Cardiometabolic disease in South Asians: A global health concern in an expanding population

Perceived stress and progression of cardiometabolic risk factors among South Asians with prediabetes in a lifestyle intervention trial

AIMS

To examine associations between perceived stress and cardiometabolic risk factors in South Asians with prediabetes and assess whether a diabetes prevention program mitigates the impact of stress on cardiometabolic health.

METHODS

We conducted a secondary analysis of the Diabetes Community Lifestyle Improvement Program, a lifestyle modification trial for diabetes prevention in India (n = 564). Indicators for cardiometabolic health (weight, waist circumference, blood pressure, glucose, HbA1c, and lipids) were measured at each visit while perceived stress was assessed via questionnaire at baseline. Multivariable linear regression assessed associations between stress and cardiometabolic parameters at baseline and 3-year follow up.

RESULTS

At baseline, perceived stress was associated with higher weight (b=0.16; 95% CI: 0.04, 0.29) and waist circumference (b=0.11; 95% CI: 0.01, 0.21) but lower 30-minute postload glucose (b=-0.44; 95% CI: -0.76, -0.14) and LDL cholesterol (b=-0.40; 95% CI: -0.76, -0.03). Over the study period, perceived stress was associated with weight gain (b=0.20; 95% CI: 0.07, 0.33) and increased waist circumference (b=0.14; 95% CI: 0.04, 0.24). Additionally, higher perceived stress was associated with lower HDL cholesterol among the control arm (pinteraction = 0.02).

CONCLUSIONS

Baseline stress was associated with negative cardiometabolic risk factor outcomes over time in those with prediabetes.

Racial/Ethnic Disparities of Cancer, Metabolic Syndrome, and Lifestyle Behaviors in People under 50: A Cross-Sectional Study of Data from the National Health and Nutrition Examination Survey

INTRODUCTION

Recent epidemiological studies have suggested a trend of increasing prevalence of metabolic syndrome (MetS) and certain types of cancer among adults under age 50. How MetS is associated with cancer in adults under the age of 50, however, remains unclear. Furthermore, it remains unknown whether associations between MetS and cancer vary by racial/ethnic group and whether modifiable lifestyle factors influence MetS-cancer relationships.

METHODS

We used data from the 2011-2018 National Health and Nutrition Examination Survey (NHANES) to define a case-control sample to examine potential racial/ethnic disparities associated with MetS and cancer of any type. We used a chi-square test and binary logistic regression to examine the MetS and cancer association.

RESULTS

From a total sample of 10,220 cases, we identified 9960 no-cancer cases and 260 cancer cases. Binary logistic regression results showed that MetS was significantly associated with a cancer risk among non-Hispanic whites (odds ratio = 1.48, 95% confidence interval = 1.00-2.19); however, it was not associated with a risk among non-Hispanic Blacks, Hispanic/Latinos, or Asian Americans. We also found several significant predictors of cancer, including age, gender, tobacco use, and sleep duration, with their roles varying by racial/ethnic subgroup.

CONCLUSION

The findings of this study indicate that racial/ethnic differences are involved in the association between MetS and cancer, and highlight the potential mediating effects of lifestyle and behavioral factors. Future research should leverage the existing longitudinal data or data from cohort or case-control studies to better examine the causal link between MetS and cancer among racial/ethnic minorities.

About 1/3rd of north Indian patients less than 50 years of age with type 2 diabetes have high pulse wave velocity indicating high risk of atherosclerosis

BACKGROUND AND AIMS

Asian Indian patients with type 2 diabetes mellitus (T2DM) have a high cardiovascular risk even at young age. There is a need to assess this increased risk and identify atherosclerosis early so that appropriate measures for risk reduction can be taken. We aimed to study carotid-femoral pulse wave velocity (Cf-PWV), a non-invasive indicator of atherosclerosis, in patients with diabetes below 50 years of age and its correlation with markers of obesity and other cardiovascular risk factors.

METHODS

Patients (n, 299) with T2DM below 50 years of age underwent measurement of Cf-PWV by applanation tonometry. Anthropometric parameters, blood pressure, liver span, glycosylated hemoglobin, serum lipid profile, urinary microalbumin, ankle brachial index and carotid intima media thickness were measured.

RESULTS

Data show that 32.4% of patients had high Cf-PWV, with mean values higher in males than females. On stepwise multiple linear regression analysis, the significant independent determinants of PWV were age, systolic blood pressure, waist circumference, microalbumin and liver span.

