1. South Asian HEART: Another enigma of ARRIVAL 

2. The rising toll of coronary heart disease

3. south Asian Heart: Action Plan for Change 

4. Coronary artery disease and diabetes in South Asian emigrants

5 Heart Healthy Eating for South Asiana 

South Asian HEART: Another enigma of ARRIVAL 

Dr VS Rambihar’s Arrival Lecture 2003.

Nobel Laureate VS Naipaul writes of the enigma of arrival, in his book of the same name, that we cannot ever go back, at least not entirely, to the place we came from. Everything changes and so must we. We can look back, but must look forward, making the best of both worlds, or of all worlds to shape our future, adapting to new environments.

There is another enigma of arrival - that migration to western countries or moving to cities exposes people to new and adverse lifestyles and environments they are not adapted for, unmasking hidden health risks. For South Asians (IndoCaribbean, Asian Indian, PIO, etc), this sedentary lifestyle, over consumption and high stress leading to obesity or being overweight, adverse blood lipids, high blood pressure and a prediabetic or diabetic state, seem to unmask a tendency to earlier heart and blood vessel disease, including stroke, kidney and other diseases, with biological and other factors amplifying risk even further.

This is the other enigma of Arrival we must not lose sight of when we celebrate Heritage Month and Arrival. The high rates of obesity, diabetes, prediabetes, heart and blood vessel disease we find in our community have something to do with the very fact of migration and arrival we celebrate. This is why we continue to hear of friends, acquaintances, colleagues and family members affected at a young age, and of such high rates of illness in this and some other communities. Children, increasingly overweight and with declining exercise levels will develop the related illnesses earlier than previously, with resultant earlier disability or death.

We need a departure to overcome this other enigma of arrival. A departure from our current thinking that we can continue as before, doing things as we have always done. A new thinking is needed, with innovative ideas and novel approaches, since the usual and traditional ways do not work well enough. These involve both community and personal initiatives and changes.

THE USUAL: Never smoke. Reduce stress. Assess your risk starting early. Eat a nutritious low fat, lower salt, high fiber, vegetarian or close to vegetarian diet (with fish beneficial). Eat less fast food, more fresh greens, vegetables and fruit. (Note: many advertised low fat foods are high sugar and just as bad). Exercise more, every little counts. Achieve and maintain desired weight, fitness and shape. Check blood levels for risk factors, treat blood pressure, diabetes and prediabetes. More often now medications are needed for prevention or to achieve targets.

THE NEW: Teach healthy lifestyle and choices starting in childhood, especially if early family history or other risks. Search for info - internet, doctors, health advisors, Heart and Stroke Foundations, and everywhere else. Keep up to date with advances; things change all the time. Seek lower targets for cholesterol, etc than advised, and more aggressive risk reduction especially if early family history (South Asian guidelines suggest more aggressive risk reduction than National guidelines, which do not reflect SA reality). Live according to your risks, not that of others. Insist on heart healthy choices for yourself and others, when eating out, at home and at social functions. Always provide healthy choices to friends and guests at social and other occasions, as positive feedback for heart health and to avoid increasing their risk. 

Diet: Search internet for New Food Pyramid (2003, the 1992 version is now outdated). All fats and carbohydrates are not created equal. Choose less - refined carbohydrates, white bread and white flour. Choose more - complex, stone milled, whole wheat or multigrain, low glycemic index carbohydrates. Reduce sugar, sweets and dairy (skim milk OK). Avoid saturated, trans and hydrogenated fats, but can use small amounts of poly and mono unsaturated fats and oils.

INNOVATIVE IDEAS:

Personal: Consider social functions and work as opportunities for heart health rather than excuses for exceptions. Don’t blame convenience factors or lack of time for poor choices. It doesn’t take much longer to prepare healthy snacks or meals, and healthy choices easily become natural and easy, and also make you feel better. Think health every day making healthy choices part of who you are. It will become second nature and your best investment.

Organizational: Make May South Asian Heart Month and every day South Asian Heart Day. Use the opportunity of South Asian Heritage Month activities to focus on health, raise awareness, teach heart health, reach out to the community and lead by example.

2 Minute Heart: take two minutes at every Heritage Month and even at other events to mention heart health. This will amplify benefits, which will ripple across the community and make significant change. Do not accept the argument that arrival is to celebrate and to have fun and is not to be a health seminar. Everything touches the heart of people and every opportunity should be used for heart health, especially for South Asians.

 Invitation for your involvement: Take these ideas to your friends, your local communities, schools and everywhere. Do seminars, Health Fairs, writing contests, songs, plays, skits, tell stories. Use the resources available and take them deep within the community. Lead by example showing what’s possible. Be courageous and do things differently to make a difference for yourself and the community. Avoid the aspects of culture and tradition that increase risk. Talk about health. Make it acceptable. Share ideas. Adapt to changes. Get children involved. Design a new heart healthy cuisine. Get friends together for walks, exercise, fitness, discussions, etc. Create a new South Asian diaspora with an ethic of health at its heart - a new South Asian Heart. Enjoy the process and the benefits of better health. Use your creativity and imagination and do what you can. You have the power to make the difference – for yourself and for all communities.

Based on Arrival Lectures at the Trinidad Heart Foundation Day 2002, French Caribbean Cardiology Conference Martinique 2002, Caribbean Cardiac Conference in Barbados 2001, Cambridge University UK 2000, and various in Canada. Innovative pioneering chaos and complexity science ideas were used by the author in the South Asian Heart project 1990-2003, the South Asian Heart: Preventing Heart Disease book 1996 and 2003, South Asian Heart Month from 2002, and other projects. For more info Ph: 416 438 2100: Fax 416 438 2106.

The Rising Toll Of Cardiovascular  Disease: Increased Risk Among South Asians

by Dr. Ganraj Kumar, BSc, MDCM, FRCP, FACP

In 1990 of the 50 million people who died from a variety of diseases throughout the world, deaths from cardiovascular disease (heart attacks and strokes) accounted for 12   million. By the year 2020 the number of people dying from cardiovascular disease throughout the world will be 25 million, 2/3 of whom will be in the developing countries. The risk of dying from heart attacks is at least double among people of South Asian origin.

