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To achieve cardiovascular health (CVH) equity in the United States, an understanding of the social and structural factors that contribute to differences and disparities in health is necessary. The Asian American population is the fastest-growing racial group in the United States but remains persistently underrepresented in health research. There is heterogeneity in how individual Asian American ethnic groups experience CVH and cardiovascular disease outcomes, with certain ethnic groups experiencing a higher burden of adverse social conditions, disproportionately high burden of suboptimal CVH, or excess adverse cardiovascular disease outcomes. In this scientific statement, upstream structural and social determinants that influence CVH in the Asian American population are highlighted, with particular emphasis on the role of social determinants of health across disaggregated Asian American ethnic groups. Key social determinants that operate in Asian American communities include socioeconomic position, immigration and nativity, social and physical environments, food and nutrition access, and health system-level factors. The role of underlying structural factors such as health, social, and economic policies and structural racism is also discussed in the context of CVH in Asian Americans. To improve individual-, community-, and population-level CVH and to reduce CVH disparities in Asian American ethnic subgroups, multilevel interventions that address adverse structural and social determinants are critical to achieve CVH equity for the Asian American population. Critical research gaps for the Asian American population are given, along with recommendations for strategic approaches to investigate social determinants of health and intervene to reduce health disparities in these communities.

BackgroundSouth Asians are at higher risk for type 2 diabetes (T2D) than many other race/ethnic groups. Ectopic adiposity, specifically hepatic steatosis and visceral fat may partially explain this. Our objective was to derive metabolite risk scores for ectopic adiposity and assess associations with incident T2D in South Asians.MethodsWe examined 550 participants in the Mediators of Atherosclerosis in South Asians Living in America (MASALA) cohort study aged 40-84 years without known cardiovascular disease or T2D and with metabolomic data. Computed tomography scans at baseline assessed hepatic attenuation and visceral fat area, and fasting serum specimens at baseline and after 5 years assessed T2D. LC-MS-based untargeted metabolomic analysis was performed followed by targeted integration and reporting of known signals. Elastic net regularized linear regression analyses was used to derive risk scores for hepatic steatosis and visceral fat using weighted coefficients. Logistic regression models associated metabolite risk score and incident T2D, adjusting for age, gender, study site, BMI, physical activity, diet quality, energy intake and use of cholesterol-lowering medication.ResultsAverage age of participants was 55 years, 36% women with an average body mass index (BMI) of 25 kg/m2 and 6% prevalence of hepatic steatosis, with 47 cases of incident T2D at 5 years. There were 445 metabolites of known identity. Of these, 313 metabolites were included in the MET-Visc score and 267 in the MET-Liver score. In most fully adjusted models, MET-Liver (OR 2.04 [95% CI 1.38, 3.03]) and MET-Visc (OR 2.80 [1.75, 4.46]) were associated with higher odds of T2D. These associations remained significant after adjustment for measured adiposity.ConclusionsMetabolite risk scores for intrahepatic fat and visceral fat were strongly related to incident T2D independent of measured adiposity. Use of these biomarkers to target risk stratification may help capture pre-clinical metabolic abnormalities.

We examined relationships between resilience resources (optimism, social support, and neighborhood social cohesion) and cardiovascular disease (CVD) incidence and assessed potential effect-measure modification by psychosocial risk factors (e.g., stress, depression) among adults without CVD in 3 cohort studies (2000-2018): the Jackson Heart Study, the Multi-Ethnic Study of Atherosclerosis, and the Mediators of Atherosclerosis in South Asians Living in America (MASALA) Study. We fitted adjusted Cox models accounting for within-neighborhood clustering while censoring at dropout or non-CVD death. We assessed for effect-measure modification by psychosocial risks. In secondary analyses, we estimated standardized risk ratios using inverse-probability-weighted Aalen-Johansen estimators to account for confounding, dropout, and competing risks (non-CVD deaths) and obtained 95% confidence intervals (CIs) using cluster bootstrapping. For high and medium (versus low) optimism (n = 6,243), adjusted hazard ratios (HRs) for incident CVD were 0.94 (95% CI: 0.78, 1.13) and 0.90 (95% CI: 0.75, 1.07), respectively. Corresponding HRs were 0.88 (95% CI: 0.74, 1.04) and 0.92 (95% CI: 0.79, 1.06) for social support (n = 7,729) and 1.10 (95% CI: 0.94, 1.29) and 0.99 (95% CI: 0.85, 1.16) for social cohesion (n = 7,557), respectively. Some psychosocial risks modified CVD HRs. Secondary analyses yielded similar findings. For optimism and social support, an inverse relationship was frequently most compatible with the data, but a positive relationship was also compatible. For neighborhood social cohesion, positive and null relationships were most compatible. Thus, specific resilience resources may be potential intervention targets, especially among certain subgroups.

AimsWe examined associations between lipoprotein subfractions and prevalent and incident T2D in two race/ethnically diverse cohort studies.MethodsAdults self-identifying as White, Black, Chinese, Hispanic and South Asian-American without cardiovascular disease, with fasting serum, demographic, and clinical data at enrollment and after 5 years of follow-up were included. Lipoprotein subfractions were measured at enrollment using NMR spectrometry. LASSO regularized logistic regression models adjusted for age, sex, race/ethnicity, lipid-lowering agent use, and waist circumference assessed odds of incident T2D in pooled analyses.ResultsThere were 4474 participants with lipoprotein subfraction data at enrollment and 3839 participants without prevalent diabetes, mean age 62 years, 51 % women, with 234 incident T2D cases at 5 years. Triglycerides in small, dense LDL-5 [OR 1.26 (95 % CI 1.11,1.43)], VLDL triglycerides 1.30** [1.16,1.46] and phospholipids in VLDL-1 [OR 1.31 (1.17,1.47)] were associated with higher odds of incident T2D, while free cholesterol in large HDL-1 [OR 0.75 (95 % CI 0.63,0.89)] was inversely associated. The results were similar for prevalent diabetes and did not vary by race/ethnic group.ConclusionsComposition of lipoprotein subfractions is differentially associated with prevalent and incident T2D without difference by race/ethnic group. Assessment of lipoprotein composition may enhance targeted risk reduction for T2D.

PurposeSouth Asian (SA) persons have increased risks for diabetes mellitus (DM) and atherosclerotic cardiovascular disease (ASCVD). We examined whether the association of DM with subclinical atherosclerosis assessed by coronary artery calcium (CAC) differs in SA versus other ethnic groups.MethodsWe studied adults from the Multi-Ethnic Study of Atherosclerosis and the Mediators of Atherosclerosis in South Asians Living in America studies without ASCVD. CAC was examined among those normoglycemic, pre-DM and DM. Logistic regression examined pre-DM and DM with the odds of any CAC > 0 and CAC ≥ 100.ResultsAmong 7562 participants, CAC > 0 and CAC ≥ 100 in those with DM was highest in non-Hispanic White (NHW) (80% and 48%) and SA (72% and 41%) persons. Adjusted Ln (CAC + 1) was highest in NHW (3.68 ± 0.21) and SA (3.60 ± 0.23) (p < .01) DM patients. SA and NHW adults with DM (vs normoglycemic) had highest odds of CAC > 0 (2.13 and 2.27, respectively, p < .01). For CAC ≥ 100, SA and Chinese adults had the highest odds (2.28 and 2.27, respectively, p < .01). Fasting glucose and glycated hemoglobin were most strongly associated with CAC among SA.ConclusionsDiabetes mellitus most strongly relates to any CAC in SA and NHW adults and CAC ≥ 100 in SA and Chinese adults, helping to explain the relation of DM with ASCVD in these populations.

