Promoting Cardiovascular Health in the Developing World A Critical Challenge to Achieve Global Health (2010) / Chapter Skim
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2 Epidemiology of Cardiovascular Disease
2 Epidemiology of Cardiovascular Disease
Pages 49-124
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From page 49... ...
Of these, 7.6 million were attributed to coronary heart disease and 5.7 million to stroke. More than 80 percent of the deaths occurred in low and middle income countries (WHO, 2009e)
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From page 50... ...
the interface between chronic infectious 2-1 Figure diseases and CVD risk are briefly R01642 discussed later in this chapter. Broad systemic drivers that contribute to the global burden of CVD, such as urbanization and image uneditable bitmapped globalization, are referred to in this chapter where they relate to trends in CVD burden and to the classically defined individual risk factors.
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From page 51... ...
In many countries -- especially in low and middle income countries -- health statistics are often based on surveillance that does not cover all areas of the country, is incomplete in the areas it does cover, or is collected by undertrained staff who do not, or cannot, accurately report the pertinent data. These realities limit the reliability of some country health data (Mathers et al., 2005; Rao et al., 2005)
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From page 52... ...
The lowest age-adjusted mortality rates are in the advanced industrialized countries and parts of Latin America, whereas the highest rates today are found in Eastern Europe and a number of low and middle income countries. For example, age-standardized mortality rates for CVD are in excess of 500 per 100,000 in Russia and Egypt; between 400 and 450 for South Africa, India and Saudi Arabia; and around 300 for Brazil and China.
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FIGURE 2.2 Age-standardized deaths due to cardiovascular disease (rate per 100,000)
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Conclusion 2.1: Chronic diseases are now the dominant contributors to the global burden of disease, and CVD is the largest contributor to the chronic disease cluster. Although CVD death rates are declining in most high income countries, trends are increasing in most low and middle income countries.
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. The median age of heart attack and first stroke and the median age at death from ischemic heart disease (IHD)
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of ischemic heart disease deaths, (c) at first stroke, and (d)
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(d) 45 50 55 60 65 70 75 80 85 90 45 50 55 60 65 70 75 80 85 90 Uganda Uganda Ghana Ghana India India Low Low Cote d'Ivoire Cote d'Ivoire Egypt Egypt China China Peru Peru Thailand Thailand Brazil Brazil Lower Middle Lower Middle Russian Federation Russian Federation Argentina Argentina South Africa South Africa Chile Chile Mexico Mexico Upper Middle Upper Middle R01642 R01642 Saudi Arabia Saudi Arabia Figure 2-3c EPIDEMIOLOGY OF CARDIOVASCULAR DISEASE Figure 2-3d Republic of Korea Republic of Korea editable vectors editable vectors Italy Italy Australia Australia France France High High Netherlands Netherlands Finland Finland United Kingdom United Kingdom Japan Japan United States United States Males Males Female Females
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From page 58... ...
It is clear that by 1920 CVD was already the leading cause of death in the United States. Scientific articles from the 1930s and 1940s suggest hypertension, cholesterol, poor nutrition, obesity, smoking, physical inactivity, and psychosocial stress as the leading factors contributing to heart disease, but they do not provide strong evidence to support this assertion (Ellis, 1948; Gager, 1931; Heart disease likely fate, 1937)
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From page 59... ...
. Undernutrition has been the hallmark of the low and middle income countries of Africa, Latin America, and South Asia for decades.
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From page 60... ...
. Epidemiological evidence suggests that dietary changes associated with the nutritional transition, specifically the increasing consumption of energydense diets high in unhealthy fats, oils, sodium, and sugars, have contributed to an increase in CVD incidence in low and middle income countries (Hu, 2008)
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From page 61... ...
, the population consequences for CVD of these very steep and rapid production trends have yet to be directly quantified in developing countries. Gaining a better understanding of the implications of oil production trends as well as those for several other food categories that impact CVD risk is necessary to better inform current and future actions to address CVD, including those related to agricultural policy.
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From page 62... ...
