Introduction:

Modifiable and non-modifiable risk factors contribute to the significant rise of non-communicable
diseases (NCDs), most notably cardiovascular disease (CVD), in the Pacific Island nations. The aim of this
study is to review previously published articles to understand common modifiable and non-modifiable
risk factors of CVD among Pacific countries. Methods: This systematic review is conducted using
different databases including; Scopus, Medline, EMBASE, and psycINFO. This systematic review is based
on the Cochrane review process. All articles published in the English language from 1st January 2000 to
1st September 2016, will be included in the study. After reviewing all of the articles’ titles, abstracts, and
full text, the final articles were reviewed and the relevant data was included in the data extraction
sheet. A descriptive analysis was conducted to measure the common risk factors of CVD in Pacific
countries. Results: Overall, 45 articles met the inclusion criteria of the study. The results showed that
age was the most common non-modifiable risk factor while diabetes, high blood lipid, and high blood
pressure were the most common modifiable risk factors of CVD. There were only three interventional
studies which had all of the significant influences in reducing the risk factors of CVD when the results
were compared with the control group. Conclusion: While it is not possible to change the non-
modifiable risk factors for CVD, we encourage policy makers to use the results of this study to develop
health promotion strategies to address the modifiable risk factors for CVD. Interventional strategies are
highly recommended in the Pacific countries to tackle the modifiable risk factors for CVD.

Non-modifiable risk factors are:

age

ethnic background

family history of heart disease.

Age

The older you are, the more likely you are to develop coronary heart disease or to have a cardiac event

(angina, heart attack or stroke).

Ethnic background

South Asians living in the UK are twice as likely to develop coronary heart disease compared to the rest
of

the UK population. Also, people from African Caribbean backgrounds have a higher than average risk of

developing high blood pressure.

But remember that you can still reduce your risk as much as possible by controlling your other risk
factors.

Family history

Your own risk of developing coronary heart disease is increased if:

your father or brother was diagnosed with the disease, or had a cardiac event under the age of 55
your mother or sister was diagnosed with the disease or had a cardiac event under 65.

If you have a family history of heart disease, it may help to reduce your own risk if you look at what the
risk

factors affecting your family member were. Ask yourself:

Did they smoke?

Were they overweight?

Did they have a diet high in saturated fat?

Were they physically inactive?

Did they have diabetes?

If the answer is yes to one or more of these, then you can reduce your risk by making sure your lifestyle
is not

the same as theirs.

Some risk factors, such as being overweight, are sometimes related to lifestyle habits that are passed on

from one generation to the next. However, it’s also likely that genes are responsible for passing on the
risk of

developing coronary heart disease. Genes can also pass on other conditions, such as high blood pressure
or

high cholesterol levels. Both of these conditions increase the risk of getting coronary heart disease.

.1 Modifiable behavioral risk factors

Tobacco

Globally, almost 6 million people die from tobacco use each year, from either direct tobacco use or

secondhand smoke exposure. By 2020, this number is expected to increase to 7.5 million or 10% of all

deaths. Smoking is estimated to cause about 71% of lung cancer, 42% of COPD, and nearly 10% of

cardiovascular disease. It is responsible for 12% of male deaths and 6% of female deaths. Now, death

rates for smoking-related diseases are lower in low-income countries than in middle- and high-income

countries, reflecting the past trends in consumption. However, the impact of smoking-related diseases
on

mortality in low- and middle-income countries will continue to rise for at least two decades, even if

successful efforts to reduce smoking are made.18

There are about 145 million tobacco smokers in the Americas. The prevalence of current adult tobacco

use varies widely across the Region, from 38% in Chile to 9.4% in Panama.19 Although most of the
Region’s

smokers are men, tobacco use is increasing in women, especially at younger ages.20 Of all the WHO

regions, the smallest gap between male and female tobacco consumption is in the Region of the

Americas, with it being only about 1.5 times more common for men than for women.21

In the high-income countries of the Americas, tobacco use caused 470,000 deaths, and in the middle-
and

low-income countries 271,000 deaths, according to PAHO calculations based on data taken from the
2009

WHO Global Health Risks document.

Insufficient physical activity

Insufficient physical activity is the fourth leading risk factor for mortality. Globally, almost 3.2 million

deaths and 32.1 million DALYs each year are attributable to this risk factor.22

Physical activity has been customarily measured as related to the practice of sport of structured
exercise.

