1. The Rise in Cardiovascular Risk Factors & Chronic Diseases in Guyana
A narrative literature review
A Presentation By: Loshana Sockalingam
M.Sc. Candidate
Medical Sciences Graduate Program
Division of Nutrition & Metabolism
Supervisor: Dr. S. Anand

2. Methods & Sources of data
Key Search Terms
Population, mortality, cardiovascular disease, type 2 diabetes, diabetes mellitus, hypertension, obesity, overweight, diet, nutrition, physical activity, smoking, alcohol, ethnicity, race, health risks, risk factors, health, South Asian, Indian, African, Amerindians, mixed race, Portuguese, Chinese, Whites, Indo-Guyanese, Afro-Guyanese, Indigenous, heart disease, life expectancy, Guyana, non-communicable disease, prevalence, incidence, health outcomes, burden of disease, trends, morbidity, government statistics, screening programs, treatment programs, primary prevention, health promotion
Search Limiters
Country: Guyana
Language: English
Publication Date: last 18 years ( )
Databases
Scholars Portal Journals, PubMed and Google Scholar as well as government health agency reports
Table 1: Summary of search terms, search limiters, databases, and inclusion and exclusion criteria for published literature search

3. Background

5. geographic Georgetown 10 regions Capital of Guyana Region 4
41.7% of total population
10 regions
Hinterland (10.9%)
Coastal (89.1%)

6. Ethnic composition East Indian (39.8%) African (29.3%)
Mixed-race (19.9%)
Amerindians (10.5%)
Portuguese (0.3%)
Chinese (0.2%)
White (<0.1%) backgrounds
* Based on 2012 statistics

7. Figure 1: National distribution of Guyana by ethnicity, 2002 & 2012
2002
746,955
2012
742,300
2017

8. Age & sex distribution
2012
371,805 men (49.8%)  29% >20 years of age
375,150 women (50.2%)  30% >20 years of age
The percentage of women over the age of 20 was consistently higher than men
Higher suicide rate (46.6/100,000 men vs 14.2/100,000 women) – 2016
Traffic accident deaths (74%)

9. *Women live ~6 years longer*
Life expectancy
69 years vs 63 years
2011
73 years vs 67 years
2016
71 years vs 64 years
2017
72 years vs 66 years
*Women live ~6 years longer*

10. Non-communicable diseases in guyana

11. Introduction
Guyana experiences health challenges related to non-communicable diseases (NCDs)
The main cause for the increased prevalence of NCDs are
Modifiable risk factors (e.g. obesity, hypertension, elevated cholesterol, diabetes, low physical activity, and unhealthy dietary patterns)
Non-modifiable risk factors (e.g. age and genetics)
Among both men and women, the most common NCD in Guyana is cardiovascular disease (CVD)

12. Mortality of NCD A rise in the burden of NCDs
Leading cause of death
822 deaths / 100,000 individuals / year
Most common: Cardiovascular Disease (CVD)
526 deaths / 100,000 individuals / year

13. Primary causes of death
2002
2003
2004
% Deaths (N=5003)
% Deaths Men (N=2906)
% Deaths Women (N=2097)
% Deaths (N=4986)
% Deaths Men (N=2898)
% Deaths Women (N=2088)
% Deaths (N=5141)
% Deaths Men (N=2929)
% Deaths Women (N=2212)
Diabetes Mellitus
7.8
5.0
11.6
7.3
5.6
9.7
7.5
5.4
10.2
Ischemic and other Heart Disease
11.2
11.1
11.3
13.9
14.4
13.2
14.5
13.6
15.6
Hypertensive Diseases
4.1
3.0
5.7
3.9
3.2
4.7
4.8
3.6
6.4
Cerebrovascular Disease
10.5
10.3
10.9
12.0
10.1
11.8
Source: Bureau of Statistics (BOS), Guyana, 2008
Table 2: The primary causes of death in relation to sex in Guyana

14. prevalence of NCD Leading causes of death Indo-Guyanese Afro-Guyanese
CVD
Diabetes
Cancer
Indo-Guyanese
CVD (35% vs 30.2%)
Diabetes (10.4% vs 7.3%)
Afro-Guyanese
CVD (25.6% vs 19.7%)
Cancer (12.7% vs 10.1%)
Amerindians
Cancer (13.5% vs 7.8%)
Cerebrovascular Disease (11.2%)
Diabetes (7.8%)

