Advertisement

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

  • Miguel Cainzos-Achirica
    Correspondence
    Corresponding author. Hospital Universitari de Bellvitge, Department of Cardiology, 19th Floor, Feixa Llarga s/n, 08907, Hospitalet de Llobregat, Barcelona, Spain.
    Affiliations
    Department of Cardiology, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain

    Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain

    Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins Medical Institutions, Baltimore, MD, USA

    School of Medicine and Health Sciences, Universitat Internacional de Catalunya, Sant Cugat Del Vallès, Barcelona, Spain
    Search for articles by this author
  • Ugo Fedeli
    Affiliations
    Department of Epidemiology, Azienda Zero, Veneto Region, Italy
    Search for articles by this author
  • Naveed Sattar
    Affiliations
    Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland, UK
    Search for articles by this author
  • Charles Agyemang
    Affiliations
    Department of Public Health, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
    Search for articles by this author
  • Anne K. Jenum
    Affiliations
    General Practice Research Unit (AFE), Department of General Practice, University of Oslo, Institute of Health and Society, Norway
    Search for articles by this author
  • John W. McEvoy
    Affiliations
    Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins Medical Institutions, Baltimore, MD, USA

    National University of Ireland and National Institute for Preventive Cardiology, Galway, Ireland

    Division of Cardiology, Department of Medicine, Saolta University Healthcare Group, University College Hospital Galway, Galway, Ireland
    Search for articles by this author
  • Jack D. Murphy
    Affiliations
    Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
    Search for articles by this author
  • Carlos Brotons
    Affiliations
    Casernes Primary Care Center, Àmbit D'Atenció Primària Barcelona Ciutat, Barcelona, Spain
    Search for articles by this author
  • Roberto Elosua
    Affiliations
    Cardiovascular Epidemiology and Genetics, Mar Institute of Medical Research, Barcelona, Spain

    Biomedical Research Network in Cardiovascular Diseases (CIBERCV), Barcelona, Spain

    School of Medicine, Universitat de Vic-Central de Catalunya, Vic, Spain
    Search for articles by this author
  • Usama Bilal
    Affiliations
    Urban Health Collaborative, Drexel Dornsife School of Public Health, Philadelphia, PA, USA
    Search for articles by this author
  • Alka M. Kanaya
    Affiliations
    University of California, San Francisco, CA, USA
    Search for articles by this author
  • Namratha R. Kandula
    Affiliations
    Northwestern University, Departments of Medicine and Preventive Medicine, Chicago, IL, USA
    Search for articles by this author
  • Pablo Martinez-Amezcua
    Affiliations
    Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
    Search for articles by this author
  • Josep Comin-Colet
    Affiliations
    Department of Cardiology, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain

    Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain

    School of Medicine, University of Barcelona, Barcelona, Spain
    Search for articles by this author
  • Xavier Pinto
    Affiliations
    School of Medicine, University of Barcelona, Barcelona, Spain

    Cardiovascular Risk Unit, Department of Internal Medicine, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain

    Biomedical Research Network in Obesity and Nutrition (CIBEROBN), Instituto de Salud Carlos III, Madrid, Spain
    Search for articles by this author

      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.

      Graphical abstract

      Keywords

      Abbreviations:

