From the Department of Cardiology, All India Institute of Medical
Sciences (K.S.R.), New Delhi, India, and the Department of Medicine, McMaster
University (S.Y.), Hamilton, Canada L8L 2X2.
Correspondence to Dr K.S. Reddy, Professor of Cardiology, Cardiothoracic Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India.
This high, yet inadequately recognized, contribution of developing
countries to the absolute burden of CVD is readily explained by the
fact that 78% of the 49.9 million global deaths (from all causes) in
1990 occurred in regions other than the established market economies or
former socialist economies (Table 2
The ratio of deaths due to pretransitional diseases (related to
infections and malnutrition) to those caused by post-transitional
diseases (eg, CVD and cancer) varies among regions and between
countries, depending on factors such as the level of economic
development and literacy as well as availability and access to health
care. The direction of change toward a rising relative contribution of
posttransitional diseases is, however, common to and consistent
among the developing countries.6 The experience
of urban China, in which the proportion of CVD deaths rose from 12.1%
in 1957 to 35.8% in 1990, is illustrative of this
phenomenon.10
It has been the historical experience of the developed countries that
the CVD epidemic usually commences in members of the higher social
classes, who are the first to change from a low-risk to a high-risk
lifestyle, which is characterized by diets rich in fat and calories,
sedentariness, and smoking. Later, the risk permeates across the social
spectrum, affecting all classes. The higher-social classes are, again,
the first to respond to the knowledge of risk factors and the message
of prevention. The CVD rates begin to decline in them, with the
present pattern of higher CVD rates among the lower social classes
becoming increasingly established. In most developing countries, there
has been an initial preponderance of CVD in the higher socioeconomic
strata. However, the pattern observed in the developed countries, in
which the burden of disease shifts progressively to the lower social
classes, is likely to be replicated as the epidemic advances. Indeed,
recent reports from India, based on community surveys and case-control
studies, suggest that poor educational or economic status is associated
with higher risk of CHD in some regions.25 26
There are several countries in Latin America and the Caribbean in which
the poor are more likely to be obese than the
rich.27 If the social gradient completely
reverses when the CVD epidemic fully matures, progressively larger
numbers of poor individuals will become its victims and will be unable
to obtain the necessary health care.
The essential components of any CVD control program would be the
following: (1) establishment of efficient systems for estimation of
CVD-related burden of disease and its secular trends; (2) estimation of
the levels of established CVD risk factors (eg, smoking, elevated
cholesterol, or blood pressure) in
representative population samples to help identify risk
factors that require immediate intervention; (3) evaluation of emerging
risk factors (eg, glucose, abdominal obesity, fibrinolytic status,
homocysteine) that may be of special relevance to the populations
concerned; (4) identification of the determinants of health behavior
that influence the levels of both traditional and emerging risk factors
in the specific context of each society; and (5) development of a
health policy that will integrate population-based measures for CVD
risk modification and cost-effective case management strategies for
individuals who have clinically manifested CVD or are detected to be at
a high risk of developing it.
All of these require a strengthening of policy-relevant research that
can support and evaluate CVD control programs in the developing
countries. The challenge of CVD control is especially complex in
settings in which epidemiological data related to the incidence of
fatal and nonfatal CVD events as well as population-attributable risk
of various risk factors of CVD are not readily or reliably available at
present.
However, the need for tobacco control currently assumes the highest
priority, both because no context-specific scientific validation is
needed to establish its risk factor status as a program prerequisite
and because of the wide-ranging benefit that will accrue for a whole
host of chronic diseases. Although strategies for behavior modification
in relation to specific dietary practices may require further research
within each population, the imperatives of tobacco control are
universal and should be implemented without delay.
Obtaining a fuller estimate of the burden of disease also requires
standardized morbidity data. Although gathering such data on a national
basis would be impractical, obtaining prevalence data from
cross-sectional sample surveys of selected communities and incidence
data from selected cohort studies would provide a reasonable basis for
extrapolation. Health services of large organized sector industries may
offer opportunities for convenient and cost-effective prospective
studies and registries.
