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J Immigrant Minority Health DOI 10.1007/s10903-006-9027-5

ORIGINAL PAPER

Nutrient Intake, Body Composition, Blood Cholesterol and Glucose Levels among Adult Asian Indians in the United States Satya S. Jonnalagadda Æ Pramod Khosla

Ó Springer Science+Business Media, LLC 2007 Abstract Asian Indian (AI) immigrants have been suggested to be at increased risk for chronic disease. This study examined the metabolic risk factors for CVD among AI immigrants participating in a health fair in Southern Michigan, in the U.S. Participants included AI men (n = 44) and women (n = 57) who completed a demographic questionnaire, blood lipid (TC and HDL-C) and blood glucose (BG) test, resting BP check (SBP and DBP), body composition analysis and 24-h diet recall. For the entire group, the mean values were: BMI = 25.5, % body fat (BF) = 29.3; SBP = 129 mmHg; DBP = 76 mmHg; TC = 198 mg/ dL; HDL-C = 48 mg/dL; BG = 111 mg/dL. Significant gender differences were observed: % BF (20% vs. 36%, P < 0.0001), lean body mass (122 vs. 48 lbs, P < 0.0001), HDL-C (42 vs. 52 mg/dL, P < 0.0025), TC/HDL-C (4.86 vs. 4.11, P < 0.03) and BG (122 vs. 105 mg/dL, P < 0.0001), for males and females, respectively. Dietary carbohydrate, protein and fat contributed 64, 14 and 25% of total energy intake. Among males, BMI was positively correlated with % BF (0.729, P < 0.01) and negatively correlated with HDL-C (–0.457, P < 0.05). Among females, BMI was positively correlated with % BF (0.801, P < 0.01), SBP (0.425, P < 0.05) and DBP (0.538, P < 0.01), and negatively correlated with % energy from saturated fat (–0.523, P < 0.01) and calcium intake (–0.445, S. S. Jonnalagadda (&) Research and Development, Novartis Medical Nutrition, 1541 Park Place Blvd, St. Louis Park, MN 55416, USA e-mail: [email protected] P. Khosla Department of Nutrition and Food Science, Wayne State University, Detroit, MI 48202-3424, USA

P < 0.05). Despite having a dietary intake that meets the National Cholesterol Education Program, Adult Treatment Panel III recommendations, this group was at a higher risk for chronic disease, by virtue of increased BMI and % BF along with an altered metabolic profile (high BP and TC and low HDL-C). Keywords Nutrient intake  Body fat  Blood cholesterol  Blood glucose  Asian Indians  Immigrants

Introduction Ethnicity is a construct of biology, culture, language, religion, distinct health beliefs and behaviors, encompassing a range of biological and environmental exposures [1–3]. Ethnicity can therefore have a significant impact on health. Furthermore, immigration and adaptation to a new culture can also impact risk of chronic diseases in ethnic immigrants. Immigrant populations afford an opportunity to study differences in morbidity and mortality patterns with exposures to different environments, since lifestyle characteristics may or may not be maintained with assimilation into local culture. Impact of these lifestyle characteristics on morbidity and mortality has been well researched in some ethnic communities (Japanese, Chinese, Koreans), but not in others (Asian Indians) [1–4]. In general, immigrant groups that maintain their traditional dietary habits and lifestyles have been shown to have a lower risk of morbidity and mortality compared to those who have adopted the patterns of the host country. Asian Indians are one of the fastest growing immigrant groups within the category of Asian and Pacific

