired
of
insulin
levels
ratio
insulin
serum
ratio
triglyceride
of
in
and 2-hour
Waist-hip
respectively.
and Coronary
Inclusion
variables
fasting
in
Diabetes
body
are
consequences
fat,
for
inappropriate
such
69
of
identifying
central
as girth
ratios
obesity.
or
South
More
skinfold
Preliminary
results
thicknesses,
(iv)
It
0.2
and
a small
of the
part
the high
CHD mortality
pathways
other
association
mmol/l
than
between
in west London.
in South Asians
the
levels
insulin
could
excess CHD mortality
If
lipid
70
more than
in South Asians
resistance
fractions
and CHD risk.
in mean HDL
explain
compared with
of these
resistance
insulin
Study
practice.
of 0.1 mmol/l
in mean triglyceride
50 percent
Risk
and clinical
the differences
that
Europeans
compared with
and Coronary
in research
are essential
is unlikely
cholesterol
Diabetes
the
of
other
underlies
groups,
must mediate
the
Conclusion
8.
Conclusion:
insulin
the
in
syndrome
resistance
epidemiological
perspective
8.1 The concept
of
The interpretation
emerging
view
resistance
this
disease
cardiovascular
200
normal
(1936)
first
demonstrated
in whom hyperglycaemia
insensitivity
to
impaired
with
impaired
was
glucose
insulin:
intercorrelations
confirmed
in
in
and
for
insulin
obesity,
physiological
lipoprotein
consistent
finding
dependent
diabetes:
dependent
diabetes
and hyperglycaemia
tentatively
intolerance,
fundamental
in
impaired
it
1950s
then
pressure,
disturbance
pressure,
glucose
intolerance,
surveys
tolerance
than
led
Metabolic
.
and pointed
study
The
in population
147,205,206
Hyperinsulinaemia
process.
to
without
feasible.
hyperinsulinaemia
that
of
disposal
glucose
in
individuals
became possible
and glucose
were
also
could
to
to
and
affect
insulin
is
a more
in non-instilin-
that
the
is consistent
non-insulinview
with
hyperinsulinaemia
in
late
which
stage
a
represents
Reaven has
failure207.
leads to islet-cell
this
V
'syndrome
the
glucose
to
of
the
associations
given
name
hypertriglyceridaemia
hypertension,
and
hyperinsulinaemia,
low HDL cholesterol
uptake200:
development
blood
and blood
metabolism
resistance
the
studies
suggested
studies
as the
or
levels
idea of a common underlying
but
many obese
With
might
glucose
hypertensive
and HDL cholesterol
triglyceride
insulin
to
maturity-onset
the
insulin
population
of
in
maturity-onset
diabetics
tolerance203,204.
volunteers
a relative
insulin-mediated
that
to
maturity-onset
that
antagonist
a circulating
only
tolerance
between
relationship
insulin,
work
in
He concluded
existed
failed
insulin
healthy
or
in
is
tolerance
load
diabetics
insulin
of
that
not
glucose
normal
injecting
the
action
Subsequent
radioimmunoassays
the
the
of
a glucose
was suppressed202.
and speculated
be present.
disposal
response
increased
with
injection
to
an
caused bý- insulin
whose glucose
that
with
is but one
disturbances
to juvenile-onset
in contrast
diabetics
diabetes
even in those
risk
the writer
aligns
is associated
syndrome
hyperglycaemic
the
diabetics,
thesis
non-insulin-dependent
and that
Himsworth
in this
proposed
that
syndrome
resistance
of a syndrome of metabolic
complication
suppress
an insulin
other
with
writers
resistance
would
to insulin-stimulated
include
central
71
obesity
glucose
on this
list.
Conclusion
The association
diabetes
for
studies
disease.
Three
and CHD risk
lacked
adequate
were
the
cases
2-hour
with
These
body
triglyceride,
HDL cholesterol
8.2
mass index,
Pathophysiology
associated
insulin
correcting
obesity
This
sensitivity.
to insulin
insulin
muscle.
tissue,
glucose
or
implies
that
in the
One possible
free
state
are
the
uptake
the
fatty
main
fuel
by skeletal
acids,
for
later
of
pressure.
in
of
this
for
leads
of
path
are
the
and for
chapter.
takes
from
derived
skeletal
in
place
for
mechanism
12
uptake
between
lipolysis
fasting
Free
obesity
in skeletal
in
In
the
adipose
fatty
state
by
insulin
cycle199,213.
muscle.
the
that
from
runs
association
glucose-fatty-acid
between
on glucose
effects
poorly
insulin
increased
causation
is
still
evidence
and any postulated
the
it
association
the
to
disposal
for
muscle:
by which
mechanism
involve
explanation
and obesity
was
The limitations
study.
account
exercise
liver212
the
and
glucose,
blood
and
discussed
obesity,
therefore
is
fasting
quintile
of
disturbances
Most glucose
must
resistance
resistance
fasting
than
rather
must
by diet
resistance.
ten-
at
association
highest
activity
and the
and central
resistance
independent
the
were
63 new CHD
with
and Paris
were
lipoprotein
and
Any explanation
Study,
in
5-17 men
two studies
126 CHD deaths
risk
are
studý-211
the
up of
CHD and the
either
insulin
resistance
resistance
obesity
with
understood.
muscle
insulin
of
kind
this
insulin
of
in
of
The Busselton
follow
ill
in case-
between
Helsinki
physical
measured
of
analyses
The causes
excess
bias
relationship
with
of
associations
was not
multivariate
predictors
the
of
for
the onset
Policemen
In both
in cases than
The other
Study,
Helsinki
were
most
levels.
insulin
19 CHD deaths.
survivors
after
13-year
at
Prospective
levels
the
might
these
with
were higher
of
levels
infarction
reported95,96,211,
follow-up96.
insulin
non-linear,
levels
power:
and the
91-year
2
at
been
only
Paris
follow-up95;
year
associated
myocardial
studies
have
insulin
elevated
CHD risk
insulin
that
non-insulin-dependent
that
comparing
statistical
there
larger:
much
idea
the
prospective
levels
40-59
aged
with
There are obvious possibilities
based on metabolic
measurements
controls208-210.
control
studies
found
controls
to
increased
the
Early
conditions.
resistance
led
and obesity
be responsible
with
insulin
of
this
acids
block
spares
Conclusion
for
glucose
levels
after
lipolysis
tissues
other
a meal causes
free
glucose
uptake.
fatty
or by the effects
An alternative
resistance
action
Effects
insulin
of
between
demonstrated
in
rise
in
insulin
blood
sympathetic
that,
8.2.2
For
by lipoprotein
could
be
fat
cells
186
vein
in the portal
between insulin
to the
resistance
uptake
and
of
have
the
insulin
insulin
lipids
synthesized
by the
liver
lipoprotein
lipase
to
the
liver
animal
studies:
for
more
of
a
feeding
of
of
of
sodium
reabsorption
it
sufficient
is
and a
an effect
stimulation
in
to
disturbances,
lipoprotein
with
are
evidence
mechanisms
discussion
this
is
and hypertension
the
probabl"
insulin.
liT)ovrotein
on
resistance
from
particles.
of
patients
state
hyperinsulinaemia
resistance,
resistance
effect
from
available
and promotion
association
Steady
Experimental
been suggested:
of
have been
pressure
hypertensive
that
insulin
purposes
by a direct
of
is
activity;
the
between
Effects
Transfer
resistance
studies206,217-219.
Two possible
pressure
unlike
association
mediated
sensitive
pressure
blood
and
controls220,221,
produces
nervous
note
in
insulin216.
of
is that
on blood
demonstrated
pressure200.
on blood
kidney.
are less
cells
of glucose
stimulation
insulin
relationship
fructose
the
levels
acid
population
than
and effect
with
fatty
levels
of abdominal
the association
glucose,
have
studies
rats
Obesitv
acid
action
levels
acid
resistance
several
resistant
cause
fat
activity
fatty
both
affects
Associations
insulin
free
even in the
lipolysis200.
of
suppression
infusion
lipolytic
for
have
studies
fatty
and insulin
obesity
free
explanation
insulin
of
8.2.1
of high
and elevated
free
Omental
central
by the high
either
several
to the antilipolytic
cells
between
The association
to suppress
to
insulin-stimulated
to
concentrations'98,213,214.
insulin215.
fat
than subcutaneous
Failure
muscle.
in diabetics
are raised
insulin
failure
with
to exogenous
explained
by skeletal
uptake
levels
acid
or raised
associated
response
insulin
acids
of normal
is also
glucose
The rise in glucose
levels
which suppresses
would cause resistance
In support of this hypothesis,
free
shown that
presence
fatty
in
a rise
and accelerates
suppress
depend on it.
which
to
intermediate-density
peripheral
(Sf
73
accomplished
VLDL particles
in
and catabolized
is
tissues
peripheral
Triglyceride-rich
metabolism
12-60)
tissues
are
by
low-density
and
Conclusion
lipoprotein
in
particles:
tissues.
this
The low-density
distinct
subclasses
lipoprotein
this
Atherogenesis
does
not
individuals
with
has two main
actions
LDL since
to
heterogeneous
and
up by
are taken
to
cholesterol
depend
to
cells.
on receptor-mediated
LDL receptor
the
in normal
LDL particles
delivers
process
appear
is
delivered
have been identified
of particles
receptors:
is
fraction
The cholesterol-rich
individuals222.
specific
triglyceride
process
deficiency
are
uptake
of
risk
of
high
at
CHD.
Insulin
triglyceride
is
It
and it
synthesis,
the
association
between
insulin
of
indicate
that
VLDL triglyceride
levels
in
individuals225.
levels.
triglyceride
free
is
fatty
supplied
infusions
lower
Insulinoma
The principal
acid226
for
does
fatty
levels
free
acid
and
elevated
145,227.
insulin
If
VLDL
triglyceride
of
-resistant
a carbohydrate
free
fatty
Elevated
IDL and LDL.
are
not
diabetics228.
central
In
elevated
less
obesity,
small,
elevated
pattern
than
is
suppress
occur.
by
these
of
levels
IDL
and
are
are
associated
by a
dense LDL particles
the
and
contain
the presence
so that
ratio
with
associated
low HDL cholesterol,
of
are
present
characterized
strongly
are
syndrome
produced
IDL levels
is
elevation
74
synthesis
to
resistance
main LDL subclasses
with
of
respond
fail
would
pattern
VLDL triglyceride,
associated
hepatic
IDL fraction
individuals
LDL particles
the other
combination
mechanisms
the
of
These small
triglyceride
individuals
fractions
An LDL subclass
IDL levels230,231.
cholesterol
this
of
levels
dense
cause
VLDL trigl-yceride
non-diabetic
obesitý_229.
preponderance
insulin
The precise
understood.
and increased
the
synthesis
the
low
as insulin-sensitive
lipoprotein
VLDL:
of
in
levels
on the
correlated
central
VLDL triglyceride
triglyceride
and also
same extent
by effects
associations
with
the
VLDL triglyceride
catabolism
in
hyperinsulinaemia
with
to
increased
accompanied
highly
levels
acid
individuals,
of
load
by
as the
hepatic
that
appears
insulin
to
stimulate
have extremely
patients
substrate
it
and
lines
VLDL triglyceride
is
alone
insulin
Euglycaemic
normal
synthesis
when glucose
the
Several
does not
alone
inhibits
Insulin
activity.
to underlie
levels145.
VLDL
affects
lipase
believed
hyperinsulinaemia
hepatocytes
substrate223,224.
is
and triglyceride
synthesis.
rat
cultured
lipoprotein
that
it
metabolism:
increases
on VLDL synthesis
effect
evidence
on lipoprotein
of
apoprotein
Conclusion
B to cholesterol
in the LDL fraction.
It is suggested that
dense LDL particles
are produced from VLDL and IDL particles
2292
cycles of triglyceride
enrichment
and lipolysis
these
An inverse
association
is
consistent
finding
association
Several
that
possible
lipid
of
lipase,
depleting
are
levels233.
obesity
this
associated
This
How could
process
The
studies.
