Diabetes and cardiovascular disease in South Asians: A global perspective

Gundu H R Rao

doi:10.4103/JCPC.JCPC_29_18

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Year : 2018 | Volume : 7 | Issue : 4 | Page : 161-167

Diabetes and cardiovascular disease in South Asians: A global perspective

Gundu H R Rao PhD,
Department of Laboratory Medicine and Pathology, Lillehei Heart Institute, University of Minnesota, MN, USA

Date of Web Publication

15-Oct-2018

Correspondence Address:
Prof. Gundu H R Rao
12500 Park Potomac Ave, Unit 306N, Potomac, MD 20854
USA

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/JCPC.JCPC_29_18

Abstract

South Asians (Indians, Pakistanis, Bangladeshis, and Sri Lankans), have very high incidence of metabolic diseases, such as hypertension, abdominal obesity, metabolic syndrome, type-2 diabetes, and vascular disease. To create awareness, develop educational and preventive strategies, we started a professional society, South Asian Society on Atherosclerosis and Thrombosis (SASAT) in 1993, at the University of Minnesota. Since that time, we have organized fifteen international conferences in India and published several monographs on this topic. In our conferences, we have discussed all aspects of epidemiology, risk factors, and excess burden of these diseases in this ethnic group in India and abroad. In general, South Asians seem to have excess incidence of diabetes and coronary artery disease, no matter which country they live. There are speculations about the reasons for this excess; however, no definite risk factor or a cluster of risks have been attributed to be responsible for this excess disease burden. National health programs in various countries, such as the UK, and Canada, with large number of South Asian Immigrants, have developed ethnic-specific preventive measures. The World Health Organization has issued special guidelines about the BMI cutoff, for this ethnic group. During the tenure of the President William Clinton, recognizing the important role the South Asian community has played in the USA, he recommended some studies related to their health. Again in 2009, President Barack Obama signed an executive order, calling for strategies to improve the health of Asian Americans. In a recent issue of the Journal of Circulation, the American Heart Association has published a scientific statement about the atherosclerotic disease in the South Asians living in the USA. The Vice chair of one of the councils, Dr Latha Palaniappan also has published a companion report called, “Call to Action”: A science advisory from the AHA. In this overview, we will discuss briefly the work of SASAT, and present our views with a global perspective.

Keywords: Metabolic diseases, South Asians, vascular diseases, visceral adiposity

How to cite this article:
R Rao GH. Diabetes and cardiovascular disease in South Asians: A global perspective. J Clin Prev Cardiol 2018;7:161-7

How to cite this URL:
R Rao GH. Diabetes and cardiovascular disease in South Asians: A global perspective. J Clin Prev Cardiol [serial online] 2018 [cited 2023 Mar 29];7:161-7. Available from: https://www.jcpconline.org/text.asp?2018/7/4/161/243256

Introduction

In a recent issue of the Journal CIRCULATION, the American Heart Association (AHA), has published a Scientific Statement, about the “Atherosclerotic Cardiovascular Disease in South Asians in the United States: Epidemiology, Risk Factors, and Treatments: A Scientific Statement from the AHA.”^[1] Circulation. 2018; CIR.0000000000000580. This article is put together by Dr Volgman and associates, on behalf of the various Councils of AHA. In the abstract to this article they write, “Although native South Asians share genetic and cultural risk factors with South Asians abroad, South Asians in the United States, differ in socioeconomic status, education, healthcare behaviors, attitudes, and health insurance, which can affect their risk and the treatment and outcomes of atherosclerotic cardiovascular disease (ASCVD).” They also report that South Asians have a higher proportional mortality rates from ASCVD compared with other Asian groups and non-Hispanic whites. Although, the article has over 325 references, I was surprised to see, that they do not mention any of our work done on this subject, for the last three decades. Having said that, I urge all the readers interested in this topic, to refer to this seminal scientific statement of AHA, as well as the complimentary article by Dr. Latha Palaniappan, titled, “Call to Action: Cardiovascular Disease in Asian Americans.”^[2] After reading these articles, I decided to write a “mini review” with a historical perspective, expressing my point of view, as the founder, CEO of South Asian Society on Atherosclerosis and Thrombosis (SASAT).^[3],[4] I was invited by the Government of India, under a unique United Nations Development Program called, Transfer of Knowledge Through Expatriate Nationals in 1990. My application was sponsored by the pioneer Cardiologist, Dr. Khalilullah, the then Director of G. B. Pant Hospital, New Delhi. I came to India under this program, 3 years in a row and visited major heart specialty hospitals in the country. During these visits, I realized the fact, that Indians, in general, had a very high incidence of coronary artery disease (CAD). Given this observation, to create awareness, develop educational and preventive strategies, I started a professional society; SASAT at the University of Minnesota in 1993.^[3],[4]

