Incidence of Major Cardiovascular Events in Immigrants to Ontario, Canada
Jack V. TuAnna ChuMohammad R. RezaiHelen GuoLaura C. MaclaganPeter C. AustinGillian L. BoothDouglas G. ManuelMaria ChiuDennis T. KoDouglas S. LeeBaiju R. ShahLinda R. DonovanQazi Zain SohailDavid A. Alter
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Abstract:
Immigrants from ethnic minority groups represent an increasing proportion of the population in many high-income countries but little is known about the causes and amount of variation between various immigrant groups in the incidence of major cardiovascular events.We conducted the Cardiovascular Health in Ambulatory Care Research Team (CANHEART) Immigrant study, a big data initiative, linking information from Citizenship and Immigration Canada's Permanent Resident database to nine population-based health databases. A cohort of 824 662 first-generation immigrants aged 30 to 74 as of January 2002 from eight major ethnic groups and 201 countries of birth who immigrated to Ontario, Canada between 1985 and 2000 were compared to a reference group of 5.2 million long-term residents. The overall 10-year age-standardized incidence of major cardiovascular events was 30% lower among immigrants compared with long-term residents. East Asian immigrants (predominantly ethnic Chinese) had the lowest incidence overall (2.4 in males, 1.1 in females per 1000 person-years) but this increased with greater duration of stay in Canada. South Asian immigrants, including those born in Guyana had the highest event rates (8.9 in males, 3.6 in females per 1000 person-years), along with immigrants born in Iraq and Afghanistan. Adjustment for traditional risk factors reduced but did not eliminate differences in cardiovascular risk between various ethnic groups and long-term residents.Striking differences in the incidence of cardiovascular events exist among immigrants to Canada from different ethnic backgrounds. Traditional risk factors explain part but not all of these differences.Keywords:
Ethnic origin
The question of to what extent ethnicity contributes to the risk of cardiovascular morbidity and mortality has been of longstanding interest. A great number of publications have documented differences in the degree of cardiovascular risk in relation to ethnic origin. Most prominently, it was found that African Americans and people of East Indian descent had a significantly greater cardiovascular morbidity and mortality than Caucasians [1–4]. The search for explanations revealed that some classical risk factors were more prevalent and often of greater severity in different geographical areas and in certain ethnic groups [5–8]. However, the same ethnic groups could have different degrees of cardiovascular risk depending on environmental factors, such as lifestyle [5] or geographical location [9]. Many studies including race or ethnicity as a possible risk factor studied different racial or ethnic groups after they had emigrated to a country that was largely different from their country of origin, and thus had a different socio-economic background, lifestyle and culture [1,10–12]. The presence of a variety of cardiovascular risk factors with variable differences between ethnic groups renders it difficult to separate an independent ethnic contribution from that of other cardiovascular risk factors. In Afro-Caribbeans living in the UK, ischaemic heart disease was found to be relatively low [13] compared to individuals of East Indian descent and similar to White Europeans, although they had a high prevalence of insulin resistance [13] and thus a higher prevalence of type 2 diabetes [14]. Coronary heart disease was more prevalent in Malays and in East Indians than in Chinese all living in Singapore [15]. Classical risk factors did not appear to be a major contributor to these ethnic differences. However, East Indians were found to have a greater prevalence of abdominal obesity, lower high-density lipoprotein cholesterol concentrations and higher levels of thrombogenic factors and lipoprotein (a) [16]. Individuals from South Asia have one of the highest rates of coronary artery disease in Canada, and have a greater carotid artery intimal thickness compared to Europeans and Chinese, reflecting a greater atherosclerotic burden that is most likely related to a higher prevalence of diabetes [2,17]. In a follow-up of the Seven Country Study, although significant differences were found with respect to mortality rates for coronary heart disease and levels of blood pressure, the incremental risk over time was similar for a given increase in blood pressure in all countries, suggesting that blood pressure was the main determinant for ethnic and geographical differences in the risk of cardiac fatal events [18]. Often, the results of studies were more complex and the presence and severity of risk factors did not appear to fully explain ethnic differences in cardiovascular morbidity and mortality. For example, in the Dallas Heart Study, the amount of coronary atherosclerosis, as measured by electron beam computed tomography, was similar between Whites and African Americans even though African Americans had a higher mortality from coronary heart disease, suggesting that factors other than the coronary atherosclerotic burden determined cardiac mortality [19]. In the Study of Health Assessment and Risk in Ethnic groups, the amount of carotid atherosclerosis was greatest in