Transcript No Slide Title

Cardiac Risk Factor Management in
the Older South Asian Female
Dr. Aashish Contractor
Head of Dept: Preventive Cardiology and Rehabilitation
Asian Heart Institute, Mumbai, India
e-mail: [email protected]
Outline
•
Reasons for higher CHD prevalence in S. Asians
•
Significance of CHD risk factors in S. Asians
•
Factors affecting risk factor reduction in S. Asians
•
Conclusions
Leading Causes of Death in India
Year
2000
2010
Total death 9.4
(in millions)
10.2
CVD
(only IHD)
Infectious
Diseases
3.75
2
2.2
3
1.6
2.4
Burden of CHD in the U.K.
•
•
Coronary heart disease (CHD) remains the
leading cause of death in the United Kingdom
(UK) accounting for around 300,000 deaths
per year.
South Asians have a 40–50% greater
mortality from CHD compared to the
indigenous white European population
Coronary heart disease statistics 2004: British Heart Foundation Statistics:
website www.heartstats.org
Why do South Asians have
premature CHD mortality?
• Several hypotheses, which include:
• Higher prevalence of the metabolic
•
•
•
syndrome and diabetes mellitus
Pro-atherogenic diet
Lack of physical activity
High levels of homocysteine and Lp(a)
Presentation of CHD
• South Asians, especially women are
more likely to present with ‘atypical’
symptoms and more likely to be
diagnosed as ‘non-cardiac’
Barakat K,Wells Z, Ramdhany S,Mills P,Timmis A. Bangladeshi
patients present with non-classic features of acute myocardial
infarction and are treated less aggressively in east London,
UK.Heart 2003; 89: 276–9.
Estimation of CHD risk
•
•
•
CHD risk estimation tool validated in this
ethnic group is currently non-existent.
The available scales such as the
Framingham, FINRISK and the SCORE
systems (derived from cohort studies of
American and European white populations)
have been shown to underestimate CHD risk
in South Asians
Bhopal R, Fischbacher C,Vartiainen E,Unwin N,White M, Alberti G.
Predicted and observed cardiovascular disease in South Asians:
application of FINRISK, Framingham and SCORE models to Newcastle
Heart Project data. Journal of Public Health. 2005;27: 93–100.
Outline
•
Reasons for higher CHD prevalence in S. Asians
•
Significance of CHD risk factors in S. Asians
•
Factors affecting risk factor reduction in S. Asians
•
Conclusions
Age
•
The INTERHEART study revealed that the
median age for presentation with a cardiac
event was 50 years for men of South Asian
origin vs 59 years for European men
•
The median age for South Asian women was
60 vs 68 for European women
•
Effect of potentially modifiable risk factors associated with myocardial
infarction in 52 countries (the INTERHEART study): case-control study
Lancet 2004; 364: 937–52
Diabetes
•
•
•
Diabetes is 3-5 times more common in
people of South Asian origin living in the UK
Mortality rates in South Asians with diabetes
are two fold higher compared to Europeans
with diabetes
Cappuccio FP,Cook DG,Atkinson RW, Strazzullo P. Prevalence,
detection and management of cardiovascular risk factors in different
ethnic groups in South London. Heart 1997; 78: 555–63.
Diabetes
• Premature death, especially in South
Asian females, is reportedly linked with
the earlier onset of diabetes
Sverdlow AJ, Laing SP, Dos Santos Silva I et al. Mortality of South
Asian patients with insulin-treated diabetes mellitus in the United
Kingdom: a cohort study. Diabetic Medicine 2004; 21 (8): 845-51
Diabetes
• Figures suggest that 20 per cent of the
South Asian community living in the UK
have Type 2 diabetes in contrast to
three per cent of the general population.
•
Diabetes and the disadvantaged: reducing health inequalities in
the UK World Diabetes Day 14 November 2006. A report by the
All Parliamentary Group for Diabetes and Diabetes UK
Attitudes towards diabetes
•
South Asians with diabetes in the U.K. have
been shown to have accepted their diagnosis
with resignation and expressed the view that
the condition had been “sent by God” .
•
Most people have family members and
friends with the disease, and accept it as
inevitable, and are therefore less motivated to
attempt to control it.
•
Stone M et al. Empowering patients with diabetes: a qualitative primary
care study focusing on South Asians in Leicester, UK. Family Practice
2005;22:647-52
Hypertension
•
The prevalence of hypertension appears to
be significantly higher in some studies of
South Asian immigrants in the UK compared
to Europeans
•
This contrasts with some reports both in the
UK and in the South Asian groups living in
Tanzania
•
•
(Cappuccio FP,Cook DG,Atkinson RW, Strazzullo P. Prevalence, detection and
management of cardiovascular risk factors in different ethnic groups in South
London. Heart 1997; 78: 555–63.)
