**4. Cost of management of cardiovascular disease in Africa**

In Africa, the cost of management is variable. With regard to hypertension, the overall average daily cost of drug treatment for uncomplicated hypertension is estimated at 368 ± 234.6 FCFA, i.e. 0.68 ± 0.44 dollars, representing more than a third of the daily income (1.90 dollars) [11]. In view of the cost of treatment, the absence of symptoms associated with hypertension is often the cause of non-adherence to treatment. Also, some patients who often reach the stages of complications of CVDs often experience the cost of treatment increased by the additional cost of treating the associated complications [12].

In Africa, 60–70% of health expenditure is paid by households directly to health facilities, compared to a global average of 46%. This may be due to the preponderance of the informal sector (farmers, craftsmen,…) which groups together more than 70% of the African population who are not covered by health insurance. Contrary to those in the informal sector, some African governments are setting up compulsory health insurance systems for the formal sector, civil servants or employees of private companies, financed through employee and employer contributions [13].

#### **5. Poverty, malnutrition and cardiovascular disease: a vicious cycle**

Poverty is one of the socio-economic factors at the root of malnutrition in Africa. The prevalence of malnutrition in SSA rose from 181 million in 2010 to 222 million in 2016 [14]. Poverty and malnutrition are part of a vicious circle. Poverty

*Lifestyle and Epidemiology - The Double Burden of Poverty and Cardiovascular Diseases...*

the age of degenerative and man-made diseases.

prevention and improvement of the management of CVD.

their impact on morbidity and mortality.

**3. Poverty in Africa**

its meaning [2]. The transition process according to Omrad was in three ages or phases [2]: The age of pestilence and famine, the age of receding pandemics, and

The age of pestilence and famine is characterized by a period of high infant and child mortality with a low mean life expectancy of less than 30 years. This stemmed from the high rate of malnutrition and infectious diseases or communicable disease like tuberculosis, pneumonia, and diarrheal diseases in Africa; with less than 10% of the mortality rate due to cardiovascular diseases [2, 3]. The age of receding pandemics is characterized by an improvement in public health policies and nutrition patterns leading to a decrease in the rate of infant and child deaths from to malnutrition and infectious diseases. This decrease in mortality was accompanied by a rise in the life expectancy from 30 to 50 years or more [2, 3]. The age of degenerative and man-made diseases is marked by an excessive intake of fat and calories with a decrease in physical activity leading to the emergence of non-communicable diseases (NCDs) such as ischemic heart diseases and heart failure. An increase in life expectancy as a result of a reduction in the mortality rate of infectious or communicable diseases tremendously marked the age of degenerative and man-made diseases. On the other hand, there is a higher death rate shift in NCD, more specifically cardiovascular diseases (CVDs). The death rate due to CVDs varies between 35 and 65% of the overall mortality rate [2, 3]. The challenges entail strengthening the

Low- to middle-income countries (LMICs) in Sub-Saharan Africa (SSA) are of the epidemiological transition process [4]. A 20-year assessment of the disease burden in SSA between 1990 to 2010 shows a decline in premature mortality and disability attributable to neonatal, nutritional and maternal communicable diseases, including lower respiratory infections and diarrhoeal diseases [4]. It is worth mentioning that there were communicable diseases that occur permanently with the same high mortality rate over these 20 years-periods [4]. With only 12% of the world's population in Africa, Africa bears a considerable proportion of the global burden of tuberculosis, HIV/AIDS and malaria with rates of 31%, 62% and 70% respectively [5]. Besides communicable diseases, the disease burden due to NCDs is not trivial. Between 1990 to 2010, the disease burden from several NCDs increased, particularly stroke, depression, diabetes, and ischemic heart disease [4]. An assessment made in SSA from 1990 to 2017 shows a 67% growth in the total number of disability-adjusted lives (DALYS) due to NCDs (90.6 million in 1990 and 151.3 million in 2017) [6]. The increment in NCDs in SSA was mainly flued by CVDs, ranked as the second leading cause of the NCD burden in 2017, resulting in 22.9 (21.5–24.3) million DALYs (15.1% of the total NCD burden), after the group of disorders categorized as other NCDs (28.8 million [25.1–33.0] DALYs, 19.1%) [6]. This data show the progressive and increasing installation of NCDs in Africa and