      AMI (acute myocardial infarction), CHD (coronary heart disease), ESC (European Society of Cardiology), NICE (National Institute for Health and Care Excellence), PURE (Prospective Urban Rural Epidemiology), SA (South Asian), SCORE (Systematic Coronary Risk Evaluation)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Atherosclerosis
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Piepoli M.F.
        • Hoes A.W.
        • Agewall S.
        • Albus C.
        • Brotons C.
        • Catapano A.L.
        • Cooney M.T.
        • Corrà U.
        • Cosyns B.
        • Deaton C.
        • Graham I.
        • Hall M.S.
        • Hobbs F.D.R.
        • Løchen M.L.
        • Löllgen H.
        • Marques-Vidal P.
        • Perk J.
        • Prescott E.
        • Redon J.
        • Richter D.J.
        • Sattar N.
        • Smulders Y.
        • Tiberi M.
        • van der Worp H.B.
        • van Dis I.
        • Verschuren W.M.M.
        • Binno S.
        • ESC Scientific Document Group
        2016 european guidelines on cardiovascular disease prevention in clinical practice: the sixth joint task force of the european society of Cardiology and other societies on cardiovascular disease prevention in clinical practice.
        Eur. Heart J. 2016; 37: 2315-2381
        • Grundy S.M.
        • Stone N.J.
        • Bailey A.L.
        • Beam C.
        • Birtcher K.K.
        • Blumenthal R.S.
        • Braun L.T.
        • de Ferranti S.
        • Faiella-Tommasino J.
        • Forman D.E.
        • Goldberg R.
        • Heidenreich P.A.
        • Hlatky M.A.
        • Jones D.W.
        • Lloyd-Jones D.
        • Lopez-Pajares N.
        • Ndumele C.E.
        • Orringer C.E.
        • Peralta C.A.
        • Saseen J.J.
        • Smith Jr., S.C.
        • Sperling L.
        • Virani S.S.
        • Yeboah J.
        2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol: a report of the American College of Cardiology/American heart association task force on clinical practice guidelines.
        J. Am. Coll. Cardiol. 2018 Nov 8; (pii: S0735-1097(18)39034-X) (Epub ahead of print)https://doi.org/10.1016/j.jacc.2018.11.003
        • Mohan V.
        • Deepa R.
        • Rani S.S.
        • Premalatha G.
        Chennai Urban Population Study (CUPS No.5). Prevalence of coronary artery disease and its relationship to lipids in a selected population in South India: the Chennai Urban Population Study (CUPS No. 5).
        J. Am. Coll. Cardiol. 2001; 38: 682-687
        • Soman C.R.
        • Kutty V.R.
        • Safraj S.
        • Vijayakumar K.
        • Rajamohanan K.
        • Ajayan K.
        • PROLIFE Study Group
        All-cause mortality and cardiovascular mortality in Kerala state of India: results from a 5-year follow-up of 161,942 rural community dwelling adults.
        Asia Pac. J. Public Health. 2011; 23: 896-903
        • Yusuf S.
        • Hawken S.
        • Ounpuu S.
        On behalf of the INTERHEART Study Investigators. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study.
        Lancet. 2004; 364: 937-952
        • Yusuf S.
        • Rangarajan S.
        • Teo K.
        • Islam S.
        • Li W.
        • Liu L.
        • Bo J.
        • Lou Q.
        • Lu F.
        • Liu T.
        • Yu L.
        • Zhang S.
        • Mony P.
        • Swaminathan S.
        • Mohan V.
        • Gupta R.
        • Kumar R.
        • Vijayakumar K.
        • Lear S.
        • Anand S.
        • Wielgosz A.
        • Diaz R.
        • Avezum A.
        • Lopez-Jaramillo P.
        • Lanas F.
        • Yusoff K.
        • Ismail N.
        • Iqbal R.
        • Rahman O.
        • Rosengren A.
        • Yusufali A.
        • Kelishadi R.
        • Kruger A.
        • Puoane T.
        • Szuba A.
        • Chifamba J.
        • Oguz A.
        • McQueen M.
        • McKee M.
        • Dagenais G.
        PURE Investigators. Cardiovascular risk and events in 17 low-, middle-, and high-income countries.
        N. Engl. J. Med. 2014; 371: 818-827
        • Anand S.S.
        • Yusuf S.
        • Vuksan V.
        • Devanesen S.
        • Teo K.K.
        • Montague P.A.
        • Kelemen L.
        • Yi C.
        • Lonn E.
        • Gerstein H.
        • Hegele R.A.
        • McQueen M.
        Differences in risk factors, atherosclerosis, and cardiovascular disease between ethnic groups in Canada: the Study of Health Assessment and Risk in Ethnic groups (SHARE).
        Lancet. 2000; 356: 279-284
        • Hajra A.
        • Li Y.
        • Siu S.
        • Udaltsova N.
        • Armstrong M.A.
        • Friedman G.D.
        • Klatsky A.L.
        Risk of coronary disease in the South Asian American population.
