Transcript Postpartum Depression and Vitamin D Sub

CV Risk Factors in South
Asians of Canada
Sonia Anand
McMaster University
Feb 21, 2013
Excess Coronary Heart Disease
in South Asian Migrants
North America
Europe
Asia
Middle East
Africa
Australia
South and Central America
Mortality for CHD and Cancer
Age 35 – 74
(1979-1993)
CHD & Cancer Mortality ..
Rate/100,000
160
140
120
100
CHD
Cancer
80
60
40
20
0
South Asian
Chinese
European
Sheth T et al, CMAJ 1999
Ethnic Profile in Ontario
South Asian 7%
Black 4%
Other 9%
White 75%
Statistics Canada, 2006
Changes in Risk Factors with
Migration
60
30
51.6
25.2
50
% Risk Factor
36 lbs
40
26.3
42 lbs
30
15
23.5
19.4
10
0
19
16.8
13.5
10
9.3
6.6
5
1.8
1
Rurual India
n=972
25
20
19.1
20
BMI
0
Urban India
n=775
Canada
n=342
Smoke
DM
HTN
BMI
Evolution of risk factors in South Asians
1. Weight gain
2. pre-Diabetes
3. Diabetes
• Lipids
• Blood Pressure
4. Heart Disease
5.? Some Cancers
6
Metabolic Syndrome Phenotype:
A Cluster of Metabolic Abnormalities
Visceral Adipose Tissue
• Abdominal
Adiposity
• Dysglycemia
• HDL Cholesterol
• Triglycerides
• +/- Elevated BP
Subcutaneous Adipose
Tissue
Associated with a significant increase in type 2 diabetes and CHD
Age-Adjusted Prevalence of Metabolic Syndrome in
Canada
50
45
40
35
30
25
20
15
10
5
0
45.4
41.3
28.8
25.2 26.8
28.3
Women
Men
23.4
15.9
14.3
7.1
Overall
Chinese
Euro
South
Asian
Aboriginal
Age-Adjusted
Anand et al Circulation 2003
INTERHEART: MS and MI by
Region
Region
% Contr
OR
Overall
26.1
2.69 (2.48,2.92)
29.2 ( 27.1, 31.3)
W Europe
16.7
3.86 (2.61,5.70)
36.0 ( 27.5, 45.4)
C/E Europe
32.0
1.82 (1.46,2.26)
20.4 ( 14.3, 28.2)
Middle E/Egypt
35.7
2.53 (2.08,3.08)
34.8 ( 29.1, 41.1)
Africa
24.6
4.02 (2.76,5.86)
41.7 ( 32.6, 51.4)
South Asia
26.9
2.72 (2.18,3.39)
31.6 ( 25.9, 37.9)
China /H.K.
13.9
2.27 (1.89,2.73)
15.1 ( 12.1, 18.7)
S.E. Asia/Japan
22.4
5.59 (4.22,7.41)
50.0 ( 43.5, 56.6)
Aust/N. Z.
26.4
2.20 (1.30,3.72)
22.0 ( 10.5, 40.3)
South Am./Mex.
36.3
2.74 (2.18,3.44)
40.3 ( 33.1, 47.9)
North Am
27.4
2.30 (0.97,5.47)
21.5 ( 5.5, 56.3)
Mente et al JACC
(99% CI)
PAR (99% CI)
0.5
1
2
4
OR (99% CI)
8
16
Summary of Risk Factors
•
•
•
•
•
•
•
1) Increased body fat
2) Tendancy toward central adiposity
3) Visceral Fat excess
4) Fatty liver
5) Low HDL, High LDL, High TRGS
6) Increased Diabetes
7) Smoking is lower
Summary of Presentation,
Diagnosis, and Treatment
• Presentation time to hospital with chest
pain symptoms is later in SA
• Management of acute coronary
syndromes is similar
• Case fatality rate is similar
• Long-term morbidity, mortality appears
similar
• Lower attendance at Cardiac Rehab
Community Level
Pregnancy and
Early Childhood
Adult Metabolic
Syndrome
Interventions to
Change Health
Behaviours
Individual
SouTh Asian BiRth CohorT
Early Life Determinants
“Thin-fat” baby
• Newborns, relatively small at birth (BW < 2.9
kg) reported to have greater subscapular skin
fold thickness, which is shown to correlate
well with truncal obesity
• This adiposity tracks to 4 years of age
• An increase of BMI of 1 SD from 2 to 12
years of age, increased the odds ratio for
disease (IGT / DM) by 1.36. in young adults
Krishnaveni GV, Hill JC, Veena SR, Fall CHD. Indian Pediatr 2005; 42: 527-538
New Eng J Med 2004; 350: 865-875.
LBW persists in South Asian
babies in UK
• X- sectional data record linkage 2005 –
2006 n=861,654 births of white, or
South Asians
• 1st generation: Born in Indian
subcontinent
• 2nd generation: Born in England/Wales
Singleton Birth Weights
N = 772,128
1st Generation
2nd Generation
White
Mean = 3457g
Bangladesh
Mean = 3074g
13,261
Mean = 3084g
3,015
Mean = 3026g
Indian
Mean = 3089g
15,733
Mean = 3105g
11,368
Mean = 3062g
Pakistani
Mean = 3130g
28,566
Mean = 3148g
17,583
Mean = 3097g
Leon, J Epidemiol Community Health 2012;66:544-61
Birth Weight by Maternal Region of Birth
(Canada and South Asia only).