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Islander populations in the U.S. [5]. Asian Indians witnessed a 6% growth rate in the past decade, making them the third largest group among Asian and Pacific Islanders [5]. Asian Indian immigrants in the U.K. and Canada have been found to be at greater risk of morbidity and mortality of chronic disease compared to the native population in the host country and other immigrant groups [6–10]. Available data in the U.S. indicates that heart disease is the leading cause of death in both genders of this ethnic community [11–15]. In the U.S., the prevalence of coronary artery disease among Asian Indians has been observed to be fourfold higher than among whites (10% vs. 2.5%), with associated mortality rates being threefold higher in men under the age of 45 years [11–15]. The excess coronary artery disease mortality among Asian Indian women is greater than in their male counterparts, with the mortality being twofold higher in Asian Indian women, 45–64 years of age, compared to white females [9, 10]. The excess coronary artery disease risk in Asian Indians also appears at a younger age. In the U.K. the relative risk of coronary artery disease mortality in Asian Indian men compared to whites, was 3.3 when considering men aged 20–29 years and 1.36 overall [9, 10]: however, the factors contributing to this increased risk of morbidity and mortality in this ethnic community are poorly understood. Although Asian Indians exhibits some of the conventional risk factors of coronary artery disease, compared with whites, they have a lower prevalence of traditional risk factors such as, hypertension, hypercholesterolemia, obesity and smoking, but exhibit a higher prevalence of hypertriglyceredemia, low HDL-cholesterol, glucose intolerance and central obesity [9, 10, 15]. Among Asian Indians, regardless of gender, the BMI values that correspond to ‘‘overweight’’ and ‘‘obese’’ are two and five units lower, respectively, than the corresponding values in Whites, suggesting that the traditional risk factors may need to be reevaluated for this ethnic group [16–18]. Durenberg-Yap et al. [19] observed the absolute and relative risk of cardiovascular disease among Asians to be high at BMI values, which correspond to normal weight status for Caucasian populations. For example, at BMI of 22–24, the relative risk was 2.22 in females and 3.14 in males, which could represent an increased body fat despite normal BMI, in this ethnic population [19]. Abnormalities in glucose metabolism are also particularly common in Asian Indians and often occur without significant obesity. Insulin resistance is a precursor of diabetes and a common pathogenic mechanism for development of coronary artery disease. Insulin resistance is associated

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with hyperlipidemia, dyslipidemia, glucose intolerance, central obesity and hypertension. For comparable age, BMI and waist to hip ratios, Asian Indians are more insulin resistant than their white counterparts. However, diabetes and metabolic syndrome cannot fully explain the excess burden of coronary artery disease among Asian Indians [20–23]. Potentially, the high rates of CAD among Asian Indians may be due to a combination of nature (genetic predisposition) and nurture (lifestyle factors). The lifestyle factors could be associated with increased urbanization, immigration and acculturation, which typically are associated with physical inactivity, increased consumption of fat and calorie dense foods, resulting in abdominal obesity, insulin resistance and dyslipidemia [7, 21, 24, 25]. About 50% of Asian Indians are vegetarians but their rates of diabetes and coronary artery disease are as high as non-vegetarians, furthermore the lipoprotein levels among vegetarians are no different than that of non-vegetarians. This could be due to their liberal consumption of high fat, high saturated fat foods such as ghee, butter, dairy, and fried foods, and sedentary lifestyles [6, 12, 13, 24]. Only a handful of studies have examined the associations between the conventional CAD risk factors in this immigrant population in the U.S. [6, 12, 13]. More studies are needed to better understand the risks of this immigrant group. The purpose of this exploratory study was to examine the relationship between dietary intake, body composition, plasma lipoprotein and glucose concentrations in immigrant Asian Indian men and women in the United States.

Methods Sample The Human Subject Review Board at Georgia State University approved the study protocol. All participants signed an informed consent form prior to completion of the study procedures. Participants included adult Asian Indian men (n = 44) and women (n = 57) participating in a community based health-screening program in Canton, MI. Participants completed a basic demographic questionnaire and the individual study procedures described below. Dietary Assessment A single 24-h dietary recall was collected from each participant during the health screening. The dietary recalls were used to determine the macro and

