Cardiovascular Risk Factors Among Young People in Haiti: Implications for Low-Income Countries

Introduction

Cardiovascular disease (CVD) is the leading cause of mortality globally, with over 80% of the global CVD burden falling on low-income countries, including Haiti (1). CVD risk factors such as hypertension, dyslipidemia, kidney disease, obesity, tobacco use, and sedentary lifestyle are underlying factors that are correlated with later life cardiovascular events including cardiac dysfunction, heart failure, and mortality (2, 3, 4). Preceding CVD risk factors is the preclinical phase of CVD, defined as asymptomatic cardiometabolic abnormalities, are associated with the development of premature CVD events and mortality (5, 6, 7, 8, 9, 10). Our knowledge of the epidemiology of the preclinical phase of CVD among young people in low-income settings is limited. Understanding which preclinical CVD risk factors are most prevalent, the age of onset, and associated independent factors can inform targeted primordial and primary prevention strategies which are essential to prevent the development of disease and ultimately premature CVD. Early intervention—during adolescence and young adulthood—is essential, as studies show later life interventions cannot fully reverse previously acquired CVD risk (7).

Preliminary data from Haiti indicate CVD risk factors emerge earlier in the life-course. For example, hypertension occurs nearly two decades earlier in Haitians than similarly aged Black Americans (11, 12). Young people living in Haiti are exposed to a host of structural challenges associated with a low-income setting, including chronic and extreme poverty, food insecurity, and a fragile health infrastructure. These factors may directly influence the development of preclinical CVD risk factors and may intensify exposures that are known to be associated with CVD risk factors such as stress, depression, or poor diet (13, 14). Before disentangling multiple, potentially synergistic, risk factors which may contribute to preclinical CVD, we need to establish the epidemiology of CVD among young people in low-income country settings. This includes determining which preclinical CVD risk factors are most prevalent, the age at which these factors emerge, and identifying the independent, modifiable risk factors associated with these conditions. This data will inform screening for young people at the highest risk to help identify and implement prevention interventions.

Adolescence and young adulthood are critical developmental periods when future lifestyle habits and behaviors become engrained and when interventions for primordial CVD prevention can be most effective. Targeted prevention interventions during these periods are supported by the WHO-affiliated World Heart Federation and American Heart Association (AHA) as cost-effective and cost saving (15). Diagnosis of preclinical CVD early in the life-course can trigger interventions that can halt progression, and even reverse course (16). For example, reducing salt intake or increasing physical activity can reduce blood pressure (BP) and prevent hypertension (17, 18).

In this study, we report the population-based estimates of CVD risk factors among young people ages 18–30 years in Haiti. This data can provide critical guidance for developing and implementing primordial and primary CVD prevention interventions for young people in low-income countries.

Methods

Results

Sex Stratification

The prevalence of CVD risk factors varied significantly by sex. Males had a higher prevalence of high BP, with 33.6% compared to 14.0% of females (p < 0.001). Additionally, 9.3% of males reported any lifetime use of tobacco, whereas only 3.5% of females did (p < 0.001). In contrast, females had a higher prevalence of obesity, with 11.4% compared to just 1.9% of males (p < 0.001), as well as a greater prevalence of dyslipidemia, at 45.1% versus 23.9% of males (p < 0.001). Males had significantly higher SBP and females had higher DBP, though this difference was less pronounced. Average SBP and DBP increased with age in both sexes, but at a greater rate among males (Figure 1). A higher proportion of females with dyslipidemia were also categorized as borderline high/high LDL-C–12.9% vs. 6.3% of males (p < 0.001). The proportion of participants with more than one CVD risk factor was high and did not differ by sex. Among all participants, 34.6% had 1 CVD risk factor and 48.7% had 2 or more CVD risk factors, with only 16.7% with no prevalent CVD risk factor (Table 2).

