The landscape of preventive cardiology in Turkey: Challenges and successes





Abstract


Turkey, like many countries, is facing a growing burden of non-communicable disease (NCD)s and is among the countries with high cardiovascular mortality in Europe. Moreover, Turkey currently has the highest rate of premature cardiovascular disease (CVD) in Europe. During the last decades, Turkey made fundamental reforms in the health system to improve the treatment of risk factors to prevent CVD. The most outstanding success was in the area of tobacco control (13.4% decrease in smoking prevalence) and decreasing the salt consumption of the population (from 18 to 9.9 g/day) leading to a significant decrease in CVD mortality from 45% to 36.8% of all deaths. However, obesity and diabetes are increasing rapidly as a result of urbanization, low physical activity and unhealthy eating and the new generation is starting to take up smoking. The increase in cardiometabolic risk factors and aging of the population are expected to increase the number of CVD deaths. All CVD risk factors except smoking are significantly more prevalent in women. In addition, rare disease is a country specific problem with a significant contribution to the high rates of premature CVD in Turkey. Despite major improvements in management in acute coronary syndromes, sustained achievement in guideline recommended goals is suboptimal. In patients with a previous cardiovascular event smoking rate is 25.5%, 80.9% of these patients are overweight (BMI ≥25 kg/m 2 ), 30% obese (BMI ≥30 kg/m 2 ), and LDL‐cholesterol targets of 70 mg/dL are attained in only 18%. Herein, we scrutinize the achievements and challenges of Turkey in establishing a ‘National Heart Health Policy’ aiming to decrease the burden of CVD and its risk factors.


Graphical abstract





With preventive efforts and modern treatments post-myocardial infarction mortality decreased 50% during the last 20 years. For risk factors smoking and hypertension are decreasing however, obesity and diabetes are on rise. *Smoking is defined as current smokers or those who quit smoking less than 1 year before the assessment. Hypertension was defined as raised blood pressure (BP) (Systolic BP ≥ 140 and/or Diastolic BP ≥ 90 mmHg) or currently on medication for raised BP. STEPS survey defined individuals with raised FBG > 126 mg/dL or currently on anti-diabetic medication as diabetes mellitus.



Introduction


There has been a dramatic increase in deaths from non-communicable disease (NCD)s globally in the last decades. The most recent European Cardiovascular Statistics show that cardiovascular disease (CVD) is still the leading cause of mortality in Europe especially in middle income countries . Turkey is a developing Eurasian country located in the Eastern Mediterranean Region with a population of 85 million. The median age is 32.4 years and while 54% of the population is still under the age of 30 years, the population is aging rapidly ( Fig. 1 ). Demographical projections suggest that half of the population will be over the age of 34 years and 10.2% will be over the age of 65 years in 2023 .




Fig. 1


Population Pyramids of Turkey according to gender (%), years 2007–2019.


Turkey, like many countries, is facing a growing burden of NCDs and is among the countries with high cardiovascular mortality in Europe [ , ]. CVD has been the leading cause of all deaths by 40% in 1989, 45% in 1993, 40% in 2009, 38% in 2012, 39.5% in 2017, 37.8% in 2018, and 36.8% in 2019 in Turkey . Age adjusted coronary heart disease (CHD) mortality rates fell between 1995 and 2008 parallel to the falls reported in Western countries . These reductions were mostly attributed to a better control of risk factors like smoking, high blood pressure, and modern therapies (Graphical Abstract). However, due to aging of the population and increasing rates of diabetes and obesity; mortality due to CVD is projected to increase by about 2.3 times in males and about 1.8 times in females by 2030 [ , ]. Furthermore, Turkey currently has the highest rate of premature myocardial infarction (MI) below the age of 50 in Europe and the mean age at the index coronary event is almost 10 years younger .



Major cardiovascular risk factors


The most prevalent risk factors in Turkey are hypertension, tobacco use, obesity, hypercholesterolemia, and diabetes [ , ]. Except for smoking, all of these risk factors are significantly more common in women than in men. There are several national surveys conducted in Turkey to determine the prevalence of major risk factors in the adult population. Among these Turkish Adults Risk Factors Study (TARF) − the earliest and longest epidemiological study was a comprehensive cohort study that evaluated CVD and its risk factors in Turkey from 1992 to 2016 [ , ]. More recently, Turkish Society of Cardiology (TSC) conducted meta-analyses enrolling epidemiologic studies with low bias and high representativeness of the country population distribution using data from the past 15 years . These meta-analyses revealed an overall prevalence of hypertension 31.2%, smoking 30.3%, hypercholesterolemia 29.1%, diabetes 14.6%, obesity 28.5%, and metabolic syndrome 43.3%. Finally, the Ministry of health (MoH) conducted two household surveys in the years 2011 and 2017 [ , ]. The latter was conducted in cooperation with World Health Organization (WHO) (STEPwise approach to surveillance) (STEPS 1 Survey). Currently STEPS2 survey is underway. The primary aim of STEPS, which covers all NCDs and risk factors, is to gather all the basic data pertaining to risk factors to start and maintain the chronic disease surveillance . Table 1 shows the crude prevalence of major CVD risk factors generated from the TSC meta-analysis of last 15 years’ studies, National Household Survey 2011, and WHO-STEPSI Survey of Turkey.



