The cardiometabolic phenotype of UK South Asian Men

Migrant South Asian populations in Europe, North America the Westernised countries have a greater cardiovascular disease (CVD) risk than their respective indigenous populations. Both overall and premature CVD morbidity and mortality is significantly higher in migrant South Asians than in white populations in the UK and globally. Despite this, the role of ultrasound as a screening tool for CVD risk assessment in South Asians has not been studied extensively. Data also suggest that increased susceptibility to the adverse effects of insulin resistance and type 2 diabetes mellitus (T2DM) may contribute to the increased CVD risk. South Asians living in the United Kingdom also have a 3-5 fold increased prevalence of T2DM, developing the disease around a decade earlier and at a lower body mass index (BMI) compared to white Europeans. Furthermore, non-diabetic South Asians have higher fasting glycaemia and are more insulin resistant than Europeans. Liver fat is also associated with insulin resistance and T2DM risk and is considered to play a causal role in diabetes. Limited data suggest that South Asians have higher liver fat content than age- and BMI-matched Europeans, but it is not currently clear whether this contributes to the observed ethnic difference in insulin resistance. The first aim was to determine the extent to which increased insulin resistance and fasting glycaemia in South Asian, compared to white European men, living in the UK, was due to lower cardiorespiratory fitness (maximal oxygen uptake [VO2max]) and physical activity. The second aim was to determine whether South Asians have increased liver fat compared to Europeans and the extent to which any such differences can explain the increased insulin resistance observed between these groups. The final aim was to determine whether South Asians had a difference in carotid intima-media thickness (cIMT) or carotid plaque presence compared to Europeans; and if so, whether any measured risk factors (if any) could account for any such observed differences in cIMT and/or carotid plaque disease. 100 SA and 100 age and BMI-matched European men without diagnosed diabetes, aged 40-70 years, had fasting blood taken for glucose concentration, insulin, plus other risk factors, and underwent 2-dimensional carotid ultrasound for measurement of intima-media thickness and carotid plaque analysis, assessment of physical activity (using accelerometry), VO2max, body size and composition, and demographic and other lifestyle factors. For addressing the first aim of this thesis, 13 South Asian and 1 European man had HbA1c levels >6.5% indicating potential undiagnosed diabetes and were excluded from the analyses relating. Linear regression models were used to determine the extent to which body size and composition, fitness and physical activity variables explained differences in insulin resistance (assessed by Homeostasis Assessment Model of Insulin Resistance, HOMAIR) and fasting glucose between SA and Europeans. For the second aim, 28 South Asian and 24 European participants were chosen at random (but matched for age) within 4 months of their original main study visit to undergo magnetic resonance spectroscopy for quantification of liver fat. HOMAIR and fasting glucose were 67% (p<0.001) and 3% (p<0.018) higher, respectively, in South Asians than Europeans. Lower VO2max, lower physical activity and greater total adiposity in SA individually explained 68% (95% confidence interval [CI], 45-91%), 29% (95% CI, 11-46%) and 52% (95% CI, 30-80%), respectively, and together explained 83% (95% CI, 50-119%) (all p<0.001), of the ethnic difference in HOMAIR. Lower VO2max and greater total adiposity respectively explained 61% (95% CI, 9-111%) and 39% (95% CI; 9-76%) (combined effect 63% (95% CI 8-115%); all p<0.05)) of the ethnic difference in fasting glucose. Unadjusted mean liver fat content did not differ significantly between South Asians compared to Europeans (5.28 (standard deviation [SD], 2.11)% vs 5.41 (SD,2.35)%, p=0.913), but following adjustment for alcohol consumption was significantly lower in South Asians than Europeans (5.30 (SD, 2.10)% vs 9.03 (SD, 2.22)% p=0.017). Adjustment for alcohol-adjusted liver fat did not attenuate the difference in HOMAIR between ethnic groups. There were no significant differences in unadjusted or age-adjusted in mean cIMT between South Asians and Europeans. There was an increased odds ratio for the presence of plaque disease in South Asians compared to Europeans, however this was not significant (OR 1.57, 95% CI 0.89-2.77, p=0.13). Lower cardiorespiratory fitness is a key factor associated with the excess insulin resistance and fasting glycaemia in middle-aged South Asian compared to European men living in the UK. Also, whilst clear associations between liver fat and insulin resistance were observed in South Asians and Europeans, these results challenge the notion that excess liver fat per se explains the greater insulin resistance observed in South Asians. Finally, cIMT is similar between South Asian and European men and there is also currently no clear evidence for more carotid plaques in South Asian compared to European men living in the UK. This important negative finding highlights the need for further studies on carotid plaque or research in alternative screening methods for CVD which are more sensitive in identifying subclinical CVD

