Type 2 diabetes and cardiovascular risk in the UK south Asian community
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A popular hypothesis for the greater prevalence of type 2 diabetes and cardiovascular disease in UK south Asians is that they have an increased susceptibility of developing insulin resistance in response to certain environmental factors, including obesity and adoption of a sedentary lifestyle. Insulin resistance is postulated as a central feature of the metabolic syndrome, culminating in type 2 diabetes, atherosclerotic vascular disease and CHD; a pathway potentially accelerated by migration/urbanisation. We describe and compare the prevalence of type 2 diabetes, cardiovascular disease and their associated risk factors in UK south Asian and white Caucasian populations to determine possible reasons for the increased preponderance of these diseases in south Asians, and highlight key evidence for optimal risk factor management. Finally, we describe a UK community-based programme that attempts to reduce the morbidity and mortality from type 2 diabetes and cardiovascular disease in south Asians through a new approach to management.
KeywordsCardiovascular disease Ethnic Metabolic syndrome Migration Risk factors South Asian Type 2 diabetes
plasminogen activator inhibitor 1
plasma cell membrane glycoprotein 1
UK Asian Diabetes Study
Following the Second World War, countries such as the Netherlands, France and the UK actively recruited labour from their ex-colonies to fuel their post-war economic recovery. In a similar fashion, wealthy European countries recruited migrant labour from poorer European regions to staff their manufacturing and service industries. More recently, political changes and conflicts between different ethnic groups in central and eastern Europe have affected the size and direction of European migration flows, while flows from non-European countries continue to account for a very sizeable component of migration into Europe. The result is that all the major European countries now have significant ethnic minority populations.
The prevalence of type 2 diabetes and cardiovascular disease in south Asian immigrants
While population migration from the Indian subcontinent countries of India, Pakistan and Bangladesh (South Asia) has occurred to many parts of the world, over 2 million south Asian people have settled in the UK, representing 4% of the total population .
In most countries, the same is true for the prevalence of cardiovascular disease [7, 8, 9, 10], although some reports have shown similar risks to indigenous populations [6, 11, 12]. Although beyond the scope of this review, the prevalence of renal disease is also increased in south Asian compared with indigenous populations, and shares many of the same risk factors as diabetes and cardiovascular disease .
While not the focus of this review, data suggest that the incidence of type 1 diabetes may also be increased in UK south Asian populations compared with south Asians from the Indian subcontinent . The incidence of type 1 diabetes in children in India and Pakistan is remarkably low . However, a report that focused on an area of the UK with a high south Asian population showed that the incidence of type 1 diabetes increased in south Asian immigrants to the UK from 3.1/100,000 per year to 11.7/100,000 per year over a period of just 10 years, thus approaching that of the indigenous population [18, 20]. Such a rapid change is unlikely to be explained by genetic factors, implying an influence of environmental factors in disease aetiology.
In the UK, the rates of ischaemic heart disease (myocardial infarction and angina) are 30–40% higher amongst south Asian men than men in the general population . South Asians have an age-standardised mortality rate from CHD that is 50% higher than that for the total population of England and Wales . Women are proportionally more affected than men (increased by 51 vs 46%, respectively), and the sex difference in coronary mortality is smaller in south Asian than in white Caucasian UK populations . The excess mortality is primarily explained by an increased risk of ischaemic heart disease and type 2 diabetes [14, 22].
The excess risk of CHD is seen in all UK south Asian populations  and also applies to second-generation immigrants . Much of the excess risk also occurs relatively early [5, 8, 21, 25]. In one study, mean age at first myocardial infarction was approximately 5 years lower for south Asian men than for the indigenous UK population (50.2 vs 55.5 years) . Furthermore, the excess mortality in south Asian immigrants steadily increased with decreasing age . Other studies have also reported that south Asians frequently have premature atherosclerosis with more diffuse and aggressive disease than their Caucasian counterparts [7, 26].
