Background
Cardiovascular disease is the leading cause of death for both men and women worldwide. According to the World Health Organization (2017), in 2016 alone, 17.9 million people worldwide died of heart disease, accounting for 31% of total deaths over the span of the year. Out of those 17.9 deaths, 85% were caused by a heart attack and stroke. Given the epidemiology of heart disease, one may speak of a full-blown epidemic taking over the world.
Not only is the number of heart patients increasing across the globe, but the condition is starting to affect younger demographic cohorts (Gehani et al., 2014). Another trend that is raising concerns is the prolonged life expectancy in high- and middle-income countries due to the quality of life and access to healthcare. Improved longevity inevitably leads to a surge in heart disease due to old age being one of the contributing factors and a natural cause of developing heart problems. The burden of heart disease is putting a strain on national economies, calling for preventive measures rather than handling the consequences.
The Middle East is a region that has lately been drawing interest of researchers in regards to cardiovascular epidemiology. The transcontinental region is economically diverse with countries’ standings ranging from low- to middle, upper-middle, and high-income (Narula, 2017). Despite the differences, the Middle East displays trends in cardiovascular diseases reminiscent of those in the West. Heart disease has grown to be the leading cause of death in the entire region, slightly surpassing the world average in prevalence (34% vs. 31% of all deaths) (Narula, 2017). What makes researching the issue of CVDs in the Middle East compelling is the region-specific risk factors.
It is true that as anywhere in the world, CVDs are predetermined by a person’s genetic makeup to a certain extent with the lifetime risks modified depending on a person’s behavior (Narula, 2017). However, what is often dismissed is environmental factors that are hard if not impossible to control but that should be discussed when addressing the issue of CVD epidemiology. All in all, it is essential to study the epidemiology of cardiovascular disease in the Middle East, approaching the topic from different angles and taking into account all kinds of factors – genetic, behavioral, and environmental.
Literature Review
The central question in many epidemiological studies on heart disease is what triggers developing a heart condition in humans, in other words, what risk factors there are and what one can do about them. The World Heart Federation (2019), uniting more than 200 heart health organizations and scientific communities all over the world, provides exhaustive information on the many risk factors. According to the World Heart Federation (2019), the risk factors may be divided into three groups: modifiable, non-modifiable, and others. This literature review draws on the theoretical framework provided by the World Heart Federation with the focus on the Middle Eastern countries. It addresses each risk factor in regards with relevant statistics and research findings in the region with the purpose of drawing a full picture of the current state of CVD in the Middle East.
Modifiable Risk Factors
Obesity
Obesity is an established risk factor for developing CVD. It is argued that being overweight affects the human body in a variety of ways, including changing hemodynamics and the heart structure. With this being said, it is readily imaginable how the growing burden of CVD around the globe is directly linked to the increasing number of obese individuals of all ages. In recent years, obesity has become a full-fledged epidemic in the Middle East. Statistics show that some countries are in a particularly grave situation: for example, in Bahrain, every second adult is obese (Mirmiran, Sherafat Kazemzadeh, Jalali Farahani, & Azizi, 2010). In Saudi Arabia, 35.2% of the population weigh well above the norm, and in the United Arab Emirates, 27.8% of citizens suffer from obesity.
What is even more concerning is that obesity is becoming “younger”: it no longer solely affects the adult population but also children and teenagers. While the statistics on childhood obesity in the Middle East are scarce, those that are available may provide one with some insights on the problem. As Mirmiran et al. (2010) report, in Bahrain 35% of girls and 22% of boys are overweight. In the UAE, the metrics are somewhat more positive (around 13% for both boys and girls), but then again, the scarcity of data does not allow for making inferences. It is argued that living in the desert impacts people’s choices regarding their health and lifestyle.
The hot climate discourages both children and adults from partaking in outdoor activities such as sports. Hiking or reaching destinations on foot in the hot weather is also not an option for the majority of the Middle Easterners as they prefer to go by car.
Lastly, as the region became more open to the outside world, many fast food chains opened their cafes and restaurants there. It is no secret that food served at restaurants such as McDonalds and Burger King is high in saturated fats, which is why it is not advised to make fast food part of one’s daily diet. According to the World Heart Federation (2010), high-fat diet is responsible for 31% of coronary heart disease and 11% of incidents of heart stroke around the globe. It seems that the Middle East is not an exception, and the population’s preferences of the novel kinds of food may be contributing to the burden of CVD.
Bad Habits
Another lifestyle choice that may impact a person’s chances of developing heart disease is increased alcohol consumption. The World Heart Federation (2010) reports that worldwide binge drinking is the factor behind about 2.5 million deaths per year, or 5% of the global burden of disease. When an individual abuses alcohol, it leads to increased blood pressure, acute myocardial infarction, cardiomyopathy, cirrhosis of the liver. One may presume that alcohol consumption should not be that great of a factor for the Middle East. After all, the majority of the countries in the region have quite strict alcohol regulations.