HDL2 subfraction.
the
is
most plausible
HDL particles
rapidly
by the
possible
effect
activity:
of
elevated
triglyceride
elevated
plasminogen
earlier
observation
inhibitor
activator
of
HDL2
by hepatic
catabolized
elevated
lysis
clot
insulin
the
are
Another
may explain
a
The triglyceride-enriched
on fibrinolytic
with
and prolonged
VLDL to
protein149,232.
is
the
with
from
HDL levels.
levels
triglyceride
levels
in
and clinical
have been suggested:
transferred
transfer
produced
surveys
by repeated
and HDL levels
cerides
be specifically
mechanisms
is
trigly.
population
to
appears
articles
8.3
in
triglyceride
action
between
small
between
associations
times234.
resistance
syndrome
cause
heart
coronary
disease?
Based on the
insulin
from
in
summarized
insulin
in
a single
resistance
this
model:
formulation,
is
hypertension,
individuals
with
the
explanation
insulin
insulin,
on
atherogenesis
syndrome predict
that
through
the
of
is
pathway,
disease
1D
leads
insulin
thev
factors
risk
-
in
to
resistance
mechanisms,
blood
pressure,
and more plausible
syndrome
because
the
to
intolerance
different
and that
pathways
In Reaven's
that
An alternative
resistance
and
most of
coronary
that
tolerance,
glucose
causal
for
and glucose
syndrome
is
obesity
syndrome
'cluster'
a
by several
insulin
a single
coronary
two ways.
The assumption
HDL
cholesterol.
and
is
in
resistance
on atherogenesis
effects
of
this
disturbances
disease200.
effects
triglyceride
of
presence
lipoprotein
cardiovascular
including
the
the
evidence
reasonable
be
interpreted
may
risk
it
is
there
model
central
of
well-understood
The relationship
shown.
cardiovascular
least
the
disturbances
of
This
between
the
above,
as a group
a system.
The relationship
otherwise
relationships
exerts
is
in
perturbation
6.
Figure
outlined
be
may
considered
syndrome
resistance
resulting
relationships
pathophysiological
exerts
other
effects
on
features
of
for
this
are markers
the
uonclusion
To justify
process.
the
validity
Results
the
of
of
cohort
as logistic
model,
considered
to
studies
those
intercorrelated
and the
is
An example
of
predictor
(at
differences
than
levels
that
a single
long-term
It
is
disease
factors,
they
is
is
does
is
highly
relatively
to
is
not
the
levels
CHD
to
'independent'
an independent
that
as evidence
relationship
account
of
of
the
within-individual
labile
HDL
whereas
individuals.
CHD simply
predicts
fasting
take
within
stable
is
relationship.
and the
not
in
the
analysis
interpreted
causal
with
triglyceride
because
It
it
as a marker
is
is
better
for
the
triglyceride.
plasma
this
that
to the
predict
are associated
with
of multivariate
misinterpretation
hampered the understanding
which
the
rather
measurement.
of
a consistent
has been
This
triglyceride
of
but
epidemiology
triglyceride
HDL and triglyceride
are
of
association
relationships
causal
a regression
slope
are
within-individual
measurement
low HDL is
CHD risk
not235.
of
and HDL cholesterol
This
men).
measurement
led
and
the
are
have been
by a single
cardiovascular
elevated
HDL cholesterol
suggested
seriously
CHD is
Plasma
cholesterol
in
HDL to
between
variability.
possible
in
of
to
of
analyses
least
are
the
of
triglyceride
plasma
relationship
results
situation
CHD whereas
of
triglyceride
the
estimate
multivariate
predictor
the
this
of
relationship
risk.
the
zero
in
model
predictive
that
the
causal
independent
effects
characterized
error
of
measurements
strongest
in
significantly
the
that
the
factors
of
upon
in
repeat
for
the
reliably
effect
variable
towards
In
the
that
those
with
because
unless
corrected
is
of
analysed
'independent'
these
assumption
valid
analysis
can be most
independent
bias
not
necessarily
that
this
usually
Evidence
included
measurements
The problem
are not
This
is
factors.
factors.
included
are
examine
risk
are
disease
demonstration
and labile,
causation
factors
predict
risk
on the
When the
variation.
still
to
necessarý,
disease
When all
which
is
'independent'
cardiovascular
models.
rests
associations.
those
of
it
identify
to
used
be 'independent'
relationships
obtained
hypothesis
radical
methods
regression
regression
implies
this
identification
not
of the aetiology
of cardiovascular
'independent'
of spurious
risk
because they
other
risk
analyses
are truly
factors
76
which
causal
but because
cannot
be reliably
has
Conclusion
measured.
Of the many 'independent'
likely
a few are truly
causal.
to the labile
and intercorrelated
that
haemodynamics
and
metabolism
We cannot
resistance
syndrome.
distinguish
causal
alternative
approaches
of
single
studies
of
different
is
the
for
of
this
of
serum
cholesterol
South
instance
the
very
not
in
Punjabi
other
Asia
between
South
the
insulin
of
these
two
established
coronary
and hypertension.
helps
break
to
the
low HDL cholesterol
Sikhs
in
syndrome
and CHD must be unfavourably
Although
is
there
may be directly
relationship
effects
of
for
the
suggest
insulin
to
putative
may not
this
study
with
insulin
later
cardiovascular
in this
lipoprotein
trial:
patterns
for
is
Muslims
same elevated
between
insulin
the
distributed
in
the
all
that,
that
as with
or
90th
centile
of
of
a dose-response
the
have
to
was not
treated
with
the
placeb0237.
is not
insulin
differ
between men and women.
levels
to
Diabetes
in
but
that
the
one of
been subjected
higher
of
insulin
suggests
is
this
236
the
a threshold
post-load
Group
University
syndrome
glucose,
with
Insulin
causal.
factors
resistance
effect
to
objections
plasma
non-linear
mortality
it
insulin
insulin
that
studies
powerful
is
in the group
chapter,
also
CHD risk
risk
controlled
than
different
of
the
as
upon atherogenesis
the
of
be directly
cardiovascular
randomized
such
further:
association
experimental
are
effects
studies
elevated
risk
at the 80th
95,96.
leve,
This absence
association
from
there
atherogenic,
The prospective
insulin
of
some evidence
as an explanation
confounding
populations.
direct
Possible
the
syndrome
factors
risk
share
resistance
Asian
breaks
Bangladeshi
groups
the
underlie
resistance
confounding
found
both
and yet
and Europeans
Comparison
factors
8.3.1
Two
clinical
Asians
groups
Whatever
South
to
analyses
and epidemiological
CHD risk.
high-risk
insulin
associations:
metabolism,
effects
between
with
seen
the
The contrast
from
these
of body fat
and disease.
syndrome
break
to
comparisons
isolate
syndrome
elevated
the
is
applies
the
comprise
on multivariate
lipid
of
argument
it
groups.
to
study.
groups
can help
contribution
ability
rely
identified,
disturbances
that
between
pathways
defects
studies
A unique
This
only
especially
pattern,
factors
risk
the
few
a
Program.
groups
treated
As reviewed
the associated
If
the
In
insulin
u6nclusion
in
syndrome does have something to do with sex differences
disease risk,
the mechanism of action cannot be a direct
cardiovascular
effect
of insulin.
resistance
8.3.2
It
Effects
blood
on
is unlikely
that
pressure
the association
with
its
the effect
of
effect
have failed
to yield
convincing
mechanism of
trials
hypertension
it
thesis
this
CHD morbidity
reduces
demonstrated
was
between some South Asian
8.3.3
The insulin
resistance
concentration
atherogenesis,
defects
single
for
a direct
increased
in blood
in
pressure
it
is useful
in
lipoprotein
if
composition
any,
insulin
of these
resistance
effects
familial
could
evidence
between LDL and atherogenesis
hypercholesterolaemia
familial
In heterozyous
is the
caused by
hypercholesterolaemia
levels
but
IDL
VLDL
are normal.
and
are markedly elevated
(on
lipase
CII
the
lipoprotein
deficiency
which
or
apo
of
contrast,
VLDL
triglyceride
lipase depends) leads to elevated
and
chylomicrons
In
LDL levels
with
is not elevated,
CHD risk
disease
of VLDL, IDL,
HDL2,
enriched
rather
atherogenesis.
action
of
This
than
It
coronary
with
In these
lipase
hepatic
atherogenic
lipoprotein
lipase
have
deficiency
LDL and triglyceridewith
vascular
peripheral
disease240.
implicates
indicates
(unless
conditions
such as
complications
other
is associated
strongly
also
LDL levels.
triglyceride-enriched
condition
evidence
clinical
directly
although
Subjects
occur240.
pancreatitis
high levels
This
low
or normal
and
low HDL levels
of
syndrome and
The most compelling
metabolism.
with
and size
syndromes caused by
to examine the clinical
relationship
of the
fractions:
main lipoprotein
which,
atherogenesi
disturbances
with
IDL and altered
between the
deficiency.
LDL receptor
four
of all
in patients
risk
of
Earlier
mechanism for
is associated
In considering
causal
treatment
are in the wrong direction
and Europeans
syndrome
the association
mediate
differences
as a possible
or composition
the LDL particles.
that
evidence
and mortalitý-238,239.
VLDL, low HDL, elevated
elevated
Randomized
in CHD risk.
on lipoproteins
Effects
can be the main
pressure
on atherogenesis.
that
groups
the differences
to explain
blood
the
LDL particle
VLDL particles
that
atherogenesis
as Zilversmit241
18
i
is
itself
are
in
unlikely
dependent
suggested).
to be
on the
The possible
Conclusion
role
IDLs
of
remains
LDL to atherogenesis
resistance
on the
mechanism
by which
cardiovascular
CHD.
In
for
in
of
were
a formal
from
to
related
of being
the
insulin
model and the
finding
the
subclass
pattern
particles
was not
to
test
was associated
IDL mass predicted
the
trial244.
of
triglyceride
levels
than
emphasized
were
levels
with
earlier,
multivariate
analyses
8...4 Implications
the
for
are
risk
implicates
coronary
angiography
the
these
not
of
an LDL
of
LDL
myocardial
IDL levels243-245.
disease
in
an intervention
with
B and IDL
coronary
HDL, VLDL or
LDL fractions245.
disturbances
are
highly
artery
As
intercorrelated,
helpful.
necessarily
the
3 for
associated
the understanding
epidemiology
was
dense
IDL apoprotein
patients,
more strongly
comes from
which
small
artery
in
total
or
The presence
of
B
angiography-
Boston,
of
with
apoprotein
evidence
elevated
participating
of
since
in
study
a relative
association
another
impressive
lipid
several
was with
in
LDL
factor
a risk
LDL cholesterol
with
confirmed
of
as
of
hypothesis230.
progression
patients
a study
strength
dense
small
Australia,
by a preponderance
evidence
hypercholesterolaemic
In
their
More
the
with
Similar
of
cholesterol,
in
case-control
characterized
infarction230.
in
than
same city243.
designed
presence
association
rather
population-based
specifically
of coronary
heart
the
insulin
disease
could
disease:
how
resistance
explain'
The arguments
above
may provide
a unifying
hypertension,
glucose
CHD risk.
is
would then be a final
patients
for
compared
The strongest
This
study
s.yndrome
insulin
of
advantage
the
low
angiography
LDL fraction,
the
for
B but
apoprotein
a study
cholesterol.
much of
relating
as a possible
syndrome
has the additional
evidence
disease242.
in
disease
resistance
the LDL particle
the dietary
fat-lipid
both
measurements
coronary
based
LDL particle
hypothesis:
high
levels
This
evidence
to the effects
the
of
insulin
the
some preliminary
is
lipid
attention
The compelling
model.
particles,
for
directs
risk.
common pathway
There
question.
composition
most parsimonious
resistance
an open
A review
have
suggested
for
explanation
intolerance,
of
findings
that
the
the
insulin
resistance
relationships
low HDL and elevated
in
other
79
populations
of
syndrome
obesity,
triglYceride
suggests
the
to
uonclusion
this
that
possibility
but
in South Asians
8.4.1
also
Relevance
no prevalence
clinical
experience
commoner
in
that
suggest
in
diabetes
of
to
women aged 35-69
adjusted
UK the
criteria.
in
1978 the
and Nutrition
British
native
Americans246
and the
prevalence
results
men and
diabetes,
of
British
men in
5 percent88.
about
and
is
In African
In
Survey
during
was 18% in
Blacks
aged 40-64
high
of
Examination
by WHO criteria
prevalence
diabetes
In native
is
age range
data
mortality
the
diagnostic
this
Americans
and in Black
11
was
percent13.
in
Health
in
Trinidad13
Trinidad
urban
prevalence
States
diabetes
in
reported,
have been undertaken
modern
WHO criteria,
to
in
prevalence
according
reported
and Black
UK than
such as
men.
non-insulin-dependent
the
CHD ris'ý,
in CHD rates,
and Afro-Caribbean
have been
studies
high
the
only
differences
ethnic
In Afro-Caribbeans
surveys
not
Afro-Caribbeans
Afro-Caribbeans
population.
