(Circulation. 1996;94:2671-2673.)
© 1996 American Heart Association, Inc.
Articles |
The Modernization of Asia
Implications for Coronary Heart Disease
the Clinical Biochemistry Unit (E.D.J.), The University of Hong Kong; Department of Clinical and Experimental Medicine (A.P.), "Federico II" University of Naples, Italy; Medical Hospital and Research Centre (R.B.S.), Moradabad, India; and University of London (B.L.), UK.
Correspondence to Alfredo Postiglione, MD, Chairman, ISFC Council on Arteriosclerosis, Department of Clinical and Experimental Medicine, "Federico II" University of Naples, via S. Pansini 5, 80131 Naples, Italy.
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Introduction |
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 Top Introduction Regional Differences Relevant to...ConclusionsReferences |
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Some 50% of the world's population resides in Asia, including
1000 million in China, a similar number in the Indian subcontinent, and >200 million in Indonesia. This region is undergoing unprecedented economic growth, rapid technological changes, urbanization, and major changes in lifestyle. The very high CHD death rates in Singapore (the most economically developed country in the region), which are similar to those of the United States and Australia, provide a warning that Asia may expect a surge in CHD.1 2 3 The dramatic rise in CHD experienced in eastern Europe must be prevented in Asia. To achieve acceptable and effective CHD prevention programs requires a thorough knowledge of the region, recognizing in particular the diversity of its countries. These range in size from compact urbanized places (Singapore and Hong Kong) to vast countries such as India and China, each with marked regional differences. The demography is equally varied: in the Philippines, for example, 60% of the population are younger than 19 years, whereas in Japan and Hong Kong, there is an increasing proportion of elderly people, and life expectancies at birth are among the longest in the world, eg, 75.1 years for men and 80.3 years for women in Hong Kong in 1993.4 The degree of economic development varies greatly. It is advanced in Japan, Korea, Taiwan, Hong Kong, and Singapore and is changing rapidly in China, Philippines, Malaysia, Thailand, Indonesia, and India. Nearby Australia and New Zealand, with predominantly Caucasian populations, are increasingly economically interdependent with Asia. They have achieved substantial reductions in CHD death rates from very high rates in the late 1960s because of the favorable lifestyle changes encouraged by their national heart foundations and supported by their respective governments.
Established clinical guidelines such as those of the NCEP, the International Task Force on CHD Prevention, and the European Atherosclerosis Society on desirable lipid levels, eg, cholesterol <5.2 mmol/L (<200 mg/dL) and diet (total fat intake <30% of energy), may require considerable adaptation to meet the special conditions in each Asian country. In some countries in Asia, eg, Korea, rural China, and India, average energy from fat intake is usually still <20%5 (although probably with wide diversity); in others (eg, Japan), <30%6 ; and in some (eg, Taiwan), already well over 30%.1 Mean cholesterol levels currently range from 2.8 to 4.7 mmol/L (110 to 180 mg/dL) in China1 and rural India7 to 5.7 mmol/L (220 mg/dL) in Singapore.8
Cigarette smoking is common (30% to 70%) in men (including many doctors) and is still uncommon (3% to 10%) among Asian women.2 In some countries, such as Indonesia, tobacco growing provides a livelihood. As tobacco companies lose ground in North America, Australia, and New Zealand, they have targeted Asia. Many Asian governments, notably Singapore, have already taken steps to reduce smoking, but free trade treaties can impede this.
Hypertension and stroke (often hemorrhagic stroke) remain common, especially in northern Asia.9 Mainland China, with a prevalence of diabetes mellitus of 1%, has close to 50% of the world's diabetics.10 Diabetes is becoming a serious problem in most of the region as dietary energy intake and the prevalence of overweight and obesity increase. In Taiwan, Hong Kong,11 and Singapore,8 insulin-dependent diabetes is rare, but prevalence rates of non–insulin-dependent diabetes are now very high, at 10% in the over-40 age group and as high as 20% in those aged >70 years (E.D.J., personal observations). Deep vein thrombosis is rare, and there appear to be differences in coagulation: fibrinogen levels are significantly lower in natives of Japan12 and Hong Kong (mean, 2.40 g/L for men and 2.55 g/L for women) than in Caucasians. This difference possibly contributes to the present low CHD rates in both countries, where increasing life expectancy and an increasing proportion of elderly people, rather than increasing age-standardized CHD mortality, are major factors in the increasing total number of CHD deaths.
During recent visits to Taiwan, Philippines, Malaysia, Indonesia, and India, members of the ISFC Council on Arteriosclerosis met colleagues from local heart foundations and cardiac societies and a number of governmental health officials. Some specific matters may be of interest because they clearly show how a single prevention strategy for all of Asia may be inappropriate.
