Centre of Excellence
Collaborating Centre
Southeast Asian Diaspora
Francesco P Cappuccio MD MSc DSc FRCP FFPH
E.S.H. Centre of Excellence – W.H.O. Collaborating Centre
University of Warwick, Coventry, UK
E.S.H. Working Group “Hypertension and Cardiovascular Risk Assessment in
Subjects Living in or Emigrating from Low Resource Settings”
Collaborating Centre
Centre of Excellence
Conflicts of Interest Declaration
• None to declare
Collaborating Centre
Health trends in Europe
European health for all database. WHO Regional Office for Europe (Copenhagen), 2004
World Health Report. Reducing risks, promoting health life. WHO (Geneva), 2002
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Collaborating Centre
South Asian Diaspora
East Africa
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Indian sub-continent
Total population (2010) 1.65b
28.4m
Sudan
36.0m
26.8m
173.1m
Uganda
34.0m
151.1m
Kenya
41.0m
Tanzania
45.0m
Malawi
15.0m
Mauritius
1.2m
51.9m
1.20b
Middle East
Europe
East Africa
South Africa
Canada
USA
Seychelles
0.09m
20.7m
0.3m
Total population (2010) 172.3m
0.7m
Singapore
Malaysia
Brunei
Indonesia
Australia
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Country
South Asian Diaspora
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Migration
(2005-10)
million
Destination (World Bank 2010)
million
US
Canada
UK
Afghanistan
0.7
0.06
0.04
0.06
Pakistan
1.8
0.30
0.15
0.45
0.02
0.05
0.06
India
3.0
1.60
0.50
0.66
0.04
0.07
0.10
Nepal
0.8
Bhutan
0.7
Bangladesh
3.6
0.15
0.04
0.21
Myanmar
0.8
Sri Lanka
0.4
0.03
0.12
0.11
Maldives
0.3
TOTAL
11.4
France
Germany
Italy
0.08
0.07
0.04
0.05
0.08
Epidemiological Transition
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Cardiovascular Disease
Hypertensive
Atherosclerotic
Low smoking,
moderate fat
and salt intake
Moderate smoking,
moderate fat
but high salt intake
1
2
3
High smoking,
fat and salt
intake
4
5
Stage
Increasing levels of acculturation, urbanization and affluence
Cappuccio FP. Int J Epidemiol 2004; 33: 387-8
6
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Collaborating Centre
Migration studies: models
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Model 1: high risk acquired after migration
Mainly Environmental
Low risk
High risk
Model 2: high risk present before migration and carried over with
migration
Genetic predisposition
Early environmental influences
High risk
High risk
Environmental exposures kept
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CHD Mortality in South Asians
in the UK and Overseas
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compared
to white
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Stroke in South Asians in the UK
Compared to whites, South Asians:
• have a greater incidence of CHD
• have also a higher risk of stroke and renal failure
• some sub-groups have high blood pressure and
some have very high smoking rates
• metabolic abnormalities more common
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Acceptance Rates (per million pop.) for
Renal Replacement Therapy in England (1991-92)
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Prevalence of hypertension* in South London
Collaborating Centre
(%)
50
MEN
WOMEN
50
40
40
South Asian
30
South Asian
30
20
20
White
10
White
10
0
0
<45
45-49
50-54
Age - group
*BP >160 and/or >95 mmHg or on therapy
Cappuccio FP et al. Heart 1997; 78: 555-63
55+
<45
45-49
50-54
Age - group
55+
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Collaborating Centre
Modesti P et al. 2014; in preparation
Collaborating Centre
Salt intake around the world
Powles J et al. BMJ Open 2013; 3: e003733
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PREVALENCE OF DIABETES IN SOUTH ASIAN
POPULATIONS IN THE WORLD
Collaborating Centre
35
UK
India
Overseas
Europeans
30
25
20
15
10
5
on
nd
Lo
SW
Lo
nd
on
Fij
i
NW
S.
