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Coronary heart disease in London

Mortality rates due to Coronary heart disease are increasing in the London and its one of the borough Newham. Newham has second height rates of early death due to cardiovascular disease (Newham PCT 2007). 68% of total population are South Asian origin ( Newham, 2008). This eassy is examine the distribution of coronary heart disease among the South Asian community in the London borough of Newham. It will look the demography and ethnicity of borough by using various epidermiolgical data to follow the situation of coronary heart disease among the various community of South Asian ethnic groups.It will also disscuss the mortality rates due to coronary heart disease in different boroughs of London. In addition, it will also disscuss the social and other factors that is responseable for coronary heart disease in the South Asian population in the borough. And at last it will discuss the various international, national and local policies and from the various service gaps it will give some recommendation and ended with conclusion.

Coronary heart disease is the one of the main cause of death in the whole world, accounting 18 million death s each year (33% of total death in each year) (World Health Organization, 2001 ). Mortality rates vary considerably between countries, being lower in Japan and Mediterranean countries such as France, Spain, Portugal and Italy, and highest in eastern European countries such as Latvia and Lithuania (World health organization). Around 50% of these deaths are from CHD and further 25% from stroke. Cardiovascular disease mortality rates in the UK are currently amongst the highest in the world, accounting for 36% of premature deaths in men ( those aged less then 75 years ) and 75% amongst women . (sara stanner, 2005,p1 & p5 ) Death rates from coronary heart disease are higher in south Asian (Indian, Pakistani, Bangladeshi) men and women than general population of United Kingdom. Across all the age groups, the death rates are 40% higher in south Asian community, with a two fold excess of deaths in south Asian men before the age of 40. South Asian women are affected at later stage. The high death rates due to coronary heart disease are common feature of all the main groups of coming from south Asia. ( Paul McKeigue & Leena Sevak, 1994, p1).

London, the capital of England and U.K, is the world's ninth largest city. It has 32 boroughs, of which 13 are situated in the inner London and 19 are situated in outer London. It is the second largest region in terms of total population, accounting for 12 per cent of the UK total. There were 7.6 million residents in 2007.( National Statistics 2009 ). Newham is one of the boroughs of London. The population of Newham is about 262,116 in 2008. The age structure of the population of Newham is predominantly young as shown on the fig1

Source: Joint Strategic Needs Assessment 2008

Only 8% of populations are over 65 years old, compared to national average of 16%. This is the second lower proportion of older people in the country.35% of population are under 25, highest proportion in the country. 22% population is under 15 years old, compared to national average, which is 18%.The population of Newham is estimated to have grown by 7.5 % between the 2001

National Census ( 243,891) and 2008 ( 262,116 ). Two thirds (68%) of population of Newham are usually BMI groups. The largest group was estimated to be South Indian (32%) of which Indian (12%), Pakistani (10%), Bangladeshi (10%).There is also significant numbers of Black African(15%) and Black Caribbean(7%) people in 2006. A large number of people who live in this borough come from outside of the UK. 38% of borough's population was born outside of the UK. This includes a significant number of people who came as asylum seekers or refugees. There is a marked change in the ethnic composition of wards in Newham between 1991 and 2001. There was an inverse relation ship between the proportion of White resident and Asian. Normally, the wards with high proportion of white residents had a low proportion of Asian residents and vice versa. For example, in Green Street east ward 65% was Asian where only 16% was white resident. In contract, in Royal dock, 61% of population was white and only 7% was Asian (Newham, 2008)

Ethnicity by ward in Newham

Source: Joint Strategic Needs Assessment 2008

Coronary Heart Disease is the major cause of death in the South Asian population in the UK and the death rates of South Asian population due to CHD is higher than the indigenous white population which is stated 46% higher in men and 51% higher in women in the south Asian community in the United Kingdom. Besides the death rates between the South Asian community and rest of the population is increasing they by day due to slow decreasing rates of mortality in the South Asian community rather than the rest of the population ( DOH, 2003). Coronary Heart Disease is prevalent among the South Asians. South Asian people born in India, Bangladesh, Sri Lanka and Pakistan are approximately 50% more susceptible to die prematurely from coronary heart disease than the general population. A joint report by NHS and British Heart Foundation said that it is not completely uncovered why South Asian suffered more heart disease than the other group of population. There is several hypothesis have been offered. For example, South Asian are genetically more prone to have coronary heart disease and their back ward socio-economic position may also put them at higher risk. Other risk factor common in South Asians are high level of smoking ( Particularly amongst the Bangladeshi men ), low exercise rate and taking high fat diet and low intake of food and vegetables. In addition to suffering high level of heart disease, evidence shows that Asian communities tends to be diagnosed at late stage of the disease and that leeds to poorer survival rates ( DHSSPS, 2004).