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micronutrient intakes of the study participants. Trained interviewers conducted the 24-h dietary recalls. All interviewers were of Asian-Indian background and were nutrition graduate students or trained dietitians. All interviewers were trained in collecting the recalls and instructions were provided for obtaining detailed descriptions regarding the foods and fluids consumed and portion sizes. Participants were asked to report all food, fluids and supplements consumed during the previous 24-h period, starting with the time they woke up to the time they went to bed. Participants were instructed about appropriate portion size estimation and were provided with aids and various foodbased cues to assist with portion size estimation. The first author reviewed all 24-h dietary recall data for missing or incomplete information and any questions regarding the recalled intake were clarified with the participants. Subsequently, the first author conducted all the dietary analyses. This enabled uniform decisionmaking regarding the data entry and analysis process. The Food Processor nutrient analysis software (version 9.0, ESHA, Salem, OR) was utilized to analyze the 24h dietary recalls. The Food Processor consists of data entry and analysis software, and a comprehensive food database that includes the USDA standard release and manufactures nutrient database. Additionally, it allows the addition of new items, such as ethnic foods and recipes into the database. Anthropometric and Body Composition Assessment Participant’s height was measured without shoes using a standard measuring tape fixed to the wall. The Tanita body composition analyzer (TBF-300, Carpinteria, CA) was used to measure the participant’s body weight and body composition. The TBF-300 utilizes the foot-to-foot bioelectrical impedance analysis (BIA) technology to determine the body composition and provides information regarding body weight, fat mass, fat free mass, fat percentage, and total body water. BIA is considered to be an accurate method for estimation of body fat [26]. Resting blood pressure was measured using an automatic (arm cuff) blood pressure monitor (Omron, Vernon Hills, IL). Two blood pressure readings were measured five minutes apart with the participants seated. Blood Lipids and Glucose Measurements Trained technicians collected finger-stick, blood samples for immediate analysis using the Cholestech LDX Analyzer (Hayward, CA). Total cholesterol,

HDL-cholesterol and glucose concentrations were determined using the Lipid/Glucose panel. The nonHDL-cholesterol was calculated as the difference between TC and HDL-C, while the TC/HDL-cholesterol ratio was calculated from the individual parameters. Statistical Analysis Descriptive and correlation analysis were performed on all data using the Statistical Package for Social Sciences (version 11.5, SPSS, Chicago, IL). An independent t-test was used to examine the differences between males and females for the main study variables. Significance was set at P < 0.05.

Results Participant characteristics are presented in Table 1. Study participants were middle aged, with an age range of 20–80 years. The mean BMI of study participants is indicative of overweight status, while the percent body fat indicates excess body fat, especially among the female participants. Significant (P < 0.05) differences were observed among men and women with regards to height, body weight, percent body fat, fat mass, lean body mass and total body water. Table 2 presents the physiological measurements made in the study participants. The mean systolic blood pressure levels for both genders were in the prehypertension range (120–139 mm Hg) (Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VII)), while the diastolic blood pressure was within the target range, albeit towards the upper end of the recommendations ( 23 and > 27 would correspond to overweight and obesity, respectively, despite having total fat and fatty acid intake within the NCEP recommended ranges. Furthermore, they also observed the overall diet of these individuals was low in fruits and vegetables (1.35 servings/d) and whole grain products (6 servings/d) implying a reduction in total fiber intake. Total cholesterol was positively correlated with consumption of rice and rice alternatives (r = 0.60) and negatively correlated with vegetables (r = –0.82), while HDL-cholesterol was negatively correlated with fat intake (r = –0.70) and rice alternatives (r = –0.63). Likewise, in the present study, although the macronutrient intakes were well within the Dietary Reference Intakes recommendations, these participants had high percent body fat, BMI indicative of obesity (based on the new cut-off values), high total

Table 5 Micronutrient intake of study participants— minerals

N/A = no EAR Values are Mean ± SD

%RDA/ AI

%EAR Females (n = 57)