Af
ric
a
Si
ng
ap
or
e
s
ad
Tr
ini
d
tiu
uri
Ma
Ka
r
na
dr
ba
n
Ma
ur
ba
n
ur
tak
a
as
u
ad
w
mi
lN
rro
Ta
Ha
ral
ru
rth
ll
ds
wo
tha
W
an
So
u
ve
n
try
0
Co
(%)
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Collaborating Centre
Prevalence and management of diabetes
Whites (n=380)
90%
South Asian (n=340)
10%
New
Known untreated
Known treated
Cappuccio FP et al. Br J Diabetes Vasc Dis 2003; 3: 286-93
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Collaborating Centre
Smoking prevalence
Cappuccio FP et al. Br J Diabetes Vasc Dis 2003; 3: 286-93
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Body mass and adiposity
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BMI
(kg/m2)
Waist:Hip
*P<0.001
White
(n=524)
S Asian
(n=505)
♂
25.8
24.8*
♀
26.1
27.1*
♂
0.92
0.94*
♀
0.80
0.85*
The two authors have an identical BMI, but as dual X-ray absorptiometry
shows, Yainik (R) has substantially more body fat than Yudkin (L) (21.2% v
9.1%). Lifestyle may be relevant: Yudkin runs marathons whereas Yajnik’s
main exercise is running to beat the closing doors of the elevator in the
hospital every morning. The image is a useful reminder of the limitations of
BMI as a measure of adiposity across populations.
Yajnik CS & Yudkin JS. Lancet 2004; 363: 163
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Homocysteine in South Asians
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Collaborating Centre
Case-control study in the UK
Cross-sectional study in Canada
12
E:507;SA:518
E:294;SA:257
Men
Men & women combined
P<0.0001
Fasting homocysteine (umol/l)
11
S. Asians
(n=342)
10
Europeans
(n=326)
9
Chinese
(n=317)
8
Chambers JC et al. Lancet 2000; 355: 523-7
Anand SS et al. Lancet 2000; 356: 279-84
Plasma homocysteine levels by ethnic and
cultural background
Collaborating Centre
Total homocysteine (mmol/l)
13
12
11
10
9
Adjusted for age,sex,BMI,smoking
Adjusted for age,sex,BMI,smoking, vegetarianism
P<0.001
Cappuccio FP et al. Atherosclerosis 2002;164: 95-102
b
ea
n
C
ar
ib
A
t
W
es
S
(geometric mean and 95% CI)
fr
ic
an
u
sl
im
.A
.M
.A
.H
S
W
h
in
d
it
e
u
8
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Plasma Vitamin C (µmol/l)
by Gender and Ethnic Group
Collaborating Centre
60
Centre of Excellence
P<0.001
50
P=0.048
40
White
S Asian
30
20
10
(n=147)
(n=169)
(n=189)
(n=159)
0
Men
adjusted for age, BMI, smoking,
supplement use and vegetarianism
Ness AR et al. Int J Epidemiol 1999;28:450-5
Women
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Prevalence of hypertension
by social class in rural India
(%)
High
Low
Socioeconomic Status
RB Singh et al. J Hum Hypertens 1997
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Fetal growth and CHD in South India: study in
men and women born between 1934 and 1954
Collaborating Centre
Centre of Excellence
CHD prevalence (%)
20
20
n=517
*p=0.03
15
20
n=512
*p=0.04
15
10
10
10
5
5
5
0
0
0
<5.0
5.1-
5.6-
6.1-
6.6-
Birth weight (lb)
>7.0
<18
18Birth length (inches)
>19
n=511
*p=0.02
15
<13
13-
>13.5
Head circumference at birth (inches)
*Adjusted for age and sex
CE Stein et al. Lancet 1996
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•
•
•
•
Conclusions
South Asians are at higher risk of coronary heart disease,
stroke and renal failure
They have more central adiposity, diabetes and insulin
resistance.
Hypertension prevalence varies by subgroups, is not well
diagnosed and diabetes is not well controlled
Vegetarian Hindus have higher homocysteine and lower
vitamin C as a result of vegetable overcooking
• To improve understanding of risk stratification in migrant
populations from the Indian Sub-continent and East Asia
• To develop culturally appropriate preventive strategies
• To improve detection and management
• To study interaction between genes and environment
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