Thus, CVD is a global health problem that demands a global approach to prevention. Its impact is greatest in developing countries because of scarcity of both financial resources and professionals with expertise in prevention and management of CVD. A global action for prevention needs to take into consideration stages of development in countries and regions-the epidemiologic transition-to be most effective.
Epidemiologic transition refers to the shift that occurs in developing countries as mortality rates from infectious diseases and nutritional deficiencies decrease and mortality from noncommunicable diseases increases. This shift or transition in disease and mortality rates reflects economic development, urbanization, industrialization, and changes in social organization within countries and regions with increased exposure to risk factors driven by changes in diet, physical activity, and environment.2,7,8 The overall epidemiologic transition has been triggered by the "globalization" of dietary habits, characterized by increased consumption of fats and sugars,9 and urbanization.9-12 Statistical projections suggest that by 2025, 43.5% of the population in the developing world will be living in urban centers, compared with 21.9% in 1994.13 For example, in India, the proportion of the population living in urban centers in 1981 was 23.3%, and this will increase to 42.8% in 2021.14
Yusuf et al15 describe 5 stages of epidemiologic transition. Much of sub-Saharan Africa and rural regions of India and South America are in the first stage, in which circulatory diseases are primarily due to rheumatic heart disease and nutritional cardiomyopathies. Stage 2 sees an increase in hypertensive heart disease and hemorrhagic stroke (eg, China), and stage 3 is characterized by early onset of atherosclerotic CVD, obesity, and diabetes (urban India, former socialist economies, aboriginal communities), added to the continuing burden of infectious diseases. Developed countries are in stage 4, where noncommunicable diseases occur primarily at older ages. Stage 5 is a regressive stage caused by social upheaval or war, with resurgence in infectious diseases, and high mortality from both CVD and non-CVD causes.15 The high burden of CVD in developing countries is due to not only to the high levels of risk factors, but also to the relatively early age at onset among largely young and middle-aged populations.15 In the seminal INTERHEART Study, the average age of patients with acute myocardial infarction (AMI) in South Asians was 52 years, as compared with 60 to 65 years in European and North American cohorts.8
Risk Factor Prevalence and Burden in Developed and Developing Countries
Cardiovascular disease is usually associated with 1 or more characteristics, known as risk factors that describe "any attribute, characteristic or exposure of an individual that increases the likelihood of developing a disease or injury."16 In general, risk factors for CVD include demographic characteristics, family history of CVD, cigarette smoking, physical inactivity, abnormal serum lipids and lipoproteins, body weight (obesity), hypertension, and diabetes mellitus.17 Newly emerging CVD risk factors, such as low birth weight, folate deficiency, and infections, are also more frequent among the poorest segments of the population in low- and middle-income countries.2
Knowledge of risk factors that lead to the development of CVD has been derived mainly from developed countries, beginning with epidemiologic studies such as Framingham. These results have generally proven to be consistent throughout the world. INTERHEART was a case-control study of 27 098 participants in 52 countries in which 9 modifiable risk factors were found to account for 90% of AMI in men and women across all ages and major ethnic groups.8 These risk factors were abnormal lipids, hypertension, smoking, diabetes, abdominal obesity, physical inactivity, unhealthy diet, no alcohol consumption, and psychosocial stress. In addition, in developed and developing countries, low income and poor education have been consistently associated with increased CVD mortality and higher rates of CVD risk factors such as smoking, obesity, and hypertension.18 The INTERHEART study also found that poor education was associated with increased risk for AMI, largely through its association with modifiable risk factors, especially in those countries designated as high income.19
Although CVD is the leading cause of death for women as well as men, women are generally a decade older than men when CVD develops; in the INTERHEART study, two-thirds of women with AMI were 60 years or older, compared with 40% of men.20 In that analysis, 80% of the earlier age at onset of the first AMI in men was due to a higher distribution of significant risk factors in men at younger ages.20 Thus, the finding of an increase in the proportion of women smokers younger than 50 years in Europe from 1995 to 1996, to 2006 to 2007, as well as increases in obesity and diabetes for both sexes, is ominous.21 Because risk from smoking is multiplicative when it occurs in the presence of other risk factors, this becomes even more worrisome. In other parts of the world, such as the Middle East, rates of obesity and hypertension are much higher in women than in men, although smoking rates remain lower.22
Although the same risk factors are important throughout the world, their specific prevalence varies. For example, the prevalence of hypertension in developing countries has been estimated to be between 1% and 30%, varying largely between continents.23 Developing countries have the largest proportion of smokers in the world, and rates of smoking in these countries are on the rise (Table 3).6 In contrast, the rates of smoking in developed countries have been declining dramatically.24 The decline can be attributed to aggressive public antismoking policies: for example, increasing the cost of cigarettes through taxation, laws restricting smoking in public places, and laws that restrict advertising and sale of cigarettes to minors.