Europeans compared to South Asians and Chinese but South Asians had the highest prevalence of cardiovascular diseases. This discrepancy could not be fully explained by the presence of classical or newer (prothrombotic markers] risk factors [20], although blood glucose concentrations were related directly to the degree of carotid intimal medial thickness [14]. Therefore, the variability and complexity of the results of studies makes it difficult to determine whether ethnicity per se represents an independent cardiovascular risk factor contributing to differences in cardiovascular morbidity and mortality between ethnic groups. It is very likely that genetic factors are involved to determine differences in cardiovascular risk either by determining type or severity of risk factors, as well as the susceptibility to the exposure of environmental/lifestyle factors [21–24]. However, it appears that, whatever the cause of ethnic differences, they all act predominantly through the classical or more novel cardiovascular risk factors with respect to the final pathophysiological pathway for the observed differences in cardiovascular risk among various ethnic groups. In this issue of the journal, Lane et al. [25] investigated all-cause and cardiovascular mortality in three different ethnic populations (South Asian men, African Caribbeans, White Europeans) living in Birmingham, UK, 20–25 years after an initial baseline assessment. They found that there were no significant differences in cardiovascular mortality between the three ethnic groups and, in a multivariate analysis, ethnicity did not emerge as an independent predictor for cardiovascular mortality whereas other risk factors such as age, male gender, smoking and systolic blood pressure independently related to cardiovascular and all cause mortality. Furthermore, no ethnic differences emerged in the subgroup of individuals who were hypertensive at baseline. However, a number of limitations apply and they have been addressed by the authors. One of the major limitations concerns the mortality data being obtained from death certificates that may not be completed accurately, but this would probably apply to all ethnic groups. Of greater impact on the results would be the lack of data from 5% of the study population which, with the relatively small number of cardiovascular death, could influence the results significantly if this related predominantly to one particular ethnic group; unfortunately, no additional information is provided. The most important information that this type of study does not make available is how well these study individuals were treated. Assuming that their cardiovascular risk factors were well treated and controlled, it is possible that ethnic differences in cardiovascular mortality could be reduced or eliminated. This makes this type of study different from cross-sectional studies, which may not reflect a possible treatment effect. In this respect, it is noteworthy that, at baseline, African Caribbeans had a higher blood pressure and body mass index than South Asian men and White Europeans. Moreover, previous cross-sectional studies performed in the UK showed that, compared to White Europeans, South Asian men had an approximately 50% higher coronary heart disease and stroke mortality, whereas African Caribbeans had an approximately 60% higher stroke mortality and a higher mortality due to endstage renal disease, but only had approximately 50% of the mortality due to coronary artery disease [25]. Initially, the results of the study by Lane et al. [25] appear to be at variance with those of other studies. However, assuming that differences in cardiovascular morbidity and mortality between various ethnic groups are mainly determined by differences in the number or severity of cardiovascular risk factors, this could explain the results of their study, particularly if risk factors were treated appropriately. Thus, the results obtained by Lane et al. [25] would appear quite plausible in the light of the recently published results of the INTERHEART study, which found that, regardless of ethnicity, race or country of residence, more than 90% of the study participants’ risk for a myocardial infarction could be explained on the basis of classical risk factors [26]. The practical message is that, regardless of ethnicity or country of residence or origin, the treatment and control of cardiovascular risk factors comprises the most important task for reducing cardiovascular morbidity and mortality and reducing the growing burden of cardiovascular diseases worldwide. At the same time, research investigating genetic differences among ethnic groups should continue to do so because this may bring us an step closer to the optimal management of people of different ethnicity. However, until then, the control of cardiovascular risk factors requires our utmost attention.
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While ethnic identity, ethnic relations, ethnic conflict, and immigration are increasingly important factors in national, regional, and international affairs, there are no definitions or criteria consistently applied to delineate ethnic groups in nation worldwide. Thus, in this article, I have examined the concept of ethnic groups and theories of ethnicity concisely, in the hope of promoting discussions of the theories of ethnicity, and popularizing those concepts of ethnic groups and ethnicity.