Besides, given the prevalence of Islam, many people give up on alcohol in alignment with their religious beliefs. In actuality, as the statistics gathered by the World Health Organization (2014) show, alcohol is widely consumed across the region. The average consumption of pure alcohol per person is 6.5 liter per year (The World Health Organization, 2014). While none of the countries in the region reach the world’s average, some come quite close. For instance, in the UAE, the average annual consumption for people older than 16 is 4.2 liter.
Physical Activity
An obvious solution to obesity and unhealthy lifestyle is regular, age-, and gender appropriate physical activity. According to the World Heart Federation (2019), over the last decades, individuals in developed countries have reduced their level of physical activity significantly. It is unfortunate since being physically active has been found to present many health advantages, including a healthier heart (Guthold, Stevens, Riley, & Bull, 2018). For instance, keeping the physical activity level at 150 minutes (2 hours 30 minutes) per week helps to reduce the risks of developing coronary heart disease by 30% (The World Heart Organization, 2019). Even though dedicating this amount of time to fitness and health does not seem to be that big of an effort, many people still struggle with maintaining a healthy lifestyle.
In the Middle East, sedentary lifestyle and obesity are taking a toll on the population’s quality of life, which led to the governments promoting fitness and raising awareness of its health benefits. Apparently, the Gulf fitness marked has been revived in recent years, with foreign investors being interested in funding fitness clubs and the state passing down policies that ensure better access to fitness venues. For instance, in Saudi Arabia, the academic year 2017-2018 was the first year when girls were allowed to take physical education classes (Anderson. 2019). At the same time, the government started giving out more permissions than ever to open female-only gyms (Anderson, 2019).
The United Arab Emirates are going through a similar situation: the fitness market for women is practically untapped, with only 1% coverage (Anderson, 2019). However, based on statistics, despite the small number of female customers, the revenue per person is high, which opens up bright future prospects for the industry. Admittedly, both genders are interested in fitness, and it is projected that both female and male gyms will skyrocket in number by the year 2022. Hopefully, the population’s engagement in sport will mean a decrease in the burden of CVD.
Non-Modifiable Factors
Age
Many heart conditions are age-related: the older a person becomes, the more he or she is at risk of developing one. This is a non-modifiable factor: even if a person leads a healthy life, as he or she ages, their heart muscle weakens. One trend that highlights the contribution of the age factor to the burden of CVD in the MIddle East is increased life expectancy. Worldwide, the average life expectancy is 71 year old (Index Mundi, 2017).
When it comes to the Middle Eastern region, the statistics show that at least 14 countries surpassed the world’s average. For instance, in Bahrain and Kuwait the average life expectancy is 78 and 79 respectively (Index Mundi, 2017). In the grand scheme of things, a larger older demographic means more incidents of heart disease since it is a natural occurrence. As the quality of life in the Middle Eastern countries increases, the region is likely to see more aging populations and a greater burden of CVD.
Gender
It has now been established by the scientific community that gender plays a role in the development of CVD. While CVDs are the leading cause of death for both men and women worldwide, men seem to be more at risk. While for women, the average age of a first heart attack is 72, men typically have their first at a younger age – in their fifties or sixties (Murray, Bode, & Whittaker, 2019). A gender disparity that does not favor women is the negligence of female specific CVD symptoms by healthcare workers and women themselves. Given the issues with health literacy in the region, this might be another factor behind the burden of CVD in women.
Genetics
Family history is one of the non-modifiable factors of CVD. As the World Heart Federation (2019) states, if both parents suffer from heart disease before the age of 55, their children’s chances of developing it are 50% higher than the average population. Surely, having parents with CVD is not a sentence – belonging to a group of risk does not mean that a person will necessarily develop a condition. It only means that people need to be more aware of their genetics and make choices thoughtfully.
Doing so requires a good level of health literacy, which would prompt a person to seek medical help and adjust their lifestyle to avoid risks. As Nair, Satish, Sreedharan, and Ibrahim (2016) discovered, health literacy varies greatly in the Middle East. Due to the socioeconomic disparities, many individuals do not have access to medical information and healthcare services (Kelishadi et al., 2014). Therefore, people may be unaware of what is happening to them, and even when something becomes a cause of concern, they are unable to receive treatment.
Comorbidities
One common comorbidity that may trigger a rapid development of CVD is diabetes. It should be noted that specific ethnicities are more at risk of developing diabetes, namely, Hispanics, Asians, Arabs, Africans, Pacific Islanders and indigenous (American, Canadian and Australian). As of now, 9.1% of Middle Easterners, or 35.2 million people suffer from diabetes (Majeed et al., 2014).