Ethnic differences in Glycaemic control in people with type 2 diabetes mellitus living in Scotland

Background and Aims: Previous studies have investigated the association between ethnicity and processes of care and intermediate outcomes of diabetes, but there are limited population-based studies available. The aim of this study was to use population-based data to investigate the relationships between ethnicity and glycaemic control in men and women with diabetes mellitus living in Scotland.&lt;p&gt;&lt;/p&gt; Methods: We used a 2008 extract from the population-based national electronic diabetes database of Scotland. The association between ethnicity with mean glycaemic control in type 2 diabetes mellitus was examined in a retrospective cohort study, including adjustment for a number of variables including age, sex, socioeconomic status, body mass index (BMI), prescribed treatment and duration of diabetes.&lt;p&gt;&lt;/p&gt; Results: Complete data for analyses were available for 56,333 White Scottish adults, 2,535 Pakistanis, 857 Indians, 427 Chinese and 223 African-Caribbeans. All other ethnic groups had significantly (p&#60;0.05) greater proportions of people with suboptimal glycaemic control (HbA1c &#62;58 mmol/mol, 7.5%) compared to the White Scottish group, despite generally younger mean age and lower BMI. Fully adjusted odds ratios for suboptimal glycaemic control were significantly higher among Pakistanis and Indians (1.85, 95% CI: 1.68–2.04, and 1.62,95% CI: 1.38–1.89) respectively.&lt;p&gt;&lt;/p&gt; Conclusions: Pakistanis and Indians with type 2 diabetes mellitus were more likely to have suboptimal glycaemic control than the white Scottish population. Further research on health services and self-management are needed to understand the association between ethnicity and glycaemic control to address ethnic disparities in glycaemic control.&lt;p&gt;&lt;/p&gt

Fasting during Ramadan and the COVID-19 pandemic

No abstract available

Ramadan and Diabetes: A Narrative Review and Practice Update.

Fasting in the Islamic month of Ramadan is obligatory for all sane, healthy adult Muslims. The length of the day varies significantly in temperate regions-typically lasting ≥ 18 h during peak summer in the UK. The synodic nature of the Islamic calendar means that Ramadan migrates across all four seasons over an approximately 33-year cycle. Despite valid exemptions, there is an intense desire to fast during this month, even among those who are considered to be at high risk, including many individuals with diabetes mellitus. In this review we explore the current scientific and clinical evidence on fasting in patients with diabetes mellitus, focussing on type 2 diabetes mellitus and type 1 diabetes mellitus, with brief reviews on pregnancy, pancreatic diabetes, bariatric surgery, the elderly population and current practice guidelines. We also make recommendations on the management of diabetes patients during the month of Ramadan. Many patients admit to a do-it-yourself approach to diabetes mellitus management during Ramadan, largely due to an under-appreciation of the risks and implications of the rigors of fasting on their health. Part of the issue may also lie with a healthcare professional's perceived inability to grasp the religious sensitivities of Muslims in relation to disease management. Thus, the pre-Ramadan assessment is crucial to ensure a safe Ramadan experience. Diabetes patients can be risk-stratified from low, medium to high or very high risk during the pre-Ramadan assessment and counselled accordingly. Those who are assessed to be at high to very high risk are advised not to fast. The current COVID-19 pandemic upgrades those in the high-risk category to very high risk; hence a significant number of diabetes patients may fall under the penumbra of the 'not to fast' advisory. We recognize that fasting is a personal choice and if a person chooses to fast despite advice to the contrary, he/she should be adequately supported and monitored closely during Ramadan and for a brief period thereafter. Current advancements in insulin delivery and glucose monitoring technologies are useful adjuncts to strategies for supporting type 1 diabetes patients considered to be high risk as well as 'high-risk' type 2 patients manage their diabetes during Ramadan. Although there is a lack of formal trial data, there is sufficient evidence across the different classes of therapeutic hypoglycaemic agents in terms of safety and efficacy to enable informed decision-making and provide a breadth of therapeutic options for the patient and the healthcare professional, even if the professional advice is to abstain. Thus, Ramadan provides an excellent opportunity for patient engagement to discuss important aspects of management, to improve control in the short term during Ramadan and to help the observants understand that the metabolic gains achieved during Ramadan are also sustainable in the other months of the year by maintaining a dietary and behavioural discipline. The application of this understanding can potentially prevent long-term complications. Electronic Supplementary Material The online version of this article (10.1007/s13300-020-00886-y) contains supplementary material, which is available to authorized users