Determinants of Cardiovascular Disease in the 21st Century- -Insights from Two Diverse Populations

Abstract

Seminal work by Ancel Keys established the critical role of elevated cholesterol in explaining population differences in rates of CVD. Subsequent work added hypertension and smoking, and major progress has been made in controlling all three. Despite this, world-wide rates of CVD are increasing, and in the US, there are persistent population disparities. We have conducted longitudinal cohort studies in two uniquely-informative populations in order to evaluate the determinants of CVD. The Strong Heart Study is a population based sample of American Indians. Although little CVD was observed in the mid 20 th century, rates of both CHD and stroke now exceed those in other US populations. Most events are in persons with diabetes; renal impairment is another major risk factor. Both obesity and diabetes lead to CVD risk factors and preclinical disease at young ages. The GOCADAN (Genetics of Coronary Artery Disease in Alaska Natives) and ASP (Alaska-Siberia Project) studies involve populations of Alaska Eskimos. Once thought to have little CVD, they now manifest high rates of CHD, stroke and heart failure. Obesity and diabetes in this population are lower than US averages, especially in men. However rates of smoking and subclinical infection are high and there has been a dramatic change from their unique traditional diet and physical activity patterns. These two groups serve as models for the many populations now experiencing increases in CVD. For those with epidemics of obesity and diabetes, control of the inevitable CVD will require both aggressive management of CVD risk factors and reversing the trends in obesity and diabetes. In other populations, perhaps in less developed areas, control of CVD may depend on aggressive smoking cessation and on efforts to facilitate lifestyle transitions.