. The mortality rates due to coronary heart disease in most deprived 20% areas of England is nearly 60% higher than the mortality rates of the least 20% areas of England for both sex between 2001 to 2006. The most vulnerable groups in the United kingdom for coronary heart disease are the South Asian community. Compared to national average, men born in Pakistan or Bangladesh who live in UK are more than twice chance of die due to coronary heart disease ( British Heart Foundation, 2009).

Several risk factors that causes the coronary heart disease is identified after extensive statistical study. There are several risk factors pointed by the American Heart Association of which some of the risk factors can be modified or treat ed and some of the risk factors are not, causes of this risk factors are idiopathic. The major risk factors that can't be changed are usually increasing age, gender and the hereditary factor. Above 83% of people, who died due to coronary heart disease are usually over 65years old. Men are more vulnerable to heart attack then women and they are developing the heart disease early stage of the life then women. The third risk factor is hereditary, means the children are more risk of developing heart disease in their life whose parents are suffering from heart disease as well (American Heart Association, 2009).

The other major risk factors that can be modified, controlled or treated to cure are discussed below:

SMOKING:

The people who smoke usually put themselves 2-4 times more risk to develop coronary heart disease then the non smokers (American Heart Association, 2009). South Asian people usually smoke more than the overall general population. But the level of smoking may differ in various ethnic groups. The level of smoking is relatively high in Bangladeshi community and particularly in older people. 42% people in Bangladeshi community are smoker, where only 27% of general population are smoker. 70% of the older men in Bangladeshi community aged 54-70 are usually smokes and the percentage of smoker in the age range of 30-49 is 54%. Smoking levels of South Asian women are much lower than South Asian men and lower than the women who smoke in general population. But there is marked number of Bangladeshi women (14%) are usually smoking cigarettes (DOH, 2004).Chewing tobacco is common in Bangladeshi community .19% of men and 26% of women in the Bangladeshi community are fond of chewing tobacco. Chewing tobacco is the main tobacco product among the women of Bangladeshi community ( British Heart Foundation, 2002).Fig-4 shows the prevalence of smoking in Newham, where 46% Bangladeshi men and 33% Pakistani men are smoker and among the women the percentage is Pakistan 4%, India1%, and Bangladesh 1% ( Savings life 2007).

DIET :

The one of the main reason of high prevalence of coronary heart disease in UK is unhealthy diet. People intake too much saturated fat in their diet and consumption of vegetable and fruit. Total energy receive from the fat by adults is falling in a very slow rate, 40% in mid 1970s and now it is around 37%. Now the food habit of the population is changing and percentage of taking saturated fat are falling from around 19% to around 15%. In contrast, 88% of men and 83% of women still taking saturated fat higher than the normal level. The people are eating more fresh fruits since 1940s but the level of taking vegetable is going low. Now a days only 13% of men and 15% of women are taken the right amount of fruit and vegetable in UK. Among the minor ethnic groups, Indian and Pakistani men and women are taking sufficient amount of fruits (British Heart Foundation, 2009).Normally, Bangladeshi men and women are fond of red meat and fried food so their intake of red meat and fried food is higher than the other community. On the other hand, the men and the women of the Indian community take red meat less frequently and Indian men are not fond of fried food. This food habits affects the overall fat score. The highest fat score in men is naturally goes to Bangladeshi men (22%) and lowest with the Indian men (11%) men. 27% of Bangladeshi women have high fat score compare to Indian women, they have only 8% of them with high fat score. Bangladeshi adults take the lowest level of fruits. Only 15% of Bangladeshi men and 16% of Bangladeshi women eats fruits more than six times in a week. The Pakistani Community have lowest level of vegetable consumption. Only 7% of men and 11% of women in the Pakistani community takes vegetable more than six times a week (British Heart Foundation, 2002).

