Semin Vasc Med 2002; 2(2): 199-214
DOI: 10.1055/s-2002-32043
Copyright © 2002 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel.: +1(212) 584-4662

Diabetes, Insulin Resistance and Vascular Disease Among Indian Asians and Europeans

John C. Chambers, Jaspal S. Kooner
  • National Heart and Lung Institute, Imperial College School of Medicine, Hammersmith Hospital, London, England
Further Information

Publication History

Publication Date:
06 June 2002 (online)

ABSTRACT

Indian Asians account for one-fifth of all cardiovascular deaths worldwide. Cardiovascular mortality in Indian Asians overseas is higher than in indigenous populations. Diabetes, insulin resistance, and related metabolic disturbances are more common among Indian Asians than Europeans and may account for up to 70% of major Q wave ECG abnormalities in Asians. Previous studies provide evidence that genetic and environmental factors, the latter including intrauterine growth retardation, reduced physical activity, increased weight, and dietary intake, contribute to the high prevalence of diabetes and insulin resistance in Asians. The importance of conventional coronary risk factors is emphasized by studies showing higher prevalence of cigarette smoking, hypertension, and hypercholesterolemia in migrant and urban Indians compared with rural Indians. Recent studies suggest that new risk factors, including C-reactive protein, homocysteine, and lipoprotein(a), are increased among Indian Asians compared with Europeans and may contribute to part of the excess cardiovascular risk in Asians. Further work is needed to identify the precise genetic and environmental mechanisms underlying increased vascular risk in Indian Asians. Clinical strategies must be developed that identify Indian Asians at increased risk and assess the effectiveness of treatment for insulin resistance, and other cardiovascular risk factors, in this racial group.

REFERENCES

  • 1 Reddy K S, Yusuf S. Emerging epidemic of cardiovascular disease in developing countries.  Circulation . 1998;  97 596-601
  • 2 Lopez A D, Murray C C. The global burden of disease, 1990-2020.  Nat Med . 1998;  4 1241-1243
  • 3 Chadha S L, Gopinath N, Shekhawat S. Urban-rural differences in the prevalence of coronary heart disease and its risk factors in Delhi.  Bull World Health Organ . 1997;  75 31-38
  • 4 Balarajan R. Ethnicity and variations in mortality from coronary heart disease.  Health Trends . 1996;  28 45-51
  • 5 Wild S, McKeigue P. Cross-sectional analysis of mortality by country of birth in England and Wales, 1970-92.  BMJ . 1997;  314 705-710
  • 6 Sheth T, Nair C, Nargundkar M, Anand S, Yusuf S. Cardiovascular and cancer mortality among Canadians of European, south Asian and Chinese origin from 1979 to 1993; an analysis of 1.2 million deaths.  CMAJ . 1999;  161 132-138
  • 7 Chen A J. Recent trends in the mortality and morbidity of cardiovascular diseases.  Ann Acad Med Singapore . 1980;  9 411-415
  • 8 Seedat Y K. The prevalence of hypertension and the status of cardiovascular health in South Africa.  Ethn Dis . 1998;  8 394-397
  • 9 Miller G J, Beckles G L, Maude G H. Ethnicity and other characteristics predictive of coronary heart disease in a developing community: principal results of the St. James Survey, Trinidad.  Int J Epidemiol . 1989;  18 808-817
  • 10 Collins V R, Dowse G K, Cabealawa S, Ram P, Zimmet P Z. High mortality from cardiovascular disease and analysis of risk factors in Indian and Melanesian Fijians.  Int J Epidemiol . 1996;  25 59-69
  • 11 McKeigue P M, Miller G J, Marmot M G. Coronary heart disease in south Asians overseas: a review.  J Clin Epidemiol . 1989;  42 597-609
  • 12 Wilkinson P, Sayer J, Laji K. Comparison of case fatality in south Asian and white patients after acute myocardial infarction: observational study.  BMJ . 1996;  312 1330-1333
  • 13 Balarajan R, Bulusu L, Adelstein A M, Shukla V. Patterns of mortality among migrants to England and Wales from the Indian subcontinent.  BMJ . 1984;  289 1185-1187
  • 14 Balarajan R, Raleigh V S. Patterns of mortality among Bangladeshis in England and Wales.  Ethn Health . 1997;  2 5-12
