Raj Bhopal

Heterogeneity of coronary heart disease risk factors in Indian, Pakistani, Bangladeshi, and European origin populations: cross sectional study

Abstract Objective: To compare coronary risk factors and disease prevalence among Indians, Pakistanis, and Bangladeshis, and in all South Asians (these three groups together) with Europeans. Design: Cross sectional survey. Setting: Newcastle upon Tyne. Participants: 259 Indian, 305 Pakistani, 120 Bangladeshi, and 825 European men and women aged 25-74 years. Main outcome measures: Social and economic circumstances, lifestyle, self reported symptoms and diseases, blood pressure, electrocardiogram, and anthropometric, haematological, and biochemical measurements. Results: There were differences in social and economic circumstances, lifestyles, anthropometric measures and disease both between Indians, Pakistanis, and Bangladeshis and between all South Asians and Europeans. Bangladeshis and Pakistanis were the poorest groups. For most risk factors, the Bangladeshis (particularly men) fared the worst: smoking was most common (57%) in that group, and Bangladeshis had the highest concentrations of triglycerides (2.04 mmol/l) and fasting blood glucose (6.6 mmol/l) and the lowest concentration of high density lipoprotein cholesterol (0.97 mmol/l). Blood pressure, however, was lowest in Bangladeshis. Bangladeshis were the shortest (men 164 cm tall v 170 cm for Indians and 174 cm for Europeans). A higher proportion of Pakistani and Bangladeshi men had diabetes (22.4% and 26.6% respectively) than Indians (15.2%). Comparisons of all South Asians with Europeans hid some important differences, but South Asians were still disadvantaged in a wide range of risk factors Findings in women were similar. Conclusion: Risk of coronary heart disease is not uniform among South Asians, and there are important differences between Indians, Pakistanis, and Bangladeshis for many coronary risk factors. The belief that, except for insulin resistance, South Asians have lower levels of coronary risk factors than Europeans is incorrect, and may have arisen from combining ethnic subgroups and examining a narrow range of factors. Key messages South Asians have more coronary heart disease than Europeans despite apparently lower levels of risk factors This study shows that Indians, Pakistanis and Bangladeshis differ in a wide range of coronary risk factors and combining their data is misleading Among South Asians, Indians were least and Bangladeshis most disadvantaged in a range of coronary risk factors. South Asians were disadvantaged in comparison with Europeans Future research and prevention strategies for coronary heart disease in South Asians should acknowledge a broad range of risk factors, the heterogeneity of these populations, linguistic and cultural needs, and environmental factors

Ethnicity as a variable in epidemiological research

Ethnicity is used increasingly as a key variable to describe health data, and ethnic monitoring in the NHS will further stimulate this trend. We identify four fundamental problems with ethnicity in this type of research: the difficulties of measurement, the heterogeneity of the populations being studied, lack of clarity about the research purpose of the research, and ethnocentricity affecting the interpretation and use of data. Ethnicity needs to be used carefully to be a useful tool for health research. We make nine recommendations for future practice, one of which is that ethnicity and race should be recognised and treated as distinct concepts.

Glossary of terms relating to ethnicity and race: for reflection and debate

This glossary focuses on the concepts and terminology used in the study of the health of minority ethnic and racial groups. It is hoped that it will stimulate debate on this subject so that an internationally applicable glossary may emerge.

White, European, Western, Caucasian, or what? Inappropriate labeling in research on race, ethnicity, and health.

The request for scientifically appropriate terminology in research on race, ethnicity, and health has largely bypassed the term White. This and other words, such as Caucasian, are embedded in clinical and epidemiological discourse, yet they are rarely defined. This commentary analyzes the issue from the perspective of the epidemiology of the health of minority ethnic and racial groups in Europe and the United States. Minority groups are usually compared with populations described as White, Caucasian, European, Europid, Western, Occidental, indigenous, native, and majority. Such populations are heterogeneous, the labels nonspecific, and the comparisons misleading. Terminology that reflects the research purpose-for examples, reference, control, or comparison--is better (unlike White, these terms imply no norm, allowing neither writers nor readers to make stereotyped assumptions about the comparison populations. This paper widens the debate on nomenclature for racial and ethnic groups. Many issues need exploration, including whether there is a shared understanding among the international research community of the terms discussed.

Prevalence and time trends in obesity among adult West African populations: a meta-analysis

The objective of this study was to determine the distribution of and trends in obesity in adult West African populations.

Negro, Black, Black African, African Caribbean, African American or what? Labelling African origin populations in the health arena in the 21st century

Broad terms such as Black, African, or Black African are entrenched in scientific writings although there is considerable diversity within African descent populations and such terms may be both offensive and inaccurate. This paper outlines the heterogeneity within African populations, and discusses the strengths and limitations of the term Black and related labels from epidemiological and public health perspectives in Europe and the USA. This paper calls for debate on appropriate terminologies for African descent populations and concludes with the proposals that (1) describing the population under consideration is of paramount importance (2) the word African origin or simply African is an appropriate and necessary prefix for an ethnic label, for example, African Caribbean or African Kenyan or African Surinamese (3) documents should define the ethnic labels (4) the label Black should be phased out except when used in political contexts.