 If you are a male and your waist circumference, measured just above the top of your hip bone, is greater than 94 cm (37 ins) or if you are a female and your waist circumference, measured the same way is greater than 88 cm (34 1/2  ins)   then read the rest of this article very, very carefully.

 HEART DISEASE is the leading cause of death in Southwestern Ontario which includes the Greater Toronto Area. Disease of the blood vessels account for 40% of deaths in Ontario. 60% of these are from heart attacks, 12% from strokes and 4% from heart failure.

 Therefore in the general population 40 out of every 100 deaths will be from disease of the blood vessels of which 24 will be from heart attacks and for the South Asian population that number rises to a staggering 48 out of every 100 deaths.

 I am sure that among members of your own family and close friends there are several examples of people who have had heart attacks, who have undergone bypass surgery or angioplasty, or who have died heart attacks or strokes. Many stroke and heart attack survivors remain debilitated and unable to function in society.

 RISKS

What are the risk factors responsible for this scourge in our society? If your father suffered a heart attack before the age of 55 or your mother below the age of 65, then family history is significant. Although not modifiable, such a history should set off an alarm bell so that you will pay greater attention to the factors that are modifiable eg cigarette smoking, diabetes mellitus, high blood pressure (hypertension), obesity and inactivity.

 There is an incremental risk associated with multiple risk factors eg if you have High Blood pressure alone the risk is increased by 1 1/2 times. If you have High Cholesterol Levels alone the risk is increased by 2.3 times. If you have Diabetes alone the risk is increased 1.8 times.

 If on the other hand you have diabetes and High Cholesterol the risk increases 4 times and if you have Diabetes and High Blood Pressure, diseases that often go together, your risk will increase to 2.8 times. If you have High Blood Pressure and High Cholesterol your risk increases 3 1/2 times.   However if you have Diabetes, High Cholesterol and High Blood Pressure your risk will increase by a whopping 6.2 times. Let us now deal with the individual risk factors.

 SMOKING: 20% of Ontario residents are daily smokers. In general males smoke more than females. The smoking rate is higher among 20-45 year olds and lowest among those who are older than 65. But the rate of smoking among teenagers is on the rise.

 HIGH BLOOD PRESSURE: High blood pressure is a significant risk factor for stroked heart attacks, heart failure, kidney failure and dementia. If you are younger than 60 treating high blood pressure will reduce your risk of stroke by 42% and the risk of coronary events (heart attacks) by 14%. lf you are older than 60 the incidence of stroke wi11 be reduced by 40% while the risk of cardiovascular deaths wi11 be reduced by 33%.

 Of special interest is the fact that older people with systolic blood pressure of 160 and a normal diastolic reading are at increased risk. Effective treatment of the systolic blood pressure will reduce the risk of stroke by 36% and the risk of heart attacks by 25%. Systolic Blood Pressure is the top reading obtained when your heart contracts while diastolic blood pressure is the bottom reading obtained when your hem relaxes. Normal blood pressure is 120/70.

 If you are a DIABETIC the target goal is a blood pressure of 130/80 or less. This level has been shown to provide the greatest protection for your kidneys. Remember that most of the patients in Canada who are on dialysis are diabetics.

 DIABETES: The incidence of diabetes is on the rise. It is estimated that we have at least 5 million diabetics in Canada alone. Diabetes is also common in developing countries. While the exact cause for Type I diabetes is not known, Type 11 diabetes the more common form is definitely related to obesity and inactivity.

 The amount of sugar in your diet should be drastically reduced. Type 11 diabetes is now becoming common even among teenagers and young people in their 20's and 30's. The importance of diabetes is that it causes disease of blood vessels in the brain, in the eyes, in the heart, in the kidneys and in the lower limbs, increasing the risk of stroke, blindness, heart attacks, kidney failure and loss of limb.

 CHOLESTEROL: The body needs a certain amount of cholesterol. The levels often become too high both because of the type of food we eat and the fact that in some of us our livers make too much total cholesterol, too much of the bad ones and too little of the good ones. Foods such as beef, pork, lamb, duck, egg yolks and dairy products, butter, ghee, cheese and milk as well products made out of coconut are high in saturated fats.

 OBESITY is a growing problem throughout Canada and has increased over the past 10 years. 33% of Ontario residents are now considered overweight i.e. weighing 25 to 29.9 pounds above ideal and 15% of Ontario residents are considered obese i.e. they weigh 30 pounds or more above the ideal. The maximum waist circumference for a man should be 94 cm (37 ins), for a woman 88 cm (34 1/2 ins) Being overweight is a combination of inactivity and large meals particularly those with extra fat and sugars.

 INACTIVITY: Even people who live in senior citizens' homes have access to a gym in their buildings. Using the treadmill or an exercise bicycle will help you to continue your physical activity throughout the year regardless of the weather. If you can't do 30 minutes at one time, 15 minutes twice a day is quite acceptable or you can walk along the hallway in your apartment building if you can't use the gym. Depending on your physical condition you may wish to climb at least one flight of stairs every day as a part of your walk.

 TREATMENT

The new paradigm for cardiovascular disease is simultaneous management of all modifiable risk factors. This requires a comprehensive assessment and treatment of high blood pressure, high cholesterol, diabetes, smoke cessation, management of obesity and increased physical activity.

SMOKING: For those who smoke, help is available. You should consult your doctors: nicotine patch, hypnosis and anti-depressants (Wellbutrin) have been used with success. However unless you are willing to make a decision to stop smoking, these measures wi11 never be successful.

 HIGH BLOOD PRESSURE is treatable but remember that on the average a person may require 3 1/2 drugs a day to keep the blood pressure within an acceptable range. You don't need more than one teaspoonful of salt per day.