        J. Am. Coll. Cardiol. 2013; 62: 644-645
        • Danaraj T.J.
        • Acker M.S.
        • Danaraj W.
        • Wong H.O.
        • Tan B.Y.
        Ethnic group differences in coronary heart disease in Singapore: an analysis of necropsy records.
        Am. Heart J. 1959; 58: 516-526
        • Tuomilehto J.
        • Ram P.
        • Eseroma R.
        • Taylor R.
        • Zimmet P.
        Cardiovascular diseases and diabetes mellitus in Fiji: analysis of mortality, morbidity and risk factors.
        Bull. World Health Organ. 1984; 62: 133-143
        • McKeigue P.M.
        • Marmot M.G.
        Mortality from coronary heart disease in Asian communities in London.
        BMJ. 1988; 297: 903
        • Wild S.H.
        • Fischbacher C.
        • Brock A.
        • Griffiths C.
        • Bhopal R.
        Mortality from all causes and circulatory disease by country of birth in England and Wales 2001-2003.
        J. Public Health. 2007; 29: 191-198
        • Hippisley-Cox J.
        • Coupland C.
        • Brindle P.
        Development and validation of QRISK3 risk prediction algorithms to estimate future risk of cardiovascular disease: prospective cohort study.
        BMJ. 2017; 357: j2099
        • Fedeli U.
        • Ferroni E.
        • Pigato M.
        • Avossa F.
        • Saugo M.
        Causes of mortality across different immigrant groups in Northeastern Italy.
        Peer J. 2015; 3: e975
        • Fedeli U.
        • Avossa F.
        • Ferroni E.
        • Schievano E.
        • Bilato C.
        • Modesti P.A.
        • Corti M.C.
        Diverging patterns of cardiovascular diseases across immigrant groups in Northern Italy.
        Int. J. Cardiol. 2018; 254: 362-367
        • Fedeli U.
        • Cestari L.
        • Ferroni E.
        • Avossa F.
        • Saugo M.
        • Modesti P.A.
        Ethnic inequalities in acute myocardial infarction hospitalization rates among young and middle-aged adults in Northern Italy: high risk for South Asians.
        Int. Emerg. Med. 2018; 13: 177-182
        • Regidor E.
        • Astasio P.
        • Calle M.E.
        • Martínez D.
        • Ortega P.
        • Domínguez V.
        The association between birthplace in different regions of the world and cardiovascular mortality among residents of Spain.
        Eur. J. Epidemiol. 2009; 24: 503-512
        • Cainzos-Achirica M.
        • Vela E.
        • Cleries M.
        • Bilal U.
        • Mauri J.
        • Pueyo M.J.
        • Rosas A.
        • Enjuanes C.
        • Blaha M.J.
        • Kanaya A.M.
        Comin Colet J. 2019 Feb 28; (pii: heartjnl-2018-314436) (Epub ahead of print)https://doi.org/10.1136/heartjnl-2018-314436
        • Caínzos-Achirica M.
        • García-García C.
        • Elosua R.
        • Piulats N.
        • Recasens L.
        • Bruguera-Cortada J.
        Myocardial infarction in South asian immigrants in Catalonia. Results from the ASIAM study.
        Rev. Esp. Cardiol. 2013; 66: 405-407
        • Hempler N.F.
        • Larsen F.B.
        • Nielsen S.S.
        • Diderichsen F.
        • Andreasen A.H.
        • Jørgensen T.
        A registry-based follow-up study, comparing the incidence of cardiovascular disease in native Danes and immigrants born in Turkey, Pakistan and the former Yugoslavia: do social inequalities play a role?.
        BMC Public Health. 2011; 11: 662
        • Rabanal K.S.
        • Meyer H.E.
        • Tell G.S.
        • Igland J.
        • Pylypchuk R.
        • Mehta S.
        • Kumar B.
        • Jenum A.K.
        • Selmer R.M.
        • Jackson R.
        Can traditional risk factors explain the higher risk of cardiovascular disease in South Asians compared to Europeans in Norway and New Zealand? Two cohort studies.
        BMJ Open. 2017; 7: e016819
        • Rabanal K.S.
        • Selmer R.M.
        • Igland J.
        • Tell G.S.
        • Meyer H.E.
        Ethnic inequalities in acute myocardial infarction and stroke rates in Norway 1994-2009: a nationwide cohort study (CVDNOR).
        BMC Public Health. 2015; 15: 1073
        • Hedlund E.
        • Lange A.
        • Hammar N.
        Acute myocardial infarction incidence in immigrants to Sweden. Country of birth, time since immigration, and time trends over 20 years.
        Eur. J. Epidemiol. 2007; 22: 493-503
        • Ikram U.Z.
        • Mackenbach J.P.
        • Harding S.
        • Rey G.
        • Bhopal R.S.
        • Regidor E.
        • Rosato M.
        • Juel K.
        • Stronks K.
        • Kunst A.E.
        All-cause and cause-specific mortality of different migrant populations in Europe.
        Eur. J. Epidemiol. 2016; 31: 655-665