Individuals of South Asian (SA) ancestry are predisposed to a higher risk of atherosclerotic cardiovascular disease (ASCVD). Coronary artery calcium (CAC) volume and density can identify coronary plaque characteristics unique to SA that may provide important prognostic information to identify high risk individuals beyond traditional CAC scores. We used data from the Mediators of Atherosclerosis in South Asians Living in America (MASALA). CAC density and volume were assessed according to established protocols. ASCVD risk was estimated using the pooled cohort equations (PCE). Multivariable-adjusted linear regression models were used to study the association between the PCE and advanced CAC measures, and between cardiovascular risk factors and CAC density and volume. Our analyses included 1,155 participants (mean age 57 (SD 9) years, 52% men) with information on advanced CAC measures. After multivariable-adjustment, the PCE was associated with both CAC density (β 0.24, 95% CI 0.12,0.35) and CAC volume (β 0.43, 95% CI 0.38,0.48). High-density lipoprotein cholesterol was directly associated with CAC density while waist circumference was inversely associated with it. Body mass index, hypertension status, statin use, diabetes, and HOMA-IR were all directly associated with CAC volume. Estimated ASCVD risk was associated with both CAC volume and density. Different cardiometabolic risk factors are associated with CAC density and volume. Future longitudinal studies are required to demonstrate the interrelationship of advanced CAC measures and cardiovascular risk factors with incident ASCVD outcomes.

BackgroundPlant-based diets are recommended for chronic disease prevention, yet there has been little focus on plant-based diet quality among participants of South Asian ancestry who consume a predominantly plant-based diet.ObjectivesWe evaluated cross-sectional and prospective associations between plant-based diet quality and cardiometabolic risks among participants of South Asian ancestry who are living in the United States.MethodsWe included 891 participants of South Asian ancestry who completed the baseline visit in the Mediators of Atherosclerosis in South Asians Living in America (MASALA) study. The prospective analysis included 735 participants who completed exam 2 (∼5 years after baseline). The plant-based diet quality was assessed using 3 indices: an overall plant-based diet index (PDI) that summarizes the consumption of plant foods, a healthy PDI (hPDI) that measures consumption of healthy plant foods, and an unhealthy PDI (uPDI) that reflects consumption of less healthy plant foods.ResultsAt baseline, the PDI score was inversely associated with fasting glucose. We observed inverse associations between PDI and hPDI scores and HOMA-IR, LDL cholesterol, weight, and BMI (all P values

Background and aimsWe aimed to identify predictors of change in direct measures of coronary artery calcium (CAC) volume and density in South Asian participants.MethodsWe used data from participants in the Mediators of Atherosclerosis in South Asians Living in America (MASALA) study with prevalent CAC and direct measures of CAC by serial computed tomography (CT) exams (2010-2013, 2016-2018). We examined the distribution of incident CAC volume and peak density, as well as progression and identified risk factors for progression of change in volume and density in multivariable models.ResultsThe study cohort consisted of 102 participants with incident CAC and 285 with CAC progression. CAC volume and density were highest, and incident CAC was most common in the left anterior descending artery (LAD). The greatest progression in volume was in the right coronary artery and the greatest change in density was in the left main. In linear regression models for CAC progression adjusted for baseline density, volume, risk factors, smoking (β +190.1, p = 0.02), baseline volume (β +0.24 per mm3, p

The Collaborative Cohort of Cohorts for COVID-19 Research (C4R) is a national prospective study of adults comprising 14 established US prospective cohort studies. Starting as early as 1971, investigators in the C4R cohort studies have collected data on clinical and subclinical diseases and their risk factors, including behavior, cognition, biomarkers, and social determinants of health. C4R links this pre-coronavirus disease 2019 (COVID-19) phenotyping to information on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and acute and postacute COVID-related illness. C4R is largely population-based, has an age range of 18-108 years, and reflects the racial, ethnic, socioeconomic, and geographic diversity of the United States. C4R ascertains SARS-CoV-2 infection and COVID-19 illness using standardized questionnaires, ascertainment of COVID-related hospitalizations and deaths, and a SARS-CoV-2 serosurvey conducted via dried blood spots. Master protocols leverage existing robust retention rates for telephone and in-person examinations and high-quality event surveillance. Extensive prepandemic data minimize referral, survival, and recall bias. Data are harmonized with research-quality phenotyping unmatched by clinical and survey-based studies; these data will be pooled and shared widely to expedite collaboration and scientific findings. This resource will allow evaluation of risk and resilience factors for COVID-19 severity and outcomes, including postacute sequelae, and assessment of the social and behavioral impact of the pandemic on long-term health trajectories.

AimsTo evaluate the burden of cardiovascular risk factors and disease (CVD) among five Asian groups living in Catalonia (Spain): Indian, Pakistani, Bangladeshi, Filipino, and Chinese.Methods and resultsRetrospective cohort study using the Catalan Health Surveillance System database including 42 488 Pakistanis, 40 745 Chinese, 21 705 Indians, 9544 Filipinos, and 6907 Bangladeshis; and 5.3 million native individuals ('locals'). We estimated the age-adjusted prevalence (as of 31 December 2019) and incidence (during 2019) of diabetes, hypertension, hyperlipidaemia, obesity, tobacco use, coronary heart disease (CHD), cerebrovascular disease, atrial fibrillation, and heart failure (HF). Bangladeshis had the highest prevalence of diabetes (17.4% men, 22.6% women) followed by Pakistanis. Bangladeshis also had the highest prevalence of hyperlipidaemia (23.6% men, 18.3% women), hypertension among women (24%), and incident tobacco use among men. Pakistani women had the highest prevalence of obesity (28%). For CHD, Bangladeshi men had the highest prevalence (7.3%), followed by Pakistanis (6.3%); and Pakistanis had the highest prevalence among women (3.2%). For HF, the prevalence in Pakistani and Bangladeshi women was more than twice that of locals. Indians had the lowest prevalence of diabetes across South Asians, and of CHD across South Asian men, while the prevalence of CHD among Indian women was twice that of local women (2.6% vs. 1.3%). Filipinos had the highest prevalence of hypertension among men (21.8%). Chinese men and women had the lowest prevalence of risk factors and CVD.ConclusionsIn Catalonia, preventive interventions adapted to the risk profile of different Asian immigrant groups are needed, particularly for Bangladeshis and Pakistanis.

The menopausal transition is a time of accelerating risk of cardiovascular disease (CVD), and promoting cardiovascular health during midlife is an important period of time to prevent CVD in women. The association of menopause with cardiovascular risk factors or subclinical atherosclerosis has not previously been evaluated in South Asian American women, a population with a disproportionately higher CVD burden compared with other race/ethnic groups. The objective of this study was to evaluate the association of menopause with CVD risk factors and subclinical cardiometabolic disease markers. We studied women aged 40 to 84 years from the Mediators of Atherosclerosis in South Asians Living in America study. The association of self-reported menopausal status with multiple demographic and clinical variables was assessed with linear and logistic regression adjusted for age and cardiovascular health behaviors. In a secondary ("age-restricted") analysis, postmenopausal participants outside the age range of premenopausal participants were excluded. In the age-restricted sample, menopause was associated with a higher adjusted odds of hypertension (odds ratio = 1.19, 95% confidence interval [CI] 1.02 to 1.41), and higher systolic blood pressure (β = 6.34, 95% CI 0.82 to 11.87), and significantly higher subcutaneous fat area (β = 42.8, 95% CI 5.8 to 91.4). No significant associations between menopause and ectopic fat deposition, coronary artery calcium, or carotid intima-media thickness were observed. In South Asian American women in the Mediators of Atherosclerosis in South Asians Living in America study, menopause was associated with cardiovascular risk factors and higher subcutaneous fat deposition. Menopausal status is an important factor to examine and address CVD risk factors.