We published our first article on the topic in the Indian Heart Journal the same year.^[5] By this time, Dr. Mckeigue et al. at the Epidemiology Unit, London School of Hygiene and Tropical Medicine, UK, had reviewed this topic and identified that central abdominal obesity, insulin resistance, and diabetes as risk factors for high incidence of CVD.^{[5],[6],[7],[8]} In an editorial in the British Heart Journal, Prof. Mckeigue writes, that high rates of CAD in people of South Asian origin, were first reported from Singapore, South Africa, and Trinidad in the 1950s^[7],[8] One of these articles, was coauthored by Dr. Bela Shah of Indian Council of Medical Research, and in my opinion, these articles were one of the first articles, to identify the importance of insulin resistance, visceral fat, and diabetes, as the risks contributing for excess CVD in this ethnic group.^[6] We debated this issue during the SASAT meetings, in 1994 (Mumbai), 1996 (Bengaluru), and in 2000 (New Delhi). We published our first book on the subject in 2001.^[9] In the introduction of this book I wrote, “Studies done in Africa, New Zealand, Singapore, Malaysia, Fiji, United Kingdom and the USA, have revealed a high incidence of CAD, in men and women of South Asian origin, compared to other ethnic groups. Since the time we started our professional society in 1993, we have organized international conferences on this topic in India every other year, and in 2010, in Amsterdam, The Netherlands, with the faculty from Harvard University. SASAT organized half-day conferences in collaboration with the International Union of Angiology at Lisbon, Portugal (2006), Athens, Greece (2008), Buenos Aires, Argentina (2010), Prague, Czech Republic (2012), Sydney, and Australia (2014). In view of the fact, that SASAT was affiliated with the North American Thrombosis Forum at the Harvard University and the International Union of Angiology, France, we were able to develop active collaboration with National and International experts all over the world, in the field of thrombosis research. Under the aegis of SASAT, we published several books related to the topic of our interest.^{[9],[10],[11],[12]}

The purpose of this minireview is not to catalog achievement of SASAT in the last few decades, but to highlight the earlier findings on this very important topic of excess diabetes and CVD burden in South Asians, living in India and abroad.^[8] Since the recent Scientific Statement of AHA has done a marvelous job of analyzing the risks associated with atherosclerotic disease in South Asians living in the USA, I will reproduce the top ten things one should know according to the AHA.

Top Ten Things to Know: Atherosclerotic Cardiovascular Disease in South Asians in the United States: Epidemiology, Risk Factors, and Treatments

(https://professional.heart.org/idc/groups/ahamah-public/@wcm/@sop/@smd/documentsdownloadable/ucm_501320.pdf)