United
may explain
American
Africans,
to
Although
the
other
among Black
low risk
the
mechanism
the
1976-80,
and 10%
in Whites246.
insulin
If
resistance
diabetes
in
Afro-Caribbeans
proposed
in
this
these
for
ratio
rate
heart
coronary
Interpretation
of
inequalities
all-cause
most
White
in
mortality
mortality
In
groups.
Whites
mortality
relatively
was 0.93
in
rates
deprived
high
risk.
in
being
Data
equal,
from
men the
the
UK
opposite
is
mortality
standardized
This
low CHD mortality
morbidity
data
from
a
Londonl4.
CHD mortality
do not
ratio
of
meii and 1.28
inner-city
the
with
in
Black
In Washington
rates
in
Blacks
and
because of the social
Another
distinguish
CHD mortality
communities
80
is that
complication
Blacks
from
in
US Blacks
High
women248.
DC, which
higher
in markedly
reflected
BlackS247.
among
1977 the
risk
= 100)15.
and Whites,
data
factors
hypothesis
88
in
Caribbean-born
and
men
is difficult
States
the
then
and Black
1970-72
in
differentials
between Blacks
published
in
non-insulin-dependent
CHD mortality.
consistent
registry
in the United
Whites
in
and Wales
men is
attack
high
Caribbean-born
(England
Afro-Caribbean
other
Afro-Caribbean
and Wales
CHD was 45 in
women aged 20-69
in
in
rates
Americans,
that,
have
also
that
In England
case.
and Black
predicts
would
USA suggest
and the
the
thesis
populations
the
underlies
to
nonthat
all-cause
contributes
contains
other
to
this
an exceptionallý
Conclusion
deprived
the
Black
ratio
2 in
CHD mortality
of
3
in
men and
USA have
the
together
population
Blacks
sufficient
on selection
of
cohort
Cancer
in
interval
0.72
0.84).
-
In women the
interval
0.98
1.17).
-
The MRFIT study
at
5 years
0.89,
the
not
the
cohort
population
follow
different
CHD in
but
it
contained
men was 0.86
but
These data
are
effects
social
of
ratio
this
deprivation
and Black
This
groups.
either
There
American
are
load
on volunteers250:
White
versus
men to
men was
in
the
of
not
in
that
White
men.
when the
is
general
lower
in
both
population
of
hypertension
shared
At 20-
in Black
CHD risk
is
Study
on a
that
conclusion
CHD is
in
Black
the
by Black
women in
response
to
but
versus
versus
0.73).
in
not
of
been
levels
or
In
women this
American
Black
These findings
men than
in
between
women tend
to
indicate
that
in Blacks
or
European
levels
be more obese
although
than
diabetes
81
White
in
in White
are
(0.82
(0.75
Blacks
in
older
consistently
in Afro-Caribbeans
descent(Table
and Whites
Blacks
than
levels
higher
consistently
higher
in
insulin
Triglyceride
years
than Whites
higher
was
pattern
men of
difference
13 percent
a
in
that
with
in Black
higher
ratio
reported.
and HDL cholesterol
Black
fat
body
were
was lower
women waist-hip
Studies
have
levels
45
percent
men and
ratio
Americans
18-30
men and women aged
of
study
insulin
fasting
In men waist-hip
0.84)
or Black
large
insulin
the
comparing
studies
a recent
in White
wome,1253.
because
general
of
(95% confidence
31 deaths
on only
based
(95% confidence
based
Black
in
with
ratio
866 men aged 40-64252.
prevalence
to
Afro-Caribbeans
States,
than
age groups
in
In
United
lower
relative
no published
Europeans.
Black
immunity
the
have been based
men than
high
the
but
The Evans County
discounted,
are
a comparison
12 years
Black
ill
country.
glucose
the
the
with
UK and USA, despite
the
was large
unity.
only
based
was
ratio
consistent
Afro-Caribbean
cohort
in
CHD mortality
of
CHD mortality
of
was 1.07
to
19 5 exceeded
for
was also
Blacks
in
men was 0.78
ratio
from
of
up the
White
population,
Blacks
at
CHD death
of
study
sample
in
that
risk
significantly
only
year
men to
relative
of
Society
CHD mortality
Whites
studies
by volunteers251;
respondents
Black
in
that
numbers
The American
white
a privileged
to
Three
women249.
included
Whites250-252.
in
with
is
not
47)253-258.
seen,
possibly
women259.
and hypertension
are
in
Conclusion
common in Afro-Caribbeans
insulin
resistance
central
obesity
and Black
Americans
features
the other
of the
high triglycerlde
syndrome - central
obesity,
and low
HDL - are not unfavourably
distributed
in Black men. The differences
in
lipoprotein
between Black and White men are in the
pattern
opposite
direction
to that which would be expected if insulin
resistance
and
differences
between
cholesterol
are less
Blacks
parallel
American
and Afro-Caribbean
These differences
rates
does?
One small
secretory
of
capacity
in
descent
African
disturbances
in
if
Even
does
is
not
discussed
Americans,
stimulus
later
less
Blacks
in
in
are
people
not
more
why triglýrceride
in White
Black
than
the
section
in
what
beta-cell
was
explain
and HDL so much higher
explanation
the
with
of glucose
that
suggested
a maximal
this
in Black
inconsistent
and Black
EuropeanS260.
Whites,
than
A possible
men.
to
response
be so much lower
should
insulin
If
pattern
in the contrast
between Black
does not explain
the
resistance
in South Africa
than
insulin-resistant
The low CHD rates
in Afro-Caribbeans
study
in lipoprotein
not
However the dissociation
and lipoprotein
diabetes
of
and and HDL
men are therefore
and White men is puzzling.
high
In women the
men.
in triglyceride
in CHD risk.
here.
proposed
intolerance
and Whites
evident.
the differences
hypothesis
in Black
were more prevalent
on sex
differences.
8.4.2
Relevance
Certain
have
States
United
a similar
appear
to
low
dissociation
of
risk
this
insulin
diabetes
Prevalence
in
the
occur
in
recorded
Pimas,
by WHO criteria
47
percent
men and
in
heart
is
in
Pimas
women261,
South
rates
Pimas
are
Asians
to
but
of
the
apparent
Pimas and in
below.
of
non-insulin-dependent
li, ý'ing
group
35-64
aged
appear
Criticism
on the
in
examined
American
origin
disease.
CHD
risk
and
prevalence
a Native
in
has been based
thesis
The evidence
highest
American
found
that
coronary
resistance
Mexican-Americans236.
Some of
for
Native
of
to
pattern
in
proposed
and Mexican-Americans
populations
metabolic
be at
hypothesis
Pimas
to
in
1965-75
exceptionally
in Arizona.
was 37 percent
obese
and
30
35-44
kg
in
index
body
exceeds
maged
the median
men and women
mass
2.
distribution
fat
data
measurements
No
or other
ratio
on waist-hip
2-hour serum insulin
In a study of volunteers,
have been reported.
82
Conclusion
levels
more than
were
steady-state
Pimas
metabolic
is
from
US Whites
Laboratory
Pimas
LRC data,
lower
slightly
features
that
a higher
proportion
are
for
CHD mortality
assess
a population
of
In
survey266.
lower
in
Whites,
this
series
there
are
in
1976,
351 men aged over
than
in
was not
1965-75
reported
statistically
was not
than
Pima men up to
of
there
levels
age
were
in
the
levels
in
surveys
and over
in
1965-73,15
although
the
in
In
the
US White
Total
significant.
associated
with
body
of
mortality
index
mass
but
except
myocardial
was
on US
from
a
survey
found
in
9 of
was lower
prevalence
in
Pima
autopsies
comparisons
but
and in
for
of
to
prevalence
Q waves were
populations
Attempts
records
a population
age-standardized
US265.
series
cases
a series
making
and LDL
been reported,
age-standardized
in
in Pimas
264
to LDL
intakes
the
of
a post-mortem
of
findings.
fat
data.
a review
autopsy
of
dietary
120 necropsy
reported
be something
cholesterol
certification
difficulties
40 years:
total
population
were made in
and low HDL
conversion
Pimas have not
death
prevalence,
Europeans:
with
of
metabolic
diabetes
without
general
the
may also
compared
electrocardiographic
major
Asians
low plasma
the
that
obvious
review
retrospective
reported
identified:
were
for
Compared
studies.
triglyceride
that
despite
group
40
years
men and women aged
infarction
of
data
Pima women than
high
high
Pimas
rates
this
South
load.
unreliable
of
in
CHD rates
in
a surveY
with
HDL cholesterol
catabolized
Pimas263
incidence
because
presumably
in
lower
with
relatively
those
to
or
higher
syndrome:
in
VLDL is
the
in
similar
of
in
StudY263.
the
were
has suggested
of
levels
cholesterol
share
VLDL catabolism
may account
Results
and
disposal
glucose
between
55.
age
a glucose
One study
about
that
Prevalence
levels
resistance
after
cholesterol.
Clinics
standardized
Pimas
insulin
the
hyperinsulinaemia
which
Research
Europeans,
groups.
suggest
of
as in
have been compared
Pima men and markedly
White
These data
1979-82
Pima women up to
in
corresponding
This
during
were
Pimas
insulin262.
of
triglyceride
in
in
have confirmed
action
Lipid
the
45 and higher
unusual
the
measurements
the
with
in
as high
studies
to
resistant
lipids
plasma
twice
the
difference
Pimas during,
in
those
with
did
diabetes
in
40
kg
not
men
body mass index greater
m-2, and
been
to
have
findings
These
against
used
argue
mortality267.
predict
CHD
insulin
between
risk236.
and
resistance
causal relationship
than
83
a
(-onclusion
However,
inner-city
as with
groups
living
manner
as rates
mortality
of
1970 shows
on the
for
the
that
higher
in
causes
such
the
that
Pimas
group
low.
Only
low,
one possible
of
is
in
the
insulin
UK.
If
Pimas die
for
true
rates
CHD rates
it
then
is
or
is
CHD prevalence
in
differences
from
on the
CHD in
of
or
this
Pimas was indeed
data
prevalence
the
times
post-mortem
small
in
mortality,
remained
not
in
in
suggested,
VLDL catabolism
US Whites,
least
Mexican
other
aged
35-64
1980 the
0.81
was
appears
The most
men.
and Anglos
ratio
in
of
84
total
268
in
body
lower
and
levels
cholesterol
in
the
than
data
published
(non-Hispanic
CHD mortality
men and 1.06
(Table
women
be lower
recent
under
compared
triglyceride
similar
to
(area
area
triglyceride
Plasma
were
South
higher
had
women
higher
had
men
and Anglos
in
as
in
in Mexicans
in
serum
measures.
and
higher
are
insulin
test)
groups
genetic
be as high
the
higher
ratio,
in
levels
women, Mexican
Anglo
waist-hip
insulin
higher
31%
men and
in
with
American
southern
Mexican
values
Native
may not
the
(non-Hispanic
Anglos
reflectance
study
in
low-income
in
tolerance
a glucose
Mexican-Americans
where
but
Mexican-Americans
at
in
of
in
than
skin
San Antonio
the
in Mexicans
highest
lowest
Anglos
on the
in
is
and post-load
levels268.
differ
higher
times
the
Mexican-Americans
in
diabetes
proportions
during
higher
CHD mortality
Anglos
In
Compared
HDL cholesterol
Texas,
have
higher
26%
was
mass index,
mortality
If
in
prevalence
than
curve
Anglos
in
three
Fasting
47)268,270.
for
lie
may
highest
the
Mexican-Americans
levels
be known.
electrocardiographic
about
also
admixture269.
did
too
same
US Whites
three
predict
at
and the
non-insulin-dependent
groups
presumably
but
do not
is
for
the
the
of
and violence
infarction
number
in
about
.
alcoholism
determined
never
Diabetes
these
with
are
48)267
and obesity
This
data
with
240 Pima men aged 40-59
as the
States
Whites)268.
the
be interpreted
rates
(Table
deprived
earlier.
