|Childhood cardiovascular risk factors in South Asians: A cause of concern for adult cardiovascular disease epidemic.|
|Jump to Full Text|
|PMID: 21976880 Owner: NLM Status: PubMed-not-MEDLINE|
|Cardiovascular risk factors in children are increasing at an alarming rate in the western world. However, there is limited information regarding these in the South Asian children. This review attempts at summarizing such evidence. South Asians are remarkable for the earlier onset of adult cardiovascular disease (CVD) by almost a decade compared to the Caucasians. We identified published literature, mainly on PubMed, Embase and Cochrane library using specific search terms such as lipid abnormalities, high blood pressure, hyperglycemia, tobacco use, obesity, physical inactivity, and unhealthy dietary practices. Atherosclerotic CVD processes begin early in childhood and are influenced over the life course by genetic and potentially modifiable risk factors and environmental exposure. 80% of adult CVD burden will fall on the developing nations by 2020. The concept of primordial prevention is fast emerging as a necessary prevention tool to curb adult CVD epidemic. Established guidelines and proven preventive strategies on cardiovascular health exist; however, are always implemented half-heartedly. Composite screening and prediction tools for adults can be adapted and validated in children tailored to South Asian population. South Asian children could be at a greater risk of developing cardiovascular risk factors at an earlier stage, thus, timely interventions are imperative.|
|Duggirala Sivaram Prasad; Zubair Kabir; Ashok Kumar Dash; Bhagabati Charan Das|
|Type: Journal Article|
|Title: Annals of pediatric cardiology Volume: 4 ISSN: 0974-5149 ISO Abbreviation: Ann Pediatr Cardiol Publication Date: 2011 Jul|
|Created Date: 2011-10-06 Completed Date: 2012-11-27 Revised Date: 2013-05-29|
Medline Journal Info:
|Nlm Unique ID: 101495459 Medline TA: Ann Pediatr Cardiol Country: India|
|Languages: eng Pagination: 166-71 Citation Subset: -|
|Sudhir Heart Centre, Dharmanagar, Berhampur, Orissa, India.|
|APA/MLA Format Download EndNote Download BibTex|
Journal ID (nlm-ta): Ann Pediatr Cardiol
Journal ID (publisher-id): APC
Publisher: Medknow Publications, India
© Annals of Pediatric Cardiology
Print publication date: Season: Jul-Dec Year: 2011
Volume: 4 Issue: 2
First Page: 166 Last Page: 171
PubMed Id: 21976880
Publisher Id: APC-4-166
|Childhood cardiovascular risk factors in South Asians: A cause of concern for adult cardiovascular disease epidemic|
|Duggirala Sivaram Prasadaff1|
|Ashok Kumar Dash2|
|Bhagabati Charan Das3|
|Sudhir Heart Centre, Dharmanagar, Berhampur, Orissa, India
1Epidemiologist, Research Institute for a Tobacco Free Society, The Digital Depot, Thomas Street, Dublin, Ireland, India
2Department of Pathology, M.K.C.G. Medical College, Berhampur, Orissa, India
3Department of Community Medicine, Kalinga Institute of Medical Sciences, Bhubaneshwar, Orissa, India
|Correspondence: Address for correspondence: Dr. Duggirala Sivaram Prasad, Consultant Cardiologist, Sudhir Heart Centre, Main Road, Dharamnagar, Berhampur-760 002, Orissa, India. E-mail: Sudhir_heartcare@hotmail.com
Coronary heart disease (CHD) manifests a decade earlier[1, 2] with an increased prevalence in South Asians as compared to other ethnic groups, and the average age of stroke is much lower than in western countries.[3, 4] Such a phenomenon can be attributed to atherosclerotic processes initiated early in childhood and being affected over the life course by both genetic and environmental interactions.[5, 6] Such underlying pathogenesis underscores the significance of earlier cardiovascular risk factor screening in at risk children and youth, which can be tracked to predict future levels.[7–10] Nevertheless, the specifics of the transition from these risk factors in childhood to overt cardiovascular disease (CVD) in adulthood are not clear.[9, 11] Such gaps in knowledge base have prompted evidence based initiatives for high risk individuals and population centric approaches for primordial/primary prevention of CVD in children and youth. Such approaches may be more effective to prevent the development of risk factors rather than attempting to reverse the atherosclerotic risk in adulthood. The aim of this review is to synthesize the clinico pathological and epidemiological evidence for clinicians of South Asia to promote preventive pediatric cardiovascular health.
