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CV risk factors and Lifestyle Modification among
South Asians A call to action

• Dr. Sonia Anand MD, PhD
• Associate Professor of Medicine
• McMaster University

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Outline

• Cardiovascular disease among South Asians in
  Canada
• Role of Diet
• Abdominal Obesity
• Role of Genetics
• Prevention Strategies

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Changes in Risk Factors with Migration
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Excess Coronary Heart Disease in South Asian
Migrants
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Mortality for CHD and CancerAge 35 74
(1979-1993)
Sheth T et al, CMAJ 1999
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Data from UK and others

• ? type 2 diabetes
• ? Abdominal obesity
• ? HDL cholesterol
• ? Triglycerides
• ? Lipoprotein (a)
• other causes ?????

7
Study of Health Assessment and Risk in Ethnic
groups (SHARE)
South Asian
Chinese
Euro
Aboriginal
N
342
317
326
301
Age
49.4
47.4
51.3
53.1
Sample
Random
Random
Random
Random
Surname
Surname
Surname
Band List
Location
Hamilton
Six
Toronto
Nations
Edmonton
Brantford
Time
1996 to 1998
1998-00
SHARE99/10/12
Anand et al SHARE Lancet 2000/1
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Main Findings in SHARE
Dietary Intake
Insulin Resistance
Abdominal Adiposity
CVD
ATH
Physical inactivity
Thrombosis
Genetics
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Insulin Resistance
TG
Coronary Artery
Glucose
Apo B
Atherogenic dyslipidemia

• Soft Lipid Risk Core
• Impaired fibrinolysis

Insulin
IL-6 TNF
1. Liver
Beta cell dysfunction
2.
Adiponectin Leptin
FFAs
Expanded Visceral AT
Glucose
Insulin resistance
3. Adipokines
X
4. Skeletal Muscle
FFAs
IMCL Mitochondrial Dysfunction
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Age-Adjusted Prevalence of Metabolic Syndrome by
Ethnic Group
Age-Adjusted
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(No Transcript)
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Relationship of Glucose Factor to Body Mass Index
Among South Asians, Chinese, Aboriginal and
Europeans
BMI 30
BMI21
Razak et al Circ 2005
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You are what you eat!

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Dietary Factors in South Asians in Canada

• Consume excess calories from carbohydrates
• Low protein intake
• Higher reported folate intake, low serum folate
• Higher vegetarianism
• Higher trans fats

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SHARE- Nutrition
South Asians Chinese Euro
N 173 167 185
Age 46.3 45.8 47.7
Calories/Day 1911 1898 2072
Vegetarian 18.8 2.1 0.6
Carbohydrates g/day 298.8 240.7 269.5
Sugar g/day 11.2 6.9 8.9
Protein g/day 70.1 100.5 78.0
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Commonest Sources of Carbohydrate by Ethnic Group
Rank South Asians Chinese European
1 Roti, Chapati Rice, Sticky Rice Banana
2 Rice, Boiled Banana Orange or Grapefruit juice
3 Banana Citrus Fruit Bread Rolls
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The effect of Carbohydrate intake on HDL-C

.13 mmol/L In HDL for every 100 gld In CHO
HDL-C mmol/L
P for trend lt0.001
Tertile CARBOHYDRATE INTAKE
Adjusted for age, sex, ethnicity, physical
activity, smoking, WHR, Etoh, total energy,
protein, fiber, (excluded diabetes, any CVD)
Merchant et al J Nutr 2005
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Stronger in women.
P trend 0.06 (men) P trend .01 (women)
Note more servings of sugar containing soft
drinks, juices, and snacks associated with HDL
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Protein Intake and Abdominal Obesity

• Substituting a modest amount of protein for
  carbohydrate may reduce abdominal obesity
• Physical Activity is inversely associated with
  abdominal obesity

Independent of age, sex, BMI, height, smoking,
physical activity, alcohol, and total ebnergy,
and ethnicity
Merchant et al J Nutr 2005
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Protein Intake vs WHR
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Commonest Protein Sources
Rank South Asians Chinese European
1 Roti, Chapati Fish Soup Chicken
2 Yogurt Curd Chicken Ground Beef
3 2 Milk Pork 2 Milk
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SHARE- Fried Foods
South Asians Chinese Euro
Fried Foods( serv./week) 4.8 3.9 5.0
Total Fat g/day 59.1 70.3 61.8
Saturated Fat g/day 19.6 17.3 21.6
Trans Fats (g) 0.34 0.27 0.56

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Polyunsaturated to Saturated Fat Ratio
?0.2 ? RR of CHD 10-20
P/S Ratio
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Commonest Sources of Total Fat
Rank South Asians Chinese European
1 Roti, Chapati Fish Soup Cheese, regular fat
2 2 Milk Stirred Fried Pork or Beef Ground Beef
3 Yogurt Curd Chicken 2 Milk
4 Nuts Pork Fried Egg
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SHARE- Fish
South Asian Chinese Chinese Euro
Fish ( serv./week) 1.1 6.3 1.6 1.6
Omega-3 FA 0.13 0.76 0.04 0.04
Omega-6 FA 0.37 0.42 0.31 0.31
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Ethnic Differences in Folate
South Asian Chinese Euro
N 283 275 260
Homocysteine (umol/L) 10.5 8.7 9.7
Dietary Folate (ug) 385 291 352

