Heart disease is considered a lifestyle ailment usually caused by a combination of factors like lack of exercise, eating unhealthy food, and smoking. It's often used interchangeably with cardiovascular disease (CVD), although CVD technically includes conditions of both the heart and blood vessels.¹ It's also often referred to as "Western diseases" or "diseases of affluence" as it's reasoned that its predisposing lifestyle habits could only be afforded by people from wealthy, industrialized nations.²
Here's how the theory goes. Ever since the industrial and technological revolution, the developed world has seen drastic changes in the way we live, work, and play. People don't need to walk as much anymore for daily needs and desk-bound jobs add to the overall increase in sedentary behaviour. Diets have also evolved. And with the proliferation of fast food, we've gravitated towards consuming high-cholesterol, nutrient-poor foods more regularly.
The combination of these factors leads to a cascade of health complications like blocked arteries, high blood pressure, strokes, heart attacks, and more.
On the other hand, people from developing nations were more likely to be engaged in manual labour without access to cheeseburgers and fries.
For a long time, it was assumed that, as societies transitioned through phases of economic and technological advancement, so too would the characteristics of the health issues plaguing their population.
The main concerns of the developing world were infectious disease and malnutrition. While the rich nations had to battle heart disease, diabetes, and obesity.³ ⁴
However, data over the past few decades is showing that heart disease may not actually be a “rich man’s disease” after all.
Since the 1970s, rich countries have seen a steady decline of CVD deaths between 40-80% (even though it still remains a major cause of death in the developed world).⁵ The same can’t be said for developing nations where the trend seems to be moving in the opposite direction.
In 2019, 17.9 million people around the world died from CVD. And over three-quarters of these deaths occurred in low- and middle-income countries (LMICs) — more than 13 million people.⁶
To put this into perspective, 680,000 people died from HIV and 1.5 million died from tuberculosis in 2020.⁷ ⁸
The idea that developing nations only have to worry about infectious diseases is no longer true. More than 40% of deaths in LMICs are attributed to CVD, but this is less than 30% for high-income nations.⁹
Researchers have also found that the nations with the highest number of heart disease deaths were China, India, Russia, US, and Indonesia respectively. While France, Peru, and Japan had one of the lowest rates.¹⁰ ¹¹
CVD also seems to affect a lot more younger people in LMICs. For example, half of cardiovascular-related deaths in Sub-Saharan Africa happen within the 30-69 year old demographic — about 10 years earlier than what we see in high-income countries. Other researchers have also noted that the average age of acute myocardial infarction incidence in South Asian patients is 52 years. Significantly younger than the European and North American average which is between 60-65 years.¹² ¹³
Even within developing nations themselves where there's significant wealth disparity, the poor are also at greater risk of adverse CVD outcomes compared to the rich. A 2020 report showed that the mortality rate for people in rural China has been consistently higher than that in urban areas from 2006 to 2016. And since 2016, the mortality rate for acute myocardial infarctions (heart attack) in rural areas has far exceeded the rate in urban areas (as of 2016, it's 74.72/100,000 and 58.69/100,000 respectively).¹⁴ ¹⁵
The indirect economic impact that CVD can have on developing regions is equally devastating. It was estimated that LMICs lost $3.7 trillion between 2011 and 2015 — about 2% of Gross Domestic Product (GDP) across all those nations combined. It's estimated that India will lose $2.4 trillion (and for China $8.8 trillion), over the period of 2012–2030. The relative cost of treating CVD is also high. Researchers estimate that the total cost of treating a coronary heart disease patient in LMICs can be almost 27.83 times greater than the total health expenditure per capita — with the median ratio being 10.02.¹³
A big part of why we're seeing this rise in CVD amongst LMICs is because of advances in healthcare and the increase in life expectancy. As people start living past 50 years of age, mortality rates from non-communicable diseases start to exceed deaths from infections and malnutrition.¹⁶ ³
But similar to what we see in developed nations, lifestyle risk factors are key contributors to the rise of CVD in LMICs.
The impact of what we eat mustn't be underestimated as more than two-thirds of CVD-related deaths are due to dietary choices.¹⁷ Similar to what has happened in the Western world, developing nations are also seeing an increase in unhealthy diets that are high in fat, salt, and sugar. However, the changes that took place in the West over 100-200 years are happening within a couple of decades with the current LMICs.¹⁸
Diets high in saturated fat are a particular risk factor in North African, Middle Eastern, and South-East Asian regions. And the transition usually starts with an increased intake of partially hydrogenated cooking oils before moving on to animal fats like meat or milk.¹⁹ ¹⁸
What's causing the shift in what people in LMICs are consuming? The paradoxical thing about nations emerging from low- to middle-income status is that while healthy food starts becoming more available, so does unhealthy food. But, the unhealthy choices are usually cheaper, more convenient, fill you up longer, and are less perishable. In some of these nations, nutrient-dense foods (like eggs or milk) can cost up to ten times more than staples. Potato chips have also become very cheap relative to healthier foods in countries like China, India, and East Asia.²⁰ ²¹ ²²
Particular segments within these countries also show an extra vulnerability to CVD-predisposing diets. Some studies have shown that individuals who move from rural to urban areas are at particular risk of shifting to highly processed, "westernised" diets. In our highly globalized world, transnational fast food companies are clamouring to get a piece of the emerging markets pie as they reach saturation point in developed nations. And they're pulling out all the tricks from the marketing handbook to reach profit goals.