  • 15 Ramachandran A, Snehalatha C, Latha E, Manoharan M, Vijay V. Impacts of urbanisation on the lifestyle and on the prevalence of diabetes in native Asian Indian population.  Diabetes Res Clin Pract . 1999;  44 207-213
  • 16 Patandin S, Bots M L, Abel R, Valkenburg H A. Impaired glucose tolerance and diabetes mellitus in a rural population in south India.  Diabetes Res Clin Pract . 1994;  24 47-53
  • 17 Wander G S, Khurana S B, Gulati R. Epidemiology of coronary heart disease in a rural Punjab population-prevalence and correlation with various risk factors.  Indian Heart J . 1994;  46 319-323
  • 18 Ramachandran A, Snehalatha C, Shyamala P, Vijay V, Viswanathan M. High prevalence of NIDDM and IGT in an elderly south Indian population with low rates of obesity.  Diabetes Care . 1994;  17 1190-1192
  • 19 Singh R B, Bajaj S, Niaz M A, Rastogi S S, Moshiri M. Prevalence of type 2 diabetes mellitus and risk of hypertension and coronary artery disease in rural and urban population with low rates of obesity.  Int J Cardiol . 1998;  66 65-72
  • 20 McKeigue P M, Shah B, Marmot M G. Relation of central obesity and insulin resistance with high diabetes prevalence and cardiovascular risk in South Asians.  Lancet . 1991;  337 382-386
  • 21 Mather H M, Keen H. The Southall Diabetes Survey: prevalence of known diabetes in Asians and Europeans.  BMJ . 1985;  291 1081-1084
  • 22 Chambers J C, Obeid O A, Refsum H. Plasma homocysteine concentrations and risk of coronary heart disease in U.K. Indian Asian and European men.  Lancet . 2000;  355 523-527
  • 23 Bhopal R, Unwin N, White M. Heterogeneity of coronary heart disease risk factors in Indian, Pakistani, Bangladeshi, and European origin populations: cross-sectional study.  BMJ . 1999;  319 215-220
  • 24 Nicholl C G, Levy J C, Mohan V, Rao P V, Mather H M. Asian diabetes in Britain: a clinical profile.  Diabet Med . 1986;  3 257-260
  • 25 Mather H M, Chaturvedi N, Fuller J H. Mortality and morbidity from diabetes in South Asians and Europeans: 11-year follow-up of the Southall Diabetes Survey, London, U.K  Diabet Med . 1998;  15 53-59
  • 26 Anand S S, Yusuf S, Vuksan V. Differences in risk factors, atherosclerosis, and cardiovascular disease between ethnic groups in Canada: the Study of Health Assessment and Risk in Ethnic groups (SHARE).  Lancet . 2000;  356 279-284
  • 27 McKeigue P M, Ferrie J E, Pierpoint T, Marmot M G. Association of early-onset coronary heart disease in South Asian men with glucose intolerance and hyperinsulinemia.  Circulation . 1993;  87 152-161
  • 28 Nathan D M, Meigs J, Singer D E. The epidemiology of cardiovascular disease in type 2 diabetes mellitus: how sweet it is .  . . or is it? Lancet . 1997;  SI4-SI9
  • 29 Yudkin J S. Abnormalities of coagulation and fibrinolysis in insulin resistance. Evidence for a common antecedent?.  Diabetes Care . 1999;  C25-C30
  • 30 Ginsberg H N. Insulin resistance and cardiovascular disease.  J Clin Invest . 2000;  106 453-458
  • 31 Gerstein H C, Pais P, Pogue J, Yusuf S. Relationship of glucose and insulin levels to the risk of myocardial infarction: a case-control study.  J Am Coll Cardiol . 1999;  33 612-619
  • 32 Balkau B, Bertrais S, Ducimetière P, Eschwège E. Is there a glycemic threshold for mortality risk?.  Diabetes Care . 1999;  22 696-699
  • 33 Rodriguez B L, Lau N, Burchfiel C M. Glucose intolerance and 23-year risk of coronary heart disease and total mortality: the Honolulu Heart Program.  Diabetes Care . 1999;  22 1262-1265
  • 34 Mohanty P, Hamouda W, Garg R, Aljada A, Ghanim H, Dandona P. Glucose challenge stimulates reactive oxygen species (ROS) generation by leucocytes.  J Clin Endocrinol Metab . 2000;  85 2970-2973
  • 35 Ho F M, Liu S H, Liau C S, Huang P J, Lin-Shiau S Y. High glucose-induced apoptosis in human endothelial cells is mediated by sequential activations of c-Jun NH(2)-terminal kinase and caspase-3.  Circulation . 2000;  101 2618-2624
  • 36 Williams S B, Goldfine A B, Timimi F K. Acute hyperglycemia attenuates endothelium-dependent vasodilation in humans in vivo.  Circulation . 1998;  97 1695-1701
