© Springer International Publishing Switzerland 2015
Jadelson Andrade, Fausto Pinto and Donna Arnett (eds.)Prevention of Cardiovascular Diseases10.1007/978-3-319-22357-5_12Other Determinants of Cardiovascular Diseases: Social, Globalization, and Urbanization
(1)
Catholic University of Parana, Curitiba, Brazil
(2)
Brazilian Society of Cardiology, Rio de Janeiro, Brazil
(3)
Institute of Cardiology from Santa Catarina, Florianópolis, Brazil
Introduction
Cardiovascular diseases (CVD) are responsible for 30 % of the annual worldwide mortality. There is a trend toward decreased mortality rates in developed countries but increased rates in countries with lower socioeconomic levels, particularly the socialist and emerging third world countries. India, China, and Latin America have the worst predictions of growth of cardiovascular mortality [1]. In 2010, Brazil accounted for one third of all deaths and nearly 30 % of all deaths in the age group of 20–59 years, which affected the economically active adult population [2].
All developed and developing countries have experienced large reductions in mortality rates over the past century, and the pattern of epidemiological transition in these countries suggests that the main causes of mortality have changed from transmissible diseases—especially those prevalent among children and the young population—to problems resulting from chronic degenerative diseases at older ages. The prevalence of classic risk factors has increased in recent decades, with the exception of smoking, and cannot explain the observed decreases in mortality rates. Therefore, other factors could explain this decrease; including the social determinants of health [3]. The World Bank classifies countries according to their economy into high-income, middle-income, and low-income. These categories are widely used in the context of the implementation of global actions for health promotion [4]. Non-communicable diseases (NCDs) accounted for 35 million deaths in 2005 (60 % of the total) worldwide, and 80 % of these deaths occurred in low- and middle-income countries, with the expectation of a 20 % increase between 2006 and 2015 [4]. A major problem in emerging and third world countries is the low investment in healthcare, particularly for the prevention of chronic diseases. This scenario has improved in many countries, including Brazil, with respect to communicable diseases, including AIDS, rheumatic fever, and Chagas disease [2].
Another aspect to be considered is the demographic transition of the world population, which involves population aging, particularly in developing countries. This transition will bring profound changes in the epidemiological planning of the population as well as in government welfare actions and disease prevention and healthcare programs [4–5].
Social Determinants
Since the establishment of the World Health Organization in 1948, health has been defined as a state of complete physical, mental, and social development and not merely the absence of disease [4].
In the first International Conference for the Promotion of Health conducted on November 21, 1986 in Ottawa, a letter of intent known as the Ottawa Charter was drafted with the aim to promote improvement of the health of the world’s population. This letter stressed that the improvement of health conditions would require the allocation of core resources to health, including those for the promotion of peace, shelter, education, food, income, stable ecosystems, sustainable resources, social justice, and equity [4].
Subsequently, a Commission of Social Determinants of Health was established by the WHO in 2005 to address the social factors responsible for inequalities in health. The main objective was to draw the attention of governments and society to the development of better social conditions for health, especially for those populations living in vulnerable conditions [4].
These actions are focused on the key risk factors that can significantly decrease the incidence of atherosclerotic diseases and other non-communicable diseases. The target risk factors were tobacco use, high blood pressure, increased cholesterol levels, and diabetes mellitus, whose incidence has increased significantly in recent years because of populational aging and the increased prevalence of obesity [6]. Other contributing factors include low socioeconomic status, physical inactivity, poor diet, obesity, insulin resistance, and family history of early coronary disease [7].
Other diseases, including Chagas disease and rheumatic heart disease, are closely associated with the socioeconomic level of the country and with the uncontrolled urbanization of major urban centers, leading to poverty, malnutrition, improper housing, and overcrowding, among other problems [8, 9].
Social and economic determinants not only affect the occurrence and distribution of traditional risk factors but also directly influence the biological mechanisms closely associated with cardiovascular pathogenesis (e.g., low birth weight and the chronic impairment of neuroinflammatory processes). Due to the limited knowledge of the relationship between social sciences and neuropsychology and how these determinants interact in the regionalization of biological vulnerability to diseases, the advancements in this field have been limited [10].
One of the most important determinants that should be addressed for the prevention of cardiovascular diseases is social inequality, considering the internal socioeconomic differences in certain countries. The socioeconomic status (SES) has four main characteristics, which were described by Link and Phelan [11]: influence of multiple diseases, influence of SES on disease outcomes through multiple risk factors, access to resources (or loss of resources) that can prevent risks and disease outcomes, and the association between the fundamental cause of health-related problems and health conditions, which, over time, may be replaced by predisposing factors (lifestyle, behavior, and strategies aimed to minimize social inequalities).
The migration of knowledge from individual-based determinants of disease to determinants based on socioeconomic indicators, particularly low socioeconomic status, poverty, and loss of benefits from social interaction, was achieved by understanding how these determinants affect prevalence, morbidity, and disease outcomes, particularly mortality, because this understanding is essential for resource allocation for disease prevention, treatment, and longevity in multiple population groups [12].
Phelan et al. observed that the incorporation of new knowledge of the risk factors that affect multiple non-communicable diseases, including the effect of smoking on cardiovascular and neoplastic diseases, and the incorporation of new technologies, including antiretroviral therapy and surgical procedures for the treatment of ischemic heart disease, produced the most benefits for the reduction of mortality and morbidity among the population groups with higher socioeconomic status [13].
A systematic review of 20 studies published between 1998 and 2010 on social inequalities in health and disease prevention in Germany showed a significant association between morbidity, mortality, horizontal inequalities (age, gender, marital status, and nationality), and vertical inequalities (occupation, education, and income) [14]. The INTERHEART study analyzed the association between risk factors and myocardial infarction in men and women and indicated that psychosocial factors, together with diabetes, dyslipidemia, smoking, obesity, and high blood pressure, were the major causes of myocardial infarction [15].
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