        • Rafnsson S.B.
        • Bhopal R.S.
        • Agyemang C.
        • Fagot-Campagna A.
        • Harding S.
        • Hammar N.
        • Hedlund E.
        • Juel K.
        • Primatesta P.
        • Rosato M.
        • Rey G.
        • Wild S.H.
        • Mackenbach J.P.
        • Stirbu I.
        • Kunst A.E.
        Sizable variations in circulatory disease mortality by region and country of birth in six European countries.
        Eur. J. Public Health. 2013; 23: 594-605
        • Eurostat
        Population by Country of Birth at National Level.
        (Available at:)
        • Volgman A.S.
        • Palaniappan L.S.
        • Aggarwal N.T.
        • Gupta M.
        • Khandelwal A.
        • Krishnan A.V.
        • Lichtman J.H.
        • Mehta L.S.
        • Patel H.N.
        • Shah K.S.
        • Shah S.H.
        • Watson K.E.
        American heart association council on epidemiology and prevention; cardiovascular disease and stroke in women and special populations committee of the council on clinical Cardiology; council on cardiovascular and stroke nursing; council on quality of care and outcomes research; and stroke council. Atherosclerotic cardiovascular disease in South Asians in the United States: epidemiology, risk factors, and treatments: a scientific statement from the American heart association.
        Circulation. 2018; 138: e1-e34
        • Wong N.D.
        Appreciating Cardiovascular Disease Risk in South Asians: the Time Is Now.
        (Available at:)
        • The World Bank
        Total Population.
        (Available at:)
        • Ahmed S.T.
        • Rehman H.
        • Akeroyd J.M.
        • Alam M.
        • Shah T.
        • Kalra A.
        • Virani S.S.
        Premature coronary heart disease in South Asians: burden and determinants.
        Curr. Atheroscler. Rep. 2018; 20: 6
        • Office for National Statistics
        Statistical Bulletin: Migration Statistics Quarterly Report.
        February 2018 (Available at:)
        • Generalitat de Catalunya
        La població de nacionalitat pakistanesa a Catalunya.
        (Available at:)
        • GOV.UK
        Household Income. Ethnicity Facts and Figures.
        (Available at:)
        • Pew Research Center
        5 Facts about Indian Americans.
        (Available at:)
        • Bhopal R.
        • Unwin N.
        • White M.
        • Yallop J.
        • Walker L.
        • Alberti K.G.
        • Harland J.
        • Patel S.
        • Ahmad N.
        • Turner C.
        • Watson B.
        • Kaur D.
        • Kulkarni A.
        • Laker M.
        • Tavridou A.
        Heterogeneity of coronary heart disease risk factors in Indian, Pakistani, Bangladeshi, and European origin populations: cross sectional study.
        BMJ. 1999; 319: 215-220
        • Chambers J.C.
        • Eda S.
        • Bassett P.
        • Karim Y.
        • Thompson S.G.
        • Gallimore J.R.
        • Pepys M.B.
        • Kooner J.S.
        C-reactive protein, insulin resistance, central obesity, and coronary heart disease risk in Indian Asians from the United Kingdom compared with european whites.
        Circulation. 2001; 10: 145-150
        • Jenum A.K.
        • Diep L.M.
        • Holmboe-Ottesen G.
        • Holme I.M.
        • Kumar B.N.
        • Birkeland K.I.
        Diabetes susceptibility in ethnic minority groups from Turkey, Vietnam, Sri Lanka and Pakistan compared with Norwegians - the association with adiposity is strongest for ethnic minority women.
        BMC Public Health. 2012; 12: 150
        • Marzona I.
        • Avanzini F.
        • Tettamanti M.
        • Vannini T.
        • Fortino I.
        • Bortolotti A.
        • Merlino L.
        • Genovese S.
        • Roncaglioni M.C.
        Prevalence and management of diabetes in immigrants resident in the Lombardy Region: the importance of ethnicity and duration of stay.
        Acta Diabetol. 2018; 55: 355-362
        • Franch-Nadal J.
        • Martínez-Sierra M.C.
        • Espelt A.
        • Sagarra-Busquets E.
        • Patitucci-Gómez F.
        • Goday-Arno A.
        • redGDPS
        The diabetic immigrant: cardiovascular risk factors and control. Contributions of the IDIME study.
        Rev. Esp. Cardiol. 2013; 66: 39-46
        • Johns E.
        • Sattar N.
        Cardiovascular and mortality risks in migrant South Asians with type 2 diabetes: are we winning the battle?.
        Curr. Diabetes Rep. 2017; 17: 100
        • Hippisley-Cox J.
        • Coupland C.
        • Robson J.
        • Sheikh A.
        • Brindle P.
        Predicting risk of type 2 diabetes in England and Wales: prospective derivation and validation of QDScore.