  • 37 Meigs J B, Mittleman M A, Nathan D M. Hyperinsulinemia, hyperglycemia, and impaired hemostasis: the Framingham Offspring Study.  JAMA . 2000;  283 221-228
  • 38 Festa A, D'Agostino R, Mykkänen L. Relative contribution of insulin and its precursors to fibrinogen and PAI-1 in a large population with different states of glucose tolerance. The Insulin Resistance Atherosclerosis Study (IRAS).  Arterioscler Thromb Vasc Biol . 1999;  19 562-568
  • 39 U.K. Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33).  Lancet . 1998;  352 837-853
  • 40 Verges B L. Dyslipidaemia in diabetes mellitus. Review of the main lipoprotein abnormalities and their consequences on the development of atherogenesis.  Diabetes Metab . 1999;  32-40
  • 41 Grundy S M. Hypertriglyceridemia, atherogenic dyslipidemia, and the metabolic syndrome.  Am J Cardiol . 1998;  81 18B-25B
  • 42 Balarajan R. Ethnic differences in mortality from ischaemic heart disease and cerebrovascular disease in England and Wales.  BMJ . 1991;  302 560-564
  • 43 Zoratti R, Godsland I F, Chaturvedi N. Relation of plasma lipids to insulin resistance, nonesterified fatty acid levels, and body fat in men from three ethnic groups: relevance to variation in risk of diabetes and coronary disease.  Metabolism . 2000;  49 245-252
  • 44 Chaturvedi N, McKeigue P M, Marmot M G. Relationship of glucose intolerance to coronary risk in Afro-Caribbeans compared with Europeans.  Diabetologia . 1994;  37 765-772
  • 45 Whitty C J, Brunner E J, Shipley M J, Hemingway H, Marmot M G. Differences in biological risk factors for cardiovascular disease between three ethnic groups in the Whitehall II study.  Atherosclerosis . 1999;  142 279-286
  • 46 Singh R B, Rastogi V, Niaz M A, Ghosh S, Sy R G, Janus E D. Serum cholesterol and coronary artery disease in populations with low cholesterol levels: the Indian paradox.  Int J Cardiol . 1998;  65 81-90
  • 47 Reddy K K, Ramachandraiah T, Reddanna P, Thyagaraju K. Serum lipid peroxides and lipids in urban and rural Indian men.  Arch Environ Health . 1994;  49 123-127
  • 48 Swaroop V, Agnihotri M S. Smoking habits, its forms and impact on pulmonary health in planes of Uttar Pradesh.  J Indian Med Assoc . 1998;  96 80-81
  • 49 Singh R B, Sharma J P, Rastogi V. Prevalence of coronary artery disease and coronary risk factors in rural and urban populations of north India.  Eur Heart J . 1997;  18 1728-1735
  • 50 Singh R B, Rastogi S S, Rastogi V. Blood pressure trends, plasma insulin levels and risk factors in rural and urban elderly populations of north India.  Coron Artery Dis . 1997;  8 463-468
  • 51 Bhatnagar D, Anand I S, Durrington P N. Coronary risk factors in people from the Indian subcontinent living in west London and their siblings in India.  Lancet . 1995;  345 405-409
  • 52 Ross R. Atherosclerosis-an inflammatory disease.  N Engl J Med . 1999;  340 115-126
  • 53 Ridker P M, Hennekens C H, Buring J E, Rifai N. C-reactive protein and other markers of inflammation in the prediction of cardiovascular disease in women.  N Engl J Med . 2000;  342 836-843
  • 54 Haverkate F, Thompson S G, Pyke S D, Gallimore J R, Pepys M B. Production of C-reactive protein and risk of coronary events in stable and unstable angina. European Concerted Action on Thrombosis and Disabilities Angina Pectoris Study Group.  Lancet . 1997;  349 462-466
  • 55 Danesh J, Whincup P, Walker M. Low-grade inflammation and coronary heart disease: prospective study and updated meta-analyses.  BMJ . 2000;  321 199-204
  • 56 Chambers J C, Eda S, Bassett P. C-reactive protein, insulin resistance, central obesity, and coronary heart disease risk in Indian Asians from the United Kingdom compared with European whites.  Circulation . 2001;  104 145-150
  • 57 Yudkin J S, Stehouwer C D, Emeis J J, Coppack S W. C-reactive protein in healthy subjects: associations with obesity, insulin resistance, and endothelial dysfunction: a potential role for cytokines originating from adipose tissue?.  Arterioscler Thromb Vasc Biol . 1999;  19 972-978