Objectives: Examine the social influence of adult children on the cardiovascular-related health behaviors of older South Asian (SA) immigrants to inform lifestyle interventions.Design: This mixed-methods study used data from an ancillary study of social networks (2014-2018) in the Mediators of Atherosclerosis in South Asians Living in America cohort. Phase 1 was a quantitative analysis of self-reported diet and physical activity among SA adults (n = 448, mean age = 58 years, SD 8.4) who named at least one adult child to their social network. The Alternative Healthy Eating Index (AHEI) was used to measure parents' diet; higher numbers indicate a healthier diet (range 0-110). Phase 2 was a thematic content analysis of in-depth qualitative interviews from a subsample of these parents (n = 23, mean age = 55, SD 7.6).Results: Parents with an adult child in their network who consumed uncooked vegetables daily had mean parental AHEI score 1.5 points higher (adjusted p-value = 0.03) than those who had a child in the network who ate uncooked vegetables less often. When at least one adult child in their network ate fresh fruit daily compared to less frequently or when at least one child ate non-SA food daily compared to less frequently, mean parental AHEI scores were higher by 2.0 (adjusted p-value = 0.01) and 1.6 (adjusted p-value = 0.03) points respectively. Parents with an adult child in their network who exercised at least weekly were more likely to meet guideline-recommended physical activity levels than parents with children who exercised less often (76% v. 56%, adjusted p-value = 0.02). Adult children provided social support and were seen as 'role models' for healthy behavior, especially when adopting Western health behaviors.Conclusion: Positive role modeling and support from adult children were important facilitators of healthy behavior change in older SA immigrants and can inform health behavior interventions for SA adults.

Asian Americans (AsA), Native Hawaiians, and Pacific Islanders (NHPI) comprise 7.7% of the U.S. population, and AsA have had the fastest growth rate since 2010. Yet the National Institutes of Health (NIH) has invested only 0.17% of its budget on AsA and NHPI research between 1992 and 2018. More than 40 ethnic subgroups are included within AsA and NHPI (with no majority subpopulation), which are highly diverse culturally, demographically, linguistically, and socioeconomically. However, data for these groups are often aggregated, masking critical health disparities and their drivers. To address these issues, in March 2021, the National Heart, Lung, and Blood Institute, in partnership with 8 other NIH institutes, convened a multidisciplinary workshop to review current research, knowledge gaps, opportunities, barriers, and approaches for prevention research for AsA and NHPI populations. The workshop covered 5 domains: 1) sociocultural, environmental, psychological health, and lifestyle dimensions; 2) metabolic disorders; 3) cardiovascular and lung diseases; 4) cancer; and 5) cognitive function and healthy aging. Two recurring themes emerged: Very limited data on the epidemiology, risk factors, and outcomes for most conditions are available, and most existing data are not disaggregated by subgroup, masking variation in risk factors, disease occurrence, and trajectories. Leveraging the vast phenotypic differences among AsA and NHPI groups was identified as a key opportunity to yield novel clues into etiologic and prognostic factors to inform prevention efforts and intervention strategies. Promising approaches for future research include developing collaborations with community partners, investing in infrastructure support for cohort studies, enhancing existing data sources to enable data disaggregation, and incorporating novel technology for objective measurement. Research on AsA and NHPI subgroups is urgently needed to eliminate disparities and promote health equity in these populations.

Objectives: Only one community-based study has assessed religious group involvement and health outcomes among South Asians in the U.S., with mixed results. Here, using a large, South Asian community-based sample, the effects of six religious group involvement predictors - religious tradition, attendance, group prayer, giving/receiving congregational emotional support, congregational neglect, and congregational criticism - were examined in relation to four health outcomes: self-rated health, positive mental health functioning, trait anxiety, and trait anger.Design: The study used a new religion/spirituality questionnaire in the Mediators of Atherosclerosis Among South Asians Living in America (MASALA), the largest study of mental and physical well-being among U.S. South Asians. Associations were assessed cross-sectionally using OLS regression in both the full sample (N = 928) and a subsample of congregation members (N = 312).Results: Jains reported better self-rated health compared to Hindus and Muslims. Group prayer involvement, when measured ordinally, was positively associated with self-rated health and mental health functioning. In reference group comparisons, individuals who participated in group prayer once/day or more had lower levels of anxiety and anger compared to several comparison groups in which individuals prayed less than once a day. Religious service attendance was associated with higher levels of anxiety. Giving/receiving congregational emotional support was positively associated with self-rated health and mental health functioning, and inversely associated with anxiety. Congregational criticism was associated with higher levels of anger and anxiety.Conclusions: This study provided a new assessment of religious group involvement and health in the U.S. South Asian population. Religious group participation was associated with mental and self-rated health in well-controlled models, indicating this is a fruitful area for further research. Group religious involvement may be a health-promoting resource for U.S. South Asians who are religiously active, but it is not an unalloyed boon.

South Asians in the United States have disproportionately high burden of cardiovascular disease compared to other race/ethnic groups but are a heterogenous population, so we evaluated differences in prevalence and adjusted odds of cardiovascular risk factors including diabetes, hypertension, dyslipidemia, and obesity between North Indian, South Indian, and Pakistani immigrants in the United States in the Mediators of Atherosclerosis in South Asians Living in America (MASALA) study. Given cultural differences among residents of Indian regions, for example in dietary patterns, we categorized Indian participants as North or South Indian. In 1,018 participants (728 North Indian [47% women], 223 South Indian [43% women], 67 Pakistani [52% women]), unadjusted diabetes and obesity prevalence was highest in Pakistani participants (33% and 48%, respectively); hypertension prevalence was highest in North Indian participants (54%); dyslipidemia prevalence was highest in South Indian and Pakistani participants (55%); and South Indian participants had a higher odds of dyslipidemia (OR 1.77, 95% CI 1.27, 2.47) compared with North Indian participants in fully adjusted models. As differences in cardiovascular risk factors were observed across South Asian American subgroups, identifying the determinants of suboptimal cardiovascular health within South Asian American subgroups may help to better tailor cardiovascular disease prevention strategies.

BackgroundPsychosocial stressors increase the risks for cardiovascular disease across diverse populations. However, neighborhood level resilience resources may protect against poor cardiovascular health (CVH). This study used data from three CVH cohorts to examine longitudinally the associations of a resilience resource, perceived neighborhood social cohesion (hereafter referred to as neighborhood social cohesion), with the American Heart Association's Life's Simple 7 (LS7), and whether psychosocial stressors modify observed relationships.MethodsWe examined neighborhood social cohesion (measured in tertiles) and LS7 in the Jackson Heart Study, Multi-Ethnic Study of Atherosclerosis, and Mediators of Atherosclerosis in South Asians Living in America study. We used repeated-measures, modified Poisson regression models to estimate the relationship between neighborhood social cohesion and LS7 (primary analysis, n = 6,086) and four biological metrics (body mass index, blood pressure, cholesterol, blood glucose; secondary analysis, n = 7,291). We assessed effect measure modification by each psychosocial stressor (e.g., low educational attainment, discrimination).ResultsIn primary analyses, adjusted prevalence ratios (aPR) and 95% confidence intervals (CIs) for ideal/intermediate versus poor CVH among high or medium (versus low) neighborhood social cohesion were 1.01 (0.97-1.05) and 1.02 (0.98-1.06), respectively. The psychosocial stressors, low education and discrimination, functioned as effect modifiers. Secondary analyses showed similar findings. Also, in the secondary analyses, there was evidence for effect modification by income.ConclusionWe did not find much support for an association between neighborhood social cohesion and LS7, but did find evidence of effect modification. Some of the effect modification results operated in unexpected directions. Future studies should examine neighborhood social cohesion more comprehensively and assess for effect modification by psychosocial stressors.