These data reinforce the importance of a balanced approach to combating CVD that includes both treatment and prevention. Better diagnosis and treatment can extend and improve the lives of those individuals who have established disease or high risk, but successful prevention of CVD and CVD risk factors will be required to reduce the incidence of CVD.
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, reduce smoking prevalence, and promote the use of risk factor-reducing medications where indicated. As a result of these comprehensive efforts to reduce CVD risk, between 1972 and 2007, serum cholesterol declined 21 percent among men and 23 percent among
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From page 64... ...
In summary, examination of global trends in CVD burden and mortality as well as analysis of the causal factors driving these trends provide a compelling argument in support of the prioritization of CVD prevention and reduction efforts worldwide -- and especially in low and middle income countries. Countries and regions are either currently experiencing high CVD burden and mortality rates or they can expect to see CVD burden and mortality rates increase because of disturbing trends in the prevalence of well-established CVD risk factors in their population.
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From page 65... ...
By middle age, many individuals have often already accumulated significant risk, yet the potential for ongoing accumulation exists. This is demonstrated by the effectiveness of rigorous prevention and reduction of risk factors during middle age, including continued management of blood pressure, blood lipids, and diabetes; promotion of exercise and healthful eating; and quitting smoking (Goldman et al., 2009; Kalache et al., 2002)
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From page 66... ...
Risk factors for incidence become important starting very early in life and accumulate with behavioral, social, and economic factors over the life course to culminate in biological risks for CVD such as increased cholesterol, blood pressure, blood glucose, and clinical disease. Over the past few decades, the effectiveness of early screening and long-term treatment for biological risks or early
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From page 67... ...
High blood pressure, tobacco use, elevated blood glucose, physical inactivity, and overweight and obesity are the five leading factors globally. In middle income countries, alcohol replaces high blood glucose in the top five; in low income countries, a lack of safe water, unsafe sex, and undernutrition are important.
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PROMOTING CARDIOVASCULAR HEALTH IN THE DEVELOPING WORLD TABLE 2.2 Ranking of 10 Selected Risk-Factor Causes of Death by Income Group, 2004 Region Rank Risk Factor Deaths (Millions) % of Total World 1 High Blood Pressure 7.5 12.8 2 Tobacco Use 5.1 8.7 3 High Blood Glucose 3.4 5.8 4 Physical Inactivity 3.2 5.5 5 Overweight and Obesity 2.8 4.8 6 High Cholesterol 2.6 4.5 7 Unsafe Sex 2.4 4.0 8 Alcohol Use 2.3 3.8 9 Childhood Underweight 2.2 3.8 10 Indoor Smoke from Solid Fuels 2.0 3.3 High 1 Tobacco Use 1.5 17.9 Income 2 High Blood Pressure 1.4 16.8 Countriesa 3 Overweight and Obesity 0.7 8.4 4 Physical Inactivity 0.6 7.7 5 High Blood Glucose 0.6 7.0 6 High Cholesterol 0.5 5.8 7 Low Fruit and Vegetable Intake 0.2 2.5 8 Urban Outdoor Air Pollution 0.2 2.5 9 Alcohol Use 0.1 1.6 10 Occupational Risks 0.1 1.1 Middle 1 High Blood Pressure 4.2 17.2 Income 2 Tobacco Use 2.6 10.8 Countriesa 3 Overweight and Obesity 1.6 6.7 4 Physical Inactivity 1.6 6.6 5 Alcohol Use 1.6 6.4 6 High Blood Glucose 1.5 6.3 7 High Cholesterol 1.3 5.2 8 Low Fruit and Vegetable Intake 0.9 3.9 9 Indoor Smoke from Solid Fuels 0.7 2.8 10 Urban Outdoor Air Pollution 0.7 2.8 Low 1 Childhood Underweight 2.0 7.8 Income 2 High Blood Pressure 2.0 7.5 Countriesa 3 Unsafe Sex 1.7 6.6 4 Unsafe Water, Sanitation, Hygiene 1.6 6.1 5 High Blood Glucose 1.3 4.9 6 Indoor Smoke from Solid Fuels 1.3 4.8 7 Tobacco Use 1.0 3.9 8 Physical Inactivity 1.0 3.8 9 Suboptimal Breastfeeding 1.0 3.7 10 High Cholesterol 0.9 3.4 a Countries grouped by gross national income per capita -- low income ($825 or less)
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From page 69... ...