  • 58 Mohamed Ali V, Goodrick S, Rawesh A. Subcutaneous adipose tissue releases interleukin-6, but not tumor necrosis factor-alpha, in vivo.  J Clin Endocrinol Metab . 1997;  82 4196-4200
  • 59 Chambers J C, McGregor A, Jean-Marie J, Kooner J S. Abnormalities of vascular endothelial function may contribute to increased coronary heart disease risk in U.K. Indian Asians.  Heart . 1999;  81 501-504
  • 60 Joannides R, Haefeli W E, Linder L. Nitric oxide is responsible for flow-dependent dilatation of human peripheral conduit arteries in vivo.  Circulation . 1995;  91 1314-1319
  • 61 Drexler H. Nitric oxide and coronary endothelial dysfunction in humans.  Cardiovasc Res . 1999;  43 572-579
  • 62 Chambers J C, Kooner J S. Homocysteine: a novel risk factor for coronary heart disease in U.K. Indian Asians.  Heart . 2001;  86 121-122
  • 63 Chambers J C, Ireland H, Thompson E. Methylenetetrahydrofolate reductase 677 C → T mutation and coronary heart disease risk in U.K. Indian Asians.  Arterioscler Thromb Vasc Biol . 2000;  20 2448-2452
  • 64 Chambers J C, Ueland P M, Obeid O A, Wrigley J, Refsum H, Kooner J S. Improved vascular endothelial function after oral B vitamins: an effect mediated through reduced concentrations of free plasma homocysteine.  Circulation . 2000;  102 2479-2483
  • 65 Scanu A M. The role of lipoprotein(a) in the pathogenesis of atherosclerotic cardiovascular disease and its utility as predictor of coronary heart disease events.  Curr Cardiol Rep . 2001;  3 385-390
  • 66 Shlipak M G, Simon J A, Vittinghoff E. Estrogen and progestin, lipoprotein(a), and the risk of recurrent coronary heart disease events after menopause.  JAMA . 2000;  283 1845-1852
  • 67 Evans R W, Shpilberg O, Shaten B J, Ali S, Kamboh M I, Kuller L H. Prospective association of lipoprotein(a) concentrations and apo(a) size with coronary heart disease among men in the Multiple Risk Factor Intervention Trial.  J Clin Epidemiol . 2001;  54 51-57
  • 68 Boerwinkle E, Leffert C C, Lin J, Lackner C, Chiesa G, Hobbs H H. Apolipoprotein(a) gene accounts for greater than 90% of the variation in plasma lipoprotein(a) concentrations.  J Clin Invest . 1992;  90 52-60
  • 69 Pati U, Pati N. Lipoprotein(a), atherosclerosis, and apolipoprotein(a) gene polymorphism.  Mol Genet Metab . 2000;  71 87-92
  • 70 Low P S, Heng C K, Saha N, Tay J S. Racial variation of cord plasma lipoprotein(a) levels in relation to coronary risk level: a study in three ethnic groups in Singapore.  Pediatr Res . 1996;  40 718-722
  • 71 Godfrey K M, Barker D J. Fetal nutrition and adult disease.  Am J Clin Nutr . 2000;  71 1344S-1352S
  • 72 Forsen T, Eriksson J G, Tuomilehto J, Osmond C, Barker D J. Growth in utero and during childhood among women who develop coronary heart disease: longitudinal study.  BMJ . 1999;  319 1403-1407
  • 73 Martyn C N, Barker D J, Osmond C. Mothers' pelvic size, fetal growth, and death from stroke and coronary heart disease in men in the UK.  Lancet . 1996;  348 1264-1268
  • 74 Rich-Edwards J W, Stampfer M J, Manson J E. Birth weight and risk of cardiovascular disease in a cohort of women followed up since 1976.  BMJ . 1997;  315 396-400
  • 75 Eriksson J G, Forsen T, Tuomilehto J, Winter P D, Osmond C, Barker D J. Catch-up growth in childhood and death from coronary heart disease: longitudinal study.  BMJ . 1999;  318 427-431
  • 76 Forsen T, Eriksson J, Tuomilehto J, Reunanen A, Osmond C, Barker D. The fetal and childhood growth of persons who develop type 2 diabetes.  Ann Intern Med . 2000;  133 176-182
  • 77 Roseboom T J, van der Meulen H J, Ravelli A C. Blood pressure in adults after prenatal exposure to famine.  J Hypertens . 1999;  17 325-330
  • 78 Ravelli A C, van der Meulen H J, Michels R P. Glucose tolerance in adults after prenatal exposure to famine.  Lancet . 1998;  351 173-177
  • 79 Fall C H, Osmond C, Barker D J. Fetal and infant growth and cardiovascular risk factors in women.  BMJ . 1995;  310 428-432
  • 80 Barker D J, Martyn C N, Osmond C, Hales C N, Fall C H. Growth in utero and serum cholesterol concentrations in adult life.  BMJ . 1993;  307 1524-1527
