Sri Lankan Heart Disease

• The recent estimates for mortality from CVD (cardiovascular diseases) for Sri Lanka was 524 deaths per 100,000 which is higher than that observed in many high-income countries.¹

• Coronary artery disease (CAD) is the leading cause of death in Sri Lanka while stroke is the third cause of death.^{2, 3} CAD accounted for 34% of deaths in an autopsy study.⁴ For comparison, CAD accounts for only 17% of deaths in the US and UK.⁵

• Between 2005 and 2010 and beyond, exponential increase in hospitalization is projected for three diseases: heart disease 29%, diabetes 36%, and high blood pressure 40%.⁶ Diabetes and CAD are estimated to be the leading cause of morbidity and mortality in the coming years.²

• The CAD risk factors are high and increasing: diabetes 7%, high blood pressure 27%, obesity 18%, high cholesterol 17%, and abdominal obesity 50%.

• Median body mass index (BMI) was 20 units; smoking was very high at 58%; high cholesterol, obesity, and diabetes were more prevalent among urban subjects.³ A large national study in Sri Lanka has demonstrated that living in urban areas is associated with 2-3 fold rate of physical inactivity, obesity, and diabetes.⁷

• A comparison of Sri Lankans who have immigrated from Kandy, Sri Lanka to Oslo, Norway showed striking differences in risk factors. Those living in Oslo had favorable lipid profiles and blood pressure levels despite being more obese; those living in Kandy had worse lipid profiles (higher total/HDL cholesterol ratios) despite having lower rates of obesity and abdominal obesity.⁸  Reduction in saturated fat intake from coconut in those who immigrated to Oslo may have contributed to this paradox.

• The average total fat intake of Sri Lankans is 25 percent of total energy, with 80% of that coming from saturated fat from coconut products (meat, milk, and oil). With regard to the type of dietary fatty acids, Sri Lankans consume 9 times more saturated fats than polyunsaturated fatty acids (PUFAs) compared with the current recommended ratio of less than one.¹

• Neither an excessive total fat intake nor an increase in the more traditional plasma lipid markers, like LDL-C levels could fully explain the increased vulnerability to CVD in this population.¹ Several studies from Sri Lanka have reported high levels of lipoprotein(a).⁹ High homocysteine is common in people with and without CAD.¹⁰

Conventional Risk Factors

• One in five adults in Sri Lanka has either diabetes or pre-diabetes and one-third of those with diabetes is undiagnosed. The rates are double in urban than in rural areas. The projected diabetes prevalence for the year 2030 is 14%. Both diabetes and pre-diabetes is accompanied by other risk factors like dyslipidemia, obesity, and high blood pressure.¹¹

• According to statistics of the National Authority on Tobacco and Alcohol (NATA) smoking kills 50 to 60 people everyday and 15,000-20,000 people annually in Sri Lanka. Approximately 4 billion cigarettes are sold daily in the Sri Lankan market.

• Although coronary procedures (such as angioplasty/stent and bypass surgery) are carried out in Sri Lanka, it is not financially affordable to most Sri Lankans. For instance, a coronary bypass surgery costs around $2000 whereas the average income of a Sri Lankan is around $3362 per annum.²

• Medications are equally expensive with an average cost of a prescription of a patient with diabetes and CAD (containing a cocktail of drugs including statins, oral hypoglycemic agents, and an ACE inhibitor) being around $2000 per annum.

• Moreover, thrombolytic drugs such as streptokinase are not available in most hospitals in Sri Lanka, except for the teaching hospitals and general hospitals.

• Since both primary preventionand secondary prevention is very expensive, it is imperative that preventive measures (regular exercise, healthy eating habits, and most importantly cessation of smoking) should be implemented as soon as possible. Unfortunately, prevention of CVD has not been given much emphasis in the primary health care system in the country.¹²

Sources

1.  Abeywardena MY. Dietary fats, carbohydrates and vascular disease: Sri Lankan perspectives. Atherosclerosis. Dec 2003;171(2):157-161.

2. Mendis S. Coronary risk factors in the Sri Lankan population. Colombo: Ministry of Health, Sri Lanka; 1998.

3. Mendis S, Ekanayake EM. Prevalence of coronary heart disease and cardiovascular risk factors in middle aged males in a defined population in central Sri Lanka. Int J Cardiol. 1994;46(2):135-142.

4. Fernando R. A study of the investigation of death (coroner system) in Sri Lanka. Med Sci Law. Jul 2003;43(3):236-240.

5. American Heart Association. Heart and Stroke Statistical Update2011.

6. Premaratne R, Amarasinghe A, Wickremasinghe AR. Hospitalisation trends due to selected non-communicable diseases in Sri Lanka, 2005-2010. Ceylon Med J. Jun 2005;50(2):51-54.

7. Allender S, Wickramasinghe K, Goldacre M, Matthews D, Katulanda P. Quantifying Urbanization as a Risk Factor for Noncommunicable Disease. J Urban Health. Jun 3 2011.

8. Tennakoon SU, Kumar BN, Nugegoda DB, Meyer HE. Comparison of cardiovascular risk factors between sri lankans living in kandy and oslo. BMC Public Health. 2010;10:654.

9.  Atukorala S, Balagalle S, Jayasinghe S, Thenuwara N. Prevalence of high serum lipoprotein (a) in a selected sample of Sri Lankan adults. Ceylon Med J. Dec 2002;47(4):144-145.

10. Mendis S, Ranatunga P, Jayatilake M, Wanninayake S, Wickremasinghe R. Hyperhomocysteinaemia in Sri Lankan patients with coronary artery disease. Ceylon Med J. Sep 2002;47(3):89-92.

11. Katulanda P, Constantine GR, Mahesh JG, et al. Prevalence and projections of diabetes and pre-diabetes in adults in Sri Lanka–Sri Lanka Diabetes, Cardiovascular Study (SLDCS). Diabet Med. Sep 2008;25(9):1062-1069.

12. Malavige GN, de Alwis NM, Weerasooriya N, Fernando DJ, Siribaddana SH. Increasing diabetes and vascular risk factors in a sub-urban Sri Lankan population. Diabetes Res Clin Pract. Aug 2002;57(2):143-145.