Abstract
Malta is situated in the central Mediterranean region. Mediterranean region is known to follow the Mediterranean diet; therefore, the incidence of heart diseases is low. Inspite of that, the rate of coronary artery disease (CAD) is very high in Malta. The latest WHO report shows 27.45% of all deaths in Malta due to CAD alone. Maltese have been following a sedentary lifestyle particularly due to lack of breathing space and urbanisation (dependency on motor vehicles and sitting in front of computers for long). Though standardized mortality rate is decreasing in Malta, it is higher than the rate of old EU member states. Though age-standardized mortality rates are published in reports by the WHO, there seems to be a limitation of epidemiological research in the area of CAD in the region of Malta, which we can very well categorize as a unmet medical need.
Malta is a south European country situated in the center of the Mediterranean covering just 316km2 of area, making it one of the smallest nations on earth, but it is also one of the most heavily populated countries. It is a beautiful country consisting of three islands and a population of just over 350,000.
According to a latest report “Country and Regional Assessment of Malta”, youngsters in Malta aged between 18 to 24 years rate their health as being significantly better when compared to elderly persons aged 65 years or above. The report states that the age-standardized mortality rate in Malta is reducing overall and it compares well with the old member states, EU-15 and the new member states, EU-12. Mortality due to cardiovascular system diseases (e.g., ischaemic heart disease (IHD), stroke, and cardiac failure) are the leading causes of mortality accounting for 44% of all deaths. However, this mortality rate in Malta is lower than the EU – 15 states, but higher than that the EU-12 states (Health and structural funds in 2007-2013).
Government of Malta reports major non-communicable diseases (NCDs) like cardiovascular disease (CVD), cancer, COPD, and mental ill health to be responsible for about 82% of deaths in Malta, of which only CVD accounts for 40% of all deaths. In 2007, the percentage prevalence of diabetes, which is a risk factor for coronary artery disease (CAD), in the age group of 20 to 79 years was 8.4% in Europe while during the same period, in Malta, it was 9.2%, and this is expected to rise to 11.6% by 2025 (Government of Malta).
According to latest WHO data, published in 2011, coronary artery disease (CAD) stands at number one position, which has caused 27.45% of all deaths in Malta. For cardiovascular disease and diabetes, the age-standardized death rate per 100 000 population was 202.0 for males and 148.2 for females (World Health Organisation, 2011).
A times of Malta newspaper article quoted Malta to have 44.3% deaths to be caused by diseases of circulatory system in 2005. This figure is according to the National Statistics' Office Demographic Review of 2005 (Times of Malta).
Trends in mortality and life expectancy from major NCDs in Malta were analysed from the national vital statistics available. The data was published by Tuomilehto in 1988. Interestingly it was observed that most of the increased life expectancy during the 20th century in Malta took place between the decades of 1930 and 1960, but after this period only a minor increase was observed. The age standardized mortality peak in men and women was observed in the age group of 40 - 69 during the time period of 1974 - 1976. Total mortality in men was about 40% higher than that of women. During the period of 1983 to 84, the age group of 45 - 64 years had 54% of deaths in men and 43% in women due to cardiovascular diseases alone. When data was compared internationally, it showed that mortality from cardiovascular disease was clearly higher than in other European Mediterranean countries ranking among the highest in the whole Europe (Tuomilehto, 1988).
According to another latest data by Department of Health Information and Research published in 2011, the prevalence of heart disease in Malta has tend to increase with age and is predominant in middle-aged and the elderly, especially elderly men. The table below shows the prevalence of heart disease in Malta (Department of Health Information and Research).
According to Gauci et al, the leading cause of death is heart disease amongst the elderly population in Malta (Gauci, 2008). The European Health Interview Survey of 2008 reported that 21% of deaths in females and 23% of deaths in males were due to a heart disease. Also, published by the European Health Interview Survey of 2008 were the top reported health conditions in those aged 60 and above. The most common top reported health condition in 2008 was hypertension afflicting 46% of the elderly population. According to an article published in 1995 by Mizzi and colleagues, Malta has the highest diabetes rate in Europe (Mizzi, 1995), and is second only to the United States in obesity rates. In the National Obesity Campaign of 2010, Malta was estimated to have 50% of adults between the age group of 35 and 65 years who were overweight or obese (Bromaghim, 2011).
According to European Cardiovascular Disease Statistics, 2008 edition, CVD is the main cause of death before the age of 75 years for men in twelve countries of the twenty seven EU countries, one of which is Malta. In the year 2005, Malta had 414 deaths alone due to CAD of the total 1576 deaths in men; and 348 deaths out of 1554 total women deaths in Malta. During the same year, total deaths of men under the age of 75 were 746 of which 190 were due to CAD, while 484 total deaths in women occurred in the same age group, 72 of which were due to CAD. In the age group under 65, there were 357 total deaths of which 87 were due to CAD with 238 total women deaths, 22 of which due to CAD (Allender, 2008).