  • 81 Barker D J, Meade T W, Fall C H. Relation of fetal and infant growth to plasma fibrinogen and factor VII concentrations in adult life.  BMJ . 1992;  304 148-152
  • 82 Yajnik C. Interactions of perturbations in intrauterine growth and growth during childhood on the risk of adult-onset disease.  Proc Nutr Soc . 2000;  59 257-265
  • 83 Steer P, Alam M A, Wadsworth J, Welch A. Relation between maternal haemoglobin concentration and birth weight in different ethnic groups.  BMJ . 1995;  310 489-491
  • 84 Peabody J W, Gertler P J, Leibowitz A. The policy implications of better structure and process on birth outcomes in Jamaica.  Health Policy . 1998;  43 1-13
  • 85 Wen S W, Kramer M S, Usher R H. Comparison of birth weight distributions between Chinese and Caucasian infants.  Am J Epidemiol . 1995;  141 1177-1187
  • 86 Caulfield L E, Harris S B, Whalen E A, Sugamori M E. Maternal nutritional status, diabetes and risk of macrosomia among Native Canadian women.  Early Hum Dev . 1998;  50 293-303
  • 87 Stein C E, Fall C H, Kumaran K, Osmond C, Cox V, Barker D J. Fetal growth and coronary heart disease in south India.  Lancet . 1996;  348 1269-1273
  • 88 Barakat K, Stevenson S, Wilkinson P, Suliman A, Ranjadayalan K, Timmis A D. Socioeconomic differentials in recurrent ischaemia and mortality after acute myocardial infarction.  Heart . 2001;  85 390-394
  • 89 Chaturvedi N, Rai H, Ben Shlomo Y. Lay diagnosis and health-care-seeking behaviour for chest pain in south Asians and Europeans.  Lancet . 1997;  350 1578-1583
  • 90 Lear J T, Lawrence I G, Burden A C, Pohl J E. A comparison of stress test referral rates and outcome between Asians and Europeans.  J R Soc Med . 1994;  87 661-662
  • 91 Lear J T, Lawrence I G, Pohl J E, Burden A C. Myocardial infarction and thrombolysis: a comparison of the Indian and European populations on a coronary care unit.  J R Coll Physicians Lond . 1994;  28 143-147
  • 92 Dhawan J, Bray C L. Angiographic comparison of coronary artery disease between Asians and Caucasians.  Postgrad Med J . 1994;  70 625-630
  • 93 Shaukat N, de Bono P D, Cruickshank J K. Clinical features, risk factors, and referral delay in British patients of Indian and European origin with angina matched for age and extent of coronary atheroma.  BMJ . 1993;  307 717-718
  • 94 Kahn B B, Flier J S. Obesity and insulin resistance.  J Clin Invest . 2000;  106 473-481
  • 95 Forouhi N G, Jenkinson G, Thomas E L. Relation of triglyceride stores in skeletal muscle cells to central obesity and insulin sensitivity in European and South Asian men.  Diabetologia . 1999;  42 932-935
  • 96 McKeigue P M, Pierpoint T, Ferrie J E, Marmot M G. Relationship of glucose intolerance and hyperinsulinaemia to body fat pattern in south Asians and Europeans.  Diabetologia . 1992;  35 785-791
  • 97 Banerji M A, Faridi N, Atluri R, Chaiken R L, Lebovitz H E. Body composition, visceral fat, leptin, and insulin resistance in Asian Indian men.  J Clin Endocrinol Metab . 1999;  84 137-144
  • 98 Yudkin J S, Yajnik C S, Mohamed Ali V, Bulmer K. High levels of circulating proinflammatory cytokines and leptin in urban, but not rural, Indians. A potential explanation for increased risk of diabetes and coronary heart disease.  Diabetes Care . 1999;  22 363-364
  • 99 Trevisan M, Krogh V, Freudenheim J. Consumption of olive oil, butter, and vegetable oils and coronary heart disease risk factors. The Research Group ATS-RF2 of the Italian National Research Council.  JAMA . 1990;  263 688-692
  • 100 Maron D J, Fair J M, Haskell W L. Saturated fat intake and insulin resistance in men with coronary artery disease. The Stanford Coronary Risk Intervention Project Investigators and Staff.  Circulation . 1991;  84 2020-2027
  • 101 Ascherio A, Rimm E B, Giovannucci E L, Spiegelman D, Stampfer M, Willett W C. Dietary fat and risk of coronary heart disease in men: cohort follow-up study in the United States.  BMJ . 1996;  313 84-90
  • 102 Snowdon D A, Phillips R L. Does a vegetarian diet reduce the occurrence of diabetes?.  Am J Public Health . 1985;  75 507-512