Use spices to make your food tasty.

 OBESITY: There is no simple way to manage obesity, but a healthy diet which includes 5 helpings of vegetables and 5 helpings of fruit per day smaller portions, avoidance of sugars and saturated fats together with increased physical activity are the mainstay of management.

 CHOLESTEROL: For high cholesterol, management is a combination of regular exercise. 30-45 minutes of walking or some form of equivalent aerobic exercise at least 6 days a week a low fat diet and medications. A group of drugs exiled Statins are the most effective.

 The healthy oils are: olive, canola, corn, soya, sunflower and safflower. Palm oil made from the kernel of the fruit has bad cholesterol. Palm oil made from the fleshy part of the fruit is low in saturated fats and therefore healthy. Coconut oil and ghee are high in saturated fats and therefore unhealthy.

 DIABETES: Some diabetics can be managed on a diet alone or diet plus exercise. Some will require tablets and some will require insulin. The tablets that are available are not insulin substitutes. They, in a variety of ways, increase the amount of insulin produced by your pancreas or make the insulin that is produced more available and more effective.

 CONCLUSION

I trust it is now dear that treatment of cardiovascular disease, involves lifestyle modifications along with medications and that best results are obtained when there is a true partnership between the patient and the physician. Al1 modifiable risk factors have to be dealt with together and we have to start with our children and our youths rather than waiting until disaster strikes.

 Children and youths have to be encouraged to participate in some form of regular physical activity and to make it a part of their daily lives. Mens sana in corpore sana - a healthy mind in a healthy body

 Above all remember that your life is in your own hands.

There are no miracles.

South Asian Heart: Action Plan for Change.

VS Rambihar MD, Toronto. Inaugural Speech at CN Tower, Toronto, May 2006 of Canadian Association of Physicians of Indian Heritage.

For more on these ideas: Google Tsunami Chaos Global Heart

I would like to congratulate CAPIH for achieving the launch of an organization that will be very important for medicine, health and humanity.

Last year talking about heart disease in South Asians, AAPI said in Houston, “Houston, we have a problem.” This year CAPI should say at the CN Tower Skypod we have an Action Plan. That should keep both AAPI and CAPI happy.

My talk bridges the gap from gold, how to make a million to how to save a billion people and from wealth to health. “GOLD, should we invest?” becomes “HEALTH, how should we invest?” Health these days is not just health however, it is everything, from socio-economics and real economics, the dismal science to real science, mathematics, risk management and even derivatives. Investing in health means investing in everything, from math to medicine, from economics to ecology. 

My friend Michael Kangalee, Director of Medical Administration for Surrey Health Services had invited me in 1995 to speak on Heart Disease in South Asians in BC, which led to the BC Heart and Stroke SA initiative and to various discussions. He says he’s not coming all this way to hear the same thing again, but to hear something new and provocative, but no more than three points.  So blame or thank Mike for what you are going to hear now - Change, Heritage, Health which will morph into choice, chance and change.

I finally opened a book I bought a few years ago - Stephen Wolfram’s - A New Kind of Science, 1200 pages and quite heavy - at10 lbs. How many of you bought it? How many of you read it? It’s like Stephen Hawking’s A Brief History of Time, the world’s least read most popular book. The CN Tower and that book screams for new ideas, extend horizons, seek new perspectives and be provocative.

I suggest that the different pattern of diabetes and CV diseases in South Asians and others, is a new kind of disease requiring a new kind of prevention and management ---- a derivative disease arising from complex dynamic interactions of biology and society - a disease of the nature of interactions, moving from a biological Theory of Medicine to a new Mathematical Theory of complex dynamics. Stephen Hawking would agree. He said that this is the century for complexity. 

How many of you buy this...... Economics Nobel Laureate Amartya Sen in Ottawa a week ago, discussing social determinants of health, said that skepticism is good; it stimulates discussion. So please disagree, and lets talk about it.

I actually talked to Dr Dhalla about this about 10 years ago. He was not impressed. He sent me to see some guy in New York. It was not a psychiatrist.

Less provocative are these stories of change, heritage and health.

• The 50^th Anniversary Celebrations in Guyana of Indian Independence was held without the Indian Ambassador. He died of a heart attack preparing for it at the age of 55, despite a healthy diet, frequent exercise and remaining slim. His next posting was to be Toronto.

• The Indian Cultural representative bringing Indian culture to Guyana lived next door to me in the 60’s, moving later to Toronto. He had a bypass at a young age, a metaphor for culture and health.

• Children of patients seen 25 years ago now seen with heart disease. They had received good usual care - clearly not enough.     

• A 60 year old physician in Canada - 2 vessels 100%  blocked and the third 95%, followed his best prevention - not enough.

Raises the question - do you know what your arteries look like?

• Trinidadian born Vidya Naipaul who writes about South Asians’ experiences around the world spoke of his book “An Enigma of Arrival” at his Nobel Prize for Literature Acceptance Speech. His brother Shiva died of a heart attack in his 40’s at Oxford.

It is another enigma of arrival - the excess, premature and different pattern of diabetes and CVD in South Asians across the diaspora, requiring a new thinking.

South Asian health across the diaspora is a call to action. A Working Group met in London UK in December to plan strategies for multilevel change. This weekend brings us closer to a much needed international collaboration to solve and act on this complex problem.

I told you its like math.

Here’s what we need to do.

1) Change the Way you See Everything – through Asset based thinking

Kathryn Cramer and Hank Wasiak, Google title for image or at

http://www.amazon.com/Change-Way-You-See-Everything/dp/076242723X

Like Mahatma Gandhi’s “There is no way to Peace. Peace is the Way” CHANGE is the way. 