Poverty is a multidimensional concept. According to the United Nations Development Programme (UNDP), poverty is not only the lack of income necessary to meet food and non-food needs (clothing, energy, housing) but also a lack of basic human capabilities (illiteracy, malnutrition, reduced life expectancy, poor maternal health, illness) [7]. Therefore poverty should not be considered only under the spectrum of financial income; as a result, the concept of poverty is difficult to quantify. But for a global assessment of poverty, a monetary scale has been developed as a common denominator between the different regions of the world in

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leads to malnutrition, especially maternal malnutrition, which causes low birth weight, stunted infants and adolescents. These individuals will be disadvantaged later in life because they may show a reduction in physical and mental development leading to low skills and reduced human capital. Competence is one of the faculties developed through adequate nutrition of children and adolescents. Wachs has defined competence as the ability to adapt and interact with one's environment [15]. Human capital refers to well-nourished, healthy, educated, skilled and alert individuals - an improved human condition - resulting in a workforce that could be the most productive asset of any country. However, the absence of this productivity, particularly economic productivity, perpetuates poverty [16]. Alongside poverty, we also have a trend towards the Westernization of the African lifestyle, which is not the least compounding factor for the emergence of CVDs in Africa.

The African population is experiencing an increasing rate of urbanization, with a shift in migration from rural to urban areas, with changes in lifestyle habits in particular, as the traditional diet rich in fruits and vegetables is gradually being replaced by a diet rich in calories densed foods from snacks, sweetened beverages, animal fats and low in complex carbohydrates. This change in diet is accompanied by weight gain (overweight and obesity) and a decrease in physical activity due to the abolishment of traditional agriculture for sedentary work [9]. This change in lifestyle is contributing to an increase in the prevalence of cardiovascular risk factors in Africa, with a tendency to equalize the prevalence in high-income countries. The prevalences of some cardiovascular risk factors in SSA are given below in comparison with high-income countries (HICs): Smoking rates are 10% in SSA versus 30% in HIC; hypertension prevalence in individuals ≥18 years old is 30% in SSA (40% in urban and 20% in rural populations) versus 20% in HIC; diabetes mellitus prevalence in persons aged above 17 years is 7.1% in adult males and females in SSA compared with up to 8% in males and up to 6% in women in HIC. Also, dyslipidemia prevalence in adults is 25% in SSA versus 40–60% in HICs; physical inactivity prevalence is 22% in SSA versus 29–40% in HIC; and obesity whose prevalence rates are variable in SSA and higher among women (2–40%) compared with men (1–15%) versus 18–35% in women and 12–30% among men in HIC [17]. Poverty has several consequences, including the development of communicable and non-communicable diseases.

In the 1980s, a real revolution in the understanding of chronic diseases in adults was initiated with the pioneering work of an English epidemiologist named David Barker. During an observational study, he found that regions of UK that had a high rate of cardiovascular mortality, also had a high infant mortality rate [18]. Then a meticulous study of patients with NCDs [18], allowed him to put forward a hypothesis on the "origin of the development of health and disease" or early origin of adult diseases based on the premise that environmental factors during foetal life have a considerable impact on the susceptibility to various pathologies later in life of these exposed persons [18]. More precisely; malnutrition occuring in utero permanently changes the body's structure and function in ways that "programme" the appearance of disease in childhood, adolescenthood or adulthood [18].

At present it has been recognized that malnutrition during pregnancy is the cause of an alteration in the fetus in the short term of the programmed metabolism of carbohydrates and lipids and of the functions of the genes. In the long term, these changes will lead to reduced cognitive development, decreased educational performance, compromised immunity, lower physical capacity and an increased risk of several NCDs [18–21]. The physiopathological mechanisms by which foetal malnutrition can lead to NCDs are better elucidated to date. Gluckman and collaborators have shown that malnutrition is responsible for a modification of gene expression via epigenetic modification by methylation of foetal DNA. They

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*Lifestyle and Epidemiology: Poverty and Cardiovascular Diseases a Double Burden in African…*

hypothesized that the changed genetic expression may change physiological set points that will eventually change the way individuals respond to environmental exposures later on their lives [22]. The management of CVDs management leads to