Usually, countries with high levels of sport participation rarely reach levels above 30% of people

considered “physically active.” However, in recent years, after the development the International
Physical

Activity Questionnaire (IPAQ), it has become possible to ascertain the contribution to physical activity in

several other domains such as domestic, work and transportation physical activity. Now, increasing

attention is being paid to “active transportation.” The example below, from the last national nutrition

survey in Colombia (2010), shows that among men the level of physical activity is 63.5% and among

women 46.1%. Interestingly, two thirds of those levels are contributed by transport-related physical

activity (Figure 3).23

In brief, most current data collection only captures leisure time physical activity. Using that
measurement

approach, between 10% and 40% of adults reach the recommended minimum 150 minutes of moderate

physical activity per week.

The prevalence of insufficient physical activity rises with country income. High-income countries have

more than double the prevalence compared to low-income countries, for both men and women. These
data may be related to higher levels of activity related to work and transportation in the low- and
lowermiddle-income

countries. In the Region of the Americas 30% to 60% of the population do not achieve

even the minimum level of recommended physical activity.24

Some evidence indicates that girls are less likely to engage in physical activity than are boys, and that

sports opportunities for girls are limited.25

Harmful use of alcohol

The harmful use of alcohol is a major risk factor for premature deaths and disabilities around the world.

Hazardous and harmful drinking was responsible for 2.3 million deaths worldwide in 2004.26 More than

half of these deaths occurred as a result of NCDs. In the Americas in 2004, over 347,000 deaths were

attributed to alcohol, with 42% of alcohol deaths coming from cardiovascular diseases, liver cirrhosis,

cancers, and diabetes. Harmful use of alcohol is also the leading risk factor for the burden of disease in

the Region, with 16 % of the DALYs related to NCDs.

At about 8.1 liters, the average per capita consumption of pure alcohol in the Region of the Americas is

50% higher than the global average. The pattern of drinking is, on average, of heavy episodic drinking.

Men drink more often and in higher quantities on average and with a higher frequency of episodic heavy

drinking than do women in almost all countries in the Region, and young people drink more than do
older

people. Also in general, increasing economic standing equates to increases in alcohol consumption in
the

Americas.27

Unhealthy diet

The populations in the Americas have undergone a “diet transition.” This change has been characterized

by increased consumption of high-calorie foods and of more highly processed foods (rich in salt, sugars,

and fat). In addition, there is lower consumption of staple foods (such as maize/white corn and beans)

and inadequate consumption of fruits and vegetables.

28
The amount of dietary salt consumed is an important determinant of blood pressure levels and overall

cardiovascular risk as well as renal disease. The current overall levels of salt†

consumption in the Region of

the Americas, as in the rest of the world, well exceed the daily physiological need.‡

The INTERSALT study,

performed in 1985-87, provided standardized estimates from 32 countries, of which 7 were from the

Americas. In addition, the INTERMAP study (1996-99) included salt intake data from the United States.

Unfavorably high salt intake levels are prevalent in many countries of the Americas. Recent estimates of

dietary and urinary sodium indicate this is true for Brazil (4,500 mg of sodium/day, or 11.25 g of
salt/day),

Argentina (4,800 mg of sodium/day, or 12.0 g of salt/day), Chile (3,600 mg of sodium/day, or 9.0 g of

salt/day), and the United States (3,466 mg of sodium/day, or 8.66 g of salt/day). Sources of dietary

sodium vary, from 75% of it coming from processed food in the United States and Canada, to 70%
coming

from discretionary salt added in cooking or at the table in Brazil.29

There is convincing evidence that saturated fats and trans fats increase the risk of coronary heart
disease

and that replacement with monounsaturated fats and polyunsaturated fats reduce the risk. There is also

evidence that the risk of type 2 diabetes is directly associated with consumption of saturated fat and
trans

fat and inversely associated with polyunsaturated fat from vegetable sources.

There are large variations across regions of the world in the amount of total fats available for human

consumption, with the Region of the Americas having one of the highest rates for saturated fatty
acids.30

It is worth noting that even though information is still incomplete, it has been estimated that the

consumption of trans fats may be approximately 2% to 3% (4.5-7.2 g/d) of the total intake of calories in

the United States, 3% (7.2 g/d) in Argentina, 2% (4.5 g/d) in Chile, and 1.1% (2.6 g/d) in Costa Rica.