Studies of rates of type 2 diabetes and CHD in the Indian subcontinent are, to an extent, confounded by limited data and the fact that rates in the Indian subcontinent vary greatly depending on geographical distribution  and socioeconomic status . Several reports suggest, however, that risk factors associated with an urban lifestyle are critical [5, 27, 29, 30]. Indeed, south Asians living in cities in the subcontinent have much higher rates of type 2 diabetes and CHD compared with rural populations [5, 27, 30], but rates are increasing in both rural and urban areas as lifestyles become more Westernised. A National Urban Diabetes Survey conducted in India in 2000 reported a prevalence of type 2 diabetes of 13.5% .
Insulin resistance, type 2 diabetes and cardiovascular risk
Defining the risk
While conventional risk factors influence the high CHD rates in south Asians just as they do in indigenous Caucasian populations, the characteristic risk factor profile of south Asians is very different. Furthermore, while CHD risk, to a large extent, is shared across south Asian subgroups, most risk factors vary enormously . Indians, in particular, are extremely heterogeneous in terms of their risk factor profiles, so findings are likely to vary in different geographical regions and communities. In particular, religion has an important effect. For example, smoking is much less common in Sikhs than in Hindus. The reverse applies to drinking alcohol . Dietary habits are also relatively diverse and are again influenced by religious belief, as well as area of origin in the Indian subcontinent.
The South Asian risk factor profile
A recent prospective cohort study that compared weight, length, abdominal circumference and skinfold measurements of newborn babies from Mysore, India, with those of newborns from Southampton, UK, reports that this pattern of body fat distribution is present at birth . Other studies have also found early evidence of altered body fat distribution in south Asians .
Certain populations may have an increased genetic susceptibility to deposit intra-abdominal fat, particularly when encountering a Western style of living. Migration and urbanisation often lead to dietary changes with higher intakes of sugars, animal fats and vegetable oils. Poor gestational nutrition as a factor for the development of chronic diseases later in life, including type 2 diabetes and CHD, is also well documented .
Reduced physical activity
Prevalence of age-standardised risk ratios for cardiovascular disease risk factors in south Asian populations compared with the general population 
Risk factor (men/women)
South Asian ethnicity
Current cigarette smoking
Obesity (BMI >30 kg/m2)
WHR >0.95 (men), >0.85 (women)
High blood pressurea
Low HDL cholesterol (<1.0 mmol/l)
High triglycerides (≥1.6 mmol/l)
High LDL cholesterol (≥3.0 mmol/l)
High total cholesterol (≥5.0 mmol/l)
Raised blood pressure
Reported prevalence rates for raised blood pressure in UK south Asians vary, with some studies showing a higher prevalence of hypertension in this population than in white Caucasians [17, 46, 47] and some reporting no difference [4, 5]. These studies were based on specific local populations sampled, e.g. from general practitioner lists, and may therefore be subject to sample bias. The large nationally distributed random sample of the Health Survey for England overcomes some of these problems . It shows that after adjustment for age there is some heterogeneity within the UK south Asian population (Table 1). Only Bangladeshi men were significantly (almost 25%) less likely to have high blood pressure than men in the general population. Bangladeshi women also had a lower prevalence of high blood pressure than women in the general population, but Pakistani women were significantly more likely (25%) to have raised blood pressure . While the prevalence of raised blood pressure in UK south Asians overall may be similar to the indigenous population, it remains a significant risk factor. Age-adjusted data show that approximately one-third of UK adults may have high blood pressure (≥140/90 mmHg). Furthermore, UK south Asians may be at higher risk of diabetic and cardiovascular complications as a result of raised blood pressure because of their overall adverse risk factor profile.
Smoking in the south Asian population overall is the same or less than white Caucasian males and low in south Asian women [5, 16] (Table 1). There are differences between groups, however, with 44% of Bangladeshis, 26% of Pakistanis and 23% of Indians smoking cigarettes, compared with 27% of men in the general population .
While total cholesterol is not significantly greater in UK south Asians (it may, in fact, be less) compared with the white Caucasian population (Table 1) [16, 48, 49], levels remain significantly higher than those seen in the Indian subcontinent . Migration is therefore clearly associated with increased cholesterol levels in this population, and raised total or LDL cholesterol remain important risk factors for the development of CHD in UK south Asians . Furthermore, south Asians have an increased prevalence of atherogenic small, dense LDL cholesterol compared with white Caucasians .
