Metabolic syndrome and cardiovascular disease in South Asians

Figures & data

Table 1 Definitions of metabolic syndrome

	WHO (1999)	NCEP ATP III (2001)	IDF (2005)	EGIR (1999)
	Diabetes mellitus, impaired glucose tolerance, impaired fasting glucose, or insulin resistance* with two or more of the following:	Three or more of the following:	Central obesity (ethnicity-specific)‡ and two or more of the following:	Nondiabetics with insulin resistance§ and two or more of the following:
Fasting glucose		≥ 110 mg/dL (6.1 mmol/L)†	≥ 100 mg/dL (5.6 mmol/L) or T2DM diagnosis	≥ 110 mg/dL (6.1 mmol/L), but nondiabetic
Obesity	Central obesity (WHR > 0.90 in males or >0.85 in females) and/or BMI > 30 kg/m^2	Waist circumference >102 cm (40 in) in males or >88 cm (35 in) in females		Waist circumference ≥ 94 cm (37.0 in) in males or ≥ 80 cm (31.5 in) in females
Blood pressure	≥ 140/90 mm Hg	≥ 130/≥ 85 mm Hg	≥ 130/≥ 85 mmg or treatment	≥ 140/90 mm Hg or treatment
Triglycerides	≥ 150 mg/dL (1.7 mmol/L)	≥ 150 mg/dL (1.7 mmol/L)	≥ 150 mg/dL (1.7 mmol/L) or treatment	> 178 mg/dL (2.0 mmol/L) or treatment
	and/or			and/or
HDL cholesterol	< 35 mg/dL (0.9 mmol/L) in males or < 39 mg/dL (< 1.0 mmol/L) in females	< 40 mg/dL (1.03 mmol/L) in males or < 50 mg/dL (1.29 mmol/L) in females	< 40 mg/dL (1.03 mmol/L) in males, < 50 mg/dL (1.29 mmol/L) in females, or treatment	< 39 mg/dL (1.0 mmol/L) or treatment
Other	Microalbuminuria (urinary albumin excretion rate ≥ 20 mg/min or albumin:creatinine ratio ≥ 30 mg/g)

* Notes: Refer to WHO publication for definitions of hyperglycemic states. Insulin resistance defined as glucose uptake below lowest quartile for background population under investigation, in hyperinsulinemic, euglycemic conditions.

† Revised in 2004 to ≥ 100 mg/dL (5.6 mmol/L) to reflect the American Diabetes Association’s updated definition of impaired fasting glucose.^9,132

‡ Defined as ≥ 94 cm (males) or ≥ 80 cm (females) in Europids and ≥ 90 cm (males) or ≥ 80 cm (females) in South Asians, among others.

§ Defined as the 25% of the nondiabetic population with the highest insulin resistance or the highest fasting insulin concentrations.

Abbreviations: BMI, body mass index; EGIR, European Group for the Study of Insulin Resistance; HDL, high-density lipoprotein; IDF, International Diabetes Federation; NCEP ATP III, National Cholesterol Education Program Adult Treatment Panel; T2DM, type 2 diabetes mellitus; WHO, World Health Organization; WHR, waist-to-hip ratio.

Table 2 Cited primary works relating to metabolic syndrome and cardiovascular disease in South Asians

Topic of focus	Studies in native populations	Studies in migrant populations
Cardiovascular outcomes and epidemiology	Joshi,^Citation24 Xavier,^Citation25 Joshi,^Citation26 Yusuf,^Citation48 Deepa^Citation111	Palaniappan,^Citation18 Sheth,^Citation19 Harding,^Citation20 Tuomilehto,^Citation22 McKeigue,^Citation32 Singh,^Citation33 Gupta,^Citation34 Wilkinson,^Citation35 Patel,^Citation36 Miller^Citation53,Citation54
Traditional cardiovascular risk factors	Joshi,^Citation26 Yusuf,^Citation48 Hodge,^Citation50 Lubree,^Citation58 Rastogi^Citation61	Bhopal,^Citation16,Citation73 Enas,^Citation29 Singh,^Citation33 Gupta,^Citation34 Patel,^Citation36 Anand,^Citation45 Miller,^Citation54 Tai,^Citation55 Bhatnagar,^Citation88 Miller,^Citation112 Kamath,^Citation122 Lear^Citation127
Diabetes mellitus	Mohan,^Citation38 Sayeed,^Citation39 Lubree,^Citation58 Snehalatha,^Citation100 Jafar^Citation126	Tuomilehto,^Citation22 Patel,^Citation36 Venkataraman,^Citation44 Tai,^Citation55 McKeigue^Citation57
Hypertension	Jafar,^Citation126 Mohan^Citation135	Patel^Citation36
Obesity	Mohan,^Citation38 Sayeed,^Citation39 Yajnik,^Citation118,Citation142 Jafar,^Citation126 Mohan,^Citation135 Bavdekar^Citation139	Chandalia,^Citation119 Razak^Citation124
Lipid disturbances	Reddy,^Citation60 Gambhir,^Citation82 Gupta,^Citation83 Misra^Citation117	Bhopal,^Citation16 Enas,^Citation29 Gama,^Citation49 Kulkarni,^Citation52 Miller,^Citation53 Tai,^Citation55 Hoogeveen,^Citation89 Kamath,^Citation122 Lovegrove,^Citation128 Kalhan^Citation121*
Emerging cardiovascular risk factors	Joshi,^Citation26 Yusuf,^Citation48 Gambhir,^Citation82 Gupta,^Citation83 Deepa,^Citation97 Snehalatha,^Citation100 Gheye S^Citation101	Anand,^Citation45,Citation95 Hughes,^Citation51 Hoogeveen,^Citation89 Chambers,^Citation96,Citation102,Citation104 Raji,^Citation99 Chandalia^Citation103
Metabolic syndrome	Mohan,^Citation110 Deepa,^Citation111 Vikram^Citation144	Hughes^Citation51
Insulin resistance	Hodge,^Citation50 Deepa,^Citation97 Yajnik,^Citation136,Citation142 Bavdekar,^Citation139 Vikram^Citation144	Hughes,^Citation51 Tai,^Citation55 McKeigue,^Citation57 Liew,^Citation98 Raji,^Citation99 Banerji,^Citation108 Sharp,^Citation113 Chandalia,^Citation119 Chowdhury,^Citation120 Forouhi,^Citation125 Lovegrove,^Citation128 Kalhan,^Citation121* Whincup^Citation134*
Anthropometry	Dudeja,^Citation115 Misra,^Citation117 Mohan,^Citation123 Jafar,^Citation126 Misra,^Citation131 Vikram^Citation144	Patel,^Citation17 Razak,^Citation124 Lear,^Citation127 Whincup^Citation133*
Fat patterning	Hodge,^Citation50 Lubree,^Citation58 Dudeja,^Citation115 Misra,^Citation117 Yajnik^Citation118,Citation136	Hughes,^Citation51 McKeigue,^Citation57 Banerji,^Citation108 Chandalia,^Citation119 Chowdhury,^Citation120 Forouhi,^Citation125 Lovegrove^Citation128
Pediatric and developmental considerations	Yajnik,^Citation118,Citation136,Citation142 Mohan,^Citation135 Bavdekar,^Citation139 Vikram^Citation144	Kalhan,^Citation121* Whincup^Citation133,Citation134*
Other	Mohan^Citation110	Dhawan,^Citation30 Gupta,^Citation31 Abraham,^Citation66 Matthews,^Citation68 Bhopal^Citation73

