Bovet, Pascal

Stringhini, Silvia

RERO DOC Digital Library

13 Magee MJ, Blumberg HM, Narayan KM. Commentary:Co-occurrence of tuberculosis and diabetes: new para-digm of epidemiological transition. Int J Epidemiol 2011;40:428–31.14 Muhammad RD, Oza-Frank R, Zell E et al. Epidemiologyof invasive pneumococcal disease among high-risk adultssince the introduction of pneumococcal conjugate vaccinefor children. Clin Infect Dis 2013;56:e59–67.15 Skoff TH, Farley MM, Petit S et al. Increasing burden ofinvasive group B streptococcal disease in nonpregnantadults, 1990-2007. Clin Infect Dis 2009;49:85–92.Published by Oxford University Press on behalf of the International Epidemiological Association The Author 2013; all rights reserved. Advance Access publication 5 September 2013International Journal of Epidemiology 2013;42:1429–1431doi:10.1093/ije/dyt084Commentary: The social transition ofcardiovascular disease in low- andmiddle-income countries: wait and seeis not an optionSilvia Stringhini1* and Pascal Bovet1,21University Institute of Social and Preventive Medicine (IUMSP) and Lausanne University Hospital, Lausanne, Switzerland and2Ministry of Health, Victoria, Republic of Seychelles*Corresponding author. University Institute of Social and Preventive Medicine (IUMSP) and Lausanne University Hospital, Biopoˆle2, Route de la Corniche 10, 1010 Lausanne, Switzerland. E-mail: silvia.stringhini@chuv.chAccepted 18 March 2013A critical question for public health is whether, inlow- and middle-income countries (LMIC), theincreasing burden of cardiovascular disease (CVD)concentrates more on the advantaged or on the dis-advantaged sections of society, and how this socialpatterning of CVD changes over time. Subramanianand colleagues argue that CVD concentrates on therich in India, with limited evidence for the occurrenceof a shift towards the poor.1Operationally, the social patterning of CVD in LMICscan be usefully framed along two different perspec-tives: (i) what is the current social patterning of CVDbased on reliable population-based epidemiologicaldata, acknowledging that few data are available inLMICs; and (ii) what is the potential relevance ofdifferent scenarios of social patterning of CVD onpolicy development, considering that definite dataare not yet available in many LMICs but some toolscan help anticipate future trends (i.e. findings inhigh-income countries, theory of the health transi-tion, social theory about adoption of lifestyles, etc.).Subramanian and colleagues mainly adopt the firstperspective (i.e. current factual evidence in India), al-though they also attempt to draw some conclusionson policy. They reviewed mainly cross-sectionalstudies covering a fairly large time lapse (1969 to2008), but there is little attempt to examine changesin the social patterning of CVD/CVD risk factorsduring this period. A clearer view on the social tran-sition of CVD and related risk factors could have per-haps emerged if they had restricted their review tothose studies using longitudinal data or repeatedcross-sectional surveys on the same population; orby attempting to compare studies from differenttime periods.It seems to us that substantial evidence supports theview that the socioeconomic gradient in CVD andCVD risk factors is reversing from the rich to thepoor in those LMICs which are at an intermediatestage of the health transition, and that such a shiftis likely to occur in those LMICs at an early stage ofthe health transition (in which the burden of CVDstill concentrates among the rich). This frame is im-portant as it provides a rationale for tackling CVDamong the poor at an early stage of the non-commu-nicable disease (NCD) epidemics. Here a crucial ques-tion arises: who are the poor? Referring to a study ofPednekar et al., Subramanian and colleagues reportthat age-adjusted CVD mortality in Mumbai was654, 618, 518 and 450 (per 100 000) among menSOCIAL TRANSITION OF CARDIOVASCULAR DISEASE IN LOW- AND MIDDLE-INCOME COUNTRIES 1429with, respectively, primary, middle, secondary and ter-tiary education. Subramanian and colleagues rejectthe interpretation that there is a negative associationbetween educational level and CVD because the CVDmortality rate among the illiterates was 471 (per100 000), which was higher than that of highly edu-cated persons, yet lower than that of people with pri-mary or intermediate education. It seems to us thatthis result on the contrary clearly shows a negativesocioeconomic gradient in CVD mortality among theliterates.It is unquestionable that the most socioeconomicallydeprived individuals, who cannot