Ethnic differences between South Asians and White Caucasians in cardiovascular disease-related mortality in developed countries: a systematic literature review

Rural-urban migration dynamics and double burden of malnutrition among women across 29 low and middle income countries

The double burden of malnutrition (DBM) is a significant public health issue in low- and middle-income countries (LMICs), resulting from complex socioeconomic, demographic and nutrition transitions. This study examined the association between internal migration and DBM among women across LMICs, focusing on direction, recency, and age at migration. Using the latest Demographic and Health Survey (2010-2023), data on body mass index, migration status, and covariates were extracted from 232,449 women aged 15-49 years in 29 countries. Migration status was categorised as urban non-migrants, rural non-migrants, urban-to-rural, or rural-to-urban based on prior and current residences. Recency and age at migration were categorised as recent/non-recent (within the last five years or earlier) and childhood/adulthood (before or after age 19). Multinomial multivariable logistic regressions were used to estimate odds ratio for each migrant groups relative to urban and rural non-migrants, respectively. Further analyses examined the association between DBM and recency, and age at migration, among migrants. Overall, 32.1 % of women were overweight/obese while 9.7 % were underweight. Urban-to-rural migrants accounted for 9.5 % of the sample, and rural-to-urban migrants constituted 7.0 %. Rural-to-urban migrants had 21.0 % higher odds of being overweight/obese (95 % CI: 1.15-1.29) compared to rural non-migrants. Urban-to-rural migrants showed 9.0 % lower odds of being underweight (95 % CI: 0.85-0.99) compared to urban non-migrants. Among migrants, recency of migration and age at migration were found to be significantly associated with DBM. This study emphasises the need for targeted public health strategies to enhance immediate and distal determinants of DBM in urban and rural settings in LMICs.

Circulating lipidome underpins gender differences in the pathogenesis of type 2 diabetes

Metabolic alterations in human lipidome significantly impact various chronic diseases including type 2 diabetes (T2D). However, epidemiology and clinical studies have yet to identify clinically meaningful lipid markers for T2D. Fatty acids (FAs) are the backbone of lipid species. However, conflicting results on the essential FAs including omega 3 and omega 6 in the development of metabolic diseases urge deeper evaluations of diverse clinical cohorts including underrepresented populations. This study investigated the lipidomics profiles of 3000 individuals from a well-characterized cohort of Asian Indians. Untargeted lipidomic profiles were created using blood samples applying reversed-phase liquid chromatography-accurate mass tandem mass spectrometry. Free FAs and lysophosphatidylcholines (LPC) were upregulated, while sphingomyelin (SM) and phosphatidylcholines (PC) were decreased in T2D. We observed a significant increase of essential FAs -FA20:4 (AA), FA20:5 (EPA), and FA22:6 (DHA) in T2D after adjusting for age, gender, and BMI. However, most ω-3 and ω-6 FAs were reduced by 2 to 6-fold in obesity in both genders. We also observed gender differences in age-associated lipid patterns in which cholesterol sulfate and LPC 22:6 were elevated in all age groups in men, but LPC 22:6 rapidly increased after menopause in women, and SMs increased in men after 40 years. Machine learning analysis identified long-chain FAs, ether-based LPCs, and clinical risk scores among the most informative features associated with T2D. Our study identified lipidomic markers that could be potential mediators of T2D and obesity. Their patterns may underpin sex differences in the pathogenesis of metabolic and cardiovascular diseases.

Ethnic variations in cardiovascular disease (CVD) risk factors and associations with prevalent CVD and CVD mortality in the United States

OBJECTIVE

To explore the association between ethnicity and cardiovascular disease (CVD) risk factors, including physical inactivity, obesity, hypertension, type 2 diabetes (T2D), lack of health insurance and low family income in a nationally representative sample of U.S. adults.

RESEARCH DESIGN AND METHODS

Adults from the National Health and Nutrition Examination Survey (NHANES 2011-2020, n = 17,355) were classified as having CVD risk factors based on both self-reported and metabolic data. Ethnic differences in how these CVD risk factors relate to prevalent CVD and CVD mortality was examined in Whites, Blacks, Asians and Hispanics.