South Asians (from Bangladesh, Bhutan, India, the Maldives, Nepal, Pakistan, Sri Lanka) comprise one-quarter of the world's population and are one of the fastest growing ethnic groups in the United States. South Asians have higher mortality rates from ASCVD compared to other Asian groups and non-Hispanic whites, in contrast to the finding that Asian Americans (Asian Indian, Chinese, Filipino, Japanese, Korean, and Vietnamese) aggregated as a group is at lower risk of ASCVD, largely due to the lower risk observed in East Asian populations
The South Asian population is not only diverse with regard to regional and religious practices but also with many discrete spoken and written languages. Although native South Asians share genetic and cultural risk factors with South Asians abroad, South Asians in the US can differ in socioeconomic status, education, healthcare behaviors, attitudes and health insurance, which in turn can affect their risk, treatment, and outcomes of ASCVD
The goal of this AHA statement is to review the scientific literature relevant to the South Asian population living in the United States regarding demographics and risk factors, health behaviors, interventions including physical activity, diet, medications, and community strategies
Ethnicity is known to account in part for interindividual variability in the pharmacodynamics and pharmacokinetics of medications including cardiometabolic drugs. These differences translate into variability in efficacy and side effect profiles between ethnic subgroups. While clinical factors such as diet, concomitant medications, and age are partially related to this variability, a significant proportion can be related to the underlying genetic differences between ethnic subgroups in drug metabolism pattern
Genetic variants in pharmacokinetic pathways are some of the most common pharmacogenetic effects and many show differences across ethnic subgroups, including South Asians. Genetic polymorphisms in key proteins can reside in one of four key pathways related to drug effects: Pharmacodynamic (affecting interaction between the drug and its target), those related to the disease process (i.e., not directly affecting drug, but affecting the underlying disease process, which then modifies the drug effect), and off-target pathways (i.e., idiosyncratic responses)
In an effort to describe the collective experience and provide structure and guidance for cardiology practitioners and healthcare providers serving the South Asian population in the US, this Scientific Statement focuses on how ASCVD risk factors affect the South Asian population to make recommendations for clinical strategies to reduce disease and directions for future research to reduce ASCVD in this population
There is a great need for dedicated pharmacogenetics studies in South Asians. With the known clear differences in allele frequencies of drug metabolizing enzymes and other key proteins affecting drug response, efforts to provide a more personalized approach to choosing the right medication and right dose for South Asian populations will require more careful collection of ethnicity information including differentiating between South and East Asians, and evaluating whether underlying genetic allele frequency differences translate into clinically relevant and actionable differences
From a population perspective, it is imperative that the health needs of US South Asians are critically examined in order to: (1) ensure culturally appropriate medical and health services; (2) address a variety of serious health conditions they face; (3) create informed policy decisions; and (4) improve current and future clinical research in this race/ethnic minority group
Future studies should focus on increasing representation of South Asians in clinical trials and elucidating genetic and pharmacogenetic differences specific to South Asians, to enhance precision medicine efforts
Community strategies in limited settings have been successful to date and may be adopted in a more widespread manner to lower disease risks among South Asians. At the individual level, concerted effort should be made with regard to the healthcare providers and nonphysician providers (nurse practitioners and physician assistants) that frequently deliver primary care to patients. Clinicians must demonstrate “cultural competency” not only when it comes to understanding the increased risk of ASCVD in South Asian patients, but more importantly when making recommendations on diet and lifestyle modification.

Discussion

South Asians (Indians, Pakistanis, Bangladeshis, and Sri Lankans) have very high incidence of cardiometabolic disorders (CMDs), such as atherosclerosis, hypertension, central abdominal obesity, metabolic syndrome, type-2 diabetes, CAD, and stroke.^[1],[2],[3] According to World Diabetes Federation, currently, we have over 75 million diabetics and an equal number of prediabetics. India and China were in race for the first place in the number of diabetics and according to recent reports China has taken the number one spot with over 114 million diabetics. In spite of the fact, that large numbers of individuals are at risk, according to reliable sources, 50%–70% of the subjects in China and 30%–80% of the individuals in India, are not diagnosed and are therefore left untreated.^[13] This is to a large extent due, to lack of public awareness and limited opportunities for diagnosis. World Health Organization prediction of losses in national income for China exceeds USD378 billion, and for India USD237 billion (www.cadiresearch.org).