Triglycerides are almost always higher in studies on south Asians compared with those on white Caucasians (Table 1) [4, 7, 16, 45, 48, 50]. The majority of studies examining HDL cholesterol concentrations have reported lower levels in south Asian immigrants compared with white Caucasians [4, 7, 16, 25] (Table 1). This pattern of dyslipidaemia, involving raised triglycerides and reduced HDL cholesterol, is typical of the dyslipidaemia associated with diabetes and an important characteristic of the metabolic syndrome.
Emerging risk factors
A number of emerging risk markers may also play a role in the differing prevalence of type 2 diabetes and cardiovascular disease between south Asian and indigenous populations. Lipoprotein(a) [Lp(a)] has been designated an emerging risk factor by the US National Cholesterol Education Program, Adult Treatment Panel III , and serum concentrations are elevated in south Asians, irrespective of their migrant status [50, 53, 54]. Lp(a) is an independent risk factor for early atherosclerosis, and the effect is magnified where LDL cholesterol or the total cholesterol:HDL cholesterol ratio is increased . Levels of Lp(a) are largely genetically determined, accounting for over 70% of the variation in Lp(a) in the population [50, 55].
Risk markers associated with proinflammatory and prothrombotic states have also attracted attention. Levels of the acute-phase reactant, C-reactive protein (CRP), are strongly associated with CHD . In healthy UK south Asian men, CRP levels were found to be 17% higher than in European white men, and were accounted for by greater central obesity and insulin resistance . CRP levels in patients with the metabolic syndrome correlate directly with the number of metabolic abnormalities . Differences in CRP levels between south Asians and other ethnic groups have been found in children as young as 10 years of age . Adiposity was found to be a major determinant of the difference in CRP levels, and its strong associations with fibrinogen and HDL cholesterol suggest a role for inflammation in the development of atherosclerosis beginning early in life.
The secretory activity of adipose tissue may play an important role in the proinflammatory and prothrombotic states of the metabolic syndrome. The adipose tissue-derived cytokine adiponectin has regulatory functions on energy metabolism, and concentrations are inversely related to fasting plasma insulin and glucose levels. Low levels compared with indigenous populations suggest that it may be an independent predictor of type 2 diabetes in south Asians [60, 61, 62].
Both insulin resistance and type 2 diabetes are associated with endothelial dysfunction, and enhanced platelet aggregation and activation, which favour the development of a prothrombotic state and enhance cardiovascular risk . Markers of a prothrombotic state include high levels of fibrinogen and plasminogen activator inhibitor 1 (PAI-1); both have been associated with insulin resistance in south Asian and other populations. Whether this can explain the increased prevalence of type 2 diabetes and cardiovascular disease is controversial, with some , but not all , studies showing higher levels in south Asians.
A number of studies have investigated the contribution of homocysteine to cardiovascular disease risk. Although south Asians consistently have higher plasma homocysteine levels than control populations, studies are inconsistent, with some showing no difference in levels between patients with and without CHD [7, 66] and others suggesting that homocysteine may be an independent risk factor in south Asians . Interestingly, Chambers et al. suggested that raised homocysteine concentrations in south Asians may be related to reduced vitamin B12 and folate levels, implying that increased CHD risk in this group may be reduced by dietary vitamin supplementation .
Vitamin D deficiency has been found in some UK south Asian populations . Deficiency is known to impair insulin synthesis and secretion in human and animal models of diabetes, suggesting a possible role in the development of type 2 diabetes .
The metabolic syndrome
A common mechanism is thought to link the increased prevalence of type 2 diabetes and cardiovascular disease in the south Asian population. On the basis of studies comparing UK south Asian and indigenous populations, there is evidence that the pattern of insulin resistance and associated metabolic abnormalities known as the metabolic syndrome might be responsible [4, 70].
There is currently heated debate among leading professional bodies over the definition and clinical significance of the metabolic syndrome [52, 72, 73, 74]. Until recently, definitions of the metabolic syndrome did not take into account ethnic-specific variations in risk factors. The International Diabetes Federation has recently provided a definition more applicable to ethnic populations by providing a range for increased waist circumference, which is lower for certain racial groups, e.g. south Asians . Steps such as these are more likely to identify those individuals at risk of cardiovascular disease and type 2 diabetes who are likely to benefit from lifestyle interventions.