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The ethnic diversity in medical practices is increasing rapidly. In the Netherlands, ethnic groups are predominantly defined on the basis of their geographical origin, e.g. inhabitants of Turkish, Moroccan or Surinamese origin. The prevalence of health problems and the utilisation of health care differ between ethnic groups. This ethnic variation arises, firstly, from characteristics that are inherent to these groups such as genetic profile and culture, and, secondly, from characteristics that reflect their position in Dutch society such as socio-economic position and discrimination on the other. If we could fully understand which of these specific characteristics leads to a specific pattern of health problems or health care use, the classification of patient into ethnic groups would then become redundant. As long as we do not completely understand this variation, however, ethnic origin is a good entry-point for targeting health care to groups of patients.
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ABSTRACT Two studies of applicants to United Kingdom medical schools show that ethnic origin of surnames is reliably assessable by independent judges, and that surnames are valid indicators of ethnic origin as determined by self-classification, showing very high specificity (97%) and slightly lesser sensitivity (84%). Ethnic origin can also be determined from residential information derived from post-codes and place of birth, information in each case being highly specific (99% and 98%) but lacking in sensitivity (25% and 33%). The addition of place of birth and post-code data to surnames provides an increase in overall sensitivity (90%) with no improvement in specificity (94%). A comparison of survey respondents and nonrespondents shows that applicants from ethnic minorities are somewhat less likely to respond than non-minority applicants, although the effect is small. Responding applicants from ethnic minorities reply as quickly as non-minority applicants. Our survey confirms the feasibility of direct monitoring of the ethnic origin of applicants by asking applicants to complete a short questionnaire, and of its indirect monitoring by the use of surname. Both UCCA (Universities' Central Council on Admissions) and PCAS (Polytechnic Central Admissions System) have announced that they will instigate the ethnic monitoring of applicants for admission in autumn 1990.
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We aimed to evaluate the acceptability, feasibility, and understanding of a donor ethnic-ancestry question with Australian blood donors.Ethnic-ancestry assists blood collection agencies to meet the demand for rare blood-types. However, there is no standard ethnicity question used by health/blood services around the world and we do not know how blood donors in Australia will respond to being asked for this information.A survey and ethnic-ancestry question was administered to a sample of donors (n = 506) to evaluate their views on being asked for their ethnic-ancestry, test a comprehensive ethnic-ancestry list, and determine the level of information required by donors.Donors reported being very comfortable providing their ethnic-ancestry and the majority of donors found an ethnic-ancestry option they were happy with (91.3%). Overall donors reported a high level of understanding of why ethnic-ancestry was important to blood donation. However, when provided more information on why ethnic-ancestry is required, donors reported increased understanding.The findings from this study demonstrated that it is acceptable and feasible to introduce a comprehensive ethnic-ancestry question for Australian blood donors. We also found that a greater understanding is achieved when a more comprehensive explanation for inclusion of the question is provided.
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The book Ethnic Groups and Their Culture,whose chief editor is Professor Xu Jie-shun,was published by the Heilongjiang People's Publishing House in 2006 and collected the relevant achievements of studies of ethnic groups of the contemporary anthropology researchers.The works provides the latest interpretation of ethnic groups study in the academic circle in China and falls into such sections as special articles,concept of ethnic groups,theory of ethnic groups,identity of ethnic groups,relations of ethnic groups and culture of ethnic groups.
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Implementing modern ethnic education will lead t o creation of a culture conforming to the times and with local and ethnic charac teristics.To achieve this goal,ethnic education must combine objective reality a nd general demands of modern education with subjective desires and special deman ds of ethnic students.Ethnic education must serve ethnic development.
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For the total population there is evidence of substantial over‐education in the sense that workers possess higher qualifications than are strictly required for the job. Using the fourth wave of the British National Survey of Ethnic Minorities, this paper attempts to ascertain whether ethnic minorities suffer from higher over‐education than whites due to possible discrimination. The results suggest a differential effect across various ethnic groups and a tendency for foreign qualifications to be rewarded less.
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In this note we take a first look at the extent to which ethnic minorities in the UK maintain or diverge from the diet associated with their country of origin; and whether those who maintain their ethnic origin diet eat more or less healthily. We find that immigrants are more likely to eat food of ethnic origins than minority group members born in the UK. Those of Indian, Pakistani and Bangladeshi ethnicity are more likely than other minority groups to eat food of ethnic origin whether immigrant or UK-born. UK born minorities who eat ethnic origin food less often also eat fruits and vegetables less often. Thus maintenance of an ethnic origin diet appears to be associated with healthier eating patterns.
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