ABSTRACT Introduction: Modifiable and non-modifiable risk factors contribute to the significant
rise of non-communicable diseases (NCDs), most notably cardiovascular disease
(CVD), in the Pacific Island nations. The aim of this study is to review previously
published articles to understand common modifiable and non-modifiable
risk factors of CVD among Pacific countries. Methods: This systematic review is
conducted using different databases including; Scopus, Medline, EMBASE, and
psycINFO. This systematic review is based on the Cochrane review process. All articles
published in the English language from 1st January 2000 to 1st September 2016,
will be included in the study. After reviewing all of the articles’ titles, abstracts, and
full text, the final articles were reviewed and the relevant data was included in the
data extraction sheet. A descriptive analysis was conducted to measure the common
risk factors of CVD in Pacific countries. Results: Overall, 45 articles met the inclusion
criteria of the study. The results showed that age was the most common
non-modifiable risk factor while diabetes, high blood lipid, and high blood pressure
were the most common modifiable risk factors of CVD. There were only three interventional
studies which had all of the significant influences in reducing the risk factors
of CVD when the results were compared with the control group. Conclusion: While it is not possible to change the non-modifiable risk factors for CVD, we encourage
policy makers to use the results of this study to develop health promotion
strategies to address the modifiable risk factors for CVD. Interventional strategies are
highly recommended in the Pacific countries to tackle the modifiable risk factors for
Cardiovascular disease (CVD) is a lifestyle disease that is defined as heart and blood vessel disease, also known as heart disease, which is related to atherosclerosis [1).
Globally, according to the World Health Organization (WHO), an estimated 16.7 million people die from CVD annually. Of the total deaths, about 8.6 million are women and 4.5 million are men  . In Canada, an estimated 8 million deaths are caused by CVD  . In the United Kingdom, an estimated 245,000 deaths occur as a result of CVD  . The burden of CVD is not only affecting developed countries, instead the burden is worldwide. According to WHO (2009), 16.6 million deaths attributed to CVD worldwide. 80% of deaths are in the developing countries, including Pacific regions  . The prevalence of CVD in the Pacific was 21.1% in 2011 with an increasing trend  . For instance, 26.2% of Samoan diabetic adults had CVD  .
Some of the identified risk factors of CVD in the world are; high blood pressure, rapid acculturation and improvement in economic conditions, economical transition, increased tobacco use, high blood lipids, physical inactivity, over-weight and obese, diabetes and poor nutrition   . In the Asia-Pacific regions there was also some research done to identify some of the major risk factors for CVD. For instance, Asian Pacific Countries Society (APCS) identified obesity, diabetes, dyslipidemia and hypertension as risk factors for CVD in the Asia-Pacific regions  . Furthermore, according to  , the study identified five other risk factors which are chiefly; socio-demographic, economical transition, elevated blood pressure, cigarette smoking, lipids and excess body weight. It has also been found that different ethnic groups have their own risk behaviors for CVD   .
Based on the literature review, there was no systematic review study in the Pacific identifying the risk factors or determinants of CVD. Therefore, the main purpose of this systematic review is to identify the determinants of CVD existing in the Pacific region as a platform for the Pacific Island Countries (PIC) to develop their own health promotion and prevention strategies on how to tackle the identified risks in the future. On the other hand, as we know CVD has a greater impact to the developing nation hence, to reduce the burden from happening we have to identify the risk as possible in-order to find solution on how to promote and prevent people life.
Finally, 31 articles were included in the review. The bibliography of those articles were reviewed and 14 articles were added so 45 studies were considered for the final study. All relevant information was extracted and included in the data extraction sheet. The data extraction sheet was in four parts including the study, participants, methodology, and results (Appendix 1 and Appendix 2). A descriptive analysis was conducted using frequency and percentage to measure the common risk factors of CVD in Pacific countries.