Ontario, 2002-2006 Combined
Risk of Gestational Diabetes Mellitus in Association with
Maternal Place of Birth
4
3.5
3
2.5
2
1.5
1
0.5
0
Country of Birth
Odds ratios were adjusted for maternal age (continuous in years), number of livebirths, multifetal pregnancy, place of residence,
neighborhood income quintile, and fiscal year of delivery. b Reference category.
a
Epidemiology: November 2011 – Volume 22 – Issue 6 – pp 879-880.
Relative Risk of DM,
obesity, CVD
Both low birth weight and high birth are associated with
long-term metabolic disease risk for offspring
Low
Higher Risk with
LOW Birth
Weight
• Placental insufficiency
•Maternal undernutrition
•Hypoxia (smoking, anemia, altitude)
•Genetics
High
Birth Weight
Higher Risk with
HIGH Birth
Weight
• Maternal diabetes
• Obesity
• Excess gestational
weight gain
• Genetics
Diverse Environments
250
Mothers/Babies
Rural India
250
Mothers/Babies
Urban India
1000
Mothers/Babies
Urban Canada
PSYCHSOCIAL SRESS, SOCIAL SUPPORT
ACCESS to PRIMARY CARE
DIETARY DIFFERENCES (WEIGHT GAIN)
GENETIC/EPIGENETIC FACTORS
20
Birthweight among GA > 37
weeks
3.6
3.55
3.5
3.45
3.4
Series 1
3.35
3.3
3.25
3.2
3.15
START
FAMILY (EC)
In singleton newborns with a gestational age >=37 weeks
START: Is thin fat phenotype
Observed in Canada?
%fat/kg BW
3.4
3.3
3.2
3.1
3
%fat/kg BW
2.9
2.8
2.7
2.6
South Asian
FAMILY (EC)
In singleton newborns with a gestational age >=37 weeks
Epigenetic
• Maternal Exposures linked to DNA
methylation in offspring:
– Smoking
– Depression
– Under or over nutrition
Regions of Genome associated
with Birth Weight
•
•
•
•
Development and morphagenesis
Cell Cycle/Cell division
Metabolism and biosynthesis
Not imprinted regions or housekeeping
genes
• 60% methylation discordance between
heavy and light birth weight babies
Explanations
• 1) Genetic- Transgenerational, DNA
inherited
• 2) EpiGenetic – Transgenerational,
inherited, non-DNA
• 3) Cultural: Diet deficiency or imbalance
• 4) Other: Brown fat, telomere length
What can we do to prevent
Metabolic Syndrome in
about the South Asian
population in Canada?
SAHARA Project
A multi-media based intervention aiming to
provide culturally tailored health messaging
and feedback to participants with the goal of
reducing their cardiac risk score over a 6month period.
http://www.youtube.com/watch?v=SwZdUSm
WBpo
Screening Cohort
• 320 Men and women of South Asian ancestry
• Permanent residents of Ontario/BC
• ≥30 years
• Access to email, cell phone with text messaging
capability, or a smart phone
• No previous MI, CABG, Stroke
Study Outcomes
• Primary outcome: change in IHRS after 1 year
• Secondary outcomes:
• Change in components of risk score - blood pressure, HbA1c, waist to
hip ratio, and apolipoproteins B and A
• Difference in clinical events between the intervention and control
groups at the end of the study
• Rate of change in IHRS over time
INTERHEART Modifiable Risk Score Report
Genetic Risk Score Report
Community or Contextual
Factors and Future Interventions
Social Networks
• 12,000 people tracked for 32 yrs
• Social networks play a powerful role in
determining weight gain
• If spouse or brother is overweight –1.40x
would be overweight
• Friends had the most powerful influence 1.52.0x - “kind of social contagion”
• Think about typical S. Asian social networkscentered around eating, not around moving
• Older cultural beliefs must change to prevent
weight gain
Kristakis NEJM 2007
Obesity in a Facebook Network
Social Networks 2008; 30: 330-34
Population & high risk individualized strategy
for the Prevention of CVD
GOAL
Type of
Strategy
Determinants of
Risk Behaviours in a
Population
Individuals with
Risk Factors for
CVD
Individuals with
Manifest CVD
Interventions with a
Socio-Economic &
Political Focus
Interventions
with a
Preventive
Focus
Interventions
with a Clinical
Focus
• Taxing Tobacco
Examples
• Subsidizing healthy
foods
• Health Education
• Promote Physical
Activity
•Identifying &
treating
individuals with
high cholesterol or
hypertension
•Smoking
cessation in a
smoker
•
•
•
•
•
Lipid Lowering
Aspirin
Beta blockers
ACE-inhibitors
Appropriate
revascularizatio
n
A PolyPill for all?
Aspirin
Statin
Thiazide
BB
ACE - I
October 30, 2008