For example, while abdominal obesity was the greatest or second-greatest contributor to CVD risk in 8 of the 10 regions studied, it was the smallest contributor in China. In addition, while psychosocial factors were among the top three risk factors by both population attributable risk and odds ratio (measures of risk-factor burden and impact, respectively)
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From page 70... ...
) to IHD and Stroke Burdens, 2001 Low and High Middle Income Income Risk Factor World Countries Countries Ischemic High Blood Pressure 45% 48% 44% Heart High Cholesterol 48% 57% 46% Disease Overweight and Obesity 18% 27% 16% Low Fruit and Vegetable Intake 28% 19% 30% Physical Inactivity 21% 21% 21% Smoking 17% 23% 15% Alcohol Use 2% –13% 4% Urban Air Pollutiona 2% 1% 2% Stroke High Blood Pressure 54% 56% 54% High Cholesterol 16% 25% 15% Overweight and Obesity 12% 20% 10% Low Fruit and Vegetable Intake 11% 9% 11% Physical Inactivity 7% 8% 6% Smoking 13% 21% 12% Alcohol Use 3% –11% 5% Urban Air Pollutiona 3% 1% 4% a PAFs for Urban Air Pollution have large uncertainty.
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U ve ui Fr O w Lo High Income Countries Low and Middle Income Countries FIGURE 2.4 Contribution of selected risk factors (by PAF) to IHD and stroke burdens, 2001.
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From page 72... ...
. By 2030, researchers estimate that 80 percent of tobacco-related deaths will occur in low and middle income countries (Mathers and Loncar, 2006)
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Although nutritional research has traditionally focused on the effect of individual food groups or nutrients on CVD, there has been a shift in recent years toward comparing how different types of dietary patterns in their entirety affect CVD risk. The following sections reflect this shift by first discussing research on oils and salt -- two key di
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From page 74... ...
Improved data about details of the contribution of major food groups to diets around the world are needed to better inform future agricultural policy and gain a more accurate picture of how changes in consumption affect CVD risk. Oils1 As discussed earlier, the rapid rise in the production and consumption of tropical oils has worried many CVD researchers because of their adverse effects on CVD risk.
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. The most well-established mechanism by which sodium intake increases CVD risk is by increasing blood pressure.
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FIGURE 2.5 Fatty acid content and shelf life of selected oils used in the food industry. SOURCE: Khan and Mensah, 2009.
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. Dietary Patterns The effect on CVD risk of diets rich in whole grains and low in processed foods that are high in fat, sodium, and sugars has been increasingly investigated in both developed and developing countries.
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Although evidence indicates that low to moderate alcohol use can reduce the risk of CHD, excessive and harmful use clearly increases CVD risk (Beilin and Puddey, 2006; Lucas et al., 2005)
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Despite the heterogeneity of the data, the study indicated that levels of physical inactivity in a number of low and middle income countries and among certain subgroups, particularly women aged 60-69 years, are disconcertingly high. Few studies have explored the reasons why levels of physical activity are declining in developing countries.
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. Even in low and middle income countries where undernutrition is still highly prevalent, overweight and obesity -- especially among women -- is a bourgeoning issue (Caballero, 2005)
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, which has led the American Heart Association to recommend an upper limit of 100 calories per day for women and 150 calories per day for men from added sugars, including soft drinks (Johnson et al., 2009)
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(2008) found that more than 80 percent of the attributable burden of hypertension in 2001 occurred in low and middle income countries, and both another recent review and an analysis commissioned for this report found the prevalence of hypertension to be equally high in developed and developing countries (Gaziano and Kim, 2009; Pereira et al., 2009)
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From page 83... ...
Finland's experience (Karppanen and Mervaala, 2006) has potential applications for low and middle income countries where treatment levels remain extremely low and health systems have yet to adapt to managing chronic diseases like hypertension.
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From page 84... ...