Serum Folate (nmol/L) 18.9 22.0 21.7

Plt0.001
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Beverages Servings/week
South Asians Chinese European
Coffee 4.5 6.1 20
Tea 11.7 0.36 5.49
White/Red Wine/Spirits 1.3 0.52 3.49
Servings of Fresh Fruit/week 13.8 11.6 13.7
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INTERHEART DIETARY ANALYSIS

• Methods
• 6,530 cases and 10,792 controls
• 19 items food groups questionnaire
• Dietary Patterns
• Prudent diet raw and cooked vegetables, legumes
  and fruits
• Oriental diet tofu, soy sauce and green leafy
  vegetables
• Western diet dairy, fried foods and meats (high
  in saturated fats)

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INTERHEART Relative Risk of AMI by Dietary Type
? 29
? 24
Adjustment factors Age, sex, region, BMI, WHR,
physical activity, alcohol intake, smoking,
apoB/apoA1, psycho-social factors, and education
Iqbal R et al 2006
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How active Are We?


SHARE 2005
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Human Genome Program, U.S. Department of Energy,
Genomics and Its Impact on Medicine and Society
A 2001 Primer, 2001
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Clues that suggest South Asians have a Genetic
Propensity to CHD

• Family history of premature MI suggests increased
  genetic susceptibility
• Increased propensity to develop type 2 diabetes
• Lower BMI threshold to develop glucose metabolic
  abnormalities
• Risk factors apparent in children

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The search for Genes Thrifty, Gluttonous, or
Slothful Energy Conservation
Adapted from Bouchard 2003
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Population Genetic Studies have yielded few True
Positives
Gene Polymorphism Condition Frequency
Factor V Leiden Arg506Gly DVT 1.5
APO E E 2/3/4 Alzheimers Disease 16-24
PPAR Gamma Pro12 Pro Type 2 Diabetes 85 RR1.24
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Ethnic Differences in SNP frequency PPARg Pro12Ala
Ethnic Group South Asian Chinese European
Pro12Pro 75 93 78
Pro12Ala 23 7 20
Ala12Ala 1.5 0 1.4
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Scanning the Genome
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Defective Biology
Obesogenicenvironment
BMI
Restrictiveenvironment
Resistant Prone
Obesity Predisposition
Adapted from Ravussin and Bouchard, 2000
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Prevention of weight gain

• If overweight or obese avoid rapid reductions in
  weight with intensive lifestyle change (regain
  occurs in 90)
• In patients in early 20s advise to prevent or
  minimize weight gain
• Modest energy intake and regular activity

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Specific Issues Relevant to Women

• Abdominal Obesity the rolls are not stylish!
• Abdominal obesity increases in Post-menopausal
  women
• Regular Physical Activity is essential to
  maintain weight
• Mothers watch your children- prevent childhood
  obesity, encourage exercise
• Mothers watch your cooking increase raw and
  lightly cooked vegetables, avoid ghee, increase
  protein, decrease carbohydrate

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Benefits of Physical Activity

• Physical activity has protective effects
• Lowers LDL (bad) cholesterol and triglycerides
• Increases HDL (good) cholesterol
• Reduces body weight
• Lowers blood pressure
• Lack of physical activity has the reverse effects

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Walking

• Walking is a popular and the most commonly
  reported leisure activity
• Walking is accepted and easily accessible to
  everyone
• 30 minutes of activity corresponds to
  approximately 3000-4000 steps/day
• Goal is 30 minutes/day of walking or 10,000
  steps/day

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Substantial Gains from Modest levels of Physical
activity

• Women who increase their physical activity (30
  min x 5 days) after age 65 can lower their risk
  of death by nearly 50 (Womens Health Study)
• Moderate physical activity can add 1.5 years of
  life (free of heart disease) (Netherlands)

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Summary

• South Asians (including women) are among the
  highest risk group for early CHD in the world
• Prevention must start in childhood
• Turn off the Genetic Effects by regular
  exercise, lower carbohydrate modest protein diet,
  prevention of abdominal obesity,
• Liberal use of proven medical therapies

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PPARg Pro12Ala

• PPARs
• adipogenesis, lipid metabolism, glucose
  metabolism
• nuclear receptors for various ligands
• fatty acids
• glitazones (PPARg), fibrates (PPARa)
• Pro12Ala SNP
• 25 frequency1
• T2D (relative risk, RR 0.79)1
• Pro12Pro (wild type)
• 85 frequency1
• T2D (relative risk, RR 1.25)1
• May influence 25 of the risk of T2D
• 1. Altshuler et al. The common PPAR. Pro12Ala
  polymorphism is associated with decreased risk of
  type 2 diabetes. Nature Genetics 2000. 26 76-80.