Table 1

Crude prevalence of major cardiovascular risk factors in Turkey. There are 3 data sets presented below: (1). the pooled values that are obtained from a recent meta-analysis of epidemiological studies conducted in Turkey during the last 15 years , (2) 2011-Household study conducted by ministry of Health , and (3) 2017- Household Study conducted by Ministry of Health and WHO (STEPSI) .











































































Meta-analysis conducted
by TSC
2011-Household Study
(aged > 15 years)
2017- Household Study STEPSI
(aged > 15 years)
Overall Women Men Overall Women Men Overall Women Men
Smoking * 30.3% 15.7% 46.1% 30% 17% 43% 31.5% 19.7% 43.4%
Obesity (BMI≥30 kg/m 2 ) 28.5% 33.2% 18.2% 24.1% 31.1% 16.2% 28.8% 35.9% 21.6%
Hypertension ⁎⁎ 31.2% 36.0% 30.0% 24.0% 26.0% 21.0% 27.7% 29.3% 26.1%
Diabetes mellitus ⁎⁎⁎ 14.6% 16.5% 14.3% 11.1% 11.4% 10.8% 11.1% 11.5% 10.6%
Hyperlipidemia ⁎⁎⁎⁎ 29.1% 30.2% 27.8% 28.4% 29.6% 26.9% 24.7% 28.5% 20.9%

BMI: Body mass index, LDL: Low density lipoprotein, TSC: Turkish Society of Cardiology.

Smoking is defined as current smokers or those who quit smoking less than 1 year before the assessment for all studies. The major fall in smoking rates between 2008 and 2012 were not sustained thereafter.


⁎⁎ Hypertension prevalence is based on medical history and measurements in Meta-Analysis and on medical history and measurements in 2011 National Household Survey. Hypertension was defined as raised blood pressure (BP) (Systolic BP ≥ 140 and/or Diastolic BP ≥ 90 mmHg) or currently on medication for raised BP in STEPS Surveys.


⁎⁎⁎ Diabetes mellitus is defined as fasting blood glucose (FBG) ≥ 126 mg/dL and/or being on anti-diabetic medication in Meta-analysis. For 2011 household Study, diabetes was defined as diabetes and medication history, and/or FBG ≥ 126 mg/dL. STEPS survey defined individuals with raised FBG ≥ 126 mg/dL or currently on anti-diabetic medication as diabetes mellitus.


⁎⁎⁎⁎ Hypercholesterolemia is defined as; LDL-cholesterol ≥130 mg/dL and/or cholesterol lowering medication in Meta-analysis and 2011 National Household Survey. STEPS 1 used the total cholesterol (≥ 190 mg/dL) or currently on medication for raised cholesterol criteria for defining hypercholesterolemia.




Smoking


Smoking is still the most important risk factor in Turkey despite major efforts to combat tobacco use. Turkey is the first country in the world to implement the full range of policies to address each of WHO’s M-P-O-W-E-R (MPOWER) strategies to reduce tobacco use . After a national smoking ban, several campaigns and programs, prevalence of smoking decreased significantly and rapidly in a relatively short period of time – especially between 2008 and 2012. During that period, an impressive success was gained in tobacco control, and smoking rates decreased by 13.4% with a set of consistently implemented, wide-ranging policies to reduce the demand for tobacco including tax increases, large health warnings on cigarette packages, bans on advertising, promotion and sponsorship campaigns within mass media, and smoke-free policies in public buildings, working environments, and transportation [ , , , ]. Sale of tobacco products to individuals below 18 years of age was banned, and a free national 24 h quit-line service was introduced. Exposure to secondhand smoke in restaurants fell from 55.9 to 12.7% in 8 years [ , , , ]. Declines in exposure to second-hand smoke were also seen in workplaces, public transportation, government buildings, and even in homes.


Despite this initial success, with the termination of active campaign against smoking, the smoking rate has started to rise again due to the new generation taking up the smoking habit. Findings from the 2012 Global Adult Tobacco Survey indicated that there were 14.8 million smokers in Turkey (MoH, 2014) putting Turkey the tenth among the countries in which tobacco is consumed the most. Smoking prevalence declined between 2008 and 2012 for both men and women to become 41.5% for men and 13.1% for women by 2012. Currently, Turkey’s adult smoking rate is 31.5%, [ , ]. Smoking rate (aged ≥ 15 years) in men is still much higher than in women (43.4% versus 19.7%, respectively) and the age group with the highest smoking rate is 30–44 years (41.8%) [ , ].