We abstracted the most significant published literature on the electronic databases (all in English language), namely, Pub Med, Embase and Cochrane Library applying specific search terms such as “South Asians” “pediatric”; “childhood”; “CVD”; “CHD”; “physical inactivity”; “Diabetes mellitus”; “hypertension”; “dyslipidemia”; “smoking” etc. We have also gone through abstracts of conference/meetings; consulting authors/experts in the field; text books; publications of governmental/non-governmental organization.
A consistent body of evidence from epidemiological, clinical and laboratory studies on cardiovascular risk factors among the younger populations, including children, adolescents, and youth exists worldwide.[8–10] However, such evidence is mainly confined to developed countries. In India and the rest of South Asia, similar studies systematically evaluating cardiovascular risk factors across younger populations are generally inadequate. Such evidence synthesis is essential to help develop cost-effective screening and intervention programs in a specific population group.
Randomized controlled trials documenting the effect of risk reduction in childhood on the development of CVD in adults, are lacking.[12, 13] However observations from Bogalusa, pathobiological determinants of atherosclerosis in children and young adults (PDAY)[15, 16] and Muscatine studies provide compelling evidence linking potentially modifiable cardiovascular risk factors and CVD in adults, and thus support the need for preventive interventions early in life.[5, 6]
Epidemiological studies from South Asia[10, 18–20] provide reliable data regarding prevalence and trends of cardiovascular risk factors in children and youth. These studies have confirmed that the cardiovascular risk factors begin early, track through young age and tend to magnify and manifest in middle age in most societies.[21, 22]
South Asia has high rates of poverty, gender inequalities, illiteracy, ignorance and religious beliefs towards pregnant mothers that contribute to fetal and early infant undernutrition with long-term negative health consequences.[21, 23] Evidence from birth cohort studies have linked maternal glucose intolerance, diabetes, hypercholesterolemia, vitamin D, vitamin B12 status, placental morphology and birth weight[21, 22] with childhood onset of adult disease. Therefore Barker's Thrifty phenotype hypothesis and Neel's Thrifty Genotype hypothesis are of particular relevance in South Asia.
Most of the potentially modifiable risks factors that affect children can be controlled early in life, lowering the risk of heart disease later in life. They are enumerated below.
Physical inactivity is a major modifiable risk factor for CVD. The health benefits associated with physical activity include weight control, lower blood pressure, improved psychological well being and decreased risk of CVD. However, unfortunately, physical activity levels in children are decreasing mainly from sedentary life-style entertainments. The recommended frequency of 150 minutes of physical activity for elementary schools and 225 minutes for middle/junior and senior high schools per week including a mix of recreational and organized aerobic activities based on child's age, sex, race, sexual maturity, size, skill and social class should be implemented.
Tobacco smoking is an important and modifiable cardiovascular risk factor. Both smoking and smokeless tobacco is equally prevalent amongst the youth of developing countries. A recent Indian study reports more than 25% in 13- to 15-year-olds to be tobacco users, contributing to 17% of current total tobacco users. More than 80% established adult smokers initiate smoking before the age of 18 years.[38–40] Hence, there is an urgent need to intervene early. There are numerous interacting determinants that influence smoking behavior. Environmental factors (sociocultural, economic and political) and personal characteristics like demographics, personality, education, and information are main influences in smoking initiation in children. Prenatal maternal smoking has immediate and long-term adverse birth outcomes, including the onset of adult chronic diseases. Therefore, targeting smoking cessation among pregnant women should contribute to a healthy intergenerational effect.