The South Asian experience also illustrates this need to evaluate risk
factors in the context of ethnic diversity in CVD. Several studies
around the world have consistently revealed excess, early, and
extensive CHD in persons of South Asian
origin.29 30 The excess mortality has not been
fully explained by the major conventional risk factors in
cross-sectional comparisons with other population groups. Diabetes
mellitus and impaired glucose tolerance are, however, highly prevalent
in South Asian migrants.29 Central obesity, high
levels of triglycerides, and low levels of HDL
cholesterol, with or without glucose intolerance, seem to
characterize a phenotype frequently noted among South Asian
migrants. A similar profile has been observed to be common in urban
Indians in a recent population survey.31
However, a substantial urban excess in several of the conventional risk
factors (body mass index, blood pressure, plasma
cholesterol, diabetes) has been identified in
cross-sectional urban-rural comparisons in
India.9 A recent case-control comparison of
incident acute myocardial infarction cases and age-and sex-matched
hospital controls in India revealed that the most important predictors
of acute myocardial infarction were current smoking, history of
hypertension, overt diabetes mellitus, and abdominal obesity as
measured by waist-to-hip ratio.26 A comparison of
Indian migrants to the United Kingdom with their siblings who remained
in Punjab reported that although both Indian groups had higher
lipoprotein(a) levels in comparison to the Europeans in the United
Kingdom, the South Asians in London had higher body mass index and
plasma cholesterol and fasting blood glucose levels as well
as a lower HDL cholesterol level and reduced insulin
sensitivity in comparison with their siblings.32
Thus, South Asians in urban and migrant environments may be at a higher
risk of CHD due to the confluence of (1) genetic factors that
predispose to higher lipoprotein(a) levels, the central obesity/glucose
intolerance/dyslipidemia complex collectively labeled as
the "metabolic syndrome," and a possible "thrifty
gene" effect with (2) environmental influences that lead to weight
gain, rise in plasma cholesterol and blood pressure levels,
and, as yet inadequately studied, probable psychosocial risk factors.
Such genetic environmental interactions may need to be clarified in the
varied ethnocultural populations of the developing countries so that
the relevant environmental interventions could be preferentially
promoted for CVD prevention.
The marked ethnic diversity in the manifestations of CVD is another
potentially profitable area for study in the developing countries. The
high rates of stroke coupled with low rates of CHD in Chinese (despite
high smoking rates) as well as African populations must be
explained.10 33 The lack of association between
the high prevalence of diabetes and CHD in groups such as the
Afro-Caribbeans calls for critical enquiry.34
Studies of CVD risk factors in the varied populations of the developing
countries may help complement the knowledge already gained from studies
in Western populations by supplying the missing pieces in the
multifactorial puzzle of CVD causation.
Certain additional areas of CVD epidemiology
need special attention in the studies to be initiated in the developing
countries. Nutritional epidemiology in diverse
cultural settings with widely varying dietary practices faces the
challenge of identifying prudent, affordable, and culturally acceptable
diets for each population. It also offers the potential opportunity of
identifying protective practices (eg, vegetarianism) that may reduce
the risk of CVD if adopted by other populations.
Psychosocial factors are likely to have varied components and
determinants in different cultures. Apart from the challenge of
cross-cultural validation and adaptation of instruments developed for a
very different cultural context, these studies must explore the
psychosocial factors that are conditioned by the rapid socioeconomic,
cultural, and health transitions occurring in the developing countries
as well as identify the elements in their tradition that are likely to
offer continued protection if preserved.
Health policy research also must be strengthened. The existing health
care infrastructure is equipped to handle mostly the pretransitional
agenda of infectious and nutritional deficiency disorders. It must be
reinforced, reoriented, and recruited to the task of meeting the
challenge of posttransitional diseases. Health education (of public,
providers, and patients) is a priority. Some of the knowledge and
process components of Western health educational interventions are
likely to be applicable but require adaptation to the needs of each
community's sociocultural milieu. Integration with other chronic
disease control programs also is essential. Tobacco control and diet
are clearly on the agenda of several lifestyle-related disease control
programs.
The relatively low levels of the conventional CVD risk factors in
the large rural segments of the developing countries, however, do offer
a window of opportunity for early and effective control of the
epidemic. Strategies to prevent acquisition or augmentation of CVD risk
factors in these communities (primordial prevention) must be combined
with programs to reverse and reduce the risk factor elevations observed
in the urban communities (primary prevention). At the present
levels of these risk factors in the developing countries, the approach
would be predominantly nonpharmacological, population based, and
lifestyle linked. This would largely avoid the biologic and economic
costs of a pharmacological approach warranted by high levels of these
risk factors in the developed countries.
There also is a clear need to develop cost-effective methods for
the timely diagnosis and management of manifest disease. Suitable
clinical algorithms for diagnosis and low-cost life-saving
interventions (eg, aspirin) must be widely available to and adopted by
health professionals in primary and secondary care settings. Although
tertiary care expertise is growing, the patterns of practice must
include optimization of resources and avoidance of heavy investment in
high-cost, low-yield technologies.
Thus, the new century dawns on a period of challenge and opportunity
for the developing countries as they embark on their efforts to quell
the emerging epidemic of CVD. National and international efforts must
be coordinated to recognize this epidemic and respond without
delay.
2.
Murray CJL, Lopez AD. Global Comparative
Assessments in the Health Sector. Geneva, Switzerland: World
Health Organization; 1994.
3.
Thom TJ, Epstein FH, Feldman JJ, Leaverton PE, Wolz M.
Total Mortality and Mortality From Heart Disease, Cancer, and
Stroke From 1950 to 1987 in 27 Countries: Highlights of Trends and
Their Interrelationships Among Causes of Death. Washington, DC: US
DHHS PHS, National Institutes of Health; NIH publication No. 92–3088,
1992.
4.