Prevalence
Asians
mortality
for
Comparison
1965-75
myocardial
explanation
mentioned
but
of
probably
relatively
during
diabetes
data
populations.
disease,
be reliably
to
society
US Whites
by 1975266.
will
United
in
than
prevalence
incidence
cannot
Pima cohort
that
reservation
of
more cohesive
as respiratory
relatively
mortality
age-specific
surprising
not
margin
US Blacks,
Whites)
Mexicans
women271.
For
to
average
on CHD
are
that
all-caus,
for
in
Conclusion
mortality
the
mortality
rates
ratios
SMRs for
the
Mexican-born
ischaemic
disease
disease
in
those
decade,
low
exceptionally
Similarities
Mexicans
mortality
and differences
and South
Asian/native
15-74
(Anglos
in
Illinois
in
from
in
reported
this
men and 68 for
had migrated
fitness
where
Mortality
was not
Mexican-born
1979-81,
33 and 58 in
were
= 100).
category
in
for
and selection
Chicago
aged
SMR was 51 for
Most
women.
Even lower
respectively.
metropolitan
as a separate
The all-cause
Mexican-born
Texas
for
recorded
heart
heart
previous
and 1.00
men and women respectively
study272.
the
were
all
0.97
were
this
group
during
the
for
may account
rates.
between
the
British
contrasts
Mexican/Anglo
in
in
comparisons
London
are
summarized
below: (i)
Prevalence
the
differences
load
glucose
native
(ii)
diabetes
of
between
are
Mexicans
than
smaller
both
in
South
in
and Anglos
the
Asians
insulin
the
differences
between
Mexicans
between
When South
Asians
differences
are
are
South
both
have
men
in
than
distribution
in
seen
Asian
overweight
compared
from
are
the
with
native
Asians
and
a
population,
waist-hip
British
is
overweight
ratio
but
no more
not
dissociation
This
men.
seen
are
rates
men but
high
rates
high
both
men and women compared
is
CHD mortality
in Mexicans
CHD mortality
in
women.
these
body
of
fat
in Mexicans.
in
Mexican
HDL
in
only
British
of
and Anglos
in Mexican
In South
women.
low
suggests
with
the
Asians
native
population.
are
One possibility
Asians:
despite
is
the
metabolic
that
insulin
for
explanations
possible
several
Mexicans
South
to
ratio,
seen clearly
Comparison
in
response
South
waist-hip
(iii)
There
but
sexes.
high
native
in
and Anglos
in Mexicans
and triglyceride
cholesterol
British
and Mexicans
British.
Differences
Hv)
high
is
the
patterns
suggest
are
that
85
low CHD rates
relatively
indicating
disturbances
data
the
insulin
quantitati,
insulin
resistance.
ely
-,
resistance
less
than
may not
in
Conclusion
be as extreme
values
Mexicans
up to
are
Another
in
generalized
central
from
obesity,
but
obesity
are
the
the
where
South
Asians
population.
syndrome
Asians:
insulilý
post-load
British
native
underlying
in
that
South
unlike
Asians,
as in
be that
could
different
qualitatively
South
as high
twice
explanation
as in
Mexicans
in
Mexicans
tend
who have an extreme
than
no more overweight
the
have
to
form
is
of
British
native
population.
Even
if
South
these
considerations
does
Asians
do not
than
Mexicans
than
Anglos.
important:
in
relevant
that
American
descent,
homogeneous.
origin
Relevance
from ischaemic
two cities
cholesterol,
higher
have
exceptionally
diabetes273,27/4
However
extremely
deprived
than
high
be
may also
and Native
study
suggest
that
from
protection
hybrid
of
vigour
is
of CHD may be
risk
age have a threefold
levels
of
have
higher
than
earlier
it
and higher
of healthy
a study
levels
Aboriginal
of
HDL
insulin
Australians
non-insulin-dependent
prevalence
Australians
is
higher
men had lower
the Scottish
the Swedish men169.
signs
of CHD
risk
at high
middle
prevalence
and also
as emphasized
Trinidad
high
at
found that
triglyceride
electrocardiographic
It
who may be more
than men in Stockholm:
disease
load
the
who have been
work.
phenomenon
populations
men in early
heart
a glucose
of
biological
populations
in other
men in these
after
Anglos
haý,e
this.
Edinburgh
relevant.
or
during
may also
migrants
European
mixed
be so
that
is
migration
as farm
they
plasma
influences
recent
considerable
the
to other
findings
of
Asians
may confer
for
such
The results
disease92;
basis
a possible
Similar
South
unlike
at
in
seen
men should
One possibility
are
are
same extent,
average
fitness
jobs
Mexican-Americans
cardiovascular
8.4.3
demanding
physically
genetic
mixed
for
Selection
the
atherogenic
most Mexican-Americans
employed
genetically
similar
fewer
to
CHD risk
in Mexican
and Anglos.
exposed
excess
to
rates
despite
in Mexicans
may have been
childhood
been
CHD mortality
US average,
the
levels
cholesterol
Mexican-Americans
affect
why the
explain
much lower
not
why the
can explain
difficult
populations.
86
of
rates
of
European
to
interpret
ischaemic
275,276
origin
CHD rates
in
uonclusion
8.4.4
to sex differences
Relation
in body fat
Sex differences
Although
higher
in men after
fat
body
of
on the trunk
body
fat
of
is associated
in both
insulin
load
levels
higher
slightly
sex differences
insulin
do not differ
fasting
surveys
immunity
relative
with
glucose
This
raises
central
uptake,
lipoprotein
and impaired
disturbances
insulin
and
levels
two questions
for
plasma HDL
why are
Second,
differences
sex
absence
of
the
in
in
insulin
greater
mass of
skeletal
to
the
by the existence
sensitivity
muscle
in
with
the
hypothesis.
fasting
fat
insulin
of
First,
on glucose
and post-load
are
pattern
how does
responsible
happen
this
plasma
in
the
levels?
insulin
response
load
to a glucose
of two equal
and opposing
factors:
muscle
in women but
a greater
of skeletal
available
action
in body
in the
The absence of sex differences
insulin
consistent
consistent
resistance
levels,
lipoprotein
difference
a
be
explained
may
insulin
differences
sex
if
display
-
The correlation
differences
no sex
there
the
with
of triglyceride
is weaker in women than in men205.
resistance
causes
glucose
associated
in European populations,
of women from CHD.
obesity
insulin9
least
at
and post-
between the sexes2771 or are
Similarly
there are no consistent
syndrome - plasma triglyceride,
and the composition
of LDL particles
differences,
sex
for
and glucose intolerance
in the insulin
sex difference
is no obvious
the
proportion
distribution
a central
resistance
cholesterol,
if
Although
in women than men278.
in the prevalence
diabetes
of
In contrast
tolerance.
have
men
a higher
puberty,
In population
either
is generally
hyperinsulinaemia
with
load.
to a glucose
made up by fat
and abdomen.
men and women, there
response
and metabolism
body
of
weight
the proportion
in women than
Dattern
to dispose
of a glucose
load
in men.
body
for
the
When obese men and women were matched
of
weight
proportion
higher
in
than
insulin
fat,
fasting
by
men
in
were
and post-load
made up
blood
in
insulin,
triglyceride
Levels
men at
pressure
and
of
womenl5l.
level
each
fat
body
of
mass were equivalent
fat.
In
body
a small study measuring
more
in 11 men and 13 women in Finland,
directly
insulin
by
an
maintained
However in the women fat
infusion
to those
of women with
steady-state
glucose
disposal
disposal
glucose
of
279
in men and women
the rate
was equal
accounted for a higher
8-1
20 kg
proportion
of body
Conclusion
in
than
weight
kilogram
of
the
so that
men,
tissue
muscle
the
rate
be 45% higher
to
was estimated
disposal
glucose
of
per
in
women than
men.
A possible
sex differences
insulin
of
discussed
to
synthesis,
and that
central
levels,
in
men.
This
acid
levels
turn
hypothesis
lower
are
have
adults
been
in
were
insulin
upon
disposal
the
acids
could
Black
and Afro-Caribbean
these
groups.
explain
Central
obesity,
factors
in
Although
association
with
cohort
of
fatty
of
free
that
action
free
in
this
a
of
fatty
in
pattern
diabetes
US
in
and HDL as CHD risk
triglyceride
between
sexes
it
syndrome,
women.
from
infarction
Prospective
a cohort
of
appears
such
are
studies
Gothenburg'76,180.
of
of
of
that
strength
risk
factors
associated
obesity,
glucose
as central
especially
waist-hip
792 men aged
sufficient
the
CHD incidence
incidence
1462 women aged
CHD contain
studies
factors,
resistance
follow-up
myocardial
the
of
in
men after
suppress
prevalence
fat
free
found
lipoprotein
of
low
HDL
cholesterol,
and
reported
13-year
high
intolerance,
comparison
CHD risk
insulin
CHD in
been
despite
men
a few prospective
of
intolerance
of
relatively
glucose
women for
of
the
favourable
body
studies
women than
to
acid
post-load
between
ability
fatty
free
12 volunteers
dissociation
in
men and women
only
numbers
No large
in
to
men than
of
in
and the
in
post-load
that
significantly
and
insulin-mediated
to
demonstrating
on
lower
ability
failure
with
distribution
of
the
VLDL triglyceride
levels
men.
with
hyperinsulinaemia
of
stimulates
more central
A similar
glucose
studies
by higher
one study
breakfast280.
standard
The metabolic
as resistance
women than
reported;
levels
acid
depends
pattern
in
VLDL triglyceride
by the
fat
may be associated
be explained
caused
body
a sex difference
levels
acid
as well
The higher
in
combination
obesity
acids
therefore
women could
fatty
fatty
the
fatty
is
acids.
that
free
disposal.
glucose
fatty
indicate
suppress
free
suppress
levels
free
suppress
earlier
failure
sex differences
lipoprotein
in
to
link
to
explanation
powerful
ratio
of
predictors
and CHD have
was examined
180
54 years
and
at
follow
was examined at 12-year
up of a
176.
38-60
based
The analyses
were
on small
88
uonclusion
numbers of events (91 new CHD cases in the men and 29 first
myocardial
infarctions
in the women).
From the published
data it is possible
to
for each study a ratio
for incidence
calculate
rates in two groups:
those whose waist-hip
40 percent of the
ratios
were in the highest
distribution,
whose waist-hip
of the distribution.
percent
7.1
and those
in Gothenburg
This
lowest
were in the
ratios
was 1.4 in Gothenburg
ratio
40
men and
Although
the numbers are small and the
in the two studies,
measurement techniques
and end points were different
this suggests that central
in
obesity
may be a more powerful risk factor
in men.
women than
In
Framingham
the
Study
in
Framingham
lipoprotein
1969-71:
levels
in women than
of CHD risk
The only
to coronary
cholesterol
study,
between
comparison
with
subset
the
of
the
number
original
of
cohort
are
weight
were stronger
predictors
of association
between
was about
equal
in both
reported
men and women is the Donolo-Tel
the
strength
for
this
found
also
of
severity
with
of HDL
of the relation
86
events
and
men
in
HDL
in men and women (Table
study
prospective
risk
correlated
more strongly
but
reported
to
and relative
patients
angiography
coronary
follow-
CHD incidence
of
in men; the strength
been
18-year
2815
on
men and women in
relation
this
men and women of
has not
CHD risk
women at
compared
analyses
291 events
with
in
diabetics
regression
large
other
CHD in
logistic
and CHD risk
LDL cholesterol
the
of
in
for
measured
sex have been
each
triglyceride,
cholesterol,
Aviv
were
follow-up
of
risk
men and 5.1
In univariate
given282.
48)282.
in
analyses
in
and length
cases
relative
fractions
Lipoprotein
UP281.
the
was 2.4
non-diabetics
with
not
women176,180.
in
women283;
a direct
of
association
of
dataset.
that
A study
disease
of
triglyceride
plasma
HDL
was
in
in women than
men243.