Obesity in childhood and adolescence is attaining an epidemic proportion at about 15–20% in India. Overweight and obesity in childhood are associated with diverse cardiovascular risk factors and has been shown to be related with premature atherosclerotic lesions.[33, 44] Unlike in adults it is not possible to identify a single BMI (body-mass-index) cut off point as a threshold for defining obesity in children, as BMI changes with age across development. Further, there is also a need for age and gender specific percentile based cut off points of anthropometric and metabolic variables in South Asian children and adolescents. South Asia is facing the double burden of over and under-nutrition.[47–49] The South Asian newborns, children and adults have higher body fat compared to the Caucasians of similar body weight, and cardiovascular risk manifests at a lower level of adiposity. Obesity in South Asian children is also reported to be related with adverse lipid profile.
Excess body fat, thick truncal subcutaneous fat, and abdominal adiposity are major predisposing factors for insulin resistance in South Asian children. They manifest adiposity, insulin resistance and metabolic perturbations earlier in life with a higher magnitude than with children of other ethnic groups. Since the metabolic syndrome and obesity track into adulthood, these clinical entities need to be recognized early for effective prevention of diabetes and CVD. Insulin resistance and hyperinsulinemia are early metabolic manifestations and should be incorporated to define insulin resistance and metabolic syndrome in these children.
Childhood hypertension is a recognized predisposing factor of adult hypertension as reported in the Bogalusa Heart Study. Current guidelines suggest that children ≥3years of age have to get their blood pressure measured during their routine health assessment. Hypertension in children is defined as systolic or diastolic blood pressure steadily above 95th percentile on three different occasions. Furthermore children have a 10% higher risk of developing hypertension in adulthood for each 1 to 2 mmHg increment of systolic BP. These guidelines need to be validated and re-examined in South Asian children for population-specific reference values.[20, 55]
Epidemiological studies have established positive relationship between conventional dyslipidemia in patients of CVD and their children.[56, 57] Lipid abnormalities in children indeed contribute to adult CVD. However, such traditional lipid risk factors do not explain fully the increased susceptibility of South Asians to CVD. Hence, there is a strong need to identify the nontraditional lipid risk factors in childhood such as alterations in serum levels of Lp(a), Apo A-I, and Apo B-100 in children of premature South Asian CVD patients.[56, 59] Consequently, emerging concepts like Lipid Tetrad Index [Total cholesterol x triglycerides x Lp(a)/HDL Cholesterol], Lipid Pentad Index (Total Cholesterol x Triglyceride x Lp(a) x Apo B-100]/Apo A-I and Atherogenic Index [Log(Triglycerides/HDL Cholesterol)) are to be validated to explain the risk profile of premature CVD in South Asian children and youth. Cholesterol levels track over time, and it is interesting to note that adult serum lipid and lipoprotein levels are observed in children as young as 2 years of age. Consequently, the United States (US) national cholesterol education programme suggested at-risk children screening based on a family history of premature CHD or parental dyslipidemia after 2 years of birth. Nonetheless, gender and ethnic-specific guidelines of similar nature are important potential tools for certain pediatric populations.
Family history of CVD encompasses genetically transmitted risk along with shared environment and behaviors influencing modifiable risk factors. It is an important step in screening children's risk, as CVD tends to cluster in families and is a proxy for inherited tendency for coronary risk. It is an independent CHD risk predictor. Family history of premature CHD is defined as a documented myocardial infarction, angiographic documentation of CHD, angina pectoris, or sudden cardiac death in first or second degree relatives (parents, siblings, grandparents, or blood-related aunts and uncles) ≤ 55 years of age. However there is paucity of data regarding this from South Asia.
Disproportionate predilection of CVD in South Asians[4, 65] is due to genetic predisposition mediated by high lipoprotein (a)[66, 67] and cardiovascular risk factors potentiated by environment or life style. South Asians are genetically susceptible to CVD from early childhood. Ethnic differences in lipids, lipoproteins, insulin resistance and blood pressure are well documented in adults and begin early in childhood.[68, 69] South Asian children demonstrate increased levels of insulin and insulin resistance in contrast to Caucasian children.[69, 70] Such ethnic differences in insulin resistance are not correlated with matching differences in adiposity. However, insulin metabolism seems to be more sensitive to a known degree of adiposity among South Asian children.
