Tackling the challenge of cardiovascular disease
burden in developing countries
Salim Yusuf, DPhil, FRCPC,
a
Mario Vaz, MD,
b
and Prem Pais, MD
b
Hamilton, Ontario, Canada, and Bangalore,
India
See related article on page 7.
The last century has witnessed the rise and a partial
fall in the rates of cardiovascular disease (CVD) in
most Western countries. The rise in CVD coincided
with increasing industrialization and urbanization,
which were associated with increasing levels of dyslip-
idemia, blood pressure, and diabetes.
1,2
Concurrently,
there has also been an increase in the rates of tobacco
consumption in several countries. After reaching a
peak around the 1960s to 1970s, the CVD rates started
to decline in several Western countries, perhaps due
to aggressive policies to curb tobacco use, increased
awareness by both physicians and lay people that CVD
is preventable, the identification of methods for con-
trolling risk factors, and effective strategies for second-
ary prevention. It has been, therefore, a combination
of obtaining reliable data on incidence and prevalence
of CVD, research that has identified both risk factors
and the demonstrable value of modifying them, and
public health policies and awareness that has stemmed
the tide of CVD in developed countries.
A half century later, it is now recognized that the
epidemic of CVD has shifted to middle-income and
low-income countries (collectively termed developing
countries in this article), so that about 80% of the
global burden of CVD currently occurs in these coun-
tries.
1
It is likely that this epidemic is fuelled by similar
societal and biologic factors globally. With increasing
industrialization and urbanization worldwide, 2 major
lifestyle changes are occurring. First, with increased
automation at work and at home, sedentariness has
increased, leading to marked reductions in energy ex-
penditure. Second, a nutritional transition to increased
energy consumption (especially to foods high in satu-
rated fats and refined carbohydrates) is transforming
food consumption globally. These 2 lifestyle changes,
occurring across the whole spectrum of societies (es-
pecially urban), are probably the root cause of increas-
ing rates of obesity, diabetes, elevated lipids, and ele-
vated blood pressure (BP) levels. Combined with high
rates of tobacco consumption, all the ingredients for a
dramatic increase in CVD are set. So what can be done
about this looming pandemic?
First, there is an urgent need to better document the
current rates (incidence and prevalence) of CVD mor-
tality and morbidity in—at least—the large developing
countries of the world (eg, China, India, Brazil, etc), as
well as in some representative countries in several
other regions of the world (eg, Middle East, Eastern
Europe, and Latin America). In many countries, reliable
mortality statistics, especially by cause of death, are
not available, and in most developing countries, repre-
sentative data on morbidity (eg, non fatal vascular
events) and risk factors are not available. Data on mor-
bidity and risk factors over time from “sentinel sites”
(representing geographically diverse locations, includ-
ing rural and urban populations and different socioeco-
nomic classes) are urgently needed. This will allow
accurate assessment of current disease burdens, as
well as allow reliable projections of the future course
of the CVD epidemic.
Second, while data on the importance of risk factors
for CVD are being generated from developing coun-
tries, it would be reasonable to extrapolate from stud-
ies conducted in Western countries to formulate strate-
gies for prevention. Such strategies, including tobacco
control programs, BP control, lipid lowering, as well as
the promotion of healthy lifestyles (increased con-
sumption of fruits and vegetables, along with regular
physical activity), could be the cornerstone of a global
program for prevention. Such strategies are best ap-
plied taking into account local economic and social
circumstances, with emphasis being placed on risk
factors that are common in particular populations.
Third, societal-level strategies that include health-
oriented agricultural, food, and tobacco policies are
essential (as the roots of CVD are probably embedded
within an unhealthy societal environment). Food poli-
cies that increase the availability of low-cost fresh veg-
etables and fruits would likely increase their use.
While many countries have promulgated some tobacco
control policies, enforcement is lax and there are sev-
eral local barriers to its success that differ from West-
ern countries. For example, the 2 countries with the
largest tobacco production are China and India.
3
In
From the
a
Population Health Research Institute, McMaster University and Hamilton
Health Sciences, Hamilton, Ontario, Canada, and the
b
Population Research Institute,
St. John’s Medical College, Bangalore, India.
Reprint requests: S. Yusuf, Population Health Research Institute, Hamilton General Hos-
pital, 237 Barton St. East, Hamilton, Ontario L8L 2X2.
E-mail: yusufs@mcmaster.ca
Am Heart J 2004;148:1–4.
0002-8703/$ - see front matter
© 2004, Elsevier Inc. All rights reserved.
doi:10.1016/j.ahj.2004.03.045
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