Whelton PK, Brancati FL, Appel LJ, Klag MJ. The
challenge of hypertension and atherosclerotic
cardiovascular disease in economically developing
countries. High Blood Press. 1995;4:36–45.
5.
Feinleib M, Ingster L, Rosenberg H, Maurer J, Singh G,
Kochanek K. Time trends, cohort effects and geographic patterns in
stroke mortality: United States. Ann Epidemiol. 1993;3:458–465.[Medline]
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6.
Pearson TA, Jamison DT, Tergo-Gauderies J.
Cardiovascular disease. In: Jamison DT, Mosley WH, eds.
Disease Control Priorities in Developing Countries. New
York, NY: Oxford University Press; 1993.
7.
Omran AR. The epidemiologic transition: a key of the
epidemiology of population change.
Milibank Memorial Fund Q. 1971;49:509–538.
8.
World Bank. World Development Report: Investing
in Health. New York, NY: Oxford University Press; 1993.
9.
Reddy KS. Cardiovascular disease in
India. World Health Stat Q. 1993;46:101–107.[Medline]
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10.
Yao C, Wu Z, Wu J. The changing pattern of
cardiovascular diseases in China. World Health
Stat Q. 1993;46:113–118.[Medline]
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11.
Peto R. Tobacco: the growing epidemic in China.
JAMA. 1996;275:1683–1684.
12.
Peto R, Lopez AD, Boreham J, Thun M, Heath C Jr, Doll
R. Mortality from smoking worldwide. Br Med Bull. 1996;52:12–21.
13.
Drewnowski A, Popkin BM. The nutrition transition: new
trends in the global diet. Nutr Rev. 1997;55:31–43.[Medline]
[Order article via Infotrieve]
14.
Lang T. The public health impact of globalisation of
food trade. In: Shetty PS, McPherson K, eds. Diet, Nutrition and
Chronic Disease: Lessons From Contrasting Worlds. Chichester, UK:
Wiley; 1997:173–187.
15.
Barker DJP. Fetal origins of coronary heart
disease. BMJ. 1995;311:171–174.
16.
Barker DJP, Martyn CN, Osmond C, Haleb CN, Fall CHD.
Growth in utero and serum cholesterol concentrations in
adult life. BMJ. 1993;307:1524–1527.
17.
Martyn CN, Barker DJP, Jespersen S, Greenwald S, Osmond
C, Berry C. Growth in utero, adult blood pressure and
arterial compliance. Br Heart J. 1995;73:116–121.
18.
Law CM, Shiell AW. Is blood pressure inversely related
to birth weight? The strength of evidence from a systematic review of
the literature. J Hypertens. 1996;14:935–941.[Medline]
[Order article via Infotrieve]
19.
Joseph KS, Kramer MS. Review of evidence on fetal and
early childhood antecedents of adult chronic disease. Epidemiol
Rev. 1996;18:158–174.
20.
World Health Organization. Tobacco or Health?
First Global Status Report. Geneva, Switzerland: World Health
Organization; 1996.
21.
Bulatao RA, Stephens PW. Global Estimates and
Projections of Mortality by Cause. Washington, DC: Population,
Health and Nutrition Department; World Bank; preworking paper 1007,
1992.
22.
Nicholls ER, Peruga A, Restrepo HE.
Cardiovascular mortality in the Americans. World
Health Stat Q. 1993;46:134–150.[Medline]
[Order article via Infotrieve]
23.
InterAmerican Heart Foundation.
Cardiovascular and Cerebrovascular Diseases in
the Americas. Dallas, Texas: InterAmerican Heart Foundation Inc,
1996.
24.
Walker ARP, Sarell P. Coronary heart disease:
outlook for Africa. J R Soc Med. 1997;90:23–27.[Abstract]
25.
Gupta R, Gupta VP, Ahluwalia NS. Educational status,
coronary heart disease and coronary risk factor
prevalence in a rural population in India. BMJ. 1994;307:1332–1336.
26.
Pais P, Pogue J, Gerstein H Zachariah E, Savitha D,
Jayprakash S, Nayak PR, Yusuf S. Risk factors for acute myocardial
infarction in Indians: a case-control study. Lancet. 1996;348:358–363.[Medline]
[Order article via Infotrieve]
27.
Popkin BM. The nutrition transition in low-income
countries: an emerging crisis. Nutr Rev. 1994;52:285–298.[Medline]
[Order article via Infotrieve]
28.
Verschuren WMM, Jacobs DR, Bloemberg BPM,
Kromhout D, Menotti A, Aravanis C, Blackburn H, Buzina R, Dautas AS,
Fidaza J, Karvonen MJ, Nedelj Kovic S, Nissinen A, Toshima H. Serum
total cholesterol and long-term coronary heart
disease mortality in different cultures: twenty-five year follow-up of
the Seven Country Study. JAMA. 1995;274:131–136.
29.
McKeigue PM, Ferrie JE, Pierpont T, Marmot MG.
