|Year : 2020 | Volume
| Issue : 4 | Page : 184-188
Is migration stress related to increased cardiovascular diseases?
Shridhar Dwivedi1, Ramesh Aggarwal2, Nisha Vohra3
1 Department of Cardiology, National Heart Institute, New Delhi, India
2 Department of Medicine, Lady Hardinge Medical College and Smt. Sucheta Kriplani Hospital, New Delhi, India
3 Department of Clinical Research, Delhi Pharmaceutical Sciences and Research University, New Delhi, India
|Date of Submission||21-May-2020|
|Date of Decision||18-Jun-2020|
|Date of Acceptance||18-Jun-2020|
|Date of Web Publication||09-Dec-2020|
Dr. Ramesh Aggarwal
Department of Medicine, Lady Hardinge Medical College and Smt. Sucheta Kriplani Hospital, New Delhi
Source of Support: None, Conflict of Interest: None
Introduction: Mass migration during the war, frenzy riots, famine, or due to compelling economic reasons are known to be associated with different health issues besides human distress and suffering. India has witnessed such a mass migration immediately before/during the independence (August 15, 1947) consequent to partition riots occurring in west and East Pakistan (present Bangladesh). Although many publications are there about the human and social tragedies associated with partition not much is known about the long-term cardiovascular related diseases of partition migrant individuals. The current communication is trying to address whether cardiovascular diseases in post-partition migrant subjects are any different from non-migrant individuals. Objectives: To evaluate cardiovascular morbidity pattern among partition migrants and non-migrant people. Materials and Methods: This is an observational study done at a tertiary care center from January 2016 to June 2019. The study population had migrant ethnic Indians (n = 30) from West Pakistan and non-migrant ethnic Indians based in Delhi (n = 30). Patients were asked about their demographic details, birthplace particularly the pre-independence place of birth/residence, a detailed pedigree analysis and cardiovascular risk was assessed. Statistical analysis was done to compare the proportion between the migrants and non-migrants subjects using Chi-square/Fisher’s exact test. Results: The mean age of migrants and non-migrants was found to be 78.46 ± 7.13 years and 78.16 ± 6.10 years respectively. Males (65%) were found to be more in both groups compared to females (35%). Both the migrants (83.33%) and non-migrants (73.33 %) were mostly from socioeconomic status (SES) I and II. Migrants (16.66%) showed more smoking habits compared to non-migrants (10%). Migrants were mostly suffering from hypertension alone (20%) or with two comorbidities (63.2%) like hypertension and diabetes, hypertension and coronary artery disease (CAD), diabetes and CAD, cardiovascular diseases (CVD) with stroke. In non-migrant patients hypertension alone was seen in 16.6% of cases which is not statistically significant. Two comorbid cardiovascular conditions in this group were seen in 36.8% of cases as compared to migrant population with two comorbid conditions and this difference was statistically significant (P = 0.039).
Keywords: Cardiovascular diseases, migration, stress
|How to cite this article:|
Dwivedi S, Aggarwal R, Vohra N. Is migration stress related to increased cardiovascular diseases?. MGM J Med Sci 2020;7:184-8
| Introduction|| |
Humans have migrated since ancient times for various reasons including better living conditions, a safe environment, better work opportunities, and sometimes unwillingly as during wars and famines. Although the migratory population has been studied from social, cultural, economic, and historical perspectives, their health, particularly cardiovascular health, has not been studied to detail. The migrant population at arrival is susceptible to accidents, gastrointestinal problems, pregnancy and delivery-associated complications, and sexual assault and violence. Vulnerable populations such as children are deprived of nutrition, vaccinations, and are prone to respiratory illness and other communicable diseases. Similarly, the elderly population at the time of migration may have psychosomatic stress, impaired glycemic control, and vulnerability for hypo- and hyperthermia. Persistent stress is associated with psychological and metabolic health diseases. This stress becomes more intense when people are forced to migrate from their parents’ land and may exacerbate existing health problems or predispose them to future health issues. The cardiovascular risk remains one such under researched area that may have developed in these individuals over a period because of exposure to stress in early childhood. India has witnessed such a mass migration immediately before/during the independence (August 15, 1947) consequent to partition riots occurring in the West and East Pakistan (present Bangladesh). Almost seven decades have passed and the people who migrated with their families at the time of partition were exposed to the new environment and unforeseen stresses. Has this migration stress made them more prone to cardiovascular diseases (CVDs) compared to nonmigrant people? We, therefore, planned to study the cardiovascular health of migrant subjects from West and East Pakistan and to compare with nonmigrant people residing in Delhi.