RESULTS

Compared to Whites, significant disparities were noted in several CVD risk factors in ethnic minorities, such as lower PA, lower income, and more prevalent metabolic risk factors. Blacks and Hispanics commonly had higher prevalent CVD risk as compared to Whites even after adjusting for income and metabolic risk factors. Physical inactivity was most strongly associated with prevalent CVD and CVD mortality among Whites and Blacks. There were no ethnic differences in the inverse association between income and prevalent CVD risk, but Blacks with low income were associated with the greatest elevated CVD mortality. Hypertension and T2D were similarly related with prevalent CVD across ethnic groups, but Blacks and Hispanics with hypertension or T2D were at greater CVD mortality risk as compared to Whites.

CONCLUSION

Our study identified that socioeconomic and metabolic risk factors may relate differently to CVD outcomes among ethnic minority groups in the United States. Addressing these ethnic disparities in health warrants further investigation.

Food and exercise practices among British Pakistanis; how can Bourdieu's theory of practice help to understand them?

OBJECTIVES

The prevalence of cardiovascular diseases (CVDs) are significant among the Pakistani ethnic group in the UK. Existing literature has identified food and exercise practices as contributing factors. This qualitative inquiry investigates food and exercise practices among this group. The study also identifies any cultural resistance to changing prevailing unhealthy practices.

METHODS

Five qualitative semi-structured interviews with local Pakistani community leaders, two focus group discussions, and 40 individual interviews with participants of both genders. Bourdieu's theory of practice was used to analyse the data.

RESULTS

The lifestyle choices of the participants mainly follow the cultural practices of their home country. In particular, three cultural phenomena might have been contributing to CVDs among this community: a culture of consuming fatty and calorie-dense food, complexity in joint decision-making among family members, and a lack of motivation and cultural support for healthy physical activities, especially among women and older adults.

CONCLUSION

It would be challenging to significantly influence this unhealthy lifestyle in the short term. Integrating religious discourse within health promotion, adopting a whole-family approach, and working with the community on healthier cooking and making exercise options culturally relevant could be helpful for reducing the prevalence of CVDs among the Pakistani community in the UK.

Ethnic-Specific Threshold Analysis and BMI and Waist Circumference Cutoffs for Cardiovascular Disease and Subjective Wellbeing: Results using Data from the UK Biobank

OBJECTIVES

We aimed to identify ethnicity-specific BMI and waist circumference cutoffs for cardiovascular disease (CVD) and to define optimal thresholds for CVD risk and subjective wellbeing (SWB) through predictive modelling, to inform precise public health initiatives.

METHODS

We used data from 296,767 UK Biobank participants and adjusted logistic and linear regression models for CVD and SWB, respectively, complemented by receiver operating characteristic analysis, to explore optimal risk thresholds of CVD in six different ethnic groups and to calculate ethnicity-specific cutoffs of BMI and waist circumference (WC) to further elucidate the relationships between demographic factors and cardiovascular risk among diverse populations.

RESULTS

The logistic regression model of CVD revealed moderate discriminative ability (AUROC ~ 64-65%) across ethnicities for CVD status, with sensitivity and specificity values indicating the model's predictive accuracy. For SWB, the model demonstrated moderate performance with an AUROC of 63%, supported by significant variables that included age, BMI, WC, physical activity, and alcohol intake. Adjusted-incidence rates of CVD revealed the evidence ethnic-specific CVD risk profiles with Whites, South Asians and Blacks demonstrating higher predicted CVD events compared to East Asians, mixed and other ethnic groups.

CONCLUSION

Alterations of ethnicity-specific BMI and waist circumference are required to ensure ethnic minorities are provided with proper mitigation of cardiovascular risk, addressing the disparities observed in CVD prevalence and outcomes across diverse populations. This tailored approach to risk assessment can facilitate early detection, intervention and management of CVD, ultimately improving health outcomes and promoting health equity. The moderate accuracy of predictive models underscores the need for further research to identify additional variables that may enhance predictive accuracy and refine risk assessment strategies.

The changing relationship between bodyweight and longevity in high- and low-income countries

Standard measures of bodyweight (overweight and obese, for example) fail to reflect differences across populations and technological progress over time. This paper builds on the pioneering work of Hans Waaler (1984) and Robert Fogel (1994) to empirically estimate how the relationship between body mass index (BMI) and longevity varies across high-, middle-, and low-income countries. Importantly, we show that these differences are so profound that the share of national populations above mortality-minimizing bodyweight is not clearly greater in countries with higher overweight and obesity rates (as traditionally defined)-and in fact, relative to current standards, a larger share of low-income countries' populations can be unhealthily heavy.