31
One of the main drivers of the diet transition is food marketing targeted to children. There are
systematic

reviews showing that this is a public health threat that requires attention and public policies to control

it.32, 33 Among the key conclusions from previous research on this topic are that:

(1) various marketing

communication strategies are used to market food to children around the world;

(2) most of the

marketing activity is for foods high is calorie content, sugar, salt, and fat;

(3) children are exposed to a

multifaceted marketing mix, which is not only intense but is also a powerful, effective tool for gaining

The word “salt” is used to refer to sodium and the term “reducing dietary salt intake” implies the

reduction of total sodium intake from all dietary sources including, for example, additives such as

monosodium glutamate and other sodium-based preservatives or taste enhancers.

Conversions: 5 g salt (NaCl) = 2,000 mg sodium = 87 mmol sodium = 87 mEq sodium.

brand loyalty among youth; and

(4) there is compelling evidence that food and beverage advertising on

television influences children’s preferences, purchase requests, consumption patterns, and health. That

evidence led WHO to propose 12 major recommendations on marketing food and nonalcoholic
beverages

to children during the 2010 World Health Assembly.

MODIFIABLE PREDISPOSING RISK FACTORS

Smoking:

Smoking is considered as strong risk factor for

myocardial infarction, premature atherosclerosis and

sudden cardiac death. Smoking results in early

STEMI especially in otherwise healthier patients.

Smoking causes an average of 7 years earlier and

more likely twice the chances of infarction than non smokers.

Physical activity:
Inactive people with multiple cardiac risk factors are

more likely to develop MI. To get benefit, these

individuals should start from modest exercise

training. There should be aggressive risk factor

modification before performance of vigorous activity.

LDL and triglyceride levels:

Elevated triglyceride levels and dense, small LDL

particles act as predisposing risk factors for MI. Non

fasting triglyceride levels appear to be a strong and

independent predictor of future risk of MI,

particularly when the total cholesterol level is also

elevated. The reason behind it is that decreased

HDL-C levels and increased triglyceride levels cause

metabolic perturbations thus causing adverse

consequences. To identify high risk individuals,

-MODIFIABLE PREDISPOSING RISK FACTORS

Increasing Age

Older adults are more likely to die of heart disease.

About 80% of heart disease deaths occur in people

aged 65 or older.

Gender

Men tend to have heart attacks earlier in life than

women. Women's rate of heart attack increases after

menopause but does not equal men's rate. Even so,

heart disease is the leading cause of death for both

men and women.

Heredity/Family history:

Increased risk if a first degree blood relative has had

coronary heart disease or stroke before the age of 55

years for male relative and 65 years for female

relatives.

Genetic factor:

Coronary artery disease and myocardial infarction

are the most frequent causes of death.

Modify Risk Factors

Risk factors are traits related to the development and progression of heart disease. By decreasing your
risk factors, you can improve your long term survival and quality of life.

Risk factors can be divided into:

Non-modifiable risk factors - risk factors you cannot change

Modifiable risk factors - those you can change

Non-modifiable Risk Factors

Male gender. The risk of heart attack is greater in men than in women, and men have heart attacks
earlier in life than women. However, at age 70 and beyond, men and women are equally at risk.

Advanced age. Coronary artery disease is more likely to occur as you get older, especially after age 65.

Family history of heart disease. If your parents have heart disease (especially if they were diagnosed
with heart disease before age 50), you have an increased risk of developing it.

These help define your basic likelihood for developing heart disease. If you have any non-modifiable risk
factors, it is even more important to work on the risk factors you can change:

Modifiable Risk Factors

Stop cigarette smoking and the use of tobacco products

Smoking is directly related to an increased risk of heart attack and its complications. If you smoke, ask
yousssr doctor about counseling, nicotine replacement medications and programs to help you quit. You
and your family should try to avoid second hand smoke.

