Dyslipidemia in South Asians living in a western community

doi:10.1016/j.jacl.2008.12.002

Journal of Clinical Lipidology

Volume 3, Issue 1, February 2009, Pages 14-18

https://doi.org/10.1016/j.jacl.2008.12.002 Get rights and content

Abstract

An increased prevalence of coronary heart disease (CHD) has been well documented in the South Asian population living worldwide. The prevalence of certain traditional CHD risk factors, like diabetes mellitus and tobacco use, have been on the rise in this ethnic group and likely contribute to the increase in CHD prevalence. Still, a disproportionate excess of CHD exists, and this may be linked to novel CHD risk factors. We have reviewed the prevalence of CHD in South Asians and its association to both traditional and novel CHD risk factors. We present a literature review of traditional and novel CHD risk factors, and incorporate the results of a cross-sectional study investigating the prevalence of these factors in a South Asian population residing in the United States with no prior diagnosis of CHD. The total cholesterol (TC) (mean ± standard deviation) was 193.72 ± 33.76 mg/dL, high-density lipoprotein (HDL) was 42.20 ± 12.11 mg/dL, and low-density lipoprotein (LDL) was 124.88 ± 27.22 mg/dL. The mean triglyceride level was 166.60 mg/dL. The prevalence of elevated TC (>200 mg/dL) was 41.3% and elevated LDL (>130 mg/dL) 40.7%. There was a significant difference between men and women in the prevalence of reduced HDL (<40 mg/dL) (67.3% vs. 49.4%), elevated triglycerides (>130 mg/dL) (56.4 vs. 30.4%), and small-dense LDL particles (53.6% vs. 27.8%).

Considerably higher prevalence of novel CHD risk factors has been noted in the South Asian population. The CHD risk may increase significantly when these novel factors co-exist with traditional CHD risk factors.

Section snippets

Methods

Subjects of South Asian ethnicity who were >25 years of age living in the Columbus, Ohio area of the United States included 189 volunteers (110 males and 79 females) without a history of dyslipidemia, diabetes, or vascular disease. Detailed family histories or anthropometric determinations were not available. All volunteers were eligible to be tested if they were free of any clinical disease and not on medications. The parameters investigated included fasting total cholesterol, HDL, LDL,

Results

The total cholesterol (TC) (mean ± standard deviation) was 193.72 ± 33.76 mg/dL; HDL was 42.20 ± 12.11 mg/dL and LDL was 124.88 ± 27.22 mg/dL. The mean triglyceride and large VLDL cholesterol concentrations were 166.60 ± 114.44 and 31.54 ± 61 mg/dL, respectively. The prevalence of elevated TC (>200 mg/ dL) was 41.3% and elevated LDL (>130 mg/dL) 40.7%. There was a significant difference between men and women in the prevalence of reduced HDL-cholesterol (<40 mg/dL) (67.3% vs. 49.4%, P < .001),

Discussion

Studies have shown the South Asians have a lower HDL level than other ethnic groups.19, 20, 21 There also appears to be a qualitative difference in HDL particles between Caucasians and South Asians. Bhalodker et al²² found that South Asian men had greater concentrations of the smaller HDL particles and less of the larger HDL particles. Our data show that over one-third of male patients who are free of “clinical disease” had the characteristic lipid profile associated with both insulin

Conclusion

South Asians are faced with a rising CHD epidemic not seen in other ethnic groups. Traditional risk factors play a major role in the development of CHD. The prevalence of factors such as tobacco consumption and DM are on the rise in this population. Yet traditional risk factors do not fully explain the overwhelming increase in CHD in South Asians. Novel CHD risk factors such as hs-CRP, LP(a), and small-dense LDL are prevalent in this population. As clinicians we should be aware of potential

References (46)

