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64 CVD in India

area, the prevalence of diabetes was 18.3%, a rate higher fasting serum leptin and lower insulin sen-
markedly higher than reported for other populations sitivities, and stepwise regression analysis showed
in the United States, including whites, blacks, and that ethnicity was the only significant independent
Hispanics determinant variable for the differences in insulin
sensitivity index.
Diabetes may well serve as a link between potential
genetic predisposition and premature CAD in South CRP is the key inflammatory molecule associated
Asians- as levels of glucose intolerance, central with the metabolic syndrome in Caucasians, while C3
obesity (as measured by waist to hip ratio), fasting is the central inflammatory molecule in South Asians.
triglyceride, and insulin are uniformly elevated com- The mechanism for the increased C3 plasma levels in
pared to Europeans and these factors are key fea- South Asians with the metabolic syndrome is unclear
tures of the insulin resistance syndrome. but may be related to the close association between
insulin resistance and C3 in this population.
C reactive protein (CRP) concentrations are elevated
in South Asians, caused at least in part by a great- These changes in the south Asian population is mir-
er degree of central adiposity which promotes CRP rored in the East Asian population as Type 2 diabetes
expression. CRP is highly correlated with fasting and develops in East Asian patients at a lower mean body
post-load insulin, and independently predicts the risk mass index (BMI) and at any given BMI, East Asians
of IHD. PAI-1 and homocysteine concentrations are have a greater amount of body fat and a tendency
also raised in South Asians, and endothelial func- to visceral adiposity. DM develops at a younger age
tion is impaired; these may also contribute to the and is characterized by early B cell dysfunction in
elevation in IHD risk, either related to or separately the setting of insulin resistance, with many requiring
from their associations with insulin resistance. Poor early insulin treatment. The increasing proportion of
in utero development, resulting in low birth weight, in young-onset and childhood type 2 diabetes is pos-
particular coupled with catch up growth in early child- ing a particular threat, with these patients being at
hood, has been associated with a greater prevalence increased risk of developing diabetic complications.
of insulin resistance in South Asians. East Asian patients with type 2 diabetes have a
higher risk of developing renal complications than
Compared with European populations, South Asians
have increased abdominal visceral fat and greater European and with regard to cardiovascular compli-
insulin resistance at similar levels of BMI. insulin re- cations, a predisposition for developing strokes.
sistance is commonly noted in South Asians at BMI
levels that are traditionally considered “ideal” (25 kg/ Cardiovascular disease in DM.
m2). This body type, often termed “thin-fat pheno- DM is an established risk factor for CVD in both
type” (muscle thin but body fat) is associated with men and women. Women with DM especially, seem
an increased risk of developing diabetes. to lose their inherent protection against developing
CVD.
Lipoprotein(a), homocysteine, and plasminogen ac-
tivator inhibitor- 1 levels tend to be higher in South CVD accounts for the cause of death in 65% of those
Asians than in white populations. Numerous studies with DM and acts as an independent risk factor for
have suggested that altered adipokine production or CVD. Once CVD develops prognosis is far worse in
action may play a role in the heightened vascular risk DM patients. Both type 1 and type 2 are independent
observed in South Asian patients. risk factors for CVD. Also with diabetic neuropathy
symptoms can be absent even with the presence of
Raji et al, found adiponectin levels were to be lower myocardial ischemia and multivessel atherosclerosis
in Asian Indians than in whites, which corresponded is often present by the time symptoms develop. Also
to increased whole-body insulin resistance, impaired the development of myocardial dysfunction due to
fibrinolysis, and altered endothelial function in this DM leads to accelerated heart failure due to a com-
population. Low adiponectin levels in nondiabetic bination of atherosclerosis, hypertension, chronic hy-
South Asians may not only confer increased vascu- perglycemia, microvascular disease, glycosylation of
lar risk but also may be linked to the development myocardial proteins and autonomic neuropathy.
of diabetes in Asian Indians.
DM also increase the mortality from stroke 3 fold and
In a study by Liew et al, 44 healthy, nondiabetic usually causes occlusion of small paramedical pen-
Asian Indians were compared with white and Chinese etrating arteries and increases likelihood of carotid
subjects living in Singapore with respect to insulin atherosclerosis. 13% of those with DM >65 years have
sensitivity and leptin levels. Indians had significantly
had a stroke and are more likely to develop irrevers-

GCDC 2017