%RDA/ AI

%EAR

168 40 55

242 N/A 68

150 30 39

211 N/A 48

44 94 125 92 136

N/A 113 150 109 181

24 68 1.2 0.8 15.8

± ± ± ± ±

18 57 0.4 0.4 5.6

27 91 109 73 113

N/A 113 133 89 144

135 106 50 60

168 129 60 N/A

391 1.2 0.8 2.7

± ± ± ±

210 0.7 1.1 1.3

98 80 33 54

98 92 40 N/A

1,053 ± 1,038 3.0 ± 1.8 5.8 ± 2.9

cholesterol and low HDL-cholesterol. These results suggest that the dietary recommendations for the ethnic groups need to be modified given their lower risk threshold. In addition, as Asian Indian populations hailing from different regions of the subcontinent have different dietary habits, further modification of dietary recommendations may be required to account for this variation. Cardiovascular disease in India accounts for 25% of all mortality [27], while Asian Indian immigrants in western countries have been observed to have a 40% higher risk of ischemic heart disease mortality than their western counterparts [28]. Low vitamin B6, and folate intakes and high trans fatty acid intakes have been suggested to be potential factors contributing to the increased risk of ischemic heart disease in Asian Indians. Rastogi et al. [27] observed 38% of the study participants were vegetarians, but had significantly higher BMI, waist-to-hip ratio, alcohol intakes, high prevalence of hypertension, high cholesterol, diabetes and family history of IHD, lower intakes of green leafy vegetables and low rate of exercise. These results, along with those from the present study, suggest that the dietary patterns and food choices of Asian Indians need to be carefully evaluated to identify the unique features that contribute to their increased risk of chronic

Males (n = 44) %RDA/AI %EAR Females (n = 57) %RDA/AI %EAR Calcium (mg) 866 ± Phosphorus (mg) 883 ± Magnesium (mg) 361 ± Iron (mg) 17 ± Zinc (mg) 8± Copper (mg) 1.5 ± Selenium (mcg) 84 ± Potassium (mg) 2,468 ± Sodium (mg) 3,059 ±

344 350 174 6 5 0.7 43 989 1,653

72 126 86 212 73 167 153 52 235

N/A 126 103 283 85 214 187 N/A N/A

697 712 264 12 6 1.2 71 1,932 2,455

± ± ± ± ± ± ± ± ±

339 281 93 4 2 0.4 25 876 866

58 102 82 150 75 133 129 41 189

N/A 102 100 240 88 171 158 N/A N/A

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disease. Additionally, these results provide further evidence that a vegetarian dietary pattern is not necessarily always a healthy one and individuals need to be educated about making the appropriate food choices. McNeely and Boyko [3] in the 2001 BRFSS observed, after adjusting for BMI, age and sex, the odds of diabetes was 1.6 higher among Asian Americans compared to non-Hispanic whites. This increased risk of diabetes may be associated with body fat distribution and body composition, intra abdominal fat distribution and impaired beta-cell function. Similarly, Middlekoop et al. [20] observed increased prevalence of diabetes among South Asian immigrants in the Hague (6.4–31.7%), with individuals belonging to a lower SES exhibiting a higher prevalence, especially among the younger age groups. Baweja et al. [11] observed one-fifth of Gujarati Asian Indian immigrants residing in the state Georgia to be overweight, with an overall mean BMI of 26.1. The prevalence of hypertension was 26% in women and 21% in men; diabetes was 22.5% in women and 13.6% in men; hypercholesterolemia was 21% in women and 16% in men. The results of the present study are indicative of the presence of metabolic syndrome among this group of immigrants. The results of these studies taken together imply that Asian Indians are at higher risk of chronic diseases. Vallapuri et al. [14] observed Asian Indians to have a greater extent of coronary artery disease than American Caucasians, while they had lower BMIs (24.8 vs. 29.6). Sixty-four percent of Asian Indians versus 56% of American Caucasians had hypertension, while TC/HDL-C ratio was 4.9 vs. 5.1, respectively. Percent current smokers were lower in Asian Indians than American Caucasians (6 vs. 42%). Asian Indians had LDL-C of 118 mg/dL compared to 111 mg/dL in American Caucasians. Overall, Asian Indians were younger and had a greater extent of angiographic CAD. Similar results were observed by Ang et al. [17] and Lee et al. [16] among Asian Indian immigrants in Singapore, potentially, suggesting that Asian Indians may have an inherently higher risk of chronic disease compared to other Asian and Western counterparts. Misra [21] suggests that body fat patterning may be more critical to Asian Indians who have a high prevalence of coronary heart disease, insulin resistance syndrome and type 2 diabetes. Asian Indians have a distinct body composition with excess body fat, abdominal adiposity and less lean mass at the range of BMI considered normal. Thus, when assessing risk of chronic disease among Asian Indians, it is essential to examine anthropometric, dietary and blood chemistries to make a complete evaluation of their risk.

