Mortality from all causes and circulatory disease by country of birth in England and Wales 2001-2003

The problematic nature of existing explanations for differential immigrant mortality: Insights from a comparative cross-national systematic review and meta-analysis

Empirical studies in multiple disciplines have frequently observed an immigrant mortality advantage. Yet, questions remain regarding the possible mechanisms underlying this phenomenon. We obtained data from 61 studies of relative immigrant mortality from single origin-destination country pairings, providing information on immigrants from 77 origin countries. We systematically review the arguments made in these studies about origin-country factors that might influence immigrant mortality and then use meta-analyses to examine the veracity of these arguments. We find that most existing origin-country explanations for immigrant mortality patterns (e.g., health behaviors, genetic characteristics, environmental conditions, and socioeconomic conditions) are problematic or insufficient when accounting for differential mortality by origin country. We identify non-comparative analyses and geographic aggregation as the two major obstacles to understanding the mechanisms underlying the immigrant mortality advantage. We conclude by advocating for a risk-factor-based, cross-national approach.

Visceral-to-peripheral adiposity ratio: a critical determinant of sex and ethnic differences in cardiovascular risks among Asian Indians and African Creoles in Mauritius

BACKGROUND/AIMS

Coronary heart disease morbidity and mortality are higher in people of South Asian origin than in those of African origin. We investigated whether as young adults without diabetes, people in Mauritius of South Asian descent (Indians) would show a more adverse cardiovascular risk profile that those of predominantly African descent (Creoles), and whether this could be explained by ethnic differences in visceral adiposity or other fat distribution patterns.

METHODS

The study was conducted in 189 young non-physically active adults, with the following measurements conducted after an overnight fast: anthropometry (weight, height, waist circumference), whole-body and regional body composition by dual-energy x-ray absorptiometry, blood pressure, and blood assays for glycemic (glucose and HbA1c) and lipid profile (triglycerides and cholesterols).

RESULTS

The results indicate higher serum triglycerides and lower HDL cholesterol in men than in women, and in Indians than in Creoles (p < 0.001). No significant differences due to sex or ethnicity are observed in body mass index and waist circumference, but indices of visceral adiposity (visceral/android, visceral/subcutaneous) and visceral-to-peripheral adiposity ratio (visceral/gynoid, visceral/limb) were significantly higher in men than in women, and in Indians than in Creoles. The significant effects of sex and ethnicity on blood lipid profile were either completely abolished or reduced to a greater extent after adjusting for the ratio of visceral-to-peripheral adiposity than for visceral adiposity per se.

CONCLUSIONS

In young adults in Mauritius, Indians show a more adverse pattern of body fat distribution and blood lipid risk profile than Creoles. Differences in their fat distribution patterns, however, only partially explain their differential atherogenic lipid risk profile, amid a greater impact of visceral-to-peripheral adiposity ratio than that of visceral adiposity per se on sex and ethnic differences in cardiovascular risks; the former possibly reflecting the ratio of hazardous (visceral) adiposity and protective (peripheral) superficial subcutaneous adiposity.

Cultural Adaptation and Psychometric Validation of a Cardiac Knowledge Questionnaire for Chinese Immigrants

BACKGROUND

Disease-related knowledge deficits are common in Chinese immigrants living in Western countries, putting them at risk of disease progression and mortality, particularly those with a coronary heart disease (CHD) diagnosis. However, no measurement instrument is available to assess CHD-related knowledge in this population.

OBJECTIVES

The aim of this study was to culturally adapt and examine the psychometric properties of the short version of Coronary Artery Disease Education Questionnaire (CADE-Q SV) (simplified Chinese version) in Chinese immigrants with CHD.

METHODS

Mandarin-speaking people recruited from medical centers and cardiology clinics across metropolitan Sydney completed the 20-item CADE-Q SV (5 domains; potential scores: 0-20). Internal consistency was assessed using Cronbach α . A subgroup (n = 40) repeated the survey 2 weeks later for test-retest reliability by intraclass correlation coefficient. Factor structure (confirmatory factor analysis) and discriminant (known-groups) validation using education and English proficiency (univariate general linear model) were also undertaken.

RESULTS

Participants (n = 202) had a mean (SD) age of 66.08 (10.93) years, 45.1% were male, and the mean (SD) total CADE-Q SV score was 13.07 (4.57). Reliability and consistency were good (intraclass correlation coefficient > 0.70; Cronbach α coefficients > 0.70, for total and per domain, respectively). The 5-domain structure was validated by confirmatory factor analysis. The scale demonstrated discriminant validity, with low education ( P < .001) and low English proficiency ( P = .017) associated with lower knowledge scores.

CONCLUSION

The CADE-Q SV (simplified Chinese version) can be used as a valid and reliable instrument, either paper based or digital, to evaluate the CHD-related knowledge of Chinese immigrants. This scale can be adapted to other migrant populations in the future.

Ethnicity-specific blood pressure thresholds based on cardiovascular and renal complications: a prospective study in the UK Biobank

BACKGROUND

The appropriateness of hypertension thresholds for triggering action to prevent cardiovascular and renal complications among non-White populations in the UK is subject to question. Our objective was to establish ethnicity-specific systolic blood pressure (SBP) cutoffs for ethnic minority populations and assess the efficacy of these ethnicity-specific cutoffs in predicting adverse outcomes.

METHODS

We analyzed data from UK Biobank, which included 444,418 participants from White, South Asian, Black Caribbean, and Black African populations with no history of cardiorenal complications. We fitted Poisson regression models with continuous SBP and ethnic groups, using Whites as the referent category, for the composite outcome of atherosclerotic cardiovascular disease, heart failure, and chronic kidney disease. We determined ethnicity-specific thresholds equivalent to the risks observed in Whites at SBP levels of 120, 130, and 140 mm Hg. We adjusted models for clinical characteristics, sociodemographic factors, and behavioral factors. The performance of ethnicity-specific thresholds for predicting adverse outcomes and associated population-attributable fraction (PAF) was assessed in ethnic minority groups.

RESULTS

After a median follow-up of 12.5 years (interquartile range, 11.7-13.2), 32,662 (7.4%) participants had incident composite outcomes. At any given SBP, the predicted incidence rate of the composite outcome was the highest for South Asians, followed by White, Black Caribbean, and Black African. For an equivalent risk of outcomes observed in the White population at an SBP level of 140 mm Hg, the SBP threshold was lower for South Asians (123 mm Hg) and higher for Black Caribbean (156 mm Hg) and Black African (165 mm Hg). Furthermore, hypertension defined by ethnicity-specific thresholds was a stronger predictor and resulted in a larger PAF for composite outcomes in South Asians (21.5% [95% CI, 2.4,36.9] vs. 11.3% [95% CI, 2.6,19.1]) and Black Africans (7.1% [95% CI, 0.2,14.0] vs. 5.7 [95% CI, -16.2,23.5]) compared to hypertension defined by guideline-recommended thresholds.

CONCLUSIONS

Guideline-recommended blood pressure thresholds may overestimate risks for the Black population and underestimate risks for South Asians. Using ethnicity-specific SBP thresholds may improve risk estimation and optimize hypertension management toward the goal of eliminating ethnic disparities in cardiorenal complications.

Kidney Function and Long-Term Risk of End-Stage Kidney Disease and Mortality in a Multiethnic Population

Introduction

Contemporary differences between South Asian and White ethnicities in the incidence of end-stage kidney disease (ESKD) and mortality are poorly described.

Methods

Data for all South Asian patients who had an estimated glomerular filtration rate (eGFR) measure after January 1, 2006, and 1 million randomly selected participants of other ethnicities were extracted from the Clinical Practice Research Datalink (CPRD). All participants were followed-up with from index date until ESKD, all-cause mortality, or end of study. All-cause mortality rate and ESKD incidence rate by age were described among Whites and South Asians, and adjusted hazard ratios (HRs) of these 2 outcomes by baseline eGFR estimated using Cox proportional hazard model.

Results

A total of 40,888 South Asians and 236,634 Whites were followed for a median of 5.3 and 9.4 years for ESKD incidence and mortality outcomes, respectively. All-cause mortality rates were higher among Whites than South Asians; South Asian women aged between 70 and 85 years had a slightly higher ESKD incidence rate compared to their White counterparts. Compared to Whites with a baseline eGFR of 90 ml/min per 1.73 m2, adjusted HRs for all-cause mortality were significantly lower among South Asians than Whites; however, adjusted HRs for ESKD incidence by baseline eGFR were similar in both ethnicities. Calculating South Asian eGFRs using an ethnicity-specific equation had no impact on the results.

Conclusions

South Asians experience lower mortality than Whites but not substantially higher rates of ESKD. Further research is warranted to better understand the reasons for these ethnic differences and possible impacts on chronic kidney disease (CKD) service delivery and patient outcomes.

Different effects of cardiometabolic syndrome on brain age in relation to gender and ethnicity

BACKGROUND

A growing body of evidence shows differences in the prevalence of cardiometabolic syndrome (CMS) and dementia based on gender and ethnicity. However, there is a paucity of information about ethnic- and gender-specific CMS effects on brain age. We investigated the different effects of CMS on brain age by gender in Korean and British cognitively unimpaired (CU) populations. We also determined whether the gender-specific difference in the effects of CMS on brain age changes depending on ethnicity.

METHODS

These analyses used de-identified, cross-sectional data on CU populations from Korea and United Kingdom (UK) that underwent brain MRI. After propensity score matching to balance the age and gender between the Korean and UK populations, 5759 Korean individuals (3042 males and 2717 females) and 9903 individuals from the UK (4736 males and 5167 females) were included in this study. Brain age index (BAI), calculated by the difference between the predicted brain age by the algorithm and the chronological age, was considered as main outcome and presence of CMS, including type 2 diabetes mellitus (T2DM), hypertension, obesity, and underweight was considered as a predictor. Gender (males and females) and ethnicity (Korean and UK) were considered as effect modifiers.