The age-standardized death rate from CAD in adults aged 0 to 64 years in the time period of 1972 to 2005 was 90 deaths per 1,00,000 men in 1972 which decreased to 45 deaths per 1,00,000 men in 2005. 35 women deaths per 1, 00, 000 deaths for CAD decreased to 11 per 1, 00,000 during the same year (Allender, 2008).
According to European Cardiovascular Disease Statistics, 2010 edition, the age-standardized death rate per 1, 00,000 populations from CAD was 153 in men and 85 in women in the year 2008. The rate of hospital discharge due to CVD rose from 666 per 100000 population in 2000 to 942 per 100000 in 2008 (Scarborough, 2010).
According to research published by Levi and colleagues in 2002, the age standardised death certification rates for CAD in Malta was 162.4 in the period between 1965 –19 69, 238.1 in the period from 1975 -1979, 183.4 in the period from 1985 – 1989, 139.7 in the period from 1995 -98 for men; the per cent change was -14.0. The same rate for women was 84.1 for the time period 1965 -1969, 140.1 for the time period 1975 -1979, 101.4 for the time period 1985 -1989, and 80.9 for the time period 1995 – 98 with a per cent change of -3.8 (Levi, 2002).
A retrospective survey by Maempal published in 1978 of 1,118 admissions for acute ischemic heart disease (AIHD) at St. Luke's Hospital in Malta between the time period of 1963 – 1972 observed 945 (84.5%) cases of acute myocardial infarction (AMI) and 173 (15.5%) cases of acute coronary insufficiency (ACI). Among these patients, the proportion of patients with diabetes was 30.2%, which was significantly higher (P < 0.01) than the corresponding rate of diabetes (20.2%) among the general population of Malta. There was a significantly greater prevalence of diabetes (especially T2D) among women than among men with AIHD (Maempal, 1978).
According to WHO’s Environmental and Health Performance Review published in 2009, one of the main cause of death in Malta is cardiovascular disease (World Health Organisation).
As per an article published in MaltaMedia in 2005, Malta is the lowest spender for diseases related to heart. While the United Kingdom spends more on treating heart disease per head than any other country in Europe, Malta spends the lowest amount at just 5.93 euros per head. Britain spends about 87.9904 euros per head annually (MaltaMedia, 2005).
Another News published in MaltaMedia in 2006 quoted Malta as a sole nation having the least economic burden of heart disease. According to a research by Oxford University, Malta has the least economic burden of heart disease in the European Union. The UK allocates the highest amount of money of its total healthcare budget to the problem (17.1 %), while Malta allocates only 2%. The study revealed that the heart disease problem is the biggest health problem that the EU is facing (MaltaMedia, 2006).
Commonwealth Online, in 2003, reported Ischaemic heart disease (IHD) as the single biggest killer in Malta causing 22% of all deaths in the year 2003. Maltese men and women above the age of 30 years have a higher risk of dying from heart disease than other Europeans (CommonWealth, 2003).
Another latest report published last year in Times of Malta shows more people dying of physical inactivity in Malta than anywhere else in the world. Nearly 19.2% of deaths i.e., one-fifth of all deaths in Malta are attributed to the fact that people here have the most sedentary lifestyle. Nearly 72 % of the Maltese lead sedentary lifestyles. The main cause of death resulting from lack of exercise includes CAD and diabetes. The Lancet reported these shocking figures presenting it to be a major public health issue. The report used the WHO data to suggest that the couch potato lifestyle has killed about five million people worldwide a year, making sedentary lifestyles an equal culprit as smoking in terms of the effect on health. Physical inactivity was largely due to social trends such as spending more time in vehicles and in front of computers (Times of Malta, 2012).
According to British Heart Foundation survey published in 2010, the age standardized death rate per 1,00,000 population from CAD was 518 in 1980 which dropped down to 153 in 2008 in men, while in women, it dropped from 334 in 1980 to 85 in 2008. However, rate of hospital discharges due to CVDs were 666 in the year 2000 which rose up to 942 in the year 2008 (British Heart Foundation).
According to Fenech A, in his article “A view from Malta” CAD is the main cause of death in Malta and it has one of the highest incidences of diabetes mellitus in the world (Fenech, 2007).