These
CHD in
diabetes
are
suggests
that
of
sex
Asians
women than
to
sufficient
the
of
insulin
in
differences
examination
high
the
Blacks.
and
abolish
CHD risk.
both
of
syndrome
This
in
is
groups
89
in
or
This
CHD risk.
principal
in
CHD risk
in
cause
by
supported
differences
sex
relative
obesity
central
be
the
may
hypothesis
differences
sex
these
of
difference
sex
the
higher
with
asociated
The effects
men.
resistance
patterns
In
in
are
high
diabetes,
ratio,
waist-hip
low
HDL
cholesterol
and
triglyceride
risks
suggests
results
for
that
South
triglyceride
ý-onclusion
and HDL levels
have
the
have
a lipoprotein
lipoprotein
attenuation
Asians
8.5
the
parallels
hypothesis
first
of
to
possible
food
genes
by Nee1133.
food
interference
to
spare
of
glucose
glucose
for
traits
with
high
have
led
diabetes
differences
isolated
survival
powerful.
fat
This
CHD risk.
depended
for
Similar
the
develop
for
conditions
of
fuel
would
allow
starvation,
and
free
that
ensure
when
and causing
lipolysis
suppressing
of
food
active
Under
would
obesity
surviving
peripheral
is
It
development
the
explain
under
levels.
fat,
in
idea
general
for
activity
to
suggestion
non-insulin-dependent
than
physical
exertion:
the
need
for
against
the
resistance
the
fatty
this
acids
would
ketogenesis
such
on long
the
selection
in
storage
would
have
or
would
of
medical
to
survive
pressure
the
it
associated
of
emergence
possible
acted
would
than
would
sex
resistance.
Australians,
starvation
may have
90
is
to
rather
insulin
and
and Aboriginal
journeys,
these
childbearing
of
to
is
care
extra-abdominal
led
of
have predisposed
obesity
central
Pimas
as
desert
ability
absence
expression
The requirements
to
susceptibility
populations
selection
in
for
depots.
in
and South
original
more metabolically
operated
mortality.
selection
intra-abdominal
to
insulin
which
perinatal
to
women
protein.
since
women,
to
minimizing
have
may
pressure
gestational
brain,
the
of
advantages
insulin
used
were
physical
by muscle
uptake
from
gluconeogenesis
in
being
action
glucose
Selective
fat,
locomotion
with
than
rather
men
genotype'
his
risk
A tendency
obvious
the
stimulating
This
have
been
may
selected
have
quickly.
resistance
men.
Blacks
'thrifty
the
high
confer
syndrome.
be mobilized
to
Asian
in
Although
hypothesis
this
body
Central
energy
South
has been abandoned,
and high
scarcity
would
was abundant
less
which
countries
resistance
scarcity.
in
Black
effect,
European
of
sex differences
of
mechanism
reformulate
insulin
the
that
was made to
developed
developed
conditions
that
attenuation
In
women, while
lipoproteins
in
reference
plausible:
in
European
of
resembling
a pathopbysiological
diabetes
Europeans.
considerations
I brief
remains
in
than
sex differences
of
In Section
In
pattern
pattern
Evolutionary
for
be less
to
tend
to
whose
imagine
have been
upon the
group
that
Conclusion
first
South
settled
Subsequent
intake
physical
in
first
appeared
populations
8.6
form
the
The rarity
intervention
avoidance
of
smoking
South
Asians
indicates
that
for
in
is
no less
for
Strategies
aetiological
fraction
of
CHD prevention
in
UK emphasize
dietary
fat
for
large
a
of
of
South
disease
the
to
and reduction
The distribution
urban
amenable
risk
Asians
are
which
are
the
CHD
and plasma
factors,
these
have
would
rose.
populations.
factors
energy
and the
possibilities
below.
reviewed
Smoking
than
have
surveys
where
a powerful
in
men studied
in
survey
smokers
Only
in
groups
in
of
the
South
Asian
South
most
have
can
smoking
both
in
Muslims
from
South
smoking
Asian
not
a modest
only
Pakistan
Asian
control
groups
doubt,
and Bangladesh.
on total
the
rates
CHD rates
are
that
Gujarati
Hindus,
Among Sikhs
91
population.
already
rates
all
migrants
between
are
these
in
already
to
policies
in
men
uncommon in
rates
CHD rates
will
In our
smoking
remains
smoking
Sikh
of
Hindu
general
smoke
Sikhs,
smokers.
high
are
in
are
association
on CHD rates
that
patients
first-generation
follows
it
common to
smoking
the
since
effect
indicates
and are
sexes
in
communities
evidence
epidemiological
occur
is
in
Although
now occurring.
CHD
risk
and
smoking
least
women, at
the
Smoking
for
Gujarati
group)
small
to
3 percent
are
of
men in
of
population29.
native
London
likely
case
rates
only
1982 34 percent
(a
relatively
men
Bangladeshi
than
in
38 percent
with
compared
among whom CHD is
in
London
north-west
were
higher
current
smoking
in west
survey
the
also
exists:
prohibition
less
men are
is
The lowest
religious
our
Asian
and this
men18,33,60
infarction22.
myocardial
South
shown that
British
native
with
of
account
diabetes
and intakes
European
on identifying
intervention,
Several
all
in
than
strategies
cholesterol.
low
India
rural
and which
Current
in
a high
of
through
spread
fell
subcontinent.
be associated
would
carbohydrates:
expenditures
prevention
the
availability
later
and
affluent,
Indian
depend
prevention
8.6.1
and refined
CHD in
in
preventable
for
fat
for
of
cases.
and with
as energy
Implications
the
activity
the
in
arrival
development
and economic
of
in
before
perhaps
urbanization
less
with
Asia,
control
groups.
South
Punjabi
The
Asians
Sikhs
and among women of
low
that
so
be negligible.
the
effect
and
Uonclusion
8.6.2 Diet and vlasma cholesterol
.
The 1984 report of the Committee on Medical
(COMA) recommended that the average dietary
UK population
from 20 percent
alcohol)
to 15 percent,
and that
increase
from 0.23
to
allowed
saturated
to 0.45284.
fat
and polyunsaturated
of Food Policy
fat
saturated
be reduced
should
(excluding
Aspects
intake
of total
of the
intake
energy
the P/S ratio
be
should
The relationships
dietary
of
to plasma cholesterol,
and the
to CHD risk underpinned the
of plasma cholesterol
basis of these recommendations and similar
scientific
advice from other
The Committee did not give a target
level for the
sources284-286.
relationship
average
from standard
formulae58
have lowered
the average
about
6.1 mmol/I
There
have been
in
adults
up most
for
national
Asian
population18,60.
12% of
total
energy
average
18%18.
of
1985 confirmed
higher
the
fat
saturated
intake
The relationship
COMA recommendations
CHD.
levels
cholesterol
would
be achieved
diet
Although
relatively
compared
fat
with
intakes
holds.
British
applicable
dietary
the
are
is
This
in
this
not
to
dispute
but
saturated
only
Asians,
South
fat
to
intakes
group:
make
fat
with
0.28
with
below
already
only
cholesterol
if
also,
in
imply
population
the
point
at
out
least
and plasma
92
that
that
in
for
are
saturated
relationship58
not
some groups
cholesterol
the
average
standard
they
that
Bangladeshis
COMA recommendations
the
levels
Gujaratis,
levels
of
implemented.
were
for
the
average
the
are
the
native
necessarily
average
already
in
data
separate
prevention
Sikhs,
a
in
underpinned
dietary
on
except
available
since
Hindus
investigators
of
levels
advice
are
group
to
this
cholesterol
groups
all
British
low
population
to
plasma
native
in
Asian
compared
compared
group
South
given.
Asians
are
from
saturated
Asians
was 0.85
COMA recommendations
data
average
the
in
1982,
South
by another
similar
South
if
survey
low
fat
that,
in
in
in
Gujarati
where
P/S ratio
not
were
and all
47 shows
Table
dietary
dietary
of
intake
survey
changes would
intake
In
The P/S ratio
A second
dietary
dietary
London
north-west
be
may
estimated
age.
of
South
UK population.
for
in
it
of the UK population
to 5.6 mmol/1 in middle
surveys
but
these
plasma cholesterol
two population
the
of
implementing
that
UK, both
the
accounted
the
of the UK population
plasma cholesterol
at
or
Conclusion
below
levels
the
specifically
recommended for
to ethnic
minorities
acids284.
Adoption
fatty
saturated
in South Asians
guidelines
should
Conclusion
While
smoking
South
the
South
Asian
Asians
Gujarati
in
South
reducing
at
South
suggests,
physical
Asians
mmol/1
for
activity
preventing
of
these
measures
to
attitudes
with
insulin
factors
communities
risk
of
Further
studies
in
South
such
may also
Asian
the
are
high
as obesity
the
measures
required
at
to
be necessary
for
strategies.
93
effective
cholesterol
risk
of
CHD
thesis
such
as increased
most effective
define
the
means
efficacy
Understanding
risk.
and physical
for
metabolic
as this
may be the
populations
data
If
of
dietary
plasma
plasma
resistance,
obesity
the
in
rates
average
by a syndrome
within
that
average
but
ameliorative
and control
excess
possible
the
be sufficient.
mediated
at
is
further
is
those
CHD.
It
the
be effective,
even
may not
overseas
then
groups.
lowering
CHD risk
predict
explain
still
dietary
still
amenable to intervention.
do not
would
that
associated
of
other
CHD prevention
plasma cholesterol
may well
they
aimed
Asians
disturbances
cholesterol
with
5.0
than
fatty
from the
consumption
to set more radical
either
pathways
population,
women suggest
less
to apply
low in saturated
For effective
group.
the average
compared
in
cholesterol
to
in this
other
fat
saturated
be necessary
will
and plasma
intervention
Asian
it
or to identify
8.6.3
consumed a diet
of average
aimed at reducing
further,
intended
were not
of the COMArecommendation that
account for 15 percent of energy intake
12 percent
of
The Committee
by Gujaratis
acids
level
recommendations
who already
would mean an increase
present
its
that
stated
the UK population.
activity
in
South
intervention
Appendix
Table
1-
CHD mortality
Country
Period
of
in
South
Groups
A
Asians
overseas
Rate
contrasted
rat io
Age
study
range
Sex
(age-adjusted)
Singapore
1957-78
Indians/Chinese
20-69
M&F
3
South
1957-77
Indians/Europeans
30-69
M&F
1.5
Uganda
1956-58
S Asians/Africans
30-
m
not
given
England
1970-72
S Asians/UK-born
20-69
M&F
1.2
(M),
Fiji
1971-80
Indians/Melanesians
20-
M&F
3
Trinidad
1977-85
Indians/Africans
35-69
Africa
94
M
2.6
1.3
(F)
A
Appendix
2-
Table
from
Mortality
aged 20-64
(a)
Standardized
in
coronary
heart
disease
boroughs,
London
for
to the average
among South
1979-83
each boroug
Standardized
Number
of
Asians
mortality
Proportional
ratio
(%) and 95% CI
deaths
mortality
W
ratio
Males
Brent
& Harrow
(Gujarati)
(Punjabi)
Ealing
177
163
138-187
146
118
136
111-161
122
Tower Hamlets
(Bangladeshi)
49
118
85-151
132
Waltham Forest
(Pakistani)
36
180
121-239
121
(Gujarati)
33
157
103-211
145
30
173
111-235
158
(Bangladeshi)
2
(106)
-
(136)
(Pakistani)
7
(318)
Females
& Harrow
Brent
(Punjabi)
Ealing
Tower
Hamlets
Waltham
(b)
.
Forest
Standardized
to the average
for
England
Standardized
and Wales
95%
confidence
mortality
(%)
ratio
(268)
interval
Males
Brent
& Harrow
(Gujarati)
(Punjabi)
Ealing
160
136-183
147
120-173
Tower Hamlets
(Bangladeshi)
141
102-180
Waltham Forest
(Pakistani)
156
105-207
(Gujarati)
160
105-215
206
132-280
Tower Hamlets
(Bangladeshi)
(108)
-
Waltham Forest
(Pakistani)
(217)
Females
Brent
Ealing
& Harrow
(Punjabi)
95
Appendix
Table
3-
Year
Ref.