Association of early-onset coronary heart disease in South
Asian men with glucose intolerance and
hyperinsulinemia. Circulation. 1993;878:152–161.
30.
Enas EA, Mehta JL. Malignant coronary artery
disease in Young Asian Indians: thoughts on pathogenesis, prevention
and treatment. Clin Cardiol. 1995;18:131–135.[Medline]
[Order article via Infotrieve]
31.
Reddy KS. Cardiovascular disease and
diabetes in migrants: interaction between nutritional changes and
genetic background. In: Shetty PS, McPherson K, eds. Diet,
Nutrition and Chronic Disease: Lessons From Contrasting Worlds.
Chichester, UK: Wiley; 1997:71–75.
32.
Bhatnagar D, Anand IS, Durrington PN, Patel DJ, Wander
GS, Mackness MI, Creed F, Tomenson B, Chandrashekar I, Winterbotham M,
Britt RP, Keil JE, Sutton GC. Coronary risk factors in people
from the Indian Subcontinent living in West London and their siblings
in India. Lancet. 1995;345:404–409.[Medline]
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33.
Muna WFT. Cardiovascular disorders in
Africa. World Health Stat Q. 1993;46:125–133.[Medline]
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34.
Chaturvedi N, McKeigue PM, Marmot MG. Relationship of
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© 1998 American Heart Association, Inc.
Current Perspectives
Emerging Epidemic of Cardiovascular Disease in Developing Countries
Key Words: cardiovascular diseases • mortality • risk factors
Introduction
Top
Introduction
Burden of CVD in...
Early Age of CVD...
Epidemiological Transition
Lifestyle Changes
Nutrition Transition
Potential Effect of Impaired...
Tobacco Trends
Projected Rise in CVD...
Varied Profile Between...
Health Care and Economic...
CVD Control Programs: Need...
Strengthening the Estimation of...
CVD Risk Factor Studies
Research Priorities
Dynamics of Prevention in...
References
As the twentieth century draws
to a close, it is clear that cardiovascular disease
(CVD) has become a ubiquitous cause of morbidity and a leading
contributor to mortality in most countries.1 2
The rise and recent decline of the CVD epidemic in the developed
countries have been well documented.3 4 The
identification of major risk factors through population-based studies
and effective control strategies combining community education and
targeted management of high risk individuals have contributed to the
fall in CVD mortality rates (inclusive of coronary and stroke
deaths) that has been observed in almost all industrialized countries.
It has been estimated that during the period 1965 to 1990, CVD related
mortality fell by 
50% in Australia, Canada, France, and the United
States and by 60% in Japan.1 Other parts of
Western Europe reported more modest declines (20% to 25%). The
decline in stroke mortality has been more marked compared with the
decline in coronary mortality. In the United States, the
decline in stroke mortality commenced nearly two decades earlier than
the decline in coronary mortality and maintained a sharper rate
of decline. During the period 1979 to 1989, the age-adjusted mortality
from stroke declined, in that country, by about one third, whereas the
corresponding decline in coronary mortality was
22%.4 5 In Japan, where stroke mortality
outweighs coronary mortality, the impressive overall decline in
CVD mortality is principally contributed by the former. The discordant
trend of rising CVD mortality rates in Eastern Europe, however, is in
sharp contrast to the decline in Western
Europe.1
Burden of CVD in Developing Countries
Top
Introduction
Burden of CVD in...
Early Age of CVD...
Epidemiological Transition
Lifestyle Changes
Nutrition Transition
Potential Effect of Impaired...
Tobacco Trends
Projected Rise in CVD...
Varied Profile Between...
Health Care and Economic...
CVD Control Programs: Need...
Strengthening the Estimation of...
CVD Risk Factor Studies
Research Priorities
Dynamics of Prevention in...
References
The emergence of the CVD epidemic in the developing
countries during the past two to three decades has attracted less
comment and little public health response, even within these countries.
It is not widely realized that at present, the developing countries
contribute a greater share to the global burden of CVD than the
developed countries.1 4 It has been estimated
that 5.3 million deaths attributable to CVD occurred in the developed
countries in 1990, whereas the corresponding figure for the developing
countries ranged between 8 to 9 million (ie, a relative excess of
70%).1 Regional estimates of CVD mortality
indicate that the difference would be even higher if the term
"developed countries" is restricted to established market economies
only and excludes the former socialist economies (Table 1
).
View this table:
[in a new window]
Table 1. Regional Differences in Burden of CVD (1990) ).
Although the relative contribution of CVD deaths to total mortality was
higher in the developed countries (49%) than that in the developing
countries (23%), the excess total mortality in the latter is
translated into excess absolute CVD mortality due to the large
populations involved. Thus, in 1990 the developing countries
contributed 68% of the total global deaths due to noncommunicable
disease and 63% of world mortality due to CVD.2
Although the inadequacies and imperfections of cause-specific mortality
ascertainment methods currently used in many developing countries call
for cautious interpretation of these estimates, the conservative
assumptions made by the analysts suggest that the absolute burden of
CVD mortality is indeed likely to be high in developing countries.