RESULTS

The presence of T2DM and hypertension was associated with a higher BAI regardless of gender and ethnicity (p < 0.001), except for hypertension in Korean males (p = 0.309). Among Koreans, there were interaction effects of gender and the presence of T2DM (p for T2DM*gender = 0.035) and hypertension (p for hypertension*gender = 0.046) on BAI in Koreans, suggesting that T2DM and hypertension are each associated with a higher BAI in females than in males. In contrast, among individuals from the UK, there were no differences in the effects of T2DM (p for T2DM*gender = 0.098) and hypertension (p for hypertension*gender = 0.203) on BAI between males and females.

CONCLUSIONS

Our results highlight gender and ethnic differences as important factors in mediating the effects of CMS on brain age. Furthermore, these results suggest that ethnic- and gender-specific prevention strategies may be needed to protect against accelerated brain aging.

Incidence of Parkinson's disease and modifiable risk factors in Korean population: A longitudinal follow-up study of a nationwide cohort

Introduction

We aimed to investigate the incidence of Parkinson's disease (PD) by age and year for each sex as well as the modifiable risk factors for PD. Using data from the Korean National Health Insurance Service, 938,635 PD and dementia-free participants aged ≥40 years who underwent general health examinations were followed to December 2019.

Methods

We analyzed the PD incidence rates according to age, year and sex. To investigate the modifiable risk factors for PD, we used the Cox regression model. Additionally, we calculated the population-attributable fraction to measure the impact of the risk factors on PD.

Results

During follow-up, 9,924 of the 938,635 (1.1%) participants developed PD. The incidence of PD increased continuously from 2007 to 2018, reaching 1.34 per 1,000 person-years in 2018. The incidence of PD also increases with age, up to 80 y. Presence of hypertension (SHR = 1.09, 95% CI 1.05 to 1.14), diabetes (SHR = 1.24, 95% CI 1.17 to 1.31), dyslipidemia (SHR = 1.12, 95% CI 1.07 to 1.18), ischemic stroke (SHR = 1.26, 95% CI 1.17 to 1.36), hemorrhagic stroke (SHR = 1.26, 95% CI 1.08 to 1.47), ischemic heart disease (SHR = 1.09, 95% CI 1.02 to 1.17), depression (SHR = 1.61, 95% CI 1.53 to 1.69), osteoporosis (SHR = 1.24, 95% CI 1.18 to 1.30), and obesity (SHR = 1.06, 95% CI 1.01 to 1.10) were independently associated with a higher risk for PD.

Discussion

Our results highlight the effect of modifiable risk factors for PD in the Korean population, which will help establish health care policies to prevent the development of PD.

Liver, visceral and subcutaneous fat in men and women of South Asian and white European descent: a systematic review and meta-analysis of new and published data

AIMS/HYPOTHESIS

South Asians have a two- to fivefold higher risk of developing type 2 diabetes than those of white European descent. Greater central adiposity and storage of fat in deeper or ectopic depots are potential contributing mechanisms. We collated existing and new data on the amount of subcutaneous (SAT), visceral (VAT) and liver fat in adults of South Asian and white European descent to provide a robust assessment of potential ethnic differences in these factors.

METHODS

We performed a systematic review of the Embase and PubMed databases from inception to August 2021. Unpublished imaging data were also included. The weighted standardised mean difference (SMD) for each adiposity measure was estimated using random-effects models. The quality of the studies was assessed using the ROBINS-E tool for risk of bias and overall certainty of the evidence was assessed using the GRADE approach. The study was pre-registered with the OSF Registries ( https://osf.io/w5bf9 ).

RESULTS

We summarised imaging data on SAT, VAT and liver fat from eight published and three previously unpublished datasets, including a total of 1156 South Asian and 2891 white European men, and 697 South Asian and 2271 white European women. Despite South Asian men having a mean BMI approximately 0.5-0.7 kg/m² lower than white European men (depending on the comparison), nine studies showed 0.34 SMD (95% CI 0.12, 0.55; I²=83%) more SAT and seven studies showed 0.56 SMD (95% CI 0.14, 0.98; I²=93%) more liver fat, but nine studies had similar VAT (-0.03 SMD; 95% CI -0.24, 0.19; I²=85%) compared with their white European counterparts. South Asian women had an approximately 0.9 kg/m² lower BMI but 0.31 SMD (95% CI 0.14, 0.48; I²=53%) more liver fat than their white European counterparts in five studies. Subcutaneous fat levels (0.03 SMD; 95% CI -0.17, 0.23; I²=72%) and VAT levels (0.04 SMD; 95% CI -0.16, 0.24; I²=71%) did not differ significantly between ethnic groups in eight studies of women.

CONCLUSIONS/INTERPRETATION

South Asian men and women appear to store more ectopic fat in the liver compared with their white European counterparts with similar BMI levels. Given the emerging understanding of the importance of liver fat in diabetes pathogenesis, these findings help explain the greater diabetes risks in South Asians.

FUNDING

There was no primary direct funding for undertaking the systematic review and meta-analysis.

Are you as old as your arteries? Comparing arterial aging in Japanese and European patient groups using cardio-ankle vascular index

BACKGROUND

Most comparisons of arterial stiffness between ethnic groups focus on pulse wave velocity. This study used the cardio-ankle vascular index (CAVI) in European compared to Japanese individuals to investigate how cardiovascular risk factors affect arterial aging across geographic regions.

METHODS

Four hundred and ninety-four European and 1044 Japanese individuals underwent measurements of CAVI, blood pressure and information on cardiovascular risk factors. Both datasets included individuals with 0-5 cardiovascular risk factors.

RESULTS

Average CAVI was higher in the Japanese than the European group in every age category, with significant differences up to 75 years for males and 85 for females. The correlation of CAVI with age, controlled for cardiovascular risk factors, was slightly higher in Japanese females (r = 0.594 vs. Europeans r = 0.542) but much higher in European males (r = 0.710 vs. Japanese r = 0.511). There was a significant correlation between CAVI and total cardiovascular risk factors in the Japanese (r = 0.141, P < 0.001) but not the European group. On linear regression, average CAVI was significantly dependent on age, sex, diabetes, BMI, SBP and geographic region. When divided into 'healthy' vs. 'high risk', the healthy group had a steeper correlation with age for Europeans (r = 0.644 vs. Japanese r = 0.472, Fisher's Z P < 0.001), whereas in the high-risk group, both geographic regions had similar correlations.

CONCLUSION

Japanese patient groups had higher arterial stiffness than Europeans, as measured by CAVI, controlling for cardiovascular risk factors. Europeans had greater increases in arterial stiffness with age in healthy individuals, particularly for males. However, cardiovascular risk factors had a greater impact on the Japanese group.

The Effects of Ethno-cultural Origin-Destination Interactions on Immigrants' Longevity

A large body of research has documented an immigrant mortality advantage. However, we still do not know enough about how interactions between the characteristics of origin and destinations countries shape variabilities in immigrants' experiences and health. In this paper, we examine the effects of ethno-cultural similarities and differences between the country of origin and the country of destination on immigrants' longevity. We use meta-regression methods to examine data on 78 origin and 16 destination countries (1092 risk estimates from 69 studies). In contrast to expectations from approaches that focus on immigration/acculturation stress, we found that a shared official linguistic family, moving to a country where one is not likely to be considered a visible minority, and more integrative immigration policies actually reduce or even eliminate the immigrant mortality advantage. We discuss potential explanations for these findings and argue that selection mechanisms provide a better account.

Coronary artery disease in East and South Asians: differences observed on cardiac CT

Epidemiological studies have observed East Asians (EAs) are significantly less likely to develop or die from coronary artery disease (CAD) compared with Caucasians. Conversely South Asians (SAs) develop CAD at higher rate and earlier age. Recently, a range of features derived from cardiac CT have been identified which may further characterise ethnic differences in CAD. Emerging data suggest EAs exhibit less coronary calcification and high-risk, non-calcified plaque compared with Caucasians on CT, with no difference in luminal stenosis. In contrast, SAs exhibit similar to higher coronary calcification and luminal stenosis, smaller luminal dimensions and more high-risk, non-calcified plaque than Caucasians. Beyond demonstrating ethnic differences in CAD, cardiac CT may enhance and individualise cardiovascular risk stratification in EAs and SAs. While data thus far in EAs have demonstrated calcium score and CT-derived luminal stenosis may incrementally predict cardiovascular risk beyond traditional risk scores, there remains a paucity of data assessing its use in SAs. Future studies may clarify the prognostic value of cardiac CT in SAs and investigate how this modality may guide preventative therapy and coronary intervention of CAD in EAs and SAs.

Differential associations of ankle and brachial blood pressures with diabetes and cardiovascular diseases: cross-sectional study

Increased brachial systolic blood-pressure (BP) predicts diabetes (T2DM) but is not fully effective. Value of absolute ankle systolic BP for T2DM compared to brachial systolic BP is not known. Our objectives were to assess independent relationships of ankle-systolic BP with T2DM and cardiovascular disease in Europeans and south Asians. Cross-sectional studies of anonymised data from registered adults (n = 1087) at inner city deprived primary care practices. Study includes 63.85% ethnic minority. Systolic BP of the left and right-brachial, posterior-tibial and dorsalis-pedis-arteries measured using a Doppler probe. Regression models’ factors were age, sex, ethnicity, body mass index (BMI) and waist height ratio (WHtR). Both brachial and ankle systolic-BP increase with diabetes in Europeans and south Asians. We demonstrated that there was a significant positive independent association of ankle BP with diabetes, regardless of age and sex compared to Brachial. There was stronger negative association of ankle blood pressure with cardiovascular disease, after adjustment for BMI, WHtR and ethnicity. Additionally, we found that ankle BP were significantly associated with cardiovascular disease in south Asians more than the Europeans; right posterior tibial. Ankle systolic BPs are superior to brachial BPs to identify risks of Type 2DM and cardiovascular diseases for enhanced patient care.