BackgroundSouth Asian Americans experience disproportionately high burden of cardiovascular diseases. Estimating predicted heart failure (HF) risk distribution may facilitate targeted prevention. We estimated the distribution of 10-year predicted risk of incident HF in South Asian Americans and evaluated the associations with social determinants of health and clinical risk factors.Methods and resultsIn the Mediators of Atherosclerosis in South Asians Living in America (MASALA) Study, we calculated 10-year predicted HF risk using the Pooled Cohort Equations to Prevent Heart Failure multivariable model. Distributions of low (

South Asians, who are at a disproportionately greater risk of atherosclerotic CVD (ASCVD), represent a rapidly growing population in the USA. The relationship between dairy products, a major component of South Asian diets, and body composition - an established risk factor for ASCVD, is unclear. The aim of the present study was to examine associations between dairy intake and multiple measures of body composition (BMI, waist and hip circumference, waist:hip ratio, abdominal lean mass, subcutaneous, visceral, and intermuscular fat areas) among South Asian adults in the USA. A baseline analysis was conducted using existing data from the Mediators of Atherosclerosis in South Asians Living in America cohort. In women, the highest (>1·9 servings/d) v. lowest (80 cm (95 % CI 0·25, 0·89, Pfor trend3 servings of low-fat yogurt/week was associated with a 9·9 cm2 lower visceral fat area (95 % CI -19·07, -0·72, P

Background and aimsSouth Asian (SA) ethnicity is associated with an increased risk of atherosclerotic cardiovascular disease (ASCVD). However, the implications of considering SA ethnicity as a "risk-enhancing factor" per recent American College of Cardiology/American Heart Association guidelines are not fully understood.MethodsWe used data from the Mediators of Atherosclerosis in South Asians Living in America (MASALA) study, a community-based cohort study of individuals of SA ancestry living in the US. The Pooled Cohort Equations were used to estimate 10-year ASCVD risk. Metabolic risk factors and coronary artery calcium (CAC) scores were assessed.ResultsAmong 1114 MASALA participants included (median age 56 years, 48% women), 28% were already using a statin at baseline, 25% had prevalent diabetes, and 59% qualified for 10-year ASCVD risk assessment for statin allocation purposes. The prevalence of low, borderline, intermediate, and high estimated ASCVD risk was 65%, 11%, 20% and 5%, respectively. Among participants at intermediate risk, 30% had CAC = 0 and 37% had CAC>100, while among participants at borderline risk, 54% had CAC = 0 and 13% had CAC>100. Systematic consideration of intermediate and, particularly, of borderline risk individuals as statin candidates would enrich the statin-consideration group with CAC = 0 participants up to 35%. Prediabetes and abdominal obesity were highly prevalent across all estimated risk strata, including among those with CAC = 0.ConclusionsOur findings suggest that systematic consideration of borderline risk SAs as statin candidates might result in considerable overtreatment, and further risk assessment with CAC may help better personalize statin allocation in these individuals. Early, aggressive lifestyle interventions aimed at reducing the risk of incident diabetes should be strongly recommended in US SAs, particularly among those considered candidates for statin therapy for primary prevention. Longitudinal studies are needed to confirm the favorable prognosis of CAC = 0 in SAs.

We describe cardiovascular health (CVH) in second-generation (U.S.-born) South Asian Americans in the MASALA study, a population for whom CVH is not previously described. CVH factors in second-generation (N = 21) compared with first-generation (N = 495) South Asian Americans included: total cholesterol (199 ± 31 versus 191 ± 35 mg/dL, p = 0.25), low-density lipoprotein cholesterol (121 ± 27 versus 115 ± 30 mg/dL, p = 0.41), triglycerides (163 ± 197 versus 138 ± 72 mg/dL, p = 0.10), diet score (66 ± 8 versus 70 ± 6 points, p = 0.06), BMI (27.6 ± 4.9 versus 26.2 ± 4.1 kg/m2, p = 0.12), and CAC prevalence (26.3% versus 23.9%, p = 0.34). Age- and sex-adjusted differences were not statistically significant. Further investigation of CVH in this risk-enhanced population may help identify differences between second-generation and first-generation immigrant South Asians in the U.S.

Objective: To investigate associations between a vegetarian diet and depression among South Asians in the United States.Design: Data from 892 South Asians (age range 40-83 y, 47% women) enrolled in the Mediators of Atherosclerosis in South Asians Living in America (MASALA) study were included. A vegetarian diet was defined as no intake of meat, poultry or fish in the previous year as reported on a validated food frequency questionnaire. Depressive symptomology was assessed using the Center for Epidemiologic Studies-Depression Scale (CES-D) and depression was classified as CES-D score ≥16. Multivariable logistic regression was used and covariates included age, sex, study site, education, smoking, body mass index, acculturation, intentional exercise, alcohol and energy intake, and antidepressant medication use.Results: Our study demonstrated 43% lower odds of depression among vegetarians (p = 0.023).Conclusions: Vegetarian diet was found to be inversely associated with the prevalence of depression. Longitudinal examinations confirming these findings are needed.

BackgroundSouth Asians are at higher risk for diabetes (DM) than many other racial/ethnic groups. Circulating metabolites are measurable products of metabolic processes that may explain the aetiology of elevated risk. We characterized metabolites associated with prevalent DM and glycaemic measures in South Asians.MethodsWe included 717 participants from the Mediators of Atherosclerosis in South Asians Living in America (MASALA) study, aged 40-84 years. We used baseline fasting serum for metabolomics and demographic, behavioural, glycaemic data from baseline and at 5 years. We performed LC-MS untargeted metabolomic and lipidomic analysis with targeted integration of known signals. Individual linear and ordinal logistic regression models were adjusted for age, sex, BMI, diet, exercise, alcohol, smoking and family history of DM followed by elastic net regression to identify metabolites most associated with the outcome.ResultsThere were 258 metabolites with detectable signal in >98% of samples. Thirty-four metabolites were associated with prevalent DM in an elastic net model. Predominant metabolites associated with DM were sphingomyelins, proline (OR 15.86; 95% CI 4.72, 53.31) and betaine (OR 0.03; 0.004, 0.14). Baseline tri- and di-acylglycerols [DG (18:0/16:0) (18.36; 11.79, 24.92)] were positively associated with fasting glucose and long-chain acylcarnitines [CAR 26:1 (-0.40; -0.54, -0.27)] were inversely associated with prevalent DM and HbA1c at follow-up.DiscussionA metabolomic signature in South Asians may help determine the unique aetiology of diabetes in this high-risk ethnic group. Future work will externally validate our findings and determine the effects of modifiable risk factors for DM.

Social and built environments may influence physical activity (PA). However, evidence for South Asian Americans (SAA), a group with low PA levels and high cardiometabolic risk, is lacking. We assessed the association between five neighborhood factors and PA behaviors in a community-based cohort of SAA. Data were from the Mediators of Atherosclerosis in South Asians Living in America (MASALA) Study 2010-2013 (n = 906). Adjusted multivariable models stratified by sex regressing PA behaviors on neighborhood factors were run. Higher neighborhood social cohesion was associated with 17% more PA MET minutes/week in men (p

Background and aimsSouth Asians (SA) experience disproportionately higher rates of atherosclerotic cardiovascular disease (ASCVD) events than non-Hispanic whites (NHW) and several other Asian groups. The coronary artery calcium (CAC) Agatston score may not capture the unique characteristics of coronary plaque in SA. We therefore evaluated the prevalence and patterns of advanced CAC measures (specific coronary vessel involvement, CAC volume and density) in SA versus other race/ethnicities.MethodsWe combined data from the Mediators of Atherosclerosis in South Asians Living in America (MASALA) and Multi-Ethnic Study of Atherosclerosis (MESA) cohorts. We used multivariable-adjusted linear regression models to compare advanced CAC measures between SA and other ethnicities.ResultsOur analyses included 7,625 individuals (810 SA, 2,622 whites, 1,893 African Americans, 1,496 Hispanics, 803 Chinese Americans) with mean (SD) age 62 (10) years and 48% men. In adjusted analyses, compared to NHW, SA had lower overall CAC volume [beta coefficient (95% CI)] [-0.46 (-0.62,-0.29)] but higher overall CAC density [0.14 (0.11,0.18)]. These trends were similar when SA were compared to non-whites (Hispanics, Chinese Americans, and African Americans). SA had higher overall [0.07 (0.03,0.12)] and right coronary artery [0.09 (0.03,0.16)] CAC density compared to non-whites, while CAC volume was not significantly different between these two groups.ConclusionsSA have lower CAC volume compared to NHW but similar compared to non-whites. Overall CAC density is higher among SA compared to NHW and non-whites. Future longitudinal studies of ASCVD events are required to confirm the prognostic significance of these findings among SA.