Lifestyle-related risk factors


The unfavorable lifestyle-related risk factors are increasing with urbanization and globalization. Obesity, high salt /sodium consumption, and low level of physical activity are all prevalent and are all higher than the average values for Europe [ , ]. There have been efforts to reduce unhealthy dietary foods, including the adoption of policies on salt including elimination of saltshakers from the restaurant tables, saturated and trans fats, and restrictions on food marketing. As a result of these campaigns, the mean salt intake declined from 18 to 9.9 g/day between 2011 and 2017 and 75.6% of the overall population is aware of the importance of lowering dietary salt intake . However, more than a quarter of the population (28.1%) is still automatically adding salt to the food before tasting . Despite being a Mediterranean country, 87.8% of the population has a consumption level lower than the recommended amount of five servings per day of fruit and vegetables . The average fruit and vegetable consumption is 4.6 and 5.1 days per week, respectively. Overall, the awareness of the health benefits of fruit and vegetable consumption is only 30%.


In general, physical activity level is far from being ideal; 43.6% of the population has insufficient physical activity, defined as < 150 min of moderate-intensity activity per week (33.1% for men and 53.9% for women) . Half (49.4%) of the population were reported to be mildly active, and only 24% engaged in intense level of physical activity [ , ]. Daily median activity duration is 30 min with a 4.3 to 90 interquartile range. Around a quarter (29%) of physical activity is work-related; over half (59.5%) is transport-related and only an eighth is recreational (12.5%). Men significantly have more daily physical activity than women (51.4 min for men and 17.1 min for women].



Obesity


Obesity has significantly increased in the past decade as the inevitable result of unhealthy eating and low level of physical activity with 64.4% of the adult population being overweight (62.8% of men and 66% of women) and 28.8% obese (21.6% of men and 35.9% of women) [ , ]. Turkey has one of the highest obesity (BMI≥ 30 kg/m 2 ) rates in Europe ( Fig. 2 ). Average waist circumference is 91.3 cm for males and 87.9 cm for females . The TURDEPII study has calculated the cut-off points of waist circumference of 90.5 cm in women and 95.5 cm in men for increased CVD risk in adult Turkish population . The same study showed a high abdominal visceral obesity prevalence of 53% in the general population (female 64%, male 35%) in 2010 whereas 12 years before the prevalence of abdominal obesity was 34% (female 49%, male 17%) TURDEP I . A survey on childhood obesity revealed that the prevalence of obesity among children aged 7–8 years was 23.3% in boys and 21.6% in girls. Lack of physical activity, consuming unhealthy food, increased screen time over 2 h/day in 40% of children and decreased playtime less than an hour a day in a third of the children are the main reasons for childhood obesity in Turkey [ , , ].




Fig. 2


International Comparison of the prevalence of obesity with body mass index (BMI) ≥ 30 kg/m 2 , Source : Ministry of Health, 2010; WHO, 2012.


The Ministry of Health has prioritized public education and awareness campaigns on physical activity and childhood obesity [ , ]. An action plan to restrict marketing and media advertisements of unhealthy food and restricting sale of unhealthy foods in school canteens has been introduced and public education campaigns have been launched [ , , , ]. A recent step has been to standardize the infant/baby formulas to restrict salt and sugar and increase campaigns to encourage breast feeding up to 2 years. All these precautions have helped to blunt but not control the increase in childhood obesity [ , ].



Hypertension


Hypertension is prevalent, with a third of the adult Turkish population having high blood pressure [ , ]. The recent WHO National Household Survey -STEPSI showed that hypertension was more common in women than in men (29.3% women and 26.1% men) in Turkey . The same survey revealed that 13.6% of the adult population had never had their blood pressure measured. The adherence to the blood pressure lowering drugs was low; half the patients with blood pressure over 140/90 mmHg were not on antihypertensive medications.


To combat hypertension, measures to reduce salt intake and awareness campaigns targeting blood pressure and unhealthy lifestyles have been carried out in the past two decades. This has helped to increase the awareness of hypertension among patients with hypertension from 40.7% to 54.7% and proportion of patients on antihypertensive medication from 31.1% to 47.7% [ , ]. A corresponding improvement was attained at the control rate of high blood pressure in treated patients from 20.7% to 53.9% . Factors associated with better control of hypertension were younger age, female sex, residing in an urban area, and higher education level . Despite these efforts, the number of hypertensive patients is still unacceptably high.



Diabetes mellitus


The prevalence of diabetes has increased significantly in the past 20 years from 7% of the adult population to 14.6% of the population [ , , , ]. Diabetes prevalence is very high compared to the rest of the world and Turkey is accepted as the country with highest prevalence of diabetes in Europe ( Fig. 3 ) . In the recent WHO National Household Survey -STEPSI 17.3% of the adults had fasting plasma venous glucose ≥ 126 mg/dL or HbA1c ≥ 6.5% or were currently on medication for raised blood glucose (16.3% for men and 18.3% for women) . Diabetes is associated with age, waist circumference, BMI, hypertension in women and age, BMI, and hypertension in men . Furthermore, nearly one in three people in Turkey have metabolic syndrome [ , , ].


Jul 16, 2021 | Posted by in CARDIOLOGY | Comments Off on The landscape of preventive cardiology in Turkey: Challenges and successes
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