AAPI Convention 2005

 


                       

Heart Disease in Indians

2005 Update

 

 

 

 

 

 

Houston we have a Problem!

 

 

Yes, we do!  last fifty years have witnessed literally hundreds of reports in reputed medical journals from England, Singapore, USA, Canada and India about the alarmingly high prevalence of heart disease in Indians- men and  women, vegetarians and  non-vegetarians, young and old alike. However very little has been achieved to curb this epidemic among us despite great concerns expressed by the scientific community.

 

Recently, BMJ has reported early evidence of insulin resistance and impaired glucose tolerance in Indian children compared to British children living in England. (Peter H Whincup, Julie A Gilg, Olia Papacosta, Carol Seymour, George J Miller, K G M M Alberti, Derek G Cook Early evidence of ethnic differences in cardiovascular risk: cross sectional comparison of British South Asian and white children. BMJ. 2002 March 16; 324(7338): 635)

 

Table 4. Plasma glucose and serum insulin concentrations in South Asian and white children

 

South Asian*

 

White*

 

Difference (95% CI)

 

 

No

Mean (SE)

 

No

Mean (SE)

 

Adjustment 1

Adjustment 2

Fasting

   Glucose (mmol/l)

41

4.85 (0.07)

 

625

4.85 (0.01)

 

0.00 (−0.14 to 0.14)

0.02 (−0.12 to 0.15)

Insulin (pmol/l)a

40

47.8

 

622

31.2

 

53.4% (14.4% to 105.6%)§

68.0% (29.1% to 118.5%)§

After glucose load

Glucose (mmol/l)

31

7.16 (0.32)

 

587

7.01 (0.06)

 

0.15 (−0.49 to 0.79)

0.18 (−0.46 to 0.82)

Insulin (pmol/l)a

31

459.8

 

581

298.7

 

54.0% (19.1% to 99.0%)§

42.7% (12.8% to 80.3%)§

1-Adjusted for age, sex, and town. 2-Adjusted for age, sex, town, childhood height, and ponderal index. A-Geometric mean. §-P<0.005.

 

 

Palaniappan from Stanford reported that heart disease and related mortality in Asian Indian women is on the rise whereas women of all other ethnic groups in the U.S have documented a decline in the incidence of heart disease. (Palaniappan L, Wang Y, Fortmann SP. Coronary heart disease mortality for six ethnic groups in California, 1990-2000).

 

 

We (Kotha, Enas, Superko) reported low levels of HDL- 2b (cardio-protective), implying impaired reverse cholesterol transport and increased heart disease risk in Indian men living in the U.S compared to their Caucasian counterparts. Impaired Reverse Cholesterol Transport in Asian Indians. R Superko, P.Kotha, E.Enas, H.Hecht. JACC: 2001; 37(2): 1305-180-300).

 

                                          Asian Indian              non-Asian Indian                                    p

Triglycerides > 200 mg/dl                             16.2%                                             29.7%                                        0.002

LDLC > 160 (mg/dl)                                       15.0%                                             17.7%                                           0.46 

LDLC > 130 (mg/dl)                                       39.5%                                             42.6%                                           0.53

LDL IIIa+b > 20%                                          61.8%                                             67.1%                                           0.27

HDLC < 40 mg/dl                                           36.9%                                             49.1%                                          0.02

HDL2b<20%                                                   91.8%                                             75.7%                                     0.0001

Lp(a) > 20 (mg/dl)                                          44.3%                                             25.5%                                     0.0001

 THcy > 14 (umol/L)                                        7.7%                                               3.1%                                          0.05

Percent of subjects in each group with values below or above cut points that reflect increased CAD risk (Chi-square).

 

Bogalusa, FELIC and PDAY studies have shown that early, fatty streaks appear as early as in the intra uterine life and progress over a period of years to advanced coronary artery disease. There is a strong correlation between parents’ genetic predisposition and dietary habits and their cholesterol levels and onset of atherosclerosis in fetuses, infants, children and adolescents.

 

 We are witnessing advanced heart disease both in India and in Indians living in the U.S at younger ages and in men and women alike. Many times the first presentation of CAD is ‘out of hospital cardiac arrest’ otherwise known as ‘sudden cardiac death’! There is no second chance!

 

Our estimated risk for heart disease compared to Framingham population is shown below.

The good news is that help is on the way.

 

 In the first few years of our 21st century we have witnessed a great deal of enthusiasm in the U.S to address the issue of coronary artery disease not only in the Caucasian population but also in other ethnic groups. The recognition of Metabolic Syndrome as the secondary  target of attack after lowering the LDL-C to goals ( the primary target), labeling DM-2 as coronary heart disease equivalent, identifying Lp(a), Homocysteine, CRP-hs as new emerging risk factors and advocating more plant stanols and less animal fats in the diet are few examples of this renaissance. (Ref: WHO & The Adult Treatment Panel III (ATP III) of the National Cholesterol Education Program-Executive Summary. JAMA; 2001; 285:2486-2497).

 

The NIH program ‘Healthy People 2010’ has designated the Asian Indian Immigrant population in the US as the high risk group for Coronary Heart Disease.

 

According to the World Health Organization 60% of the children today are physically inactive and consume too many calories through unhealthy diets.