Acculturation may influence diet pattern, a risk factor for cardiometabolic disease. We assessed whether strength of traditional cultural beliefs and practices, a robust measure of acculturation, affects diet pattern among South Asians in America. With data from the Mediators of Atherosclerosis in South Asians Living in America (MASALA) cohort, we used ordinal logistic regression to assess the association between strength of traditional cultural beliefs, 6 cultural practices and diet pattern. Of 892 participants, 47% were women. Weaker traditional cultural beliefs [OR(95%CI) 1.07(1.04,1.10)] and cultural practices (p

IntroductionSouth Asians have a high prevalence of type 2 diabetes mellitus (T2DM). This may be associated with high rates of conversion through the natural history of disease. However, there is a paucity of data on prediabetes and T2DM incidence and related predictors in South Asians in the USA.Research design and methodsWe estimated prediabetes and T2DM incidence after 5 years of follow-up in the Mediators of Atherosclerosis in South Asians Living in America study (n=481) and examined the associated correlates. We defined T2DM and prediabetes using the American Diabetes Association criteria. Prediabetes included isolated impaired fasting glucose (iIFG), isolated impaired glucose tolerance (iIGT) and combined IFG and IGT.ResultsOverall, 152 (32%, 95% CI: 27.6 to 35.9) individuals progressed either from normal glucose tolerance to prediabetes or T2DM, or from prediabetes to T2DM. In standardised logistic regression models controlling for age and sex, only hepatic fat attenuation (increased hepatic fat) (OR: 0.67 (95% CI: 0.55 to 0.87) per SD, visceral fat area (OR: 1.36 (95% CI: 1.06 to 1.74) per SD and hypertension (OR: 2.21 (95% CI: 1.44 to 3.40) were associated with any glycemic progression.ConclusionsSouth Asians in the USA have a high incidence of dysglycemia. Hepatic and visceral fat may be factors in glycemic progression, and prevention efforts should target ectopic fat reduction.

BackgroundDiet quality is an important risk factor for type 2 diabetes (T2D) and cardiovascular disease (CVD). Little is known about the diet quality of South Asians in the United States, a group with higher rates of T2D and CVD compared with other racial/ethnic groups.ObjectiveThis study determined whether diet quality differs between South Asian adults in the Mediators of Atherosclerosis in South Asians Living in America (MASALA) Study and whites, Chinese Americans, African Americans, and Hispanics in the Multi-Ethnic Study of Atherosclerosis (MESA).MethodsCross-sectional data from 3926 participants free of CVD from MESA visit 5 (2010-2011) and 889 South Asian participants from MASALA visit 1 (2010-2013) were pooled. Diet quality was assessed using the Alternative Healthy Eating Index (AHEI-2010) derived using FFQs. Multivariable linear regression models adjusted for age, sex, and total energy intake were used to compare mean differences in diet quality between the racial/ethnic groups.ResultsMESA participants were, on average, 14 y older than MASALA participants. The adjusted mean (95% CI) scores for the AHEI-2010 were 70.2 (69.5, 70.9) among South Asians, 66.2 (66.3, 68.2) among Chinese Americans, 61.1 (60.7, 61.6) among whites, 59.0 (58.4, 59.7) among Hispanics, and 57.5 (56.9, 58.1) among African Americans. The mean AHEI scores among South Asians were 3.1 (1.8, 4.3), 9.2 (8.3, 10.1), 11.2 (10.2, 12.3), and 12.8 (11.8, 13.7) points higher compared with Chinese Americans, whites, Hispanics, and African Americans, respectively.ConclusionsSouth Asian adults in the United States have a higher diet quality compared with other racial/ethnic groups. This paradoxical finding is not consistent with the observed higher rates of T2D and CVD compared with other groups. This is further evidence of the importance of studying the South Asian population to better understand the causes of chronic disease not explained by diet quality.

PurposeConnections between private religion/spirituality and health have not been assessed among US South Asians. The aim of this study was to examine the relationship between private religion/spirituality and self-rated and mental health in a community-based sample of US South Asians.MethodsData from the Mediators of atherosclerosis in South Asians living in America (MASALA) study (collected 2010-2013 and 2015-2018) and the attendant study on stress, spirituality, and health (n = 881) were analyzed using OLS regression. Self-rated health measured overall self-assessed health. Emotional functioning was measured using the mental health inventory-3 index (MHI-3) and Spielberger scales assessed trait anxiety and trait anger. Private religion/spirituality variables included prayer, yoga, belief in God, gratitude, theistic and non-theistic spiritual experiences, closeness to God, positive and negative religious coping, divine hope, and religious/spiritual struggles.ResultsYoga, gratitude, non-theistic spiritual experiences, closeness to God, and positive coping were positively associated with self-rated health. Gratitude, non-theistic and theistic spiritual experiences, closeness to God, and positive coping were associated with better emotional functioning; negative coping was associated with poor emotional functioning. Gratitude and non-theistic spiritual experiences were associated with less anxiety; negative coping and religious/spiritual struggles were associated with greater anxiety. Non-theistic spiritual experiences and gratitude were associated with less anger; negative coping and religious/spiritual struggles were associated with greater anger.ConclusionPrivate religion/spirituality is associated with self-rated and mental health. Opportunities may exist for public health and religious care professionals to leverage existing religion/spirituality for well-being among US South Asians.

ObjectivesThe objective of this study was to examine the association between high risk of obstructive sleep apnea (OSA) and subclinical atherosclerosis among South Asians in the United States.DesignA secondary analysis of cross-sectional data.Setting/participantsA community-based cohort of 906 men and women participating in the Mediators of Atherosclerosis in South Asians Living in America (MASALA) study.MeasurementsThe Berlin Questionnaire was used to screen for OSA risk. Coronary artery calcium (CAC), common carotid artery intima-media thickness (IMT), and internal carotid artery IMT were used as measures of subclinical atherosclerosis.ResultsThe majority of participants (59%) with high OSA risk had CAC scores >0 compared with only 41% of participants with low OSA risk (P

Almost no research exists on the relationship between religiosity/spirituality (R/S) and health in the US South Asian population. Using data from the joint Study on Stress, Spirituality, and Health and Mediators of Atherosclerosis Among South Asians Living in America Study (MASALA), this article examined associations between self-rated R/S and self-rated health, emotional functioning, trait anxiety, and trait anger in a community-based sample (n = 933) from the Chicago and San Francisco Bay areas. Ordinary least squares regression was used to analyze categorical differences in levels of R/S and ordinal trends for R/S, adjusting for potential confounders. Being slightly or moderately religious/spiritual was associated with lower levels of self-rated health compared with being very religious/spiritual, and being slightly or moderately religious/spiritual was associated with higher levels of anxiety. In both cases, there was no significant difference between very religious/spiritual individuals and non-religious/spiritual individuals, suggesting a curvilinear relationship. Self-rated R/S was not significantly associated with emotional functioning or anger. In sum, high-R/S and low-R/S individuals had salutary associations with self-rated health and anxiety compared with individuals with slight/moderate levels of R/S. It is important for clinicians and policy makers to recognize the role R/S can play in the health status of South Asians living in the United States.

