Swapna S. Dave

Understanding the High Prevalence of Diabetes in U.S. South Asians Compared With Four Racial/Ethnic Groups: The MASALA and MESA Studies

OBJECTIVE We compared South Asians with four other racial/ethnic groups in the U.S. to determine whether sociodemographic, lifestyle, or metabolic factors could explain the higher diabetes prevalence and whether insulin resistance and β-cell dysfunction occurred at younger ages and/or lower adiposity levels compared with other groups. RESEARCH DESIGN AND METHODS We performed a cross-sectional analysis of two community-based cohorts, the Mediators of Atherosclerosis in South Asians Living in America (MASALA) study and the Multi-Ethnic Study of Atherosclerosis (MESA); all participants had no known cardiovascular disease and were between 44 and 84 years of age. We compared 799 South Asians with 2,611 whites, 1,879 African Americans, 1,493 Latinos, and 801 Chinese Americans. Type 2 diabetes was classified by fasting plasma glucose ≥126 mg/dL or use of a diabetes medication. Insulin resistance was estimated by the homeostasis model assessment (HOMA) and β-cell function was measured by the HOMA-β model. RESULTS South Asians had significantly higher age-adjusted prevalence of diabetes (23%) than the MESA ethnic groups (6% in whites, 18% in African Americans, 17% in Latinos, and 13% in Chinese Americans). This difference increased further after adjustment for potential confounders. HOMA of insulin resistance (HOMA-IR) levels were significantly higher and HOMA-β levels were lower among South Asians compared with all other racial/ethnic groups after adjustment for age and adiposity. CONCLUSIONS The higher prevalence of diabetes in South Asians is not explained by traditionally measured risk factors. South Asians may have lower β-cell function and an inability to compensate adequately for higher glucose levels from insulin resistance.

Comparing coronary artery calcium among U.S. South Asians with four racial/ethnic groups: the MASALA and MESA studies.

OBJECTIVES South Asians (individuals from India, Pakistan, Bangladesh, Nepal, and Sri Lanka) have high rates of cardiovascular disease which cannot be explained by traditional risk factors. Few studies have examined coronary artery calcium (CAC) in South Asians. METHODS We created a community-based cohort of South Asians in the United States and compared the prevalence and distribution of CAC to four racial/ethnic groups in the Multi-Ethnic Study of Atherosclerosis (MESA). We compared 803 asymptomatic South Asians free of cardiovascular disease to the four MESA racial/ethnic groups (2622 Whites, 1893 African Americans, 1496 Latinos and 803 Chinese Americans). RESULTS The age-adjusted prevalence of any CAC was similar between White and South Asian men, but was lower in South Asian women compared to White women. After adjusting for all covariates associated with CAC, South Asian men were similar to White men and had higher CAC scores compared to African Americans, Latinos and Chinese Americans. In fully adjusted models, CAC scores were similar for South Asian women compared to all women enrolled in MESA. However, South Asian women ≥70 years had a higher prevalence of any CAC than most other racial/ethnic groups. CONCLUSIONS South Asian men have similarly high CAC burden as White men, but higher CAC than other racial/ethnic groups. South Asian women appear to have similar CAC burden compared to other women, but have somewhat higher CAC burden in older age. The high burden of subclinical coronary atherosclerosis in South Asians may partly explain higher rates of cardiovascular disease in South Asians.

Translating a heart disease lifestyle intervention into the community: the South Asian Heart Lifestyle Intervention (SAHELI) study; a randomized control trial

BackgroundSouth Asians (Asian Indians and Pakistanis) are the second fastest growing ethnic group in the United States (U.S.) and have an increased risk of atherosclerotic cardiovascular disease (ASCVD). This pilot study evaluated a culturally-salient, community-based healthy lifestyle intervention to reduce ASCVD risk among South Asians.MethodsThrough an academic-community partnership, medically underserved South Asian immigrants at risk for ASCVD were randomized into the South Asian Heart Lifestyle Intervention (SAHELI) study. The intervention group attended 6 interactive group classes focused on increasing physical activity, healthful diet, weight, and stress management. They also received follow-up telephone support calls. The control group received translated print education materials about ASCVD and healthy behaviors. Primary outcomes were feasibility and initial efficacy, measured as change in moderate/vigorous physical activity and dietary saturated fat intake at 3- and 6-months. Secondary clinical and psychosocial outcomes were also measured.ResultsParticipants’ (n = 63) average age was 50 (SD = 8) years, 63 % were female, 27 % had less than or equal to a high school education, one-third were limited English proficient, and mean BMI was 30 kg/m2 (SD ± 5). There were no significant differences in change in physical activity or saturated fat intake between the intervention and control group. Compared to the control group, the intervention group showed significant weight loss (−1.5 kg, p-value = 0.04) and had a greater sex-adjusted decrease in hemoglobin A1C (−0.43 %, p-value <0.01) at 6 months. Study retention was 100 %.ConclusionsThis pilot study suggests that a culturally-salient, community-based lifestyle intervention was feasible for engaging medically underserved South Asian immigrants and more effective at addressing ASCVD risk factors than print health education materials.Trial registrationNCT01647438, Date of Trial Registration: July 19, 2012