How we see the world determines the way to change. At the OMA last evening, Dr John Howard described the ecosystem type medicine and health at Schulich UWO Med School where social, economic, biological and other systems nested in each other shape the future. Chaos and complexity is the basic science for this, which should be second nature for South Asians who live this daily, in the complexity of identity, life, politics, diversity, complex cities,

and even Bollywood, filled with nonlinearity and turbulence, bifurcations and self-criticality, people instantly transported from a village in India to the slopes of Europe or the beaches of Mauritius, boy meets girl always by chance, or necessity, order and chaos intertwined. Change the way you see Bollywood and maybe get CME credits for Bollywood tomorrow?

2) HERITAGE or IDENTITY: Change the way you see Identity - and health.

At a social determinants of health talk in Ottawa last week, Amartya Sen mentioned his recent book Identity and Violence: the illusion of destiny, claiming that the focus on one aspect of identity, religion or other, has been exploited for violence. He feels that choosing to see ourselves and each other as complex everchanging multiplicities rather than monocultural in a multiple monocultural society, may reduce ethnic violence. 

Similarly South Asian ethnicity and health: the illusion of destiny.  South Asian ethnicity should not imply destiny, of violence or of health. We should tap the multiplicities of our identity to change health. Ethnicity is not the problem, it is sensitivity and complex or nonlinear dynamics which needs attention. 

3) Action Plan for change: system failure and a systems approach

Reducing CV globally requires addressing the specific needs of South Asian and other vulnerable communities, in whom CV diseases behave differently. Although the risk factors are the same, the dynamics, severity, prematurity and progression are different, requiring the usual, as well as different strategies for change. 

A recent Scientific American Special Issue reports an Action Plan for the 21^st Century, with three intertwined transitions, demographic, economic and environmental transforming the next few decades. South Asians as one seventh of humanity, will be affected. UN Secretary General Kofi Annan says that to reach Millennium Development Goals, which may soon include reducing CV diseases, we must break with business as usual…” To reduce CVD for South Asians we must do the same.

Bringing these three ideas together:

Jeff Reading brought these three points together in this week’s CMAJ Editorial “The Quest for Aboriginal Health” – writing “diabetes [I will add and CVD] is a complex disease nested in the experience of rapid social and cultural change: thus its prevention and control may need new ideas that go beyond an individual approach in a clinic or hospital ward.”

Every time you hear the word complex this weekend, remember – If you call it complex, you have to learn complexity. Maybe CAPI buys one of my books every time someone says complex this weekend, then I won’t have to invest in gold.

A new idea in the quest for South Asian health would be its complex dynamics and  fractal patterns worldwide - self-similar with regional differences - a new geography and dynamics of health and disease, requiring different strategies. Ethnicity then becomes a unifying force and a tool for change, as today, bringing us together for the view, with new ideas and perspective.  

A Working Group on South Asian Health met in London UK in December to look at Guidelines and action plans. At meetings like CAPIH we need to give time for feedback and strategy, hear about the experiences of those working in the field, discussing how to take the evidence to where it is needed.

HERE’S WHAT THEY DO- SHOW UK BOOKS.

I understand my 3 page Action Plan giving Guidelines and discussing this, on which this talk was based did not make it to the printers. Look for it on the website. And to read about these ideas just Google Tsunami Chaos Global Heart.

CONCLUSIONS:

1) South Asian ethnicity should not imply destiny, of violence or of health.

2) To ensure this, please join us in shaping a New South Asian Health.

3) What can we do this weekend?

1. At the end of every session and the conference think of an Action Plan for Change.
2. Ask not what new things you learn but what new things you can do
3. Use the ideas of Asset Based Thinking in this book to focus on a new kind of change

• Opportunities rather than problems
• Strengths more than weaknesses
• What can be done instead of what can’t

As physicians, we have an important role as agents of change, not only for the individual patient in our office, but to change the community. We need to go beyond awareness, to making the change happen. We need to change the very fabric of what it is to be South Asian, by changing the complex and dynamic interactions. CAPIH gives us the opportunity for this, for choice, and a chance for change.  Thank you.

 CORONARY ARTERY DISEASE AND DIABETES IN SOUTH ASIAN EMIGRANTS

By Feroze Omardeen MBBS, MRCP, DM 

Presented at ISER_NCIC conferences on Challenge and Change: the Indian Diaspora in its historical and contemporary contexts. The University of the West Indies, St Augustine, Trinidad, 11-18 August, 1995 

INTRODUCTION

Q: Is there any disease in your family?

A: No, doc. Just the usual pressure, sugar, heart.

-An East Indian Trinidadian, 1994

Certain chronic diseases have become so prevalent in the East Indian community in Trinidad that their occurrence is almost accepted as part of normal existence.

All Trindadian hospital doctors are aware of the extraordinarily high incidence of diabetes mellitus and myocardial infarction (heart attacks) in Indian trinitarians. In the past, basic and clinical research into these two diseases has been carried out principally in white European populations. Such research indicated that these chronic diseases are related to lifestyle, principally nutritional factors. They are incurable diseases. Treatment is directed at improving the quality of and prolonging life.

Diabetes (noninsulin dependent diabetes) is a disorder of metabolism whereby the normal mechanisms for control of blood sugar are deranged. The resulting high blood sugar level has a multitude of long term damaging effects on the heart, kidneys, eyes and nerves.

Atherosclerosis is a disease of arteries, a system of branching tubes that supply all organs with blood.

Atherosclerosis disease damages the inner lining of these vessels , causing deposition of lump- like plaques .

Typically this process may affect the coronary arteries which supply the muscular wall of the heart with blood .

Plaques may narrow the coronary arteries and if occlusion of the arterial channel occurs,   the area supplied by that artery dies in a process commonly referred   to as a heart attack - medically   a myocardial infarction.     Atherosclerosis and diabetes did not exist in primitive traditional societies. Life was very different then. Westernization has resulted in profound changes in our lifestyle, especially in our diet and in our level of physical activity.

In the developed Western countries coronary artery disease prevalence has risen rapidly in this venture to peak in the l960s. Thence there has been a slow but highly significant decline in frequency of heart attacks. The decline has correlated with an improvement in public understanding of the condition in the developed countries and a gradual decline in hazardous lifestyles. Dietary changes, exercise and reduced rates of tobacco consumption have accounted for the great reductions   in heart attack rates in North America and Europe.