15. In the americas Country (Year)* Cardiovascular Disease
Ischemic Heart Disease
Cerebrovascular Disease
Region of the Americas (2007)
167.9
71.7
37.3
Guyana (2006)
291.9
104.4
87.6
Puerto Rico (2007)
121.0
57.9
24.8
Trinidad & Tobago (2007)
288.5
128.5
77.8
Cuba (2009)
205.4
93.0
55.8
Suriname (2007)
215.3
62.9
99.4
Venezuela
246.1
123.8
64.1
* Latest year available for each country 2 1 3 1 1 2
Table 3: Mortality rates (age-adjusted rate/100,000) due to CVD, IHD and cerebrovascular disease of Selected Countries in the Americas

16. Trends in cvd risk factors

17. CVD Risk Factors Hypertension Diabetes Diet Physical Activity Obesity
Smoking
Alcohol
Physical Activity
Diet

18. Population attributable risk
Hypertension
Diabetes
Obesity
Smoking
Alcohol
Physical Activity
Diet
IHD
23.4%
12.3%
33.7%
36.4%
13.9%
25.5%
12.9%
Stroke
47.9%
3.9%
18.6%
12.4%
5.8%
35.8%
23.3%
Yusuf S, Hawken S, Ounpuu S et al. Effect of Potentially Modifiable Risk Factors Associated with Myocardial Infarction in 52 Countries (the INTERHEART study): Case-Control Study. The Lancet 2004;364(9438): doi:
O’Donnell MJ, Chin SL, Rangarajan S et al. Global and Regional Effects of Potentially Modifiable Risk Factors Associated with Acute Stroke in 32 Countries (INTERSTROKE): A Case-Control Study. The Lancet 2016;388(10046): doi:

19. hypertension Second leading cause of morbidity
: ~ 15,000 new cases are diagnosed
: prevalence ↑ 32%
Women have a higher rate of death

20. Heart Attack or Heart Problem
hypertension
Health Problems
Age by Race (%)
19-29
30-39
40-49
50 and older AG IG
M/O
Hypertension
4.8
12.9
3.6
17.1
10.1
19.4
22.2
30.5
25.7
39.5
45.9
44.6
Stroke
0.0
1.2
4.2
6.0
5.4
Heart Attack or Heart Problem
2.4
2.8
2.5
2.9
7.9
11.9
10.7
Diabetes
1.6
5.7
4.3
8.3
12.2
11.4
16.8
25.9
Abbreviations: Afro-Guyanese (AG), Indo-Guyanese (IG) and Mixed/Other Guyanese (M/O)
Source: Wilson et al (2004) Family Processes and Health in Guyana.
Table 4: The age specific prevalence of chronic illnesses in Guyana in relation to ethnicity

21. diabetes 2012: 64, 800 adults were diagnosed; many remain undiagnosed
~ 2000 new cases each year
74% diagnosed <65 years of age
2017: ↑ 10.3% prevalence

22. Heart Attack or Heart Problem
diabetes
Health Problems
Age by Race (%)
19-29
30-39
40-49
50 and older AG IG
M/O
Hypertension
4.8
12.9
3.6
17.1
10.1
19.4
22.2
30.5
25.7
39.5
45.9
44.6
Stroke
0.0
1.2
4.2
6.0
5.4
Heart Attack or Heart Problem
2.4
2.8
2.5
2.9
7.9
11.9
10.7
Diabetes
1.6
5.7
4.3
8.3
12.2
11.4
16.8
25.9
Abbreviations: Afro-Guyanese (AG), Indo-Guyanese (IG) and Mixed/Other Guyanese (M/O)
Source: Wilson et al (2004) Family Processes and Health in Guyana.
Table 4: The age specific prevalence of chronic illnesses in Guyana in relation to ethnicity

23. obesity In 2010 Education = ↓ % overweight and obese
11% and 12% underweight
26% and 23% overweight
22% and 9% obese
Education = ↓ % overweight and obese
Wealth = ↑ % overweight and obese
Higher education and wealth = highest prevalence of overweight or obese

24. Smoking
Women: 3% (15-49) use cigarettes and <1% use other tobacco products
Men: 29% (15-49) smoke cigarettes, 3% use tobacco products and <1% use a pipe
With age, % of women and men smoking ↑
1%  7% 40-44
8%  45% 40-44
2013
15% of the population smoke
More men (35%) than women (4%)

25. Smoking
Urban women (5%) have a higher percentage of smoking vs rural women (2%)
Urban men (23%) have a lower percentage of smoking vs rural men (32%)
Education and wealth have no impact on women
Men with secondary school or higher education and in the highest wealth category are the least likely to smoke