According to the noncommunicable risk factor collaboration (NCD-RisC), since 1980, the incidence of obesity has increased by 2-fold, and diabetes by 4-fold.^[14],[15] According to these experts, no country has reversed this trend in the increase of these epidemics. Chances of achieving the Millennium Development Goals (MDG), set by the United Nations, of arresting the increase in the incidence of these diseases at 2025 to the level of 2020, is next to nothing. How did we reach this disastrous public health tragedy worldwide? What can be done about it? Who is going to do it? These questions are begging for answers and action plans. In the China National Plan for Noncommunicable Disease Prevention and Treatment (2012–2015), the Chinese Government proposed use of public measures, multisectoral collaborations, and social mobilization to create a health-enabling environment and to reform the healthcare system. A search on the Internet gives very little information on what exactly are India's National Plan, for noncommunicable disease prevention and treatment.

A blog “UGEC VIEWPOINTS” dated July 19, 2016, by Kroll and Krass, of the University of Cologne, Germany, has an article titled, “noncommunicable disease in urban India: Challenges for public health”. The authors discuss various problems associated with this growing public health problem (ugecviewpoints.wordpress.com/2016/07/19/non). Of course, the authors quote the work of many India scientists, researchers and clinicians; however, there is really not very much about what the Government of India is doing, to combat these diseases. As we have mentioned in many of our earlier articles, India is probably one of the few countries, which has no national platform, to address the issues related to the cardiometabolic diseases. In the absence of such a professional platform, who has to address the pressing issues related to the healthcare burden of the twin epidemics of obesity and CVDs? According to the authors of this report, the WHO has identified six objectives to fight NCDs: (1) raising priority on prevention and control, (2) strengthening national capacity for NCD control, (3) reducing modifiable risk factors, 4) strengthening health systems, (5) promoting research, and (6) monitoring trends and determinants of NCDs and evaluating progress in prevention and control. This is the equivalent of MDG of the United Nations (www.un.org/millenniumgoals). According to the NCD risk task force, no country has reversed the trend in the increase in the incidence of obesity and diabetes, and chances of achieving MDG are minimum. It takes lot more efforts than passing resolutions at the National and International level.

It is well recognized, that robust management of modifiable risks, will reduce the morbidity and mortality related to, cardiovascular and cerebrovascular diseases. According to Drs. Meena Shah and Abhimanyu Garg of the University of Texas (UT Southwestern Medical Center), nutrient-deficient diet consumed by the South Asians living in the USA seems to be the key contributor for the excess incidence of diabetes. They write in their report that, “This is the first study, that thoroughly compared both the macronutrient and micronutrient intakes in South Asians with and without Type-2 diabetes, using an objective measure – a 3-day dietary assessment method, that included images of all foods consumed,” according to Dr. Abhimanyu Garg, Professor of Internal Medicine and senior author of the study in Diabetes Research and Clinical Practice.^[16] If this is true for the South Asians living in the USA, what about those living abroad or even those living in India? Just about everything you buy in food stores in the USA, to some extent even the drinking water, claims to have micronutrients. Discussion of an ideal diet is the most difficult topic and that too if we want to plan an ideal diet for South Asians.^{[16],[17],[18]} I have no idea as to whether or not such a study has been done in India and to evaluate the effect of different diets on the incidence or prevalence of cardiometabolic diseases.^[16],[17] India Heart Study sponsored by SASAT under the leadership of Dr Rajeev Gupta of Jaipur did a 21-State lifestyle study.^[19] They found that coronary heart disease (CHD) mortality was greater in south India while stroke was more common in the Eastern Indian states. CHD prevalence was higher in urban Indian populations, while stroke mortality was similar in urban and rural regions. They concluded that the common modifiable risk factors account for more than 90% of the incidence of myocardial infarctions and stroke. SASAT also sponsored another study on the lifestyle differences if any, between the local residents and migrant Tibetans in Ladakh valley of Jammu and Kashmir, as a bilateral collaboration between cardiorenal Society of America and SASAT India.

