Risk factors and the growing
burden of cardiovascular disease
in the Arab world


The rapid urbanization and changing ways of life in the Middle East has led to an alarming escalation in cardiovascular disease in the region. Ronney Shantouf, MD looks at the risk factors related this complex issue and what can be done to modulate them.

The Arab world is an eclectic mix of countries that bind together on many common themes and history, yet individual countries vary in their own unique way regarding social and societal ways of life. The region has become a growing hotbed of economic, political, and cultural shifts, contributing to the rapid urbanization in the region. Although not fully explained by urbanization alone, rapid shifts in ways of life coupled with slow adaption to wide spread public healthcare policies have contributed to the alarming prevalence of cardiac risk factors and its associated cardiovascular morbidity and mortality.

The heavy burden of cardiovascular disease (CVD) relates to the high prevalence of well-known risk factors including hypertension, smoking, dyslipidemia (high cholesterol), diabetes, obesity, and sedentary lifestyle. These risk factors translate into cardiovascular events, such as devastating heart attacks, taking a high toll on Arab individuals at an early age.

Prominent research such as the Gulf- RACE and INTERHEART study found that patients in the Arab world present with heart attacks at a significantly younger age, on average 10-12 years sooner, compared to their Western counterparts. This intriguing, yet highly alarming finding deserves focus not just from a clinical or research standpoint, but also from an overall public health lens. While genetics may play a part, the rapid urbanization of the region, the increased sedentary lifestyle, lack of well-developed public health and screening programmes, and suboptimal medical management both at the primary and secondary level have likely contributed to this rapid rise in both risk factor prevalence and subsequent cardiovascular complications in the region.


Basic epidemiologic statistics, mostly from the World Health Organisation (WHO), outline a very grim and challenging pathway for the region. For example, hypertension is very common – 39% in Lebanon and 28% in United Arab Emirates, for example. Six of the world’s top 10 countries with diabetes are in the Middle East – United Arab Emirates, Kuwait, Qatar, Saudi Arabia, Bahrain, and Lebanon. What’s more concerning is that the 32.8 million (2011 figure) adults with diabetes in the Arab world are expected to double to 59.7 million by year 2030.

The incidence of obesity, a risk factor for several health problems as well as CVD, is astoundingly high in the Arab female population. 55.2% of Kuwaiti women (age >15) are obese (BMI > 30 kg/m2) according to WHO 2010 statistics, making it the 9th highest ranked nation in the world in terms of female obesity. In the Arab world, Egyptian women follow at 48%. Kuwaiti men rank 13th in the world (29.6%) compared to other nations. This epidemic of obesity is prevalent throughout the Middle East. The prevalence of obesity in women in countries such as Lebanon, Syria and Iraq is 27.4%, 24.6%, and 19.1% respectively. In almost every Arab country, female obesity rates are significantly higher than men and are nearly double that of men in some countries (Kuwait 55.2% vs. 29.6%, UAE 42% vs. 24.5%, Lebanon 27.4% vs. 14.9%) – making women a unique target for intervention.

Other risk factors such as smoking are extremely prevalent in Jordanian males at 61% (8th highest ranked nation). Males in Tunisia follow suit at 58% (Rank 11). Among men, Oman has one of the lowest smoking prevalences in the Arab world (20%) which is still relatively high. Smoking prevalence among males in the United States is 25%, for example. The reported differences between smoking rates among men and women based on 2006 WHO statistics was again extremely eyeopening. Jordanian women have the highest prevalence at 10% followed by Lebanon and Tunisia at 7%. Gulf nations such as Kuwait, Saudi Arabia, UAE, and Bahrain report a very low prevalence of 3- 4%. Moroccan women have an impressively low prevalence of just 0.2%. These sweeping differences again create a unique opportunity for intervention.

Data from 2003 showed that while trends in cigarette consumption have decreased in the Americas since the 1980s, trends continue to rise in parts of the Arab world in general.

There is a growing perception that more and more younger men and women in nations such as Lebanon are smoking at extremely higher rates than what these numbers may reflect.

Overall this has resulted in a relatively high mortality from CVD in the Middle East. If we look at age-standardized cardiovascular death rates in countries such as Iraq, Yemen, Egypt, Lebanon, and Jordan, they are more than double the comparative figures for the United States. On estimate, approximately 25-40% of deaths in many Arab countries are due to cardiovascular disease. As such, these risk factors contribute to the growing burden of strokes, heart failure, myocardial infarction and peripheral vascular disease, leading to amputations, blindness and death.

While interventional cardiologists, vascular surgeons, cardiothoracic surgeons and other specialists intervene following a cardiovascular event in patients with more advanced cardiovascular disease, there needs to be a massive societal push towards both targeted primary and secondary prevention for the Arab world. More specifically, since the prevalence of particular risk factors vary by country, the preventive approach should be developed and targeted with this in mind.