V. Mohan et al.
Prevalence of coronary artery disease and its relationship to lipids in a selected population in South India: The Chennai Urban Population Study (CUPS No. 5)
J Am Coll Cardiol
(2001)
K. Srinath Reddy et al.
Responding to the threat of chronic diseases in India
Lancet
(2005)
L.O. Hughes et al.
Relationship between plasma cholesterol and coronary artery disease in Asians
Atherosclerosis
(1990)
P.M. McKeigue et al.
Coronary heart disease in south Asians overseas: a review
J Clin Epidemiol.
(1989)
P.M. McKeigue et al.
Relation of central obesity and insulin resistance with high diabetes prevalence and cardiovascular risk in South Asians
Lancet
(1991)
R. Zoratti et al.
Relation of plasma lipids to insulin resistance, nonesterified fatty acid levels, and body fat in men from three ethnic groups: relevance to variation in risk of diabetes and coronary disease
Metabolism
(2000)
E.J. Jeyarajah et al.
Lipoprotein particle analysis by nuclear magnetic resonance spectroscopy
Clin Lab Med
(2006)
P.M. McKeigue et al.
Diet and risk factors for coronary heart disease in Asians in northwest London
Lancet
(1985)
N.C. Bhalodkar et al.
Comparison of levels of large and small high-density lipoprotein cholesterol in Asian Indian men compared with Caucasian men in the Framingham Offspring Study
Am J Cardiol
(2004)
R. Gupta et al.
Prevalence of metabolic syndrome in an Indian urban population
Int J Cardiol
(2004)

R. Rajeshwari et al.

Cardiovascular diseaes: a major health risk in Asian Indians

Nutr Res.

(2005)

L. Palaniappan et al.

Coronary heart disease mortality for six ethnic groups in California, 1990-2000

Ann Epidemiol

(2004)

H. Refsum et al.

Hyperhomocysteinemia and elevated methylmalonic acid indicate a high prevalence of cobalamin deficiency in Asian Indians

Am J Clin Nutr

(2001)

J.C. Chambers et al.

Plasma homocysteine concentrations and risk of coronary heart disease in UK Indian Asian and European men

Lancet

(2000)

O.A. Obeid et al.

Homocysteine and folate in healthy east London Bangladeshis

Lancet

(1998)

J. Lee et al.

Risk factors and incident coronary heart disease in Chinese, Malay and Asian Indian males: the Singapore Cardiovascular Cohort Study

Int J Epidemiol

(2001)

P. Joshi et al.

Risk factors for early myocardial infarction in South Asians compared with individuals in other countries

JAMA

(2007)

J. Dhawan et al.

Insulin resistance, high prevalence of diabetes, and cardiovascular risk in immigrant Asians. Genetic or environmental effect?

Br Heart J

(1994)

Prevalence of cigarette use among 14 racial/ethnic populations—United States, 1999-2001

MMWR

(2004)

Tobacco or health: a global status report

(1997)

S. Wild et al.

Global prevalence of diabetes: estimates for the year 2000 and projections for 2030

Diabetes Care

(2004)

J.S. Kooner et al.

Abdominal obesity, impaired nonesterified fatty acid suppression, and insulin-mediated glucose disposal are early metabolic abnormalities in families with premature myocardial infarction

Arterioscler Thromb Vasc Biol.

(1998)

H.M. Lakka et al.

The metabolic syndrome and total and cardiovascular disease mortality in middle-aged men

JAMA

(2002)

Cited by (8)