Studies on Japanese migrants to the United States have demonstrated that a migrant population will gradually acquire the rates of coronary disease of its adopted country. This rule is now generally taken for granted.

However there has been a striking and remarkably

consistent exception - Indian emigrants overseas.

Emigration to the plantation communities occurred from the 1860s onwards but the British Indians are largely late arrivals most of whom arrived in the UK after 1960.

CORONARY DISEASE IN THE DIASPORA COMMUNITIES

  In 1957 in Singapore a pathologist noticed that at postmortem indian males were 7 times as likely to have coronary disease as Chinese males (Danaraj et al 1957). In 1959 Shaper reported his experience in Kampala. Beginning with the statement that ''in the African population of Uganda coronary artery disease is virtually nonexistent, he documented that 43% of deaths in Indian males over age 30 were from heart attacks.

      From the early l960s, a series of reports appearing in the South African Medical Journal clearly documented the high coronary mortality in the Asian population of the Republic of South Africa (RSA). Walker in 1963 described ''wide extremes'' of mortality in coronary disease in different ethnic groups in the RSA. He found the whites to have one of the highest rates of coronary disease in the world. The ethnically African population was almost unaffected, but the Indians had rates equal to the whites.

By the time that Wyndham (1979) published mortality rates fifteen years later, the Asians had clearly overtaken the whites, particularly in the younger age groups of 35 to 54. At this point the RSA Indians probably had higher rates of coronary disease than any other ethnic group in the world.

  By then reports had already appeared from other areas. In Fiji, a 1973 study (Sorokin et a1) indicated that 87% of heart attacks were in indians who comprised 50% of the population. In Jamaica where Indians made up only 2% of the population, they sustained 15.6% if heart attacks (Ashcroft and Stuart, 1973).

In London the problem was first reported in 1975, when Tunstall Pedoe et al described the pattern of heart attacks in the East London district of Tower Hamlets. They found the large West Indian community (predominantly of African descent) to be ''remarkably free of the disease but Asians to be excessively vulnerable. Several subsequent reports in the 1980s would confirm the high prevalence, severity and prematurity of coronary disease in the British Asian population, while other immigrant groups consistently had low levels. In Birmingham in the late 1980s (Lowry et al, 1984) the relative risk of infarction in Asians was almost 3 times that of whites. By the early 1980s, British medical registrars were becoming accustomed to being called at six a.m. to treat Indian men with massive heart attacks. Most disturbing, however, was the age of the patients involved. The disease occurred prematurely in Asians with devastating effects on men in the late bus and 40s. This was a consistent, outstanding feature of infarcts in Indians, the tendency to occur in young males at the peak of their productive life. Rahaman et al studied myocardial infarction in the young in the San Fernando hospital in 1981. That study found all the patients with heart attacks at a young age to be East Indian.

CORONARY HEART DISEASE IN INDIA

One might next ask if India was experiencing a similar problem. The vast geographic, cultural, genetic aid socioeconomic diversity of India makes large scale epidemiologic study difficult and expensive. Relatively little work was done in the early stages. Padmavati reviewed three small epidemiologic studies in 1962. She concluded that in the lower income groups coronary disease was virtually unknown, although some urban high income groups were beginning to show significant rates. Later work in the 1960s and 70s confirmed that rates were rising in urban Indians. (Savotham and Berry, 1968; Dewan, 1974). In a tertiary care centre for cardiovascular diseases in Vellore, a review of 40,000 admissions over a 30 year period revealed a linear rise in the proportion of patients with coronary disease from 4% in 1960 to 33% in 1989, but it is difficult to extrapolate from that data to gauge the prevalence of the disease (Krishnaswami et al 1991). Prevalences reported from rural areas remained low (Jagoo et at, 1993).

THE DIABETES EPIDEMIC

Equally disturbing figures were emerging about diabetes mellitus in Indian emigrants, beginning in South Africa. In the late 1970s the death rate there for diabetes in Asians was eight times that in Whites (Wyndham et al 1979). In Trinidad and in London similar  extraordinary prevalence of diabetes (approximately 20% of adult Indians) were being reported.

Historically in India diabetes was said to be a disease of the affluent. Ramaiya et al (1990) reviewed the existing epidemiologic studies on diabetes in India. In the early 1970s urban and rural reported prevalence were very low, between 0.5 and 2.3%. Even in 1979 a survey of rural chronic diseases did not mention diabetes (Gary et a1). By 1992 a study be Ramachandran and colleagues in Madras indicated prevalently of 8.2% in the urban sector, and rural rates by comparison of 2.4%.

So in rural India diabetes is still uncommon, even today. The majority of Indian emigrants originated from such rural areas. And the first generation of arrivals in Britain were in 1985 showing prevalences of diabetes 3.8 times as high as their European coworkers in Southall (Mather and Keen, 1985). Mc Keigue restudied that area in 1991 to show that this figure had risen to 4.3 times the Europeans. By then 19% of adult Southall Asians were diabetic. This figure was similar to that produced by the St. James study in Trinidad, showing 19% of adult Indians to be diabetic (Buckles et al 1986).

 In summary, while rates of coronary disease began to decline steadily in Western countries from the l960s, and while rates in India were still low, Indian emigrants experienced a striking rise in their rates of coronary disease that was to exceed the rates of their adopted countries, their native country and of other migrant groups. Also in epidemic proportions was diabetes mellitus. Thus Indian emigrants have broken a basic epidemiologic rule. Their levels of these diseases have far exceeded the levels in their adopted country and those of other migrant groups in parallel situations.

  These changes in the health of the migrants occurred quickly - in the case of the British group, within one generation. In the case of the plantation communities, we only know of  reports dating from   the late 1950s , several generations after   their arrival. However we have every reason to believe that the epidemics of diabetes and coronary disease began after the 1950s in the diaspora peoples. For almost a century these Indian migrants had lived sheltered, relatively isolated existence on the estates.