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Regional Differences Relevant to Preventive Strategies |
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TopIntroductionRegional Differences Relevant to...ConclusionsReferences |
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In Taiwan, medical education, care, and research are advanced, especially in the major cities and their teaching hospitals. There are good epidemiological data on increasing CHD incidence and CHD risk factors. Dietary intake data obtained since 193513 show rapid changes in total energy consumption (increasing by
50% since 1950) and fivefold increases in fat and cholesterol intake between 1950 and the present to 36% of energy intake from fat and >300 mg of cholesterol daily. Soybean oil is the predominant cooking oil, and the polyunsaturated/saturated fat ratio of dietary fats had increased to 1.34 by 1988. Cigarette smoking and BMI have increased,13 and hypertension (systolic blood pressure >160 mm Hg, diastolic blood pressure >95 mm Hg) occurs in >20% of Taiwanese aged >50 years.14 Mean adult serum cholesterol levels in the population are close to 4.9 to 5.2 mmol/L (190 to 200 mg/dL).1 National guidelines have been developed for diagnosis and management of lipid disorders in Taiwan. The process has involved widespread participation, and the recommendations draw on NCEP and European guidelines but also take local factors into account. These guidelines are now being disseminated. Stroke, especially hemorrhagic stroke, remains a serious problem, although it is decreasing in incidence, while non–insulin-dependent diabetes is increasing. The Department of Health has antismoking and nutrition education policies and programs. In the Philippines, the population is predominantly young. Cigarette smoking is a problem, and cigarettes can be bought one at a time, which makes them easily accessible to adolescents and children. Increasing fat intake, diabetes, high cholesterol levels, and CHD are now increasing problems in the adult population. The population is spread over many islands, and there are diverse ethnic groups; collecting epidemiological data is difficult. One unusual strength is that the Philippines is well endowed with dietitians. Philippines experts are currently developing guidelines for the management of lipid disorders and have made a major commitment to continuing education.
Malaysia has undergone sustained high economic growth for 20 years. It is adjacent to Singapore, which has the highest age-standardized CHD mortality in Asia (150/100 000 in men, ie, similar to Australia). Although there are limited epidemiological data in Malaysia, a reasonable estimate of the CHD rate for men of all ages appears to be 100/100 000, ie, two thirds of that in Singapore (150/100 000) and double that of Hong Kong (50/100 000 for men of all ages). The rate is 1.5 to 1.8 times higher in Indians (10% of the population) than in the Malays (60%) and Chinese (30%).15 In Singapore, there is also a much higher CHD mortality for Indians than for Malays and Chinese.16 CHD mortality has risen markedly during the last 40 years, and CHD is now the leading cause of death in Malaysia. In part, this relates to an aging population, with increasing life expectancy as infectious diseases decrease. Doctors' knowledge on these issues and on diet, lipids, and other risk factors has increased markedly in the past 4 years. There is a well-argued Consensus Statement on Management of Hyperlipidemia by the Ministry of Health and the Academy of Medicine. The adult population's mean serum cholesterol level, from available data, is probably 5.2 mmol/L.17 Diabetes mellitus is of increasing concern. Coconut oil is recognized as harmful; however, there is understandable debate regarding palm oil, which is an important source of income.18 There are major antismoking initiatives that have resulted in innovative advertising counterstrategies by the tobacco industry, eg, travel agencies named after cigarette brands advertise prominently on the freeways.
Indonesia has >200 million inhabitants from a wide variety of ethnic groups spread over many islands. There, too, it has been hard to obtain good epidemiological data except in some parts of Java, where there is a MONICA center. The urban rates for CHD prevalence and mortality are probably similar to those of Malaysia. Smoking is a problem, as in the Philippines, with very high prevalence rates in men (70%) and with cigarettes sold singly at the roadside. In the cities, young patients with CHD are now encountered. Facilities and skills for treatment of heart disease in a number of major institutions are very advanced, but nationwide there is a very low doctor/population ratio of 1 doctor per 6000 people. Diabetes is a recognized problem. Hypertension and stroke are less common than in northeast Asia.