BackgroundSouth Asians are the second fastest growing ethnic group in the United States, and they have a high risk for cardiovascular disease (CVD). Moderate alcohol consumption has been associated with lower CVD risk in some race/ethnic groups, but the association of alcohol consumption and atherosclerosis in South Asians has not been investigated.Methods and resultsWe used data from 906 South Asian participants who participated in the Mediators of Atherosclerosis in South Asians Living in America (MASALA) cohort (2010-2012). Alcohol consumption was ascertained via questionnaire, coronary artery calcium (CAC) was measured with computed tomography, and common carotid artery intima-media thickness (cIMT) was measured using B-mode ultrasonography. We used multivariable regression models to examine cross-sectional associations of alcohol consumption with the presence and amount of CAC and cIMT. Compared with never drinkers, participants consuming 4-7 drinks/week had a 63% decreased odds of any CAC after adjusting for potential confounders and mediators. Participants consuming 4-7 drinks/week had significantly lower odds of CAC score between 1 and 300 [OR (95% CI): 0.34 (0.16-0.72)]. A similar inverse association was seen for the odds of CAC>300 [OR (95% CI): 0.28 (0.07-0.97)]. Alcohol consumption of >7 drinks/week was associated with a 0.096 mm increase in common-cIMT.ConclusionThere was an inverse association between the amount of alcohol intake and CAC among South Asians while a positive association was found between alcohol consumption and common-cIMT. Long-term follow-up of the MASALA cohort will examine prospective associations of alcohol intake with the progression of subclinical atherosclerosis, incident CVD events, and mortality.

BackgroundEliminating racial/ethnic disparities in physical activity remains a challenge in the United States. South Asian immigrants in the United States have particularly low physical activity levels, and evidence suggests that social context may be important. This study examined associations between personal social networks and moderate to vigorous leisure-time physical activity (MVPA) among South Asians in the United States.MethodsWe used cross-sectional data (2014-2017) from 689 South Asians (aged 43-85 y) who participated in the Mediators of Atherosclerosis in South Asians Living in America study. Self-reported physical activity and egocentric network data were collected from participants about their network members. Regression models were used to determine associations between social network characteristics and participants' MVPA.ResultsParticipants were on average 59 years old (SD = 9) and reported 1335 metabolic equivalent minutes per week of MVPA (interquartile range = 735, 2212). Having network members who exercised or who were exercise partners associated with increased MVPA in men (β coefficient = 241 MET min/wk [95% confidence interval, 63 to 419] and β = 520 MET min/wk [95% confidence interval, 322 to 718], respectively). For women, the association was only significant if the exercise partner was a spouse.ConclusionPhysical activity interventions utilizing network members as exercise partners may have potential in South Asians but must consider gender differences.

Persistent organic pollutants (POPs), such as dichlorodiphenyltrichloroethane (DDT) and other organochlorine compounds, are abundant in the environment and in foodstuffs from the Indian subcontinent. These environmental contaminants have been associated with a higher risk of diabetes in numerous studies. Asian Indians are well known to have a high risk of diabetes compared with other populations, and this risk is also found in migrant populations of Asian Indians in the United States, Europe, and elsewhere. We hypothesized that high plasma concentrations of POPs in Asian Indian migrants are linked to a variety of diabetes-related pathologies and explored the mechanism for the induction of these effects. We measured 30 environmental pollutants in plasma samples obtained from 147 participants in the Metabolic syndrome and Atherosclerosis in South Asians Living in America pilot study using a gas chromatography-tandem mass spectrometry analytical method that uses less than 0.5 mL of plasma. We found that plasma levels of o,p'-DDT and p,p'-DDT were independently associated with both body mass index (BMI) and waist circumference. Doubling the levels of the sums of these DDTs was associated with insulin insensitivity (-0.38 Matsuda index, p = 0.001), increased adiposity (1.26 kg/m2 BMI and 3.58 cm waist circumference increase, p < 0.0001), circulating insulin (12.9 mIU/L, p = 0.002), hepatic fat (-0.051 HU, p = 0.001), as well as increased odds of obesity (OR = 2.17, p < 0.001, BMI-based; OR = 2.37, p = 0.001, waist-based), prediabetes (OR = 1.55, p = 0.02), diabetes (OR = 1.72, p = 0.01), and fatty liver (OR = 1.66, p = 0.01) in multivariable models accounting for confounding by age, sex, years in the US, education, and fish protein. Furthermore, levels of DDTs were associated with increased hepatic fat and circulating insulin, independent of obesity and confounders. These findings suggest that exposure to DDTs may contribute to the risk of metabolic disease among Asian Indians by affecting hepatic fat levels independent of obesity.

BackgroundSouth Asians have disproportionately high rates of cardiovascular disease. Dyslipidemia, a contributing factor, may be influenced by lifestyle, which can vary by religious beliefs. Little is known about South Asian religions and associations with dyslipidemia.MethodsCross-sectional analyses of the MASALA study (n = 889). We examined the associations between religious affiliation and cholesterol levels using multivariate linear regression models. We determined whether smoking, alcohol use, physical activity, and dietary pattern mediated these associations.ResultsMean LDL was 112 ± 32 mg/dL, median HDL was 48 mg/dL (IQR:40-57), and median triglycerides was 118 mg/dL (IQR:88-157). Muslims had higher LDL and triglycerides, and lower HDL, while participants with no religious affiliation had lower LDL and higher HDL. The difference in HDL between Muslims and those with no religious affiliation was partly explained by alcohol consumption.ConclusionsReligion-specific tailoring of interventions designed to promote healthy lifestyle to reduce cholesterol among South Asians may be useful.

A comprehensive literature review revealed cultural beliefs, societal obligations, and gender roles within the South Asian community to be indirect contributors to the health of South Asian immigrants (SAIs). Health professionals need to increase their work with SAI communities to change less beneficial cultural elements such as misconceptions about health and exercise, and lack of communication when using alternative medicines. Community engaged efforts and continuing medical education are both needed to improve the health of the South Asian immigrant population in a culturally appropriate manner.

AimsGuidelines recommend hemoglobin A1c (HbA1c) as a diagnostic test for type 2 diabetes, but its accuracy may differ in certain ethnic groups.MethodsThe prevalence of type 2 diabetes by HbA1c, fasting glucose, and 2 h glucose was compared in 3016 participants from Chennai and Delhi, India from the CARRS-2 Study to 757 Indians in the U.S. from the MASALA Study. Type 2 diabetes was defined as fasting glucose ≥ 7.0 mmol/L, 2-h glucose ≥ 11.1 mmol/L, or HbA1c ≥ 6.5%. Isolated HbA1c diabetes was defined as HbA1c ≥ 6.5% with fasting glucose

South Asian (SA) individuals represent a large, growing population in a number of European countries. These individuals, particularly first-generation SA immigrants, are at higher risk of developing type 2 diabetes, atherogenic dyslipidaemia, and coronary heart disease than most other racial/ethnic groups living in Europe. SAs also have an increased risk of stroke compared to European-born individuals. Despite a large body of conclusive evidence, SA-specific cardiovascular health promotion and preventive interventions are currently scarce in most European countries, as well as at the European Union level. In this narrative review, we aim to increase awareness among clinicians and healthcare authorities of the public health importance of cardiovascular disease among SAs living in Europe, as well as the need for tailored interventions targeting this group - particularly, in countries where SA immigration is a recent phenomenon. To this purpose, we review key studies on the epidemiology and risk factors of cardiovascular disease in SAs living in the United Kingdom, Italy, Spain, Denmark, Norway, Sweden, and other European countries. Building on these, we discuss potential opportunities for multi-level, targeted, tailored cardiovascular prevention strategies. Because lifestyle interventions often face important cultural barriers in SAs, particularly for first-generation immigrants; we also discuss features that may help maximise the effectiveness of those interventions. Finally, we evaluate knowledge gaps, currently available risk stratification tools such as QRISK-3, and future directions in this important field.