Surveys
A
in India
of serum cholesterol
Place
Population
and Pakistan
Age
sampled
Mean serum
cholesterol
Males
1969
42 Delhi
high-income
rural
1982
1959
44 Uttar Pradesh
(Agra)
higher
1971
45 Uttar Pradesh
(Aligarh)
blood donors
voluntary
blood
donors
paid
1966
46 Bihar
(Patna)
1972
47 Bihar
(Ranchi)
middle to moderate
income
19,178
socioeconomic
income
middle
lower income
economically
privileged
upper
lower
social
classes
social
classes
academics
low income
49 Punjab
hospital
higher
1980
middle
groups
1956
51 Tamilnadu
(Coonoor)
1983
52 Tamilnadu
1982
5" Pakistan
(Peshawar)
4.5
31-60
5.3
4.8
4.5
55-
4.7
4.0
"Adults"
4.9
35-
5.9
4.2
4.5
36-51
5.6
5.1
outpatients:
classes
social
5.7
304.4
classes
middle/lower
50 Andhra Pradesh
(Kakinada)
31-50
employees:
48 Rajasthan
(Bikaner)
(Jullundur)
4.5
4.8
workers
43 Delhi
1976
30-59
workers
industrial
Females
6.2
group
industrial
(mmol/1)
31-60
4.6
high socioeconomic
low socioeconomic
40-49
4.4
3.3
Not stated
30-39
5.7
manual workers
33-48
4.8
& low income
*
96
estimations
4.4
4.3
5.4
on plasma or whole blood
Appendix
Table
Year
4Ref
Surveys
of
serum
Place
A
in
cholesterol
Population
South
sampled
No
Asians
overseas
Age
Mean serum
range
cholesterol
(mmol/1)
Males
1959
7
Uganda
GP attenders
Females
40-
6.6
35-54
5.0
5.3
35-69
5.9
6.0
(Kampala)
1968
54 Guyana
Lower
socio-economic
(Annandale)
1977
55 Trinidad
(Port-of-Spain)
and lower
Middle
socio-economic
1980
53 Surinam
(Nickerie)
Lower
socio-economic
33-48
5.3
1985
31 Fiji
Urban
and rural
30-69
4.8
18-56
4.8
residents
1987
152 Singapore
Pre-employment
screening
1982
18
England
(NW London)
Urban residents
25-65
5.0
1988
60
England
(NW London)
Urban residents
45-54
5.4
1988
29
England
(East London)
Urban residents
35-69
5.5
*
97
estimations
4.3
5.4
on plasma
Appendix
Table
5-
Year
Ref.
Surveys
diabetes
of
Place
no
Using
a 50g glucose
77
1966
19 1
84
A
in
prevalence
1973
2-hour
sampled
cut-off
value
(mmol/1)
1977
Using
East
Urban
Pakistan
residents
glucose
Orissa
Urban
Whole blood
glucose > 9.5
Whole blood
and rural
and rural
low-income
Calcutta
Trinidad
a 75g glucose
1983
81
Fiji
1985
86
Durban
1988
87
Karnatka
1988
29
London
1989
For
1985
1989
89
sample
Sex
Age
Prevalence
range
load
outpatients
13
Asians
Population
residents
85
South
urban
load
30-
1%
M &F
30-
2%
Whole blood
M &F
glucose > 10.5
7.8
>
or
30-
5-15%
35-69
19%
22%
glucose
plasma
M
F
> 11.0
mmol/l
m
F
35-
25%
22%
M&F
30-
22%
urban
residents
M&F
35-44
45-64
9%
29%
Bangladeshis
M&F
35-69
23%
40-59
'0%
urban and rural
residents
residents
Coventry
> 9.5
Whole blood
glucose > 8.9
residents
and 2-hour
M&F
mainly
Puniabis
COMDarison:
88 London
89 Coventry
An interval
is
side
either
WHO criteria.
European
sample
mainly
Europeans
given
of
break-points
since
the cut-off
value
98
in
that
the
M&F
40-
5%
M&F
40-59
4%
table
original
be
equivalent
would
lie
to
1980
A-
Appendix
6-
Table
Risk
Sample size
factor
East
for
estimates
difference
20 percent
give
in
mortality
66 percent
compared
British
to
Elevated
total
serum
cholesterol
38 percent
a relative
0.8
higher
compared
factor
clotting
levels
0.26
in
77
mean
data)
82
prevalence
with
6 percent
g/1 difference
plasma
2
(Whitehall
men (Whitehall
British
smokers
39
unpublished
intolerance
a=n=0.0,, -)
men
)
pressure
27 percent
of
in
Study93
49
in mean
(Northwick
fibrinogen
Park Study134 )
140
99
(no.
group)
in
9 mmHg difference
Glucose
each
smoking
British
men than
size
of
risk
cholesterol
Study,
in
current
men (assuming
mmol/l
Sample
for
Asians
of
(Framingham135
Elevated
higher
Mean serum
blood
estimated
Asians
with
carry
Asian
Hypertension
Study
East London Study
Hypothetical
to
Smoking
London
Appendix
Table
7: Definitions
East
A-
drinking
of
London
categories
Study
in the Quantity-Frequenc-.
Index142
Number of
Frequency
Most
of
drinking
1-2
units
on a typical
3-4
5-6
occasioi-i
7 or
more
days
Three or four
times
Once or twice
a week
a week
Once or twice
a month
Once or
in
twice
six
FREQUENT
MOD-
LIGHT
ERATE
INFREQUENT LIGHT
months
OCCASIONAL
Once or
twice
in
the
year
100
HEAVIER
MODERATE
ý
Appendix
Table
8-
Response rate
A-
clinic
London
(Percent)
253
(66)
55
(14)
Interviewed,
non-attender
Refused
Unfit
interview
/ in hospital
Not at home
Total
resident
Moved away
Study
in the East London Study
No
Attended
East
58
4
12
382
(100)
173
Dead
2
Total
557
101
Appendix
TABLE 9-
Numbers
A-
attending
East
field
Female
Non-Asian
Asian
17
22
3
45-54
35
35
38
55-64
22
31
4
18
65-69
2
2
76
90
45
42
Age
35-44
All
vr
Study
by age,
station
Male
Asian
London
Non-Asian
12
102
sex and ethnic
category
A-
Appendix
Table
10 - Daily
(PERCENT)
Non-smoker
1-15/day
16 or more
TOTAL
London
Male
Asian
Study
smoked by sex and ethnic
cigarettes
FREQUENCY
East
category
Female
Non-Asian
Asian
Non-Asian
17
54
50
28
(18)
(55)
(78)
(61)
55
11
14
7
(59)
(11)
(22)
(15)
22
34
0
11
(23)
(34)
(0)
(24)
94
99
64
46
103
A-
Appendix
Table
11 - Alcohol
in
as
classified
General
(PERCENT)
Asian
Abstainer
Occasional
Frequent
Moderate
Heav i er
TOTAL
Household
light
light
Study
by sex
and ethnic
category,
Survey142
Male
FREQUENCY
Infrequent
pattern
consumption
the
London
East
Female
Non-Asian
Asian
Non-Asian
88
10
64
6
(93)
(10)
(100)
(13)
0
6
0
16
(0)
(06)
(0)
(35)
2
11
0
6
(2)
(11)
(0)
(13)
2
31
0
17
(2)
(30)
(0)
(37)
1
21
0
1
(1)
(20)
(0)
(2)
2
24
0
0
(2)
(23)
(0)
(0)
95
103
64
46
104
Appendix
Table
12:
Coronary
(age-adjusted
Means
heart
for
East
A-
disease
all
smokers
(%)
Study
factors
risk
variables
by sex and ethnic
height)
± standard
except
Males
Non-Asian
Asian
Current
London
82%
(cm)
Asian
45%
165 tl
Non-Asian
22%
39%
NS
171 ±1
151 ±1
160 ±1
P<O. 001
P<0.001
Body mass
index (kg M-2
23.9
±0.4
23.71 ±1.0
P<0.001
Systolic
blood
pressure
(mmHg)
Diastolic
blood
pressure
(mmHg)
119 ±2
129 ±2
78 ±I
113 ±3
12 3±3
P<0.05
81 ±i
75 ±3
78 ±2
NS
(9/1)
3.03
NS
3.14
±O. 11
±O. 10
3.04
±O. 12
NS
factor
Plasma
(% of
Plasma
Percen t
Serum
5.53
HDL cholesterol
(Mmol/1)
1.13
total
cholesterol
as HDL
triglycerides
(Mmol/1)
insulin
(mU/1)
105 ±3
97 ±7
NS
6.02±0.13
±0.15
5.37
P<0-05
± 0.04
1.43±0.04
1.19
±0-08
22.4
±1.5
1.76
±0.22
±0.13
1.45
±0 . 05
25.2
±1 .0
1.77
±0.26
1.10
±0 11
.
P<0.01
P<0.001
32 ±4
65 ±8
±0 . 18
NS
P<0.01
2.59
6.09
P<0.05
25.3±0.9
±1.0
±0.25
p<0.05
P<0.001
21.3
±O. 09
99 ±1
P<0.01
total
cholesterol
(MM01/1)
3.17
NS
90 ±4
value)
reference
Plasma
Plasma
V11c
26.1 ±0. '/
p=0.06
P<0.001
fibrinogeD
Plasma
26.6
±0.4
errors
Females
P<0.001
Height
categorý-.
P<0.001
105
57 ±13
P<0.01
27 ±4
A-
Appenaix
13 - Height (cm) by age,
Means ± standard errors
Table
East
London
sex and ethnic
Men
Asian
35-44
Study
category
Women
Non-Asian
166
171
±1
±2
Asian
40-49
45-54
166
173
±1
±1
165
168
±2
±1
ALL
ALL
165
171
±1
±1
160
±3
50-59
55-
Non-Asian
106
150
160
±2
±1
151
160
±1
±1
Appendix
Table
14 - Weight
Means ± standard
(kg)
A-
by age,
East
London
Study
sex and ethnic
category
errors
Men
Asian
35-44
Women
Non-Asian
67.0
74.5
±2.5
±2.1
Asian
40-49
45-54
66.7
80.8
±1.9
±2.1
50-59
55-
63.9
77.3
±2 -0
±1 -9
ALL
ALL
65.9
78.0
±1.2
±1.2
107
Non-Asian
58.6
67.3
tl. 7
t5.3
53.0
66.2
±2.1
±3.6
56.2
66.5
±1 .4
±2.9
Appendix
Table
15 - Body mass index
Means ± standard
A-
(kg
East
m-2)
London
by age,
Asian
Non-Asian
24.2
25.4
±0.9
±0.6
Asian
24.3
26.8
±0.6
±0.5
50-59
55-
23.5
27.3
±0.5
±0.7
ALL
ALL
category
Women
40-49
45-54
sex and ethnic
errors
Men
35-44
Study
24.0
26.7
tO. 4
±0.4
108
Non-Asian
25.6
26.3
+0.7
±2.2
23.5
25.8
±0.8
±1.2
24.7
26.0
tO. 5
ti
I
Appendix
Table
16 - Systolic
Means ± standard
A-
blood
East
pressure
London
(mmHg) by age,
Asian
Women
Non-Asian
116
119
±4
±3
Asian
40-49
45-54
118
122
±3
±2
50-59
55-
122
144
±3
±4
ALL
ALL
sex and ethnic
errors
Merl
35-44
Study
119
129
±2
±2
109
Non-Asian
115
110
±3
±4
109
126
±4
±4
112
122
±2
±3
category
A-
APpencilx
Table
17 - Diastolic
Means ± standard
blood
East
pressure
London
(mmHg) by age,
Asian
Non-Asian
79
78
t3
±3
Asian
78
80
±2
±2
50-59
55-
78
84
±3
t2
ALL
ALL
categurý
Women
40-49
45-54
sex and ethnic
errors
Men
35-44
Study
78
81
±1
±1
110
Non-Asian
76
7
±2
±2
'13
-9
1
±2
±2
75
79
±2
±2
IV
Appendix
Table
18 - Mean plasma
Means ± standard
A-
fibrinogen
East
London
(9/1)
by age,
Asian
Women
Non-Asian
2.85
2.65
±0.20
±0.12
Asian
40-49
45-54
3.12
3.41
tO. 18
±0.21
50-59
55-
3.23
3.32
±0-14
±0.13
ALL
ALL
sex and ethnic
errors
Men
35-44
Study
3.12
±O 11
.
3.19
±0.10
ill
Non-Asian
3.08
2.94
±0.12
±0.16
3.19
3.21
±0.22
±0.14
3.13
3.12
tO. 12
to. 11
categorY
A-
Appendix
Table
ethnic
19 - Factor
category.