        BMJ. 2009; 338: b880
        • WHO Expert Consultation
        Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies.
        Lancet. 2004; 363: 157-163
        • Ghouri N.
        • Purves D.
        • McConnachie A.
        • Wilson J.
        • Gill J.M.
        • Sattar N.
        Lower cardiorespiratory fitness contributes to increased insulin resistance and fasting glycaemia in middle-aged South Asian compared with European men living in the UK.
        Diabetologia. 2013; 56: 2238-2249
        • Simmons D.
        • Williams R.
        Dietary practices among europeans and different South Asian groups in coventry.
        Br. J. Nutr. 1997; 78: 5-14
        • Emadian A.
        • England C.Y.
        • Thompson J.L.
        Dietary intake and factors influencing eating behaviours in overweight and obese South Asian men living in the UK: mixed method study.
        BMJ Open. 2017; 7e016919
        • Kakde S.
        • Bhopal R.S.
        • Bhardwaj S.
        • Misra A.
        Urbanized South Asians' susceptibility to coronary heart disease: the high-heat food preparation hypothesis.
        Nutrition. 2017; 33: 216-224
        • Menon A.S.
        • Kotwal N.
        • Singh Y.
        • Girish R.
        Statins: cholesterol guidelines and Indian perspective.
        Indian J. Endocrinol. Metab. 2015; 19: 546-553
        • Gupta M.
        • Brister S.
        Is South Asian ethnicity an independent cardiovascular risk factor?.
        Can. J. Cardiol. 2006; 22: 193-197
        • Shah A.
        • Hernandez A.
        • Mathur D.
        • Budoff M.J.
        • Kanaya A.M.
        Adipokines and body fat composition in South Asians: results of the metabolic syndrome and atherosclerosis in South Asians living in America (MASALA) study.
        Int. J. Obes. 2012; 36: 810-816
        • Margetts B.M.
        • Mohd Yusof S.
        • Al Dallal Z.
        • Jackson A.A.
        Persistence of lower birth weight in second generation South Asian babies born in the United Kingdom.
        J. Epidemiol. Community Health. 2002; 56: 684-687
        • Oxford Books
        Bhopal RS. Epidemic of Cardiovascular Disease and Diabetes: Explaining the Phenomenon in South Asians Worldwide.
        2019
        • Agyemang C.
        • van den Born B.J.
        Non-communicable diseases in migrants: an expert review.
        J. Travel Med. 2018 Oct 20; (Epub ahead of print)https://doi.org/10.1093/jtm/tay107
        • Cappuccio F.P.
        • Cook D.G.
        • Atkinson R.W.
        • Strazzullo P.
        Prevalence, detection, and management of cardiovascular risk factors in different ethnic groups in south London.
        Heart. 1997; 78: 555-563
        • Valerio L.
        • Milozzi J.
        • Figueredo A.
        • Reina M.D.
        • Martínez-Cuevas O.
        • Pérez-Quilez O.
        Prevalence of diabetes mellitus in young asian indian immigrants in Santa Coloma de Gramenet (Spain).
        Med. Clínica. 2006; 126: 53-56
        • Karlsen S.
        • Millward D.
        • Sandford A.
        Investigating ethnic differences in current cigarette smoking over time using the health surveys for England.
        Eur. J. Public Health. 2012; 22: 254-256
        • Andrés E.
        • León M.
        • Cordero A.
        • Magallón Botaya R.
        • Magán P.
        • Luengo E.
        • Alegría E.
        • Casasnovas J.A.
        Cardiovascular risk factors and lifestyle associated with premature myocardial infarction diagnosis.
        Rev. Esp. Cardiol. 2011; 64: 527-529
        • Makaryus A.N.
        • Dhama B.
        • Raince J.
        • Raince A.
        • Garyali S.
        • Labana S.S.
        • Kaplan B.M.
        • Park C.
        • Jauhar R.
        Coronary artery diameter as a risk factor for acute coronary syndromes in Asian-Indians.
        Am. J. Cardiol. 2005; 96: 778-780
        • Tillin T.
        • Dhutia H.
        • Chambers J.
        • Malik I.
        • Coady E.
        • Mayet J.
        • Wright A.R.
        • Kooner J.
        • Shore A.
        • Thom S.
        • Chaturvedi N.
        • Hughes A.
        South Asian men have different patterns of coronary artery disease when compared with European men.
        Int. J. Cardiol. 2008; 129: 406-413
        • Williams B.
        • Mancia G.
        • Spiering W.
        • Agabiti Rosei E.
        • Azizi M.
        • Burnier M.
        • Clement D.L.
        • Coca A.
        • de Simone G.
        • Dominiczak A.
        • Kahan T.
        • Mahfoud F.
        • Redon J.
        • Ruilope L.
        • Zanchetti A.
        • Kerins M.
        • Kjeldsen S.E.
        • Kreutz R.
        • Laurent S.
        • Lip G.Y.H.
