Barriers and Opportunities for Cardiovascular Disease Prevention in Low- and High-Income Countries

Abstract

Cardiovascular disease is the leading cause of death worldwide and hypertension is the leading modifiable risk factor for death. Global studies have shown a high prevalence of hypertension in East Africa, but the reasons for this remain unknown. We examined prevalence and determinants of high blood pressure, and barriers to diagnosis and treatment, among 2,174 adults aged ≥40 years in Dar es Salaam, Tanzania. Among a subsample of 317 participants, we validated a 179-item Food Frequency Questionnaire (FFQ) against two 24-hour diet recalls. The FFQ performed moderately well with a median correlation of 0.35 for food groups and 0.21 for nutrients. Median blood pressure was 131/81 mmHg and hypertension prevalence was 37%. Among hypertensives, 48% were diagnosed, 22% were treated, and 10% were controlled. Reasons for not seeking care or not being on treatment included lack of symptoms, cost of visit, lack of time, not being prescribed treatment, and not understanding the need for long-term treatment. Major risk factors for hypertension in Dar es Salaam are overweight, obesity, inadequate physical activity, and limited access to medical care. Hypertension and lack of access to care and treatment are not only problems in low-income countries, such as Tanzania, but also in high-income countries. The United States Congress is considering repealing the Affordable Care Act (ACA). Our goal was to assess the possible consequences on cardiovascular mortality of such a repeal among non-Hispanic Whites and Blacks aged 45-64 years. We used National Health Interview Survey data to project changes in the uninsured rate according to three policy scenarios: no change in uninsured rate, decline in uninsured rate to pre-ACA levels, and decline in uninsured rate halfway to pre-ACA levels. We projected these changes in insurance among National Health and Nutrition Examination Survey participants, and subsequent rise in systolic blood pressure, total cholesterol, and A1c among those projected to lose insurance. Finally, we calculated 10-year cardiovascular mortality risk using Cox proportional hazards models under the three scenarios. If uninsured rates were to decline to pre-ACA levels, we project that 10-year cardiovascular mortality risk would increase by 0.6% among women and 0.9% among men.