  • 103 Snowdon D A. Animal product consumption and mortality because of all causes combined, coronary heart disease, stroke, diabetes, and cancer in Seventh-Day Adventists.  Am J Clin Nutr . 1988;  48 739-748
  • 104 Kato H, Tillotson J, Nichaman M Z, Rhoads G G, Hamilton H B. Epidemiologic studies of coronary heart disease and stroke in Japanese men living in Japan, Hawaii, and California.  Am J Epidemiol . 1973;  97 372-385
  • 105 Robertson T L, Kato H, Gordon T. Epidemiologic studies of coronary heart disease and stroke in Japanese men living in Japan, Hawaii, and California. Coronary heart disease risk factors in Japan and Hawaii.  Am J Cardiol . 1977;  39 244-249
  • 106 McGee D L, Reed D M, Yano K, Kagan A, Tillotson J. Ten-year incidence of coronary heart disease in the Honolulu Heart Program. Relationship to nutrient intake.  Am J Epidemiol . 1984;  119 667-676
  • 107 Kushi L H, Lew R A, Stare F J. Diet and 20-year mortality from coronary heart disease. The Ireland-Boston Diet-Heart Study.  N Engl J Med . 1985;  312 811-818
  • 108 Mann G V. Metabolic consequences of dietary trans fatty acids.  Lancet . 1994;  343 1268-1271
  • 109 Ascherio A, Willett W C. Metabolic and atherogenic effects of trans fatty acids.  J Intern Med . 1995;  238 93-96
  • 110 Christiansen E, Schnider S, Palmvig B, Tauber-Lassen E, Pedersen O. Intake of a diet high in trans monounsaturated fatty acids or saturated fatty acids. Effects on postprandial insulinemia and glycemia in obese patients with NIDDM.  Diabetes Care . 1997;  20 881-887
  • 111 Frost G, Leeds A, Trew G, Margara R, Dornhorst A. Insulin sensitivity in women at risk of coronary heart disease and the effect of a low glycemic diet.  Metabolism . 1998;  47 1245-1251
  • 112 Frost G, Keogh B, Smith D, Akinsanya K, Leeds A. The effect of low-glycemic carbohydrate on insulin and glucose response in vivo and in vitro in patients with coronary heart disease.  Metabolism . 1996;  45 669-672
  • 113 Lissin L W, Cooke J P. Phytoestrogens and cardiovascular health.  J Am Coll Cardiol . 2000;  35 1403-1410
  • 114 Anthony M S, Clarkson T B, Bullock B C, Wagner J D. Soy protein versus soy phytoestrogens in the prevention of diet-induced coronary artery atherosclerosis of male cynomolgus monkeys.  Arterioscler Thromb Vasc Biol . 1997;  17 2524-2531
  • 115 Sevak L, McKeigue P M, Marmot M G. Relationship of hyperinsulinemia to dietary intake in south Asian and European men.  Am J Clin Nutr . 1994;  59 1069-1074
  • 116 Singh R B, Mori H, Chen J. Recommendations for the prevention of coronary artery disease in Asians: a scientific statement of the International College of Nutrition.  J Cardiovasc Risk . 1996;  3 489-494
  • 117 Helmrich S P, Ragland D R, Leung R W, Paffenbarger R S. Physical activity and reduced occurrence of noninsulin-dependent diabetes mellitus.  N Engl J Med . 1991;  325 147-152
  • 118 Wannamethee S G, Shaper A G, Alberti K G. Physical activity, metabolic factors, and the incidence of coronary heart disease and type 2 diabetes.  Arch Intern Med . 2000;  160 2108-2116
  • 119 Manson J E, Hu F B, Rich-Edwards J W. A prospective study of walking as compared with vigorous exercise in the prevention of coronary heart disease in women.  N Engl J Med . 1999;  341 650-658
  • 120 Rodriguez B L, Curb J D, Burchfiel C M. Physical activity and 23-year incidence of coronary heart disease morbidity and mortality among middle-aged men. The Honolulu Heart Program.  Circulation . 1994;  89 2540-2544
  • 121 Fletcher G F, Balady G, Blair S N. Statement on exercise: benefits and recommendations for physical activity programs for all Americans. A statement for health professionals by the Committee on Exercise and Cardiac Rehabilitation of the Council on Clinical Cardiology, American Heart Association.  Circulation . 1996;  94 857-862
  • 122 Tuomilehto J, Lindstrom J, Eriksson J G. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance.  N Engl J Med . 2001;  344 1343-1350
  • 123 Dhawan J, Bray C L. Asian Indians, coronary artery disease, and physical exercise.  Heart . 1997;  78 550-554
