Preventing cardiovascular disease. A despondent view

Editor — Both the question raised by Claude Lenfant (1) and the discussion of it made stimulating reading. The crucial issue is whether populations really make serious attempts to change their lifestyle. Undoubtedly, there is a fair appreciation of the risk factors involved. We know we should not overeat; we should eat less fat and more plant foods, especially vegetables and fruit. People should also stop smoking, restrict their alcohol consumption, and considerably increase their level of physical activity. Yet the fact must be faced that there have been very few meaningful responses to the appeals made. Thus, in European populations, there has been generally no fall in fat consumption, which still supplies about 40% of the total energy intake. Moreover, rises in vegetable and fruit consumption have been barely significant.

On the one hand, in many industrialized countries, life expectancy has increased to roughly 75 years for men and 83 years for women. The number of centenarians is increasing considerably. In the African population in South Africa, in 1985 — before the onslaught of HIV/AIDS — the mean survival time was 62 years, closely approaching that of many populations in far richer countries.

On the other hand, in industrialized countries and in measure in urban areas of developing countries, some major risk factors for cardiovascular diseases are rapidly increasing. For example, in the USA, the proportion of obese adults rose from 12% in 1991 to 17.9% in 1998 (2). The proportion of people worldwide with type 2 diabetes is "exploding" and is likely to double in the next 10 years (3). In 1992, diabetes accounted for 15% of the total health care expenditure in the USA (4), and 27% of Medicare costs (5). As for coronary heart disease, while there has been elation over major falls in the mortality rate from the disease in industrialized countries, its incidence has scarcely changed, and it remains the leading cause of death and disability (6).

In summary, the present day challenge is to increase, not so much survival time, but far more importantly, healthy life expectancy or years of "wellness" (7). To bring about meaningful beneficial improvements will require truly heroic efforts, such as those described in a Lancet editorial in 1998 (8). While there is understandable despondency over the continued lack of response, there must be greater publicity concerning the benefits of the various health promotion measures.

Alexander R. P. Walker1 & Ahmed A. Wadee2

Conflicts of interest: none declared.


1. Lenfant C. Can we prevent cardiovascular diseases in low- and middle-income countries? Bulletin of the World Health Organization 2001;79:980-2.

2. Mokdad AH, Serdula MK, Dietz WH, Bowman, BA, Marks JS, Koplan JP. The spread of the obesity epidemic in the United States, 1991-1998. JAMA 1999;282:1519-22.

3. Kopelman PG, Hitman GA. Diabetes. Exploding type II. Lancet 1998;352:Suppl 5.

4. McKinlay J, Marceau L. US public health and the 21st century: diabetes mellitus. Lancet 2000;356:757-61.

5. Clark EM, Fradkin JE, Hiss RG. Promoting early diagnosis and treatment of Type 2 diabetes. JAMA 2000;284: 363-5.

6. Walker ARP. With increasing ageing in Western populations, what are the prospects for lowering the incidence of coronary heart disease? Quarterly Journal of Medicine 2001;94:107-12.

7. Mathers CD, Sadana R, Salomon JA, Murray CJ, Lopez AD. Healthy life expectancy in 191 countries, 1999. Lancet 2001; 357:1685-91.

8. Hard sell for health [editorial]. Lancet 1998; 351:687



1Head, Human Biochemistry Research Unit, School of Pathology of the University of Witwatersrand and the National Health Laboratory Service, PO Box 1038, Johannesburg, South Africa. (email: alexw@mail.saimr.wits.ac.za). Correspondence should be addressed to this author.

2Head, Department of Immunology, School of Pathology of the University of Witwatersrand, Johannesburg, South Africa, and the National Health Laboratory Service.

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