Reducing cardiovascular risk in low- to middle-income countries

More than 500 health experts from all over the world gathered in Marrakech, this exotic and enticing city, for the first ever conference on health risk or harm reduction for the African region. The conference was organized by their ministry of health with the full support of Morocco’s King Mohammed VI.

The experts spoke on various aspects of reducing the risk of developing serious health problems in the African region.

I and several other cardiologists were invited to discuss risk-reduction strategies for cardiovascular disease (CVD), the leading cause of deaths in Northern Africa, including Morocco. This part of Africa is relatively more affluent compared to their southern counterparts like Namibia, Swaziland and Botswana.

In the southern countries or Sub-Saharan Africa, infections, particularly HIV-AIDS, are still the leading causes of death.

Developing countries

Although the recommendations were intended for Africa, they appear to be applicable to other developing countries like the Philippines.

In general, when we speak of risk or harm reduction, we don’t really aim to eliminate the risk 100 percent, but to reduce it significantly as much as possible.

Since practically all the risk factors like hypertension, diabetes, obesity and smoking, are caused by years, perhaps decades of unhealthy lifestyle practices which have become deeply set habits or vices already—it’s difficult and most challenging to lick them by simply telling the public to stop the unhealthy diet and practices, say to avoid salty foods or to stop smoking. Our best bet to lick these unhealthy lifestyle practices is to offer pragmatic alternatives to the products that are causing these risk factors.

Common examples of these pragmatic alternatives are diet cola instead of sweetened cola drinks to prevent diabetes and obesity, salt substitutes to prevent hypertension, meat substitutes to prevent cholesterol and uric acid problems and alternative tobacco products to wean patients off conventional cigarette smoking.

In much the same vein, when we aim to reduce the risk caused by high blood pressure, which remains a top world killer like smoking, our goal is to reduce the risk of complications—such that if we’re able to reduce the systolic blood pressure by 12-13 mmHg, we hope to reduce stroke by 37 percent, coronary artery disease or blocking of the heart arteries by 21 percent and heart or artery related deaths by 25 percent.

Leading silent killer

If we’re talking of a populous country like the Philippines and many African countries, this can translate to millions being saved annually from complications of high blood pressure.

Hypertension remains a leading silent killer in Africa. As of 2020, the control rate is only 13.7 percent. Although this is already much better compared to 10 years ago when the control rate was less than 10 percent, the vast majority of the African hypertensive population is still uncontrolled, and many African hypertensives may be considered walking time bombs, and anytime they can just explode with complications like stroke and heart attack. Many hypertensive Filipinos face the same situation.

On top of socioeconomic determinants or risk factors, like poverty and lack of education, prevalent cardiovascular risk factors are hypertension, smoking, diabetes, obesity and dyslipidemia. They’re pretty much the same as in the Philippines.

In Africa and in our country, the risk factors cut across the economic strata of the population—from low income to high income sectors. Diabetes and obesity are more prevalent, though, in the high income sectors. That’s just logical, since they have more money to buy the sinful dietary pleasures like calorie-dense and sweetened products.

Detecting or diagnosing these risk factors can be a challenge, and for diabetes, more than a third of Africans who have it are undiagnosed. Here, we have the same situation for diabetes and hypertension. We have to put more resources into screening programs to detect those with asymptomatic risk factors and early asymptomatic cardiovascular disease.

There can also be differences in the type of CVD depending on the economic status of the country. In North Africa, there’s increasing incidence of hypertensive CVD, congestive heart failure and the previously scarce coronary artery disease, peripheral arterial disease and atrial fibrillation, which are also causative factors for stroke.

It cannot be overemphasized that early diagnosis and treatment are of paramount importance. This can be attained by massive public education to increase awareness of CVD and its risk factors. And as mentioned earlier, we need regular screening programs to diagnose those with asymptomatic risk factor and CVD.

Unhealthy lifestyle practices

Since all the risk factors are due to unhealthy lifestyle practices, which unfortunately may be considered the norm in society, health education to inculcate in the population the value of health-promotion and health-seeking behaviors must be started early on. If this could be included in the elementary curriculum, that would go a long way in making sure the youth adopt healthy lifestyle practice when they grow up to be adults.

The value of family modelling must also be emphasized. What the children see their parents and elders do at home or around them, they’ll likely follow and adopt when they grow up.

Tweaking of risk reduction strategies may be needed, depending on the varying prevalence of risk factors and type of CVD present in a country. However, all risk-reduction programs must cover both population-wide and individual-focused strategies.

There must be an intentional and willful effort to shift from a curative or treatment-focused orientation to a preventive or health-promotion orientation of strategies and health policies. The tried-and-tested bestbuy preventive strategies are salt reduction, sugar reduction, increase in physical activity and tobacco control. It looks simple but it requires a strong political will, and it may need to be supported by legislation.

Our life expectancy of 71.4 years and the median age of 25.7 have significantly improved in the last 20 years, but we’re still not on par with the global life expectancy of 73 years, and the median age of 30.3 years. It simply means that more Filipinos are dying prematurely than their foreign counterparts like Japan, which has a life expectancy of 84.6 years. With more resources poured into health promotions, we may perhaps expect to grow as old as the Japanese 20 years from now.

More Filipinos are dying prematurely than their foreign counterparts, but with more resources poured into health promotions, we may expect to grow as old as the Japanese 20 years from now