In addition to cigarette smoking, a form of smoking that is a popular and common social practice in many regions in the world is the waterpipe (also known as argeela, arghileh, nargile, narghile, nargileh, hubbly-bubbly, shisha, sheesha, goza). This social activity usually involves 2 or more people who may share in the smoking of the same waterpipe.25 Although there is a common misconception that smoking waterpipe is not as harmful as smoking cigarettes, in fact, 1 episode of smoking waterpipe produces as much tar as smoking 20 cigarettes. One study established that waterpipe smoke contains an abundance of chemicals known to be risk factors for cancer and CVD; for example, the ratio of carbon monoxide to nicotine was 50:1, as compared with 16:1 for cigarettes.26 An analysis of studies done in Arab countries reveals that waterpipe smoking is highly prevalent,27,28 ranging from 31% to 57% of people, and that more women than men smoke a waterpipe.29
The proportion of people who are physically inactive is on the rise in many regions of the world. According to the INTERHEART study, the least active regions were in the Middle East, Africa, and China.8 A change in diet toward highly refined foods, meats, and dairy products with high levels of saturated fat, coupled with a sharp decrease in energy expenditure, has been occurring globally since the mid-20th century.30 This has led to the widespread increase in obesity (Table 4).6 In affluent societies, excess weight is more common among disadvantaged groups, but the inverse occurs in low income countries.30 Obesity in children is also rising, with serious consequences for incidence of diabetes and CVD. An increased risk of IHD in adulthood is associated with higher body mass index in childhood and adolescence.31,32
Although high intakes of fat, salt, and refined sugar have not typically been a concern for developing countries, recent shifts to unhealthy fast-food trends in eating practices globally have resulted from socioeconomic changes that make these problems increasingly relevant for countries in transition.23,33,34 In fact, in China, changing to a "Western diet" was linked to the dramatic increase in the IHD mortality rate.35
The trend in developed countries has been for mortality from IHD to decline in the last several decades. Between 1960 and 1990, CVD mortality declined by 34% to 50% in Australia, Canada, France, Japan, and the United States.36-39 Mortality rates from IHD in the United Kingdom have declined steadily since their peak levels in the early 1970s.40 Previous studies in the United Kingdom and United States suggested that modest changes in major population risk factors (notably smoking, lipid levels, and hypertension) have had the greatest effect in decreasing IHD mortality, but increases in obesity, diabetes, and sedentary lifestyles threaten to undermine these trends.40-44 A similar trend toward lower mortality from cerebrovascular disease in both men and women has been found in developed countries such as the United Kingdom, Sweden, Switzerland, Germany, New Zealand, and Australia and in some developing countries (except Russia).
Although we have fewer epidemiologic data from developing countries, the following sections provide some insight into the rise in risk factors due to the epidemiologic transition in specific countries and regions.