Direct costs are related to chronic diseases and these costs entail the direct payment by patients for cardiovascular healthcare services, cardiovascular investigation tests (12-led electrocardiogram, Holter electrocardiogram, stress electrocardiogram, heart ultrasound, transesophageal ultrasound) and medications for CVDs. Patients with CVDs are often confronted with a dilemma: to suffer and possibly die without treatment, or to seek treatment and drag their families into poverty. The situation is particularly serious for people with long-term chronic CVDs such as chronic heart failure, stroke survivals with significant physical disabilities because the costs of medical care is often life-long and relatively expensive. Indirect costs are a reduction in income subject to illness due to loss of productivity resulting from illness or death; the cost of time spent by adult members of the family household caring for those who are ill. There is also the loss of income that will result from the sale of goods necessitated by the need to meet direct costs and unpredictable expenses, and the missed opportunities for children who are forced to give up school to care for sick adults or contribute to the family economy [21]. Hence, CVDs will not only have a detrimental effect on the income of the patients with CVDs, but also on that of the family; subsequently, there will be with a marked pejorative impact on the economy of different African nations resulting in a drop in

**6. Prevention of cardiovascular diseases and insurance health system of** 

According to the WHO, primary prevention of CVDs is defined as measures put in place to decrease the incidence of cardiovascular events (ischaemic heart disease and strokes) in individuals at risk of CVDs who have not yet developed overt or clinical CVDs. Efforts geared at preventing recurrent clinical cardiovascular events in individuals with CVDs are called secondary prevention [22]. Reports have shown the beneficial impacts of pharmacological interventions in primary and secondary the prevention of CVDs, though with caveats for population-based interventions. The need for economic assessment of these studies to identify those which have best value for money is paramount in inform decision making by health policy makers in designing a health system insurance policy [23]. Furthermore, WHO projects that by 2030, NCDs will overtake all other causes of mortality in all Africa [24]. With the increasing CVDs burden in Africa, the AHN was created in 2001. The AHN is a joint collaboration of various cardiovascular societies and national heart foundations sharing the same agenda: curbing CVDs in Africa, thereby improving the cardiovascular health for all Africans. The vision of the AHN is to play a leading role in the prevention and reduction of the burden related to CVDs, including cerebrovascular accident to halt from no longer being the major etiology of disability and premature death in the African continent. The AHN shares the vision of the World Heart Federation (WHF), the main organization of national and continental cardiovascular societies and foundations globally. The WHF's global target of '25 by 25' represents the objective of decreasing premature deaths caused by CVDs by 25% by the year 2025—an interim goal addressed by the Sousse' Declaration of 2018 [25]. The objective of the AHN held in Tunisia in 2018

direct and indirect costs, thus perpetuating the vicious circle of poverty.

*DOI: http://dx.doi.org/10.5772/intechopen.95785*

the economy of the African continent.

**6.1 Prevention of cardiovascular diseases**

**African countries**

*Lifestyle and Epidemiology: Poverty and Cardiovascular Diseases a Double Burden in African… DOI: http://dx.doi.org/10.5772/intechopen.95785*

hypothesized that the changed genetic expression may change physiological set points that will eventually change the way individuals respond to environmental exposures later on their lives [22]. The management of CVDs management leads to direct and indirect costs, thus perpetuating the vicious circle of poverty.

Direct costs are related to chronic diseases and these costs entail the direct payment by patients for cardiovascular healthcare services, cardiovascular investigation tests (12-led electrocardiogram, Holter electrocardiogram, stress electrocardiogram, heart ultrasound, transesophageal ultrasound) and medications for CVDs. Patients with CVDs are often confronted with a dilemma: to suffer and possibly die without treatment, or to seek treatment and drag their families into poverty. The situation is particularly serious for people with long-term chronic CVDs such as chronic heart failure, stroke survivals with significant physical disabilities because the costs of medical care is often life-long and relatively expensive. Indirect costs are a reduction in income subject to illness due to loss of productivity resulting from illness or death; the cost of time spent by adult members of the family household caring for those who are ill. There is also the loss of income that will result from the sale of goods necessitated by the need to meet direct costs and unpredictable expenses, and the missed opportunities for children who are forced to give up school to care for sick adults or contribute to the family economy [21]. Hence, CVDs will not only have a detrimental effect on the income of the patients with CVDs, but also on that of the family; subsequently, there will be with a marked pejorative impact on the economy of different African nations resulting in a drop in the economy of the African continent.
