Larger your waist line shorter is your life span!

Indian Diaspora in the U.S and Cardio-Metabolic Syndrome

Purushotham Kotha. M.D., FACC


The IDEA study did it! International Day for Evaluating Abdominal obesity study looked at 168,000 patients in 67 countries all around the World and reconfirmed the previous observations that abdominal obesity (visceral fat) is convincingly the most important, independent and universal predictor of cardiometabolic risk in men and women of all ages, nationality and ethnicity. Many studies over the last half century reported higher cardiovascular and all cause mortality in people with Cardio-Metabolic syndrome and its high prevalence in Asian Indians.

Why Indians should be Concerned?

Because we are in the midst of a Cardiometabolic Epidemic!

High incidence of CardioMetabolic Syndrome with larger waist line(visceral fat), with or without Diabetes and with underlying excess of Insulin (Insulin Resistance), small dense LDL, remnant particles, proinflammatory, procoagulant factors contributes to the very high incidence of heart disease and all cause mortality in Indians.

Coronary Heart Disease is 3-4 times more common in Asian Indians compared to other populations.

The NIH program ‘Healthy People 2010’ designated the Asian Indian Immigrant Population in the United States as a “high risk group for heart disease”.

The World Health Report of 2002 projects Cardio Vascular Disease (CVD=heart disease and stroke) to be the largest cause of death and disability in India by 2020.

The World Health Organization estimates that about 60% of the World’s heart disease patients will be Indian by year 2010.

CVD is the largest cause of death in women. Compared to Whites, Blacks and Latinos Indian women suffered the highest all cause mortality and highest cardiovascular mortality in the U.S.

AAPI/RICADIA sponsored first randomized National DIA (Diabetes in Indian Americans) study showed that the prevalence of Metabolic Syndrome and Diabetes in Indian Americans is even higher than that reported by earlier, non-randomized, smaller studies.

What is CardioMetabolic Syndrome!

Metabolic syndrome is considered a "multiplex" cardiovascular risk factor, in that each component of the cluster of abnormalities is a risk factor in its own right. Introduced as Syndrome X by Reaven in 1988 and also termed insulin resistance syndrome, metabolic syndrome is recognized clinically by the findings of abdominal obesity, elevated triglycerides, atherogenic dyslipidemia – ie, low levels of high-density lipoprotein cholesterol (HDL-C), elevated blood pressure, high blood glucose and/or insulin resistance. Metabolic syndrome is also characterized by a prothromobotic state and a proinflammatory state.
With regard to the increase in cardiovascular risk associated with metabolic syndrome, the whole far exceeds the sum of its parts. For instance, the 4-year risk of incident myocardial infarction (MI) among men ages 40-65 in the Prospective Cardiovascular Münster (PROCAM) study was increased 2.5 times in the presence of either type 2 diabetes or hypertension; 8 times in the presence of both factors; and 19 times in the presence of both factors plus an abnormal lipid profile.
Both the proinflammatory and prothrombotic states of metabolic syndrome derive largely from the secretory activity of adipose tissue, particularly intra-abdominal or visceral fat. Contrary to the former concept of fat as an inert tissue mass, adipocytes are increasingly being recognized as secretory entities. Cytokines and other inflammatory markers or signaling molecules released by adipocytes -- termed "adipokines"--include leptin, tumor necrosis factor alpha (TNF-alpha), interleukin-6, resistin, and adiponectin. Adiponectin levels are inversely related to fasting plasma insulin and glucose levels. Weight loss by obese individuals has been associated with increased adiponectin levels.
Populations that are genetically susceptible to metabolic syndrome include South Asians (Indian subcontinent), Southeast Asians (eg, Polynesian, Japanese), African-Americans (particularly African-American women), Mexicans, and Native Americans (eg, Pima Indians).

The age-adjusted prevalence of CHD in Caucasians is highest in patients with both type 2 diabetes and metabolic syndrome (19.2%), followed by patients with metabolic syndrome but not type 2 diabetes (13.9%).
Notably, the prevalence of CHD is no higher in patients with type 2 diabetes but without metabolic syndrome than in individuals who have neither type 2 diabetes nor metabolic syndrome.

Cardiovascular disease mortality in the metabolic syndrome.


The Diabetes in Indian Americans study showed much higher age-adjusted prevalence of Metabolic Syndrome of 26.9% by the original ATP III criteria, 32.7% by the modified ATP III criteria and 38.2% by the IDF criteria.





Life habits-Diet, Exercise or their lack of play a major role in unmasking the genetic predisposition to CardioMetabolic Syndrome in Indians.


Life Habit factors unique to Asian Indians contributing to higher CardioMetabolic risk!

Being sedentary- Couch Potato!
Meager consumption of fresh fruits and fresh vegetables
Excess consumption of sweets, jaggery, dairy products and fried foods
Re-heating edible oils for cooking over and over!
High carbohydrate and low fiber diets.


Remedies to prevent and reverse Cardio- Metabolic Syndrome!

Exercise for at least 30 minutes everyday; children need to exercise 60 to 90 minutes a day!

In general 10% weight loss is associated with 30% loss in adipose tissue.

Nutrition

Restrict total calories, especially from simple carbohydrates and consume more calories from mono, poly and Omega 3 fats.

Bake and Boil! Minimize frying; Stop deep frying, Stop re-heating the edible oils for cooking

Eat at least five servings (cups) each of fresh fruits and vegetables a day. Eat whole/multi grains, legumes, lentils, variety of nuts, low fat milk products, soy milk and tofu.

Balance your Omega 3 and Omega 6 Oils!
Olive oil, Canola oil, Nuts and Avocado are rich in Monounsaturated (good) fats

Flax seed, oily fish like wild salmon are rich in Omega 3 (heart protection)

Sun flower oil, safflower oil and soy bean oil are rich in healthy polyunsaturated fatty acids. When hydrogenated become Trans Fats which are highly atherogenic.

Avoid sugars, white flour, polished rice, Colas

Avoid Trans Fats crispy and crunchy, fried and fast foods, desserts; cookies, cakes, pastries! Lower Salt intake (pickles, chips, pretzels!)

Practice Yoga, meditation

Know Your Numbers!

Consensus Target Numbers to prevent CAD in Indians developed by CAD Committee of AAPI

Waist circumference (most significant component of MetS) < 35 inches in men; in women <31 inches
Unlike <40 in western men and < 35 inches in Western women



Non HDL Cholesterol < 130 mg/dl; in Diabetics <100 mg/dl (Total Cholesterol - HDL Cholesterol = Non HDL Cholesterol)


HDL Cholesterol > 40 mg/dl in men; in women > 50 mg/dl

Triglycerides < 140 mg/dl

Hemoglobin A1c should be less than 6.5

Blood Pressure < 130/ 80 mm; in Diabetics <120/70 mm
Quit Smoking

LDL Cholesterol < 100 mg/dl; in Diabetics & known CAD <70 mg/ dl

Exercise for more than 30 minutes every day, for children 60-90 minutes every day

Take medications under your Physician’s supervision to achieve target numbers.

The abdominal adipose distribution ("apple shape") exerts a stronger adverse cardiovascular risk than the gluteofemoral distribution ("pear shape"). Abdominal adiposity is measured via waist circumference at the umbilicus or as the waist/hip ratio (WHR): waist circumference at the umbilicus divided by the hips' circumference at their widest point.


For more info please visit http://www.aapiusa.org/resources/nutrition.aspx and www.heartsmart.info

e-mail pkotha@heartsmart.info