Cohort Profile: The Born in Bradford multi-ethnic family cohort study

Bradford Institute for Health Research, Bradford Teaching Hospitals Foundation Trust, Bradford, UK, School of Health Studies, University of Bradford, Bradford, UK, Edinburgh Ethnicity and Health Research Group, Centre for Population Health Sciences, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK, School of Sport, Exercise and Health Sciences, Loughborough University, Leicestershire, UK, Medical Research Council Centre for Causal Analyses in Translational Epidemiology, School of Social and Community Medicine, University of Bristol, Bristol, UK, Paediatric Epidemiology Group, Centre for Epidemiology and Biostatistics, Leeds Institute of Genetics, Health and Therapeutics, Faculty of Medicine and Health, University of Leeds, Leeds, UK and Department of Health Sciences, University of York, York, UK

Cardiovascular disease, diabetes and established risk factors among populations of sub-Saharan African descent in Europe: a literature review

BackgroundMost European countries are ethnically and culturally diverse. Globally, cardiovascular disease (CVD) is the leading cause of death. The major risk factors for CVD have been well established. This picture holds true for all regions of the world and in different ethnic groups. However, the prevalence of CVD and related risk factors vary among ethnic groups.MethodsThis article provides a review of current understanding of the epidemiology of vascular disease, principally coronary heart disease (CHD), stroke and related risk factors among populations of Sub-Sahara African descent (henceforth, African descent) in comparison with the European populations in Europe.ResultsCompared with European populations, populations of African descent have an increased risk of stroke, whereas CHD is less common. They also have higher rates of hypertension and diabetes than European populations. Obesity is highly prevalent, but smoking rate is lower among African descent women. Older people of African descent have more favourable lipid profile and dietary habits than their European counterparts. Alcohol consumption is less common among populations of African descent. The rate of physical activity differs between European countries. Dutch African-Suriname men and women are less physically active than the White-Dutch whereas British African women are more physically active than women in the general population. Literature on psychosocial stress shows inconsistent results.ConclusionHypertension and diabetes are highly prevalent among African populations, which may explain their high rate of stroke in Europe. The relatively low rate of CHD may be explained by the low rates of other risk factors including a more favourable lipid profile and the low prevalence of smoking. The risk factors are changing, and on the whole, getting worse especially among African women. Cohort studies and clinical trials are therefore needed among these groups to determine the relative contribution of vascular risk factors, and to help guide the prevention efforts. There is a clear need for intervention studies among these populations in Europe.

Self report in clinical and epidemiological studies with non-English speakers: the challenge of language and culture

Internationally, there is a drive for equality in health care for ethnic groups. To achieve equality, produce sound policies, and provide appropriately targeted services good quality data are essential. Where data are based upon self report, especially from non-English speakers, there are major barriers to the accumulation of reliable and valid information. When data collection instruments designed for English speakers are simply translated into ethnic minority languages, measurement error can result from inadequate translation procedures, inappropriate content, insensitivity of items, and the failure of researchers to make themselves familiar with cultural norms and beliefs. More attention should be paid to conceptual and cultural factors especially in epidemiological and clinical studies where self report is used to gather data. More interdisciplinary collaboration is necessary as well as a modification of customary methods of data collection and the assumptions behind them. The essence of such modifications entails participatory research with members of the linguistic communities concerned.

Understanding influences on smoking in Bangladeshi and Pakistani adults: community based, qualitative study

Abstract Objective: To gain detailed understanding of influences on smoking behaviour in Bangladeshi and Pakistani communities in the United Kingdom to inform the development of effective and culturally acceptable smoking cessation interventions. Design: Qualitative study using community participatory methods, purposeful sampling, one to one interviews, focus groups, and a grounded approach to data generation and analysis. Setting: Newcastle upon Tyne, during 2000-2. Participants: 87 men and 54 women aged 18–80 years, smokers and non-smokers, from the Bangladeshi and Pakistani communities. Results: Four dominant, highly inter-related themes had an important influence on smoking attitudes and behaviour: gender, age, religion, and tradition. Smoking was a widely accepted practice in Pakistani, and particularly Bangladeshi, men and was associated with socialising, sharing, and male identity. Among women, smoking was associated with stigma and shame. Smoking in women is often hidden from family members. Peer pressure was an important influence on smoking behaviour in younger people, who tended to hide their smoking from elders. There were varied and conflicting interpretations of how acceptable smoking is within the Muslim religion. Tradition, culture, and the family played an important role in nurturing and cultivating norms and values around smoking. Conclusion: Although there are some culturally specific contexts for smoking behaviour in Bangladeshi and Pakistani adults—notably the influence of gender and religion—there are also strong similarities with white people, particularly among younger adults. Themes identified should help to inform the development and appropriate targeting of smoking cessation interventions. What is already known on this topic Smoking is common among Bangladeshi and Pakistani men in Britain but rare among the women Smoking is particularly common in Bangladeshi men Socioeconomic status is thought to influence smoking uptake in Bangladeshi men Influences on smoking in South Asians in Britain are poorly understood What this study adds Smoking among Pakistani and Bangladeshi men is strongly seen as socially acceptable—a “normal” part of being a man Smoking in Bangladeshi men is more deeply socially ingrained than in Pakistanis, contributing to group cohesion and identity Smoking in Bangladeshi and Pakistani women is associated with a strong sense of cultural taboo, stigma, and non-acceptance Islam forbids addiction and intoxicants, but opinions differ on whether the Muslim religion allows smoking Culturally sensitive smoking cessation interventions for Bangladeshis and Pakistanis are needed