Diabetes Around the world, diabetes is growing increasingly common and is a significant contributor to CVD risk. People with diabetes have a more than two-fold greater risk of fatal and nonfatal CVD compared to non-diabetics, with some indication that diabetes mellitus may confer an equivalent risk of having had a cardiovascular event (Asia Pacific Cohort Studies Collabora
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. Currently, 83 percent of all diabetes deaths occur in low and middle income countries (WHO, 2009b)
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Psychosocial Risk and Mental Health Psychosocial factors have been consistently associated with both the onset and the progression of CVD in large prospective and epidemiologic studies in multiple populations and regions, yet they remain underrecognized when compared with more traditional CVD risk factors. The factors that have been associated with CVD include depression, anxiety, anger, hostility, acute and chronic life stressors, and lack of social support (Everson
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, 2010-2030. SOURCE: International Diabetes Atlas, 4th edition, © International Diabetes Federation, 2010.
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From page 88... ...
found that clinical depression increased risk of MI or coronary death by more than 2.5-fold and that depressed mood increased the likelihood of a future cardiac event by approximately 1.5-fold. Depression and depressive symptoms are also associated with behaviors that increase CVD risk.
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Women and diverse ethnic groups have been underrepresented, and limited research has been conducted in low and middle income countries. There are, however, a few examples of studies examining the association between psychosocial factors and CVD in low and middle income countries and non-Caucasian, mixed-gender samples.
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From page 90... ...
Continued research is needed to further elucidate the mechanisms by which psychosocial stressors and mental illness affect CVD risk. It is also important that clinicians are made aware of the effect of psychosocial factors on CVD risk, prognosis, and adherence to prevention efforts through improved training and knowledge sharing.
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From page 91... ...
. Despite the robust epidemiological evidence of air pollution's negative effect on CVD incidence and mortality, the specific mechanisms by which particulate matter increases CVD risk are still unclear.
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From page 92... ...
Genetics Researchers have recognized for decades that family history of CVD is associated with increased atherosclerotic risk of heart disease, which led to the presumption of a genetic component to CVD. There are several wellcharacterized single-gene disorders that contribute to CVD, such as certain forms of familial hypercholesterolemia linked to mutations of the apolipoprotein B gene, and during the past few years, there have been major advances in the identification of genetic risk factors for CHD, stroke, and CVD risk factors such as blood pressure, blood lipids, obesity, and diabetes (Arking and Chakravarti, 2009; Arnett et al., 2007)
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. The reason most often cited for these gender differences is a protective effect of estrogen on the development of CVD risk factors, most notably hypertension and dyslipidemia (Regitz-Zagrosek, 2006; Roeters van Lennep et al., 2002)
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. These differences are particularly marked in low and middle income countries; however, they are also apparent in high income countries (see the discussion of regional differences in CVD earlier in this chapter)
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. In addition to traditional CVD risk factors, there are also several situations unique to women that can place them at increased CVD risk.
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HEALTH SYSTEMS AND CVD The status of health systems can have a profound impact on CVD outcomes. Significant gaps in the health care infrastructure and access to health care in many low and middle income countries contribute to CVD incidence and mortality (Yach et al., 2004)
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. While being on the list does not guarantee improved availability and access, these decisions may help ensure that governments can increase the access of their populations to pharmaceutical products needed to tackle leading risk factors for CVD.
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From page 98... ...
The role of improved health care delivery in reducing the burden of CVD is discussed in more detail in Chapter 5. THE INTERFACE BETWEEN INFECTIOUS DISEASES AND CARDIOVASCULAR DISEASE Infectious Causes of Heart Disease Although often overlooked because of their low incidence in developed countries, heart diseases caused by infectious agents remain a significant problem in many low and middle income countries (Muna, 1993; WHO, 2003; WHO Study Group on Rheumatic Fever and Rheumatic Heart Disease and WHO, 2004)
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From page 99... ...
This is most likely because many in developing regions have poor access to basic primary care and living conditions that do not promote reduction of risk of initial infection. In addition, many low and middle income countries rely almost exclusively on providing prophylactic antibiotics to those already diagnosed with RHD to control the disease rather than on other prevention efforts.