A prospective study in Malta published in 1996 evaluated 166 T2D patients and 162 non-diabetic individuals to show that diabetic group had a more than three-fold increase in mortality at three months (8·6% vs 2·5%, T2D vs. non diabetic, P=0·014) which was maintained at one year (16·7% vs. 8·6%, T2D vs. control, P=0·029). However, the incidences of unstable angina, myocardial infarction (MI), and coronary artery bypass were equal in both the diabetic and nondiabetic groups during the follow-up period (Fava, 1996).
In the general population constituting the ARIC Study, it was seen that individuals with diabetic retinopathy (DR) had an increased incidence of congestive heart failure compared to those without retinopathy that persisted following multifactorial adjustment for many risk factors including diabetic status of the individuals (relative risk [RR] 1.96; 95% CI, 1.51-2.54) (Wong, 2005).
Risk factors for development of CAD
Coronary artery disease is related to several lifestyle factors such as, unhealthy diet, physical inactivity, being overweight, being obese, tobacco use, and alcohol abuse operating in a disadvantaged environment that is relatively socioeconomically poor. CAD is the most important cause of mortality and also has a significant economic and social impact (Government of Malta, 2010).
According to an article by European commission, the data on the Maltese population showed similar characteristics to north Europe and mortality rates were higher than those of its Mediterranean neighbours. Obesity and being overweight were also responsible as risk factors for the prediction of CVD. In predicting CVD risk, abdominal obesity may play a more significant role than obesity. Other risk factors for CVD are diabetes mellitus, excessive alcohol consumption, and psychosocial stress (European commission, CVD).
According to Department of Health Promotion and Disease Prevention of Ministry of Health, most of the NCDs are related to environment either directly or indirectly. There seems to be inadequate availability of public leisure areas thus making physical activity not accessible to all. Decreased walks or mobility pattern due to car dependency and increase in motorisation has contributed to obesity and related diseases (Government of Malta, 2010).
Apart from this, one of the key concerns with Maltese population is the total calorie consumption well beyond the energy requirement of the individuals. Individuals with increased calorie intake are highly likely to develop conditions that would ultimately lead to cardiovascular diseases (CVD) (Government of Malta, 2010).
According to the Maltese Epidemiological Information, by oocities.org, obesity (Age 55-64 years - males: 77%; females: 85%), T2D (Age >15 years - males: 12.0%; females: 14.4%), hypercholesterolemia (males: 72%; females: 75%), and hypertension (26%) are all common conditions in Maltese adult population. Long-term complications arising from these conditions like CAD remains the major causes of mortality (33.0% of all deaths) (oocities.org).
Urbanization in Malta has led to physical inactivity and an increase in the unhealthy dietary habits like consumption of oily foods and sweets. This prompts for a significant effect on the rise of NCDs such as diabetes and heart disease, particularly coronary heart disease. Particularly, in Malta, there has been a significant increase in number of overweight and obese people. Malta has over 60% population that is either overweight or obese; it has one of the highest rates of obesity in the world and it is mounting. Even children are not spared, the highest rate of obesity is observed in children too, with 7.9% children obese (Malta Home).
Below table shows the risk factors for CVD in Malta (WHO, 2011)
Limitations
The data on Coronary artery disease (CAD) was attempted to obtain from internet search and using databases such as PubMed and PubMed central (PMC). The keywords used were Malta, Maltese, Coronary artery disease, coronary heart disease, cardiovascular disease, diabetes. Keywords like southern European and central Mediterranean were also used considering Malta lies in the central Mediterranean region and in south of Europe. We can very well conclude that the data available for epidemiology of coronary artery disease in Malta is limited. The available information is also limited. The limited data available hinders the outcome of the search, but information obtained from authentic sources like the WHO and European commission is alarming. An important finding was the high mortality rate due to CAD in Malta. According to very recent update by WHO, CAD alone was responsible for 27.45% of all deaths in Malta, which is a very high figure. Researchers have attributed the high figures to sedentary lifestyles and unhealthy diet.
In spite of CAD being the biggest killer in Malta, the data is limited. Though age -a standardised mortality rate for every prevalent disease is given, there is lack of clear data on the incidence and prevalence of CAD. May be the smaller size of the nation has put a limit on the research carried out. It is important to carry out more research related to epidemiology of heart diseases in Malta considering that almost 72% of Maltese lead a sedentary lifestyle.