In China, fast food ads are filled with playfulness and sentimentality as people indulge in high-fat, nutrient-lacking meals. While a study found that in South Africa, more than half of the advertisements aired during child TV programs were for junk food.²³ ²⁴
And while the reasons are unclear, research has also shown that those that people who have lived in extreme poverty for the first 2 years of their life but moved on to have some disposable income are more likely to gain weight rapidly as they get older. As a result, they're also more likely to develop nutrition-related chronic diseases.²⁴
Decreasing physical activity is also plaguing the developing world, even though rates are still better compared to developed nations. And of course, this varies widely between regions. For example, 17% of the population in Southeast Asia is considered inactive. While for the Americas and East Mediterranean, it's about 43%.²⁵ However, with increasing urbanization, LMICs are already seeing a trend towards more sedentary work and automated transportation.²⁶ One study has even shown that the increasing use of household devices (e.g. television, car, computer) is more strongly linked to obesity in LMICs compared to high-income nations.
Smoking is another major CVD risk factor as it can cause a buildup of plaque in the blood vessels.²⁷ The World Health Organization (WHO) estimates that of the 1.1 billion people that smoke worldwide, 80% can be found in LMICs countries. Rates of adolescent smoking are also much higher in such regions compared to developed nations.²⁸
The rise of smoking in LMICs can largely be attributed to big transnational tobacco companies taking advantage of the lax tobacco laws in these areas. Although they claim that their marketing campaigns are purely targeted at adult smokers, their effect on youths is still undeniable. It's estimated that people in low-income populations are exposed to tobacco advertisements 81 times more often than those in high-income countries.²⁹
They've also been known to make "philanthropic" gestures to governments in exchange for continued ease of conducting business in their country. For example, two big tobacco companies had agreed with the Mexican Ministry of Health to fund medical services in exchange for removing health warnings on cigarette packaging and increased tax.²⁸
For many cities in developing nations, air pollution can be so bad that it's almost the same as smoking. In India's New Delhi, some estimate that it's equivalent to 33 cigarettes a day.³⁰ One study has even demonstrated that long-term exposure to pollutants (like particulate matter and nitrogen oxides) at levels close to the limit set by the National Ambient Air Quality Standards (NAAQS) lead to early ageing of blood vessels and calcium build-up in coronary arteries.³¹
Another major issue facing LMICs is inadequate medical support in addressing CVD. Even for those with the advantage of diagnosis, treatment is commonly unavailable or inconsistent. In high-income countries, 80% of those with CVD receive cholesterol-lowering medication, whereas this is only 8% for those in India. We see similar trends with hypertension where only 32% of those in developing countries receive treatment for it — compared with 47% in the developed world.¹⁹
Despite the shortage of healthcare resources in the developing world, there is a silver lining to the solution — heart disease is treatable and preventable if addressed early. Making lifestyle changes like consuming less saturated fat, increasing fruit and vegetable intake, exercising more, and quitting smoking are effective ways of reducing CVD risk.³²
These can be implemented through public health education programs that inform the population about the impact of lifestyle on CVD risk.
At a national level, governments can be more restrictive about the tobacco trade through taxation and placing advertising limits.
The needs of high-risk individuals can also be addressed early through community clinics. And access to cholesterol-lowering, anti-hypertensive medications will form a big part of early intervention. As with many other diseases, funding and availability remain an issue with this. At the moment, only 54% of LMICs have access to the most common medications to treat CVD. Experts have suggested that governments, non-government organizations, and donors will need to work together to increase the resources being dedicated to CVD.³³ ³⁴
Individual countries will also need to carefully assess how they tailor CVD interventions to the specific needs of their country. For example, obesity and hypertension are more common in South Africa, while China sees more elevated levels of cholesterol.
This would determine if more effort needs to be concentrated on lifestyle changes or medication administration.³³
It's clear that CVDs are going to remain an issue for both the developing and developed world in years to come. As LMICs transition through stages of development, it's likely that governments will need to adjust resource allocation to address non-communicable diseases as infectious disease rates drop.³⁵ This all starts with changing the prevailing perception that CVD is a disease that only strikes the affluent.
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The author, Dawn Teh, is a health writer and former psychologist who enjoys exploring topics about the mind, body, and what helps humans thrive.
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