Elevated Jewish Mortality from Coronavirus in England and Wales: An Epidemiological and Demographic Detective Story

In June 2020, the Office for National Statistics (ONS) in England and Wales published the results of an investigation into mortality from COVID-19 by religious group. The analysis revealed a significant "Jewish penalty": coronavirus mortality of Jews was shown to be relatively high compared to the British Christian majority. This paper considers these findings in the light of the literature on Jewish mortality and undertakes a re-analysis of the results alongside the additional data on Jewish deaths provided by the British Jewish communal statistics. It asks two questions: (1) To what extent is elevated British Jewish mortality from COVID-19 a result of the presence of long-standing vulnerability and ill health among Jews? (2) What role do strictly Orthodox Jews play in elevating coronavirus mortality levels among British Jews? The primary contribution of the paper is to explore, via analyses of alternative data sources, the ONS finding of elevated Jewish mortality from coronavirus, to explain why it is surprising, to test whether it is real and to eliminate certain explanations. Such process of elimination in itself will highlight other alternative explanations, but the paper falls short of decisively explaining the phenomenon of the elevated British Jewish mortality from coronavirus. It ends with an outline of future directions of research in this area.

A Global Meta-analysis of the Immigrant Mortality Advantage

A large body of research on the “Healthy Immigrant Effect” (or “Paradox”) has reported an immigrant mortality advantage. However, other studies do not find such significant effects, and some even present contradictory evidence. This article is the first systematic meta-analysis that investigates the immigration-mortality relationship from a global perspective, examining 1,933 all-cause and cardiovascular mortality risk estimates from 103 publications. Our comprehensive analysis allows us to assess interactions between origin and destination regions and to reexamine, on a global scale, some of the most notable explanations for the immigrant mortality advantage, including suggestions that this paradox may be primarily the result of selection effects. We find evidence for the existence of a mild immigrant mortality advantage for working-age individuals. However, the relationship holds only for immigrants who moved between certain world regions, particularly those who immigrated from Northern Africa, Asia, and Southern Europe to richer countries. The results highlight the need in the broader migration literature for an increased focus on selection effects and on outcomes for people who chose not to migrate or who were denied entry into their planned destination country.

Prevalence of different states of glucose intolerance in Sri Lankan children and adolescents with obesity and its relation to other comorbidities

BACKGROUND

South Asian adults have higher prevalence of obesity comorbidities than other ethnic groups. Whether this also is true for Sri Lankan children with obesity has rarely been investigated.

OBJECTIVE

To investigate prevalence of glucose intolerance and other comorbidities in Sri Lankan children with obesity and compare them with Swedish children. To identify risk factors associated with glucose intolerance.

SUBJECTS

A total of 357 Sri Lankan children (185 boys), aged 7 to 17 years with BMI-SDS ≥2.0 from a cross-sectional school screening in Negombo. A total of 167 subjects from this study population were matched for sex, BMI-SDS and age with 167 Swedish subjects from the ULSCO cohort for comparison.

METHODS

After a 12 hour overnight fast, blood samples were collected and oral glucose tolerance test was performed. Body fat mass was assessed by bioelectrical impedance assay. Data regarding medical history and socioeconomic status were obtained from questionnaires.

RESULTS

Based on levels of fasting glucose (FG) and 2 hours-glucose (2 hours-G), Sri Lankan subjects were divided into five groups: normal glucose tolerance (77.5%, n = 276), isolated impaired fasting glucose according to ADA criteria (9.0%, n = 32), isolated impaired glucose tolerance (8.4%, n = 30), combined impaired fasting glucose (IFG) + impaired glucose tolerance (IGT) (3.1%, n = 11) and type 2 diabetes mellitus (2.0%, n = 7). FG, 2 hours-insulin and educational status of the father independently increased the Odds ratio to have elevated 2 hours-G. Sri Lankan subjects had higher percentage of body fat, but less abdominal fat than Swedish subjects.

CONCLUSION

High prevalence in Sri Lankan children with obesity shows that screening for glucose intolerance is important even if asymptomatic.

Ethnic differences in childhood right and left cardiac structure and function assessed by cardiac magnetic resonance imaging

Ethnic differences in cardiovascular risk factors and disease are well-known and may originate in early-life. We examined the ethnic differences in cardiac structure and function in children using cardiac magnetic resonance imaging in a European migrant population, and whether any difference was explained by early life factors. We used a prospective population-based cohort study among 2317 children in Rotterdam, the Netherlands. We compared children from Dutch (73%), Cape Verdean (3.5%), Dutch Antillean (3.3%), Moroccan (6.1%), Surinamese-Creoles (3.9%), Surinamese-Hindustani (3.4%), and Turkish (6.4%) background. Main outcomes were cMRI-measured cardiac structures and function. Cardiac outcomes were standardized on body surface area. Cape Verdean, Surinamese-Hindustani, and Turkish children had smaller right ventricular end-diastolic volume and left ventricular end-diastolic volume relative to their body size than Dutch children (p < 0.05). These results were not fully explained by fetal and childhood factors. Right ventricular ejection fraction and left ventricular ejection fraction did not differ between ethnicities after adjustment for fetal and childhood factors.Conclusion: Right ventricular end-diastolic volume and left ventricular end-diastolic volume differ between ethnic subgroups in childhood, without affecting ejection fraction. Follow-up studies are needed to investigate whether these differences lead to ethnic differences in cardiac disease in adulthood. What is Known: • Ethnic differences in cardiovascular risk factors and disease are well-known and may originate in early-life. • The prevalence of cardiovascular disease differs between ethnic groups. What is New: • We examined ethnic differences in left and right cardiac structure and function in children using cMRI. • Right and left cardiac dimensions differ between ethnic groups in childhood and are only partly explained by fetal and childhood factors.

Cardiovascular risk assessment in South and Middle-East Asians living in the Western countries

Nearly a quarter of the world population lives in the South Asian region (India, Pakistan, Bangladesh, Sri Lanka, Nepal, Bhutan, and the Maldives). Due to rapid demographic and epidemiological transition in these countries, the burden of non-communicable diseases is growing, which is a serious public health concern. Particularly, the prevalence of pre-diabetes, diabetes and atherosclerotic cardiovascular disease (CVD) is increasing. South Asians living in the West have also substantially higher risk of CVD and mortality compared with white Europeans and Americans. Further, as a result of global displacement over the past three decades, Middle-Eastern immigrants now represent the largest group of non-European immigrants in Northern Europe. This vulnerable population has been less studied. Hence, the aim of the present review was to address cardiovascular risk assessment in South Asians (primarily people from India, Pakistan and Bangladesh), and Middle-East Asians living in Western countries compared with whites (Caucasians) and present results from some major intervention studies. A systematic search was conducted in PubMed to identify major cardiovascular health studies of South Asian and Middle-Eastern populations living in the West, relevant for this review. Results indicated an increased risk of CVD. In conclusion, both South Asian and Middle-Eastern populations living in the West carry significantly higher risk of diabetes and CVD compared with native white Europeans. Lifestyle interventions have been shown to have beneficial effects in terms of reduction in the risk of diabetes by increasing insulin sensitivity, weight loss as well as better glycemic and lipid control.

Effectiveness of behaviour change techniques on lifestyle interventions of patients with a high risk of developing cardiovascular disease. Using a qualitative approach

This study aimed to identify key active ingredients on the maintenance of behaviour change for lifestyle interventions of patients with a high risk of developing cardiovascular disease (CVD) who participated in a MOtiVational intErviewing InTervention (MOVE IT) randomised control trial (RCT). A process evaluation was carried out using focus groups. Twenty-six participants of the MOVE IT RCT were purposively recruited and split into six focus groups. Four groups had attended six or more sessions of the intensive phase (completers) and two groups had withdrawn before the end of the intensive phase or had not attended any sessions (non-completers). Focus groups were audio recorded, transcribed verbatim and analysed inductively using thematic analysis. Three overall themes were generated from the six focus groups: (a) long-term benefits from diet and physical activity education, (b) group versus individual structure and adherence and (c) impact on health beliefs and risk of CVD. A fourth theme was generated from the two groups of non-completers only: (d) need for professional rapport building and feedback. We found that the key active ingredients for effective behavioural change in lifestyle interventions are having well-developed rapport between facilitators and patients; and providing alternative forms of feedback to encourage maintenance of behaviour change. Furthermore, such programmes also need to have established and strong relationships with associated health professionals (i.e. the General Practitioner) to increase participation and maintenance of engagement.