View this table:
[in a new window]
Table 2. Regional Contribution to Mortality (1990)
Early Age of CVD Deaths in Developing Countries
Top
Introduction
Burden of CVD in...
Early Age of CVD...
Epidemiological Transition
Lifestyle Changes
Nutrition Transition
Potential Effect of Impaired...
Tobacco Trends
Projected Rise in CVD...
Varied Profile Between...
Health Care and Economic...
CVD Control Programs: Need...
Strengthening the Estimation of...
CVD Risk Factor Studies
Research Priorities
Dynamics of Prevention in...
References
Although the present high burden of CVD deaths is in itself an
adequate reason for attention, a greater cause for concern is the early
age of CVD deaths in the developing countries compared with the
developed countries. For example, in 1990, the proportion of CVD deaths
occurring below the age of 70 years was 26.5% in the developed
countries compared with 46.7% in the developing
countries.2 The contrast between the truly
developed "established market economies" (22.8% of CVD deaths at
<70 years) and a large developing country like India (52.2%) was even
sharper.2 Therefore, the contribution of the
developing countries to the global burden of CVD, in terms of
disability adjusted years of life lost, was 2.8 times higher than that
of the developed countries (Table 1
).
Epidemiological Transition
Top
Introduction
Burden of CVD in...
Early Age of CVD...
Epidemiological Transition
Lifestyle Changes
Nutrition Transition
Potential Effect of Impaired...
Tobacco Trends
Projected Rise in CVD...
Varied Profile Between...
Health Care and Economic...
CVD Control Programs: Need...
Strengthening the Estimation of...
CVD Risk Factor Studies
Research Priorities
Dynamics of Prevention in...
References
A second cause for considerable alarm is the projected rise in
both proportional and absolute CVD mortality rates in the developing
countries over the next 25 years.6 7 The reasons
for this anticipated acceleration of the epidemic are many. In the
second half of the twentieth century, most developing countries
experienced a major surge in life expectancy.8
For example, the life expectancy in India rose from 41.2 years in
1951–1961 to 61.4 years in 1991–1996. This was principally due to a
decline in deaths occurring in infancy, childhood, and adolescence and
was related to more effective public health responses to perinatal,
infectious, and nutritional deficiency disorders and to improved
economic indicators such as per-capita income and social indicators
such as female literacy in some areas. Although this is a cause for
celebration (and much remains to be done in these areas), the
demographic shifts have augmented the ranks of middle-aged and older
adults. The increasing longevity provides longer periods of exposure to
the risk factors of CVD, resulting in a greater probability of
clinically manifest CVD events.9 The concomitant
decline of infectious and nutritional disorders (competing causes of
death) further enhances the proportional burden due to CVD and other
chronic lifestyle-related diseases. This shift,
representing a decline in deaths from infectious diseases
to an increase in those due to chronic diseases, is often referred to
as the modern epidemiological transition.6 7
Lifestyle Changes
Top
Introduction
Burden of CVD in...
Early Age of CVD...
Epidemiological Transition
Lifestyle Changes
Nutrition Transition
Potential Effect of Impaired...
Tobacco Trends
Projected Rise in CVD...
Varied Profile Between...
Health Care and Economic...
CVD Control Programs: Need...
Strengthening the Estimation of...
CVD Risk Factor Studies
Research Priorities
Dynamics of Prevention in...
References
A third reason to arouse concern is that if population levels of
CVD risk factors rise as a consequence of adverse lifestyle changes
accompanying industrialization and urbanization, the rates of CVD
mortality and morbidity could rise even higher than the rates predicted
solely by demographic changes. Both the degree and the duration of
exposure to CVD risk factors would increase due to higher risk factor
levels coupled with a longer life expectancy. An increase in body
weight (adjusted for height), blood pressure, and
cholesterol levels in Chinese population samples aged 35 to
64 years, between the two phases of the Sino-MONICA study (1984 to 1986
and 1988 to 1989) and the substantially higher levels of CVD risk
factors in urban population groups compared with rural population
groups in India provide evidence of such
trends.9 10 A cross-sectional survey of urban
Delhi and its rural environs revealed that a higher prevalence of
coronary heart disease (CHD) in the urban sample was associated
with higher levels of body mass index, blood pressure, fasting blood
lipids (total cholesterol, ratio of cholesterol
to HDL cholesterol, triglycerides), and
diabetes.9 The increasing use of tobacco in a
number of developing countries will also translate into higher
mortality rates of CVD, lung cancer, and other tobacco-related
diseases.11 12
Nutrition Transition
Top
Introduction
Burden of CVD in...
Early Age of CVD...
Epidemiological Transition
Lifestyle Changes
Nutrition Transition
Potential Effect of Impaired...
Tobacco Trends
Projected Rise in CVD...
Varied Profile Between...
Health Care and Economic...
CVD Control Programs: Need...
Strengthening the Estimation of...
