Elsevier

Atherosclerosis

Volume 286, July 2019, Pages 105-113
Atherosclerosis

Review article
Epidemiology, risk factors, and opportunities for prevention of cardiovascular disease in individuals of South Asian ethnicity living in Europe

https://doi.org/10.1016/j.atherosclerosis.2019.05.014Get rights and content

Highlights

  • South Asian (SA) individuals represent a large, growing population in a number of European countries.

  • SAs living in Europe are at increased risk of developing diabetes, atherogenic dyslipidaemia, and coronary heart disease.

  • SA-specific cardiovascular health promotion and preventive interventions are currently scarce in most European countries.

  • In this review, we aim to increase awareness within Europe of the public health importance of cardiovascular disease in SAs.

  • We discuss potential opportunities for multi-level, targeted, tailored cardiovascular prevention strategies.

Abstract

South Asian (SA) individuals represent a large, growing population in a number of European countries. These individuals, particularly first-generation SA immigrants, are at higher risk of developing type 2 diabetes, atherogenic dyslipidaemia, and coronary heart disease than most other racial/ethnic groups living in Europe. SAs also have an increased risk of stroke compared to European-born individuals. Despite a large body of conclusive evidence, SA-specific cardiovascular health promotion and preventive interventions are currently scarce in most European countries, as well as at the European Union level. In this narrative review, we aim to increase awareness among clinicians and healthcare authorities of the public health importance of cardiovascular disease among SAs living in Europe, as well as the need for tailored interventions targeting this group – particularly, in countries where SA immigration is a recent phenomenon. To this purpose, we review key studies on the epidemiology and risk factors of cardiovascular disease in SAs living in the United Kingdom, Italy, Spain, Denmark, Norway, Sweden, and other European countries. Building on these, we discuss potential opportunities for multi-level, targeted, tailored cardiovascular prevention strategies. Because lifestyle interventions often face important cultural barriers in SAs, particularly for first-generation immigrants; we also discuss features that may help maximise the effectiveness of those interventions. Finally, we evaluate knowledge gaps, currently available risk stratification tools such as QRISK-3, and future directions in this important field.

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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