International Migration and Cardiovascular Health: Unraveling the Disease Burden Among Migrants to North America and Europe

Europe and North America are the 2 largest recipients of international migrants from low-resource regions in the world. Here, large differences in cardiovascular disease (CVD) morbidity and death exist between migrants and the host populations. This review discusses the CVD burden and its most important contributors among the largest migrant groups in Europe and North America as well as the consequences of migration to high-income countries on CVD diagnosis and therapy. The available evidence indicates that migrants in Europe and North America generally have a higher CVD risk compared with the host populations. Cardiometabolic, behavioral, and psychosocial factors are important contributors to their increased CVD risk. However, despite these common denominators, there are important ethnic differences in the propensity to develop CVD that relate to pre- and postmigration factors, such as socioeconomic status, cultural factors, lifestyle, psychosocial stress, access to health care and health care usage. Some of these pre- and postmigration environmental factors may interact with genetic (epigenetics) and microbial factors, which further influence their CVD risk. The limited number of prospective cohorts and clinical trials in migrant populations remains an important culprit for better understanding pathophysiological mechanism driving health differences and for developing ethnic-specific CVD risk prediction and care. Only by improved understanding of the complex interaction among human biology, migration-related factors, and sociocultural determinants of health influencing CVD risk will we be able to mitigate these differences and truly make inclusive personalized treatment possible.

Factors associated with cardiovascular disease: A comparative study of the UK Asian diaspora and residents of India

INTRODUCTION

The aim of this paper is to investigate what factors are associated to cardiovascular disease and what differences exists between Asians living in the UK (from the English Longitudinal Study of Ageing) and the Asians living in India (from the Longitudinal Ageing Study in India).

METHODS

Logistic regression was used to investigate how demographic and physical performance factors were associated with cardiovascular disease using data from Wave 6 of the English Longitudinal Study of Ageing and Wave 1 of the Longitudinal Study of Ageing in India, with the main variable of interest being country of residence, Asians in England or Asians in India.

RESULTS

A total of 83,997 participants were included in the analyses. In the primary analysis, 73,396 participants from LASI were compared to 171 Asians in ELSA. After adjusting for age, blood pressure, resting heart rate, sex, waist circumference, gait, handgrip strength and standing balance, there was a statistically significant difference for the outcome of CVD between Whites ELSA (reference) and the participants of LASI (odds ratio = 0.77; 95% confidence interval = 0.60 to 0.99). There were no significant differences in CVD between the LASI participants, Asian ELSA, and the Non-White but not Asian ELSA groups.

DISCUSSION

No difference was found between Asians that live in India compared to ethnic minorities living in England, including Asians, after adjusting for confounders, but was found between Whites in ELSA compared to LASI participants. A key limitation was the massive disparity in sample sizes between the ELSA subgroups and LASI. Further work is required where comparable sample sizes and longitudinal analyses allow trends to be identified and to investigate the factors associated with the difference in CVD between two similar ethnicities living in distinct locations.

CONCLUSION

After adjusting for risk factors, there was no difference in CVD between localised Asians and the ethnic minorities in the UK, but there was a difference between the majority ethnicities in the respective countries.

Major adverse cardiovascular events in advanced-stage lung cancer: a multicenter cohort study

Background

Lung cancers are common worldwide. First-line targeted therapy and chemotherapy are both standard treatments in the current guidelines. With the development of new anticancer therapy, the lifespan of patients with late-stage lung cancer has increased. Cardiovascular events can occur during cancer treatment. This observational study aimed to report the incidence of major adverse cardiovascular events (MACE) after cancer treatment using real-world data.

Objectives

Patients diagnosed with advanced-stage lung cancer between January 2011 and December 2017 were enrolled. Data were collected from the Chang Gung Research Database (CGRD).

Design

Retrospective cohort study.

Methods

Baseline characteristics, clinical stages, pathologies, and outcomes were retrieved from the CGRD.

Results

We identified 4406 patients with advanced lung cancer, of whom 2197 received first-line epidermal growth factor receptor tyrosine kinase inhibitor (EGFR-TKI) therapy and 2209 received first-line platinum-based chemotherapy. Most patients in the first-line EGFR-TKI group were never-smokers (74.9%), whereas those in the first-line chemotherapy group were ever-smokers (66.0%). The incidence of MACE was not significantly different between the two groups (12.0% versus 11.9%, p = 0.910). However, the incidence of ischemic stroke was higher in the first-line EGFR-TKI group than in the first-line chemotherapy group (3.9% versus 1.9%, p < 0.001).