India, China, and Japan
In India, it is estimated that hypertension is directly responsible for 57% of all stroke deaths and 24% of all heart disease deaths.14 Although there is a low prevalence of multiple CVD risk factors, such as smoking and dyslipidemias, in urban Asian Indian adolescents, rapid escalation of these risk factors occurs by ages 30 to 39 years.45
Cardiovascular disease deaths are expected to increase by 77% by 2020 in China and by 106% in other Asian countries, compared with 15% for economically developed countries.14 People living in the northern and northwestern areas of China consume significantly more sodium than do people from the south.46 The prevalence of hypertension, elevated mean serum cholesterol, and high body mass index was greater in the north than in the south and in urban compared with rural areas.13 Incidences of overweight and obesity nationwide in China have increased by nearly 39% and 82%, respectively, in the past 10 years.46
In Japan, hypertension is the most important CVD risk factor. Although traditional diets are low in saturated fat, increasing adoption of Western lifestyles has led to rises in diabetes, obesity, and hypercholesterolemia. Smoking rates among men remain high despite some decline.13
In sub-Saharan Africa, hypertension remains the most threatening risk factor, with national prevalence ranging between 15% and 30% in adults.47 Rates of smoking among African men are also high, but the prevalence of most other conventional risk factors is low compared with other regions.13 The per capita burden of CVD in sub-Saharan Africa increased between 1990 and 2000,48 and deaths due to CVD are projected to more than double in sub-Saharan Africa between 1990 and 2020.49
South and Central America
Guyana has the highest CVD mortality rate in South America, followed by Suriname, Brazil, and Paraguay.50 The aging population of Brazil is expected to significantly increase the burden of CVD in the coming decades.51 About 2 million cases of severe CVD were reported in 2004 in Brazil; this accounts for 5.2% of the population older than 35 years.28 Cardiovascular disease mortality rates vary widely across South and Central America, with some of the highest rates found in Caribbean countries such as Grenada and Dominican Republic.50
Implications for Population-Based/Public Health and Individual/High-Risk Approaches to Cardiovascular Disease Prevention
Given that much of the CVD burden worldwide is avoidable, efforts to decrease modifiable risk factors are urgently needed. According to the WHO,2 the key modifiable lifestyle or behavioral risk factors for CVD worldwide are smoking, physical activity, and dietary intake. In fact, a systematic review of the causes of CVD mortality demonstrated that 4 factors improved prognosis, of which 3 were associated with lifestyle: smoking cessation, increased physical activity, and dietary changes.52 Unfortunately, in developing countries, there is a relative lack of prevention and control measures to decrease exposure to these risk factors.39
Two approaches to CVD prevention are a population strategy and an individual/high-risk strategy. The population strategy of preventive health care was proposed by Rose53 in 1992 as a radical strategy to identify and if possible remedy the underlying cause of major health problems. Rose53 argued that people with particular health problems (eg, elevated blood pressure) represent one extreme of the continuous distribution of the factor overall in the population. Shifts in the population distribution reduce the number of persons at risk; even small shifts decrease the number of persons in the most vulnerable tail of the distribution. Furthermore, because most adverse health events will occur in those with only moderate risk, simply because they comprise the largest group, so shifting the distribution to lower risk will have a huge impact.53 Thus, effective prevention requires changes that involve the population as a whole. The population strategy aims to reduce the burden of disease in the whole community while conferring small benefits on each individual.13
For Rose,53 a population strategy was based on sociological, moral, and medical grounds: (1) society is an entity with its own collective characteristics that affect health; (2) people with health problems are not independent of the rest of society and are its collective responsibility; and (3) the underlying causes of poor health are known, and this implies a duty to use that knowledge. Treating only cases and high-risk individuals was seen as a superficial and symptomatic approach.53
The reasons for declines in CVD mortality in developed countries have been evaluated in the WHO Monitoring Trends and Determinants in Cardiovascular Disease Project54 and in other analyses. Contributions to decreased CVD mortality rates occurring in most of the 21 participating countries were greater because of declining event rates (and the factors driving event rates).54 Similarly, mortality models in England and Wales showed that more than half of the decline (58%) in CVD mortality between 1981 and 2000 was attributable to reductions in population risk factors (primarily smoking, cholesterol, and blood pressure), and 42% was due to medical and surgical treatments.41 Changes in risk factors explained almost all the decline in CVD mortality in the 1970s in Finland and 53% of the decline between 1982 and 1997.55 National smoking bans in the early years of the 21st century have led to reductions in acute coronary events.56
A population approach to the primary prevention of obesity throughout the world is thought to be more likely to be beneficial. Tackling obesity requires an understanding of the complex societal factors that contribute to it: access to nutritional food supplies, built environments that promote healthier options, and living/working conditions that produce more equal material and psychosocial resources between and within social groups.30,57 The European Commission has been increasingly focusing on its public health activities, with the aim of increasing cooperation and a more strategic approach to health issues in the European Union. One initiative, modeled on the French campaign EPODE, is to recruit town mayors and citizens to encourage healthy eating among young people.58,59
Criticism of the population approach centers on the lack of consistent success in these interventions. Despite the success of programs such as the North Karelia Project in eastern Finland, and the Stanford 5-Cities Heart Disease Prevention Program, other community-based interventions have not shown a strong effect on risk factors and CVD mortality.60 A recent Cochrane Collaboration systematic review on multiple-risk-factor interventions for primary prevention of CVD found no significant pooled effect on mortality and modest changes in risk factors.60 Population strategies need to recognize the multiple factors that impact population health and bring CVD prevention to the highest policy level.