(Agyemang C,.Bhopal RS. Is the blood pressure of South Asian adults in the UK
higher or lower than that in European white adults? A review of cross-sectional
data. J Hum Hypert 2002; 16: 739–51.)
Hypertension
• Further, the risk of hypertension going
undetected is highest among South
Asians (odds ratio 2.34, 95% CI) when
compared with Caucasians and people
of African descent living in the UK
•
Cappuccio F, Oakeshott P, Strazzullo P, Kerry S. Application of
Framingham risk estimated in ethnic minorities in United Kingdom ad
implications for primary prevention of heart disease in general practice:
cross-sectional population based study. BMJ 2002; 325:1271
Hypertension: beliefs
•
•
To address the cardiovascular disparities in
South Asians in the U.S., an understanding of
the community’s health care seeking patterns
need to be considered.
A series of 8 focus groups with South Asian
community members in the New York
Metropolitan Area were conducted to
evaluate their hypertension beliefs,
knowledge, and screening and treatment
practices, and their experiences in accessing
the health care system
Hypertension: beliefs
•
While some participants did acknowledge that people in
home countries may also have hypertension/stress,
others associated high blood pressure to moving to the
US
•
Additionally, stress/fear felt specifically by Muslim
community in the United States as a result of 9/11 (and
the "war on terror"), in the community were cited as
causes for disease, heart attacks.
•
Also, for some participants, loneliness, isolation, etc.
contributes to stress and disease. They identified
stress being a result of not being able to speak about
personal, family issues, especially immigration.
Smoking
• Smoking rates are generally
significantly lower in South Asian
females than in Whites
Prevalence of Tobacco Smoked by American Adults age 20 and above
by Race/Ethnicity and Sex
White Black
Male
25.8% 26.1%
Female 21.6% 20.8%
Mexican Asian/Pac. S. Asian
24.1%
24.3%
26.8%
12.3%
7.1%
1.8%
Percentage of South Asians
Chewing Tobacco
(info.cancerresearchuk.org/.../oral/riskfactors/ )
Cholesterol
•
•
•
High triglycerides and low HDL are the most
common dyslipidemias seen in this
population
It is interesting to note that although total
plasma cholesterol may actually be lower in
UK South Asians than white Europeans, it is
still significantly higher than that seen in
South Asians in India.
South Asian women are much more likely to
have low levels of protective HDL cholesterol
Classification
BMI(kg/m²)
Principal cut-off points
Additional cut-off points
<18.50
<18.50
<16.00
<16.00
Moderate thinness
16.00 - 16.99
16.00 - 16.99
Mild thinness
17.00 - 18.49
17.00 - 18.49
Underweight
Severe thinness
Normal range
Overweight
Pre-obese
Obese
Obese class I
18.50 - 24.99
≥25.00
25.00 - 29.99
≥30.00
30.00 - 34-99
Obese class II
35.00 - 39.99
Obese class III
≥40.00
Source: Adapted from WHO, 1995, WHO, 2000 and WHO 2004.
18.50 - 22.99
23.00 - 24.99
≥25.00
25.00 - 27.49
27.50 - 29.99
≥30.00
30.00 - 32.49
32.50 - 34.99
35.00 - 37.49
37.50 - 39.99
≥40.00
Lancet 2004; 363: 157–63
Threshold for BMI cut-offs
•
•
Conventional cut points were derived
primarily in European populations to
correspond to risk thresholds for a wide range
of chronic diseases and mortality.
Emerging evidence suggests that South
Asians (people who originate from the Indian
subcontinent) and Chinese suffer from an
elevated risk of type 2 diabetes,
hypertension, and dyslipidemia even if their
BMI is low (ie, 25.0 kg/m2).
• Possible explanations include that nonEuropeans have a relative excess of
adipose tissue or deficit of lean body
mass compared with Europeans for a
given BMI.
• The study demonstrated that South
Asians, Chinese, and Aboriginal people
have similar distributions of glucose and
lipid factors at significantly lower BMI
values compared with Europeans
Circulation. 2007;115:2111-2118.)
Outline
•
Reasons for higher CHD prevalence in S. Asians
•
Significance of CHD risk factors in S. Asians
•
Factors affecting risk factor reduction in S.