26. alcohol Moderate alcohol intake is associated with a ↓risk of MI
Binge drinking ↑ risk of MI and stroke
BAC = ≥ 0.08 grams
2010: the prevalence of binge drinking is 6.1%
1.7% vs 10.7%
2017: alcohol use ranked 6th in the top 10 risks contributing to disability-adjusted life year

27. Physical activity Men are more physically active
Upbringing
However, gender differences vary by region
Rural communities – men and women have similar physical activity patterns

28. diet Associated with MI and stroke
Fruit, vegetable and legumes ↓ risk of CVD
Refined grains and high carbohydrate intake ↑ risk of CVD

29. Diet (1970) Typical Guyanese diet Ethnic differences
Starch (rice, yams, sweet potatoes, breadfruit, plantains, corn flour and wheat flour)
↓ protein
Moderate sugar; used as a sweetener
Main fat was coconut oil; butter/margarine used on bread occasionally
Ethnic differences
Afro-Guyanese: ↑ rice, ground provisions and coconut
Indo-Guyanese: ↑ flour, peas and spices
Amerindians: ↑ cassava, beef, beans and local fruit and vegetables
Ashcroft et al (1970)

30. Diet (>2010) Traditional diet  energy-dense diet
Processed foods and beverages = Western diet
Food consumption pattern depicts the lifestyle of developed countries
Animal-based
More sugar and fats

31. Next steps

32. Epidemiological transition
Nutritional deficiencies and infectious diseases  degenerative diseases (CVD, cancer and diabetes)
5 stages
Age of pestilence and famine
Age of receding pandemics
Age of degenerative and man-made diseases
Age of delated degenerative diseases
Age of health regression and social upheaval
Yusuf et al (2001)

33. Epidemiological transition
Nutritional deficiencies and infectious diseases  degenerative diseases (CVD, cancer and diabetes)
5 stages
Age of pestilence and famine
Age of receding pandemics
Infectious disease ↓
Nutrition improved
Hypertensive disease prevalence ↑
Age of degenerative and man-made diseases
Life expectancy is improved
High-fat diet, smoking and sedentary lifestyle ↑
NCD prevalence ↑
Age of delated degenerative diseases
Age of health regression and social upheaval
Yusuf et al (2001)

34. urbanization The migration towards a Western environment
↑ consumption of energy-rich foods
↓ energy expenditure
High burden of CVD attributed to the
↑ in urbanization  Changes to lifestyle  ↑ exposure to risk factors
Prevention
↓ energy intake
↑ physical activity
Avoid tobacco
Avoid alcohol
Maintain a balanced diet

35. Figure 4: Pathway for the development of cardiovascular disease in Guyana

36. Primary prevention programs for cvd risk factors
Prevention is linked to the
Reduction of risk factors
Promotion of a healthy lifestyle
Population-based health promotions
Government implemented programs
Guyana Nutrition Strategy
Basic Nutrition Programme
MPOWER
National Strategy for Prevention and Control of Chronic Diseases
Aim to
Reduce risk factors
Integrate disease management
Increase surveillance
Improve public policy

37. Primary prevention programs for cvd risk factors
Achievements
Smoke-free indoor public spaces
Multi-sector food and nutrition plan
Ongoing physical activity campaigns
Change risk factor promoting behaviours
Population-based health promotions
Risk awareness campaigns
i.e. mass media advertisements
A need for effective screening and treatment programs

38. limitations
CVD and risk factor information differentiated by gender, age and ethnicity is limited
Data is not publicly available and out-dated
Latest available census is from 2012 (PAHO, MOH and WHO)
Ethnic incidence and prevalence of CVD is scarce
Ethnic-specific data is CRUCIAL

39. Future research Focus on specific groups
Rural populations
Highest risk ethnic groups
Ethnic distribution of CVD and risk factors
Socioeconomics
Dietary
Genetic
Environmental
Ethnic information is useful to focus prevention and screening programs

40. conclusion CVD ↑  ↑ CVD risk factors
Ethnic differences exist across the 7 risk factors examined
More research is needed to understand the ethnic disparities
Unless effective preventative strategies are implemented, the incidence of CVD and its risk factors will continue to rise
Education about healthy active living
Early screening
Early treatment
Improve access to cardiac testing and interventions

42. References (Part 1 of 2)
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43. References (Part 2 of 2)
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