The few early studies in Trinidad tell us that heart attacks were uncommon here before 1960. According to Wattley's 1959 report the San Fernando General Hospital was then seeing approximately 17 cases of myocardial infarction per year. In the same hospital in the early l990s, approximately 340 cases are seen per year (Parsad, personal communication). Thus Trinidad has witnessed a dramatic rise in its rates of coronary disease in the 1960s and 70s. These were decades of great changes for the Indian community in Trinidad, seeing a shift to nontraditional occupations away   from the estates, toward a more sedentary lifestyle.   

SUBGROUPS AT RISK?

All diseases are caused by ''nature'' (the genes), ''nurture'' (environmental factors) or both. It is accepted that coronary disease and diabetes are diseases that have genetic predispositions but are profoundly subject to environmental (principally   nutritional) influences. Investigators first  tried to determine if   any subsets of the migrants were particularly susceptible.

McKeigue's group conducted studies with Gujarati Hindus in Brent, Bangladeshi Muslims in Tower Hamlets, and on areas that were predominantly (52%) Sikh. Knight et al (1992) studied a community in Bradford in which over 60% were Muslims. Epidemiologic reviews (Balarajan 1984) of death statistics showed that the high mortality from coronary disease in Britain was shared by Gujarati Hindus, Punjabi Sikhs, South Indians, and Muslims from Pakistan and Bangladesh. The high risk of Indian emigrants transcended social class, caste and religious groups, occurring in both vegetarians and nonvegetarians, rich and poor.

An important recent study by Ramaiya and co-workers (1991) in Tanzania has demonstrated that the emigrant Indian community is not homogeneous in risk for diabetes. They demonstrated widely differing prevalences of this disease in seven Gujarati castes in Tanzania with differing lifestyles and standards of living. At one extreme were the Bhatia group, a relatively wealthy merchant class with a prevalence of 3.4%. At the other end of the scale were the Limbachias, a relatively poor group, with a prevalence of 18%. The observation confirms that diabetes risk is not simply an indication of economic surest. The findings of this study are not easily explained and deserve further investigation.

CONVENTIONAL RISK FACTORS IN INDIAN EMIGRANTS

The health of poor migrants is not a subject that commands large quantities of research money. However lessons from transitional populations could shed light on the causation and treatment of major diseases of the Western world. For this reason, some attention how   focused on the Indian emigrants.

The next logical step was to quantify known risk factors. For instance, blood levels of fats such as cholesterol and triglycerides are well known risk factors in development of coronary disease. The blood cholesterol level is a powerful predictor of coronary disease in all populations. In Indian emigrants the total cholesterol is, as expected, higher than in their ancestors and families in India. However their cholesterol levels are lower than those of their white coworkers, even though their mortality from coronary disease is 40% higher than their coworkers. Hughes et al (1990) in London compared Asian and white survivors of myocardial infarction, commenting that ''in Asian men the lower level of total cholesterol compared to whites may be misleading" in terms of  assessing risk.

The St James survey done by a CAREC (Caribbean Regional Epidemiology Centre) group in Trinidad was a major contribution (Buckles et al 1986). This study showed a high total and cardiovascular mortality in adult East Indians in St James, emphasizing the poor health of the Indian community in Trinidad. Indians had an all cause mortality 1.5 times that of Africans and 1.8 times that of Europeans. The age adjusted incidence of new coronary disease in men (per 1000 patient years) was 16.4 in Indians, 6.8 in Africans, 6.2 in whites and 2.4 in men of mixed descent (Miller 1991). More importantly, the St James study demonstrated that conventional risk factors did not explain the high coronary mortality.

In fact Trinidadian Indians were showing a lipid profile rather similar to diabetics in the white populations. The Triglyceride and Very Low Density Lipoproteins (VLDL) levels were increased, while the high Density Lipoproteins (HDL) were low. In a sense, all Indian Trinidadians, including the 4/5ths who were nondiabetic and the 1/5th who were diabetic, had a tendency to behave metabolically like diabetics.

HYPERINSULINEMIA AS A POTENTIAL ATHEROGENIC MECHANISM

The close relationship of diabetes and coronary disease had long been recognized, but new clues were

  beginning to appear from ongoing research. In healthy French civil servants (Ducimetiere 1980) insulin levels had been found to be predictive of future development of coronary artery disease. A hypothesis put toward by Reaven (1988) proposed that a metabolic syndrome of resistance to insulin action was important in the genesis of coronary disease. Insulin is the major anabolic hormone in the human body. Resistance to its effects causes diabetes in its extreme form, and is associated with hyperinsulinemia (increased insulin levels) to attempt to overcome the resistance.

Hyperinsulinemia is also associated with central deposition of body fat in the abdominal region and with elevation of the triglyceride level in the blood. Doctors working among Indian emigrants soon realized that these patients fitted the description of insulin resistance perfectly, The St James study in Trinidad had produced a picture of lipid abnormality indicating insulin resistance. The next step was to screen the Asian emigrants for the syndrome.

  This was done in the early 1990s in Britain with remarkably consistent results. Two British studies have specifically sought this atherogenic profile in South Asians. McKenzie's. group (1991) studied a population in which Sikhs (52%) predominated but included Muslims, Puccini Hindus and Gujarati Hindus. In all of these groups there was a strong tendency to central obesity, hyperinsulinemia, increased triglycerides and diabetes. Knight et al (1992) carefully documented anthropometric data in a group in which Pakistani and Punjabi Muslims predominated (63%) over Gujuratis (31%). They again found higher waist-to-hip girth ratios, and higher truncal skinfolds thickness in Asians compared with their European counterparts. Despite the fact that postprandial serum insulin was twice as high in the Asians, glucose tolerance was poorer, indicating resistant to insulin action.

