Review articleEpidemiology, risk factors, and opportunities for prevention of cardiovascular disease in individuals of South Asian ethnicity living in Europe
Graphical abstract
Introduction
According to the 2016 European Society of Cardiology (ESC) guidelines for cardiovascular disease (CVD) prevention, first-generation South Asian (SA) immigrants living in Europe should have their Systematic Coronary Risk Evaluation (SCORE) estimates multiplied by a 1.4 correction factor [1]. Similarly, the American College of Cardiology and American Heart Association list SA ethnicity as a “risk enhancer” for 10-year CVD risk estimations [2].
These recommendations are the result of a wealth of research studies published since the 1950s, conducted in South Asia as well as in groups of SA immigrants living across the globe, which have demonstrated a higher cardiovascular and particularly coronary heart disease (CHD) risk in SA individuals compared to most other racial/ethnic groups [[3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25]].
In Europe, SAs represent one of the largest, fastest growing minority groups in a number of countries, including the United Kingdom (UK), Italy, Germany, France, Spain, Greece, Switzerland, the Scandinavian countries, and the Netherlands [26]. Research in these countries has consistently described individuals of SA ethnicity as having a higher burden of type 2 diabetes (T2D) and CHD compared to other local racial/ethnic groups [[11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25]]. Some studies have also demonstrated a higher risk of stroke in SAs compared to local Whites [[12], [13], [14],18,22]. Despite this large body of evidence and recent calls for action [27,28], SA-specific health promotion and preventive interventions are scarce in most European countries – as well as at the European Union level.
The aim of this narrative review is to increase awareness among clinicians and healthcare authorities of the importance of CVD in SA individuals living in Europe, as well as the need for aggressive preventive interventions targeting this group – particularly first-generation immigrants. For this purpose, we review European studies on the epidemiology of CVD in SAs, and discuss opportunities for prevention tailored to their unique risk profile. We also evaluate features that may maximise the effectiveness of those interventions in a context of cultural barriers. Finally, we evaluate knowledge gaps, currently available risk stratification tools such as QRISK-3, and future directions in this important field.
Section snippets
Demography of SA immigration to Europe
As of 2018, South Asia (i.e., India, Pakistan, Bangladesh, Sri Lanka, Nepal, Bhutan, and Maldives) accounted for 23% of the world's population – approximately 1,750 million men and women [29]. In addition, an estimated 20 million SAs live in other diaspora countries [30]. This includes large communities in the United States (US), Canada, the Middle East, Malaysia, South Africa, Australia, and several European countries, among others.
According to EuroStat, more than 2.5 million first-generation
Epidemiology of CVD in SAs living in Europe
A large number of studies have evaluated the importance of CVD and particularly CHD in individuals of SA ancestry. These include studies in South Asia, which have shown higher event and mortality rates than those reported in Western countries [3,4]; multinational studies such as INTERHEART or Prospective Urban Rural Epidemiology (PURE), in which SA countries lead the incidence of CHD events worldwide, occurring almost a decade earlier than in other world regions [5,6]; studies in non-European
Why are SAs living in Europe at higher cardiovascular risk?
Although many epidemiological studies have considered SAs to be a single, homogeneous group, the SA ethnicity is actually highly heterogeneous [35]. This may explain why almost every known cardiovascular risk factor has been described as potentially relevant to SAs, as well as some inconsistent observations regarding the importance of specific risk factors across studies. Additional heterogeneity must also be recognised within Europe, the UK accumulating several generations of progressively
SAs in European CVD prevention guidelines
The size and growth of the SA population in some European regions represents a challenge for local healthcare systems which were designed for the care of lower-CVD-risk populations [1]. It is therefore crucial to develop tailored health promotion and preventive interventions focused specifically on these individuals. Such interventions are likely not only to have large health benefits, but also to contribute to the sustainability of local healthcare systems.
Nonetheless, SA-specific
Opportunities for tailored CVD prevention interventions for SAs in Europe
The current scarcity of available guidance highlights the need for further national- and European-level efforts. Below we discuss some proposed multi-level, tailored interventions (Fig. 3, in green). Although most of them are likely to be relevant to all racial/ethnic groups living in Europe, they may be particularly beneficial for SAs provided their unique risk profile. In a context of limited resources for public health interventions, governments may want to prioritise some of these
Maximising the effectiveness of preventive efforts in SAs
Interventions may face important cultural barriers in SA communities, particularly among first-generation immigrants, and some adaptations may be necessary. Indeed, lifestyle change intervention studies in SAs living in industrialised countries have so far yielded modest results [77].
First, interventions should be holistic and culturally adapted for SAs, making them understandable, acceptable, and relevant to their context and income. For this purpose, cultural mediators and community leaders
Next steps
Despite a large body of published literature, several knowledge gaps still remain in SAs living in Europe (Table 3). These include a better characterization of the potential genetic and epigenetic factors underlying the very high prevalence of diabetes and atherogenic dyslipidemia observed in SAs; as well as of the potential role —if any— of consanguineous marriages, which are highly frequent in some SA communities [84,85]. A better characterization is also needed of the anatomical, cultural,
Conclusions
SAs living in Europe represent a large, growing population. A wealth of European epidemiological studies have shown SA immigrants to be at high risk of T2D, early coronary atherosclerosis, and CVD. Although further studies are warranted, there is currently conclusive evidence of the need for effective prevention interventions targeting this group. These should pay special attention to the promotion of regular physical activity and healthy diets, as well as to the screening and aggressive
Conflicts of interest
The authors declared they do not have anything to disclose regarding conflict of interest with respect to this manuscript.
Author contributions
All authors participated in the conception of the manuscript, and contributed to the preliminary manuscript outline. MC-A led the drafting, and UB helped prepare the figures. All authors revised the manuscript critically for important intellectual content.
Acknowledgments
The authors would like to thank Drs. Josepa Mauri, Montse Cleries, Fernando García, and Emili Vela for their critical review and valuable input on the present manuscript.
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