Coronary Artery Disease in Indians Living Abroad

CAD in Indians living abroad

ABSTRACT

 As an Indian living abroad, I have always wondered at a young age why my cholesterol levels were usually elevated.  Yes, genetics plays a part in our general make up however it does not have to be the causing factor.  Research has shown that our environment has an important role especially when it comes to diet.  The data presented in this paper will show the different ages of the participants, there cholesterol levels, family history of heart disease and their diet.  When compared to other immigrant populations Indians are at a higher risk of coronary artery disease CAD.

CAD in Indians Living Abroad

Coronary artery disease (CAD) remains one of the most significant risk factors associated with myocardial ischemia. Also, it is one of the leading causes of mortality in the United States. As a serious health condition, the treatment of CAD in hospitals is expensive therefore contributing to poor health outcomes. Studies have shown that the prevalence of CAD varies from one race to another. For instance, research has pointed out that Indian Asians living abroad have a higher prevalence of CAD than any other population. With the Asian Indians making almost a fifth of the world population, high CAD prevalence leads to a significant health challenge. As such, this calls for further investigation into the reasons that could contribute to the higher CAD prevalence among the South Asian Americans. Aspects such as the western lifestyle, strong cultural ties, and sedentary lifestyles have been mentioned in a bid to establish a causal relationship. Most Indians living abroad have a higher rate of morbidity caused by coronary artery disease than other immigrant populations.  Indian immigrants and Indians living abroad are more prone to CAD due to a sedentary lifestyle, genetic factors, cultural aspects, and poor dietary choices.

In the US, the prevalence of CAD is at 2.5% compared to 11% in Indians living in India. The rate of CAD among the Indians remains considerably higher even after migrating into the US compared to other racial and ethnic groups. As such, this point out to possible non-modifiable risk factors that inherently exist among the Indians (Ardeshna, Bob-Manuel, Nanda, Sharma, Skelton IV, Skelton, & Khouzam, 2018). The author further intimate that the rate of CAD among Indian Americans is almost three times higher compared to the national average. The rates are not only higher in Indians living in America but also in other countries such as Wales, England, Canada, South Africa, Mauritius, and Qatar among other countries. For instance, Ardeshna et al. (2018) point out that the rate of CAD among the Indian population in the United Kingdom is approximately 2 to 3 times higher than the national average. For one to understand the reasons for the high prevalence of CAD in this population, it is first critical to appreciate the general etiology of the disease.

Some of the common risk factors associated with CAD in any population include hypertension, smoking, diabetes, alcohol, and a lack of physical activity. Dyslipidemia and other psychosocial factors are also known risk factors (Tan, Scott, Panoulas, Sehmi, Zhang, Scott, & Kooner, 2014). Indians and Indians living overseas have several unique risk factors that place them at an increased position to acquire CAD. The first one is the sedentary lifestyle. Research has shown that Indians are less likely to engage in physical exercise compared to whites (Mozumder, 2018). Ardeshna et al. (2018) note that a sedentary lifestyle characterized by a lack of physical exercise leads to obesity. The accumulation of bad fats in the body of these individuals leads to heart diseases such as CAD. Furthermore, diabetes is also a risk factor associated with CAD, as earlier listed. Research by the authors found out that the rate of diabetes among Indian Americans is higher compared to the Americans and the Indians living in India. Other than lifestyle and diabetes, cultural factors could also be attributed to the increasing prevalence of CAD.

As regards culture, Ardeshna et al., (2018) assert that almost 50% of the Indians are vegetarians. However, despite their selective food choices, their rate of CAD is higher compared to other non-vegetarian populations. In justifying their prevalence of CAD despite their dietary choices, the authors say, “This is attributed to the liberal use of high-fat dairy, butter, ghee, cheese and paneer in their everyday meals” (Ardeshna et al., 2018). Other harmful practices, such as reusing cooking oil, remain a major risk factor for the development of CAD. Studies have also shown that Asian Indians eat fewer vegetables and fruits in their diet, a factor that is negatively associated with the increasing prevalence of CAD. Genetic factors are also attributed to the high prevalence of CAD among the Indians living abroad. Genetic aspects are an example of the non-modifiable risk factors associated with the disease. For instance, research shows that many Indians have Lipoprotein (a), a genetically expressed component that increases an individual’s risk of attaining CAD.