The genetics of diabetes is almost certainly complex, with a number of genes contributing something to the overall risk. Some of the susceptibility genes for diabetes are likely to be specific to certain populations, while others may be more ‘universal’, or common to multiple ethnic groups.
Both type 2 diabetes and CHD occur as a result of the complex interplay of genetic susceptibility and environmental factors. Although it is unlikely that distinct genetic factors underlie the inherited risk of type 2 diabetes and CHD in south Asians compared with Caucasians, there may be a higher prevalence of some risk alleles in specific ethnic groups. An example of an allele that may contribute to insulin resistance in south Asians is a polymorphism in the gene encoding plasma cell membrane glycoprotein-1 (PC-1), which affects insulin signalling by direct interaction with the alpha subunit of the insulin receptor, blocking insulin action. The PC-1 K121Q polymorphism has been associated with a stronger inhibitory effect on the insulin receptor than the wild-type, and occurs with a significantly higher frequency in south Asians compared with Caucasians (33 vs 26%, respectively) . Furthermore, a significantly higher insulin AUC during the OGTT and a lower insulin sensitivity during the hyperinsulinaemic–euglycaemic clamp were found in south Asians with the variant, compared with south Asians with wild-type PC-1 and with Caucasians with or without the polymorphism, suggesting that the variant is associated with primary insulin resistance in migrant south Asians .
Evidence base for treatment
Individuals from ethnic groups are not adequately targeted for risk-reduction strategies, including screening and treatment for dyslipidaemia, hypertension and diabetes. In addition, few studies have included enough individuals from these groups to confirm the value of risk-reducing interventions, such as lipid-lowering therapy.
However, while conventional risk factors, with the exception of type 2 diabetes, may not fully explain the increased cardiovascular disease risk in south Asian populations, this does not diminish their importance in disease causation . Furthermore, retrospective analyses of CHD and risk factor epidemiological studies from the Indian subcontinent have reported an increasing prevalence of these conventional risk factors [30, 31], which correlates positively with an increasing CHD prevalence in India .
Lifestyle guidelines and desirable levels of risk factors for prevention of CHD in south Asians
Risk factor/lifestyle change
4.4 mmol/l (170 mg/dl)
2.3 mmol/l (90 mg/dl)
<1.7 mmol/l (<150 mg/dl)
>0.9 mmol/l (>35 mg/dl)
Fasting blood glucose
>7.8 mmol/l (>140 mg/dl) signifies diabetes
Postprandial blood glucose
>11.1 mmol/l (>200 mg/dl) signifies diabetes
An intake of 400 g/day fruit, vegetables and legumes; mustard or soybean oil (25 g/day) instead of hydrogenated fat, coconut oil or butter
Moderate physical activity (1255 kJ/day)
Cessation of tobacco consumption and moderation of alcohol intake
Moderate to high levels of physical activity are known to significantly reduce the risk of CHD. Exercise can improve HDL cholesterol levels  and ameliorate insulin resistance  in south Asian as well as white Caucasian populations.
It can be argued that all patients with type 2 diabetes should be treated from a secondary prevention point of view. Following the publication of the Heart Protection Study  and the Collaborative Atorvastatin Diabetes Study (CARDS) , many now argue that all patients with type 2 diabetes should be prescribed a statin, particularly those of south Asian descent. It also follows that even non-diabetic individuals of south Asian extraction should receive a statin if they are at sufficiently high cardiovascular risk; for patients of south Asian origin, many advocate adding a correction factor of 50% to the value obtained using standard cardiovascular risk tables .