ObjectiveSouth Asians have a higher prevalence of type 2 diabetes compared with other race/ethnic groups. Body composition is associated with the risk for type 2 diabetes. Differences in body composition between South Asians and other race/ethnic groups are one hypothesized mechanism to explain the disproportionate prevalence of type 2 diabetes in this population.Research design and methodsThis study used data from the Mediators of Atherosclerosis in South Asians Living in America (MASALA) and the Multi-Ethnic Study of Atherosclerosis (MESA) cohorts to determine whether body composition mediated the elevated prevalence of impaired fasting glucose and type 2 diabetes in South Asians. Participants (n = 2,615) with complete body composition data were included. Ordinal logistic regression models were calculated to determine the odds for glycemic impairment in South Asians compared with the MESA cohort.ResultsIn multivariate models, South Asians had a significantly higher prevalence of glycemic impairment and type 2 diabetes compared with all four race/ethnic groups included in the MESA (P < 0.001 for all). In unadjusted and multivariate adjusted models, South Asians had higher odds for impaired fasting glucose and type 2 diabetes compared with all other race/ethnic groups (P < 0.001 for all). The addition of body composition measures did not significantly mitigate this relationship.ConclusionsWe did not identify strong evidence that accounting for body composition explains differences in the risk for type 2 diabetes. Future prospective studies of the MESA and MASALA cohorts are needed to understand how adipose tissue impacts the risk for type 2 diabetes and how to best assess this risk.

Polyglutamine expansions in the transcriptional co-repressor Atrophin-1, encoded by ATN1, cause the neurodegenerative condition dentatorubral-pallidoluysian atrophy (DRPLA) via a proposed novel toxic gain of function. We present detailed phenotypic information on eight unrelated individuals who have de novo missense and insertion variants within a conserved 16-amino-acid "HX repeat" motif of ATN1. Each of the affected individuals has severe cognitive impairment and hypotonia, a recognizable facial gestalt, and variable congenital anomalies. However, they lack the progressive symptoms typical of DRPLA neurodegeneration. To distinguish this subset of affected individuals from the DRPLA diagnosis, we suggest using the term CHEDDA (congenital hypotonia, epilepsy, developmental delay, digit abnormalities) to classify the condition. CHEDDA-related variants alter the particular structural features of the HX repeat motif, suggesting that CHEDDA results from perturbation of the structural and functional integrity of the HX repeat. We found several non-homologous human genes containing similar motifs of eight to 10 HX repeat sequences, including RERE, where disruptive variants in this motif have also been linked to a separate condition that causes neurocognitive and congenital anomalies. These findings suggest that perturbation of the HX motif might explain other Mendelian human conditions.

We sought to report the distribution of Lp(a) levels in the Mediators of Atherosclerosis among South Asians Living in America cohort of participants who were free from clinical atherosclerotic cardiovascular disease (ASCVD) at baseline and to evaluate the cross-sectional association with atherosclerosis measured by coronary artery calcification (CAC) and carotid intima media thickness. Among 886 participants (mean [SD] age: 55.4 [9.4] years, 54% male), median lipoprotein (a) level was 17 (9, 33) mg/dl. Compared with the lowest quartile (9 mg/dl), subjects in the highest Lp(a) quartile (33 to 178 mg/dl) were more likely to be women (51% vs 37%, p

Background South Asians have a relatively high prevalence of coronary artery calcium ( CAC ) compared with other race/ethnic groups. We determined CAC incidence and progression among South Asians, and compared them with 4 race/ethnic groups. Methods and Results Data from the MASALA (Mediators of Atherosclerosis in South Asians Living in America) study were used to calculate CAC incidence and progression rates and any CAC change. Data from the MESA (Multi-Ethnic Study of Atherosclerosis) were used to compare the CAC incidence and progression rates. A total of 698 South Asians had repeat CAC measurements after 4.8±0.8 years. Among those with no CAC at baseline, the age-adjusted CAC incidence was 8.8% (95% CI, 6.8-10.8%) in men and 3.6% (2.5-4.8%) in women. The median annual CAC progression was 26 (interquartile range, 11-62) for men and 13 (interquartile range, 4-34) for women. Compared with MESA , age-adjusted CAC incidence was similar in South Asian men compared with white, black, and Latino men, but significantly higher than Chinese men (11.1% versus 5.7%, P=0.008). After adjusting for age, diabetes mellitus, hypertension, and statin medication use, Chinese, black, and Latino men had significantly less CAC change compared with South Asian men, but there were no differences between South Asian and white men. There was no difference in CAC incidence or progression between South Asian women and women in MESA . Conclusions South Asian men had greater CAC change than Chinese, black, and Latino men but similar change to that of whites after adjusting for traditional risk factors.

Since 2013, the Centers for Disease Control and Prevention (CDC) has hosted an annual influenza season forecasting challenge. The 2015-2016 challenge consisted of weekly probabilistic forecasts of multiple targets, including fourteen models submitted by eleven teams. Forecast skill was evaluated using a modified logarithmic score. We averaged submitted forecasts into a mean ensemble model and compared them against predictions based on historical trends. Forecast skill was highest for seasonal peak intensity and short-term forecasts, while forecast skill for timing of season onset and peak week was generally low. Higher forecast skill was associated with team participation in previous influenza forecasting challenges and utilization of ensemble forecasting techniques. The mean ensemble consistently performed well and outperformed historical trend predictions. CDC and contributing teams will continue to advance influenza forecasting and work to improve the accuracy and reliability of forecasts to facilitate increased incorporation into public health response efforts.

BackgroundFollowing a vegetarian diet is considered to be beneficial for overall health and is associated with a lower risk of chronic disease.ObjectiveThis study examined whether South Asians in the United States who consume a vegetarian diet have a lower prevalence of cardiometabolic risk factors.MethodsData from the Mediators of Atherosclerosis in South Asians Living in America study, which included 892 South Asians (47% women), with an age range of 40-83 y and a mean ± SD age of 55 ± 9.4 y, were used. Participants were classified as vegetarian if they reported no consumption of meat, poultry, or fish in the previous year on a validated and culturally appropriate food-frequency questionnaire. Adjusted linear and logistic regression models were used to examine associations of a vegetarian diet with cardiometabolic risk factors.ResultsThirty-eight percent of the cohort participants were classified as vegetarian. Vegetarians reported more frequent weekly eating occasions of whole grains (median frequency/wk: 10 compared with 9, P = 0.012) and beans and legumes (median frequency/wk: 8.5 compared with 5.1, P

Background and aimsSouth Asian (SA) individuals are thought to represent a group that is at high-risk for atherosclerotic cardiovascular disease (ASCVD). However, the performance of the Pooled Cohort Equations (PCE) remains uncertain in SAs living in the US. We aimed to study the interplay between predicted 10-year ASCVD risk and coronary artery calcium (CAC) in SAs compared to other racial/ethnic groups.MethodsWe studied 536 SAs from the Mediators of Atherosclerosis in South Asians Living in America (MASALA) study, and 2073 Non-Hispanic Whites (NHWs), 1514 African Americans (AAs), 1254 Hispanics, and 671 Chinese Americans (CAs) from the Multi-Ethnic Study of Atherosclerosis (MESA) who were not currently on statins. We used logistic regression models to assess the association between race/ethnicity and CAC within each ASCVD risk stratum.ResultsSAs at low and at intermediate estimated ASCVD risk were more likely to have CAC = 0 compared to NHWs, while SAs at high risk had a similar CAC burden to NHWs. For example, intermediate-risk SAs had a 73% higher odds of CAC = 0 compared to NHWs (95% 1.00-2.99), while high-risk SAs were equally likely to have CAC = 0 (OR 0.95, 95% CI 0.65-1.38) and CAC >100 (OR 0.86, 95% CI 0.61-1.22).ConclusionsOur results suggest that the extent of ASCVD risk overestimation using the PCEs may be even greater among SAs considered at low and intermediate risk than among NHWs. Studies with incident ASCVD events are required to validate and/or recalibrate current ASCVD risk prediction tools in this group.