meet the minimumdietary energy requirement or indulge in unhealthybehaviours associated with globalization, are inher-ently less affected by obesity, diabetes, dyslipidaemiaand hypertension. This is true in India as in mostLMICs. However, we believe that the main issue,from a global public health perspective, is whethersocioeconomic development (which inexorably ex-tends to larger segments of the population world-wide) drives a shift in the social patterning of CVDand its risk factors towards the poor, and whetherthis unfavourable trend could be mitigated by someinterventions. For example, the prevalence of tobaccouse, the largest avoidable risk factor for NCDs, is al-ready consistently greater among the poor in mostLMICs (including India).2,3We recently examined changes in the social pattern-ing of CVD risk factors in the Republic of Seychelles(a middle-income island state in the Indian Ocean),based on serial cross-sectional surveys carried out be-tween 1989 and 2004.4 Among men, current smokingand heavy drinking were more prevalent in thelower vs the higher socioeconomic groups throughoutthe study period, but obesity was less prevalent. Thesocioeconomic gradient in diabetes reversed over thestudy period, with high prevalence shifting from in-dividuals with high socioeconomic status (SES) to in-dividuals with low SES. Hypercholesterolaemia wasless prevalent in the low vs the high SES groups in1989, but the prevalence was similar in the twogroups in 2004. Similar changes were also observedin women, where in addition a reversal in the SESgradient in smoking was noted. These changes in thesocial patterning of CVD risk factors over time paral-lelled considerable socioeconomic development (thenational gross domestic product per capita rose fromUS$600 in 1976 to US$8000 in 2004) and markedchanges in dietary patterns and physical activitylevels in the population.5 Results in Seychelles areconsistent with data in China,6 Brazil,7 seven coun-tries in Africa8 and 39 LMICs;9 these findings supportthe view that CVD risk factors do shift towards thepoor in LMICs along with economic development, glo-balization, urbanization and the nutritional transition.We understand the concern of Subramanian andcolleagues that shifting attention from communicableto non-communicable diseases in countries such asIndia, where the majority of the population stilllives on less than US$2 a day, might divert some re-sources from the very poor to the less poor. However,it is likely that interventions to prevent the increasingburden of CVD and other NCDs among the poor willbe more successful if implemented early enough inthe health transition and before the reversal of thesocial patterning of CVD is fully engaged.Furthermore, and most importantly, there is now aunique window of opportunity to curb the emergenceof CVD and other NCDs in LMICs at the global level.The importance of addressing NCDs in LMICs and theneed to focus on the poor are well recognized inrecent evidence-based global health policy documentssuch as the political declaration of the High-levelMeeting on the Prevention and Control of NonCommunicable Diseases of the General Assembly ofthe United Nations (http://www.un.org/ga/search/view_doc.asp?symbol¼A/66/L.1) or the World HealthOrganization global action plan for the prevention andcontrol of NCDs 2013–2020, to be submitted to theWorld Health Assembly in May 2013.We believe that addressing NCDs in LMICs by im-plementing cost-effective structural interventions totackle avoidable NCDs at both the population and in-dividual levels, including universal coverage for care-fully selected priority management approaches amonghigh risk individuals, is timely, justified and neces-sary.10–12 The close links between several communic-able and non-communicable diseases (i.e. HIV,tuberculosis and NCDs), the possibility of integratingtreatment for both groups of diseases at the primarycare level, the strong impact of chronic diseases oncatastrophic expenditure and impoverishment, andthe need to address NCDs as part of the broader de-velopment agenda further support this view.13FundingSilvia Stringhini is supported by a post-doctoral fel-lowship awarded by the Swiss School of Public Health(SSPHþ).Conflict of interest: None declared.References1 Subramanian SV, Corsi DJ, Subramanyam M, DaveySmith G. Jumping the gun: the problematic discourseon socioeconomic status and cardiovascular health inIndia. Int J Epidemiol 2013.2 Fleischer NL, Roux AV, Hubbard AE. Inequalities in bodymass index and smoking behavior in 70 countries: evi-dence for a social transition