Essentially, Indian emigrants showed high fasting and postprandial insulin levels, a lipid profile of high triglycerides and low HDL, high precedences of diabetes mellitus, high blood pressures, high trunk skinfold thickness (fat) and high waist to hip girth ratios (pot bellies ). McKeigue concluded in 1991 that his results ''confirmed the existence of an insulin  resistance syndrome prevalent in South Asian populations.

The World Hea1th Organization in January 1994 endorsed the concept of insulin resistance as a predisposing factor to coronary disease and has put toward the following research recommendations : 1) The importance of the metabolic insulin resistance syndrome should be studied in detail 2) Prospective studies of the relative importance of the components of the syndrome should be undertaken 3) Comprehensive population studies should be undertaken to establish the prevalence of the syndrome by age and sex.

The theory of atherogenesis causation by insulin resistance goes as follows; all Indians will hypersecrete insulin in response to a carbohydrate meal, in an attempt to compensate for the resistance to insulin's action. You're ''damned if you don't" secrete enough to keep the

blood sugar normal, because then you become diabetic and suffer the consequences of hyperglycemia. You're ''damned if you do'' secrete enough, because even if you are not diabetic, you are still hyperinsulinemic with a tendency to coronary disease. The elevated insulin levels may be atherogenic directly (as insulin is a growth factor in the arterial wails), or may cause arterial damage via its disturbance of lipid metabolism (reducing the levels of the protective HDL lipoprotein).

NATURE OR NURTURE?

Two other ethnic groups have displayed extraordinarily high prevalently of diabetes. These are the Pima Indians in Arizona and in a Melanesian group of the Pacific island of Nauru.

Neel's 1962 "thrifty genotype'' hypothesis was put toward to explain the epidemic of diabetes in Nauru but was equally applicable to Indian migrants. Essentially it states that in the original environment (of rural India), there is a survival advantage conferred by diabetogenic genes, which would cause peripheral resistance to some of the actions of insulin. These genes would be well suited to times of deprivation, with minimal and irregular caloric intake (abreast and famine'' conditions), causing secretion of relatively large and rapid insulin responses to food. Insulin is the major anabolic hormone in the body and would optimize utilization and storage of ingested food. lf such an individual is transferred to a situation of unlimited and excessive caloric intake his thrifty genes would be maladapted, causing excessive deposition of the calories as body fat.

Such genetic programming would be impossible to change. Programming of metabolism may, however, in other ways. In the past decade attention has focused on early life experiences in the production of diabetes and coronary disease in white populations (Barker et al, 1989; Hales et al 1991). It has been suggested that nutrition in late intrauterine and early postnatal life will ''program'' an individual's   metabolism for life .

Should a child be exposed to conditions of relative deprivation in early life his metabolism will be set to this level of nutrition, and would be unable to easily adjust to overnutrition in later life. Thus a transitional population may be at higher risk. For example Trinidadians born to relative deprivation in the 1930s may have experienced significant changes in their circumstances by the time they reached their 40th birthday, with an unlimited caloric intake for which they were not programmed.

Although these hypotheses cannot explain why Africans, Chinese and other migrants do not develop insulin resistance and the attendant chronic diseases, they are useful ideas for guiding research. More recent work (Bhatnagar 1995) has compared Punjabi migrants in West London with their siblings who remained in the Punjab. There were two major findings. The Punjabi migrants in London showed greater insulin resistance than  their Indian siblings, but even this factor appeared unable to account for the high excess mortality of British Asians. Elevated lipoprotein (a), a genetic marker for coronary disease was found to be very high in both groups, indicating a high genetic susceptibility of Asians. Thus both genetic and environmental factors co-exist. The genetic background of East Indians does not cope well with the environmental factors of Western lifestyle.

Although much has been written and said about the quality of Asian's diet, the bulk of the available data suggest. that the total caloric intake is the more important factor i.e. quantity of food rather than type of food. Migration has promoted increasing obesity, a more sedentary lifestyle and dietary changes that, acting on the substrate of the genes (and perhaps metabolic programming), have had disastrous consequences for Indians. Since the major factors are total caloric intake (overeating) and lack of exercise, preventive medicine potentially has a large part to play in the health of Asian emigrants.

WHAT CAN WE DO?

There is no pill, no magic bullet that science will produce that can cure or prevent diabetes and coronary disease. By the time these diseases come to medical attention they are generally at an advanced stage, incurable, and extremely expensive to treat with modern tertiary care. These diseases have already had tragic effects in the Asian emigrant communities. The potential

consequences for the native peoples of the Indian subcontinent itself are enormous. Further ''westernization'' in the lifestyle of urban and rural Indians could lead to disastrous consequences, if the experience of the emigrants is repeated on a larger scale.

What can we do? The answer is simple, yet most difficult to accomplish. Indian emigrants all over the world must be highly motivated to live disciplined, healthy lifestyles that go strongly against the currents  of market-driven consumerism and the physical inactivity of the modern world. Intense public health pressure on the Indian communities to alter lifestyle is vital if the high mortality and morbidity from coronary artery disease and diabetes is to be reduced.

Heart Healthy Eating for South Asians

By Neera Chaudhary South Asian Community Nutritionist

Did you know that South Asians are more likely to suffer from heart attack or stroke more than any other ethnic group? In Canada, 42% of all deaths among South Asian Canadian males are due to heart disease and 29% of all deaths among South Asian women. Findings published in The Lancet, a prestigious international medical journal, conclude that though European Canadians are more likely to have clogged or hardened arteries – a major risk factor – South Asian Canadians are still twice as likely to suffer a stroke or heart attack.

Head researcher Dr. Anand, an assistant professor of medicine at McMaster University, predicts that the number one cause of death by the year 2020 globally will be cardiovascular disease. The greatest number of people affected will be in developing countries like India and China. South Asians and Chinese represent over half of the world’s population and have rising rates of heart disease. It is important to identify the unique risk factors of these ethnic groups in developing and implementing strategies for the prevention of cardiovascular disease.