CVD Risk Factor Studies
Research Priorities
Dynamics of Prevention in...
References
As recently reviewed by Drewnowski and
Popkin,13 the global availability of cheap
vegetable oils and fats has resulted in greatly increased fat
consumption among low-income countries. The transition now occurs at
lower levels of the gross national product than previously and is
further accelerated by rapid urbanization. In China, for example, the
proportion of upper-income persons who were consuming a relatively
high-fat diet (>30% of daily energy intake) rose from 22.8% to
66.6% between 1989 and 1993. The lower- and middle-income classes also
showed a rise (from 19% to 36.4% in the former and from 19.1% to
51.0% in the latter).11 The Asian countries,
with a diet that is traditionally high in carbohydrates and low in fat,
have shown an overall decline in the proportion of energy from complex
carbohydrates along with the increase in the proportion of fat. The
globalization of food production and marketing is also
contributing to the increasing consumption of energy-dense foods poor
in dietary fiber and several
micronutrients.14
Potential Effect of Impaired Fetal Nutrition
Top
Introduction
Burden of CVD in...
Early Age of CVD...
Epidemiological Transition
Lifestyle Changes
Nutrition Transition
Potential Effect of Impaired...
Tobacco Trends
Projected Rise in CVD...
Varied Profile Between...
Health Care and Economic...
CVD Control Programs: Need...
Strengthening the Estimation of...
CVD Risk Factor Studies
Research Priorities
Dynamics of Prevention in...
References
A recently reported association that, if adequately validated by
the tests of causation, may have special relevance to the developing
countries is the inverse relation between birth size and CVD in later
life.15 The "fetal origins hypothesis" states
that adverse intrauterine influences such as poor maternal nutrition
lead to impaired fetal growth, resulting in low birth weight, short
birth length, and small head circumference. These adverse influences
are postulated to also "program" the fetus to develop adaptive
metabolic and physiological responses
that facilitate survival. These responses, however, may lead to
disordered responses to environmental challenges as the child grows,
with an increased risk of glucose intolerance, hypertension, and
dyslipidemia in later life and adult CVD as a consequence.
Although some supportive evidence for the hypothesis has been provided
by observational studies,16 17 18 it awaits further
evaluation for a causal role.19 If it does emerge
as an important risk factor for CVD, the populations of developing
countries will be at an especially enhanced risk because of the vast
numbers of poorly nourished infants who have been born in the past
several decades. The steady improvement in child survival will lead to
a higher proportion of such infants surviving to adult life, when their
hypothesized susceptibility to vascular disease may manifest
itself.
Tobacco Trends
Top
Introduction
Burden of CVD in...
Early Age of CVD...
Epidemiological Transition
Lifestyle Changes
Nutrition Transition
Potential Effect of Impaired...
Tobacco Trends
Projected Rise in CVD...
Varied Profile Between...
Health Care and Economic...
CVD Control Programs: Need...
Strengthening the Estimation of...
CVD Risk Factor Studies
Research Priorities
Dynamics of Prevention in...
References
The rising tobacco consumption patterns in most developing
countries contrast sharply with the overall decline in the industrial
nations. Recent projections from the World Health Organization
suggest that, by the year 2020, tobacco will become the largest single
cause of death, accounting for 12.3% of global
deaths.20 India, China, and countries in the
Middle Eastern Crescent will by then have tobacco contributing to
>12% of all deaths. In India alone, the tobacco attributable toll
will rise from 1.4% in 1990 to 13.3% in 2020.20
A large component of this will be in the form of
cardiovascular deaths. Tobacco is the leading avoidable
cause of death worldwide, and its rising consumption in the developing
countries warrants early and effective public health responses.
Projected Rise in CVD Mortality
Top
Introduction
Burden of CVD in...
Early Age of CVD...
Epidemiological Transition
Lifestyle Changes
Nutrition Transition
Potential Effect of Impaired...
Tobacco Trends
Projected Rise in CVD...
Varied Profile Between...
Health Care and Economic...
CVD Control Programs: Need...
Strengthening the Estimation of...
CVD Risk Factor Studies
Research Priorities
Dynamics of Prevention in...
References
The anticipated rise in CVD mortality, based solely on demographic
shifts of population age profile, is
staggering.6 21 It has been projected, for
example, that mortality attributable to "circulatory system
diseases" in India would rise by 103% in men and by 90% in women
during the period 1985 to 2015.21 By 2015, these
diseases are expected to account for 34% of all male deaths and 32%
of all female deaths in India. The ratio of deaths from circulatory
system diseases to deaths from infectious diseases is likely to rise
from 0.60 to 2.75 in Asia and from 1.1 to 4.75 in Latin America during
the period 1985 to 2015.6 21 Although the
categories of cause-specific mortality, in the surveys on which these
projections are based, are vulnerable to errors of
misclassification, the overall general trend is likely to be valid. The
escalation will be undoubtedly large, even if the present estimates
are unable to precisely identify the true magnitude of future CVD
mortality. If urbanization and lifestyle change contribute to increased
risk factor levels, the rise in CVD mortality may even be larger than
these estimates based solely on demographic shifts.