VIIc
East
as percent
Means ± standard
London
of
Study
reference
value
35-44
Women
Non-Asian
97
105
t7
t7
Asian
40-49
45-54
85
104
±5
±6
50-59
55-
89
106
±6
±6
ALL
ALL
sex and
errors
Men
Asian
by age,
89
105
±3
±4
112
Non-Asian
101
96
±8
±12
89
97
±5
±6
96
96
±5
±6
Appendix
Table
20
Fatty
acid
composition
London
of cholesterol
(Means ± standard
category
East
A-
Study
esters
by sex and ethnic
errors)
Female
Male
Non-Asian
Asian
Saturated
(%)
14.2
±0.3
(38)
(31")
(44)
(27)
Non-Asian
Asian
12.8
±0.2
14.2
tO. 2
12.3
tO. 2
P<0.001
P<0.001
Polyunsaturated:
w6 series
(%)
56.6
58.3
±lA
±1.1
55.3
NS
w3 series
2.78
±0-22
Ratio
of
polyunsaturated
to
tO. 18
60.1
±0.9
P<0.01
2.23
±0.17
3.38
tO. 16
2.72 tO. 16
P<0.01
p=0.05
4.28
±0.9
4.81
tO. 14
4.21
±0-14
5.21
P<0.001
P<0.05
saturated
113
±0.14
Appendix
Table
21: Prevalence
A-
East
diabetes
of
by age,
Study
sex and ethnic
Non-Asian
Asian
Non-Asian
35-44
2/17
1/22
1/2
0/12
45-54
10/32
4/34
9/36
0/11
55-64
4/22
3/28
0/3
3/18
All,
22%
10%
23%
age-
category
Female
Male
Asian
London
4%
adjusted
Mantel-Haenszel
odds
ratio
Asian/non-Asian
114
= 3.1
(p<0.01)
Appendix
22 - Insulin-glucose
Known diabetics
excluded.
Table
A-
East
ratio
London
(mU/mmol) by age,
Means t standard
Men
35-44
Asian
Non-Asian
14.7
6.9
±1 .6
±0.8
15.5
7.9
±2.7
±1 .0
15.4
8.9
±3 -9
±1 ,7
ALL
ALL
errors
Asian
50-59
55-
sex and ethnic
Women
40-49
45-54
Study
15.2
8.0
±1.6
±0.7
115
Non-Asian
12.2
6.8
±1.9
±1 .2
11.8
6.9
tl. 8
tl. 1
12.0
6.8
±1.3
±0.8
categorý--
Appendix
23 - Insulin-glucose
Known diabetics
category.
Table
A-
East
ratio
London
Study
(mU/mmol) by time
Means ± standard
excluded.
Men
Asian
<105 min
105-134
min
>134 min
ALL
of sampling,
errors
Women
Non-Asian
13.7
9.7
±1.2
±1.7
18.7
7.4
±3.6
±0.7
13.4
4.7
±7 .5
±1 .2
15.2
8.0
±1 .6
±0.7
Asian
Non-Asian
11.4
10.5
±1.9
±2.5
105-134
13.9
6.6
min
t2.2
tO. 9
>134 min
10.9
3.3
±2.7
±0.4
12.0
6.8
tl. 3
tO. 8
<105 min
ALL
116
sex and ethnic
A-
AppenciiX
24 - Percent total
Means t standard errors
Table
East
cholesterol
London
Study
as HDL by age,
Men
Asian
35-44
Women
Non-Asian
19.6
27.8
tl .3
t2.5
Asian
40-49
45-54
21.9
24.8
±1.5
±1 .6
50-59
55-
21.5
23.8
tl .4
tl .4
ALL
ALL
sex and ethiiic
21.2
25.2
±0.8
±1.0
117
Non-Asian
20.6
28.5
±1.1
±3.1
20.2
25.8
to. 9
t2.0
20.4
26.7
tO. 7
tl .7
cattgory
Appendix
Table
25 -
Age-
A-
East
London
and ethnicity-adjusted
Study
correlations
Total
chol
HDL
-0.149
chol
Tri-
HDL
chol
0.472
glyceride
Tri-
-0.381
**
glyceride
Insulin
0.213
Insulin
0.064
-0.195
0.287
Systolic
0.192
0.050
0.084
BP
BP
Diastolic
Systolic
0.103
0.069
0.098
0.181
0.686
BP
BP
Body mass
Diastolic
0.328
-0.210
0.411
0.352
0.234
index
* P<0.05
**P<O. 01
118
0.315
- men
Appendix
Table
A-
East
London
26 - Age- and ethnicity-adjusted
Study
correlations
Total
chol
HDL
0.223
chol
chol
Tri-
0.319
Systolic
-0.334
**
glyceride
Insulin
HDL
-0.065
-0.304
0.169
0.112
Triglyceride
0.120
-0.068
Insulin
0.129
BP
BP
Diastolic
Systolic
0.228
0.019
0.012
-0.151
0.498
**
BP
Body mass -0.118
-0.249
0.409
0.408
0.118
index
* P<0.05
**P< 0.01
119
Diastolic
BP
0.015
- women
Appendix
Table
27:
A-
Age distribution
Pilot
of
investigation
participants
South
Asian
European
Other
Age (years)
40-49
30
52
8
50-59
10
78
4
60-65
5
37
2
45
167
14
TOTAL
120
in
Finchley
by ethnic
group
Appenclix
Table
Pilot
A-
28: Age-adjusted
means for
investigation
in
anthropometric
South Asian
Height
(cm)
167
Weight
(kg)
-16.1
P<0-001
24.3
25.3
NS
5.5
5.4
NS
11.8
12.1
NS
skinfold
(mm)
21.5
18.3
P<0.05
skinfold
(mm)
27.5
23.2
P<0.01
15.9
13.7
])<0.05
0.933
0.920
NS
2.35
2.26
p<0.05
127
126
81
80
(mm)
Anterior
skinfold
skinfold
thigh
(mm)
skinfold
Waist/hip
ratio
Abdominal
diameter/hip
Systolic
Diastolic
European
68.6
Biceps
Supra-iliac,
groLip
P<O.001
(kg M-2
Subscapular
by ethnic
varlables
172.8
Body mass index
Triceps
Finchley
blood
blood
pressure
pressure
(mm)
ratio
(mmHg)
(mmHg)
.2
121
NS
NS
iilot
29: Age-adjusted
Table
Known diabetics
investigation
means for
metabolic
(mmol/1)
(mmol/1)
(mmol/1)
in
Fasting
2
hours
and
(mU/1)
insulin
serum
2-hour
5.79
5.84
NS
1.18
1.19
NS
1.22
1.12
NS
triglyceride
fasting
between
+3%
-5%
P<0.01
9.4
7.7
P<0.05
20.5
p<0.001
21.2
p<0.01
(mU/1):
insulin
serum
adjusted
for
age only
36.1
adjusted
for
height
and
age
32.3
Fasting
2-hour
plasma
plasma
Fasting
plasma
(mmol/1)
glucose
(mmol/1)
glucose
fatty
free
plasma
free
fatty
(peq/1)
Ratio
free
of
fatty
2-hour
acid
to
5,3
5.2
NS
5.3
4.8
NS
364
400
NS
141
127
NS
acids
(peq/1)
2-hour
EuroDean
triglyceride
plasma
Change
Asian
HDL cholesterol
plasma
Fasting
group.
cholesterol
plasma
2-hour
measurements by ethnic
are excluded.
South
Fasting
in Finchley
acids
fasting
level
0.41
122
0.34
p=0.06
Table
investigation
in
indices
fasting
ranked by strength
of association
(adjusted
for age and ethnicity)
of obesity
serum insulin
Percent
variance
L3-4
FinchleY
30
Anthropometric
with
Pilot
A-
Appendix
/
waist
Smallest
/
waist
16.1%
P<0.001
15.6%
P<0.001
15.6%
001
P<O.
14.5%
001
P<O.
13.2%
P<0.001
8.5%
P<0.001
6.0%
P<0.001
hip
ratio
circumference
Trunk
explained
level
hip
ratio
circumference
Significance
skinfolds
(supra-iliac
+ sub-scapular)
Body mass index
/hip
diameter
Abdominal
circumference
ratio
Average
/
waist
circumference
thigh
ratio
Arm skinfolds
(biceps
+ triceps)
123
investigation
in
Finchley
31
Table
indices
Anthropometric
with
Pilot
A-
Appendix
2-hour
ranked by strength
of obesity
serum insulin
(adjusted
for
age and ethnicity)
Percent
Significance
variance
Trunk
explained
level
skinfolds
(supra-iliae
+ sub-scapular)
/
diameter
Abdominal
circumference
ratio
Smallest-waist
/
waist
/
ratio
Body mass index
waist
circumference
P<0.001
4.3%
P<O.01
4.1%
P<0.01
3.1%
P<0.01
3.1%
P<0.01
2.5%
05
P<O.
2.2%
p<O. 05
hip
hip
circumference
Average
5.7%
hip
ratio
circumference
L3-4
of association
/
thigh
ratio
Arm skinfolds
(biceps
+ triceps)
124
LO
Cf
cc
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ct
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Cý
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ý
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-W
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cli
cl'ý
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A-
Appenclix
Table
34:
Principal
Pilot
component
analysis
in
of
Finchley
relationships
and metabolic
measurements
arithropometric
investigation
measurements
between
related
tolerance
Eigenvectors
1
Percent
standardized
of
explained
variance
14%
30%
Loadings
fatty
free
Fasting
fatty
free
2-hour
acids
acids
insulin
Fasting
insulin
2-hour
Fasting
glucose
2-hour
glucose
(TG)
triglyceride
Fasting
in
Change
TG from
fasting
HDL cholesterol
Waist-hip
Trunk
ratio
skinfolds
Body mass index
Systolic
Diastolic
blood
blood
pressure
pressure
to
2h
10%
on variables
0.08
0.51
03
-.
0.19
0.13
0.36
04
-.
01
-.
21
-.
0.29
0.20
31
-.
0.19
0.22
0.17
0.41
25
-.
25
-.
0.28
0.08
0.24
38
-.
16
-.
0.02
27
-.
0.37
0.18
0.26
0.09
0.36
21
-.
17
-.
0.33
24
-.
0.20
0.22
0.34
0.48
0.19
0.21
0.59
127
0.12
to
glucose
?,q)penci1X A-
Table
Preliminary
35: Age distribution
European
findings
from
Diabetes
of participants
and Coronary
by ethnic
South
Afro-
Asian
Caribbean
Other
Age (years)
40-49
193
180
16
3
50-59
141
97
25
2
60-66
40
13
4
0
TOTAL
128
group
Risk
Study
A-
,RppenalX
Table
36:
findings
Preliminary
Age-adjusted
means for
from
anthropometric
South
Body mass index
Triceps
Supra-iliac
Anterior
Asian
by ethnic
European
NS
10.6
10.5
NS
skinfold
(mm)
21.5
18.3
p<0.001
skinfold
(mm)
25.4
20.8
P<0.001
thigh
m-2)
(mm)
skinfold
(mm)
13.1
12.8
NS
skinfold
(mm)
9.3
10.2
01
P<o.
0.931
P<0.001
2.17
P<0.001
126
122
P<0.01
81
77
P<0.001
Waist/hip
ratio
0.971
Abdominal
diameter/hip
2.26
Diastolic
variables
Risk
25.9
Supra-patellar
Systolic
and Coronary
25.6
skinfold
Subscapular
(kg
Diabetes
blood
blood
pressure
pressure
ratio
(mmHg)
(mmHg)
129
Stud. v
group
findings
t-reiiminary
Table
37:
Measures
Means with
standard
of
obesity
deviations
from Diabetes
by age and ethnic
in
and Coronary
group
parentheses
South
Asian
European
25.6
25.8
(3-6)
(3.3)
25.7
25.9
(2.6)
(3.3)
AGEGROUP
Body mass index
(kg
40-49
M-2
50-64
Total
40-49
trunk
skinfolds
(mm)
50-64
Waist-hip
ratio
40-49
50-64
50.5
40.5
(14.1)
(14.2)
50.0
39.9
(14.5)
(13.8)
0.961
0.919
(0.054)
(0.055)
0.977
0.937
(0.061)
(0.061)
130
Risý- Study
A
AppeflCIIX
Table
38: Age-adjusted
group.
