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CV Risk Factors in South Asians of Canada

CV Risk Factors in South Asians of Canada. Sonia Anand McMaster University Feb 21, 2013. North America. Europe. Asia. Middle East. Africa. Australia. South and Central America. Excess Coronary Heart Disease in South Asian Migrants. Mortality for CHD and Cancer Age 35 – 74 (1979-1993).

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CV Risk Factors in South Asians of Canada

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  1. CV Risk Factors in South Asians of Canada Sonia Anand McMaster University Feb 21, 2013

  2. North America Europe Asia Middle East Africa Australia South and Central America Excess Coronary Heart Disease in South Asian Migrants

  3. Mortality for CHD and CancerAge 35 – 74(1979-1993) Sheth T et al, CMAJ 1999

  4. Ethnic Profile in Ontario

  5. Changes in Risk Factors with Migration

  6. Evolution of risk factors in South Asians 2. pre-Diabetes 3. Diabetes 4. Heart Disease 1.Weight gain • Lipids • Blood Pressure 5.?Some Cancers 6

  7. Metabolic Syndrome Phenotype: A Cluster of Metabolic Abnormalities Visceral Adipose Tissue • Abdominal Adiposity • Dysglycemia • HDL Cholesterol • Triglycerides • +/- Elevated BP Subcutaneous Adipose Tissue Associated with a significant increase in type 2 diabetes and CHD

  8. Age-Adjusted Prevalence of Metabolic Syndrome in Canada Age-Adjusted Anand et al Circulation 2003

  9. 0.5 1 2 4 8 16 OR (99% CI) INTERHEART: MS and MI by Region Mente et al JACC

  10. Summary of Risk Factors • 1) Increased body fat • 2) Tendancy toward central adiposity • 3) Visceral Fat excess • 4) Fatty liver • 5) Low HDL, High LDL, High TRGS • 6) Increased Diabetes • 7) Smoking is lower

  11. Summary of Presentation, Diagnosis, and Treatment • Presentation time to hospital with chest pain symptoms is later in SA • Management of acute coronary syndromes is similar • Case fatality rate is similar • Long-term morbidity, mortality appears similar • Lower attendance at Cardiac Rehab

  12. Community Level Pregnancy and Early Childhood Adult Metabolic Syndrome Interventions to Change Health Behaviours Individual

  13. SouTh Asian BiRthCohorTEarly Life Determinants

  14. “Thin-fat” baby • Newborns, relatively small at birth (BW < 2.9 kg) reported to have greater subscapular skin fold thickness, which is shown to correlate well with truncal obesity • This adiposity tracks to 4 years of age • An increase of BMI of 1 SD from 2 to 12 years of age, increased the odds ratio for disease (IGT / DM) by 1.36. in young adults Krishnaveni GV, Hill JC, Veena SR, Fall CHD. Indian Pediatr 2005; 42: 527-538 New Eng J Med 2004; 350: 865-875.

  15. LBW persists in South Asian babies in UK • X- sectional data record linkage 2005 – 2006 n=861,654 births of white, or South Asians • 1st generation: Born in Indian subcontinent • 2nd generation: Born in England/Wales

  16. Singleton Birth Weights Leon, J Epidemiol Community Health 2012;66:544-61

  17. Birth Weight by Maternal Region of Birth (Canada and South Asia only).Ontario, 2002-2006 Combined

  18. Risk of Gestational Diabetes Mellitus in Association with Maternal Place of Birth a Odds ratios were adjusted for maternal age (continuous in years), number of livebirths, multifetal pregnancy, place of residence, neighborhood income quintile, and fiscal year of delivery. b Reference category. Epidemiology: November 2011 – Volume 22 – Issue 6 – pp 879-880.

  19. Both low birth weight and high birth are associated with long-term metabolic disease risk for offspring Relative Risk of DM, obesity, CVD Low High Birth Weight Higher Risk with LOW Birth Weight Higher Risk with HIGH Birth Weight • Maternal diabetes • Obesity • Excess gestational weight gain • Genetics • Placental insufficiency • Maternal undernutrition • Hypoxia (smoking, anemia, altitude) • Genetics

  20. Diverse Environments 1000 Mothers/Babies 250 Mothers/Babies 250 Mothers/Babies Rural India Urban India Urban Canada PSYCHSOCIAL SRESS, SOCIAL SUPPORT ACCESS to PRIMARY CARE DIETARY DIFFERENCES (WEIGHT GAIN) 20 GENETIC/EPIGENETIC FACTORS

  21. Birthweight among GA > 37 weeks In singleton newborns with a gestational age >=37 weeks

  22. START: Is thin fat phenotype Observed in Canada? In singleton newborns with a gestational age >=37 weeks

  23. Epigenetic • Maternal Exposures linked to DNA methylation in offspring: • Smoking • Depression • Under or over nutrition

  24. Regions of Genome associated with Birth Weight • Development and morphagenesis • Cell Cycle/Cell division • Metabolism and biosynthesis • Not imprinted regions or housekeeping genes • 60% methylation discordance between heavy and light birth weight babies

  25. Explanations • 1) Genetic- Transgenerational, DNA inherited • 2) EpiGenetic – Transgenerational, inherited, non-DNA • 3) Cultural: Diet deficiency or imbalance • 4) Other: Brown fat, telomere length

  26. What can we do to prevent Metabolic Syndrome in about the South Asian population in Canada?

  27. SAHARA Project A multi-media based intervention aiming to provide culturally tailored health messaging and feedback to participants with the goal of reducing their cardiac risk score over a 6-month period. http://www.youtube.com/watch?v=SwZdUSmWBpo

  28. Screening Cohort • 320 Men and women of South Asian ancestry • Permanent residents of Ontario/BC • ≥30 years • Access to email, cell phone with text messaging capability, or a smart phone • No previous MI, CABG, Stroke

  29. Study Outcomes • Primary outcome: change in IHRS after 1 year • Secondary outcomes: • Change in components of risk score - blood pressure, HbA1c, waist to hip ratio, and apolipoproteins B and A • Difference in clinical events between the intervention and control groups at the end of the study • Rate of change in IHRS over time

  30. INTERHEART Modifiable Risk Score Report

  31. Genetic Risk Score Report

  32. Community or Contextual Factors and Future Interventions

  33. Social Networks • 12,000 people tracked for 32 yrs • Social networks play a powerful role in determining weight gain • If spouse or brother is overweight –1.40x would be overweight • Friends had the most powerful influence 1.5-2.0x - “kind of social contagion” • Think about typical S. Asian social networks- centered around eating, not around moving • Older cultural beliefs must change to prevent weight gain Kristakis NEJM 2007

  34. Obesity in a Facebook Network Social Networks 2008; 30: 330-342.

  35. Determinants of Risk Behaviours in a Population Individuals with Risk Factors for CVD Individuals with Manifest CVD GOAL Interventions with a Socio-Economic & Political Focus Interventions with a Preventive Focus Interventions with a Clinical Focus Type of Strategy • Lipid Lowering • Aspirin • Beta blockers • ACE-inhibitors • Appropriate revascularization • Identifying & treating • individuals with high cholesterol or hypertension • Smoking cessation in a smoker • Taxing Tobacco • Subsidizing healthy foods • Health Education • Promote Physical Activity Examples Population & high risk individualized strategy for the Prevention of CVD

  36. A PolyPill for all? Aspirin Statin Thiazide BB ACE - I October 30, 2008

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