Author + information
- ↵⁎Reprint requests and correspondence:
Dr. Gilles Paradis, Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Purvis Hall, 1020 Pine Avenue West, Room 47, Montreal, Quebec H3A 1A2, Canada
In 2009, the world mobilized against the threat of pandemic influenza, which infected close to half a million individuals and killed approximately 15,000 others; however, the world cannot get its act together to tackle chronic diseases that affect hundreds of millions of people worldwide and which, in 2008 alone, killed more than 30 million individuals (1). Chronic diseases, including cardiovascular diseases (CVD), cancer, diabetes, and chronic respiratory diseases, account for close to one-half of the world's global burden of disease. It is expected that by 2030, 7 of 10 deaths worldwide will be due to chronic diseases, and CVD will account for the largest share of these deaths. Currently, myocardial infarction and strokes account for approximately 12 million deaths worldwide each year. Although chronic disease mortality has been decreasing in most high-income countries of the world for many decades, the reverse is true in low- and middle-income countries (LMIC), which experience annually 9 million deaths owing to these diseases among people younger than age 60 years.
Just 23 countries, including 10 from Asia and Southeast Asia, account for 80% of the chronic disease burden and for more than 70% of all noncommunicable disease deaths among individuals younger than age 70 years in LMIC (1). India is one of these 23 countries, and its more than 1 billion people are experiencing CVD morbidity and mortality at an accelerated rate and at younger ages than in Western countries (2). The country's economic growth, one of the highest in the world, is raising the standard of living of millions of citizens who are joining the expanding ranks of a new middle class. Several other Asian countries, most notably China and Indonesia, are following similar paths and pursuing steep global domestic product growth as a means to lift tens of millions of citizens out of poverty, promote local development, and improve quality of life. The rapid economic growth being experienced by several LMIC leads to social and economic strains, including increases in income disparities, migration from rural to urban centers, insufficient infrastructures (e.g., transport, housing, sanitation), and social and familial disruptions. If general improvements in sanitation, vaccination, and control of communicable diseases raise life expectancy, they also increase the number of individuals at risk for developing chronic diseases. In addition, the rapid pace of urbanization results in major changes in lifestyles, including a reduction in physical activity and energy expenditure, an increase in the consumption of a pro-atherogenic diet, and increased tobacco use. The INTERHEART and INTERSTROKE studies showed that, in all regions of the world, both ischemic heart disease and stroke share many of the same risk factors, including smoking, obesity, hypertension, dyslipidemia, diabetes, low consumption of fruits and vegetables, and physical inactivity (3,4).
Rapid development and the resulting changes in the social fabric and physical environment are driving the CVD and other chronic diseases epidemic in LMIC. However, the steep increase in prevalence of these diseases and the young age at which they occur may ultimately slow economic growth because premature deaths and disability lead to declines in the active work force and reduction in productivity. In addition, increased healthcare costs will worsen poverty because families have to pay for more long-term healthcare services, pharmacologic treatments, and rehabilitation, and these costs will add severe strains to limited resources devoted to national healthcare expenditures. It is a sad paradox that more than 50 years of progress in the fight against CVD in most of the Western world is being superseded by the rapidly rising death toll of CVD and other chronic diseases in many LMIC.
The capacity of LMIC to respond adequately to the challenge of chronic diseases is affected by limited financial, human, and infrastructure resources. Many LMIC have few high-quality population level data, limited research infrastructures, incomplete registration of births and deaths, insufficient surveillance systems for diseases of public health importance, and few resources for population-wide health and social surveys. This is why the report by Huffman et al. (5) in this issue of the Journal on the incidence of CVD risk factors from the Indian Birth Cohort is timely and sheds new light on the dynamics of chronic diseases in LMIC. The investigators reported that among 1,100 young adult participants (mean age at baseline 29 years) followed for an average of 7 years, the average annual incidence of obesity was 2.0% in men and 2.2% in women. Average hypertension incidence was 4.2% and 1.8% per year and the incidence of diabetes was 1.0% and 0.5% per year in men and women, respectively. By the end of follow-up, the mean body mass index was 27 kg/m2 in both sexes, and the prevalence of central obesity as defined by the International Diabetes Federation for South Asian populations (a waist circumference of ≥90 cm for men or ≥80 cm in women) was 71% and 70% for men and women, respectively. The prevalence of hypertension tripled in men and women (reaching 34% and 15%, respectively), whereas the prevalence of diabetes doubled, reaching 12% in men and 7% in women at a mean age of only 36 years.