Asians
•
Conclusions
Challenges in risk factor reduction
• Barriers in communication
• Cultural issues
• Dietary practices
• Low levels of physical activity
• Its important to bear in mind, that South
Asian women do not share a
homogeneous culture or identity
Barriers in communication
• Inability to speak or read English
• This impairs comprehension of
•
education
The availability of multilingual literature
would be very helpful
Cultural issues
• Fatalistic approach to health and illness
• Often believe that illness is ‘God’s will’
•
or that ‘what is written in my destiny no
one can change’ (Karma)
Such an approach often results in
patients being less proactive in the
recovery process
Cultural issues
• In addition to Western medicine,
•
traditional healers and healing practices
are valued by South Asian women
Often patients are not told about their
diagnosis, for fear of ‘frightening’ them
Diet-composition
•
•
•
•
Fat intake is higher in South Asians. Clarified
butter, known as ‘ghee’ is used frequently in
cooking, and is very high in saturated fat
They tend to have a low level of fish
consumption (other than Bangladeshis)
Indian snacks tend to be usually deep-fried
Diet tends to high in full fat milk (buffalo milk)
Diet- cultural issues
•
•
Diet: The cultural significance of food for
South Asians is enormous. People are offered
fatty, sweet food at social gatherings,
religious festivals, weddings and celebrations.
To refuse the food would mean social
isolation, and South Asian patients in the U.K.
with diabetes have been reported as being
reluctant to do so
Hill J. Management of diabetes in South Asian communities in the UK.
Nursing Standard 2006; 20(25): 57-64.
Diet- excess sugar consumption
• In the U.K., one in three Asian Indian
•
diabetics have been reported as
consuming Asian sweets, high in sugar
content, at least once a week.
Approximately 80% consumed tea with
high sugar content, and 75% ate snacks
cooked in fats/oils daily
Samantha A, Campbell JE, Spalding DL, Panja KK, Neogi SK,
Burden AC. Eating habits in Asian diabetics. Diabet Med 2002;
3(3):283-4
Diet- fasting
•
•
Related to the dietary practices are fasts and
feasts. Muslim patients who observe
Ramadan face additional challenges to
maintain a steady blood glucose level during
this month.
In Hindus, there are several periods of fasting
throughout the year from one to nine days.
These fasts are usually preceded and
followed by feasts, and present a challenge
for self-care in the South Asian diabetic.
Results
• Indian, Pakistani and Bangladeshi men
•
were 14, 30, and 45% less likely than
the general population to meet current
guidelines for physical activity
Levels of physical activity were lower in
all South Asian groups than the general
population
Results
•
•
•
The Health Survey for England reported that
only 1 % of Bangladeshi women, and 2 % of
Indian women above 55 years, reported a
high level of physical activity
The corresponding figure in the general
population was 11 %
Very unlikely to take part in any type of
sporting activity
Attitude of healthcare professionals
• Any tendency of health promotion
strategies to overemphasize barriers of
cultural difference, which may promote
defeatist attitudes among professionals,
needs to be avoided
Barriers to exercise
• Low awareness and uncertainty
• Low priority
• Over protective attitude of family
• Worried about activity being harmful
• Mixed sex exercise facilities
Low priority
• Low priority to physical activity as a
•
leisure activity to be pursued in limited
spare time when set against family and
other obligations
They felt they were being active from
care-giving, housekeeping and workday
activities
• Attending the gym may be difficult for
South Asian women unless single-sex
facilities are available, as certain
religions require that the women keep
their bodies covered.
•
Hill J. Management of diabetes in South Asian communities in the UK.
Nursing Standard 2006; 20(25): 57-64.
Perception of exercise
•
•
Study was conducted at AHI with 40
female participants to reveal perception
of benefit and barrier to exercise using a
questionnaire.
The participants were divided in 3
groups.
• Group A- Participants attending Cardiac
•
•
rehabilitation (age 50-60 yrs).
Group B- Relatives accompanying
participants (age 50-60 yrs).
Group C- Students at AHI (age 20-25
yrs).
Exercise Benefits / Barriers Scale
143.1
130.4
A
B
Groups
134.8
C
% of patients in Cardiac Rehabilitation
(March- July 07)
60
46.26
36.6
40
Males
Females
20
0
% Joined
Males
46.26
Females
36.6
Relatives Accompanying patients
100%
80%
86%
61%
60%
40%
20%
0%
Male
Female
% of female patients in rehab
Female
18%
Male
Female
Male
82%
Outline
•
Reasons for higher CHD prevalence in S. Asians
•
Significance of CHD risk factors in S. Asians
•
Factors affecting risk factor reduction in S. Asians
•
Conclusions
Conclusions
•
•
•
South Asians are at much higher risk for CHD
than the general population
Their risk factor profile is different, especially
in relation to the metabolic syndrome
Physical activity and healthful dietary habits
need to be promoted, keeping in mind certain
cultural differences (however, these should
not be over-emphasized)