With its population of 900 million, India already has a major and increasing CHD problem. The prevalence of CHD has doubled in both rural and urban Indians during the past 20 years. In the south, CHD prevalence rates for both rural (7.4%) and urban dwellers (13.9%)19 20 are higher than in the north (rural, 3.0%; urban, 9.7%).21 22 The prevalence of hypertension follows a similar pattern. In rural areas, energy intake from fat is 15%, and mean serum cholesterol levels are 4.1 mmol/L (160 mg/dL), whereas in urban areas, fat intake accounts for 25% of energy intake, and mean serum cholesterol levels are 4.9 mmol/L (190 mg/dL), with a higher prevalence of CHD.21 22 Dietary fat intake, serum cholesterol levels, and CHD mortality increase still further in Indians who migrate, eg, to England.23 Smoking is a cause for concern, and diabetes increasingly so. In view of the severity of the problem, there is increasing local consensus that the goal for dietary fat intake should be 21% of energy intake or less, that a desirable cholesterol level is <4.4 mmol/L (<170 mg/dL), and that BMI should be <23 kg/m2.24 European and NCEP recommendations for serum cholesterol <5.2 mmol/L and for 30% energy from fat have been regarded as inappropriate in this country, as in some others in Asia. Indeed, in Singapore, the Ministry of Health has already set a target of 180 mg/dL for the mean population cholesterol by the year 2000. These population guidelines set lower target levels than those designed for European and North American populations and reflect the views of regional experts who hope to maintain current low population distributions of serum cholesterol and traditional low dietary intake of fats. This is an admirable goal, although it could be argued that such intentions could be best embodied in definitions of desirable population means and distributions rather than individual target values. In certain urban populations, an individual goal of 4.5 mmol/L (175 mg/dL) may already have been overtaken by events. Nevertheless, there are persuasive reasons to concur with the aim of maintaining dietary fat intake below a mean of 20% energy in countries where this may still be possible and particularly desirable, eg, India.
The case for an individual serum cholesterol target value <4.5 mmol/L (<175 mg/dL) is less certain, and convincing evidence would be desirable before recommending that individual serum cholesterol levels be reduced to this goal in a clinical setting. The epidemiological association between serum cholesterol and CHD incidence is not a function of the cholesterol distribution of the population under study, as is evident from the concordant longitudinal data in studies in the United States, Munster, and Shanghai. The slope of the cholesterol-CHD risk relationship is relatively shallow at low cholesterol concentrations. When the Asian population has a low cholesterol distribution but a growing and significant CHD problem, a major part of preventive effort may wisely be directed to regionally relevant risk factors, including smoking, hypertension, truncal obesity, and diabetes.
In populations with low mean serum cholesterol levels, the upper tail of the distribution may contain a higher proportion of individuals with major primary and secondary hyperlipidemias, whose management should proceed along orthodox lines. The detection of such individuals poses a problem in that the cost implications of the high-risk strategy are substantial and could inappropriately divert funding from population strategies directed to primary prevention. Family history taking and clinical awareness are likely to be the most economical routes to recognition of persons at high risk.
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Conclusions |
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TopIntroductionRegional Differences Relevant to...ConclusionsReferences |
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In the vast population of Asia, there is rapid change in lifestyles accompanied by unprecedented economic development. This has led to an increase in CHD prevalence and mortality due in part to increasing life expectancy and in part to increasing levels of CHD risk factors. Non–insulin-dependent diabetes is of increasing concern, and its prevalence appears to be much higher than in Caucasian populations. Cholesterol levels vary widely over this region, but CHD mortality is clearly greater where cholesterol levels are the highest or where they have increased recently from earlier low levels. Appropriate recommendations on diet, lifestyle, and acceptable levels of risk factors may need considerable modification from those used in Europe, North America, and Australia. In view of the great diversity of countries in this region, a single set of Asian recommendations seems inappropriate. This also applies in relation to healthcare budgets and local priorities for prevention of CHD and other diseases. Broader statements on exercise, obesity, smoking, and diet and on the prevention and control of diabetes and hypertension might be appropriate. Better epidemiological data will assist in the development of appropriate strategies and the monitoring of their impact.
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Selected Abbreviations and Acronyms |
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References |
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-
Pan WH, Chiang BN. Plasma lipid profiles and epidemiology of atherosclerotic disease in Taiwan: an unique experience. Atherosclerosis.. 1995;118:285-295.[Medline]
[Order article via Infotrieve]
-
Coronary Heart Disease in Hong Kong. Hong Kong: Department of Health; 1994. Public Health Report No. 1:14-52.
-
Hughes K. Trends in mortality from ischaemic heart disease in Singapore 1959-1983. Int J Epidemiol.. 1986;15:44-50.
[Abstract/Free Full Text]
-
Yeung S, Ho YY. Health of Community. Hong Kong: Department of Health; Public Health and Epidemiology Bulletin. 1994;3:17-21.
-
Chen CM. Eating patterns: a prognosis for China. Asia Pac J Clin Nutr. 1995;1(suppl 4):24-28.
-
Research Committee on Serum Lipid Level Survey 1990 in Japan. Current state of and recent trends in serum lipid levels in general Japanese population. J Atheroscler Thromb.. 1996;2:12-132.