In conclusion, available evidence regarding the conventional risk factors for cardiovascular disease in south Asian children is reviewed. This review underscores the need for more data collection. The situation of cardiovascular risk factors in children is concerning. Risk factor modifications earlier in childhood may control the burgeoning epidemic of adult CVD in south Asia.
Source of Support: Nil
Conflict of Interest: None declared
|1.||Yusuf S,Hawken S,Ounpuu S,Dans T,Avezum A,Lanas F,et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control studyLancetYear: 20043649375215364185|
|2.||Rao GH,Thanickachalam S. Coronary Artery Disease: Risk Promoters, Pathophysiology and PreventionYear: 20051st edNew DelhiSouth Asian Society on Atherosclerosis and Thrombosis|
|3.||Gupta R,Joshi P,Mohan V,Reddy KS,Yusuf S. Epidemiology and causation of coronary heart disease and stroke in IndiaHeartYear: 200894162618083949|
|4.||Prasad DS,Kabir Z,Dash AK,Das BC. Cardiovascular risk factors in developing countries: A review of clinico-epidemiological evidenceCVD Prev ControlYear: 2010511523|
|5.||Berenson GS. Cardiovascular risk begins in childhood: a time for actionAm J Prev MedYear: 2009371 SupplS1219524149|
|6.||Berenson GS,Srinivasan SR. Cardiovascular risk in young persons: Secondary or primordial prevention?Ann Intern MedYear: 2010153202320679564|
|7.||Enas EA,Kannan SThe Pediatric Foundations of Heart DiseaseHow to beat the heart disease epidemic among South AsiansYear: 20081st edDowners Grove, ILAdvanced Heart Lipid Clinic15360|
|8.||Davidson DM. Wong ND,Black HR,Gardin JMChildren and adolescentsPreventive cardiology: A practical approachYear: 20062nd edNew DelhiTata Mcgraw-Hill Publishing Company Limited35783|
|9.||Lane DA,Gill P. Ethnicity and tracking blood pressure in childrenJ Hum HypertensYear: 200418223815037870|
|10.||Gupta R,Misra A,Vikram NK,Kondal D,Gupta SS,Agrawal A,et al. Younger age of escalation of cardiovascular risk factors in Asian Indian subjectsBMC Cardiovasc DisordYear: 200992819575817|
|11.||Steinberger J,Daniels SR. Obesity, insulin resistance, diabetes, and cardiovascular risk in children: an American Heart Association scientific statement from the Atherosclerosis, Hypertension, and Obesity in the Young Committee (Council on Cardiovascular Disease in the Young) and the Diabetes Committee (Council on Nutrition, Physical Activity, and Metabolism)CirculationYear: 200310714485312642369|
|12.||Belay B,Belamarich P,Racine AD. Pediatric precursors of adult atherosclerosisPediatr RevYear: 20042541614702517|
|13.||Kavey RE,Allada V,Daniels SR,Hayman LL,McCrindle BW,Newburger JW,et al. Cardiovascular risk reduction in high-risk pediatric patients: a scientific statement from the American heart association expert panel on population and prevention science; the councils on cardiovascular disease in the young, epidemiology and prevention, nutrition, physical activity and metabolism, high blood pressure research, cardiovascular nursing, and the kidney in heart disease; and the interdisciplinary working group on quality of care and outcomes research: endorsed by the American Academy of PediatricsCirculationYear: 200611427103817130340|
|14.||Berenson GS,Srinivasan SR,Bao W,Newman WP 3rd,Tracy RE,Wattigney WA. Association between multiple cardiovascular risk factors and atherosclerosis in children and young adultsN Engl J MedYear: 1998338165069614255|
|15.||McGill HC Jr,McMahan CA,Malcom GT,Oalmann MC,Strong JP. Effects of serum lipoproteins and smoking on atherosclerosis in young men and women. The PDAY Research Group. Pathobiological Determinants of Atherosclerosis in YouthArterioscler Thromb Vasc BiolYear: 199717951069012643|