Known diabetics
findings
Freliminary
means for
from
metabolic
plasma
plasma
plasma
between
Fasting
2-hour
in
European
5.91
6.16
P<0.01
1.12
1.20
P<0.01
1.41
1.30
p=0.05
triglyceride
(mmol/1)
Change
by ethnic
HDL cholesterol
(mmol/1)
Fasting
measurements
Risk. Stud%
cholesterol
(mmol/1)
2-hour
and Coronary
are excluded.
South Asian
Fasting
Diabetes
triglyceride
fasting
serum
serum
and 2 hours
insulin
insulin
(mU/1)
(mU/1)
+1.9%
9.6
30.9
-5.3%
P<0.001
7.7
P<0.001
19.9
131
P<0.001
A-
findings
vreiLiminary
39; CHD risk
group:
ethnic
Table
factors
by social
from Diabetes
class
Iky
and Coronarý- Risk- Stk,ý,
_,
(manual versus
Euror)ean
non-manual)
South Asian
Manual
(375)
Non.:--Manual
(196)
Manual
(248)
Non-Manual
(41)
124
121
125
125
77
77
80
83
3.25
3.24
3.24
3.22
skinfolds(mm)
39
41
50
48
Waist-hip
0.93
0.92
0.97
0.95
5.82
6.03
5.64
6.00
Systolic
BP
BP
Diastolic
log BMI
Total
trunk
ratio
Fasting cholesterol
(mmol/1)
P=0.05
P=0.08
HDL chol
(mmol/1)
1.21
1.16
1.03
1.12
p=0.05
Fasting
TG(mmol/1)
1.42
1.49
2.03
1.55
P<0.01
2-hour
TG(mmol/1)
1.35
1.40
2.09
1.59
P<0.01
Fasting
(MU/1)
2-hour
(MU/1)
insulin
7.5
7.9
9.7
9.7
17.0
21.3
29.4
37.2
insulin
P=0.09
P<0.01
132
and
.,ippenuix
Table
40:
q-
Prevalence
of
South
40-49
findings
rreilminary
diabetes
Asian
12%
from
Diabetes
by age and ethnic
group
European
3%
(21/180)
(5/193)
50-59
14%
(14/97)
7%
(10/141)
60-64
23%
(3/13)
Mantel-Haenszel
(95% confidence
and Coronary
5%
(2/39)
South Asian/European
odds ratio
interval
1.9 - 6.1)
133
3.4
=
Risk
Study
Pivpt-nuix
A-
rreilminary
Table 41: Age-standardized
by ethnic group
diabetes
findings
prevalence
South
of
Diabetes
and Coronary
impaired
glucose
Asian
European
76.8%
Normal
Impaired
from
91.1%
glucose
tolerance
8.7%
Diabetic
14.5%
4.7%
134
Risk
tolerance
Stud. %
and
rrejum'inary
Table
of
42:
Comparison
with
associations
within-group
(With this
3.2% of the
is significant
variance
sample
variance
at
size
findings
from Diabetes
of waist-hip
ratio
and body
blood pressure
and metabolic
explained
after
any additional
in South Asians
for
index
mass
controlling
Studý
strengtli,,
percent
variables:
for age
for
at
in
effect
accounting
2.5%
or
of the variance
least
Europeans
p<0.01)
South
Waist-hip
ratio
Systolic
blood pressure
Risk
and Coronary
European
Asian
Body mass
index
Waist-hip
ratio
Body mass
index
7.2-
2.9
2.8
10.8
5.2
7.1
5.5
8.0
1.3
1.9
6.7
5.7
9.3
5.1
15.0
11.2
16.4
14.2
19.0
21.3
2.8
13.6
14.2
Diastolic
blood
pressure
HDL
cholesterol
Fasting
triglyceride
Fasting
insulin
2-hour
insulin
11.6
135
A-
Table
43:
strength
additýonal
rreiLiminary
findings
from
Diabetes
and Coronary
Risk
St,, A.,,-
waist-hip
ratio
and body nass index for
blood
with
pressure
of associations
variables:
and metabolic
by each after
variance
within-group
percent
explained
Comparison
controlling
(With this
3.2% of the
is significant
for
the
sample
variance
at
of
other.
size
any additional
in South Asians
for
effect
accounting
2.5%
or
of the variance
at least
in Europealls
p<0.01)
South
European
Asian
Body mass
index
Waist-hip
ratio
Body mass
index
0.8
1.0
3.9
0.6
1.7
3.1
ý0.4
1.9
0.4
1.1
1.0
0.5
3.4
0.4
3.0
0.8
5.1
3.0
2.2
4.0
7.7
2.1
1.6
1.8
Waist-hip
ratio
Systolic
blood
pressure
Diastolic
blood
pressure
HDL
cholesterol
Fasting
triglyceride
Fasting
insulin
2-hour
insulin
136
findings
vrehminary
from
Diabetes
and Coronary
Risk
Study
Table 44: Prevalence
(defined
of glucose intolerance
as diabetes or IGT
by tertile
by WHOcriteria)
of body mass index and waist-hip
ratio
EuroDeans
South Asians
FREQUENCY
COL PCT
Normal
Diabetic
or
1
122
35.36
Tertile
2
114
33.04
3
109
31.59
TOTAL
1
IGT
3
10.00
or
84
35.90
IGT
12
21.82
11
33.76
36.67
16
age-adjusted
3
25
45.45
234
55
124
1
87
9
113
108
31.30
TOTAL
32.73
30
32.75
ratio
71
30.34
53.33
3.33
of
2
18
345
35.94
waist-hip
Diabetic
of
age-adjusted
body mass index
Tertile
Normal
345
12
40.00
17
56.67
30
137
37.18
83
35.47
64
27.35
234
16.36
14
25.45
32
58.18
55
itlipt-iiuix
rreiiminary
q-
findings
from Diabetes
45: Prediction
of glucose intolerance
index,
for
the
top
tertile
contrasting
mass
two tertiles:
-
Table
and Coronary
by ý-aist-hip
each variable
Europeans
Body mass
index:
South
Specificitý
Sensitivity
ratio
with
Risk Stuý, %-
bodýand
the lower
Asians
Sensitivity
Specificity
70 cy.
53%
68%
45%
57%
69%
58%
Waist-hip
ratio:
Mantel-Haenszel
waist-hip
ratio
highest
contrasting
analysis
tertiles:
lowest
two
with
tertiles
South
Odds ratio
(95% Cl)
Body mass index
for
controlling
waist-hip
ratio:
1.80
(0.70
1.15
4.65)
-
(0.57
ratio
for
controlling
body mass index:
2.46
(0.95
Asians
(95% Cl)
2.31)
-
NS
NS
Waist-hip
of
-
EuroDeans
odds ratio
body mass index
3.62
6.35)
-
(1.85
P<0.001
NS
138
7.06)
-
and
Appendix
Table
in
46:
Blacks
Year
A-
Conclusion
Surveys
comparing
and Whites
Survey
plasma
triglyceride
and HDL cholesterol
Age
Ref.
Men
Black
Women
White
Triglyceride
1977
Northwick
1980
1980
1989
18-64
Cincinnati
LRC
LRC Prevalence
Survey
Evans County
CARDYAStudy
40-59
25-44
18-30
0.82
1.13
1.28
1.47
1.15
1.26
0.79
1.49
1.02
HDL cholesterol
1981
40-59
1980
1989
1.00
0.95
0.98
254
1.07
255
0.93
256
1.19
1.42
257
0.78
253
0.72
(mmol/1)
1.27
1.09
1.37
1.34
LRC Prevalence
25-44
Survey
1989
(mmol/1)
Cincinnati
LRC
1980
White
Park
(UK)
1981
Black
NHANES 11
Evans
County
CARDYA Study
20-74
18-30
1.43
1.34
1.46
1.38
1.19
1.21
1.18
1.21
139
1.53
1.43
1.53
1.43
1.53
1.45
1.44
1.45
255
256
258
257
253
le%-ls
no
Appendix
Table
during
47:
A-
Conclusion
Mortality
1965-80267,
of
Pimas
compared
resident
with
in
US Wbites
the
in
Gila
1970
Image removed due to third party copyright
140
River
Indian
Appendix
Table
in
48:
residents
A-
Conclusion
San Antonio
Heart
25-64
aged
Study:
anthropometric
by sex and ethnic
and metabolic
findings
group268,270
Image removed due to third party copyright
141
A-
Appendix
Table
of
49:
Conclusion
Framingham
association
between
Study:
risk
comparison
factors
between
men and women for
and CHD282.
Image removed due to third party copyright
142
stre,, -Igt
Appendix
Table
50:
compared
A-
Conclusion
Mean plasma
with
the
in
cholesterol
native
British
surveys
of
South
Asians
the
in
population
Mean plasma
Group
Age
studied
range
mainly
mainly
Gujarati
Gujarati
Bangladeshis
Punjabi
Sikhs
Hindus
Hindus
35-54
45-64
35-69
40-64
Ref.
cholesterol
Sex
(mmol/1)
no.
South
Native
Asian
British
M
5.4
F
4.6
5.4
M
18
6.1
60
29
M
5.5
6.0
F
5.4
6.1
M
5.9
6.2
(this
thesis)
143
L'K,
Appendix
Figure
1:
Electoral
general
wards
practices
ýý
2 0-39 -9
JE
40+
B
of
Tower
Hamlets
(numbered
1 to
Percent of electorate
of
1987
Bangladeshi
origin,
144
showl ng ethnic
compositi,
5)
the
included
in
survev
-,!! an,,I
Appendix
2: Plasma total
Figure
B
and HDL cholesterol
in East London Studv
Total Cholesterol
Females
Males
7.0
6.5
le
6.0-
5.5mmol/I
5.0-
4.5
2.0
Asian
Non-Asian
L
HDL Cholesterol
1.5
4%
-------+
1.0
I--I..
35-44
11
j
45-54
55-69
Age (years)
40-49
145
50-59
Appenclix
Figure
3:
Plasma
triglyceride
and serum
insulin
in East
London
Triglycerides
4.0
Males
mmol/I
3.0
Females
2.01
I/i
1.01
Asian
Non-Asian
0.5'
Insulin
100
mu/I
50
1
im
I
-----
i`
,'
.0
201
101
I
35-44
I-IL1
--
45-54
40-49
55-69
Age (years)
146
50-59
Study
Append
4:
Figure
Frequency
Coronary
Waist-hip
x
distributions
Risk
of
waist-hip
ratio
in
the
Diabetes
and
Study
ratio
distributions
30
x
1... -0
20
Fý European
10
LL
0
0.66 0.78 0.82 0.86 0.9 0.94 0.98 1.02 1.06 1.1 1.14
30
0
20
r-"
LJ
:3
10
LL
0
0.66 0.78 0.82 0.86 0.9 0.94 0.98 1.02 1.06 1.1 1.14
147
South Asian
Appendix
Figure
B
5: Mean serum fasting
waist-hip
Coronary
ratio
Risk
and 2-hour
within
each ethnic
levels
group
by tertiles
in the Diabetes
Study
by waist-hip
Insulin
insulin
ratio:
S Asians
40
El Fasting
2-hour
30
20
10
0
123
Tertile
waist-hip
of
by waist-hip
Insulin
ratio:
ratio
Europeans
40
30
20
10
0
Tertile
123
ot
waist-hip
148
ratio
of
and
Appendix
Figure
6:
The insulin
B
resistance
syndrome:
interrelationships
Central
obesity
P(
post-load
FFA
)k
resistanceto
insulin-stimulat
glucose uptake
VML
ta
ri,, Iyceride
A-
-0-
glucose
intolerance
insulin
TS
Ton
hypert e
I
HDL
cholesterol
t small dense
LDL parficles
149
Appenclix
Sample
Let
for
calculation
size
PC = the
prevalence
Diabetes
and Coronary
in
the
control
in
the
experimental
Risk
study
group
QC = 1-PC
Pe = the
prevalence
group
Qe = 1-PC
N=
the
in
number
Za/2
1.96
(centile
zo
1.28
(the
each
group
97.5 of a standard
90th
centile
normal
of a standard
distribution)
distribution)
normal
then we have194
2PC Qc + 2pe Qe
2PC Qc
I Pe - Pc I=Z
Zf3
ct/2
N
N
is
The equation
solved
for
Pe iteratively,
using
method.
Putting
N=
1500
PC = 0.05
we obtain
Pe = 0.0769775
Relative
risk
/
Pc
Pe
=1.53955
=
150
the
standard
calculus
D-
Appendix
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World
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