It should be noted, however, as is often the case with major clinical trials, that south Asian populations were not represented in any of the major statin trials and, therefore, definitive evidence for dyslipidaemia management is still lacking in this group. The dyslipidaemia of the metabolic syndrome (tendency towards low HDL cholesterol and raised triglycerides) is typical of the lipid profile of many south Asians, and is similar to that of patients studied in the Veterans Affairs Cooperative Studies Program High-Density Lipoprotein Cholesterol Intervention Trial . In this trial, increases in HDL cholesterol and decreases in triglyceride levels were achieved with the fibrate gemfibrozil, and a concomitant reduction in cardiovascular mortality was observed in patients with and without diabetes. Further evidence for the benefits of fibrates in the management of patients with type 2 diabetes has been provided by the results of the Fenofibrate Intervention and Event Lowering in Diabetes study, in which fenofibrate was associated with a reduction in major coronary events . In this study, fenofibrate was well tolerated, both alone and in combination with statins. There is considerable rationale for combining a fibrate or nicotinic acid derivative with statin therapy in patients with the metabolic syndrome [88, 89, 90]. This approach may only be acceptable, however, in individuals with significant dyslipidaemia, given the potential for an increased risk of side effects with statin + fibrate or statin + nicotinic acid combinations.
The evidence base for aspirin usage is not as good as that for statins, but the Hypertension Optimal Treatment study demonstrated a 15% risk reduction for cardiovascular endpoints in patients with type 2 diabetes treated with low-dose aspirin, albeit with an increased risk of (non-fatal) haemorrhage . In practice, the evidence suggests that all patients with type 2 diabetes over 50 years of age should be treated with low-dose aspirin (75 mg) once blood pressure is controlled (systolic <150 mmHg). In south Asian patients with type 2 diabetes who are aged less than 50 years, aspirin should be offered if there is a history of cardiovascular disease or they have at least one other cardiovascular risk factor (unless there is a contraindication or tolerability problem) .
Meeting the health needs of the population requires sensitivity to the many traditions, cultures and religious practices that exist in Britain today. A number of organisations, such as the Department of Health, Diabetes UK, the South Asian Health Foundation and the British Heart Foundation, have set objectives for meeting the challenge of dealing with type 2 diabetes and cardiovascular disease in ethnic minority populations. These include increasing awareness of diabetes and CHD through greater community-based activities; providing and promoting more culturally specific information for groups at increased risk; greater partnership with relevant community organisations; and funding of community and research projects.
A number of cultural and social factors may be linked to the increased prevalence of type 2 diabetes and CHD in south Asian populations, including lack of knowledge, poor use of health resources, and a different attitude towards chronic diseases. Lack of diabetes-related knowledge has been observed among UK south Asians [93, 94, 95, 96]. This could result from a communication gap between patients and their care providers or problems with literacy. A disproportionately high number of people from ethnic minority communities are on a low income. In addition, more than half live in local authority areas that are among the most deprived in the UK.
It is also clear that many people of south Asian extraction are not using health resources adequately and may be less likely to be prescribed statins and other cardioprotective treatments [97, 98, 99]. This is despite a higher CHD morbidity and mortality compared with white Caucasians.
It is crucial to address specific communities individually according to cultural features such as customs, religion, lifestyle, food and languages. Language may be a barrier for some south Asians (particularly in older Asian women) to fully access mainstream health services. Educational interventions should target not only high-risk, middle-aged people, but also adolescents and young adults, so that awareness of the disease and its effects are appreciated at an early age. Interventions to promote physical activity and control obesity among south Asian communities should be consistent with lifestyles, diet and cultural considerations.
New approaches to management need to be developed that take into account the specific needs of south Asian communities, with the long-term aim of reducing morbidity and mortality from diabetes and cardiovascular disease. It is this awareness that led to the United Kingdom Asian Diabetes Study (UKADS) .
UKADS was designed to test the hypothesis that structured, culturally sensitive care for type 2 diabetes in south Asian communities can improve cardiovascular risk factors and, ultimately, cardiovascular endpoints in a cost-effective manner . The trial included 361 patients of south Asian ethnicity with type 2 diabetes and one other risk factor (hypertension, elevated total cholesterol or poor glycaemic control) from six general practices in Birmingham and Coventry (UK). Patients were randomised to either enhanced or conventional care.