The study concluded that one identifiable risk is that South Asian Canadians were much more likely to develop blood clots than any other ethnic groups. Reason being, they exhibited higher levels of certain proteins that impair the body’s ability to dissolve blood clots in the arteries. The findings also indicated that South Asians tended to be heavier than European and Chinese Canadians and they are much more likely to put on weight around the abdomen, another risk factor for the disease. Other factors include high cholesterol levels, high blood pressure, smoking, an inactive lifestyle, being overweight, gender, aging, having diabetes and a personal or family history of heart problems.

So How Can You Reduce the Risk for You and Your Family?

One helpful way is to adopt a healthy traditional South Asian lifestyle. Going back to a more traditional diet, changing the way you prepare foods, avoiding convenience foods, and making better food choices will help reduce your risk of heart disease. By adding some form of exercise, meditation or doing yoga are all ways you can protect your heart and lead a long, healthy life.

Some Heart Healthy Nutrition Tips

Follow Canada’s Food Guide, which stresses the importance of a well-balanced diet that includes a variety of foods from each of the four food groups. Foods are grouped according to the major nutrients they provide. The number of servings you need depends on your age, gender and activity level. Each food group contains both high fat and low fat food choices. Select the lower fat food choices within each food group more often. Strive to include at least three of the four food groups at each meal.

Eat Less Fat

Due to a variety of factors, South Asians living in western countries consume a large amount of fat. On average about 40% of their energy comes from fat. You should reduce your total fat consumption to 30% of what you eat each day. Choose healthy fats and reduce your consumption of unhealthy fats. Treat your heart right by eating very little of the "bad" fats (saturated and hydrogenated). You should eat a bit more of the "good" fats (polyunsaturated and monounsaturated), but keep moderation in mind. Monounsaturated fat seems to be the most heart healthy and can be found in canola oil as well as olive oil.

Change How You Prepare Food

The South Asian diet can be a wonderfully balanced one. However, the addition of fat when cooking foods, such as dahls, sabzis and rotis adds unnecessary fat and calories. You can dramatically reduce the fat in these foods by slightly adjusting how you cook and prepare them without altering the taste.

Some Tips to Change How You Prepare Food:

• When cooking, use canola oil or olive oil and soft margarines instead of saturated fats, such as ghee, butter, shortening, coconut oil and sesame seed oil.
• Trim off all fat before cooking meat and poultry.
• Measure the amount of fat you add for tarka with a spoon, rather than pouring the oil straight from the container and gradually reduce the amount you use.
• Avoid deep-frying and frying parathas, samosas, paneer and pakoras. Try baking or broiling them instead.
• When dishes are cooked and cooled, skim off any visible fat that has hardened on top.
• Use ground chicken or ground turkey to make keema.
• Try tandoori-style, broiling, grilling or baking meats instead of making curries.
• Use 2% or 1% milk when making homemade yogurt (dhai).

Replace recipes that call for paneer with firm tofu. No one will notice the difference!

Increase Your Fibre Intake

The traditional South Asian diet is very rich in fibre and complex carbohydrates, which are good for your heart. A healthy diet should include plenty of fibre in the form of fruits, vegetables and whole grain products. It is especially soluble fibre, found in dahls and oatbran that seems to lower blood cholesterol. Eat more foods that contain fibre and complex carbohydrates by:

• Using whole-wheat flour or graham (channa) flour for chapatis, rotis and other breads.

• Mixing a tablespoon of oat bran for every cup of flour when making dough for chapatis and rotis.
• Trying steamed or boiled rice instead of pulau or biryani. Use fibre-rich brown rice occasionally.
• Using more whole dahls and beans with the skin left on, such as whole mung, whole channa and red kidney beans (rajma). Lentils are a great source of soluble fibre that helps lower cholesterol.
• Eat more vegetables and fruit and eat them unpeeled. Eat fruit instead of drinking fruit juice.

Don’t forget about taste! Traditional Indian cuisine combines herbs and spices to create unique flavours. Aromatic and colourful masalas reduce the need for salt and add variety to very simple dishes. Add flavour to your meals by having low-fat chutneys and pickles (achaar). Avoid pickles preserved in oil, or drain the oil from your serving. Here is a great recipe for mint chutney (padeene ki chutney) that is fat-free and great in taste!

Drink Less Alcohol and Quit Smoking

Excess consumption of alcohol has negative affects on the heart. If you drink limit yourself to no more than two drinks per day. Reduce the amount of alcohol you consume by drinking low or no-alcohol beer or by mixing wine or spirits with low-sodium mineral water. To protect your heart avoid binge drinking.

Smoking damages your blood vessels and contributes to heart disease. People who smoke are two and a half times more likely to have a heart attack than people who don’t smoke. It is advised that you stop smoking for your own benefit and the benefit of people exposed to your second-hand smoke.

Include Physical Activity and Reduce Stress

Often we find it difficult to include regular exercise in our busy schedules. And with stress as a part of modern life we need to learn to incorporate a "de-stressing" strategy. You can learn to manage stress and keep it from affecting your health by including some form of regular exercise. Set aside some time each day, at least 10 minutes, to relax. Try meditation or yoga and get plenty of sleep, these can all help reduce stress.

Though South Asians are at a greater risk for heart disease than any other ethnic group, by employing a traditional South Asian lifestyle we have an effective way to reduce the risk of cardiovascular disease. Making wise choices when it comes to eating and preparing food can be simple. By making small changes gradually and adopting a

healthy diet we can protect our hearts. Remember to celebrate the food that is traditionally yours!

Some Tips to Reduce Fat in Your Diet:

• Avoid spreading butter, ghee or margarine on chapatis or rotis.
• Choose meats labelled lean or extra lean. Limit lamb, pork, goat and beef.
• Limit the intake of high cholesterol foods such as egg yolks, cheese and shrimp.
• Eat chicken without the skin, and eat more fish.
• Choose dahls and other legumes more often
• Choose 2%, 1% or skim milk.
• Avoid foods prepared in fat, such as puris, bhaturas, samosas, pakoras, and other fried snacks.