Physical activity: Physically activities definitely lower the risk of coronary heart disease. As a adults, 30 minutes a moderate physical activities at least five times in a week is good for health. But the Health Survey For England shows that only 40% of men and around 28% of women in this country are as active as the recommend level is. The more recent data obtained from Health Survey For England shows that physical activity is little bit increasing between men and women in all age from 1970 to 2006 ( British Heart Foundation, 2009).South Asian men and women usually avoid the physical activities. Among all the south Asian community, lowest levels are found in Bangladeshi community. Only 18% of Bangladeshi male fulfil the recommend level of physical activities, where the percentage of Bangladeshi women is only 7% (British Heart Foundation, 2002).

Overweight and Obesity: Obesity is much lower in Indian, Pakistani and most especially in Bangladeshi men. Bangladeshi men are more then 3 times less obese than the general population. The weight to hip ratio is relatively high in Indian, Pakistani and Bangladeshi men. The percentage of centrally obese Indian men is 41% compare to the general population where the percentage is 28%. Among The women, Pakistani women have low prevalence of obesity and Bangladeshi women have high prevalence of obesity. The level of central obesity of all minor ethnic group women s is higher than the national average ( British Heart Foundation, 2002).

Alcohol: Alcohol is relevant to the control of cardio-vascular disease in both ways. First, there is some evidence that shows that moderate alcohol drinking may reduce the risk of heart disease. On the other hand, heavy drinking of alcohol may rise the blood pressure and causes the obesity. Both of them are responsible for increasing the risk of coronary heart disease ( Paul Mckeigue and Leena Sevak, 1994, p19). Adults from all minority ethnic group excluding the Irish community less likely to intake alcohol than the national average of general population. A very small amount of Bangladeshi adults the percentage is less then 5 % and less then 10% of Pakistani adults is ever drinking alcohol at all. Compare to the men , women South Asian community is usually non drinker ( British Heart Foundation, 2002,p109).

Blood Pressure: In the report of World Health Organization ( 2002) shows that marked rise of blood pressure is one of the leading risk factor of coronary heart disease (British Heart Foundation,2009). Blood pressure is similar to the levels of the Europeans, in Gujarati Hindus and Pakistani Muslims. The average blood pressure of Bangladeshis are usually lower than the European( Paul Mckeigue and Leena Sevak, 1994,p19). Bangladeshi men have 25% less chance to have high blood pressure than the men of general population. Pakistani women usually have around 25% more chance to grow high blood pressure then the women of general population ( British Heart Foundation, 2002,p130).

Psychosocial Well-being: A number of psychosocial factor have been found to associate with the risk of increasing rates of coronary heart disease. They are work stress, lack of social support, depression (including anxiety) and personality (particularly hostility). The General Health Questionnaire ( GHQ12) is used assess the levels of depression, anxiety, disturbance and happiness by the Health Survey for England. It shows that women have high GHQ12 score compared to the men. 18% of women have high score. On the other hand, the percentage of men with high score is only 13%. The younger age groups has lower score then the women and men over the age of 75. There is no strong connection between GHQ12 scores and social class but there is a inverse connection between the GHQ12 scores and income, people who incomes less money usually have high score. Men living in the inner part of the London have more scores than the men of outer London. In case of women, 25% difference between inner London and outer London. Among the ethnic community, Bangladeshis have the highest score followed by the Pakistani community. The percentage of Bangladeshi men and women who have high score is 28% and 30%.According to report, men has less social support then women. 16% of men are reported to have severe lack of social support, where only 12% women claim that they lave lack of social support according to Health Survey for England. Social support also varies with ethnicity. South Asian men and women are more reported to a lack of severe social support. Bangladeshi men are in the highest position with the 37% and Indian women with 34%.

Diabetes: Diabetes is one of the major risk factor for coronary heart disease. Men who are suffering from type-2 diabetes have two to four fold of greater risk coronary heart disease. With more risk of coronary heart disease in women. Over 5% of men and 4% of women are suffering from the diagnosed diabetes.The Health survey for England estimate that around 3% of men and 1% women are suffering from diabetes in the UK, which are not diagnosed yet ( British Heart Foundation, 2009). The prevalence of diabetes is much more higher in South Asian community than the general population. In Bangladeshi and Pakistani men and women have the prevalence of diabetes five time higher than the general population( British Heart Foundation, 20002, p-152).