The pooled number of people in 45 studies was 10,376,734. The result of the study shows that eight studies focused on older people aged 50 years old and over. Three studies focused on children and adolescents aged less than 20 years old. The rest of the thirty studies (66.7%) were conducted among adults aged 20 to 49 years old. Ages of the participants in four of the studies were not reported.
The results show that 38% of the studies were published from 2000 to 2005, 24% of the studies were published in the years 2006 to 2010, while the remaining 38% of the studies were published in 2011 to 2016. The majority of the studies (73%) were cohort studies while 2% of the studies were case control. The majority of the participants in the studies were from the Asia Pacific region (73%), while in 7% of the studies, participants were from United States of America. Thirty-three percent of the studies focused on both males and females, while 4.5% of the studies focused on male participants only (Table 1).
Figure 2 shows the frequency of the studies based on non-modifiable risk factors of cardiovascular disease. Age was the most frequent risk factor (11 studies) while ethnicity was the risk factor least associated with cardiovascular disease in the Pacific countries.
Figure 3 shows that diabetes and abnormal blood lipids, among the modifiable risk factors for cardiovascular disease, are more common in Pacific islanders, based on the studies. This was followed by high blood pressure, overweight and obesity and smoking, while alcohol intake, among the modifiable risk factors, is the least common.
Figure 2. Frequency of studies based on Non-modifiable risk factors.
Figure 3. Frequency of studies based on modifiable risk factors.
Effectiveness of the intervention:
As the results revealed, there were three randomized controlled trials (RCTs) implemented to reduce the risk factors of cardiovascular disease. Mark et.al. (2011) used “small-sided games and based exercise on fitness and health parameters among Pacific adults over four weeks”. The effectiveness of the intervention was greater among intervention participants than the control participants; cardiorespiratory fitness (p = 0.003), leg strength (p = 0.04) and high density lipoprotein (p = 0.02). The EunJoo Cho et al. (2013) study showed that proactive multifactorial intervention was more effective in reducing cardiovascular disease risk among the intervention group than usual care among participants from both Pacific Asia (−37.1% versus −3.5%, p < 0.001) and non-Pacific Asia countries (−31.1% versus −4.2%, p < 0.001). In addition, the EunJoo Cho et al. (2014) study also showed that there was a greater reduction in systolic blood pressure (−19.1 vs. −9.0, 95% CI-8.33 - 0.52), DBP (−8.3 vs. −3.9, 95% CI-3.83, −3.9), low density lipoprotein cholesterol (−20.5 vs. 1.2, 95% CI-24.66, −16.97, and total cholesterol (−28.2 vs. 3.7, 95% CI-38.25, −24.35) in the proactive multifactorial intervention (PMI) arm compared with the usual care (UC) arm at week 52 for Pacific Asia patients.
The present study highlighted the most frequent non-modifiable and modifiable risk factors of CVD in the Pacific region.
The results showed that age was the main non-modifiable risk factor of CVD among Pacific Asian countries. Most of the studies conducted among adults and older people showed that increasing age increases the chances of getting CVD  . CVD affects all age groups in the Pacific as a result of modernization associated with the modifiable risk factors for CVD, including diabetes, abnormal blood lipids, high blood pressure, overweight and obesity, unhealthy diets, physical inactivity, socio-economic status, and alcohol intake   . Nowadays, in the Pacific region, all age groups, even adolescents, are more likely to develop the risk factors for CVD at an early age as a result of modernization and changes in the family structure  . In the past, Pacific people used to live in extended families where they shared meals together, they worked together, and their children played together outdoors. As a result of modernization, there is a change in family structure in the Pacific islands where people started to shift into nuclear families, rather than extended  .