Diabetes patients are two to four times more likely to develop heart disease than people without diabetes. Diabetes increases the risk of CVD for a number of reasons with hypertension (abnormally high blood pressure) being one of them. Moreover, diabetes is often associated with increased blood lipids and obesity, which as it has already been pointed out, makes a person more prone to developing CVD.
If one fails to manage diabetes, the disease may cause damage to their body’s blood vessels, making them more vulnerable to damage from atherosclerosis and hypertension. It is argued that diabetes patients develop atherosclerosis at a younger age and suffer from its more severe forms. Furthermore, people with diabetes are more susceptible to heart attack or stroke as well as heart failure.
Environment
A subcategory within the modifiable risks category is environmental factors. As it has already been mentioned, some behaviors prevail in the Middle Eastern populations due to the realities of living in a desert. However, staying in, depending on private means of transportation, and neglecting outdoor activities are not the only implications of living in the dryland climate. Another health hazard that is often dismissed is natural occurrences such as dust storms that do not only paralyze the urban infrastructure but also endanger people’s lives in the long run.
So far, there have been a few milestone studies on the relationship between dust storms and the burden of CVDs in Australia, Asia, Eastern Europe, and Middle East. The researchers have linked a range of CV disorders – stroke, heart failure, myocardial infarction, arrhythmias and venous thromboembolism – to short-term and long-term exposure to dust particles and their increased air ambiance concentrations.
Nasser et al. (2015) studied the state of the problem in the Middle East in particular using health and environmental data collected in Iran, the United Arab Emirates, Saudi Arabia, and Qatar. The retrospective study by Nasser et al. (2015) explained the mechanism of CVD complications due to dust particle exposure. Namely, the researchers described how air pollution triggers platelet activation and atherosclerosis, which in consequence leads to CVD admissions and mortality.
Despite the scientific significance of the conducted meta-analysis, it is not exactly clear which kind of air pollution caused heart problems. Nasser et al. (2015) acknowledge the presence of multiple factors contributing to air pollution – aside from dust storms, they include gas emissions due to the extensive use of cars and low dependence on public transportation. Therefore, it is difficult to single out the most significant factor and establish that dust storms indeed were responsible for CVD complications.
Public Health Significance
Handling heart disease is challenging for a number of reasons. It puts a strain on the national budget, results in out-of-pocket expenses for those patients who lack sufficient medical insurance coverage, and subsequently decreases their quality of life. For instance, AlHabeeb et al. (2018) studied the situation in the UAE, Saudi Arabia, and Egypt. The researchers concluded that out of all of those countries’ population, an estimated 1.35 million patients were being treated for heart failure. The total estimated cost of their treatment amounted to US$1.92 billion. AlHabeeb et al. (2018) emphasized the costliness of the procedures for patients, medical facilities, and third-party payer with inpatient admission cost being the major cost driver accounting for from 25% to 56% of the total sum.
What is even more concerning is that urgent hospitalization does not always save lives. Zain (2017) reports that in the UAE, the survival rate for patients having a cardiac arrest is around 5-10% whereas the goal rate for the next year is set at 65%. The reason why the majority of patients do not make it to the hospital is the inability of those who witness an incident to step up, intervene, and do CPR (Zain, 2017).
Environmental factors also chime in on the burden of disease in the Middle East. The realities of living in the desert climate zone are something to be reckoned with. The World Health Organization reports that at least half of air pollution in the Middle East can be attributed to natural sources – sand, sea salt, and dirt (Khanjani, 2013). One in ten deaths in the region occur due to air pollution amounting to as many as 500,000 deaths per annum (Khanjani, 2013). One may assume that a significant share of these deaths is caused by heart disease complications due to inhaling dust particles during and after dust storms. Even though some studies negate the association between dust storms and mortality, the relation between this natural phenomenon and CVD morbidity still remains.
In summation, heart disease is characterized by high morbidity, increased health-related expenses, and in some cases, mortality. While reactive measures make sense, proactive (predictive and preventive) measures might prove more effective in the long term. Probably, the most proactive way to go about the problem is teach populations preventive measures so that they do not underestimate the health hazard of certain behaviors, their own genetic makeup, and natural occurrences.
In order to do that, there needs to be more research and consolidation of facts on what causes CVD in the Middle East and how prevalent various heart conditions are in different communities. The importance of research for public health lies in its potential to guide those in the decision-making positions when passing health policies. Moreover, the appropriate scope of the research may allow health advocates to customize preventive measures to accommodate the realities of living in the Middle East.
References
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