The South Asian Heart Lifestyle Intervention (SAHELI) study to improve cardiovascular risk factors in a community setting: Design and methods☆ , ☆☆

Disseminating and implementing evidence-based, cardiovascular disease (CVD) prevention lifestyle interventions in community settings and in ethnic minority populations is a challenge. We describe the design and methods for the South Asian Heart Lifestyle Intervention (SAHELI) study, a pilot study designed to determine the feasibility and initial efficacy of a culturally-targeted, community-based lifestyle intervention to improve physical activity and diet behaviors among medically underserved South Asians (SAs). Participants with at least one CVD risk factor will be randomized to either a lifestyle intervention or a control group. Participants in both groups will be screened in a community setting and receive a primary care referral after randomization. Intervention participants will receive 6weeks of group classes, followed by 12weeks of individual telephone support where they will be encouraged to initiate and maintain a healthy lifestyle goal. Control participants will receive their screening results and monthly mailings on CVD prevention. Primary outcomes will be changes in moderate/vigorous physical activity and saturated fat intake between baseline, 3-, and 6-month follow-up. Secondary outcomes will be changes in weight, clinical risk factors, primary care visits, self-efficacy, and social support. This study will be one of the first to pilot-test a lifestyle intervention for SAs, one of the fastest growing racial/ethnic groups in the U.S. and one with disparate CVD risk. Results of this pilot study will provide preliminary data about the efficacy of a lifestyle intervention on CVD risk in SAs and inform community-engaged CVD prevention efforts in an increasingly diverse U.S. population.

Life Stage Influences on U.S. South Asian Women's Physical Activity

Purpose. South Asian (SA) women in the United States report extremely low rates of leisure time physical activity (PA) compared with women in other ethnic minority groups. This study explored SA womens perspectives on PA during different life stages. Design. This is a community-based participatory research study that used focus groups. Setting. The study setting was a community-based organization that provides social services to SA immigrants in Chicago, Illinois. Participants. The study team conducted six focus groups (in English and Hindi) with 42 SA women, ages 18 to 71 years. Method. A semistructured interview guide was used to foster discussion about perceptions of, barriers to/facilitators of, and suggestions for PA programs. Discussions were transcribed and independently coded by two reviewers using thematic content analysis and guided by a coding scheme that was developed a priori. Results. Participants said that different life stages strongly influenced their PA. PA decreased after marriage and having children. Chronic diseases constrained older women from more vigorous PA. Barriers to PA among younger women were family disapproval and perceptions that PA is unnecessary if you are “skinny.” Women agreed that PA is not a priority within the culture, and that interventions must take into account cultural, religious, and family context. Conclusion. Sociocultural norms, family constraints, and lack of awareness about the benefits of PA strongly influenced PA among SA women. Culturally salient intervention strategies might include programs in trusted community settings where women can exercise in women-only classes with their children, and targeted education campaigns to increase awareness about the benefits of PA across life stages.

Qualitative Process Evaluation of a Community-Based Culturally Tailored Lifestyle Intervention for Underserved South Asians

Introduction. There are few examples of effective cardiovascular disease prevention interventions for South Asians (SAs). We describe the results of a process evaluation of the South Asian Heart Lifestyle Intervention for medically underserved SAs implemented at a community-based organization (CBO) using community-based participatory research methods and a randomized control design (n = 63). Method. Interviews were conducted with 23 intervention participants and 5 study staff using a semistructured interview guide focused on participant and staff perceptions about the intervention’s feasibility and efficacy. Data were thematically analyzed. Results. Intervention success was attributed to trusted CBO setting, culturally concordant study staff, and culturally tailored experiential activities. Participants said that these activities helped increase knowledge and behavior change. Some participants, especially men, found that self-monitoring with pedometers helped motivate increased physical activity. Participants said that the intervention could be strengthened by greater family involvement and by providing women-only exercise classes. Staff identified the need to reduce participant burden due to multicomponent intervention and agreed that the CBO needed greater financial resources to address participant barriers. Conclusion. Community-based delivery and cultural adaptation of an evidence-based lifestyle intervention were effective and essential components for reaching and retaining medically underserved SAs in a cardiovascular disease prevention intervention study.