Cerebrovascular carbon dioxide reactivity and flow-mediated dilation in young healthy South Asian and Caucasian European men

South Asians living in the United Kingdom have a 1.5-fold greater risk of ischemic stroke than the general population. Impaired cerebrovascular carbon dioxide (CO₂) reactivity is an independent predictor of ischemic stroke and cardiovascular mortality. We sought to test the hypothesis that cerebrovascular CO₂ reactivity is reduced in South Asians. Middle cerebral artery blood velocity (MCA V_m) was measured at rest and during stepwise changes in end-tidal partial pressure of CO₂ (PETCO2) in South Asian (n = 16) and Caucasian European (n = 18) men who were young (~20 yr), healthy, and living in the United Kingdom. Incremental hypercapnia was delivered via the open-circuit steady-state method, with stages of 4 and 7% CO₂ (≈21% oxygen, nitrogen balanced). Cerebrovascular CO₂ reactivity was calculated as the change in MCA V_m relative to the change in PETCO2. MCA V_m was not different in South Asians [59 (9) cm/s, mean (standard deviation)] and Caucasian Europeans [61 (12) cm/s; P > 0.05]. Similarly, cerebrovascular CO₂ reactivity was not different between the groups [South Asian 2.53 (0.76) vs. Caucasian European 2.61 (0.81) cm·s^-1·mmHg^-1; P > 0.05]. Brachial artery flow-mediated dilation was lower in South Asians [5.48 (2.94)%] compared with Caucasian Europeans [7.41 (2.28)%; P < 0.05]; however, when corrected for shear rate no between-group differences in flow-mediated dilation were observed (P > 0.05). Flow-mediated dilation was not correlated with cerebrovascular CO₂ reactivity measures. In summary, cerebrovascular CO₂ reactivity and flow-mediated dilation corrected for shear rate are preserved in young healthy South Asian men living in the United Kingdom.NEW & NOTEWORTHY Previous reports have identified an increased risk of ischemic stroke and peripheral endothelial dysfunction in South Asians compared with Caucasian Europeans. The main finding of this study is that cerebrovascular carbon dioxide reactivity (an independent predictor of ischemic stroke) is not different in healthy young South Asian and Caucasian European men.

Associations between high blood pressure and DNA methylation

Background

High blood pressure is a major risk factor for cardiovascular disease and is influenced by both environmental and genetic factors. Epigenetic processes including DNA methylation potentially mediate the relationship between genetic factors, the environment and cardiovascular disease. Despite an increased risk of hypertension and cardiovascular disease in individuals of South Asians compared to Europeans, it is not clear whether associations between blood pressure and DNA methylation differ between these groups.

Methods

We performed an epigenome-wide association study and differentially methylated region (DMR) analysis to identify DNA methylation sites and regions that were associated with systolic blood pressure, diastolic blood pressure and hypertension. We analyzed samples from 364 European and 348 South Asian men (first generation migrants to the UK) from the Southall And Brent REvisited cohort, measuring DNA methylation from blood using the Illumina Infinium^® HumanMethylation450 BeadChip.

Results

One CpG site was found to be associated with DBP in trans-ancestry analyses (i.e. both ethnic groups combined), while in Europeans alone seven CpG sites were associated with DBP. No associations were identified between DNA methylation and either SBP or hypertension. Comparison of effect sizes between South Asian and European EWAS for DBP, SBP and hypertension revealed little concordance between analyses. DMR analysis identified several regions with known relationships with CVD and its risk factors.

Conclusion

This study identified differentially methylated sites and regions associated with blood pressure and revealed ethnic differences in these associations. These findings may point to molecular pathways which may explain the elevated cardiovascular disease risk experienced by those of South Asian ancestry when compared to Europeans.

Cardiovascular Disease and hospital admissions in African immigrants and former Soviet Union immigrants: A retrospective cohort study

BACKGROUND

Previous studies reported low prevalence of cardiovascular disease (CVD) despite an increasing prevalence of metabolic abnormalities in immigrants who moved from low CVD-risk regions to Western countries. Nevertheless, little is known about hospital admissions due to CVD in immigrants.

METHODS

A retrospective cohort study of East Africa immigrants (EAI), Former Soviet Union immigrants (FSUI) and native-born Israelis (NBI) over 11-year period. Associations between ethnicity, age, sex, CVD, and hospital admission were assessed using logistic and Poisson regression models. Incidence density rates per person-years were calculated.

RESULTS

The age-adjusted prevalence rates of ischemic heart disease in EAI, FSUI and NBI, respectively, were 1.8%, 8.2%, and 5.8%, respectively (p < 0.001). The corresponding rates for stroke were 2.6%, 3.5%, and 2.5%, respectively. Multivariate odds ratios for all CVD were found to be significantly lower in EAI for both sexes. Hospitalizations rate due to CVD were 9, 17, and 6 per 1000 person-years in EAI, FSUI and NBI, respectively (p < 0.001). EAI were more likely to be hospitalized due to hypertensive disease, cerebral vascular diseases and heart disease, in comparison to NBI and FSUI. However, when controlling for CVD risk factors profile, EAI had similar admission rates to NBI. EAI were more likely to be hospitalized in internal medicine, geriatrics, and neurology departments, and less likely to be admitted to intensive care units or surgical department.

CONCLUSIONS

EAI had low rates of all types of CVD, and low risk of hospitalization after controlling for CVD risk factors profile.

Enhanced motivational interviewing for reducing weight and increasing physical activity in adults with high cardiovascular risk: the MOVE IT three-arm RCT

BACKGROUND

Motivational interviewing (MI) enhanced with behaviour change techniques (BCTs) and deployed by health trainers targeting multiple risk factors for cardiovascular disease (CVD) may be more effective than interventions targeting a single risk factor.

OBJECTIVES

The clinical effectiveness and cost-effectiveness of an enhanced lifestyle motivational interviewing intervention for patients at high risk of CVD in group settings versus individual settings and usual care (UC) in reducing weight and increasing physical activity (PA) were tested.

DESIGN

This was a three-arm, single-blind, parallel randomised controlled trial.

SETTING

A total of 135 general practices across all 12 South London Clinical Commissioning Groups were recruited.

PARTICIPANTS

A total of 1742 participants aged 40-74 years with a ≥ 20.0% risk of a CVD event in the following 10 years were randomised.

INTERVENTIONS

The intervention was designed to integrate MI and cognitive-behavioural therapy (CBT), delivered by trained healthy lifestyle facilitators in 10 sessions over 1 year, in group or individual format. The control group received UC.

RANDOMISATION

Simple randomisation was used with computer-generated randomisation blocks. In each block, 10 participants were randomised to the group, individual or UC arm in a 4 : 3 : 3 ratio. Researchers were blind to the allocation.

MAIN OUTCOME MEASURES

The primary outcomes are change in weight (kg) from baseline and change in PA (average number of steps per day over 1 week) from baseline at the 24-month follow-up, with an interim follow-up at 12 months. An economic evaluation estimates the relative cost-effectiveness of each intervention. Secondary outcomes include changes in low-density lipoprotein cholesterol and CVD risk score.

RESULTS

The mean age of participants was 69.75 years (standard deviation 4.11 years), 85.5% were male and 89.4% were white. At the 24-month follow-up, the group and individual intervention arms were not more effective than UC in increasing PA [mean 70.05 steps, 95% confidence interval (CI) -288 to 147.9 steps, and mean 7.24 steps, 95% CI -224.01 to 238.5 steps, respectively] or in reducing weight (mean -0.03 kg, 95% CI -0.49 to 0.44 kg, and mean -0.42 kg, 95% CI -0.93 to 0.09 kg, respectively). At the 12-month follow-up, the group and individual intervention arms were not more effective than UC in increasing PA (mean 131.1 steps, 95% CI -85.28 to 347.48 steps, and mean 210.22 steps, 95% CI -19.46 to 439.91 steps, respectively), but there were reductions in weight for the group and individual intervention arms compared with UC (mean -0.52 kg, 95% CI -0.90 to -0.13 kg, and mean -0.55 kg, 95% CI -0.95 to -0.14 kg, respectively). The group intervention arm was not more effective than the individual intervention arm in improving outcomes at either follow-up point. The group and individual interventions were not cost-effective.

CONCLUSIONS

Enhanced MI, in group or individual formats, targeted at members of the general population with high CVD risk is not effective in reducing weight or increasing PA compared with UC. Future work should focus on ensuring objective evidence of high competency in BCTs, identifying those with modifiable factors for CVD risk and improving engagement of patients and primary care.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN84864870.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 69. See the NIHR Journals Library website for further project information. This research was part-funded by the NIHR Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London.

Research-grade data in the real world: challenges and opportunities in data quality from a pragmatic trial in community-based practices

Randomized controlled trials face cost, logistic, and generalizability limitations, including difficulty engaging racial/ethnic minorities. Real-world data (RWD) from pragmatic trials, including electronic health record (EHR) data, may produce intervention evaluation findings generalizable to diverse populations. This case study of Project IMPACT describes unique barriers and facilitators of optimizing RWD to improve health outcomes and advance health equity in small immigrant-serving community-based practices. Project IMPACT tested the effect of an EHR-based health information technology intervention on hypertension control among small urban practices serving South Asian patients. Challenges in acquiring accurate RWD included EHR field availability and registry capabilities, cross-sector communication, and financial, personnel, and space resources. Although using RWD from community-based practices can inform health equity initiatives, it requires multidisciplinary collaborations, clinic support, procedures for data input (including social determinants), and standardized field logic/rules across EHR platforms.

Epidemiology, risk factors, and opportunities for prevention of cardiovascular disease in individuals of South Asian ethnicity living in Europe

South Asian (SA) individuals represent a large, growing population in a number of European countries. These individuals, particularly first-generation SA immigrants, are at higher risk of developing type 2 diabetes, atherogenic dyslipidaemia, and coronary heart disease than most other racial/ethnic groups living in Europe. SAs also have an increased risk of stroke compared to European-born individuals. Despite a large body of conclusive evidence, SA-specific cardiovascular health promotion and preventive interventions are currently scarce in most European countries, as well as at the European Union level. In this narrative review, we aim to increase awareness among clinicians and healthcare authorities of the public health importance of cardiovascular disease among SAs living in Europe, as well as the need for tailored interventions targeting this group - particularly, in countries where SA immigration is a recent phenomenon. To this purpose, we review key studies on the epidemiology and risk factors of cardiovascular disease in SAs living in the United Kingdom, Italy, Spain, Denmark, Norway, Sweden, and other European countries. Building on these, we discuss potential opportunities for multi-level, targeted, tailored cardiovascular prevention strategies. Because lifestyle interventions often face important cultural barriers in SAs, particularly for first-generation immigrants; we also discuss features that may help maximise the effectiveness of those interventions. Finally, we evaluate knowledge gaps, currently available risk stratification tools such as QRISK-3, and future directions in this important field.