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From page 100... ...
These have primarily consisted of widespread spraying of insecticides to prevent the parasite's insect hosts from entering homes and careful screening of the blood supply. The current estimated prevalence of Chagas is 13 million cases in 15 countries, with an annual incidence of 200,000 new infections and 21,000 annual deaths from Chagas heart disease (Moncayo and Yanine, 2006; Morel and Lazdins, 2003; WHO Expert Committee on the Control of Chagas Disease and WHO, 2002)
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From page 101... ...
Conclusion 2.4: Rheumatic heart disease, Chagas, and infectious peri carditis and cardiomyopathies continue to cause a substantial burden of disease and death in some low and middle income countries despite having been nearly eliminated in high income countries. Their ongo ing prevalence in developing countries further widens the gap between the rich and poor, yet they are easily prevented through basic primary health care screenings or proven interventions.
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From page 102... ...
The Data Collection on Adverse Events of Anti-HIV Drugs (D:A:D) study, one of the largest prospective studies of CVD risk among HIV-infected patients in 21 mostly high income countries in North America, Europe, and Australia, found that the incidence rate of a patient's first cardio or cerebrovascular event was 5.7 per 1000 personyears.
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From page 103... ...
. CVD Risk Factors and TB Recently WHO reviewed the relationship between major risk factors for CVD and TB.
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From page 104... ...
Furthermore, they share common risk factors, which suggests opportunities for integrated approaches to prevention and disease management at the health service and broader policy levels. As the HIV and TB epidemics continue to spread and more people get placed on longterm treatment, these opportunities for integrated approaches will likely increase.
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From page 105... ...
The complex, interrelated determinants of global CVD and the variation in both risk profiles and capacity among low and middle income countries means that prevention efforts will only be effective if they are adapted to account for the specific needs of the settings in which they will be applied. To achieve this, additional surveillance and implementation research in all global regions, but especially in low and middle income countries, is required.
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From page 106... ...
2002. Life course perspectives on coronary heart disease, stroke and diabetes: Key issues and implications for policy and research.
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1999. International trends in coronary heart disease mortality and incidence rates.
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1999. Contribution of modern cardiovas cular treatment and risk factor changes to the decline in coronary heart disease mortality in Scotland between 1975 and 1994.
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2004. Explaining the increase in coronary heart disease mortality in Beijing between 1984 and 1999.
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2001. Rela tionship of childhood obesity to coronary heart disease risk factors in adulthood: The Bogalusa Heart Study.
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2009. Cost of treating non-optimal blood pressure in select low and middle income countries in comparison to the United States.
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From page 112... ...
1998. Mortality from coronary heart disease in subjects with type 2 diabetes and in nondiabetic subjects with and without prior myocardial infarction.
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1971. Serum cholesterol, lipoproteins, and the risk of coronary heart disease.
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2008. Depression and coronary heart disease: Recommendations for screening, referral, and treatment -- a science advisory from the American Heart Association Prevention Committee of the Council on Cardiovascular Nursing, Council on Clinical Cardiology, Council on Epide miology and Prevention, and Interdisciplinary Council on Quality of Care and Outcomes Research.
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1992. Joint effects of serum triglyceride and LDL cholesterol and HDL cholesterol concentrations on coronary heart disease risk in the Helsinki Heart Study.
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2006. Alcohol consumption and risk for coronary heart disease in men with healthy lifestyles.
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1996. Changes in diet in Fin land from 1972 to 1992: Impact on coronary heart disease risk.
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1998. Coronary heart disease risk factors in women: Focus on gender differences.
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1995. Prevention of coronary heart disease with pravastatin in men with hypercholesterolemia.
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2009. Prevention and treatment of rheumatic heart disease in the developing world.
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1994b. Changes in risk factors explain changes in mortality from ischaemic heart disease in Finland.
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2004. Rheumatic fever and rheumatic heart disease: Report of a WHO expert consultation, Geneva, 0 October– November 00, World Health Organization technical report series.
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2000. Patients with depression are less likely to follow recommendations to reduce car diac risk during recovery from a myocardial infarction.
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