In the group receiving enhanced care, Asian Link Workers contacted patients to encourage clinic attendance, organised educational sessions, and attended clinics to facilitate patient understanding and compliance. Patients also had additional sessions with the practice nurse, with input from community diabetes specialist nurses, working to treatment protocols and targets for diabetes, hypertension and dyslipidaemia. The group receiving conventional care was treated to the same protocols, but received no additional practice resources.
Risk factor change over 1 year of follow-up in the UKADS study 
Intervention mean difference
Control mean difference
Difference (95% CI)
Systolic blood pressure
−4.58 (−8.84 to −0.32)
Diastolic blood pressure
−3.41 (−5.66 to −1.16)
−0.38 (−0.65 to −0.12)
−0.03 (−0.36 to +0.30)
Following the relative success of the pilot trial, a follow-on study has commenced to determine whether this approach can produce sustained results in a larger population. The study has recruited approximately 100 south Asian patients with type 2 diabetes from each of 18 practices in Birmingham and Coventry (around 1800 patients), as well as 500 white Caucasian patients with type 2 diabetes. The study is planned to run for 3 years after randomisation. In addition to recording cardiovascular risk markers and major outcomes, a full health economic evaluation will be performed to determine whether such an approach is economically viable.
Type 2 diabetes, cardiovascular disease and their associated complications account for a high proportion of avoidable morbidity and premature mortality in UK south Asians. Furthermore, all indicators suggest that the problem will increase, as second-generation immigrants display many of the same risk characteristics as their parents and grandparents. In addition, with the aging of these populations, the impact of ethnicity on the need for care services will become even greater. Health authorities with a high proportion of south Asian populations are likely to need considerable additional investment to meet future needs. If resource considerations constrain service provision, ethnic minorities will be particularly disadvantaged. Measures to control diabetes and cardiovascular disease in south Asian communities therefore urgently need to be addressed to forestall a significant increase in the associated human and economic costs. It should also be noted that while this review predominantly focuses on UK south Asians, migration from the Indian subcontinent has occurred to many parts of the world, and the prevalence of type 2 diabetes and cardiovascular disease is significantly increased in these populations, irrespective of the countries they have settled in. The issues discussed in this review are therefore equally applicable to other migrant south Asian communities. In addition, the epidemic in south Asians abroad is likely to forewarn of what may happen on the Indian subcontinent as standards of living rise and the adoption of Western lifestyles increases.
Approaches to the problem should be at population and individual levels. The preponderance of insulin resistance and a highly atherogenic risk factor profile in south Asian populations require a high index of suspicion of type 2 diabetes and CHD, and aggressive prevention. An intensive programme of primary prevention should be initiated early and, in particular, the promotion of efforts to reduce excess caloric intake and increase energy expenditure.
For high-risk groups, enhanced care may be necessary. Although established risk factor interventions such as statin therapy are undoubtedly of value in south Asian populations, data for ethnic minority populations, and south Asians in particular, are lacking from the majority of cardiovascular risk factor intervention trials. Therefore, conventional approaches to the testing and treatment of risk factors are not likely to be sufficient in the south Asian population. The UKADS pilot demonstrated that in 1 year, improvements in blood pressure and total cholesterol can be achieved with a structured, culturally sensitive, community-based approach to cardiovascular risk management in a population of south Asians with type 2 diabetes. The same strategy, but with more aggressive targets and in a greater number of individuals, is now being evaluated to determine if this approach is economically viable on a larger scale.
We would like to acknowledge the help and support of all general practitioners, practice nurses, and other health care workers involved in this study. We would also like to thank the UKADS Executive Committee for all their help and advice—in addition to the authors of this review we include S. Mughal, L. Dodd, Y. Ahmad, K. Mishra, A. Jones and A. Szczepura.
We would also like to thank the following companies for providing financial support in the form of grants for the UKADS. These include Pfizer, Aventis UK (now sanofi-aventis), Servier Labs UK, Merck & Co., MSD/Schering-Plough, Takeda UK, Roche, Boehringer Ingelheim, Eli Lilly, Novo Nordisk, Bristol Myers Squibb, Daiichi Sankyo UK and Sanofi-Synthelabo (now sanofi-aventis).
Duality of interest
We declare that we have no duality of interest.
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