Caucasian and south Asian men show equivalent improvements in surrogate biomarkers of cardiovascular and metabolic health following 6-weeks of supervised resistance training

Background: The South Asian population have greater cardiovascular risk than their age-matched Caucasian counterparts, characterized by unfavorable biomarkers. South Asians may also be partially resistant to the pleiotropic benefits of physical activity on cardiovascular health. There is a current absence of studies that compare markers of cardio-metabolic health between Caucasians and South Asians employing resistance exercise. This study set out to compare the response in biomarkers of cardio-metabolic health in Caucasians and South Asians in response to resistance exercise. Methods: Caucasian (n=15, 25.5 ± 4.8 yrs) and South Asian (n=13, 25.4 ± 7.0 yrs) males completed a 6-week progressive resistance exercise protocol. Fasting blood glucose, insulin, and their product insulin resistance (HOMA-IR), triglycerides (TRIGS), low density lipoprotein (LDL), high density lipoprotein (HDL), total cholesterol (TC), vascular endothelial growth factor (VEGF), asymmetric dimythylarginine (ADMA), L-arginine (L-ARG) and C-reactive protein (CRP) were established at baseline and following resistance exercise. Results: There were significant improvements in fasting glucose, TC, LDL, HDL and VEGF in both groups following resistance exercise ( p<0.05, for all). No change was observed in insulin, HOMA-IR, TRIGS, ADMA, L-ARG following resistance exercise ( p>0.05, in both groups). CRP increased in the South Asian group ( p<0.05) but not the Caucasian group ( p>0.05) Conclusions: The cardio-metabolic response to resistance exercise is comparable in young Caucasian and South Asian males though inflammatory response to exercise may be prolonged in South Asians.

Sex differences in mortality in migrants and the Swedish-born population: Is there a double survival advantage for immigrant women?

Objectives

In the present study, we examine whether the relationships between country of origin or reason for migration and mortality differ between men and women.

Methods

We apply hazard regression models on high-quality Swedish register data with nationwide coverage.

Results

Relative to their Swedish counterparts, migrants from Nordic and East European (EU) countries and former Yugoslavia have higher mortality. This excess mortality among migrants relative to Swedes is more pronounced in men than in women. Migrants from Western and Southern European countries; Iran, Iraq, and Turkey; Central and South America; and Asia, have lower mortality than Swedes, and the size of the mortality reduction is similar in both sexes. The predictive effects of the reason for migration for mortality are also similar in migrant men and women.

Conclusions

This study provides little support for the hypothesis of a double survival advantage among immigrant women in Sweden. However, it does show that the excess mortality in migrants from Nordic and EU countries and former Yugoslavia relative to the Swedish-born population is more pronounced in men than in women.

Electronic supplementary material

The online version of this article (10.1007/s00038-019-01208-1) contains supplementary material, which is available to authorized users.

Million Migrants study of healthcare and mortality outcomes in non-EU migrants and refugees to England: Analysis protocol for a linked population-based cohort study of 1.5 million migrants

Background: In 2017, 15.6% of the people living in England were born abroad, yet we have a limited understanding of their use of health services and subsequent health conditions. This linked population-based cohort study aims to describe the hospital-based healthcare and mortality outcomes of 1.5 million non-European Union (EU) migrants and refugees in England. Methods and analysis: We will link four data sources: first, non-EU migrant tuberculosis pre-entry screening data; second, refugee pre-entry health assessment data; third, national hospital episode statistics; and fourth, Office of National Statistics death records. Using this linked dataset, we will then generate a population-based cohort to examine hospital-based events and mortality outcomes in England between Jan 1, 2006, and Dec 31, 2017. We will compare outcomes across three groups in our analyses: 1) non-EU international migrants, 2) refugees, and 3) general population of England. Ethics and dissemination: We will obtain approval to use unconsented patient identifiable data from the Secretary of State for Health through the Confidentiality Advisory Group and the National Health Service Research Ethics Committee. After data linkage, we will destroy identifying data and undertake all analyses using the pseudonymised dataset. The results will provide policy makers and civil society with detailed information about the health needs of non-EU international migrants and refugees in England.

Cardiovascular risk factors from diagnosis in children with type 1 diabetes mellitus: a longitudinal cohort study

BACKGROUND

For childhood onset type 1 diabetes (T1D), the pathogenesis of atherosclerosis is greatly accelerated and results in early cardiovascular disease (CVD) and increased mortality. However, cardioprotective interventions in this age group are not routinely undertaken.

AIMS

To document prevalence of cardiovascular risk factors from diagnosis of childhood T1D and their relationship with disease duration and ethnicity.

METHODS

Routinely collected clinical records for 565 children with T1D were retrospectively analyzed. Data were collected from diagnosis and at routine check-ups at pediatric diabetes clinics across Barts Health National Health Service Trust. Age at diagnosis was 8.5 years (0.9-19.4). Mean follow-up 4.3 years (0-10.8). 48% were boys and 60% were non-white. Linear longitudinal mixed effects models were used to evaluate relationships between risk factors and diabetes duration.

RESULTS

CVD risk factors were present at first screening; 33.8% of children were overweight or obese, 20.5% were hypertensive (elevated diastolic blood pressure (BP)) and total cholesterol, low-density lipoprotein-cholesterol and high-density lipoprotein-cholesterol were abnormal in 63.5%, 34.2% and 22.0%, respectively. Significant associations between diabetes duration and annual increases of body mass index (0.6 kg/m²), BP (0.1 SD score) and lipids (0.02-0.06 mmol/L) were noted. Annual increases were significantly higher in black children for BP and Bangladeshi children for lipids. Bangladeshi children also had greatest baseline levels.

CONCLUSIONS

CVD risk factors are present in up to 60% of children at diagnosis of T1D and increase in prevalence during the early years of the disease. Commencing screening in younger children and prioritizing appropriate advice and attention to ethnic variation when calculating risk should be considered.

Global patterns of mortality in international migrants: a systematic review and meta-analysis

BACKGROUND

258 million people reside outside their country of birth; however, to date no global systematic reviews or meta-analyses of mortality data for these international migrants have been done. We aimed to review and synthesise available mortality data on international migrants.

METHODS

In this systematic review and meta-analysis, we searched MEDLINE, Embase, the Cochrane Library, and Google Scholar databases for observational studies, systematic reviews, and randomised controlled trials published between Jan 1, 2001, and March 31, 2017, without language restrictions. We included studies reporting mortality outcomes for international migrants of any age residing outside their country of birth. Studies that recruited participants exclusively from intensive care or high dependency hospital units, with an existing health condition or status, or a particular health exposure were excluded. We also excluded studies limited to maternal or perinatal outcomes. We screened studies using systematic review software and extracted data from published reports. The main outcomes were all-cause and International Classification of Diseases, tenth revision (ICD-10) cause-specific standardised mortality ratios (SMRs) and absolute mortality rates. We calculated summary estimates using random-effects models. This study is registered with PROSPERO, number CRD42017073608.

FINDINGS

Of the 12 480 articles identified by our search, 96 studies were eligible for inclusion. The studies were geographically diverse and included data from all global regions and for 92 countries. 5464 mortality estimates for more than 15·2 million migrants were included, of which 5327 (97%) were from high-income countries, 115 (2%) were from middle-income countries, and 22 (<1%) were from low-income countries. Few studies included mortality estimates for refugees (110 estimates), asylum seekers (144 estimates), or labour migrants (six estimates). The summary estimate of all-cause SMR for international migrants was lower than one when compared with the general population in destination countries (0·70 [95% CI 0·65-0·76]; I2=99·8%). All-cause SMR was lower in both male migrants (0·72 [0·63-0·81]; I2=99·8%) and female migrants (0·75 [0·67-0·84]; I2=99·8%) compared with the general population. A mortality advantage was evident for refugees (SMR 0·50 [0·46-0·54]; I2=89·8%), but not for asylum seekers (1·05 [0·89-1·24]; I2=54·4%), although limited data was available on these groups. SMRs for all causes of death were lower in migrants compared with the general populations in the destination country across all 13 ICD-10 categories analysed, with the exception of infectious diseases and external causes. Heterogeneity was high across the majority of analyses. Point estimates of all-cause age-standardised mortality in migrants ranged from 420 to 874 per 100 000 population.

INTERPRETATION

Our study showed that international migrants have a mortality advantage compared with general populations, and that this advantage persisted across the majority of ICD-10 disease categories. The mortality advantage identified will be representative of international migrants in high-income countries who are studying, working, or have joined family members in these countries. However, our results might not reflect the health outcomes of more marginalised groups in low-income and middle-income countries because little data were available for these groups, highlighting an important gap in existing research. Our results present an opportunity to reframe the public discourse on international migration and health in high-income countries.

FUNDING

Wellcome Trust, National Institute for Health Research, Medical Research Council, Alliance for Health Policy and Systems Research, Department for International Development, Fogarty International Center, Grand Challenges Canada, International Development Research Centre Canada, Inter-American Institute for Global Change Research, National Cancer Institute, National Heart, Lung and Blood Institute, National Institute of Mental Health, Swiss National Science Foundation, World Diabetes Foundation, UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, and European Society for Clinical Microbiology and Infectious Diseases (ESCMID) Study Group Research Funding for the ESCMID Study Group for Infections in Travellers and Migrants.