The World Health Organization expresses the importance of giving focus on the major known risk factors. Smoking, diet and physical activity associated with other biological factor like blood pressure, dyslipidaemias and obesity is the main risk factor coronary heart disease, so these should be the main focus of the prevention policy. Among all the factors WHO gives more importance to take more steps on tobacco use and obesity ( World Health Organization, 2002).

Due to premature mortality rates in the South Asian community ( Indians, Pakistani, Bangladeshis and Sri Lankans) and the rates are higher than national average and the difference in the mortality rates between South Asian Population and white European. Finally, the Campaigns to change the life style organised by NHS is not as effective in South Asian community as the rest of the population. So British Heart Foundation take various activities to fight with coronary heart disease.

British Heart foundation produce various videos of different case study in different language for health professionals and carers such as 'living to prevent heart disease' which focuses on prevention and management of coronary heart disease and another one is ' Get fit, keep fit, and prevent heart disease' based on physical activities. Two booklets in Urdu, Hindi, Bengali and English. 'Looking after your heart 'which contain the information about prevention and management of coronary heart disease and 'Medicine for Heart' about the drug information.

Health advocates project taken by the British Heart Foundation to deals with prevention and management of coronary heart disease in minority groups. This project deals with the training of advocacy worker to act as a interpreter in the minor ethnic groups to translate the situation in their own native language ( /////). British Heart Foundation also run health promotion in the Melas( South Asian fair) where they run a project called QUIT which gives the service of carbon monoxide check, Blood pressure checkand diabetes check ( DOH,2004).

Department of health take various policies to prevent the coronary heart disease among the South Asian like Smoking cession service which continue to give advice to qiot smoking(///). To help the South Asian community to give free advice to give up smoking, the NHS has 'NHS Asian Tobacco Helpline' in various language. To increase the physical activity Department of Health launched GP exercise referral schme where GPs are increasing people to take physical activities, Local exercise pilot programme launched at 2003. This project takes different approaches to increase the ethnic communities to take physical activities. Department of Health also take 'Walking Way to Health' project where DOH gives pedometer in various GP centre as a motivational tool to encourage the people to walking.

To improve the dietary habit Department of Health took various initiatives such as '5 A DAY' initiative where they run cookery classes to increasing the people to take fruit and vegetable. '5 A DAY' logo to to give people clear and continious message to eat more fruit and vegetables. Besides that DOH also run a project called school fruit and vegetable scheme where every children( 6-8) will have a piece of fruit or vegetable ( DOH2004). Newham Primary Care Trust also takes some initiatives to prevent coronary heart disease in the South Asian community.

Newham Stop smoking Service: This project delivers a evidence based intervention and effective service among the people who want to give up smoke. The hospital smoking service is situated in the Newham university hospital trust in 2005 who give advice to give up smoking among the patient who stay in the hospital. Beside that, as the Newham house hold panel shows that 42% Bangladeshi men 33% and 22% of Pakistani men are smoker the NHS is selecting a advisor in the mosque who will discuss the adverse effect of the smoking and run a anti smoking Champaign in the Ramjan Since 2004( Newham 2007).

Physical activities in Newham: Newham Primary Care Trust takes various initiatives to increase the physical activities among its population. Newham Step-o-metre programme to encouraging the patient to take more physical exercise by allowing them to use a free pedometer in short loan period.

The Newham gold card system allows its population aged between 5-17 to free entry to Newham leisure club for swimming and other sports. Besides that the trust takes extended school programme and school sport programme( Newham 2007)

Newham Fit Club: It is a joint venture by the between the council and PCT launched in 2005.The club gives advice to improve health among the boroughs population. It has two component, open programme for all the resident to increase awareness to improve health and Targeted programme includes a range of physical activities among the Newham employee and senior swims.

Food and Nutrition of Newham: There is number of initiatives are taken by the PCT to improve the nutritional status of the population. Food in School is the one project which established in April 2006. It took various steps such as training for the school cook by trained chef, encouraging the people to choose healthier food, a healthy eating theatre production , healthy laucnch packet session for parents etc. There is a pilot programme called Family Life Style programme takes place in autumn of 2005 to increase physical activities, improve the diatary habits and prevent obesity among the children age7-11 ( Newham 2007).