CONCLUSION

About one third patients with T2DM less than 50 years of age, in north India have increased arterial stiffness which correlates with blood pressure, abdominal obesity, liver size and microalbumin, indicating increased risk for coronary artery disease.

Feasibility of implementing a community cardiovascular health promotion program with paramedics and volunteers in a South Asian population

BACKGROUND

The South Asian population in Canada is growing and has elevated risk of cardiovascular disease and diabetes. This study sought to adapt an evidence-based community risk assessment and health promotion program for a South Asian community with a large proportion of recent immigrants. The aims were to assess the feasibility of implementing this program and also to describe the rates of cardiometabolic risk factors observed in this sample population.

METHODS

This was a feasibility study adapting and implementing the Community Paramedicine at Clinic (CP@clinic) program for a South Asian population in an urban Canadian community for 14 months. CP@clinic is a free, drop-in chronic disease prevention and health promotion program implemented by paramedics who provide health assessments, health education, referrals and reports to family doctors. All adults attending the recreation centre and temple where CP@clinic was implemented were eligible. Volunteers provided Hindi, Punjabi and Urdu translation. The primary outcome of feasibility was evaluated using quantitative process measures and a qualitative key informant interview. For the secondary outcome of cardiometabolic risk factor, data were collected through the CP@clinic program risk assessments and descriptively analyzed.

RESULTS

There were 26 CP@clinic sessions held and 71 participants, predominantly male (56.3-84.6%) and South Asian (87.3-92.3%). There was limited participation at the recreation centre (n = 19) but CP@clinic was well-attended when relocated to the local Sikh temple (n = 52). Having the volunteer translators was critical to the paramedics being able to collect the full risk factor data and there were some challenges with ensuring enough volunteers were available to staff each session; as a result, there were missing risk factor data for many participants. In the 26 participants with complete or almost complete risk factor data, 46.5% had elevated BP, 42.3% had moderate/high risk of developing diabetes, and 65.4% had an indicator of cardiometabolic disease.

CONCLUSION

Implementing CP@clinic in places of worship is a feasible approach to adapting the program for the South Asian population, however having a funded translator in addition to the volunteers would improve the program. Also, there is substantial opportunity for addressing cardiometabolic risk factors in this population using CP@clinic.

Comparative Evaluation of Biomarkers of Inflammation Among Indian Women With Polycystic Ovary Syndrome (PCOS) Consuming Vegetarian vs. Non-vegetarian Diet

Background: Sub-inflammation and insulin resistance characterize women with PCOS. Data on dietary modulation of inflammation among PCOS women is scant, particularly from Indian subcontinent. The present study aimed to assess the effect of plant based vs. animal origin diets on serum markers of inflammation (primary outcome measure). Methods: This observational case-control study compared age and BMI matched PCOS and apparently healthy women from two populations following different dietary practices. The vegetarian women from New-Delhi (n = 82 PCOS and n = 179 healthy) and non-vegetarian women from Srinagar (n = 62 PCOS and n = 141 healthy) formed the groups. Using a uniform methodology, detailed clinical, biochemical, hormonal, and inflammatory marker assessment was undertaken. Results: The mean age of the overall cohort was 26.23 ± 4.59 years with a mean BMI of 24.39 ± 3.72 kg/m². Overall pro-inflammatory markers (TNF-α, IL-6, IL-1β, hs-CRP and serum resistin) were significantly higher (p ≤ 0.05) and anti-inflammatory markers (IL-10 and adiponectin) were lower among women with PCOS than healthy subjects. On comparing vegetarian women with non-vegetarians, higher daily calorie intake (1895.46 ± 258.19 vs. 1860.13 ± 323.96 Kcal) with a higher protein and fat and lower carbohydrate intake was recorded in the latter, although the percent energy derived from carbohydrates was higher among vegetarians. Clinical and biochemical parameters were comparable among the groups except mFG score, total serum testosterone and serum lipid levels which were higher among non-vegetarian women as compared to their vegetarian counterparts from both categories (PCOS and healthy). Interestingly, vegetarian women with PCOS and healthy women had higher serum pro-inflammatory and lower anti-inflammatory markers compared to their non-vegetarian counterparts. Conclusion: Women with PCOS consuming Indian vegetarian diet have higher pro-inflammatory and lower anti-inflammatory marker levels than their age and BMI matched healthy non-vegetarian counterparts. This interesting observation can be attributed to the dietary composition, among other factors and needs confirmation from well-designed randomized studies on a larger cohort. Clinical Trial Registration: The study was registered with CTRI database under registration number CTRI/2013/09/003996.