Heterogeneity in blood pressure in UK Bangladeshi, Indian and Pakistani, compared to White, populations: divergence of adults and children

Blood pressure (BP) and hypertension prevalence differences between UK South Asians (Bangladeshis, Indians and Pakistanis) and White Europeans exist in childhood and adulthood. This meta-analysis sought to quantify these differences. We searched MEDLINE (1946-2017), EMBASE (1974-2017) and GLOBAL HEALTH (1973-2017) for comparative studies and pooled the data with Revman (Cochrane Collaboration). Twenty-two studies were included-fourteen on adults and eight on children. South Asian adults had lower systolic and slightly lower diastolic BP. However, stark heterogeneity existed between South Asian subgroups: Bangladeshis had markedly lower systolic BP (mean difference: -11.7 mmHg in men and women), Indians slightly lower (-2.0 mmHg in men and -4.5 mmHg in women) and Pakistanis intermediately lower (-7.9 mmHg in men and -8.6 mmHg in women), compared to White Europeans. However, South Asian children did not have lower systolic or diastolic BP compared to White children, and their BP was often higher. This intergenerational change in BP difference mirrored the change in body mass index difference, particularly in Bangladeshis. We conclude that ethnicity-related BP differences are heterogeneous and dependent on age, sex and South Asian subgroup. South Asian children do not have lower BP than White Europeans in contrast to their adult counterparts. There is concern that this pattern may continue into adulthood, worsening the already high cardiovascular disease burden in South Asians in future years. Further research is needed to ascertain the causes of this evolving issue.

Response bias to a randomised controlled trial of a lifestyle intervention in people at high risk of cardiovascular disease: a cross-sectional analysis

Background

Research evaluating lifestyle interventions for prevention of cardiovascular disease (CVD) may not reach those most at risk. We compared the response rate to a randomised controlled trial (RCT) of a lifestyle intervention by CVD risk, ethnicity and level of deprivation.

Methods

Primary care patients with a QRisk2 score ≥ 20% were invited to participate in a RCT of an intensive lifestyle intervention versus usual care. This cross-sectional analysis compares anonymised data of responders and non-responders with multiple logistic regression, using adjusted odds ratios (AORs) for QRisk2 score, ethnicity, Index of Multiple Deprivation (IMD 2010) quintile, age and sex.

Results

From 60 general practices, 8902 patients were invited and 1489 responded. The mean age was 67.3 years and 21.0% were female. Of all patients invited, 69.9% were of white ethnic background, 13.9% ethnic minority backgrounds and 16.2% had no ethnicity data recorded in their medical records. Likelihood of response decreased as QRisk2 score increased (AOR 0.82 per 5 percentage points, 95% CI 0.77–0.88). Black African or Caribbean patients (AOR 0.67; 95% CI 0.45–0.98) and those with missing ethnicity data (AOR 0.55; 95% CI 0.46–0.66) were less likely to respond compared to participants of white ethnicity, but there was no difference in the response rates between south Asian and white ethnicity (AOR 1.08; 95% CI 0.84–1.38). Patients residing in the fourth (AOR 0.70; 95% CI 0.56–0.87) and fifth (AOR 0.52; 95% CI 0.40–0.68) most deprived IMD quintile were less likely to respond compared to the least deprived quintile.

Conclusions

Evaluations of interventions intended for those at high risk of CVD may fail to reach those at highest risk. Hard to reach patient groups may require different recruitment strategies to maximise participation in future trials. Improvements in primary care ethnicity data recording is required to aid understanding of how successfully study samples represent the target population.

Trial registration

ISRCTN, ISRCTN84864870. Registered 15 May 2012, 10.1186/ISRCTN84864870.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5939-y) contains supplementary material, which is available to authorized users.

Understanding age variations in the migrant mortality advantage: An international comparative perspective

This paper investigates age variations in foreign-born vs. native-born mortality ratios in an international comparative perspective, with the purpose of gaining insight into the mechanisms underlying the so-called migrant mortality advantage. We examine the four main explanations that have been proposed in the literature for the migrant mortality advantage (i.e., in-migration selection effects, out-migration selection effects, cultural effects, and data artifacts), and formulate expectations as to whether they should generate an increase, a decrease, or no change in relative mortality over the life course. Using data from France, the US and the UK for periods around 2010, we then examine typical age patterns of foreign-born vs. native-born mortality ratios in light of this theoretical framework. We find that these mortality ratios vary greatly by age, with important similarities across migrant groups and host countries. The most systematic age pattern we find is a U-shape pattern: at the aggregate level, migrants often experience excess mortality at young ages, then exhibit a large advantage at adult ages (with the largest advantage around age 45), and finally experience mortality convergence with natives at older ages. The explanation most consistent with this pattern is the “in-migration selection effects” explanation. By contrast, the “out-migration selection effects” explanation is poorly supported by the observed patterns. Our age disaggregation also shows that migrants at mid-adult ages experience mortality advantages that are often far greater than typically documented in this literature. Overall, these results reinforce the notion that migrants are a highly-selected population exhibiting mortality patterns that poorly reflect their living conditions in host countries.

Associations of social and economic and pregnancy exposures with blood pressure in UK White British and Pakistani children age 4/5

South Asians have higher rates of coronary heart disease (CHD) than White European individuals. Blood pressure (BP) is one of the most important risk factors for CHD and ethnic differences in BP have been identified in childhood. Early life exposures could explain some of these differences. We examined associations of family social and economic and maternal pregnancy exposures and BP at age 4/5 in 1644 White British and 1824 Pakistani mother-offspring pairs from the Born in Bradford study. We found that systolic BP was similar but diastolic BP was higher, in Pakistani compared to White British children (adjusted mean differences were −0.170 mmHg 95% CI −0.884, 0.543 for systolic BP; 1.328 mmHg 95% CI 0.592, 2.064 for diastolic BP). Social and economic exposures were not associated with BP in either ethnic group. Maternal BMI was positively associated with BP in both groups but this association was mediated by child BMI. Only gestational hypertension was associated with child systolic and diastolic BP and this was only identified in Pakistani mother-offspring pairs. These findings suggest that Pakistani populations may have a different BP trajectory compared to White British groups and that this is already evident at age 4/5 years.

The contribution of physical fitness to individual and ethnic differences in risk markers for type 2 diabetes in children: The Child Heart and Health Study in England (CHASE)

BACKGROUND

The relationship between physical fitness and risk markers for type 2 diabetes (T2D) in children and the contribution to ethnic differences in these risk markers have been little studied. We examined associations between physical fitness and early risk markers for T2D and cardiovascular disease in 9- to 10-year-old UK children.

METHODS

Cross-sectional study of 1445 9- to 10-year-old UK children of South Asian, black African-Caribbean and white European origin. A fasting blood sample was used for measurement of insulin, glucose (from which homeostasis model assessment [HOMA]-insulin resistance [IR] was derived), glycated hemoglobin (HbA1c), urate, C-reactive protein (CRP), and lipids. Measurements of blood pressure (BP) and fat mass index (FMI) were made; physical activity was measured by accelerometry. Estimated VO_{2 max} was derived from a submaximal fitness step test. Associations were estimated using multilevel linear regression.

RESULTS

Higher VO_{2 max} was associated with lower FMI, insulin, HOMA-IR, HbA1c, glucose, urate, CRP, triglycerides, LDL-cholesterol, BP and higher HDL-cholesterol. Associations were reduced by adjustment for FMI, but those for insulin, HOMA-IR, glucose, urate, CRP, triglycerides and BP remained statistically significant. Higher levels of insulin and HOMA-IR in South Asian children were partially explained by lower levels of VO_2max compared to white Europeans, accounting for 11% of the difference.

CONCLUSIONS

Physical fitness is associated with risk markers for T2D and CVD in children, which persist after adjustment for adiposity. Higher levels of IR in South Asians are partially explained by lower physical fitness levels compared to white Europeans. Improving physical fitness may provide scope for reducing risks of T2D.

Short and long-term prognosis following acute myocardial infarction according to the country of origin. Soroka acute myocardial infarction II (SAMI II) project

BACKGROUND

Reports from many countries have shown birthplace-associated disparities in the incidence and mortality following acute myocardial infarction (AMI). The aims of the study were to identify and compare short- and long-term post-AMI mortality according to birthplace.

METHODS

A retrospective analysis of Israeli AMI patients from a tertiary medical center in Southern Israel throughout 2002-2012.

DATA SOURCE

the hospital's computerized systems. Patients were classified according to the country of birth (Israel, Southern Europe/Balkans, Northern Africa, Eastern/Central Europe, India/Pakistan, Middle-East, Yemen, and Ethiopia).

STUDY OUTCOMES

in-hospital and up to 10-years post-discharge all-cause mortality.

RESULTS

The study included 11,143 patients, age 67.4 ± 13.9 and 67.5% men. Israeli-born patients were significantly younger, with lower rate of diabetes mellitus and hypertension but significantly higher rate of obesity, smoking, history of coronary artery disease and male sex compared with immigrants. The rate of STEMI and administration of percutaneous coronary revascularization was higher, yet extent of coronary findings and severe left ventricular dysfunction was lower in Israeli-born patients. In-hospital as well as post-discharge 1-and 10-year mortality rates were approximately 65% lower in Israeli-born patients compared with immigrants. Following adjustment for potential confounders the inequalities in post-discharge mortality attenuated (Yemen OR = 2.3 [95%CI: 1.4-3.6], Southern Europe/Balkans 1.75 [1.2-2.5], Northern Africa 1.5 [1.3-1.8], Eastern/Central Europe 1.4 [1.2-1.7] and India/Pakistan 1.4 [1.1-1.9], for 10-years mortality, p < 0.05 for each) and those for in-hospital mortality disappeared.

CONCLUSIONS

Immigrants are at increased risk for post-discharge, yet not in-hospital mortality following AMI. Appropriate targeted preventive programs are required for these groups of patients.

Forearm vasodilator responses to environmental stress and reactive hyperaemia are impaired in young South Asian men

Purpose

Prevalence of cardiovascular disease (CVD) is greater in South Asians (SAs) than White Europeans (WEs). Endothelial dysfunction and blunted forearm vasodilatation to environmental stressors have been implicated in CVD. We investigated whether these features are present in young SA men.