The Morphology of Coronary Artery Disease in South Asians vs White Caucasians and Its Implications
2022, Canadian Journal of Cardiology
South Asians (SAs) experience a higher prevalence and earlier onset of coronary artery disease and have worse outcomes compared with White Caucasians (WCs) following invasive revascularisation procedures, a mainstay of coronary artery disease (CAD) management. We sought to review the differences in the CAD pattern and risk factors between SA and WC patients and to discuss their potential impact on the development of coronary disease, acute coronary syndrome, and revascularisation outcomes. SAs have a more diffuse pattern with multivessel involvement compared with WCs. However, less is known about other morphologic characteristics, such as calcification of atherosclerotic plaque and coronary diameter in SA populations. Despite a similar coronary calcification burden, higher noncalcified plaque composition, elevated thrombosis, and inflammatory markers likely contribute to the disease pattern. Although the current evidence on the role of coronary vessel size remains inconsistent, smaller diameters in SAs could play a potential role in the higher disease prevalence. This is especially important given the impact of coronary artery diameter on revascularisation outcomes. In conclusion, SAs have a unique CAD risk profile composed of traditional and novel risk factors. Our findings highlight the need for additional awareness of health professionals of this specific risk profile and potential therapeutic targets, as well as the need for further research in this vulnerable population.
Les populations sud-asiatiques (SA) présentent une prévalence plus élevée et une apparition plus précoce de la maladie coronarienne, et ont de moins bons pronostics que les Blancs caucasiens (BC) après des procédures de revascularisation invasive, fondement de la gestion de la maladie coronarienne (MC). Nous avons cherché à examiner les différences dans le canevas de la MC et les facteurs de risque entre les patients SA et BC, puis à discuter de leur impact potentiel sur le développement de la maladie coronarienne, le syndrome coronarien aigu et les conséquences d'une revascularisation. Les SA présentent un profil plus diffus avec une atteinte multivasculaire, comparés aux BC. Cependant, on en connaît moins les autres caractéristiques morphologiques, telles que la calcification de la plaque athérosclérotique et le diamètre coronaire dans les populations SA. Malgré une charge de calcification coronaire similaire, une composition plus élevée en plaque non calcifiée, une thrombose élevée et des marqueurs inflammatoires contribuent probablement à l'évolution de la maladie. Bien que les données actuelles sur le rôle de la taille des vaisseaux coronaires restent inconsistantes, des diamètres plus petits dans les SA pourraient jouer un rôle dans la prévalence plus élevée de la maladie. Ceci est particulièrement important étant donné l'impact du diamètre des artères coronaires sur les conséquences de la revascularisation. En conclusion, les SA présentent un profil de risque de MC unique, incluant des facteurs de risque traditionnels et nouveaux. Nos résultats soulignent la nécessité de sensibiliser davantage les professionnels de la santé à ce profil de risque spécifique et aux cibles thérapeutiques potentielles, ainsi que la nécessité de poursuivre les recherches sur cette population vulnérable.
Cardiovascular Disease in South Asian Migrants
2015, Canadian Journal of Cardiology
Citation Excerpt :
Specifically, a high ApoB/A1 ratio accounted for nearly half the population-attributable risk.21,80 Although SAs have levels of LDL cholesterol similar to those of Europids, they have significantly lower levels of HDL cholesterol.81-83 This may imply a genetic predisposition to low HDL cholesterol acquired through an increased propensity for visceral adiposity and liver fat to develop, with associated dysregulation in key enzymes such as cholesteryl ester transfer protein.84
Cardiovascular disease (CVD) represents a significant cause of global mortality and morbidity. South Asians (SAs) have a particularly high burden of coronary artery disease (CAD). This review describes current literature regarding the prevalence, incidence, etiology, and prognosis of CVD in SA migrants to high-income nations. We conducted a narrative review of CVD in the SA diaspora through a search of MEDLINE and PubMed. We included observational studies, randomized clinical trials, nonsystematic reviews, systematic reviews, and meta-analyses written in English. Of 15,231 articles identified, 827 articles were screened and 124 formed the basis for review. SA migrants have a 1.5-2 times greater prevalence of CAD than age- and sex-adjusted Europids. Increased abdominal obesity and body fat and increased burden of type 2 diabetes mellitus and dyslipidemia appear to be primary drivers of the excess CAD burden in SAs. Sedentary lifestyle and changes in diet after immigration are important contributors to weight gain and adiposity. Early life factors, physical activity patterns and, in some cases, reduced adherence to medical therapy may contribute to increased CVD risks in SAs. Novel biomarkers like leptin and adipokines may show distinct patterns in SAs and provide insights into cardiometabolic risk determinants. In conclusion, SAs have distinct CVD risk predispositions, with a complex relationship to cultural, innate, and acquired factors. Although CVD risk factor management and treatment among SAs is improving, opportunities exist for further advances.
Les maladies cardiovasculaires (MCV) représentent une cause importante de mortalité et de morbidité mondiales. Les Sud-Asiatiques (SA) ont un niveau particulièrement élevé de maladie coronarienne. Cette revue compile la littérature actuelle concernant la prévalence, l'incidence, l'étiologie et le pronostic des MCV chez les migrants SA vers les pays à revenu élevé. Nous avons effectué un examen narratif des MCV dans la diaspora SA via une recherche dans MEDLINE et PubMed. Nous avons inclus des études d'observation, des essais cliniques randomisés, des revues non systématiques, des revues systématiques et des méta-analyses écrites en anglais. À partir de 15 231 articles identifiés, 827 articles ont été examinés et 124 ont formé la base pour la revue. Les migrants SA ont une prévalence de maladie coronarienne 1,5 à 2 fois plus grande que les europoïdes, ajusté pour l’âge et le sexe. L’augmentation de l'obésité abdominale et du gras corporel, et l'augmentation de la charge du diabète de type 2 et la dyslipidémie semblent être le principal moteur de la charge excessive de la maladie coronarienne chez les SA. Un mode de vie sédentaire et des changements de régime alimentaire après l'immigration sont d’importants contributeurs à la prise de poids et l'adiposité. Des facteurs des stades précoces de l’existence, la façon de pratiquer une activité physique et, dans certains cas, une observance réduite du traitement médical peuvent contribuer à l'augmentation des risques de MCV chez les SA. De nouveaux biomarqueurs telles la leptine et les adipokines peuvent montrer des modèles distincts chez les SA et fournir des indications sur les déterminants du risque cardiométabolique. En conclusion, les SA ont des prédispositions distinctes de risque de MCV, avec une intrication complexe de facteurs culturels, innés et acquis. Bien que la gestion des facteurs de risque des MCV et leur traitement chez les SA s’améliore, des possibilités demeurent pour des avancées ultérieures.
Young, healthy South Asians have enhanced lipogenic sensitivity to dietary sugar
2017, Clinical Endocrinology
The prevalence of metabolic syndrome in South Asia: A systematic review
2016, International Journal of Diabetes in Developing Countries
Elevated cholesteryl ester transfer protein (CETP) activity, a major determinant of the atherogenic dyslipidemia, and atherosclerotic cardiovascular disease in South Asians
2015, European Journal of Preventive Cardiology
Relationship of maximal aerobic capacity with predictors of cardiovascular diseases in North Indian cardiac patients
2014, Heart Asia