  • 124 Pomerleau J, McKeigue P M, Chaturvedi N. Factors associated with obesity in South Asian, Afro-Caribbean and European women.  Int J Obes Relat Metab Disord . 1999;  23 25-33
  • 125 Williams R, Bhopal R, Hunt K. Coronary risk in a British Punjabi population: comparative profile of nonbiochemical factors.  Int J Epidemiol . 1994;  23 28-37
  • 126 Stern M P. Strategies and prospects for finding insulin resistance genes.  J Clin Invest . 2000;  106 323-327
  • 127 Duggirala R, Blangero J, Almasy L. A major locus for fasting insulin concentrations and insulin resistance on chromosome 6q with strong pleiotropic effects on obesity-related phenotypes in nondiabetic Mexican Americans.  Am J Hum Genet . 2001;  68 1149-1164
  • 128 Maddux B A, Sbraccia P, Kumakura S. Membrane glycoprotein PC-1 and insulin resistance in noninsulin-dependent diabetes mellitus.  Nature . 1995;  373 448-451
  • 129 Goldfine I D, Maddux B A, Youngren J F, Frittitta L, Trischitta V, Dohm G L. Membrane glycoprotein PC-1 and insulin resistance.  Mol Cell Biochem . 1998;  182 177-184
  • 130 Schumacher M C, Hasstedt S J, Hunt S C, Williams R R, Elbein S C. Major gene effect for insulin levels in familial NIDDM pedigrees.  Diabetes . 1992;  41 416-423
  • 131 Kooner J S, Baliga R R, Wilding J. Abdominal obesity, impaired nonesterified fatty acid suppression, and insulin-mediated glucose disposal are early metabolic abnormalities in families with premature myocardial infarction.  Arterioscler Thromb Vasc Biol . 1998;  18 1021-1026
  • 132 Cassell P G, Saker P J, Huxtable S J. Evidence that single nucleotide polymorphism in the uncoupling protein 3 (UCP3) gene influences fat distribution in women of European and Asian origin.  Diabetologia . 2000;  43 1558-1564
  • 133 U.K. Prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38.  BMJ . 1998;  317 703-713
  • 134 Weinstock R S, Dai H, Wadden T A. Diet and exercise in the treatment of obesity: effects of three interventions on insulin resistance.  Arch Intern Med . 1998;  158 2477-2483
  • 135 Ross R, Dagnone D, Jones P J. Reduction in obesity and related comorbid conditions after diet-induced weight loss or exercise-induced weight loss in men. A randomized, controlled trial.  Ann Intern Med . 2000;  133 92-103
  • 136 U.K. Prospective Diabetes Study (UKPDS) Group. Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34).  Lancet . 1998;  352 854-865
  • 137 Antonucci T, Whitcomb R, McLain R, Lockwood D, Norris R M. Impaired glucose tolerance is normalized by treatment with the thiazolidinedione troglitazone.  Diabetes Care . 1997;  20 188-193
  • 138 Schoonjans K, Auwerx J. Thiazolidinediones: an update.  Lancet . 2000;  55 1008-1010
  • 139 Kendall A, Levitsky D A, Strupp B J, Lissner L. Weight loss on a low-fat diet: consequence of the imprecision of the control of food intake in humans.  Am J Clin Nutr . 1991;  53 1124-1129
  • 140 McKeigue P M, Marmot M G, Adelstein A M. Diet and risk factors for coronary heart disease in Asians in northwest London.  Lancet . 1985;  2 1086-1090
  • 141 Beegom R, Beegom R, Niaz M A, Singh R B. Diet, central obesity and prevalence of hypertension in the urban population of south India.  Int J Cardiol . 1995;  51 183-191
  • 142 Pais P, Pogue J, Gerstein H. Risk factors for acute myocardial infarction in Indians: a case-control study.  Lancet . 1996;  348 358-363
  • 143 Sacks F M, Pfeffer M A, Moye L A. The effect of pravastatin on coronary events after myocardial infarction in patients with average cholesterol levels. Cholesterol and Recurrent Events Trial Investigators.  N Engl J Med . 1996;  335 1001-1009
  • 144 Downs J R, Clearfield M, Weis S. Primary prevention of acute coronary events with lovastatin in men and women with average cholesterol levels: results of AFCAPS/ TexCAPS. Air Force/Texas Coronary Atherosclerosis Prevention Study.  JAMA . 1998;  279 1615-1622
  • 145 The Long-Term Intervention with Pravastatin in Ischaemic Disease (LIPID) Study Group. Prevention of cardiovascular events and death with pravastatin in patients with coronary heart disease and a broad range of initial cholesterol levels.  N Engl J Med . 1998;  339 1349-1357