Methods

In 15 SA and 16 WE men (19–23 years), we compared changes in forearm blood flow, arterial blood pressure (ABP), forearm vascular conductance (FVC), heart rate, and electrodermal resistance (EDR; sweating) following release of arterial occlusion (reactive hyperaemia endothelium-dependent) and 5 single sounds at 5–10 min intervals (stressors).

Results

All were normotensive. Peak reactive hyperaemia was smaller in SAs than WEs (FVC increase: 0.36 ± 0.038 vs 0.44 ± 0.038 units; P < 0.05). Furthermore, in WEs, mean FVC increased at 5, 15, and 20 s of each sound (vasodilatation), but increased at 5 s only in SAs, decreasing by 20 s (vasoconstriction). This reflected a smaller proportion of SAs showing forearm vasodilatation at 15 s (5/15 SAs vs 11/16 WEs: P < 0.01), the remainder showing vasoconstriction. Concomitantly, WEs showed greater bradycardia and EDR changes. Intra-class correlation analyses showed that all responses were highly reproducible over five sounds in both WEs and SAs. Moreover, sound-evoked changes in ABP and FVC were negatively correlated in each ethnicity (P < 0.01). However, WEs showed preponderance of forearm vasodilatation and depressor responses; SAs showed preponderance of vasoconstriction and pressor responses.

Conclusions

Endothelium-dependent vasodilatation is blunted in young SA men. This could explain their impaired forearm vasodilatation and greater pressor responses to repeated environmental stressors, so predisposing SAs to hypertension and CVD.

Mortality, ethnicity, and country of birth on a national scale, 2001-2013: A retrospective cohort (Scottish Health and Ethnicity Linkage Study)

BACKGROUND

Migrant and ethnic minority groups are often assumed to have poor health relative to the majority population. Few countries have the capacity to study a key indicator, mortality, by ethnicity and country of birth. We hypothesized at least 10% differences in mortality by ethnic group in Scotland that would not be wholly attenuated by adjustment for socio-economic factors or country of birth.

METHODS AND FINDINGS

We linked the Scottish 2001 Census to mortality data (2001-2013) in 4.62 million people (91% of estimated population), calculating age-adjusted mortality rate ratios (RRs; multiplied by 100 as percentages) with 95% confidence intervals (CIs) for 13 ethnic groups, with the White Scottish group as reference (ethnic group classification follows the Scottish 2001 Census). The Scottish Index of Multiple Deprivation, education status, and household tenure were socio-economic status (SES) confounding variables and born in the UK or Republic of Ireland (UK/RoI) an interacting and confounding variable. Smoking and diabetes data were from a primary care sub-sample (about 53,000 people). Males and females in most minority groups had lower age-adjusted mortality RRs than the White Scottish group. The 95% CIs provided good evidence that the RR was more than 10% lower in the following ethnic groups: Other White British (72.3 [95% CI 64.2, 81.3] in males and 75.2 [68.0, 83.2] in females); Other White (80.8 [72.8, 89.8] in males and 76.2 [68.6, 84.7] in females); Indian (62.6 [51.6, 76.0] in males and 60.7 [50.4, 73.1] in females); Pakistani (66.1 [57.4, 76.2] in males and 73.8 [63.7, 85.5] in females); Bangladeshi males (50.7 [32.5, 79.1]); Caribbean females (57.5 [38.5, 85.9]); and Chinese (52.2 [43.7, 62.5] in males and 65.8 [55.3, 78.2] in females). The differences were diminished but not eliminated after adjusting for UK/RoI birth and SES variables. A mortality advantage was evident in all 12 minority groups for those born abroad, but in only 6/12 male groups and 5/12 female groups of those born in the UK/RoI. In the primary care sub-sample, after adjustment for age, UK/RoI born, SES, smoking, and diabetes, the RR was not lower in Indian males (114.7 [95% CI 78.3, 167.9]) and Pakistani females (103.9 [73.9, 145.9]) than in White Scottish males and females, respectively. The main limitations were the inability to include deaths abroad and the small number of deaths in some ethnic minority groups, especially for people born in the UK/RoI.

CONCLUSIONS

There was relatively low mortality for many ethnic minority groups compared to the White Scottish majority. The mortality advantage was less clear in UK/RoI-born minority group offspring than in immigrants. These differences need explaining, and health-related behaviours seem important. Similar analyses are required internationally to fulfil agreed goals for monitoring, understanding, and improving health in ethnically diverse societies and to apply to health policy, especially on health inequalities and inequities.

Ethnic inequalities in acute myocardial infarction hospitalization rates among young and middle-aged adults in Northern Italy: high risk for South Asians

The knowledge of ethnic-specific health needs is now essential to design effective health services and population-based prevention strategies. However, data on migrant populations living in Southern Europe are limited. The study is designed to investigate ethnic inequalities in hospitalization for acute myocardial infarction (AMI) in the Veneto region (Italy). Hospital admissions for AMI in Veneto for the whole resident population aged 20-59 years during 2008-2013 were studied. Age and gender-specific AMI hospitalization rates for immigrant groups (classified by country of origin according to the United Nations geoscheme) and Italians were calculated. The indirect standardization method was used to estimate standardized hospitalization ratios (SHR) for each immigrant group, with rates of Italian residents as a reference. Overall, 8200 AMI events were retrieved, 648 among immigrants. The highest risk of AMI is seen in South Asians males (SHR 4.2, 95% CI 3.6-4.9) and females (SHR 2.5, 95% CI 1.4-4.5). AMI rates in South Asian males sharply increase in the 30-39 years age class. Other immigrant subgroups (Eastern Europe, North Africa, Sub-Saharan Africa, other Asian countries, Central-South America, high-income countries) displayed age- and gender-adjusted hospitalization rates similar to the native population. Present findings stress the urgent need for implementation of ethnic-specific health policies in Italy. The awareness about the high cardiovascular risk in subjects from South Asia must be increased among general practitioners and immigrant communities.

Reassessing Ethnic Differences in Mean BMI and Changes Between 2007 and 2013 in English Children

OBJECTIVE

National body fatness (BF) data for English South Asian and Black children use BMI, which provides inaccurate ethnic comparisons. BF levels and time trends in the English National Child Measurement Programme (NCMP) between 2007 and 2013 were assessed by using ethnic-specific adjusted BMI (aBMI) for South Asian and Black children.

METHODS

Analyses were based on 3,195,323 children aged 4 to 5 years and 2,962,673 children aged 10 to 11 years. aBMI values for South Asian and Black children (relating to BF as in White children) were derived independently. Mean aBMI levels and 5-year aBMI changes were obtained by using linear regression.

RESULTS

In the 2007-2008 NCMP, mean aBMIs in 10- to 11-year-old children (boys, girls) were higher in South Asian children (20.1, 19.9 kg/m² ) and Black girls, but not in Black boys (18.4, 19.2 kg/m² ) when compared with White children (18.6, 19.0 kg/m² ; all P < 0.001). Mean 5-year changes (boys, girls) were higher in South Asian children (0.16, 0.32 kg/m² per 5 y; both P < 0.001) and Black boys but not girls (0.13, 0.15 kg/m² per 5 y; P = 0.01, P = 0.41) compared with White children (0.02, 0.11 kg/m² per 5 y). Ethnic differences at 4 to 5 years were similar. Unadjusted BMI showed similar 5-year changes but different mean BMI patterns.

CONCLUSIONS

BF levels were higher in South Asian children than in other groups in 2007 and diverged from those in White children until 2013, a pattern not apparent from unadjusted BMI data.

Protocol for project IMPACT (improving millions hearts for provider and community transformation): a quasi-experimental evaluation of an integrated electronic health record and community health worker intervention study to improve hypertension management among South Asian patients

BACKGROUND

The Million Hearts® initiative aims to prevent heart disease and stroke in the United States by mobilizing public and private sectors around a core set of objectives, with particular attention on improving blood pressure control. South Asians in particular have disproportionately high rates of hypertension and face numerous cultural, linguistic, and social barriers to accessing healthcare. Interventions utilizing Health information technology (HIT) and community health worker (CHW)-led patient coaching have each been demonstrated to be effective at advancing Million Hearts® goals, yet few studies have investigated the potential impact of integrating these strategies into a clinical-community linkage initiative. Building upon this initiative, we present the protocol and preliminary results of a research study, Project IMPACT, designed to fill this gap in knowledge.

METHODS

Project IMPACT is a stepped wedge quasi-experimental study designed to test the feasibility, adoption, and impact of integrating CHW-led health coaching with electronic health record (EHR)-based interventions to improve hypertension control among South Asian patients in New York City primary care practices. EHR intervention components include the training and implementation of hypertension-specific registry reports, alerts, and order sets. Fidelity to the EHR intervention is assessed by collecting the type, frequency, and utilization of intervention components for each practice. CHW intervention components consist of health coaching sessions on hypertension and related risk factors for uncontrolled hypertensive patients. The outcome, hypertension control (<140 mmHg systolic blood pressure (BP) and <90 mmHg diastolic BP), is collected at the aggregate- and individual-level for all 16 clinical practices enrolled.

DISCUSSION

Project IMPACT builds upon the evidence base of the effectiveness of CHW and Million Hearts® initiatives and proposes a unique integration of provider-based EHR and community-based CHW interventions. The project informs the effectiveness of these interventions in team-based care approaches, thereby, helping to develop relevant sustainability strategies for improving hypertension control among targeted racial/ethnic minority populations at small primary care practices.

TRIAL REGISTRATION

This study protocol has been approved and is made available on Clinicaltrials.gov by NCT03159533 as of May 17, 2017.