After carefully examine the policies I found some service gaps. British Heart Foundation published some videos to improve the awareness among the South Asian community but they don't mention the how it helps the target population, either it was free or people have to buy it. The booklet published in different language is good but it must be insure that it will available to the communities. Department of Health took action against the smoking is good but need more importance. The Asian help line which gives good advice to give up smoking among the South Asian did not say that caller have to pay or not. To increasing the physical activities DOH takes various initiatives but it is too general, as in the South Asian communities, women are also vulnerable to coronary heart disease, but there are no specific policies for women. In the policies to improve the diet Department of Health is focused on the particular age groups rather than the whole population. Newham Primary Care Trust takes various initiatives to stop smoking is good, but as the South Asian population is marked smoker need more focus on this communities.To increase the physical activities Newham PCT took various steps but it is more specific about the age and there is no particular steps for women as the South Asian women are conservative in nature and not like to take physical activities in front of male. The steps taken to improve the food habits by the Newham PCT is only based on specific aged groups. As the pattern of food habit is different in South Asian communities so they need more importance in this sector.

To improve the situation I have some recommendation in my mind, British Heart Foundation can play theier videos in the South Asian melas where large number of South Asian people can join. Department of Health can make the Smoking quary lines are free of charged. About the policies in physical activities national and local policies are too specific about the aged groups and more generalised. Government and Newham Local Authority can arrange some physical compition like race, marathon etc among the South Asian community so that they can incourage to have more physical activities. To improve the the food habit among the South Asian population I think the best way to trained the South Asian women, because in the South Asian communities usually women are cooking food for all the members. Besides that Government and Local Authority have to give more priorities in education, general health and to provide sufficient house among the South Asian and most importantly create more job vacancies because unemployment is one of the main cause of stress in South Asian community.

To conclude, I have to say that South Asian people are distributed largely in the United Kingdom. They are different in religious belief, language and cultural pattern from the indigenous population in the United kingdom. So the risk factors for coronary heart disease is different in South Asian population than the indigenous population. Government should be examine the demography and epidemiological factors, socio-economic factors and various cultural factors that put South Asian population in the Risk of coronary heart disease before making the policies.

Reference:

Sara Stanner(2005): Cardiovascular Disease: Diet, Nutrition and Emerging Risk Factors, Oxford, Blackwell Publishing Ltd.

Petersen, S and Rayner, M (2002): Coronary heart disease statistics, London, British Heart Foundation.

McKeigue, P and Sevak, L ( 1994): Coronary Heart Disease in South Asian Communities, London, Health Education Authority.

National Statistics (2009): London Population and Migration [online] Available from:

http://www.statistics.gov.uk/CCI/nugget.asp?ID=2235&Pos=2&ColRank=1&Rank=326 [accessed 08/0709]

Newham.com Publication (2008): Joint Strategic Needs Assessment[online] Available from:

http://www.newham.gov.uk/NR/rdonlyres/E21461B5-9D9D-4CED-8689-09AEFE90A385/0/JSNA2008ch1.pdf [accessed 08/07/09]

DHSSPS Publications (2004 ) : HEALTH AND SOCIAL WELLBEING: CORONARY HEART DISEASE [Online ] Available From: http://www.dhsspsni.gov.uk/coronaryheartdisease.pdf [accessed 08/07/09 ]

Habib Naqvi ( 2003) : Ischaemic heart disease audit of primary care patients ( 2001-2002) : comparisons by age, sex and ethnic group [online] Available from: http://www.dh.gov.uk/en/Healthcare/Coronaryheartdisease/DH_4098644 [accessed13/07/09]

Department of Health (2004): Heart disease and South Asians: Delivering the National Service Framework for Coronary Heart Disease [Online] Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4098586 [accessed13/07/09]

British Heart Foundation ( 2009): Coronary Heart Disease Statistics Fact Sheet 2008/2009 [online] Available from: http://www.bhf.org.uk/plugins/PublicationsSearchResults/idoc.ashx?docid=7480f285-ae7c-4a82-9a5e-2645112e279a&version=-1 [accessed13/07/09]

World Health Organization (200)2: Life course perspectives on coronary heart disease, stroke and diabetes, Key issues and implications for policy and research [Online] Available from: http://whqlibdoc.who.int/hq/2001/WHO_NMH_NPH_01.4.pdf [accessed 07/04/09].

Public Health For Newham ( 2007): Savings Lives 2007 [online] Available from: http://www.newhampct.nhs.uk/savingLives07/Saving%20Lives%202007%20FINAL.pdf [accessed15/07/09]

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