BackgroundUnderstanding the social lives of South Asian immigrants in the United States (U.S) and their influence on health can inform interpersonal and community-level health interventions for this growing community. This paper describe the rationale, survey design, measurement, and network properties of 700 South Asian individuals in the Mediators of Atherosclerosis in South Asians Living in America (MASALA) social networks ancillary study.MethodsMASALA is a community-based cohort, established in 2010, to understand risk factors for cardiovascular disease among South Asians living in the U.S. Survey data collection on personal social networks occurred between 2014 and 2017. Network measurements included size, composition, density, and organizational affiliations. Data on participants' self-rated health and social support functions and health-related discussions among network members were also collected.ResultsParticipants' age ranged from 44 to 84 (average 59 years), and 57% were men. South Asians had large (size=5.6, SD=2.6), kin-centered (proportion kin=0.71, SD=0.28), and dense networks. Affiliation with religious and spiritual organizations was perceived as beneficial to health. Emotional closeness with network members was positively associated with participants' self-rated health (p-value

ObjectiveSedentary behaviors related to television (TV) viewing are associated with adiposity; however, few investigations have focused on South Asians, an ethnicity particularly vulnerable to metabolic perturbations. This study examined the relationships between TV viewing and adiposity in a cohort of middle-aged and older South Asians.MethodData were obtained from Mediators of Atherosclerosis in South Asians Living in America (MASALA) study (N = 906; mean age [standard deviation] = 55 [9.4] years, 46% women). TV viewing hours per week was assessed through questionnaire and classified into tertiles for analysis. Multivariate linear regression models were used to examine the associations between TV viewing and measures of adiposity and body composition including body mass index (BMI), waist circumference, pericardial fat volume, and visceral, subcutaneous, and inter-muscular fat area after adjusting for covariates including intentional exercise.ResultsParticipants who were women, older, with lower education levels, and living longer in the United States watched TV for longer periods of times. Duration of TV viewing was positively associated with BMI (p

Accurate forecasts could enable more informed public health decisions. Since 2013, CDC has worked with external researchers to improve influenza forecasts by coordinating seasonal challenges for the United States and the 10 Health and Human Service Regions. Forecasted targets for the 2014-15 challenge were the onset week, peak week, and peak intensity of the season and the weekly percent of outpatient visits due to influenza-like illness (ILI) 1-4 weeks in advance. We used a logarithmic scoring rule to score the weekly forecasts, averaged the scores over an evaluation period, and then exponentiated the resulting logarithmic score. Poor forecasts had a score near 0, and perfect forecasts a score of 1. Five teams submitted forecasts from seven different models. At the national level, the team scores for onset week ranged from

Using latent class analysis, we previously identified three acculturation strategies employed by South Asian immigrants in the US. Members of the Separation class showed a preference for South Asian culture over US culture, while members of the Assimilation class showed a preference for US culture, and those in the Integration class showed a similar preference for South Asian and US cultures. The purpose of this study was to examine associations between these acculturation strategies and symptoms of depression, a common yet underdiagnosed and undertreated mental disorder. We used data from the Mediators of Atherosclerosis in South Asians Living in America (MASALA) study (n = 856). Data were collected between October 2010 and March 2013 in the San Francisco Bay Area and Chicago. Depressive symptoms were assessed using the CES-D Scale. Applying a simple new method to account for uncertainty in class assignment when modeling latent classes as an exposure, we found that respondents in the Separation class had more depressive symptoms than those in the Integration class, but only after taking into account self-reported social support (b = 0.11; p = 0.05). There were no differences in depressive symptoms among those in the Assimilation class vs. those in the Integration class (b = -0.06; p = 0.41). Social support may protect against elevated symptoms of depression in South Asian immigrants with lower levels of integration into US culture.

BackgroundRecent studies, primarily in non-Hispanic whites, suggest that dietary patterns have distinct metabolomic signatures that may influence disease risk. However, evidence in South Asians, a group with unique dietary patterns and a high prevalence of cardiometabolic risk, is lacking.ObjectiveWe investigated the metabolomic profiles associated with 2 distinct dietary patterns among a sample of Asian Indians living in the United States. We also examined the cross-sectional associations between metabolomic profiles and cardiometabolic risk markers.MethodsWe used cross-sectional data from 145 Asian Indians, aged 45-79 y, in the Metabolic Syndrome and Atherosclerosis in South Asians Living in America (MASALA) pilot study. Metabolomic profiles were measured from fasting serum samples. Usual diet was assessed by using a validated food-frequency questionnaire. We used principal components analysis to derive dietary and metabolomic patterns. We used adjusted general linear regression models to examine associations between dietary patterns, individual food groups, metabolite patterns, and cardiometabolic risk markers.ResultsWe observed 2 major principal components or metabolite clusters, the first comprised primarily of medium- to long-chain acylcarnitines (metabolite pattern 1) and the second characterized by branched-chain amino acids, aromatic amino acids, and short-chain acylcarnitines (metabolite pattern 2). A "Western/nonvegetarian" pattern was significantly and positively associated with metabolite pattern 2 (all participants: β ± SE = 0.180 ± 0.090, P = 0.05; participants without type 2 diabetes: β ± SE = 0.323 ± 0.090, P = 0.0005). In all participants, higher scores on metabolite pattern 2 were adversely associated with measures of glycemia (fasting insulin: β ± SE = 2.91 ± 1.29, P = 0.03; 2-h insulin: β ± SE = 22.1 ± 10.3, P = 0.03; homeostasis model assessment of insulin resistance: β ± SE = 0.94 ± 0.42, P = 0.03), total adiponectin (β ± SE = -1.46 ± 0.47, P = 0.002), lipids (total cholesterol: β ± SE = 7.51 ± 3.45, P = 0.03; triglycerides: β ± SE = 14.4 ± 6.67, P = 0.03), and a radiographic measure of hepatic fat (liver-to-spleen attenuation ratio: β ± SE = -0.83 ± 0.42, P = 0.05).ConclusionsOur findings suggest that a "Western/nonvegetarian" dietary pattern is associated with a metabolomic profile that is related to an adverse cardiometabolic profile in Asian Indians. Public health efforts to reduce cardiometabolic disease burden in this high-risk group should focus on consuming a healthy plant-based diet.

Religiosity has been associated with greater body weight. Less is known about South Asian religions and associations with weight. Cross-sectional analysis of the MASALA study (n = 906). We examined associations between religious affiliation and overweight/obesity after controlling for age, sex, years lived in the USA, marital status, education, insurance status, health status, and smoking. We determined whether traditional cultural beliefs, physical activity, and dietary pattern mediated this association. The mean BMI was 26 kg/m2. Religious affiliation was associated with overweight/obesity for Hindus (OR 2.12; 95 % CI: 1.16, 3.89), Sikhs (OR 4.23; 95 % CI: 1.72, 10.38), and Muslims (OR 2.79; 95 % CI: 1.14, 6.80) compared with no religious affiliation. Traditional cultural beliefs (7 %), dietary pattern (1 %), and physical activity (1 %) mediated 9 % of the relationship. Interventions designed to promote healthy lifestyle changes to reduce the burden of overweight/obesity among South Asians need to be culturally and religiously tailored.