Patterns of childhood body mass index (BMI), overweight and obesity in South Asian and black participants in the English National child measurement programme: effect of applying BMI adjustments standardising for ethnic differences in BMI-body fatness associations

Background:

The National Child Measurement Programme (NCMP) records weight and height and assesses overweight-obesity patterns in English children using body mass index (BMI), which tends to underestimate body fatness in South Asian children and overestimate body fatness in Black children of presumed African ethnicity. Using BMI adjustments to ensure that adjusted BMI was similarly related to body fatness in South Asian, Black and White children, we reassessed population overweight and obesity patterns in these ethnic groups in NCMP.

Methods:

Analyses were based on 2012–2013 NCMP data in 582 899 children aged 4–5 years and 485 362 children aged 10–11 years. Standard centile-based approaches defined weight status in each age group before and after applying BMI adjustments for English South Asian and Black children derived from previous studies using the deuterium dilution method.

Findings:

Among White children, overweight-obesity prevalences (boys, girls) were 23% and 21%, respectively, in 4–5 year olds and 33% and 30%, respectively, in 10–11 year olds. Before adjustment, South Asian children had lower overweight-obesity prevalences at 4–5 years (19%, 19%) and slightly higher prevalences at 10–11 years (42%, 34%), whereas Black children had higher overweight-obesity prevalences both at 4–5 years (31%, 29%) and 10–11 years (42%, 45%). Following adjustment, overweight-obesity prevalences were markedly higher in South Asian children both at 4–5 years (39%, 35%) and at 10–11 years (52%, 44%), whereas Black children had lower prevalences at 4–5 years (11%, 12%); at 10–11 years, prevalences were slightly lower in boys (32%) but higher in girls (35%).

Interpretation:

BMI adjustments revealed extremely high overweight-obesity prevalences among South Asian children in England, which were not apparent in unadjusted data. In contrast, after adjustment, Black children had lower overweight-obesity prevalences except among older girls.

Funding:

British Heart Foundation, NIHR CLAHRC (South London), NIHR CLAHRC (North Thames).

South Asian ethnicity is associated with a lower prevalence of atrial fibrillation despite greater prevalence of established risk factors: a population-based study in Bradford Metropolitan District

Aims

Previous studies indicate that South Asians (SAs) may have a reduced risk of developing atrial fibrillation (AF) despite having a higher prevalence of traditional cardiovascular risk factors. This observational study was designed to explore the relative differences between SAs and Whites in a well-defined, multi-ethnic population with careful consideration of traditional cardiovascular risk factors that are thought to contribute to the development of AF.

Methods and results

Anonymized data from 417 575 adults were sourced from primary care records within Bradford Metropolitan District, UK. Atrial fibrillation diagnosis was indicated by the presence on the AF Quality Outcomes Framework register. Self-reported ethnicity was mapped to census ethnic codes. The age-standardized prevalence rates of AF were calculated for comparison between the White and SA populations; our study sample presented relative proportions of 2.39 and 0.4%. Multivariable logistic regression analysis was performed to estimate the odds of developing AF given SA ethnicity. Adjustment for age, sex, and established risk factors found a 71% reduction in odds of AF in SAs when compared with Whites [odds ratio (OR): 0.29, 95% confidence interval (CI): 0.26-0.32]. When stratified by ethnicity, analyses revealed significantly different odds of AF for patients with diabetes; diabetes was not associated with the development of AF in the SA population (0.81, 95% CI: 0.63-1.05).

Conclusion

This study, in a multi-ethnic population, presents ethnicity as a predictor of AF in which prevalence is significantly lower in SAs when compared with Whites. This is despite SAs having a higher frequency of established risk factors for the development of AF, such as ischaemic heart disease, heart failure, hypertension, and type 2 diabetes. These findings are consistent with previous literature and add weight to the need for further investigation, although this is the first study to investigate the differential associations of individual risk factors with development of AF.

An Examination of Stroke Risk and Burden in South Asians

BACKGROUND

South Asians (India, Pakistan, Sri Lanka, Bangladesh, Nepal, and Bhutan) are at a disproportionately higher risk of stroke and heart disease due to their cardiometabolic profile. Despite evidence for a strong association between diabetes and stroke, and growing stroke risk in this ethnic minority-notwithstanding reports of higher stroke mortality irrespective of country of residence-the explanation for the excess risk of stroke remains unknown.

METHODS

We have used extensive literature review, epidemiologic studies, morbidity and mortality records, and expert opinions to examine the burden of stroke among South Asians, and the risk factors identified thus far.

RESULTS

We summarize existing evidence and indicate gaps in current knowledge of stroke epidemiology among South Asian natives and immigrants.

CONCLUSIONS

This research focuses attention on a looming epidemic of stroke mainly due to modifiable risk factors, but also new determinants that might aggravate the effect of vascular risk factors in South Asians causing more disabling strokes and death.

The "Hispanic mortality paradox" revisited: Meta-analysis and meta-regression of life-course differentials in Latin American and Caribbean immigrants' mortality

The literature on immigrant health has repeatedly reported the paradoxical finding, where immigrants from Latin American countries to OECD countries appear to enjoy better health and greater longevity, compared with the local population in the host country. However, no previous meta-analysis has examined this effect focusing specifically on immigrants from Latin America (rather than Hispanic ethnicity) and we still do not know enough about the factors that may moderate the relationship between immigration and mortality. We conducted meta-analyses and meta-regressions to examine 123 all-cause mortality risk estimates and 54 cardiovascular mortality risk estimates from 28 publications, providing data on almost 800 million people. The overall results showed that the mean rate ratio (RR) for immigrants vs. controls was 0.92 (95% CI, 0.84-1.01) for all-cause mortality and 0.73 (CI, 0.67-0.80) for cardiovascular mortality. While the overall results suggest no immigrant mortality advantage, studies that used only native born persons as controls did find a significant all-cause mortality advantage (RR, 0.86; 95% CI, 0.76-0.97). Furthermore, we found that the relative risk of mortality largely depends on life course stages. While the mortality advantage is apparent for working-age immigrants, it is not significant for older-age immigrants and the effect is reversed for children and adolescents.

Evolution of the "fourth stage" of epidemiologic transition in people aged 80 years and over: population-based cohort study using electronic health records

Background

In the “fourth stage” of epidemiological transition, the distribution of non-communicable diseases is expected to shift to more advanced ages, but age-specific changes beyond 80 years of age have not been reported.

Methods

This study aimed to evaluate demographic and health transitions in a population aged 80 years and over in the United Kingdom from 1990 to 2014, using primary care electronic health records. Epidemiological analysis of chronic morbidities and age-related impairments included a cohort of 299,495 participants, with stratified sampling by five-year age group up to 100 years and over. Cause-specific proportional hazards models were used to estimate hazard ratios for incidence rates over time.

Results

Between 1990 and 2014, nonagenarians and centenarians increased as a proportion of the over-80 population, as did the male-to-female ratio among individuals aged 80 to 95 years. A lower risk of coronary heart disease (HR 0.54, 95% confidence interval [CI]: 0.50–0.58), stroke (0.83, 0.76–0.90) and chronic obstructive pulmonary disease (0.59, 0.54–0.64) was observed among 80–84 year-olds in 2010–2014 compared to 1995–1999. By contrast, the risk of type II diabetes (2.18, 1.96–2.42), cancer (1.52, 1.43–1.61), dementia (2.94, 2.70–3.21), cognitive impairment (5.57, 5.01–6.20), and musculoskeletal pain (1.26, 1.21–1.32) was greater in 2010–2014 compared to 1995–1999.

Conclusions

Redistribution of the over-80 population to older ages, and declining age-specific incidence of cardiovascular and respiratory diseases in over-80s, are consistent with the “fourth stage” of epidemiologic transition, but increases in diabetes, cancer, and age-related impairment show new emerging epidemiological patterns in the senior elderly.

Electronic supplementary material

The online version of this article (doi:10.1186/s12963-017-0136-2) contains supplementary material, which is available to authorized users.

Body mass index adjustments to increase the validity of body fatness assessment in UK Black African and South Asian children

Background/Objectives:

Body mass index (BMI) (weight per height²) is the most widely used marker of childhood obesity and total body fatness (BF). However, its validity is limited, especially in children of South Asian and Black African origins. We aimed to quantify BMI adjustments needed for UK children of Black African and South Asian origins so that adjusted BMI related to BF in the same way as for White European children.

Methods:

We used data from four recent UK studies that made deuterium dilution BF measurements in UK children of White European, South Asian and Black African origins. A height-standardized fat mass index (FMI) was derived to represent BF. Linear regression models were then fitted, separately for boys and girls, to quantify ethnic differences in BMI–FMI relationships and to provide ethnic-specific BMI adjustments.

Results:

We restricted analyses to 4–12 year olds, to whom a single consistent FMI (fat mass per height⁵) could be applied. BMI consistently underestimated BF in South Asians, requiring positive BMI adjustments of +1.12 kg m⁻² (95% confidence interval (CI): 0.83, 1.41 kg m⁻²; P<0.0001) for boys and +1.07 kg m⁻² (95% CI: 0.74, 1.39 kg m⁻²; P<0.0001) for girls of all age groups and FMI levels. BMI overestimated BF in Black Africans, requiring negative BMI adjustments for Black African children. However, these were complex because there were statistically significant interactions between Black African ethnicity and FMI (P=0.004 boys; P=0.003 girls) and also between FMI and age group (P<0.0001 for boys and girls). BMI adjustments therefore varied by age group and FMI level (and indirectly BMI); the largest adjustments were in younger children with higher unadjusted BMI and the smallest in older children with lower unadjusted BMI.

Conclusions:

BMI underestimated BF in South Asians and overestimated BF in Black Africans. Ethnic-specific adjustments, increasing BMI in South Asians and reducing BMI in Black Africans, can improve the accuracy of BF assessment in these children.