What can be done? The most effective method of curbing such risk factors and hopefully reducing morbidity and mortality outcomes is via strong, successful preventive programmes. Many of these risk factors such as smoking, high blood pressure and high cholesterol are silent and show no symptoms until devastating complications ensue such as a debilitating stroke or heart attack. The public needs to be educated and encouraged to address these risk factors despite their silent nature.

Many patients may not want to take blood pressure medication or change their dietary habits because they “feel fine”. An individual may not always grasp the burden of suffering a heart attack or debilitating stroke until it occurs, as they may feel shielded from it ever happening to them or their family members. As such, it becomes the job of educators, scientists, public health workers, physicians, dieticians, and policy makers to continue to shed light on the subject. People have to be shown the benefits of changing their way of life through, for example, increased physical activity, eating a healthy diet, and regular health check-ups.

Several Arab countries have acknowledged the issue and are developing appropriate policies and investing in public health programmes. For example, Lebanon recently banned smoking in closed public places despite strong opposition and societal pressure against it. This needs to be encouraged and supported at local and regional levels.

And efforts are being made in other spheres to address this issue. For example, the World Congress of Cardiology held their biannual conference in Dubai recently and offered a two-day course on ‘Preventive Cardiology’ which focussed on teaching young healthcare workers about the importance of prevention. Such high level meetings not only sheds light on preventive medicine for doctors, but also helps spread general awareness in the public sphere through increased public media on the subject.

This large and growing burden needs to be addressed on all fronts. Many would advocate for health education to start in the classroom with clear goals to teach the youth about the dangers of smoking and the benefits of healthy lifestyle habits, especially regarding physical activity and food choices.

Screening programmes and implementation of well-known therapeutic options such as managing high blood pressure and high cholesterol need to be encouraged and structured.

Physicians on the front line, whether general practitioners or cardiologists, should be trained to identify high-risk individuals so that they may seek further intensive medical care.


Although research is underway in some countries in the region, much more is required within the Arab world to gain a better understanding of the epidemiology of the disease, its burden and treatment options within each country. This will help guide medical therapy and the development of treatment protocols specifically targeting the Arab population.

We have started to see excellent research and home grown clinical databases emerge from countries such as the United Arab Emirates, Lebanon, Qatar, Bahrain, and Saudi Arabia and such research efforts to collect rigorous datasets and registries should be encouraged and supported financially, as they will provide robust primary local and regional data for future medical strategies.

History repeats itself. It’s well known. But it seems that in some cases it does so more rapidly and forcefully. The health issues associated with the rapid urbanisation that the developing world currently faces were experienced decades ago by cities in what I now the developed, or economically advanced, world. However, there appears to be a difference – in the newly urbanising world changes in people’s diet, lifestyle, and sedentary habits seem to be occurring at a more rapid rate and more aggressively than they did in the past.

The Arab world never got to experience the gradual increase in caloric density of foods or beverages. Many younger individuals did not experience the 8 oz soda grow to the 12 oz, 20 oz, 32 oz and so on over the course of decades. Rather children in the Middle East (and other developing regions) essentially were introduced directly to the highly caloric, highly processed foods and beverages common today – resulting in the obesity epidemic and it co-morbidities we currently face.

Smoking, a well-known cardiotoxic habit, has for decades been allowed to flourish unacceptably in the Middle East. The harmful effects of smoking are well known, yet men and women in the Arab world continue to smoke at dangerously high rates. It is only recently that effective public health policies have started to emerge.

Developing regions such as the Arab world have the unique opportunity to learn from the mistakes, lessons and experience of its Western counterparts. The examples are numerous. Arab countries should make a strong effort to target their unique risk factors – such as obesity in Kuwaiti women and smoking in Jordanian men. With this specific focus they are more likely to achieve the lifestyle changes they seek in their populations. It will take a concerted effort by teachers, public health workers, dieticians, physical training specialists, primary care physicians, preventive cardiologists, endocrinologists, policy makers, and politicians to implement successful change.

Both primary and secondary prevention methods continuously need to be developed in concert so as to help reduce the overall cardiovascular disease burden. And although cardiovascular medical care is effective via medications, revascularization procedures, and surgeries, this is not an effective stand-alone solution to a widespread public health problem in the region. There should be a push for strong primary preventives measures, while having the safety net of medical technology, highly skilled physicians, and therapeutic options ready and available for those that still end up suffering cardiovascular complications such as a heart attack or stroke.

These ideas are not new. History repeats itself. A quote from an ancient Chinese medical text is just as relevant today as it was then: “The superior doctor prevents sickness; The mediocre doctor attends to impending sickness; The inferior doctor treats actual sickness.”

About the Author:

Ronney Shantouf, MD, cardiologist, is currently completing his cardiovascular fellowship at Harbor-UCLA Medical Center. He has served as the Health Editor of UCLA newspaper, The Daily Bruin, and currently writes about emerging medical technologies for the website

Ther Clin Risk Manag. 2012; 8: 65–72

 Date of upload: 22nd Jan 2013


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