Objective: The objective of this study was to evaluate the cardiovascular morbidity pattern among partition migrants and nonmigrant people.
| Materials and methods|| |
This was an observational study carried out at National Heart Institute, New Delhi, India, from January 2016 to June 2019. Every partition patient visiting the outpatient department was asked about his demographic details, birthplace, particularly the pre-independence place of birth/residence. A detailed pedigree analysis, the journey from a place of birth in newly created Pakistan to Indian soil, was made in addition to their detailed cardiovascular risk workup, particularly tobacco smoking, smokeless tobacco (SLT) intake, and obesity. Obesity was categorized as follows: overweight (body mass index [BMI], 25–29.9 Kg/m2), class I (BMI, 30–34.9 Kg/m2), and class II obesity (BMI, 35–39.9 Kg/m2). The salient differences in risk and clinical profile between the two groups, that is, migrants (born in Pakistan and moved to India after 1947) and nonmigrants (born in India) were worked out.
Statistical analysis: The data were analyzed by the statistical software Statistical Package for the Social Sciences (SPSS), version 16.0 (SPSS, Chicago, Illinois). Chi-square/Fisher’s exact test was applied to compare the proportion between the migrants and nonmigrants subjects. The P value of less than 0.05 was considered significant.
| Results|| |
The study is based on a group of two cohorts: migrant ethnic Indians (n = 30) from West Pakistan and nonmigrant ethnic Indians based in Delhi (n = 30). The mean age of migrants and nonmigrants was found to be 78.46 ± 7.13 and 78.16 ± 6.10 years, respectively [Table 1]. The maximum number (46.42%) of people was in the age-group between 76 and 80 years. Males (65%) were found to be more in both groups compared to females (35%). Migrants (83.33%) and nonmigrants (73.33%) in our hospital, both were mostly from socioeconomic status (SES) I and II. None of them belonged to low SES strata. Migrants were mostly Hindus (86.70%) or Sikhs (13.30%). However, among nonmigrants, we had a few Christians (6.70%) and Muslims (3.40%) also, besides Hindus and Sikhs. Migrants (16.66%) showed more smoking habits compared to nonmigrants (10%). Interestingly, none of the migrants used SLT tobacco in their lifetime as against nonmigrants (7.14%) using tobacco. Both migrants (60%) and nonmigrants (55%) had a high incidence of obesity [Figure 1].
Migrants were mostly having hypertension (HTN) alone (20%) or with two comorbidities (63.2%) such as HTN and diabetes, HTN and coronary artery disease (CAD), diabetes and CAD, and CVDs with stroke. Lone diabetes was only seen in one of the migrant cases only so also a single case of cancer and CVD.
As regards nonmigrants, HTN alone was seen in 16.6% of cases, which is not statistically significant when compared with migrants (P = 0.739). Two comorbid cardiovascular conditions in this group were seen in 36.8% of cases as compared to migrant population with two comorbid conditions and this difference was statistically significant (P = 0.039). Interestingly, nonmigrants had a higher number of patients (16.6%) with three comorbidities (HTN, diabetes mellitus [DM], and CAD) than the migrant cohort (6.7%) with P = 0.424. Furthermore, none of the nonmigrant patients had lone diabetes or cancer associated with CVD. Notably, three cases had no CVD in the migrant group as against six cases in the nonmigrant group.
| Discussion|| |
The health of migrants is important both from the public health point of view and for the medical professionals directly engaged in the management of these problems. There is now enough evidence to support the role of migration in the generation and progression of no communicable diseases. Studies from the European countries have found the prevalence of no communicable diseases such as HTN, diabetes, obesity, and metabolic syndrome to be higher in migrants than the native population. Also, it was found that migrants are healthier in their host countries, but lifestyle changes, environmental factors, genetic predisposition, and inadequate medical facilities expose them to newer risks for developing diseases. The development of future CVD risk of an individual differs among populations based on their original place. However, this future CVD risk profile of migrant populations may change over time as they adapt to the new environment.
In this study, both the migrants and nonmigrants were in their seventh decade of life at the time of this study. Notably, most of the migrants were in early childhood in the age-group of 5–10 years at the time of migration to India. Detailed pedigree analysis of all subjects was made analyzing their cardiovascular risk profile. It was also observed after this pedigree analysis that as these migrants traveled in small groups they maintained their community bonding and few of the families had married their children as they matured [Figure 2]. Both the migrants and nonmigrants belonged to higher socioeconomic strata of society. This is because of the paid tertiary care facility at our institute because of which the medical care was unaffordable for uninsured and low socioeconomic group people. The majority of the migrants were Hindus as they had to migrate to India under great duress and arson in newly created Pakistan. None of the migrants used SLT in their lifetime as against nonmigrants. Both migrants (60%) and nonmigrants (55%) had a high incidence of obesity [Graph 1]. It can partially be explained on the basis of their higher SES, which had facilitated the adoption of an unhealthy lifestyle.