References:
Health and Structural funds in 2007-2013: country and regional assessment: Malta. Retrieved from: http://ec.europa.eu/health/health_structural_funds/docs/info_sheets/mt.pdf
A Strategy for the Prevention and Control of Noncommunicable Diseases in Malta (2010) Government of Malta. Retrieved from: https://ehealth.gov.mt/download.aspx?id=4793
Malta. Noncommunicable diseases country profiles (2011) World Health Organisation. Retreived from: http://www.who.int/nmh/countries/en/index.html
'Not enough being done' on heart disease. (2008) Times of Malta. Retrieved from: http://www.timesofmalta.com/articles/view/20080114/local/not-enough-being-done-on-heart-disease.191787
Tuomilehto J, Cacciottolo J, Vassallo A, Schranz A, Nissinen A, Grech A. Trends in mortality from major non-communicable diseases in the middle-aged population of Malta. 1988; 36 (3): 216-25. Available at: http://www.ncbi.nlm.nih.gov/pubmed/3187148
Health care service usage and needs in chronic illness: Diabetes, heart disease and respiratory disease. (2011) Department of Health Information and Research. Retrieved from: http://www.google.co.in/url?sa=t&rct=j&q=coronary%20artery%20disease%20prevalence%20malta&source=web&cd=2&cad=rja&ved=0CDgQFjAB&url=https%3A%2F%2Fehealth.gov.mt%2Fdownload.aspx%3Fid%3D6150&ei=eS0WUaGUC4O0rAeJqoHoCw&usg=AFQjCNFcNPgplT08-QORkcT9O0DaK1LS7g&bvm=bv.42080656,d.bmk
Gauci, D. (2008). Health status of the elderly. European Health Interview Survey. 9-14.
Mizzi, L. (1995). Food and nutrition policy in malta. Food Policy, 20(6). 475-480.
Bromaghim K, Cassella M, Gallagher R. (2011) Dietary Trends of the Maltese Aging Population and the Resulting Morbidities. National Obesity Campaign. University of Malta.
Allender S, Scarborough P, Peto V, Rayner M. European cardiovascular disease statistics. (2008) British heart Foundation. Retreived from: http://www.herzstiftung.ch/uploads/media/European_cardiovascular_disease_statistics_2008.pdf
Scarborough P, Bhatnagar P, Wickramasinghe K, Smolina K, Mitchell C, Rayner M. European Cardiovascular Disease Statistics, (2010) Retreived from: http://www.herzstiftung.ch/uploads/media/European_cardiovascular_disease_statistics_2010.pdf
Levi F, Lucchini F, Negri E, Vecchia C. Trends in mortality from cardiovascular and cerebrovascular diseases in Europe and other areas of the world. (2002) 88: 119- 24. Retrieved from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1767229/pdf/hrt08800119.pdf
Maempal Z. Diabetes as a coronary risk factor in Malta. Isr J Med Sci. 1978; 14: 418-23. Retrieved from: http://www.ncbi.nlm.nih.gov/pubmed/669917
Environment and health performance review. World Health Organisation. Department for Environmental Health. Retrieved from: http://www.euro.who.int/__data/assets/pdf_file/0006/95343/E93547.pdf
Malta lowest spender on heart disease. MaltaMedia. (2005) Retreived from: http://www.maltamedia.com/cgi-bin/artman/exec/view.cgi?archive=13&num=5117
Malta has least heart disease economic burden (2006) MaltaMedia. Retrieved from: http://www.maltamedia.com/news/2005/eu/printer_9058.shtml
Current health issues and progress in Malta. Commonwealth Health Online. Retrieved from: http://www.commonwealthhealth.org/current-issues-and-progress/europe/malta/
Malta tops world league of deaths from lazy lifestyles. (2012) Times of Malta. Retrieved from: http://www.timesofmalta.com/articles/view/20120719/local/Malta-tops-world-league-of-deaths-from-lazy-lifestyles.429125
Coronary heart disease statistics. 2010 British Heart Foundation. Retrieved from: www.bhf.org.uk/idoc.ashx?docid=9ef69170-3edf-4fbb-a202
Fenech A. A view from Malta. European Perspectives on Cardiology. (2007) Circulation. 116: f97 – f102.
Fava S, Azzopardi J, Agius-Muscat H. Outcome of unstable angina inpatients with diabetes mellitus. Diab Med 1996; 14: 209–13.
Wong TY, Rosamond W, Chang PP, Couper DJ, Sharret AR et al. (2005) Retinopathy and risk of congestive heart failure. JAMA 293:63-69.
Health in Europe: Information and data interface. European commission. Retreived from: https://webgate.ec.europa.eu/sanco/heidi/index.php/Heidi/Major_and_chronic_diseases/Cardiovascular_disease
Maltese Epidemiological Information. The Health of the Maltese Population. Available at: http://www.oocities.org/hotsprings/2615/epidemiology/cultural.html
Welcome to Malta. Malta. Retrieved from: http://academic3.american.edu/~zaharna/hondry/Malta%20Website/maltahome.htm