* Note: Study involves the offspring of migrants.

Table 3 Distribution of acute myocardial infarction cases in the INTERHEART study

	No. of cases	Mean age ± SD at first AMI, years	% (No.) of cases before age 40
Worldwide, excluding South Asia	10728	58.8 ± 12.2	5.6% (599)
South Asian countries	1732	53.0 ± 11.4	8.9% (154)
India	470	53.0 ± 11.4	11.7% (55)
Pakistan	637	53.3 ± 11.1	8.9% (57)
Sri Lanka	153	57.7 ± 11.3	5.9% (9)
Bangladesh	228	51.9 ± 11.0	10.5% (24)
Nepal	244	58.9 ± 11.8	3.7% (9)

Note: Copyright © 2007, American Medical Association. Adapted with permission from Joshi P, Islam S, Pais P, et al. Risk factors for early myocardial infarction in South Asians compared with individuals in other countries. JAMA. 2007;297(3):286–94.

Abbreviations: AMI, acute myocardial infarction; SD, standard deviation.

Table 4 Risk factors associated with AMI in South Asia compared with other countries in the INTERHEART study

Risk factor	Prevalence in AMI cases		Prevalence in controls		Odds ratio (95% CI) for AMI		PAR, % (95% CI) for AMI
	SA	Others	SA	Others	SA	Others	SA	Others
ApoB100/ApoA-I ratio*	61.5%	48.3%	43.8%	31.8%	2.57 (2.03–3.26)	3.01 (2.77–3.26)	46.8 (36.7–57.0)	45.9 (43.0–48.7)
Current and former smoking	61.6%	65.7%	40.8%	49.4%	2.57 (2.22–2.96)	2.22 (2.09–2.36)	37.5 (33.1–42.1)	36.2 (34.1–38.3)
Hypertension	29.6%	40.5%	12.7%	23.6%	2.92 (2.46–3.48)	2.44 (2.30–2.60)	19.3 (16.6–22.4)	23.9 (22.5–25.4)
Diabetes mellitus	20.2%	18.2%	9.5%	7.2%	2.52 (2.07–3.07)	3.20 (2.93–3.50)	11.8 (9.6–14.5)	12.5 (11.6–13.4)
High waist-to-hip ratio*	44.0%	46.7%	29.6%	34.0%	2.44 (2.05–2.91)	2.21 (2.06–2.38)	37.7 (30.9–45.2)	33.3 (30.3–36.3)
Psychosocial factors (stress or depression)	86.0%	84.2%	82.6%	82.0%	2.62 (1.76–3.90)	1.83 (1.58–2.13)	16.1 (4.1–28.2)	19.6 (15.4–23.7)
Moderate- or high-intensity exercise	4.6%	15.8%	6.1%	21.6%	0.72 (0.53–0.97)	0.70 (0.65–0.76)	27.4 (11.7–51.8)†	25.2 (20.7–29.7)†
Alcohol consumption ≥ once/wk	13.3%	25.7%	10.7%	26.9%	1.06 (0.85–1.30)	0.79 (0.74–0.85)	− 4.6 (24.1–14.7)†	15.8 (11.7–19.9)†
Consumption of fruits and vegetables >1/d	20.0%	38.3%	26.5%	45.2%	0.65 (0.53–0.81)	0.70 (0.65–0.76)	21.4 (13.2–32.7)†	12.2 (9.6–14.8)†

Notes: Copyright © 2007, American Medical Association. Adapted with permission Joshi P, Islam S, Pais P, et al. Risk factors for early myocardial infarction in South Asians compared with individuals in other countries. JAMA. 2007;297(3):286–94.

* Upper one-third of global distribution.

† Statistically significant difference in South Asian population-attributable risk (PAR) compared to other countries(p < 0.05).

Abbreviations: AMI, acute myocardial infarction; ApoA-I, Apolipoprotein A-1; ApoB₁₀₀, Apolipoprotein B₁₀₀; Others, non-South Asian contries; PAR, population attributable risk; SA, South Asian countries.

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