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The participants in the present study had blood pressure and blood glucose levels in the pre-hypertensive and pre-diabetes, ranges, which when combined with their BMI, percent body fat, high carbohydrate and high fat intake can increase their risk of chronic disease, like that observed by Chambers et al. [9, 10]. Chambers et al. [10] observed Asian Indians residing in the U.K. had significantly higher prevalence of hypertension (37%) and diabetes (16%) compared to European Whites (22 and 4%, respectively). Asian Indians had higher TG and lower HDLC and higher insulin resistance scores. Asian Indians were also observed to have higher CRP concentrations (1.71 mg/L vs. 1.47 mg/L, P < 0.003), which was positively associated with age, cigarette smoking, BMI, waist-hip ratio, blood pressure, glucose, TG, insulin resistance score and inversely related to HDL-C. Age adjusted CRP levels were 17% higher in Asian Indians versus European Whites, which is associated with approximately 14% increase in CHD risk in Asian Indians compared to European Whites. These findings suggest that inflammatory mechanisms may potentially be contributing to the increased risk of CHD among insulin resistant Asian Indians. Additionally, Chambers et al. [9] observed elevated plasma homocysteine concentrations (6% higher) in Asian Indians compared to their European counterparts, which may contribute to twice as much coronary heart disease among Asian Indians compared with Europeans. These differences in homocysteine were explained by lower vitamin B12 and folate levels in Asian Indians, which typically are associated with lower dietary intakes. Given the vegetarian dietary habits of these immigrants, these individuals need to be encouraged to take supplemental forms of these key nutrients. Although, homocysteine levels were not measured in the present study, it is highly likely that these study participants would have elevated levels given the presence of other physiological risk factors and their inadequate micronutrient intakes. Although, immigrants typically originate from countries with a lower prevalence of obesity than the U.S., acculturation to U.S. norms over time may lead to an increased prevalence of obesity among this population. Goel et al. [4] observed in the NHIS that foreign born individuals were less likely to be overweight and obese compared to U.S. born individuals, but the proportion of overweight and obese increased with longer duration of residence in the U.S. (8% obese among individuals residing less than 1 year in the U.S. versus 19% in those residing greater than 15 years in the U.S.). Living in the U.S. for more than 10 years was associated with significant increases in BMI. Foreign born

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respondents were less likely to discuss their diet and eating habits with a clinician (18% vs. 24% of U.S. born, P < 0.001). This may be reflective of increased sedentary behaviors, poor dietary patterns and increased availability of calorically dense foods and higher reliance on labor saving techniques. Therefore, health care professionals, should be cognizant of not only the differences in risk, but also should make every effort to identify dietary and lifestyle practices that could potentially increase the risk of this population. Understanding the health status and needs of immigrants is important because of their growing numbers and contribution to the health of this nation [1]. The health status and health needs of Asian Indian immigrants are poorly understood. As immigrants adopt traditional American health behaviors overtime, their health status begins to converge with that of the general U.S. population. The WHO expert panel report [18] concluded that the widely accepted BMI cutoff points defining overweight and obesity should be retained but that efforts should be directed towards a process through which countries develop weight standards that are more applicable to their population. The expert panel noted that for Asian populations, BMI of 23 or higher represented increased risk, while a BMI of 27.5 or higher represented high risk. The present study and extant literature suggest that Asian Indian immigrants are at increased risk of developing cardiovascular disease and its associated co-morbidities. Limitations and Future Research The sampling strategy used in this study was non-random and purposive, and therefore the results are confined to this group of Asian Indians. Other limitations of the study include the sample size, the use of a single day dietary intake data and a single blood measurement. Nevertheless, the results of this study suggest that this group of Asian Indians is at risk of developing chronic diseases and risk assessments in this group may need to be initiated at an earlier age. More research is needed to asses how the current dietary and risk assessment recommendations of the National Cholesterol Education Program should be modified to address the needs of these Asian Indian immigrants. Health professionals should be aware of these differences and proposed cutoff values to determine what prevention and treatment strategies are necessary for this ethnic population. As numerous health fairs are conducted by Asian Indian populations throughout the U.S., these may provide an excellent opportunity for collecting and collating data that help to highlight the dietary and

lifestyle risk factors that impact Asian Indian health in the U.S. Acknowledgments We thank Dr. Sarju Shah for allowing us to participate in the health fair. We thank Meena Bhatti, Juhi Gupta, and Diksha Kapoor for conducting the dietary interviews.

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