In contrast, individual/high-risk strategies are dependent on identifying persons who are apparently well but at high multifactorial risk of developing CVD, as well as those with established CVD, to modify and/or manage risk factors and decrease the likelihood of disease development, progression, and events. The multivariable approach to predicting CVD risk in individuals is essential; consensus reached in the 1990s advocated an assessment of multiple factors to determine absolute risk of CVD.61,62 Those who favor this approach note that clinicians' ability to assess total baseline risk has greatly improved with risk algorithms incorporating multiple risk factors. As absolute risk differs among populations, so risk prediction systems derived from one population may not be as accurate for individuals from another population. In Europe, the SCORE risk charts are available for high- and low- risk countries, and the HEARTSCORE project offers assistance to countries in recalibrating risk models and charts using current national data.61 Women are less frequently assessed for risk; therefore, the American Heart Association and the European Society of Cardiology emphasize risk estimation of women with particular attention to smoking, obesity, and use of oral contraceptives.63,64
Thresholds for intervention are lower than in the 1990s. Asymptomatic individuals with multiple risk factors resulting in a 10-year risk of 5% or greater for developing a fatal CVD event, or markedly raised levels of a single risk factor, are considered high risk. Individuals at high risk might be in need of medication or individual lifestyle changes, such as diet interventions and/or changing activity levels. Although individuals who are at high risk for CVD can benefit from lifestyle changes that lower blood pressure, cholesterol, and bodyweight, specific interventions aimed at this group of patients are not widely tested, and long-term hard end points are mostly not evaluated.65 Multifactorial lifestyle interventions are increasingly recognized as important, and individuals at high risk for CVD can make positive changes in biological and lifestyle risk factors for diabetes and CVD. Only limited research is available on the effect of multifactorial intervention on the prevention of CVD.66,67 It is often challenging to motivate patients to change their lifestyle or to take medication if they do not directly perceive themselves to be at risk of CVD and its possible consequences, or if they feel that the burden of treatment outweighs the possible advantages.68
In truth, both population and individual approaches are necessary for decreasing the global burden of CVD. We cannot afford to ignore the societal factors that promote the development of unhealthy behaviors and risk factors for CVD; neither can we turn away from individuals who are at high risk. The European Heart Health Charter was developed by the European Society of Cardiology and the European Heart Network, with the support of the European Commission and WHO Regional Office for Europe, and emphasizes the importance of both population and individual strategies for reducing CVD in Europe. The charter calls on the countries and organizations that are its signatories to promote and support measures for CVD prevention, giving priority to lifestyle interventions.69
The WHO motto "think globally and act locally" can serve the international community well. The WHO proposes developing effective intercountry, interregional, and global networks and partnerships for concerted global action.2 Lessons learned about prevention of CVD from developed countries could prove beneficial in halting the rapid increase in lifestyle-related risk in developing countries.63,70-72 The Catalonia Declaration (1995)70 and The Victoria Declaration (1992)71 promoted the establishment of networks with experts from developed countries to share scientific knowledge and expertise for comprehensive health policies and efficient and cost-effective public health services. The Catalonia and Victoria Declarations also emphasized women's influential role as change agents toward CVD risk factor reduction. Specific interventions that target awareness and long-term motivation need to be developed and tested. Research supports the role of nurses in providing safe and effective primary and secondary prevention, although greater collaboration, innovation, and support for CVD risk reduction are urgently needed.73 Subsequent sections of this article review the evidence and address the important role of nurses in prevention.
Cardiovascular disease has no geographic, socioeconomic, or sex boundaries and is the leading cause of death in developing as well as developed countries. Risk factors that lead to the development of CVD are consistent throughout the world, and many are increasing in prevalence as developing countries transition to more urban, industrialized environments. Population and individual approaches are necessary for decreasing the global burden of CVD: societal factors cannot be ignored as they promote the development of unhealthy behaviors and risk factors for CVD; neither can we turn away from individuals who are at high risk. Cardiovascular disease is a global health problem that demands a global approach to prevention. Governments and Ministries of Health must make the necessary commitment to the education and training of nurses and physicians and capacity building for personnel qualified to support health promotion and risk reduction.
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Keywords:© 2011 Lippincott Williams & Wilkins, Inc.
cardiovascular disease; developing countries; prevention