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Phd-Rabanal-2019.Pdf (5.076Mb) Cardiovascular disease and ethnicity Focus on the high risk of CVD among South Asians living in Norway and New Zealand Kjersti Stormark Rabanal Dissertation for the degree of philosophiae doctor (PhD) at the University of Oslo 2018 © Kjersti Stormark Rabanal, 2019 Series of dissertations submitted to the Faculty of Medicine, University of Oslo ISBN 978-82-8377-383-5 All rights reserved. No part of this publication may be reproduced or transmitted, in any form or by any means, without permission. Cover: Hanne Baadsgaard Utigard. Print production: Reprosentralen, University of Oslo. Contents: Acknowledgements ............................................................................................................................. v Summary ............................................................................................................................................. vii List of papers ....................................................................................................................................... x Terms and abbreviations ..................................................................................................................... xi 1.0 General introduction ..................................................................................................................... 1 1.1 Cardiovascular disease (CVD) ........................................................................................................ 1 1.1.1 Cardiovascular risk factors ...................................................................................................... 1 1.1.2 Total cardiovascular risk prediction ........................................................................................ 8 1.2 CVD Epidemiology ‐ the global burden ........................................................................................ 11 1.2.1 Incidence of CVD in Norway and New Zealand .................................................................... 11 1.2.2 CVD mortality and trends in mortality rates ........................................................................ 12 1.3 Migration and ethnicity in relation to cardiovascular health ...................................................... 16 1.3.1 Migration .............................................................................................................................. 16 1.3.2 Ethnicity and cardiovascular disease .................................................................................... 17 1.3.3 Immigration to Norway ........................................................................................................ 18 1.3.4 Cardiovascular risk among immigrants in Norway ............................................................... 19 1.3.5 Immigration to New Zealand ................................................................................................ 19 1.3.6 Cardiovascular risk among South Asians in New Zealand .................................................... 20 1.3.7 High risk of CVD in South Asian populations ........................................................................ 21 2.0 Rationale and aims ...................................................................................................................... 23 3.0 Materials and methods ................................................................................................................ 23 3.1 Data sources in paper 1 ........................................................................................................... 23 3.2 Data sources in paper 2 and paper 3 ....................................................................................... 24 3.4 Study populations .................................................................................................................... 25 3.5 Statistical methods .................................................................................................................. 29 3.6 Ethical considerations .............................................................................................................. 30 4.0 Results ......................................................................................................................................... 30 4.1 Synopsis of the papers ............................................................................................................. 30 5.0 Discussion .................................................................................................................................... 33 5.1 Methodological considerations ............................................................................................... 33 5.1.1 Validity .................................................................................................................................. 33 5.2 General discussion of the results ............................................................................................. 44 6.0 Conclusions and future studies ................................................................................................... 48 References ......................................................................................................................................... 51 iii Errata………………………………………………………………………………………………………………………………………66 Papers 1‐3 Appendices iv Acknowledgements The work presented in this thesis was carried out at the Department of Noncommunicable Diseases at the Norwegian Institute of Public Health (NIPH) during the years 2013‐2018. The project was supported by the Norwegian Extra‐Foundation for Health and Rehabilitation through the Norwegian Health Association. I would like to express my deepest gratitude to my main supervisor Professor Haakon E Meyer and co‐supervisor PhD Randi M Selmer. They have both inspired me with their knowledge in the field of epidemiology, and given me tremendous support during these years. Haakon’s dedication, knowledge and experience in the fields of epidemiology, cardiovascular disease and immigrant health has been essential for my learning and for the progress in this project. I want to thank Haakon for keeping me "on track "with his exceptional ability to keep the perspective and to keep focus. I am very grateful to Haakon for giving me the opportunity to work on this project, and also for introducing me to our collaborators in New Zealand. Randi’s contributions to this project have also been invaluable. I want to thank Randi for sharing her experience and knowledge within the fields of cardiovascular disease, epidemiology and statistics in a comprehensible and inspiring way. Her guidance on the statistics and methodological issues was deeply appreciated. I have been very fortunate to have her on my team. Warm thanks to Grethe S Tell, project leader of the CVDNOR project, and to Jannicke Igland, senior engineer at the University of Bergen for their constructive comments and much appreciated contributions. It has been a privilege for me to work with both Grethe and Jannicke, and to get to work with the nationwide CVDNOR data. I am also very thankful for the significant help I got from Jannicke despite her own busy schedule while I was working with the CVDNOR data. I would like to thank our New Zealand collaborators; Rod Jackson, Romana Pylypchuk and Suneela Mehta, who I was so lucky to be able to work with and to learn from. I am very grateful that I got to work with the PREDICT data, for getting the opportunity to visit Rod Jackson and his team in New Zealand, and for all their valuable contributions to my papers. I am impressed by the way Rod Jackson and his team at the University of Auckland have managed to implement cardiovascular prediction models in clinical practice in such a large scale, and simultaneously collect important research data. v Sincere thanks to my co‐authors Bernadette Kumar and Anne Karen Jenum for their significant and important contributions. I also thank Tomislav Dimoski at the Norwegian Knowledge Centre for Health Services (now NIPH), Oslo, Norway for his contribution by developing software necessary for obtaining data from Norwegian hospitals, conducting the data collection and quality assurance of data in this project. To my amazing colleagues; Inger Ariansen for sharing her knowledge about cardiovascular disease and epidemiology, Kristine Vejrup, Maria Magnus, Cecilie Dahl, Kristin Holvik and all my other great colleagues at the department at the NIPH. I will miss the pleasant and inspiring work environment at the NIPH. I would also like to thank EPINOR, the National research school in population‐based epidemiology, for providing courses, student activities and funding possibilities. Warm thanks to Nora Rusås‐Heyerdahl and Marie Hagle – thank you for all the enjoyable coffee breaks and lunches we have shared during my time at the NIPH. Having you around meant so much to me. Last, but not least, I would like to thank my parents and family for love and support, to my encouraging husband Andreas who, together with our sons Matteo and Daniel, adds joy, love and meaning to my life. Stavanger, September 2018 vi Summary Background The burden of cardiovascular disease (CVD) differs between ethnic groups. Information from Norwegian health studies has shown that immigrants from South Asia have a high prevalence of diabetes, abdominal obesity, high levels of triglycerides and low levels of HDL. This is in agreement with international studies reporting a high risk of CVD in South Asian populations, particularly coronary heart disease
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