|16.||McGill HC Jr,McMahan CA,Zieske AW,Malcom GT,Tracy RE,Strong JP. Effects of nonlipid risk factors on atherosclerosis in youth with a favorable lipoprotein profileCirculationYear: 200110315465011257083|
|17.||Davis PH,Dawson JD,Riley WA,Lauer RM. Carotid intimal-medial thickness is related to cardiovascular risk factors measured from childhood through middle age: The Muscatine StudyCirculationYear: 20011042815911733400|
|18.||Gupta R,Goyle A,Kashyap S,Agarwal M,Consul R,Jain BK. Prevalence of atherosclerosis risk factors in adolescent school childrenIndian Heart JYear: 199850511510052274|
|19.||Sharma R,Grover V,Chaturvedi S. Recipe for diabetes disaster: a study of dietary behaviors among adolescent students in south Delhi, IndiaInt J Diabetes Dev CtriesYear: 20113148|
|20.||Raj M,Sundaram R,Paul M,Kumar K. Blood pressure distribution in Indian childrenIndian PediatrYear: 2010474778519736371|
|21.||Nair MK,Nair L,Chacko DS,Zulfikar AM,George B,Sarma PS. Markers of fetal onset adult diseases: A comparison among low birth weight and normal birthweight adolescentsIndian PediatrYear: 200946SupplS43719279368|
|22.||Lakshmy R,Fall CH,Sachdev HS,Osmond C,Prabhakaran D,Biswas SD,et al. Childhood body mass index and adult pro-inflammatory and pro-thrombotic risk factors: data from the New Delhi birth cohortInt J EpidemiolYear: 2011401021120660641|
|23.||Yajnik CS. Early life origins of insulin resistance and type 2 diabetes in India and other Asian countriesJ NutrYear: 20041342051014704320|
|24.||Luo ZC,Delvin E,Fraser WD,Audibert F,Deal CI,Julien P,et al. Maternal glucose tolerance in pregnancy affects fetal insulin sensitivityDiabetes CareYear: 20103320556120573751|
|25.||Krishnaveni GV,Veena SR,Hill JC,Kehoe S,Karat SC,Fall CH. Intrauterine exposure to maternal diabetes is associated with higher adiposity and insulin resistance and clustering of cardiovascular risk markers in Indian childrenDiabetes CareYear: 201033402419918007|
|26.||Skilton MR. Intrauterine risk factors for precocious atherosclerosisPediatricsYear: 2008121570418310207|
|27.||Krishnaveni GV,Veena SR,Winder NR,Hill JC,Noonan K,Boucher BJ,et al. Maternal vitamin D status during pregnancy and body composition and cardiovascular risk markers in Indian children: The Mysore Parthenon StudyAm J Clin NutrYear: 2011936283521228264|
|28.||Krishnaveni GV,Hill JC,Veena SR,Bhat DS,Wills AK,Karat CL,et al. Low plasma vitamin B12 in pregnancy is associated with gestational ‘diabesity’ and later diabetesDiabetologiaYear: 2009522350819707742|
|29.||Winder NR,Krishnaveni GV,Hill JC,Karat CL,Fall CH,Veena SR,et al. Placental programming of blood pressure in Indian childrenActa PaediatrYear: 20111006536021166711|
|30.||Osmond C,Barker DJ. Fetal, infant, and childhood growth are predictors of coronary heart disease, diabetes, and hypertension in adult men and womenEnviron Health PerspectYear: 2000108Suppl 35455310852853|
|31.||Neel JV. Diabetes mellitus: A “thrifty” genotype rendered detrimental by “progress”?Am J Hum GenetYear: 1962143536213937884|
|32.||Prasad DS,Das BC. Physical inactivity: A cardiovascular risk factorIndian J Med SciYear: 200963334219346639|
|33.||Williams CL,Hayman LL,Daniels SR,Robinson TN,Steinberger J,Paridon S,et al. Cardiovascular health in childhood: A statement for health professionals from the Committee on Atherosclerosis, Hypertension, and Obesity in the Young (AHOY) of the Council on Cardiovascular Disease in the Young, American Heart AssociationCirculationYear: 20021061436012093785|
|34.||Pate RR,Davis MG,Robinson TN,Stone EJ,McKenzie TL,Young JC,et al. Promoting physical activity in children and youth: A leadership role for schools: A scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism (Physical Activity Committee) in collaboration with the Councils on Cardiovascular Disease in the Young and Cardiovascular NursingCirculationYear: 200611412142416908770|
