1. Ethnic patterns in cardiovascular disease: findings from national surveys suggest change in risks across generations Seeromanie Harding University of Glasgow

2. Heterogenous patterns of cardiovascular diseases among ethnic groups High rates of coronary heart disease (CHD) among South Asians but not Caribbeans High rates of hypertensive cardiovascular disease among Caribbeans The causes of ethnic differences in cardiovascular disease are unclear Very little known about when differences begin to emerge over the lifecourse

3. 0204060 80 100 Stroke 050100150200250300350 Eng & Wales India Pakistan Bangladesh Caribbean CHD Death rates/100 000 by country of birth, E&W 1989-92

4. 0 100 200 300 CHD Hypertension Stroke 400 0 100 200 300 400 CHDHypertensionStroke Blacks born in South Blacks born in North East Whites Blacks born in Caribbean /100 000 Death rates by birthplace, New York 1988-92, 45-64 years MenWomen Fang J, Madhavan S, Alderman H N Engl J Med 1996; 335:1552-1558

5. Cappucio F 2004;33:387-388 Gillum 1996; 335(21):1597-1599 Gillums stages in the epidemiological evolution of cardiovascular disease patterns among people of sub-Saharan African origin

6. 0 10 20 30 40 % < 33.544.555.566.577.588.5 Fasting glucose mmol/l Cameroon-rural 0.5 Cameroon-urban 1.4 Jamaica 3.0 Manchester 6.4 International Comparisons: Glucose tolerance distributions among west African-origin people % diabetes (treated) Mbanya JC, Cruickshank JK, Forrester T et al. Diabetes Care 1999;22:434-40

7. BMI >=25 kg/m 2 for west African-origin populations 0 10 20 30 40 50 60 70 80 RuralUrbanJamaicaManchester Males Females Cameroon Mbanya JC, Cruickshank JK, Forrester T et al. Diabetes Care 1999;22:434-40 %

8. These international & population studies suggest that environmental factors play the major role in explaining ethnic patterns in cardiovascular disease In the UK, large government surveys (prospective & cross- sectional) provide opportunities to track changes in risk

9. ONS Longitudinal Study (LS) ONS Longitudinal Study (LS) - 1% of population of England & Wales followed up 1971-2000 Data from censuses & vital registrations linked to LS records Information on country of birth (names), year of arrival, date of birth and socio- economic circumstances in census

10. Example of LS records 1971 Census 1991 Census 1981 Census end of follow-up 2000 death Arrived 1950 aged 40 years Arrived 1960 aged 35 years

11. South Asians in the UK: Cardiovascular mortality, 1971-2000, & yearly change of residence Harding. Epidemiology 2003;14(3):287-292 Adjusted for gender and age at start of study ~ p<0.05

12. South Asian v. all other LS members: Cardiovascular mortality by duration of residence 0.5 1.0 1.5 2.0 2.5 25-3435-4445-54 Age in 1971 Long stay (arrived before mean year of arrival for age group) Short stay (arrived after mean year of arrival for age group) Harding. Epidemiology 2003;14(3):287-292

13. Caribbeans in the UK: CHD/stroke mortality,1971-2000,& yearly change in residence *Adjusted for age at migration & socio- economic circumstanc es ~ p<0.05 Harding. IJE 2004;33:382-386

14. Caribbeans in the UK: effect of age at migration & duration of residence, stroke mortality (45-54 years) *adjusted for socio-economic circumstances ~ p<0.05 Harding. IJE 2004;33:382-386

15. Using the HSE99 to track risk across generations Metabolic profiles of UK-born Black Caribbeans do not appear to be as protective against CHD as those of foreign-born Black Caribbeans Abbots, Harding, Cruickshank Atherosclerosis 2004;175:295-303

16. UK-born Black Caribbeans: Cardiovascular risk profiles, 35-44 years 27.6*27.7 BMI (kg/m 2 ) 5.35.6 Glycosylated Hb (%) 5.06.0 Fasting glucose (mmol/l) 0.9*1.5 Triglycerides (mmol/l) 1.541.32* HDL (mmol/l) 72 76 dBP (mmHg) 121132 sBP (mmHg) Black Cbean women (N=135) Black Cbean men (N=75) p<0.05 compared with general population Abbots, Harding, Cruickshank Atherosclerosis 2004;175:295-303

17. UK-born Black Caribbeans/Irish: Triglycerides x BMI, 35-44 years Abbots, Harding, Cruickshank Atherosclerosis 2004;175:295-303 womenmen

18. UK-born Black Caribbeans: Smoking prevalence among, 35-44 years 0 10 20 30 40 50 MenWomen % Black Caribbean General Population Abbots, Harding, Cruickshank Atherosclerosis 2004;175:295-303

19. HSE99 sample - difficulty in tracking risk across generations & across age

20. Biological programming - link between poor early development and adult cardiovascular disease (Barker 1995) Social programming – link between childhood disadvantage and adult health (lifecourse framework) In the UK, we know very little about the relationship between birthweight & growth in childhood, & how this influences cardiovascular risk among ethnic groups

21. School children in Jamaica: Foetal growth & cardiovascular risk Birth weight (g)Mean systolic BP <=2500105.4 2501-2750105.4 2751-3000103.6 3001-3250100.9 3251-3500102.2 3501-3750102.2 >3750101.8 Forrester T, Wilks RJ, Bennet FI et al BMJ 1996; 312:156-60

22. Birthweight distributions by ethnicity of mother African origin 0 10 20 30 40 50 1000-1500-2000-2500-3000-3500-4000->=4500 g White UK-born Black Caribbean Foreign-born Black Caribbean % 0 10 20 30 40 50 1000-1500-2000-2500-3000-3500-4000->=4500 g White UK-born Black African Foreign-born Black African % Harding S, Rosato M, Cruickshank JK. IJE 2004;33:1-7

23. 0 10 20 30 40 50 1000-1500-2000-2500-3000-3500-4000->=4500 g White UK-born Indian Foreign-born Indian % 0 10 20 30 40 50 1000-1500-2000-2500-3000-3500-4000->=4500 g White UK-born Pakistani Foreign-born Pakistani 0 10 20 30 40 50 1000-1500-2000-2500-3000-3500-4000->=4500 g White UK-born Bangladeshi Foreign-born Bangladeshi Birthweight distributions by ethnicity of mother South Asian origin Harding S, Rosato M, Cruickshank JK. IJE 2004;33:1-7

24. Intergenerational non-genetic transmission of risk Growth and social conditions in early life and childhood Health in adolescence and adulthood Social, behavioural, psychosocial influences over the life course Historical processes e.g. slavery & post- emancipation poverty

25. BUT Need for larger sample sizes of ethnic minorities to increase power of the studies Need for prospective data on ethnic minorities to track social, metabolic, anthropometric risks over the lifecourse & over generations Need for comprehensive coverage of ethnic minorities Need for recording of ethnicity on death certificates & for improving its recording on inpatient records Government surveys remain the most valuable source for examining the epidemiology of cardiovascular disease among ethnic minorities