 

Here is what is happening in your home states in India.

 

Andhra Pradesh, Tamil Nadu, Punjab are leading the country with the highest incidence of heart disease. These differences among the states have been shown to be related to the dietary consumption of milk and milk fats, green leafy vegetables and fruits, sugars and obesity levels. (Gupta R, Misra A, Pais P, Rastogi P, Gupta VP. Correlation of regional cardiovascular disease mortality in India with lifestyle and nutritional factors: A macro level analysis).

 

People with the Metabolic Syndrome (three or more components of high blood pressure, central obesity, low HDL-C, High triglycerides, Insulin resistance or impaired fasting glucose and small dense LDL particles) are even at higher risk of developing cardiovascular disease than people with diabetes alone, where as the combination of these two causes the highest risk of atherosclerosis. ((Ref: SchaperAK, McHughV, et al. Metabolic syndrome and sub clinical atherosclerosis in young to middle-aged adults. American Heart Association 2004 Scientific Sessions. Nov. 7-10, 2004).

 

A small, but significant study done on prevalence of metabolic syndrome in Asian Indian immigrants showed that Asian Indians who are physically active have a more favorable metabolic syndrome risk factor profile. Prevalence of metabolic syndrome was 33.9% (age 29 - 59 years; average BMI 26.1± 3.7) suggesting development of the syndrome at younger age. While participants reported little leisure time physical activity, men were more active than women. (Ref: Misra KB, Endemann SW, Ayer M. Physical Activity and Metabolic Syndrome Leisure Time Physical Activity and Metabolic Syndrome in Indian Americans Residing in Northern California. Ethnicity and Disease Fall 2005 Volume 15 No 4).

 

The DIA(Diabetes in Indian Asians) study sponsored by AAPI through a grant from the Center for Disease Control is in progress at eight sites in San Diego, Houston, Phoenix, Edison, Washington DC, Boston, New Delhi and Tamil nadu. Preliminary data indicate a high incidence of metabolic syndrome by using the criteria set for general U.S population.

If we apply the criteria such as BMI of 24 instead of 30, which are being recommended for our Indian community the incidence will be even much higher.

 

Ladies and gentlemen, no more excuses and no more procrastination! We have our work cut out:

 

To establish risk criteria for our own community who seem to have a high prevalence of metabolic syndrome, Lp(a), Insulin resistance, homocysteine, either alone or in different combinations. For this we need data from clinical studies with large sample sizes including men and women of youth and middle age. (Leave this to the pundits who are rocking their brains and sometimes fist fighting to bring the best criteria to you!)

 

  1. Not to hide behind the fact that many of us are vegetarians and non smokers but to acknowledge the fact that we are a ‘physically very inactive’ community. Start adapting healthy indoor and out door physical activities. Exercise increases HDL-C, lowers triglycerides, improves insulin resistance, releases lipoprotein lipase from skeletal muscles, increases fibrinolytic activity improves arterial compliance, decreases blood pressure and blood viscosity and helps you to sleep better and live younger and fit with vigor. A simple but very effective exercise is walking two miles a day every day of the week!
  2. Change our culinary habits drastically and stop deep frying, stop using the cooking oil for more than once and bake, broil and stir-fry. Avoid transfats (hydrogenated oils); eat more fresh vegetables and fruits, increase plant stanols in your diet to provide more fiber, antioxidants and flavanoids and to decrease absorption of cholesterol.
  3. Check your fasting blood sugar, HbA1c, fasting lipid profile, Lp(a),  Homocysteine and use appropriate medications such as statins, niacin, folic acid, insulin sensitizers, after making a maximum positive effort with diet and exercise to correct some of these metabolic abnormalities.
  4. Get an exercise treadmill test at age 40 and once in five years thereafter even if you are asymptomatic. At a much earlier age if you are a smoker or have a family history of premature CAD.

5.      Seek treatment and achieve optimum control of hypertension, diabetes and hyperlipidemia per JNC, ADA and AHA guide lines.

  1. Learn to handle your stress well because stress raises your blood pressure, releases excess stress steroids into the circulation which in turn will increase the blood viscosity( thrombosis), injures the endothelium( inflammation) and causes plaque rupture and heart attacks.
  2. Incorporate humor and laughter into daily life, practice Yoga and Meditation to help you relax and reduce your stress.

 

  1. The best gift you can give to your spouse, children, parents, uncles and aunts is to make them aware of the above facts and help them to adapt a healthier life style and live longer.
  2. Be a role model at your home and work and for your community to adapt a heart healthy life style and promote physical and mental wellbeing.

 

 

 For articles related to CAD in Indians, for AHA, ADA, JNC, ATP3 guidelines, to      download the e-book- Indian Nutrition guide developed  by the AAPI,  to custom design your exercises and for much more other health related information visit our dedicated website          .                                              www.heartsmart.info

 

E-mail us at pkotha@heartsmart.info with any questions you may have.

 

Have fun at the AAPI convention in Houston,

 

Wishing you a very heart healthy life,

 

Purushotham Kotha. M.D., FACC

Chair, CAD Committee AAPI

 

5555 Reservoir Drive, suite 309

San Diego CA 92120

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