in chronic disease risk. Am JEpidemiol 2012;175:167–76.3 Hosseinpoor AR, Parker LA, Tursan d’Espaignet E,Chatterji S. Socioeconomic inequality in smoking inlow-income and middle-income countries: results fromthe World Health Survey. PLoS One 2012;7:e42843.1430 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY4 Stringhini S, Viswanathan B, Gedeon J, Paccaud F,Bovet P. The social transition of risk factors for cardio-vascular disease in the African region: Evidence fromthree cross-sectional surveys in the Seychelles. Int JCardiol 2012; doi:10.1016/j.ijcard.2012.11.064.5 Bovet P, Romain S, Shamlaye C et al. Divergent fifteen-year trends in traditional and cardiometabolic risk factorsof cardiovascular diseases in the Seychelles. CardiovascDiabetol 2009;8:34.6 Jones-Smith JC, Gordon-Larsen P, Siddiqi A, Popkin BM.Emerging disparities in overweight by educational attain-ment in Chinese adults (1989-2006). Int J Obes (Lond)2012;36:866–75.7 Monteiro CA, Conde WL, Popkin BM. The burden of dis-ease from undernutrition and overnutrition in countriesundergoing rapid nutrition transition: a view from Brazil.Am J Public Health 2004;94:433–34.8 Ziraba AK, Fotso JC, Ochako R. Overweight and obesityin urban Africa: A problem of the rich or the poor? BMCPublic Health 2009;9:465.9 Jones-Smith JC, Gordon-Larsen P, Siddiqi A, Popkin BM.Is the burden of overweight shifting to the poor acrossthe globe? Time trends among women in 39 low- andmiddle-income countries (1991-2008). Int J Obes (Lond)2012;36:1114–20.10 Bonita R, Magnusson R, Bovet P et al. Country actions tomeet UN commitments on non-communicable diseases: astepwise approach. Lancet 2013;381:575–84.11 Chisholm D, Mendis S. Scaling Up Action AgainstNoncommunicable Diseases: How Much Will It Cost?.Geneva: World Health Organization, 2011.12 World Bank Human Development Network. The GrowingDanger of Non-Communicable Diseases. Acting Now to ReverseCourse. Washington, DC: World Bank, 2011.13 Alleyne G, Binagwaho A, Haines A et al. Embedding non-communicable diseases in the post-2015 developmentagenda. Lancet 2013;381:566–74.Published by Oxford University Press on behalf of the International Epidemiological Association The Author 2013; all rights reserved. Advance Access publication 6 August 2013International Journal of Epidemiology 2013;42:1431–1435doi:10.1093/ije/dyt119Commentary: Poverty and cardiovasculardisease in India: Do we need moreevidence for action?Dorairaj Prabhakaran,1,2* Panniyammakal Jeemon1,3 and Kolli Srinath Reddy31Centre for Chronic Disease Control, New Delhi, India, 2Centre of Excellence in Cardio-metabolic Risk Reduction in South Asia,Public Health Foundation of India, New Delhi, India and 3Public Health Foundation of India, New Delhi, India*Corresponding author. Centre of Excellence in Cardio-metabolic Risk Reduction in South Asia, Tower 4, Commercial Complex,C9, VasantKunj, New Delhi-110070, India. E-mail: dprabhakaran@ccdcindia.orgAccepted 21 May 2013It appears that some Western academics are stillcaught in a time warp, like Rip van Winkle. An argu-ment was advanced by a World Bank team in 1999,that any action to control non-communicablediseases (NCDs) would only help the rich and hurtthe global poor by increasing health inequity.1 Thishas subsequently been refuted by many.2,3 Even theWorld Bank changed its stance in 2007, declaringthat in ‘all countries and by any metric, NCDs accountfor a large enough share of the disease burden ofthe poor to merit serious policy response’.4 TheUnited Nations political resolution on NCDs, inSeptember 2011, also acknowledged that NCDs areimposing health and developmental burdens on thepoor in low- and low-middle income countries.5Despite this, Subramanian et al. have chosen torehash the same argument with regard to cardiovas-cular disease (CVD) in India.6 In brief, they reviewedthe available published literature from India on theassociation between socio-economic status (SES) andcardiovascular (CV) risk factors or acute events ormortality outcome. They demonstrated a positive gra-dient in socio-economic status (SES) in the preva-lence of one of the CV risk factors, obesity oroverweight in Indians, and postulated that CVD is aconcern for only the rich in India. In effect theirstated position was similar to the Gwatkin thesisand it is disheartening that we have not movedPOVERTY AND CARDIOVASCULAR DISEASE IN INDIA 1431

Commentary: The social transition of cardiovascular disease in low- and middle-income countries: wait and see is not an option

Abstract

Similar works

Full text

Available Versions

RERO DOC Digital Library