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Time to abandon the "tendinitis" myth
K M Khan, J L Cook, P Kannus, N Maffulli and S F Bonar BMJ 2002;324;626-627 doi:10.1136/bmj.324.7338.626

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Editorials

Downloaded from bmj.com on 30 June 2008
resistance is not directly causative of coronary heart disease, it is predictive of diabetes, a key and highly prevalent risk factor in South Asians. This work emphasises that the prevention of diabetes must start in early life. This study has policy and service implications. South Asians’ poor knowledgeand understanding of coronary heart disease and diabetes are shocking, particularly in Bangladeshis and Pakistanis.12 In addition to conveying effective and accurate messages about coronary heart disease prevention in adults we must weave in the key message that children are at risk. As all the established risk factors are important in South Asians, the health promotion challenge is formidable.Raj Bhopal Bruce and John Usher professor of public health
Public Health Sciences, University of Edinburgh Medical School, Edinburgh EH89AG

explained by the greater tendency to central deposition of fat in South Asian children.10 Important observations, such as those of Whincup et al and Patel et al, made on cross sectional data, need to be verified in cohort studies. But none of the manycardiovascular cohort studies in the United Kingdom can yield risk-outcome data by ethnic group.4 New risk factors—The third explanation is that specific risk factors, not yet established or discovered, may explain high risk. The search for a specific cause has led to many hypotheses, including the use of ghee and other cooking oils, subclinical hypothyroidism, central obesity, stress, racism, insulinresistance, a thrifty genotype, a thrifty phenotype, low vitamin C, high homocysteine, endothelial dysfunction, high levels of lipoprotein a, and other specific lipid abnormalities. No “South Asian cause” of coronary heart disease has been proved, though each new idea has diverted attention from established risk factors. The best studied hypothesis is that the high prevalence of insulin resistance,independent of diabetes, underlies the high rates of coronary heart disease in South Asians.1 Rigorous tests of this hypothesis, based on prospective studies, are awaited, but Whincup et al provide data of interest on children. Though South Asian children were no more obese than those of European origin, fasting and 30 minute post load insulin were about 50% higher. Competing causes—The fourth,rarely considered explanation, is that there are fewer competing causes of death in middle aged South Asians, particularly as cancer rates are comparatively low. Whincup et al do not touch on this concept. Whincup et al have paved the way to paying more attention to young South Asians, mostly born in the United Kingdom. They show that if insulin and insulin resistance do turn out to be causally...