Monday 1 September 2014

The Global Geography of Heart Disease

Why cardiovascular health is improving in the United States but falling in developing nations

Some good news for heart health this week: A new study published by the journal Circulation reports that America—home of the Big Mac, Dunkin’ Donuts, and all things super-sized—has seen a dramatic reduction in the number of cardiovascular hospitalizations and deaths over the past decade. This is a big deal, since cardiovascular disease is currently the number one cause of death in the United States.

“Nobody thought all the efforts we’re making [against heart disease] could cause so much progress so fast,” said Harlan Krumholz, lead author of the study and professor at the Yale School of Medicine. “This is a kind of triumph of implementation science and systems.”

That triumph was captured in the following numbers, for individuals older than 65: Hospitalization rates among all races and areas dropped 38 percent for heart attack, 30.5 percent for heart failure, 33.6 percent for ischemic stroke, and 83.8 percent for sudden chest pain. Similarly, individuals’ risk of dying within a year of hospitalization fell by an average of about 18 percent across those conditions. To determine this, the researchers looked at data for 34 million Medicare Fee-For-Service patients from 1999 to 2011—“a representative group” for those with heart disease, Krumholz said—controlling for age, race, sex, location, and preexisting conditions like diabetes.

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How can this be? America and much of the world is in the midst of an obesity crisis, or even a “global obesity epidemic,” as the World Health Organization has declared.

“Now there’s still a ways to go,” Krumholz, the study author, admits. “But in the U.S., we’ve seen great advances both on the prevention side and the treatment side, so outcomes have improved.”

These improvements include better screening for heart conditions, quality of care, lifestyle changes, awareness, and use of evidence-based treatments, such as surgery and cholesterol-lowering statins.

In other words, the United States has started to reverse its heart disease epidemic through conscious efforts to administer effective treatments and to combat preventable risk factors: tobacco use, lack of physical activity, abuse of alcohol, and unhealthy diets. Despite American gains, however, cardiovascular trends have not been as rosy in the developing world. In fact, Brazil, Russia, India, and China have experienced some of the globe’s fastest-growing rates of non-communicable diseases (NCDs), which kill more than 36 million people around the world each year. Heart disease accounts for roughly half of these deaths, at 17.3 million people annually, 9 million of whom die before the age of 60.

The tallies are telling. In China alone, one in five adults (totaling more than 200 million people) has cardiovascular disease, and annual cardiovascular events are predicted to jump 50 percent by 2030. Largely due to the proliferation of fast-food chains and poorer diets in China, these statistics could translate to an additional 21.3 million cardiovascular events and 7.7 million cardiovascular deaths in that country each year. Meanwhile, in Brazil, heart disease comprises more than 30 percent of annual mortality rates, followed by cancer (17 percent), and other NCDs (15 percent).

India has similar problems. In 2012, the Indian Heart Watch released an illustrative study at the World Congress of Cardiology, which found that cardiovascular disease is increasing there because of key lifestyle risk factors: 79 percent of men and 83 percent of women were found to be physically inactive, while around 50 percent of both men and women had high-fat diets. In addition, nearly 60 percent of Indian men and women showed low intake of fruit and vegetables, and 12 percent of men smoked.

"Nobody thought all the efforts we’re making against heart disease could cause so much progress so fast."
These countries’ economies may be booming, but their cardiovascular health standards are falling behind. That’s because sedentary lifestyles, cheaper costs for unhealthy food, urbanization, and cultural phenomena such as binge-watching shows on Netflix instead of exercising have put their populations at higher risks for heart disease. The same factors have long contributed to cardiovascular disease in the U.S., except now it seems we’ve found ways to fight and prevent them.

The consequences are both existential and financial. The World Economic Forum and the Harvard School of Public Health estimated in a 2011 report that the global cost of cardiovascular disease will rise 22 percent in the next 20 years and surpass $1 trillion total. This figure represents direct healthcare costs as well as productivity lost from disability or premature death, or time lost from work because of illness.

As economies have grown in these foreign countries, so has cardiovascular disease. Yet the U.S.—another country with a lot of money and a lot of heart problems—appears to have found a potential solution in preventative and evidence-based treatments.

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