Non-biological factors are also major contributors to the high prevalence of CAD among the South Asians living in other countries. In understanding this aspect, it is important to appreciate a concept known as acculturation. Acculturation is defined as the adoption of customs, principles, and beliefs belong to a different group. Some of the strategies used in acculturation include assimilation, integration, marginalization, and separation, among others. Volgman, Palaniappan, Aggarwal, Gupta, Khandelwal, Krishnan, & Shah, (2018) say, “Acculturation in other migrant groups has been shown to be associated with poor health behaviors and higher rates of developing hypertension, DM, obesity, and CAD.” Another critical concept to assess is known as biculturalism. For instance, when it comes to diet, Indians maintain their dietary ways but also remain keen to incorporate the foreign way of eating. The lack of a clear dietary pattern increases their chances of developing obesity. Despite being vegetarians, Indians consume a lot of saturated fats from their tropical oils. In adopting the American culture, they end up over-consuming processed foods, which are also associated with the development of numerous heart diseases (Volgman et al., 2018).

It is, therefore, incumbent upon the physicians and other health workers to regard ethnicity as an important determinant of health. Researchers are continuously uncovering the reasons behind the high rates of heart diseases among the South Asian people. O’Conner (2019) points out body composition as a major risk factor for heart disease among these individuals. Research has found out that most Indians are likely to have excess fats in places that they should not. Some of these areas include organs such as the liver, muscles, and abdomen. The high composition of visceral or ectopic fat implies that Indians are at a greater risk of heart diseases such as CAD.

In conclusion, Indian immigrants and Indians living abroad are more prone to CAD due to a sedentary lifestyle, genetic factors, cultural aspects, and poor dietary choices. First, many Indians living abroad are less likely to engage in physical exercise compared to their native counterparts. Genetically, they contain several components that increase their risk. Indian Asians have a culture that glorifies the consumption of highly saturated fats that leads to many lifestyle diseases. The poor dietary choices contribute to obesity and diabetes, both of which are significant risk factors for CAD.

HYPOTHESIS

Most Indians living abroad have a higher rate of morbidity caused by coronary artery disease than other immigrant populations.  The western lifestyle that Asian Indians have adopted are playing a role in their genetics thereby causing CAD.

METHOD

Participants

There were 17 participants of which 12 were female and 5 were male.  Participants’ age range were 18 to over 46. To compare Indians living abroad to other immigrant populations the ethnicity used was inclusive of all the major Indian ethnicities.  The information was gathered using the Indian population around me, like family, friends, temple, school and work.  Some participants were given a paper survey and some data was collected over the phone.

Materials and Procedure

A survey with the following questions was provided to the participants via paper and over the telephone.  This data was compared to other immigrant populations living abroad.

The following questions were provided to the participants

1. Age range

      18-25, 25-35, 35-45 and over 46

1. Gender

      Male, Female, other

1. What part of the US do you live in?
2. Which Indian ethnic group do you belong to?

      Assamese, Bengali, Gujarati, Hindi, Kashmiri, Konkani, Marathi and Punjabi

      Kannadiga, Malayali, Tulu, Tamil, and Telugu

1. What is your LDL “bad” cholesterol?

      Less than 100 mg/dL (optimal)

      100 to 129 mg/dL (near optimal)

      130 to 159 mg/dL (borderline high)

      160 to 189 mg/dL (high)

      190 mg/dL or more (very high)

1. What is your HDL ("good" - higher is better) cholesterol?

      Less than 35 mg/dL (very low)

      35 to 39 mg/dL (low)

      40 to 44 mg/dL (low normal)

      45 to 49 mg/dL (normal)