Varied Profile Between Developing Countries
Top
Introduction
Burden of CVD in...
Early Age of CVD...
Epidemiological Transition
Lifestyle Changes
Nutrition Transition
Potential Effect of Impaired...
Tobacco Trends
Projected Rise in CVD...
Varied Profile Between...
Health Care and Economic...
CVD Control Programs: Need...
Strengthening the Estimation of...
CVD Risk Factor Studies
Research Priorities
Dynamics of Prevention in...
References
Even within the group of developing countries, the degree of
development varies with a diverse profile of socioeconomic growth,
demographic change, and lifestyle practices. The direction and pace of
the CVD epidemics are therefore unlikely to be uniform across the wide
range of development, within this group. This is illustrated by Latin
America, in which countries such as Argentina, Chile, Uruguay, and Cuba
demonstrated a declining trend for both CVD and CHD mortality between
1969 and 1986, whereas countries such as El Salvador, Guatemala, and
Dominican Republic showed an increase in CVD as well as CHD mortality
during this period.22 Barbados and Costa Rica
experienced an increase in CHD mortality but had an overall decline in
CVD mortality due to a large decline in stroke
mortality.22 Despite such diversity in trends,
Latin America has a high overall burden of
CVD.22 23 For example, the state of Sao Paulo, in
Brazil, experienced declines of 33.6% for men and 40.6% for women in
age-standardized CVD mortality rates between 1970 and
1992.23 Despite this decrease, the mortality
rates in the 45- to 64-year-old age group in Sao Paulo, Porto Alegre,
and Rio de Janeiro are reported to be higher than those in the United
Kingdom and as high as or nearly equal to rates in Eastern
Europe.23 The cumulative mortality rate from CHD
is 42% for Brazilian men below the age of 65 years compared with 25%
in the industrialized countries.23 Death from
acute myocardial infarction in Brazilian men between the ages of 35 to
44 years is stated to be three times higher than in the United States
or Canada.23 In Africa, CHD is very uncommon,
whereas hypertension and stroke are frequent. However, urban dwellers
are rapidly experiencing a transition in their coronary risk
profile, and there are apprehensions that they may experience a rise in
CHD rates in the future, akin to that of
African-Americans.24 However, the pace and
direction of economic development in Africa will be the major
determinants of its epidemiological transition.
Health Care and Economic Consequences
Top
Introduction
Burden of CVD in...
Early Age of CVD...
Epidemiological Transition
Lifestyle Changes
Nutrition Transition
Potential Effect of Impaired...
Tobacco Trends
Projected Rise in CVD...
Varied Profile Between...
Health Care and Economic...
CVD Control Programs: Need...
Strengthening the Estimation of...
CVD Risk Factor Studies
Research Priorities
Dynamics of Prevention in...
References
The medical and socioeconomic consequences of the projected
substantial increase in the burden of CVD will be disastrous for the
developing countries. Health care facilities required for providing
appropriate clinical evaluation of and optimal management for the many
millions of CVD patients would be far beyond the scope of most
developing countries. Death or disability in the productive years
of life will severely strain human as well as financial resources
available to individuals, families, and the society as a whole.
Expensive interventions and costly drugs may not be available,
accessible, or affordable, except for an elite minority.
State-subsidized health care is the norm in most developing countries,
but nations that must invest their scarce resources in programs of
industrial growth and sustainable development may ill afford the
escalated health care expenditure imposed by the technology intensive
management of manifest CVD. Even at present, the high costs of CVD
management utilize a disproportionately large segment of societal
resources expended on health care in the developing countries,
diverting them from the continued efforts to control infectious and
nutritional disorders. Most developing countries will experience the
double burden of pretransitional and post-transitional diseases for
some time to come, despite the likely decline in the former, resulting
in inadequate attention to both categories of disease.
CVD Control Programs: Need for National and Global Efforts
Top
Introduction
Burden of CVD in...
Early Age of CVD...
Epidemiological Transition
Lifestyle Changes
Nutrition Transition
Potential Effect of Impaired...
Tobacco Trends
Projected Rise in CVD...
Varied Profile Between...
Health Care and Economic...
CVD Control Programs: Need...
Strengthening the Estimation of...
CVD Risk Factor Studies
Research Priorities
Dynamics of Prevention in...
References
The need to contain the epidemic as well as combat its impact and
minimize the CVD toll in terms of mortality and morbidity in the
developing countries is, therefore, obvious and urgent. Although
feasible, national strategies to meet this objective must be developed
and effectively implemented by individual countries, new regional and
global initiatives by international agencies concerned with health care
program facilitation, policy development, and research funding are also
required to strengthen and speed up these national efforts.
Strengthening the Estimation of Mortality and Morbidity
Top
Introduction
Burden of CVD in...
Early Age of CVD...