View all citing articles on Scopus

View full text

Review ArticleDyslipidemia in South Asians living in a western community

Abstract

Section snippets

Methods

Results

Discussion

Conclusion

J Am Coll Cardiol

Lancet

Atherosclerosis

J Clin Epidemiol.

Lancet

Metabolism

Clin Lab Med

Lancet

Am J Cardiol

Int J Cardiol

Nutr Res.

Ann Epidemiol

Am J Clin Nutr

Lancet

Lancet

Risk factors and incident coronary heart disease in Chinese, Malay and Asian Indian males: the Singapore Cardiovascular Cohort Study

Int J Epidemiol

Risk factors for early myocardial infarction in South Asians compared with individuals in other countries

JAMA

Insulin resistance, high prevalence of diabetes, and cardiovascular risk in immigrant Asians. Genetic or environmental effect?

Br Heart J

Prevalence of cigarette use among 14 racial/ethnic populations—United States, 1999-2001

MMWR

Tobacco or health: a global status report

Global prevalence of diabetes: estimates for the year 2000 and projections for 2030

Diabetes Care

Abdominal obesity, impaired nonesterified fatty acid suppression, and insulin-mediated glucose disposal are early metabolic abnormalities in families with premature myocardial infarction

Arterioscler Thromb Vasc Biol.

The metabolic syndrome and total and cardiovascular disease mortality in middle-aged men

JAMA

Review Article
Dyslipidemia in South Asians living in a western community