Geographic and sociodemographic variation of cardiovascular disease risk in India: A cross-sectional study of 797,540 adults

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of mortality in India. Yet, evidence on the CVD risk of India's population is limited. To inform health system planning and effective targeting of interventions, this study aimed to determine how CVD risk-and the factors that determine risk-varies among states in India, by rural-urban location, and by individual-level sociodemographic characteristics.

METHODS AND FINDINGS

We used 2 large household surveys carried out between 2012 and 2014, which included a sample of 797,540 adults aged 30 to 74 years across India. The main outcome variable was the predicted 10-year risk of a CVD event as calculated with the Framingham risk score. The Harvard-NHANES, Globorisk, and WHO-ISH scores were used in secondary analyses. CVD risk and the prevalence of CVD risk factors were examined by state, rural-urban residence, age, sex, household wealth, and education. Mean CVD risk varied from 13.2% (95% CI: 12.7%-13.6%) in Jharkhand to 19.5% (95% CI: 19.1%-19.9%) in Kerala. CVD risk tended to be highest in North, Northeast, and South India. District-level wealth quintile (based on median household wealth in a district) and urbanization were both positively associated with CVD risk. Similarly, household wealth quintile and living in an urban area were positively associated with CVD risk among both sexes, but the associations were stronger among women than men. Smoking was more prevalent in poorer household wealth quintiles and in rural areas, whereas body mass index, high blood glucose, and systolic blood pressure were positively associated with household wealth and urban location. Men had a substantially higher (age-standardized) smoking prevalence (26.2% [95% CI: 25.7%-26.7%] versus 1.8% [95% CI: 1.7%-1.9%]) and mean systolic blood pressure (126.9 mm Hg [95% CI: 126.7-127.1] versus 124.3 mm Hg [95% CI: 124.1-124.5]) than women. Important limitations of this analysis are the high proportion of missing values (27.1%) in the main outcome variable, assessment of diabetes through a 1-time capillary blood glucose measurement, and the inability to exclude participants with a current or previous CVD event.

CONCLUSIONS

This study identified substantial variation in CVD risk among states and sociodemographic groups in India-findings that can facilitate effective targeting of CVD programs to those most at risk and most in need. While the CVD risk scores used have not been validated in South Asian populations, the patterns of variation in CVD risk among the Indian population were similar across all 4 risk scoring systems.

Cytokine Responses to Acute Exercise in Healthy Older Adults: The Effect of Cardiorespiratory Fitness

Markers of chronic inflammation increase with aging, and are associated with cardiovascular disease prevalence and mortality. Increases in fitness with exercise training have been associated with lower circulating concentrations of cytokines known to have pro-inflammatory actions (such as interleukin-6 [IL-6]) and higher circulating concentrations of anti-inflammatory cytokines (interleukin-10 [IL-10]). However, the effect of cardiorespiratory fitness on acute cytokine responses to a single bout of exercise in healthy older individuals is unknown. We compared the response of plasma cytokines IL-6, tumor necrosis factor-alpha (TNF-α) and IL-10 to a bout of moderate-intensity continuous and higher-intensity interval exercise between older individuals with higher and lower levels of cardiorespiratory fitness. Sixteen lower-fit (VO_2peak: 22.6±2.8 mL.kg⁻¹.min⁻¹) and fourteen higher-fit participants (VO_2peak: 37.4±5.9 mL.kg⁻¹.min⁻¹) completed three 24 min experimental protocols in a randomized order: (1) moderate-intensity continuous exercise (40% of peak power output [PPO]); (2) higher-intensity interval exercise (12 × 1 min intervals at 70% PPO separated by 1 min periods at 10% PPO); or (3) non-exercise control. Plasma cytokines were measured at rest, immediately after, and during 90 min of recovery following exercise or control. Plasma IL-6 concentrations at baseline were greater in the higher-fit compared to the lower-fit group (P = 0.02), with no difference in plasma IL-10 or TNF-α concentrations at baseline between groups. Plasma IL-6 and IL-10 concentrations in both groups increased immediately after all protocols (IL-6: P = 0.02, IL-10: P < 0.01). However, there was no difference in the IL-6 and IL-10 response between the exercise and non-exercise (control) protocols. After all protocols, no changes in plasma TNF-α concentrations were observed in either the higher- or lower-fit groups. In this study, basal concentrations of circulating IL-6 were elevated in older individuals with higher levels of cardiorespiratory fitness. However, changes in plasma cytokine concentrations after exercise were not different to changes after non-exercise control in both the lower- and higher-fit groups.