There are an estimated 32 million people in India living with ischemic heart disease (6). The high incidence of CVD risk factors reported by Huffman et al. (5) suggest that these numbers are likely to increase substantially over the next several decades. For instance, the prevalence of diabetes, already the highest in the world (7), is expected to reach more than 80 million within the next 20 years. The seriousness of the consequences of these increasing risk factors should not be underestimated. The looming disease burden for India and for many other LMIC could overwhelm healthcare systems, which are struggling with the still prevalent communicable diseases. The impact on local families, worker productivity, international competitiveness in the global economy, and continued growth could be catastrophic and lead to serious social upheavals. The size of the epidemic requires urgent public health, policy, and healthcare responses.
How best to intervene though? Health education alone will have little impact on the epidemic because smoking, sedentariness, and poor diet do not arise in a vacuum but are determined to a great extent by social forces that act at the local, national, and international levels and that are strongly linked to social and economic development, urbanization, education, and income (8). Primordial prevention is likely the ideal option in the long term. It aims to prevent the occurrence of the risk factors themselves (9) by optimizing lifestyles that are associated with low blood pressure and cholesterol, ideal body weight, and nonsmoking. Such strategy requires tackling the roots of CVD risk factors by health promotion, healthy public policies, and improved physical environments conducive to healthy lifestyles throughout the whole life course, from conception to older age. The millions of individuals with risk factors and disease require adaptation of healthcare delivery systems, strengthening of primary care, training and deployment of local health practitioners, development of referral and information systems, production of practice guidelines adapted to the realities of LMIC, development of simple diagnostic technologic tools, and implementation of low-cost pharmacologic and nonpharmacologic treatments and evaluation and monitoring systems.
The LMIC need integrated approaches to tackle the common risk factors for chronic diseases. Realizing this necessary confluence of interest, the World Heart Federation, International Diabetes Federation, International Union Against Tuberculosis and Lung Disease, and Union for International Cancer Control recently created the Non-Communicable Disease Alliance to drive a global civil/society movement to address these diseases (10). The Alliance will need to mobilize experts from around the world to support the development, implementation, and evaluation of intervention efforts ranging from public health and healthy public policy to treatment of patients with chronic diseases. The American College of Cardiology, American Heart Association, and their sister organizations in the United States, Canada, and other high-income countries, as well as their respective members, need to draw upon their unique expertise and resources to assist in the global fight against CVD and chronic diseases worldwide.
Innovations have recently been proposed including strategies for dietary sodium reduction and tobacco control, which could prevent more than 1 million deaths per year in LMIC at a cost of approximately US$0.50 per person per year (11), and the use of aspirin and low-cost, off-patent drugs for hypertension and hypercholesterolemia among patients at high absolute risk of CVD, which could lead to 2 million fewer deaths per year at a cost of approximately US$1.00 per person per year (12). Use of safe and inexpensive pharmacologic therapies in fixed-dose combination, such as the polypill, is another promising avenue for the prevention of CVD (13). More recent reports have proposed new affordable public health and healthcare recommendations with a high potential for impact (14–16).
The task is daunting, but we have a moral obligation to support the global fight against CVD and chronic diseases, which are the pandemic of the twenty-first century.
The authors have reported that they have no relationships to disclose.
↵⁎ Editorials published in the Journal of the American College of Cardiology reflect the views of the authors and do not necessarily represent the views of JACC or the American College of Cardiology.
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