Epidemiological Transition
Lifestyle Changes
Nutrition Transition
Potential Effect of Impaired...
Tobacco Trends
Projected Rise in CVD...
Varied Profile Between...
Health Care and Economic...
CVD Control Programs: Need...
Strengthening the Estimation of...
CVD Risk Factor Studies
Research Priorities
Dynamics of Prevention in...
References
A paucity of cause-specific mortality data in the developing
countries is a major impediment to the estimation of the absolute and
relative death toll of CVD or in evaluating the time trends in
mortality. An effective program for improving the extent as well as the
quality of death certification is therefore a high priority.
Simultaneously, easy-to-administer verbal autopsy
instruments must be developed and validated for determination of
CVD-related deaths in communities in which death certification is
inadequate. One such instrument, for use by trained lay interviewers,
is being evaluated by the World Health Organization in a multicenter
validation study in several developing countries.
CVD Risk Factor Studies
Top
Introduction
Burden of CVD in...
Early Age of CVD...
Epidemiological Transition
Lifestyle Changes
Nutrition Transition
Potential Effect of Impaired...
Tobacco Trends
Projected Rise in CVD...
Varied Profile Between...
Health Care and Economic...
CVD Control Programs: Need...
Strengthening the Estimation of...
CVD Risk Factor Studies
Research Priorities
Dynamics of Prevention in...
References
With regard to CVD risk factors, the developing countries must
critically appraise the vast body of knowledge that has accrued from
studies in populations from the developed countries and identify the
elements that are generalizable to their populations. This is of
particular interest in view of the observed ethnic diversity in the
profile of CVD and varied risk associations in different populations.
Although conventional CVD risk factors such as smoking, high blood
pressure, and elevated blood cholesterol are likely to be
relevant risk factors for most populations, other risk factors and
different levels of genetic–environmental interaction may be important
in different populations. The 25-year follow-up data of the Seven
Country Study clearly demonstrate the variability in the
cholesterol–CHD heart disease risk relation across
populations.28
Research Priorities
Top
Introduction
Burden of CVD in...
Early Age of CVD...
Epidemiological Transition
Lifestyle Changes
Nutrition Transition
Potential Effect of Impaired...
Tobacco Trends
Projected Rise in CVD...
Varied Profile Between...
Health Care and Economic...
CVD Control Programs: Need...
Strengthening the Estimation of...
CVD Risk Factor Studies
Research Priorities
Dynamics of Prevention in...
References
Public health action for CVD control in the developing countries
is therefore linked to a policy-relevant research agenda. However, the
classic sequence of long-term cohort studies followed by intervention
trials to initially identify and later modify risk factors will be time
consuming and is likely to be impeded by financial constraints. Public
health action cannot afford to wait that long to initiate
interventions. The appropriate strategy would be to (1) commence
control strategies, based on what we can readily extrapolate from the
knowledge available from other populations (eg, tobacco control); (2)
evaluate known and putative risk factors through cross-sectional
studies of populations (ecological comparisons) and case-control
studies, preferably using incident cases of CVD; and (3) follow-up the
cross-sectional survey populations prospectively to obtain incidence
data on CVD-related morbidity and mortality as well as to assess the
independent and interactive risks associated with known and emerging
risk factors.
Dynamics of Prevention in Developing Countries
Top
Introduction
Burden of CVD in...
Early Age of CVD...
Epidemiological Transition
Lifestyle Changes
Nutrition Transition
Potential Effect of Impaired...
Tobacco Trends
Projected Rise in CVD...
Varied Profile Between...
Health Care and Economic...
CVD Control Programs: Need...
Strengthening the Estimation of...
CVD Risk Factor Studies
Research Priorities
Dynamics of Prevention in...
References
The dynamics of the prevention effort also are likely to differ
from those witnessed in the developed countries. Public health activism
for CVD prevention commenced in the latter when the epidemic of CVD was
close to its peak and the community had become aware and alarmed of its
impact. At a high level of economic development, counseling for
lifestyle modification to reduce the risk of disease is more readily
accepted. Advocacy of behavior modification for health promotion,
therefore, had a relatively receptive climate. In contrast, the
developing countries are grappling with the "double burden" of
pretransitional and posttransitional disease, and community awareness
of the dangers of CVD is not high. The transition toward becoming
industrial market economies is unleashing consumer aspirations that
impatiently seek an affluent and indulgent lifestyle. Messages of
moderation may not be welcome during such periods of change. The task
of CVD control in the developing countries may therefore be more
complex than that in the developed countries.
References
Top
Introduction
Burden of CVD in...
Early Age of CVD...
Epidemiological Transition
Lifestyle Changes
Nutrition Transition
Potential Effect of Impaired...
Tobacco Trends
Projected Rise in CVD...
Varied Profile Between...
Health Care and Economic...
CVD Control Programs: Need...
Strengthening the Estimation of...
CVD Risk Factor Studies
Research Priorities
Dynamics of Prevention in...
References
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