In the early 1990s, we took a delegation from the University of Minnesota to the World Health Organization (WHO), to present a case for reducing, reversing, or preventing, fetal origin of adult diseases. I was the leader of this delegation and the principle investigator of the proposed studies. In our team, we had one neonatologist (University of Minnesota), one nutritional biochemist (University of Winnipeg), one pediatric thoracic surgeon, and one preventive cardiologist (Manipal Heart Foundation, Bengaluru), and one WHO consultant (UK). We presented our proposal to Dr Margaret Chan, Director, WHO, as well as to Dr Shanthi Mendis, Chief of NCD Division, WHO. Nothing came out of this effort. On the other hand, recently, I had an opportunity to view a presentation on YouTube, by none other than Dr B. M. Hegde, Ex-Vice Chancellor of Manipal Academy, Manipal, India. In this presentation, he talks about his chance meeting of Chief Minister of Gujarat (Mr. Narendra Modi, current Prime Minister of India) in a flight from (http://deshgujarat.com/2014/04/16/video-of-dr-bm-hegdes-experience-with-modi-is-viral-online) London to Mumbai, and how he explained to the CM, the importance of providing a good meal to the pregnant women, so that they produce healthy children. It seems this suggestion was taken seriously by the CM and the mid-day meal program for pregnant women was initiated in the State of Gujarat. I congratulate both of them. But is this program adequate, to address the problems associated with nutrient-deficient diet, and its contributions to the fetal origin of adult diseases?

Since the time, I started a professional society (SASAT at the University of Minnesota (1993), we have been debating about what is the earliest risk for CMDs, and how we can develop preventive strategies for the observed risks. Just like the pioneering Framingham heart study sponsored by NHLBI and BUSM, at Massachusetts, (www.framinghamheartstudy.org/) the studies at the Mission Hospital Mysore, India, has established a correlation between the low birth weight of the children and an increase in the incidence of cardiometabolic diseases in the “Mysore Cohort.”^[20],[21] In spite of over six decades of research on this topic, very few interventions have been developed to reduce or prevent the conditions that promote fetal origin of adult diseases. Dr. Robert Freishtat et al. from the Children's National Memorial Hospital (CNMH) Washington DC, have described exosomes as “biological tweets” (that is expression in terms of short messages) shed by cells that allow for intercellular communication and alter gene expression.^[22] In their studies, they have demonstrated that adipocytes that exist in large quantities of visceral fat, “tweet” signals that cause downregulation of proteins impacting two key signaling pathways; transforming growth factor-beta and Wnt/β catenin, associated with controlling chronic inflammation and fibrotic diseases throughout the body. Since South Asian phenotype is characterized by increased the presence of visceral fat these observations become very important for exploring their role if any, in the initiation and promotion of CMDs. With this specific goal/objective in mind, we have facilitated bilateral studies between the CNMH and KEM Hospital, Pune. According to an NIH summary, the main basis of the Barker hypothesis is that undernutrition in pregnancy impairs fetal growth or promotes disproportionate fetal growth, and as a trade-off these adaptations that promote survival in adverse conditions, lead to limited physiological functions and development of adult diseases of fetal origin. In view of this observation, it is worth the effort, to develop some nutrition-based novel approaches for intervention of this known phenomenon of disease development due to intrauterine nutritional deficiencies. This problem cannot be solved by just the mid-day meal program developed in one of the States in India as discussed earlier.

In the early stages of the metabolic disease development, inflammation, oxidative stress, endothelial dysfunction, and subclinical atherosclerosis seem to play an important role. Although there is limited work going on in these areas, regarding developing preventive strategies, it is possible to develop some affordable complementary therapies for the modulation of gene expressions. The transcription factor Nrf2 (nuclear factor, erythroid-2-related factor-2, and Nrf-2) for instance, a master regulator of detoxification, anti-oxidant, anti-inflammatory, and other cytoprotective mechanisms, is raised by health promoting factors. This transcription factor activates the transcription of over 500 genes (so-called survival genes) in the human genome, most of which have cytoprotective functions. The most healthful diets such as Mediterranean and Okinawa are rich in Nrf2 raising nutrients. Recent studies, however, have demonstrated that induction of Nrf2 and Ho-1 expression by Protandim (a mixture of five phytochemicals; Ashwagandha, Indian Bacopa, Indian Green Tea, China Milk Thistle, and China Turmeric) is associated with a reduction in oxidative stress and fibrosis, preservation of the right ventricular (RV) microcirculation and RV function.^[23] Studies by the pioneer scientist, professor Joe M McCord and associates on the effect of Protandim on various pathways have shown, significant modulation by Protandim not only of pathways involving antioxidant enzymes but also those related to Colon cancer, cardiovascular disease, and Alzheimer's disease.^[24],[25]