Conclusion

MACEs are common in patients with advanced-stage lung cancer during treatment. The incidence of MACE was similar between the first-line EGFR-TKI therapy and first-line chemotherapy groups. Although more patients in the EGFR-TKI group were female and never-smokers, the risk of ischemic stroke was higher in patients who received first-line EGFR-TKI therapy than in those who received first-line chemotherapy.

Response to a low-energy meal replacement plan on glycometabolic profile and reverse cardiac remodelling in type 2 diabetes: a comparison between South Asians and White Europeans

Background

South Asians (SA) constitute a quarter of the global population and are disproportionally affected by both type 2 diabetes (T2D) and heart failure. There remains limited data of the acceptability and efficacy of low-energy meal replacement plans to induce remission of T2D in SA.

Objectives

The objective of this exploratory secondary analysis of the DIASTOLIC study was to determine if there was a differential uptake, glycometabolic and cardiovascular response to a low-energy meal replacement plan (MRP) between SA and White European (WE) people with T2D.

Methods

Obese adults with T2D without symptomatic cardiovascular disease were allocated a low-energy (~810 kcal/day) MRP as part of the DIASTOLIC study (NCT02590822). Comprehensive multiparametric cardiovascular magnetic resonance imaging, echocardiography, cardiopulmonary exercise testing and metabolic profiling were undertaken at baseline and 12 weeks. A comparison of change at 12 weeks between groups with baseline adjustment was undertaken.

Results

Fifteen WE and 12 SAs were allocated the MRP. All WE participants completed the MRP versus 8/12 (66%) SAs. The degree of concentric left ventricular remodelling was similar between ethnicities. Despite similar weight loss and reduction in liver fat percentage, SA had a lower reduction in Homeostatic Model Assessment for Insulin Resistance [-5.7 (95% CI: -7.3, -4.2) versus -8.6 (-9.7, -7.6), p = 0.005] and visceral adiposity compared to WE [-0.43% (-0.61, -0.25) versus -0.80% (-0.91, -0.68), p = 0.002]. Exercise capacity increased in WE with no change observed in SA. There was a trend towards more reverse remodelling in WE compared to SAs.

Conclusions

Compliance to the MRP was lower in SA versus WE. Overall, those completing the MRP saw improvements in weight, body composition and indices of glycaemic control irrespective of ethnicity. Whilst improvements in VAT and insulin resistance appear to be dampened in SA versus WE, given the small sample, larger studies are required to confirm or challenge this potential ethnic disparity.

Trail registration

NCT02590822.

The Racial Differences in the Clinical Outcomes of Intravascular Ultrasound-Guided Percutaneous Coronary Intervention: A Systematic Review and Meta-Analysis

Intravascular ultrasound (IVUS)-guided percutaneous coronary intervention (PCI) has been reported to significantly reduce major adverse cardiac events (MACEs) compared with angiography-guided PCI. We aimed to explore whether there were racial differences regarding the beneficial effects of IVUS-guided PCI. Randomized controlled trials for comparison of clinical outcomes between IVUS-guided and angiography-guided PCI were retrieved from PubMed, Web of Science, Embase, and the Cochrane Library from inception to March 15, 2023. The clinical outcomes included MACE, all-cause mortality, myocardial infarction (MI), target vessel revascularization (TVR), target lesion revascularization (TLR), and stent thrombosis (ST). Finally, 18 randomized controlled trials were included in this study (8 in East Asian patients and 10 in Western patients). Results showed that IVUS-guided PCI was associated with a significant reduction of MACE, TVR, TLR, and ST, but not all-cause mortality and MI in both East Asian and Western patients. The reduction of MACE was more significant in East Asian patients (odds ratio [OR] 0.57, 95% confidence interval [CI] 0.46 to 0.70) than that in Western patients (OR 0.83, 95% CI 0.67 to 1.02). Meta-regression analysis revealed that the country the study was performed in (East Asian vs Western countries) was associated with significant heterogeneity between groups, suggesting that racial differences existed (p = 0.033). In conclusion, IVUS-guided PCI was associated with a lower risk of MACE, TLR, TVR, and ST, but not all-cause mortality and MI in both East Asians and Westerners. East Asians benefited more than Westerners upon using IVUS-guided PCI in reducing MACE, suggesting that racial differences do exist between different imaging methods. Larger-sample studies are warranted for further clarification of our findings.