|35.||Prasad DS,Kabir Z,Dash AK,Das BC. Smoking and cardiovascular health: a review of the epidemiology, pathogenesis, prevention and control of tobaccoIndian J Med SciYear: 2009635203320075556|
|36.||Warren CW,Riley L,Asma S,Eriksen MP,Green L,Blanton C,et al. Tobacco use by youth: A surveillance report from the Global Youth Survey projectBull WHO Health OrganYear: 20007886876|
|37.||Reddy KS,Gupta PC. Report on tobacco Control in IndiaNew Delhi: Ministry of Health and Family Welfare, Government of India; Centers for Disease Control and PreventionYear: 2004USAWorld Health Organization|
|38.||Meijer B,Branski D,Knol K,Kerem E. Cigarette smoking habits among school childrenChestYear: 199611092168874246|
|39.||Patel DR. Smoking and childrenIndian J PediatrYear: 1999668172410798145|
|40.||Reddy KS,Arora M. Tobacco use among children in India: A burgeoning epidemicIndian PediatrYear: 2005427576116141476|
|41.||Ockene JK. Ockene IS,Ockene JKSmoking intervention: A behavioral, educational and pharmacological perspectivePrevention of Coronary Heart DiseaseYear: 1992BostonLittle Brown20130|
|42.||Singh V,Gupta R. Prevalence of tobacco use and awareness of risks among school children in JaipurJ Assoc Physicians IndiaYear: 2006546091216941790|
|43.||Manoria PC,Pankaj M,Piyush M. Metabolic obesity: A new therapeutic target for cardio-metabolic risk reductionCVD Prev ControlYear: 201053944|
|44.||Cook S,Weitzman M,Auinger P,Nguyen M,Dietz WH. Prevalence of a metabolic syndrome phenotype in adolescents: Findings from the third National Health and Nutrition Examination Survey, 1988-1994Arch Pediatr Adolesc MedYear: 2003157821712912790|
|45.||Kopelman PG,Caterson ID,Dietz WH. Clinical Obesity in Adults and ChildrenFirst Indian Reprint edYear: 2006New DelhiBlackwell Publishing|
|46.||Mohan V,Rao GH. Type 2 Diabetes in South AsainsYear: 20071st edNew DelhiSouth Asian Society on Atherosclerosis and Thrombosis|
|47.||Jeemon P,Prabhakaran D,Mohan V,Thankappan KR,Joshi PP,Ahmed F,et al. Double burden of underweight and overweight among children (10-19 years of age) of employees working in Indian industrial unitsNatl Med J IndiaYear: 200922172620131480|
|48.||Bhardwaj S,Misra A,Khurana L,Gulati S,Shah P,Vikram NK. Childhood obesity in Asian Indians: A burgeoning cause of insulin resistance, diabetes and sub-clinical inflammationAsia Pac J Clin NutrYear: 200817Suppl 1172518296330|
|49.||Sachdev HP. Recent transitions in anthropometric profile of Indian children: Clinical and public health implicationsNFI BullYear: 20032468|
|50.||Misra A,Khurana L. The metabolic syndrome in South Asians: Epidemiology,determinants, and preventionMetab Syndr Relat DisordYear: 2009749751419900153|
|51.||Kaur S,Kapil U. Dyslipidemia amongst obese children in national capital territory (NCT) of DelhiIndian J PediatrYear: 201013|
|52.||Bao W,Threefoot SA,Srinivasan SR,Berenson GS. Essential hypertension predicted by tracking of elevated blood pressure from childhood to adulthood: The Bogalusa Heart StudyAm J HypertensYear: 19958657657546488|
|53.||National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The 4th report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescentsPediatricsYear: 20041145557615286277|
|54.||Ingelfinger JR. Pediatric antecedents of adult cardiovascular disease - awareness and interventionN Engl J MedYear: 20043502123615152057|
|55.||Genovesi S,Antolini L,Gallieni M,Aiello A,Mandal SK,Doneda A,et al. High prevalence of hypertension in normal and underweight Indian childrenJ HypertensYear: 2011292172121045730|