I was to a great extent surprised, when I read this report on Protandim, which is a mixture of five phytochemicals (Ayurvedic Vaidyas will claim them as Ayurvedic Products), used extensively in Ayurvedic and Herbal products developed commercially in India. LifeVantage, a US company has three US patents (7,579,026) for Protandim. What prevents us from developing a variety of herbal preparations that can be tested on their ability to prevent one or more of metabolic risk factors? I am not talking here about the modifiable risk factors listed by the Framingham study. For instance, if we are discussing altered metabolism, and metabolic risks, then inflammation, oxidative stress, endothelial dysfunction, hardening of the arteries, calcification of the vessels as well as pericardium, insulin resistance, elevated blood glucose, subclinical atherosclerosis, excess weight, increased visceral fat, increased subcutaneous fat, altered blood lipids, changes in the microbiome, gene expressions favoring development of metabolic risk factors, altered metabolic and signaling pathways at cellular and molecular levels, can be described as metabolic risk factors. We can put together novel, simple noninvasive technologies, to follow the presence and progress or regression of metabolic risks and their clusters and follow the effect of complimentary therapies on the basis of observation-based outcomes.^{[26],[27],[28]}

During the 1990s, I visited Central Drug Research Institute (CDRI), a premier drug development facility in Lucknow. I told the then Director that I would gladly help them develop simple screening methods for developing antithrombotic, antiplatelet, and antiglycemic drugs. Three decades have passed since that time, and I do not see any programs in place, to develop such categories of drugs. If you search these names on the CDRI site, the answer will be negative. During the process of identifying preventive agents, dietary phytochemicals, which are thought to be safe, have emerged as modulators of key cellular signaling pathways. There seems to be a growing interest in the use of phytochemicals as modulators of multiple cellular pathways to prevent cancer as well as chronic metabolic diseases. In a separate study, Ferguson et al. from University of Newcastle, have demonstrated in a randomized controlled trial that curcumin potentiates cholesterol-lowering effects of phytosterols in hypercholesterolemic individuals.^[29] They concluded that the addition of curcumin (200 mg daily) to phytosterol therapy provides a complimentary cholesterol-lowering effect that is larger than phytosterol therapy alone. Similar to our ideas, they suggest that this type of studies help develop simple functional foods containing active ingredients from different sources.

Western medicine has failed to prevent the increase in the incidence of metabolic disease as it is disease-centric. However, even traditional medicine, which is supposed to be holistic, also has failed to some extent, by not coping up with the progress in the management of chronic diseases. Added to this, in a country like India, where individuals have to spend from personal resources for their healthcare, they go to the clinic only when they are sick. There is a growing interest in developing universal healthcare in several States of India. In our opinion, it should not be just limited to care of the sick but should also address preventive care needs. There is a great opportunity for the development of complementary and alternate medical (CAM) therapies, with the great abundance of herbal medicine and phytochemicals. Having said that, I have to caution the readers, that the majority of CAM studies lack the scientific rigor and much needed clinical evidence that is essential for the approval by the regulatory agencies. Whenever we discuss this topic, there is always a concern about the cost, time, and various hurdles associated with clinical studies with traditional medicine. In the USA, researchers have successfully developed complimentary therapies with drugs or drug combinations, such as Protandim, MitoQ, and NIAGEN without extensive, costly, time-consuming, clinical trials. If we can develop a product that is safe and effective, there are simple ways to develop observation-based clinical evidence, to show the beneficial effect of such preparations on specific metabolic risks or cluster of risks.^[30]