Pacific islanders now grow up in a modern world where they are being exposed to unhealthy foods through media or advertisement, which result in being the first food choices  . Physical inactivity and unhealthy diets are risk factors for CVD and this shows that Pacific islanders are more likely to have CVD if they don’t adopt a healthy lifestyle  . In the Pacific islands, culture plays an important role on the three different ethnic groups, namely Melanesians, Polynesians, and Micronesians, way of living. Pacific island men and women suffer from CVD as a result of the modifiable risk factors such as physical inactivity, high cholesterol, high blood pressure, and smoking, to name a few of them for both genders.
According to the ACPS; “17,050 deaths accounted for Asians and Pacific Islanders due to CVD in 2011, 31.5% in men and 32.4% in female  ”. Numerous lifestyle- related factors can cause the difference in the death rates in CVD among men and women in the Pacific. For example, in a Polynesian island country such as Tonga, women’s responsibilities involve house chores, taking care of the children, and many others which stood as barriers for women to engage in physical activity  . In Melanesian island countries like Vanuatu and Fiji, dress code is one of the barriers that prevent women from engaging in any sort of physical activity. Similar to Tonga and Vanuatu, Micronesian women have the same barriers that prevent them from engaging in any sort of physical activity  . Ethnicity is another non-modifiable risk factor for CVD. According to the British heart foundation, these different ethnic groups have their own culture and traditions that they are engaged in  .
As a result of these cultural and traditional differences, there are some things that restrict them from doing physical activity, which is a risk factor for CVD. In the Pacific, women who have limited transport options may be unable to travel to physical activity facilities because of the cultural barriers  . Another example is that some cultural expectations may restrict the involvement of women in certain forms of physical activity, which increases their likelihood of becoming obese, another risk factor for developing non-communicable diseases, including CVD   . Nowadays, different ethnic groups are adopting similar behaviours, especially the engagement in the risk behaviours of CVD, like inactive physical activities, smoking, hypertension and obesity. This was shown by a study done in the Asia Pacific based on two different ethnic groups, namely Asian and Non-Asian peoples  . The results of the study shows that most traditional cardiovascular risk factors, including high blood pressure, obesity, and cigarette smoking, is highly associated to heart diseases in both ethnic groups, despite the differences in ethnicity status  .
According to the results of this study, there were ten identified modifiable risk factors for CVD in the Pacific and diabetes is ranked the highest, followed by abnormal blood lipid, high blood pressure, overweight, smoking and the list continues until the least on the graph, which is alcohol intake  . Nevertheless, despite the hierarchy of the identified risk factors, they are all inter-related. For instance, those exposed to an unhealthy diet like high sugary and salty foods, will eventually developed diabetes or hypertension, which is a risk for CVD  . On the other hand, those with low socio- economic status cannot afford to buy healthy food so they buy the cheap, unhealthy diet foods that will increase their chances of becoming overweight, resulting in high lipid deposition in the adipose tissue, which will eventually increase the chances of developing hypertension and diabetes that can later lead to CVD  .
In conclusion, CVD is caused by both modifiable and non-modifiable predisposing risk factors and can be prevented mainly through health promoting life-style interventions. People need to know how to manage and monitor these risk factors. It is necessary to increase awareness among health care providers and systems serving Pacific islanders, at childhood stage, in suggesting accurate information, early screening and treatment, and recommend appropriate behavioural modifications for decreasing the prevalence of cardiovascular disease.
The Cochrane review process was used to develop the search strategy, appraise the articles, and analyze the data. However, in this study two reviewers independently extracted data from different types of studies and all discrepancies were agreed to by discussion with a third reviewer. This study had some limitations associated with the quality of the reviewed articles and also the approach. However, the quality of studies assessed did not show an assessment of bias that may have characterized the identified studies. Majority of studies included in this review were descriptive so there are potential biases that may affect the results of this study, such as: self-selected samples, poor description of participants, and non-validated data collection instruments.
Cardiovascular disease (CVD), Non-communicable diseases (NCDs), Pacific Island Countries (PIC), Randomized controlled trials (RCTs).
Appendix 1. Descriptive Studies
Appendix 2. Intervention Studies
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Cite this paper
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