|56.||Isser HS,Puri VK,Narain VS,Saran RK,Dwivedi SK,Singh S. Lipoprotein (a) and lipid levels in young patients with myocardial infarction and their first degree relativesIndian Heart JYear: 200153463611759936|
|57.||Mohan V,Deepa R,Rani SS,Premalatha G. Chennai Urban Population Study (CUPS No.5). Prevalence of coronary artery disease and its relationship to lipids in a selected population in South India: The Chennai urban population study (CUPS No. 5)J Am Coll CardiolYear: 200138682711527617|
|58.||Forouhi NG,Sattar N,Tillin T,McKeigue PM,Chaturvedi N. Do known risk factors explain the higher coronary heart disease mortality in South Asian compared with European men? Prospective follow-up of the Southall and Brent studies, UKDiabetologiaYear: 2006492580816972045|
|59.||Das B,Daga MK,Gupta SK. Lipid Pentad Index: A novel bioindex for evaluation of lipid risk factors for atherosclerosis in young adolescents and children of premature coronary artery disease patients in IndiaClin BiochemYear: 200740182417052698|
|60.||Rajappa M,Sridhar MG,Balachander J,Sethuraman KR. Lipoprotein (a) and comprehensive lipid tetrad index as a marker for coronary artery disease in NIDDM patients in South IndiaClin Chim ActaYear: 200637270516701602|
|61.||Holmes DT,Frohlich J,Buhr KA. The concept of precision extended to the atherogenic index of plasmaClin BiochemYear: 200841631518280809|
|62.||National Heart, Lung, and Blood Institute. The Lipid Research Clinics Population Studies BookThe Prevalence Study. US Department of Health and Human Services, Public Health ServiceYear: 19801Washington, DCNational Institutes of Health|
|63.||National Cholesterol Education ProgramReport of the expert panel on blood cholesterol levels in children and adolescentsYear: 1991Washington, DCUS Department of Health and Human Services, Public HealthService, National Institutes of Health|
|64.||Hayman LL,Meininger JC,Daniels SR,McCrindle BW,Helden L,Ross J,et al. Primary prevention of cardiovascular disease in nursing practice: focus on children and youth: A scientific statement from the American Heart Association Committee on Atherosclerosis, Hypertension, and Obesity in Youth of the Council on Cardiovascular Disease in the Young, Council on Cardiovascular Nursing, Council on Epidemiology and Prevention, and Council on Nutrition, Physical Activity, and MetabolismCirculationYear: 20071163445717592077|
|65.||Prasad DS,Kabir Z,Dash AK,Das BC. Coronary risk factors in South Asians: A prevalence study in an urban populace of Eastern IndiaCVD Prev ControlYear: 2010512532|
|66.||Scanu AM. Lipoprotein (a). A genetic risk factor for premature coronary artery diseaseJAMAYear: 1992267332691534588|
|67.||Williams B. Westernised Asians and cardiovascular disease: Nature or nurture?LancetYear: 199534540127853944|
|68.||Goran MI,Ball GD,Cruz ML. Obesity and risk of type 2 diabetes and cardiovascular disease in children and adolescentsJ Clin Endocrinol MetabYear: 20038814172712679416|
|69.||Whincup PH,Gilg JA,Papacosta O,Seymour C,Miller GJ,Alberti KG,et al. Early evidence of ethnic differences in cardiovascular risk: Cross sectional comparison of British South Asian and white childrenBMJYear: 200232463511895820|
|70.||Walker AR,Bernstein RE,du Plessis I. Hyperinsulinaemia from glucose dose in South African Indian childrenS Afr Med JYear: 19724619164653996|
Keywords: Cardiovascular disease, childhood, coronary heart disease, risk factors, South Asians.
Previous Document: Temporary neonatal atrial pacing through the umbilical venous route: A novel technique.
Next Document: The developing role of fetal magnetic resonance imaging in the diagnosis of congenital cardiac anoma...