        • McManus R.
        • Narkiewicz K.
        • Ruschitzka F.
        • Schmieder R.E.
        • Shlyakhto E.
        • Tsioufis C.
        • Aboyans V.
        • Desormais I.
        • ESC Scientific Document Group
        2018 ESC/ESH Guidelines for the management of arterial hypertension.
        Eur. Heart J. 2018; 39: 3021-3104
        • Catapano A.L.
        • Graham I.
        • De Backer G.
        • Wiklund O.
        • Chapman M.J.
        • Drexel H.
        • Hoes A.W.
        • Jennings C.S.
        • Landmesser U.
        • Pedersen T.R.
        • Reiner Ž.
        • Riccardi G.
        • Taskinen M.R.
        • Tokgozoglu L.
        • Verschuren W.M.M.
        • Vlachopoulos C.
        • Wood D.A.
        • Zamorano J.L.
        • Cooney M.T.
        • ESC Scientific Document Group
        2016 ESC/EAS guidelines for the management of dyslipidaemias.
        Eur. Heart J. 2016; 37: 2999-3058
        • National Institute for Health and Care Excellence (NICE)
        Cardiovascular Disease: Risk Assessment and Reduction, Including Lipid Modification.
        (Available at:)
        https://www.nice.org.uk/guidance/cg181
        Date accessed: February 7, 2019
        • National Institute for Health and Care Excellence (NICE)
        Type 2 Diabetes Prevention: Population and Community-Level Interventions.
        (Available at:)
        https://www.nice.org.uk/guidance/ph35
        Date accessed: February 7, 2019
        • Aune D.
        • Norat T.
        • Leitzmann M.
        • Tonstad S.
        • Vatten L.J.
        Physical activity and the risk of type 2 diabetes: a systematic review and dose-response meta-analysis.
        Eur. J. Epidemiol. 2015; 30: 529-542
        • Kelley G.A.
        • Kelley K.S.
        • Vu Tran Z.
        Aerobic exercise, lipids and lipoproteins in overweight and obese adults: a meta-analysis of randomized controlled trials.
        Int. J. Obes. 2005; 29: 881-893
        • Whelton S.P.
        • Chin A.
        • Xin X.
        • He J.
        Effect of aerobic exercise on blood pressure: a meta-analysis of randomized, controlled trials.
        Ann. Intern. Med. 2002; 136: 493-503
        • Ashor A.W.
        • Lara J.
        • Siervo M.
        • Celis-Morales C.
        • Oggioni C.
        • Jakovljevic D.G.
        • Mathers J.C.
        Exercise modalities and endothelial function: a systematic review and dose-response meta-analysis of randomized controlled trials.
        Sports Med. 2015; 45: 279-296
        • Ekelund U.
        • Steene-Johannessen J.
        • Brown W.J.
        • Fagerland M.W.
        • Owen N.
        • Powell K.E.
        • Bauman A.
        • Lee I.M.
        Lancet Physical Activity Series 2 Executive Committe; Lancet Sedentary Behaviour Working Group. Does physical activity attenuate, or even eliminate, the detrimental association of sitting time with mortality? A harmonised meta-analysis of data from more than 1 million men and women.
        Lancet. 2016; 388: 1302-1310
        • Khera A.V.
        • Emdin C.A.
        • Drake I.
        • Natarajan P.
        • Bick A.G.
        • Cook N.R.
        • Chasman D.I.
        • Baber U.
        • Mehran R.
        • Rader D.J.
        • Fuster V.
        • Boerwinkle E.
        • Melander O.
        • Orho-Melander M.
        • Ridker P.M.
        • Kathiresan S.
        Genetic risk, adherence to a healthy lifestyle, and coronary disease.
        N. Engl. J. Med. 2016; 375: 2349-2358
        • Colberg S.R.
        • Sigal R.J.
        • Yardley J.E.
        • Riddell M.C.
        • Dunstan D.W.
        • Dempsey P.C.
        • Horton E.S.
        • Castorino K.
        • Tate D.F.
        Physical activity/exercise and diabetes: a position statement of the American diabetes association.
        Diabetes Care. 2016; 39: 2065-2079
        • Authors/Task Force Members
        • Rydén L.
        • Grant P.J.
        • Anker S.D.
        • Berne C.
        • Cosentino F.
        • Danchin N.
        • Deaton C.
        • Escaned J.
        • Hammes H.P.
        • Huikuri H.
        • Marre M.
        • Marx N.
        • Mellbin L.
        • Ostergren J.
        • Patrono C.
        • Seferovic P.
        • Uva M.S.
        • Taskinen M.R.
        • Tendera M.
        • Tuomilehto J.
        • Valensi P.
        • Zamorano J.L.
        • ESC Committee for Practice Guidelines (CPG)
        • Zamorano J.L.
        • Achenbach S.
        • Baumgartner H.
        • Bax J.J.
        • Bueno H.
        • Dean V.
        • Deaton C.
        • Erol C.
        • Fagard R.
        • Ferrari R.
        • Hasdai D.
        • Hoes A.W.
        • Kirchhof P.
        • Knuuti J.
        • Kolh P.
