Socioeconomic Status (SES)  

• Worldwide, CVD (cardiovascular diseases) claims 17.5 million lives annually. Of these, 20% of deaths occurred in high-income countries, 8% in upper-middle income countries, 37% in lower-middle income countries, and 35% in low-income countries including India. There is epidemiological evidence that health transition is occurring rapidly in low and middle income countries, where CAD (coronary artery disease) is more prevalent among the illiterate and low socioeconomic subjects.¹

• Although self reported surveys such as the National Family Health Survey-3 and World Health Survey suggest that wealthier persons have a higher prevalence of CVD risk factors such as diabetes and obesity, well-designed studies show that risk for heart attack is more than double among the uneducated, the undereducated, and the poor.^{2, 3}

• Many of the traditional CAD risk factors such as smoking, tobacco use, low physical activity, high dietary saturated fat intake, uncontrolled blood pressure, uncontrolled high cholesterol, and diabetes are more common among those in the low SES.^{1, 4} Besides, the poor has a low risk factor awareness and control.⁵ They also lack support mechanisms and financial resources for evidence-based treatment and follow up for heart attacks.^{2, 3} All these results in 50% higher mortality among the poor as compared to the rich who suffer a heart attack.⁶

• Asian Indians in the UK have a lower SES than Europids and have a lower level of cholesterol than Europids; yet they have a 3 to 4-fold higher chance of  having high-risk lipid profile even after controlling for cholesterol, SES, age, and sex.⁷

• Asian Indians with low SES have a higher prevalence of CAD and its risk factors such as smoking and high blood pressure.⁸ However, differences in SES do not explain the excess burden of CAD among Asian Indians, unlike all other populations.^{9, 10} In general, uneducated and less educated people in rural India have a higher prevalence of high blood pressure, alcohol use, underweight, and low intake of fruits and vegetables.^{4, 11, 12}

• A higher prevalence of risk factors is present in those in the high SES group even in rural areas.¹² Obesity, dyslipidemia (cholesterol problems), diabetes (men only), and high blood pressure (women only) were more prevalent in people of higher SES.¹² Obesity was inversely related to SES with 35% of women in the highest SES being obese compared with 13% in the lowest.¹² However, smoking, was more than double in the low SES group (37% vs. 15%).¹²

• Although patients treated at tertiary care and teaching hospitals receive relatively better evidence-based care, the poor and the rural populace are inadequately treated.^{5, 13}  The WHO PREMISE Study has documented that close to half of acute coronary syndrome (ACS) patients and stroke patients in India do not receive evidence-based medicine.¹⁴

• Similarly, the “Treatment and outcomes of acute coronary syndromes in India” (CREATE) Registry highlighted the fact that the poor are less likely to get evidence-based prescriptions after ACS due to the high cost of the drugs and coronary interventions.⁶

• When compared with wealthier patients, smaller proportions of poor patients received key treatments as shown in Figure 017.⁶ Poor patients also had greater 30-day mortality (8% vs 6%). These differences disappeared after statistical adjustment for in-hospital treatment, suggesting that provision of evidence-based secondary prevention may play a large role in improving survival among ACS patients.⁶

• Data shows that access and affordability for acute care managements and long-term secondary prevention practices and compliance are lacking in these subjects. These attributes forecast a grim scenario for the evolving epidemic of CAD in India (see Tsunami of Heart Disease).¹

• The Indian gross domestic product (GDP) is projected to increase from $1 trillion in 2006-07 to $2 trillion in 2011-12 and the per capita GDP would increase from $1,090 to $1,662 or Rs. 75,000. This translates into <$5 a day or Rs 205 per day (Financial Times Express March 2, 2011).

• For comparison, the per capita income in the US is $39,626 with wide variation among the 50 states. The highest is in Connecticut (55,000) and lowest in Mississippi (30,000) and Illinois in the middle (42,000) according to the 2010 census.

• Heart disease was once a disease of the rich but not anymore. Currently heart disease is a disease of the poor in the rich countries and disease of the rich in poor countries.^{1, 5, 15}

Sources

1. Gupta R, Gupta KD. Coronary heart disease in low socioeconomic status subjects in India: “an evolving epidemic”. Indian Heart J. Jul-Aug 2009;61(4):358-367.

2.  Gupta R, Gupta VP, Sarna M, Prakash H, Rastogi S, Gupta KD. Serial epidemiological surveys in an urban Indian population demonstrate increasing coronary risk factors among the lower socioeconomic strata. J Assoc Physicians India. May 2003;51:470-477.

3. Ajay VS, Prabhakaran D, Jeemon P, et al. Prevalence and determinants of diabetes mellitus in the Indian industrial population. Diabet Med. Oct 2008;25(10):1187-1194.

4. Gupta R, Kaul V, Agrawal A, Guptha S, Gupta VP. Cardiovascular risk according to educational status in India. Prev Med. Nov 2010;51(5):408-411.

5. Vamadevan AS, Shah BR, Califf RM, Prabhakaran D. Cardiovascular research in India: a perspective. Am Heart J. Mar 2011;161(3):431-438.

6.  Xavier  D, Pais P, Devereaux PJ, et al. Treatment and outcomes of acute coronary syndromes in India (CREATE): a prospective analysis of registry data. Lancet. Apr 26 2008;371(9622):1435-1442.

7. Whitty CJ, Brunner EJ, Shipley MJ, Hemingway H, Marmot MG. Differences in biological risk factors for cardiovascular disease between three ethnic groups in the Whitehall II study. Atherosclerosis. 1999;142(2):279-286.

8. Gupta R, Singhal S. Epidemiological evolution, fat intake, cholesterol levels and increasing coronary heart disease in India. Paper presented at: National Symposium on Hyperlipidemia; 21 March 1997, 1997; New Delhi.

9. Forouhi NG, Sattar N, Tillin T, McKeigue PM, Chaturvedi N. Do known risk factors explain the higher coronary heart disease mortality in South Asian compared with European men? Prospective follow-up of the Southall and Brent studies, UK. Diabetologia. Nov 2006;49(11):2580-2588.

10. Lip GY, Barnett AH, Bradbury A, et al. Ethnicity and cardiovascular disease prevention in the United Kingdom: a practical approach to management. J Hum Hypertens. Mar 2007;21(3):183-211.

11. Gupta R, Gupta V, Ahluwalia N. Educational status, coronary heart disease, and coronary risk factor prevalence in a rural population of India. BMJ. 1994;309(6965):1332-1336.

12. Kinra S., Bowen LJ, Lyngdoh T, et al. Sociodemographic patterning of non-communicable disease risk factors in rural India: a cross sectional study. BMJ. 2010;341:c4974.

13. Karthikeyan G, Xavier D, Prabhakaran D, Pais P. Perspectives on the management of coronary artery disease in India. Heart. Nov 2007;93(11):1334-1338.

14. Mendis S, Abegunde D, Yusuf S, et al. WHO study on Prevention of REcurrences of Myocardial Infarction and StrokE (WHO-PREMISE). Bull World Health Organ. Nov 2005;83(11):820-829.

15. Hoeymans N, Smit HA, Verkleij H, Kromhout D. Cardiovascular risk factors in relation to educational level in 36 000 men and women in The Netherlands. Eur Heart J. 1996;17(4):518-525.