Global eligibility and cost effectiveness of icosapent ethyl in primary and secondary cardiovascular prevention

Icosapent ethyl (IPE) is a purified eicosapentaenoic acid-only omega-3 fatty acid that significantly reduced cardiovascular (CV) events in patients receiving statins with established cardiovascular disease (CVD) and those with diabetes and additional risk factors in the pivotal REDUCE-IT trial. Since the publication of REDUCE-IT, there has been global interest in determining IPE eligibility in different patient populations, the proportion of patients who may benefit from IPE, and cost effectiveness of IPE in primary and secondary prevention settings. The aim of this review is to summarize information from eligibility and cost effectiveness studies of IPE to date. A total of sixteen studies were reviewed, involving 2,068,111 patients in the primary or secondary prevention settings worldwide. Up to forty-five percent of patients were eligible for IPE, depending on the selection criteria used (ie, REDUCE-IT criteria, US Food and Drug Administration label, Health Canada label, practice guidelines) and the population studied. Overall, eight cost-effectiveness studies across the United States, Canada, Germany, Israel, and Australia were included in this review and findings indicated that IPE is particularly cost effective in patients with established CVD.

Risk factors for newly-developed cardiovascular disease and quality of life during the COVID - 19 pandemic: an analysis of the English longitudinal study of ageing

INTRODUCTION

The COVID-19 pandemic had a wide range of effects on the English population, including on health and quality of life due to the subsequent lockdown restrictions set.

AIMS

To investigate longitudinal changes in developing cardiovascular disease (CVD) and how that affects quality of life from pre-pandemic and during two lockdowns in England, in adults aged 50 years and above, and what factors are associated with this.

METHODS

Wave 9 of the core English Longitudinal Study of Ageing (ELSA) and Waves 1 and 2 of the ELSA COVID-19 sub-study were used to investigate the factors associated with developing CVD between timepoints, and what factors alongside CVD are associated with quality of life.

RESULTS

Higher age and depression were associated with newly-developed CVD from pre-COVID to both COVID sub-study waves. Additionally, body mass index (BMI) increased odds of CVD and physical activity decreased odds. Non-White ethnicity, depression, females, and developing CVD were lower associated with quality of life. Decreased age and increased physical activity were associated with higher quality of life.

DISCUSSION

Ethnicity was not associated with newly-developed CVD but was associated with quality of life. Other factors of importance include age, depression, gender, and physical activity. Findings are informative for future risk stratification and treatment strategies, especially while the COVID-19 pandemic is ongoing.

Performance of the pooled cohort equation in South Asians: insights from a large integrated healthcare delivery system

South Asian ethnicity is associated with increased atherosclerotic cardiovascular disease (ASCVD) risk and has been identified as a "risk enhancer" in the 2018 American College of Cardiology/American Heart Association Guidelines. Risk estimation and statin eligibility in South Asians is not well understood; we studied the accuracy of 10-years ASCVD risk prediction by the pooled cohort equation (PCE), based on statin use, in a South Asian cohort. This is a retrospective cohort study of Kaiser Permanente Northern California South Asian members without existing ASCVD, age range 30-70, and 10-years follow up. ASCVD events were defined as myocardial infarction, ischemic stroke, and cardiovascular death. The cohort was stratified by statin use during the study period: never; at baseline and during follow-up; and only during follow-up. Predicted probability of ASCVD, using the PCE was calculated and compared to observed ASCVD events for low < 5.0%, borderline 5.0 to < 7.5%, intermediate 7.5 to < 20.0%, and high ≥ 20.0% risk groups. A total of 1835 South Asian members were included: 773 never on statin, 374 on statins at baseline and follow-up, and 688 on statins during follow-up only. ASCVD risk was underestimated by the PCE in low-risk groups: entire cohort: 1.8 versus 4.9%, p < 0.0001; on statin at baseline and follow-up: 2.58 versus 8.43%, p < 0.0001; on statin during follow-up only: 2.18 versus 7.77%, p < 0.0001; and never on statin: 1.37 versus 2.09%, p = 0.12. In this South Asian cohort, the PCE underestimated risk in South Asians, regardless of statin use, in the low risk ASCVD risk category.