  • 146 Department of Health. National Service Framework for Coronary Heart Disease. London:HMSO; 2000
  • 147 Harper C R, Jacobson T A. New perspectives on the management of low levels of high-density lipoprotein cholesterol.  Arch Intern Med . 1999;  159 1049-1057
  • 148 Houterman S, Boshuizen H C, Verschuren W-MM. Predicting cardiovascular risk in the elderly in different European countries.  Eur Heart J . 2002;  23 294-300
  • 149 Assmann G, Schulte H, von Eckardstein A. Hypertriglyceridemia and elevated lipoprotein(a) are risk factors for major coronary events in middle-aged men.  Am J Cardiol . 1996;  77 1179-1184
  • 150 Rubins H B, Robins S J, Collins D. Gemfibrozil for the secondary prevention of coronary heart disease in men with low levels of high-density lipoprotein cholesterol. Veterans Affairs High-Density Lipoprotein Cholesterol Intervention Trial Study Group.  N Engl J Med . 1999;  341 410-418
  • 151 van den Hoogen C P, Feskens E J, Nagelkerke N J, Menotti A, Nissinen A, Kromhout D. The relation between blood pressure and mortality due to coronary heart disease among men in different parts of the world. Seven Countries Study Research Group.  N Engl J Med . 2000;  342 1-8
  • 152 Kaplan N M. Systolic Hypertension in the Elderly Program (SHEP) and Swedish Trial in Old Patients with Hypertension (STOP). The promises and the potential problems.  Am J Hypertens . 1992;  5 331-334
  • 153 Hansson L, Zanchetti A, Carruthers S G. Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial. HOT Study Group.  Lancet . 1998;  351 1755-1762
  • 154 Antiplatelet Trialists' Collaboration. Collaborative overview of randomised trials of antiplatelet therapy-I: Prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of patients.  BMJ . 1994;  308 81-106
  • 155 Anderson K M, Odell P M, Wilson P W, Kannel W B. Cardiovascular disease risk profiles.  Am Heart J . 1991;  121 293-298
  • 156 Grundy S M, Pasternak R, Greenland P, Smith Jr S, Fuster V. Assessment of cardiovascular risk by use of multiple-risk-factor assessment equations: a statement for healthcare professionals from the American Heart Association and the American College of Cardiology.  Circulation . 1999;  100 1481-1492
  • 157 Wood D, De Backer G, Faergeman O, Graham I, Mancia G, Pyörälä K. Prevention of coronary heart disease in clinical practice: recommendations of the Second Joint Task Force of European and Other Societies on Coronary Prevention.  Atherosclerosis . 1998;  140 199-270
  • 158 British Cardiac Society, British Hyperlipidaemia Association, British Hypertension Society, British Diabetic Association. Joint British recommendations on prevention of coronary heart disease in clinical practice: summary.  BMJ . 2000;  320 705-708
  • 159 Leaverton P E, Sorlie P D, Kleinman J C. Representativeness of the Framingham risk model for coronary heart disease mortality: a comparison with a national cohort study.  J Chronic Dis . 1987;  40 775-784
  • 160 Brand R J, Rosenman R H, Sholtz R I, Friedman M. Multivariate prediction of coronary heart disease in the Western Collaborative Group Study compared to the findings of the Framingham study.  Circulation . 1976;  53 348-355
  • 161 The Pooling Project Research Group. Relationship of blood pressure, serum cholesterol, smoking habit, relative weight and ECG abnormalities to incidence of major coronary events: final report of the Pooling Project.  J Chronic Dis . 1978;  31 201-306
  • 162 The West of Scotland Coronary Prevention Study Group. Baseline risk factors and their association with outcome in the West of Scotland Coronary Prevention Study.  Am J Cardiol . 1997;  79 756-762
  • 163 Chambless L E, Dobson A J, Patterson C C, Raines B. On the use of a logistic risk score in predicting risk of coronary heart disease.  Stat Med . 1990;  9 385-396
  • 164 Chambers J C, Wrigley J, Kooner J S. Evaluation of the Joint British Societies coronary heart disease risk calculator in U.K. Indian Asians.  Heart . 2000;  83(suppl) 43A