        • Lancellotti P.
        • Linhart A.
        • Nihoyannopoulos P.
        • Piepoli M.F.
        • Ponikowski P.
        • Sirnes P.A.
        • Tamargo J.L.
        • Tendera M.
        • Torbicki A.
        • Wijns W.
        • Windecker S.
        • Document Reviewers
        • De Backer G.
        • Sirnes P.A.
        • Ezquerra E.A.
        • Avogaro A.
        • Badimon L.
        • Baranova E.
        • Baumgartner H.
        • Betteridge J.
        • Ceriello A.
        • Fagard R.
        • Funck-Brentano C.
        • Gulba D.C.
        • Hasdai D.
        • Hoes A.W.
        • Kjekshus J.K.
        • Knuuti J.
        • Kolh P.
        • Lev E.
        • Mueller C.
        • Neyses L.
        • Nilsson P.M.
        • Perk J.
        • Ponikowski P.
        • Reiner Z.
        • Sattar N.
        • Schächinger V.
        • Scheen A.
        • Schirmer H.
        • Strömberg A.
        • Sudzhaeva S.
        • Tamargo J.L.
        • Viigimaa M.
        • Vlachopoulos C.
        • Xuereb R.G.
        ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD: the Task Force on diabetes, pre-diabetes, and cardiovascular diseases of the European Society of Cardiology (ESC) and developed in collaboration with the European Association for the Study of Diabetes (EASD).
        Eur. Heart J. 2013; 34: 3035-3087
        • American Diabetes Association
        4. Lifestyle management: standards of medical care in diabetes-2018.
        Diabetes Care. 2018; 41: S38-S50
      1. Metropolitan. Barcelona's Pakistani Community.
        (Available at:)
        • Estruch R.
        • Ros E.
        • Salas-Salvadó J.
        • Covas M.I.
        • Corella D.
        • Arós F.
        • et al.
        • PREDIMED Study Investigators
        Primary prevention of cardiovascular disease with a mediterranean diet supplemented with extra-virgin olive oil or nuts.
        N. Engl. J. Med. 2018; 378: e34
        • Salas-Salvadó J.
        • Bulló M.
        • Babio N.
        • Martínez-González M.Á.
        • Ibarrola-Jurado N.
        • Basora J.
        • et al.
        Erratum. Reduction in the incidence of type 2 diabetes with the mediterranean diet: results of the PREDIMED-reus nutrition intervention randomized trial.
        Diabetes Care. 2011; 34: 14-19
        • Dehghan M.
        • Mente A.
        • Zhang X.
        • Swaminathan S.
        • Li W.
        • Mohan V.
        • Iqbal R.
        • Kumar R.
        • Wentzel-Viljoen E.
        • Rosengren A.
        • Amma L.I.
        • Avezum A.
        • Chifamba J.
        • Diaz R.
        • Khatib R.
        • Lear S.
        • Lopez-Jaramillo P.
        • Liu X.
        • Gupta R.
        • Mohammadifard N.
        • Gao N.
        • Oguz A.
        • Ramli A.S.
        • Seron P.
        • Sun Y.
        • Szuba A.
        • Tsolekile L.
        • Wielgosz A.
        • Yusuf R.
        • Hussein Yusufali A.
        • Teo K.K.
        • Rangarajan S.
        • Dagenais G.
        • Bangdiwala S.I.
        • Islam S.
        • Anand S.S.
        • Yusuf S.
        Prospective Urban Rural Epidemiology (PURE) study investigators. Associations of fats and carbohydrate intake with cardiovascular disease and mortality in 18 countries from five continents (PURE): a prospective cohort study.
        Lancet. 2017; 390: 2050-2062
        • Yusuf S.
        • Bosch J.
        • Dagenais G.
        • Zhu J.
        • Xavier D.
        • Liu L.
        • Pais P.
        • López-Jaramillo P.
        • Leiter L.A.
        • Dans A.
        • Avezum A.
        • Piegas L.S.
        • Parkhomenko A.
        • Keltai K.
        • Keltai M.
        • Sliwa K.
        • Peters R.J.
        • Held C.
        • Chazova I.
        • Yusoff K.
        • Lewis B.S.
        • Jansky P.
        • Khunti K.
        • Toff W.D.
        • Reid C.M.
        • Varigos J.
        • Sanchez-Vallejo G.
        • McKelvie R.
        • Pogue J.
        • Jung H.
        • Gao P.
        • Diaz R.
        • Lonn E.
        • HOPE-3 Investigators
        Cholesterol lowering in intermediate-risk persons without cardiovascular disease.
        N. Engl. J. Med. 2016; 374: 2021-2031
        • Ballotari P.
        • Ferrari F.
        • Ballini L.
        • Chiarenza A.
        • Manicardi V.
        • Giorgi Rossi P.
        Lifestyle-tailored interventions for South Asians with type 2 diabetes living in high-income countries: a systematic review.
        Acta Diabetol. 2017; 54: 785-794
        • Gómez-Pardo E.
        • Fernández-Alvira J.M.
        • Vilanova M.
        • Haro D.
        • Martínez R.
        • Carvajal I.
        • Carral V.
        • Rodríguez C.
        • de Miguel M.
        • Bodega P.