Lower high blood cholesterol

A high-fat diet can contribute to increased fat in your blood. Ask your doctor to have a measurement of
your fasting lipid measurement. Follow a low-fat, low-cholesterol eating plan. When proper eating does
not control your cholesterol levels, your doctor may prescribe medications. Most patients with coronary
artery disease should target a LDL cholesterol less than 70 - 100 mg/dl and an HDL more than 40 mg/dl.
Control high blood pressure

High blood pressure can damage the lining of your coronary arteries and lead to coronary artery disease.
Check your blood pressure on a regular basis. Most patients with coronary artery disease should target a
systolic blood pressure of less than 130 mm Hg. A healthy diet, exercise, medications and controlling
sodium in your diet can help control high blood pressure.

Maintain tight diabetes control

High blood sugars are linked to the progression of coronary artery disease. If you have diabetes, it is
important to maintain a HbA1c less than 7 percent. You can control high blood sugar through
monitoring blood sugars, diet, exercise, and medications.

Learn more about diabetes.

Follow a regular exercise plan

A regular exercise program helps to regain or maintain your energy level, lower cholesterol, manage
weight, control diabetes and relieve stress. Check with your doctor first before beginning an exercise
program. if safe, 30 minutes per day of sustained aerobic exercise is recommended.

Achieve and maintain your ideal body weight

Obesity is defined as being very overweight with a body mass index (BMI) of greater than 30. When you
are very overweight, your heart has to do more work, and you are at increased risk of high blood
pressure, high cholesterol levels and diabetes. Ask your doctor what your ideal weight should be. A
healthy diet and exercise program aimed at weight loss can help improve your health.

Learn more about weight management.

Control Stress and Anger

Uncontrolled stress or anger is linked to increased coronary artery disease risk. You may need to learn
skills such as time management, relaxation, or yoga to help lower your stress levels.

Eat a diet low in saturated fat and cholesterol

Ask your doctor, based on your lipid results, how strict your diet should be. Most people should eat a
low fat diet (less than 7 percent of calories from saturated fat). A registered dietitian is a good source for
dietary information.
Reference

1. Alwan A. Global status report on noncommunicable diseases 2010. Geneva:World Health

Organization;2011.

2. Lock K, Pomerleau J, Causer L, Altmann DR, McKee M. The global burden of disease attributable to
low consumption of fruit and vegetables: implications for the global strategy on diet. Bull World
Health Organ. 2005;83:100–108. [PMC free article] [PubMed]

3. Reddy K, Srinath SY. Emerging epidemic of cardiovascular disease in developing countries.

Circulation . 1998;97:596–601. [PubMed]

4. Colin M, Ma Fat D, Boerma JT. The global burden of disease: 2004 update. Geneva: World Health
Organization, 2008.

5. Leeder S, Raymond S, Greenberg H. A race against time: The challenge of cardiovascular disease in
developing economies. New York: Trustees of Columbia University; 2004.

6. Sani MU, Wahab KW, Yusuf BO, Gbadamosi M, Johnson OV, Gbadamosi A. Modifiable
cardiovascular risk factors among apparently healthy adult Nigerian population – a cross sectional
study. BMC Res Notes. 2010;3:11. [PMC free article] [PubMed]

7. Lloyd-Jones D, Adams R, Carnethon M, De Simone G, Ferguson TB, Flegal K. et al. Heart disease and
stroke statistics—2009 update a report from the American Heart Association Statistics Committee and
Stroke Statistics Subcommittee. Circulation. 2009;119:e21–e181. [PubMed]

8. Adarsh K, Kaur H, Devi P. Coronary artery disease in women: How does it differ from men? JIACM.
2013;14:149–53.

9. Scott M, Grundy PR, Greenland P, Smith S, Fuster V. Assessment of cardiovascular risk by use of
multiple-risk-factor assessment equations. J Am Coll Cardiol. 1999;34:1348–59. [PubMed]

10. Abramson B. Hormone replacement therapy and cardiovascular disease. JOGC. 2002;24:577–82.
[PubMed]

11. Nasir K, Budoff MJ, Wong ND, Scheuner M, Herrington D, Arnett DK. et al. Family history of
premature coronary heart disease and coronary artery calcification: Multi-Ethnic Study of
Atherosclerosis (MESA) Circulation. 2007;116:619–26. [PubMed]

12. Joan S, Evans KA. The increased risk of death from ischaemic heart disease in first degree relatives
of 121 men and 96 women with ischaemic heart disease. J Med Genet. 1966;3:239–257. [PMC free
article] [PubMed]