|Figure 2: Pedigree: This pedigree analysis recalls timeline of Mr. X (Sikh) when he migrated from Lahore, Pakistan, and subsequently developed lifestyle and stress-related disorders Mr. X (Sikh) was 6.5 years old when he had to migrate from Lahore, Pakistan. In August 1947, after riots, his father took shelter in his in-law’s house in Lahore. From there, the whole family proceeded to India in small groups. They traveled for 2 days and initially had to spend their time under a leaking ceiling of a house. He was later married to a lady who herself migrated from Pakistan at the age of 1 year HTN = hypertension, DM = diabetes mellitus, CAD = coronary artery disease, BPH = benign prostatic hypertrophy, CVA = cerebrovascular accident|
Click here to view
There was a marginal difference in a higher percentage of hypertensive in migrants (20%) than nonmigrants (16.6%) but this difference was not statistically significant. Previous studies had also shown a higher prevalence of HTN in migrants than their counterparts in their own country. CVDs were more in the migrant population than those in the nonmigrant patients. Most (63.2%) migrants had a combination of either HTN and diabetes, CAD and HTN, CAD and diabetes, and CAD and stroke compared to nonmigrants who had such a combination in only 36.8% of the cases. A study comparing Gujaratis in Britain and their contemporaries in villages of origin in India found a higher number of CAD risk factors in migrants. Similar studies have highlighted the role of stress in developing CVDs in migrant people., Notably, three cases had no CVD in the migrant group as against six cases in the nonmigrant group. It could be because of their healthy lifestyle or due to genetic disposition. As regards nonmigrants, HTN alone was seen in 16.6% of cases. Interestingly, nonmigrants had a higher number of patients (16.6%) with three comorbidities (HTN, DM, and CAD) than the migrant cohort (6.7%). Furthermore, none of the nonmigrant patients had lone diabetes or cancer associated with CVD.
| Conclusion|| |
The migrant population had a higher percentage of subjects with HTN and two or more CVDs, namely CAD, diabetes, HTN, and stroke. Although the study had limitations because of the small sample size and many other environmental factors, which might have influenced the cardiovascular morbidity, it, however, highlights the message that migrants are more susceptible to CVDs due to stress in their early childhood.
This study was done in a tertiary care hospital with advanced facility for diagnosing and treating cardiac diseases. The prior sample size calculation was not performed and both the migrant and non migrant population who visited this center with intention of cardiovascular evaluation were enrolled for the study.
We would like to express our sincere gratitude to Dr. Rajeev Kumar, Sr. Scientist (Statistics), Dr. B.R.A. IRCH, All India Institute of Medical Sciences, New Delhi, India for his invaluable help in preparing this manuscript.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ahmed I The Punjab Bloodied, Partitioned and Cleansed: Unravelling the 1947 Tragedy through Secret British Reports and First-Person Accounts. Pakistan: Oxford University Press; 2012. p. 500.
Reeves M, de Wildt G, Murshali H, Williams P, Gill P, Kralj L, et al
. Access to health care for people seeking asylum in the UK. Br J Gen Pract 2006;56:306-8.
Wani RT Socioeconomic status scales-modified Kuppuswamy and Udai Pareekh’s scale updated for 2019. J Family Med Prim Care 2019;8:1846-9.
Bhugra D, Becker MA Migration, cultural bereavement and cultural identity. World Psychiatry 2005;4:18-24.
Bo A, Zinckernagel L, Krasnik A, Petersen JH, Norredam M Coronary heart disease incidence among non-Western immigrants compared to Danish-born people: Effect of country of birth, migrant status, and income. Eur J Prev Cardiol 2015;22:1281-9.
Modesti PA, Bianchi S, Borghi C, Matteo Cameli M, Giovambattista Capasso G, Antonio Ceriello A, et al
. Cardiovascular health in migrants: Current status and issues for prevention. A collaborative multidisciplinary task force report. J Cardiovasc Med (Hagerstown) 2014;15:683‐92.
Bedi US, Singh S, Syed A, Aryafar H, Arora R Coronary artery disease in South Asians: An emerging risk group. Cardiol Rev 2006;14:7 4-80.
Dawson AJ, Sundquist J, Johansson S The influence of ethnicity and length of time since immigration on physical activity. J Ethnicity Health 2005;10:293-309.
Agyemang C, Bindraban N, Mairuhu G, Montfrans GV, Koopmans R, Stronks K Prevalence, awareness, treatment, and control of hypertension among black Surinamese, South Asian Surinamese and white Dutch in Amsterdam, The Netherlands: The SUNSET study. J Hypertens 2005;23:1971-7.
Patel JV, Vyas A, Kruickshank JK, Prabhakaran D, Hughes E, Reddy KS, et al
. Impact of migration on coronary heart disease risk factors: Comparison of Gujaratis in Britain and their contemporaries in villages of origin in India. Atherosclerosis 2006;185:297-306.
Dwivedi S, Singh S, Agarwal MP, Rajpal S, Aneja . Migration stress and premature coronary artery disease: An illustrative pedigree. J Assoc Physicians India 2004;52:340-2.
Dwivedi S, Agarwal MP, Suthar CP, Dwivedi G Migration accelerates development of metabolic syndrome—An interesting pedigree. Indian Heart J 2004;56:258-9.
[Figure 1], [Figure 2]