        • Santos-Beneit G.
        • Peñalvo J.L.
        • Marina I.
        • Pérez-Farinós N.
        • Dal Re M.
        • Villar C.
        • Robledo T.
        • Vedanthan R.
        • Bansilal S.
        • Fuster V.
        A comprehensive lifestyle peer group-based intervention on cardiovascular risk factors: the randomized controlled fifty-fifty program.
        J. Am. Coll. Cardiol. 2016; 67: 476-485
        • Bhatnagar P.
        • Shaw A.
        • Foster C.
        Generational differences in the physical activity of UK South Asians: a systematic review.
        Int. J. Behav. Nutr. Phys. Act. 2015; 12: 96
        • Mediterranean Diet Foundation
        Mediterranean Diet Pyramid: a Lifestyle for Today.
        (Available at:)
        • Kanaya A.M.
        • Ewing S.K.
        • Vittinghoff E.
        • Herrington D.
        • Tegeler C.
        • Mills C.
        • Kandula N.R.
        Acculturation and subclinical atherosclerosis among U.S. South Asians: findings from the MASALA study.
        J. Clin. Exp. Res. Cardiol. 2014; 1: 102
        • Talegawkar S.A.
        • Kandula N.R.
        • Gadgil M.D.
        • Desai D.
        • Kanaya A.M.
        Dietary intakes among South Asian adults differ by length of residence in the USA.
        Publ. Health Nutr. 2015; : 1-8
        • Al Rifai M.
        • Cainzos-Achirica M.
        • Kanaya A.M.
        • Kandula N.R.
        • Dardardi Z.
        • Joshi P.H.
        • Patel J.
        • Budoff M.
        • Yeboah J.
        • Guallar E.
        • Blumenthal R.S.
        • Blaha M.J.
        Discordance between 10-year cardiovascular risk estimates using the ACC/AHA 2013 estimator and coronary artery calcium in individuals from 5 racial/ethnic groups: comparing MASALA and MESA.
        Atherosclerosis. 2018; 279: 122-129
        • Hussain R.
        Community perceptions of reasons for preference for consanguineous marriages in Pakistan.
        J. Biosoc. Sci. 1999; 31: 449-461
        • Saleheen D.
        • Zaidi M.
        • Rasheed A.
        • Ahmad U.
        • Hakeem A.
        • Murtaza M.
        • Kayani W.
        • Faruqui A.
        • Kundi A.
        • Zaman K.S.
        • Yaqoob Z.
        • Cheema L.A.
        • Samad A.
        • Rasheed S.Z.
        • Mallick N.H.
        • Azhar M.
        • Jooma R.
        • Gardezi A.R.
        • Memon N.
        • Ghaffar A.
        • Fazal-ur-Rehman
        • Khan N.
        • Shah N.
        • Ali Shah A.
        • Samuel M.
        • Hanif F.
        • Yameen M.
        • Naz S.
        • Sultana A.
        • Nazir A.
        • Raza S.
        • Shazad M.
        • Nasim S.
        • Javed M.A.
        • Ali S.S.
        • Jafree M.
        • Nisar M.I.
        • Daood M.S.
        • Hussain A.
        • Sarwar N.
        • Kamal A.
        • Deloukas P.
        • Ishaq M.
        • Frossard P.
        • Danesh J.
        The Pakistan Risk of Myocardial Infarction Study: a resource for the study of genetic, lifestyle and other determinants of myocardial infarction in South Asia.
        Eur. J. Epidemiol. 2009; 24: 329-338
        • Brindle P.
        • May M.
        • Gill P.
        • Cappuccio F.
        • D'Agostino Sr., R.
        • Fischbacher C.
        • Ebrahim S.
        Primary prevention of cardiovascular disease: a web-based risk score for seven British black and minority ethnic groups.
        Heart. 2006; 92: 1595-1602
        • Selmer R.
        • Igland J.
        • Ariansen I.
        • Tverdal A.
        • Njølstad I.
        • Furu K.
        • Tell G.S.
        • Klemsdal T.O.
        NORRISK 2: a Norwegian risk model for acute cerebral stroke and myocardial infarction.
        Eur. J. Prev. Cardiol. 2017; 24: 773-782
        • Volpe M.
        • Tocci G.
        • Accettura D.
        • Battistoni A.
        • Bellone S.
        • Bellotti P.
        • Bertolotti M.
        • Borghi C.
        • Casasco M.
        • Consoli A.
        • Coppini R.
        • Corsini A.
        • Costanzo G.
        • Desideri G.
        • Ferri C.
        • Galanti G.
        • Giada F.
        • Icardi G.
        • Lombardi N.
        • Modena M.G.
        • Modesti P.A.
        • Monti G.
        • Mugelli A.
        • Orsi A.
        • Parati G.
        • Pedretti R.F.
        • Perseghin G.
        • Pirro M.
        • Ricotti R.
        • Rizzoni D.
        • Rotella C.
        • Rubattu S.
        • Salvetti G.
        • Sarto P.
        • Tassinari F.
        • Trimarco B.
        • de Kreutzenberg S.V.
        • Volpe R.
        Consensus document and recommendations for the prevention of cardiovascular disease in Italy - 2018.
        G. Ital. Cardiol. 2018; 19: 1S-95S