-
Gupta R, Gupta HP, Kumar N, Joshi AK, Gupta VP. Lipoprotein lipids and the prevalence of hyperlipidaemia in rural India. Cardiovasc Risk.. 1994;1:179-184.
-
Hughes K, Yeo PPB, Lun KC, Thai AC, Sothy SP, Wang KW, Cheah JS, Poon WO, Lim P. Cardiovascular diseases in Chinese, Malays and Indians in Singapore, II: differences in risk factors. J Epidemiol Community Health.. 1990;44:29-35.[Abstract]
-
Jones. Hypertension in East Asia. Am J Hypertens.. 1995;8:111S-114S.
-
King H, Rewers M, for the World Health Organization Ad Hoc Diabetes Reporting Group. Global estimates for the prevalence rates of diabetes mellitus and impaired glucose tolerance in adults. Diabetes Care.. 1993;16:157-177.[Abstract]
-
Cockram CS, Woo J, Lau E, Chan AYW, Swaminathan R, Donnan SPB. The prevalence of diabetes mellitus and impaired glucose tolerance among Hong Kong Chinese adults of working age. Diabetes Res Clin Pract.. 1993;21:67-73.[Medline]
[Order article via Infotrieve]
-
Iso H, Folsom AR, Sato S, Wu KK, Shimamoto T, Koike K, Iida M, Komachi Y. Plasma fibrinogen and its correlates in Japanese and US population samples. Arterioscler Thromb.. 1993;13:783-790.
[Abstract/Free Full Text]
-
Ding YA, Chang WK, Chen ML. Changes in nutritional supply and atherosclerotic diseases from 1945 to 1989 in Taiwan. J Clin Biochem Nutr.. 1992;13:137-146.
-
Chen CH, Lin HC, Kno HS, Chang MS, Chou P. Epidemiology of hypertension in Kin-Hu, Kinmen. Am J Hypertens.. 1995;8:395-403.[Medline]
[Order article via Infotrieve]
-
Khoo KL, Tan H, Khoo TH. Cardiovascular mortality in peninsular Malaysia: 1950-1989. Med J Malaysia.. 1991;46:7-20.[Medline]
[Order article via Infotrieve]
-
Emmanuel SC. Trends in coronary heart disease mortality in Singapore. Singapore Med J.. 1989;30:17-23.[Medline]
[Order article via Infotrieve]
-
Khoo KL, Sambhi JS, Aljafri AM, Hatijah. Screening for blood pressure, cholesterol and glucose during National Heart Weeks 1992-1994. Med J Malaysia.. 1996;5:307-316.
-
Ony ASH. Nutritional aspects of palm oil: an introductory review. Asia Pac J Clin Nutr.. 1994;3:201-206.
-
Begom R, Singh B. Prevalence of coronary heart disease and the risk factors in the urban population of south and north India. Acta Cardiol.. 1995;50:227-240.[Medline]
[Order article via Infotrieve]
-
Raman Kutty V, Balakrishnan KG, Jayasree AK, Thomas J. Prevalence of coronary heart disease in the rural population of Thiruvananthapuram district, Kerala, India. Int J Cardiol.. 1993;39:59-70.[Medline]
[Order article via Infotrieve]
-
Singh RB, Ghosh S, Niaz AM, Gupta S, Bishnoi I, Sharma JP, Agarwal P, Rastogi SS, Beegum R, Chibo H, Shoumin Z. Epidemiologic study of diet and coronary risk factors in relation to central obesity and insulin levels in the urban population of north India. Int J Cardiol.. 1995;47:245-255.[Medline]
[Order article via Infotrieve]
-
Chadha SL, Radhakrishnan S, Ramachandran K, Kaul U, Gopinath N. Epidemiological study in coronary heart disease in urban population of Delhi. Indian J Med Res.. 1990;92:424-430.[Medline]
[Order article via Infotrieve]
-
McKeigue PM, Marmot MG, Adelstein AM, Hunt SP, Shipley MJ, Butler SM, Riemersma RA, Turner PR. Diet and risk factors for coronary heart disease in Asians in north west London. Lancet.. 1985;2:1086-1090.[Medline]
[Order article via Infotrieve]
-
Singh RB, Sainani GS, Ratsogi SS, Madhu SU, Krishnaswami S, Wander GS, Shah NA, Gupta R, Shantaram V, Yeolekar ME, Bhatnagar D, Postiglione A, Janus ED. Diet and lifestyle guidelines and desirable levels of risk factors for prevention of coronary heart disease in Indians. J Intern Med.. 1996;7:46-49.
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