      50 to 59 mg/dL (high normal)

      60 mg/dL or more (high optimal)

1. Does anyone in your immediate family (mother, father, sister, brother) have Cholesterol?

      Yes, No or Maybe

1. Is there a history of high blood pressure in the family?

      Yes, No or Maybe

1. What is your BMI?

      Below 18.5 – Underweight

      18.5 – 24.9 - Normal or Healthy Weight

      25.0 – 29.9 – Overweight

      30.0 and Above – Obese

      Unsure

1. Which most closely describes your diet?

      Mostly high-fat foods (fatty cuts of meat, whole-milk products, eggs); white bread/rice/pasta; fast or processed foods; baked goods

      Some high-fat foods, but trying to eat lean meats and low-fat dairy products; whole grains; fruits and vegetables

      Mostly low-fat foods, or vegan or vegetarian diet

Data collected

Based on the data collected from the participants about half are borderline high, a quarter have high LDL levels and the last quarter are at near optimal levels. According to the American Heart Association LDL levels should be less than 100 mg/dL.  Per this data I was unable to find one participant with optimal LDL levels.  As shown in the chart below HDL levels do not correlate with LDL levels especially when it comes to heart disease in the South Asian community.  Of the 17 responses a little over 50% have normal HDL levels, about 25% are high normal and a little under 20% have low normal levels.  When compared to other ethnic groups South Asians had the highest prevalence of CAD when compared to Europeans and Chinese who immigrated to Canada (Anand et al., 2000).  When LDL levels are high to counteract plaque build up HDL levels must be optimal.  However in the South Asian community although LDL levels are high and HDL levels are optimal the risk of CAD is still high.  In the chart below labeled “Risk factors in other immigrant groups” one can see a big difference among Indians, Europeans and Chinese groups that myocardial, coronary heart disease and any cardiovascular disease is high among Indian immigrants.  A surprising factor were the participant’s BMI, which were normal per the data collected.  About 80% were at a normal or healthy weight and about 20% were overweight.

Risk factors in other immigrant groups

DISCUSSION

As shown in the results from the data collected and when compared to other immigrant populations, Indians are at a higher risk of developing CAD. As stated, before genetics is not the only factor involved, environmental factors influenced by an individual’s behavior can have an effect on BMI, cholesterol levels and blood pressure (Henkhaus et al., 2011).  Although most Indians have a vegetarian diet, it’s a diet that is mostly carbohydrates which I can attest too.  From the research done and data collected this can also be a factor affecting Indian’s CAD mortality rate.  It is not fully understood what factors are affecting the Indian immigrant population as more tests needs to be performed.

References

• Ardeshna, D. R., Bob-Manuel, T., Nanda, A., Sharma, A., Skelton IV, W. P., Skelton, M., & Khouzam, R. N. (2018). Asian-Indians: a review of coronary artery disease in this understudied cohort in the United States. Annals of translational medicine, 6(1).
• Mozumder, S.G. (2018). AHA says South Asian Americans at high risk of heart disease. Indian-Americans
• O’Connor, A. (2019). Why Do South Asians Have Such High Rates of Heart Disease? The New York Times
• Tan, S. T., Scott, W., Panoulas, V., Sehmi, J., Zhang, W., Scott, J. ... & Kooner, J. S. (2014). Coronary heart disease in Indian Asians. Global Cardiology Science and Practice, 2014(1), 4.
• Volgman, A. S., Palaniappan, L. S., Aggarwal, N. T., Gupta, M., Khandelwal, A., Krishnan, A. V. ... & Shah, S. H. (2018). Atherosclerotic cardiovascular disease in South Asians in the United States: epidemiology, risk factors, and treatments: a scientific statement from the American Heart Association. Circulation, 138(1), e1-e34.
• Henkhaus, R. S., Dodani, S., Manzardo, A. M., & Butler, M. G. (2011). APOA1 gene polymorphisms in the South Asian immigrant population in the United States. Indian Journal of Human Genetics, 17(3), 194–200