Urbanization and cardiovascular disease

Urbanization, simply defined, is the shift from a rural to an urban society. The world is urbanizing at a rapid pace and it is estimated that by 2050 seven out of 10 people will live in cities.  While some characteristics of urban settings may lead to a better quality of life, rapid growth and unplanned urbanization have created cities that in many ways hinder an individual’s ability to live healthily. Where an individual lives, works, plays, and what they eat affects their cardiovascular health.

An individual’s exposure to certain cardiovascular disease (CVD) risk factors, which include tobacco use, physical inactivity, obesity and unhealthy diets/inadequate nutrition, is highly influenced by their socioeconomic status and the environment in which they live. Poverty, lack of education, and unplanned urbanization can increase exposure to risk factors, and in turn have a negative impact on heart health. Within this, children are particularly impacted due to their unique vulnerabilities.

Quick facts:

• CVD is the number one cause of death worldwide causing 17.3 million deaths
  • Over 80% of these deaths take place in low- and middle-income countries (LMICs).
• CVD deaths occur almost equally in men and women.
• By 2030 almost 23.6 million people are predicted to die from CVD
• CVD places a substantial burden on national economies.
  
  • In China annual direct costs are estimated at more than USD 40 billion (4 per cent of gross national income).
• Increasing urbanization threatens the current and future heart health of children and the amount of the world population living in urban areas is increasing:
  • 10 per cent of the world’s population lived in cities in 1900 50 per cent live in cities today
  • 75 per cent will be living in cities in 2050
• The rise of CVD in LMICs has been linked to progressive urbanization and the globalization of unhealthy lifestyles which are facilitated by urban life.
• Foetal development and nutrition during infancy and early childhood affects risk for developing CVD later in life.

The negative impacts of urbanization on cardiovascular health:

• Cities in developing countries are urbanizing at a rapid rate without much foresight.
• This has led to the creation of cities with unequal distribution of goods with some areas having insubstantial housing conditions and low access to healthcare services, healthy foods and safe, green places for outdoor activity that are free of environmental toxins and pollutants.
• Crowded city living environments can spread diseases such as rheumatic fever, which if left untreated can cause rheumatic heart disease.
• Considering the major CVD risk factors, city dwellers are more likely to be exposed to marketing schemes and advertisements for unhealthy foods, tobacco and alcohol. 
• Cities tend to have higher levels of particulate matter air pollution, exposure to which increases the risk for developing and dying from CVD.

Impact of urbanization on physical inactivity:

• Built urban environments may discourage physical activity and encourage sedentary habits:
  • Construction of cities that promote transport by car rather than transport by foot or bike discourage daily physical activity
  • 93 per cent of students who have regular access to television watch it for an average of three hours a day
  • Lack of safe green spaces within cities, particularly the low-income areas, hinders the ability to be physically active outside
    

The impact of urbanization on under- and over-nutrition:

• Urbanization encourages individuals to forego traditional cooking and turn to prepared and heavily processed convenience foods that are often high in sugar, salt, saturated and trans fats leading to an increase in CVD risk.
• Gaining calories from sugar and fats has become cheaper and more accessible than fruit, vegetables, grains, beans or lentils.
• Worldwide, poor communities are often hurt most by unhealthy diets:
  • 35 million overweight children are living in developing countries
  • 8 million overweight children are living in developed countries
• Under-nutrition is also found in urban settings, especially in areas of extreme food insecurity. Exposure to under-nutrition during infancy, childhood and adolescence may negatively affect cardiovascular health in adult life.
  

The impact of urbanization on tobacco use:

• Both first-hand use of tobacco and second-hand exposure to smoke increases CVD risk.
• City dwellers are more frequently tobacco users than are rural dwellers.
• Children in cities may be particularly susceptible to second-hand smoke given the number of smokers in urban areas along with crowded living conditions.
• First-hand use of tobacco by children is on the rise and those residing in cities may more vulnerable due to increased access to cigarettes and increased exposure to adverts that encourage smoking.
  

The unique vulnerabilities of children:

• Children can be impacted both directly and indirectly by CVD:
  • Some may suffer from either congenital heart disease (CHD) or an acquired heart disease 
  • Even if they themselves do not have heart disease, children with a family member who suffers from CVD may face food, economic and social insecurity because of it
• Children lack independence to make their own decisions and are most manipulated by their environment.
  

Why act?

• Children are core to global efforts to prevent and control CVD, particularly within urbanizing populations.
  • The behaviour of children now affects the likelihood of a CVD epidemic in future years
• Investments in urban health can create major returns for the economy.
• Children have a right to the highest attainable level of health.
• The health of children is central to achieving the Millennium Development Goals (MDGs).

Solutions

• Taking a life-course (whole of life) approach to CVD prevention:
  • CVD risk can be determined as early as foetal development and the first 1000 days of life.
• Utilizing cities as a leverage point for change by implementing the World Heart Federation S.P.A.C.E. strategy:
  • Stakeholder collaboration: inclusion of all government sectors, the private sector and civil society
  • Planning cities: develop infrastructures that facilitate heart-healthy behaviour
  • Access to healthcare: ensure that the health needs of all members of society are accounted for regardless of economic income
  • Child-focused dialogue: discussions around CVD must focus on children specifically
  • Evaluation: evaluate which city dwellers face which barriers to heart-healthy living and why