What do we mean by complementary therapies? These are therapies that supplement the standard medical care recommended by the clinicians and not replace them (alternate therapy). Let us briefly review some successful examples. The above-mentioned studies by Joe McCord and associates, using Protandim for reducing or preventing oxidative stress relate injuries, serves as the first example for such a therapeutic modality. Developing such a combination of herbal drugs is no rocket science for the Traditional Medicine Practitioners of India and China. Ridker et al. at the Brigham and Women's Hospital, Boston, Mass., used a monoclonal antibody for alleviating the effect of inflammation in a large clinical study and for the first time, showed that inflammation indeed plays a critical role in the precipitation of acute CVD events.^[31] Scientists from Lancaster University and University of Leeds have shown that an active molecule found in the green tea, epigallocatechin-3-gallate bind to the amyloid fibers of apoA-1 and reduces the vascular plaques.^[32] A few years ago, we demonstrated that green tea from mulberry leaves lowered the postmeal glucose peaks (personal communications). We feel confident with the abundance of herbal medicinal products available we can develop drug combinations, which could effectively act as complimentary therapeutic modalities and provide additional protection to individuals on cardiovascular prophylaxis.

Currently, we do not have the tools and the technologies, to determine the early signs of metabolic risks. In addition, we do not have any proven complimentary therapy to include in the standard care for these diseases. Therefore, we are left with the only proven method that is change in the lifestyle. As part of the 2020 impact goals, the AHA has set out seven ideal health goals; not smoking, maintaining a normal weight, increased physical activity, a healthy diet, normal blood lipids, and a normal fasting glucose.^[33] An analysis of the National Health and Nutritional Examination Survey of the USA showed that individuals who met five of the seven ideal metrics of AHA had a 78% reduction in the hazard ratio for the all-cause mortality. From the INTERHEART study under the leadership of Professor Salim Yusuf, which included 52 countries, it is estimated that modifiable risk factors account 90% of the population attributable risk for heart disease in men and 94% of the risk in women.^[34] However, a recent study by Khera et al. described in New England Journal of Medicine (2016) showed that in four studies with over 55,685 participants, a favorable lifestyle intervention was associated with nearly 50% lower relative risk for CAD than was with unfavorable lifestyle.^[35]

Conclusions

South Asians have very high incidence of metabolic diseases, such as hypertension, visceral adiposity, metabolic syndrome, type-2 diabetes, and vascular diseases. Studies done on this ethnic group, in other countries, have revealed the excess incidence of diabetes and CVDs in South Asians living abroad. A report from the AHA has confirmed these findings and has issued a scientific statement and a scientific advisory. We the members of the SASAT have recognized the existence of this disproportionality of metabolic risks in South Asians and have been working on this problem for the last three decades. Several major studies have demonstrated that death due to cardiovascular disease is on the decline in industrialized nations. The very same studies have noted that in spite of this decline in CVD-related deaths, diabetes-related deaths are on the rise. When considering metabolic diseases, we should keep in mind that several risk factors and clusters of risks factors, influence progress of the disease as well as, development of acute vascular events. Standard of care in majority of the countries is to manage the modifiable risk factors that are well recognized and approved by the care providers. Several early risks such as inflammation, oxidative stress, endothelial dysfunction, hardening of the arteries, and subclinical atherosclerosis are poorly recognized and go untreated for a long period. These observations tempt us to recommend the development of noninvasive diagnostic tools and incorporate complementary therapies in the management of known cardiometabolic risks as well as in the management of the lesser known metabolic risks.

Acknowledgments

SASAT is located at the Division of Clinical and Preventive Cardiology, Medanta Hospital, Gurugram, New Delhi, India. The President of SASAT is Dr Ravi Kasliwal, HOD, Division of clinical and Preventive Cardiology, Medanta Hospital, New Delhi. Author wishes to thank, SASAT and the President of SASAT for the continued support.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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