Figure 1

Discussion

These data provide previously unknown estimates of early-onset CVD risk factors among young adults in a setting of extreme poverty and adversity. Rates of high BP and dyslipidemia are alarmingly high for this group of young adults so early in their life course. Over one third of young men and 1 in 10 young women had prevalent high BP. Young women had a particularly high prevalence of dyslipidemia at almost 1 in 2 compared to 1 in 5 young men. These early onset CVD risk factors are likely predictive of CVD events later in adulthood, given high BP is predictive of incident hypertension (28) and dyslipidemia is predictive of atherosclerotic disease (29, 30, 31). In turn, these risk factors are correlated with grave CVD outcomes including heart failure, ischemic heart disease, stroke, and mortality (2, 3, 32). These data provide evidence to support routine screening for high BP and dyslipidemia of young people as early as age 18 years and underscore the need for additional research to identify the onset of preclinical markers even before young adulthood, and their associated poverty-related social determinants.

Hypertension is a well-established risk factor for the development of heart disease including heart failure and stroke (28). The prevalence of hypertension in the US National Health and Nutrition Examination Surveys (NHANES) 2017–2020 data, among participants ages 20–44 years, was similar to our findings. Given our younger age range of 18–30 years, this is concerning and indicates potentially an earlier onset of elevated BP and hypertension among Haitians. In the US National Longitudinal Study of Adolescent to Adult Health study, which followed young people ages 11–18 years through young adulthood ages 24–32 years, male sex and Black race/ethnicity were both associated with higher odds of hypertension compared to females and White race/ethnicity, respectively (33). Potential drivers of earlier onset of high BP in our population may include poverty-specific social and environmental determinants in a younger population. For example, another analysis from the Haiti CVD Cohort Study found that neighborhoods with the most extreme social vulnerabilities (e.g., poverty, food insecurity, neighborhood violence, etc.) as compared to neighborhoods with lesser vulnerabilities had higher association of hypertension, with the association greatest among young people <45 years (34). Studies on BP trajectories across the life-course indicate that persistent, sustained high BP from young adulthood through middle adulthood results in adverse cardiovascular outcomes in middle age (35). Further research is needed to understand the acceleration of high BP to hypertension in this population but regardless, this data underscores the need for early screening and primary prevention in young adulthood in Haiti. A quarter of our study population had high BP and would be a candidate for early intervention.

Dyslipidemia rates in our study were similar to those found in US populations in NHANES 2003 to 2020 (36). Approximately one third of Haitian young adults ages 18–30 years in our study had dyslipidemia compared to over half of US young adults ages 20–39 years. However, among the US population in NHANES, a significantly greater proportion of men had dyslipidemia compared to women. In our study, young adult females were twice as likely to have dyslipidemia and more likely to be overweight or obese. Dyslipidemia was defined as LDL-C level of >100 mg/dL, consistent with definitions from U.S.-based longitudinal cohort studies indicating that even moderately elevated LDL-C levels in young adulthood are associated with increased CVD risk later in life (37, 38). This lower threshold prioritizes early identification of risk and may capture individuals who would not be classified with dyslipidemia under European guidelines, which define elevated LDL-C as >116 mg/dL (39). As a result, our dyslipidemia prevalence estimates may be higher, reflecting a more preventive approach to cardiovascular risk stratification in young adults. Data on dyslipidemia among young people in low-income countries is scarce, and additional drivers behind the risk for early dyslipidemia among young Haitian women needs to be explored.

Studies among young adults in the US have shown that exposure to elevated LDL-C between ages 18–40 years is significantly associated with risk of incident CVD events. Furthermore, higher LDL-C between the ages of 18–30 increased later life CVD risk more than low LDL-C during that same age range and high LDL-C between the ages 30–40. This indicates that early exposure to higher LDL-C, before the age of 30, cannot be reversed, making early life primordial and primary prevention essential to prevent increased risk for CVD events after the age of 40 (7).

These data highlight the need for optimizing CVD screening and prevention interventions for young people in urban Haiti, which may reflect similar needs in other low-income global settings. Traditional CVD risk assessment typically does not start until age 40, and risk scores for young adults are lacking. Uptake of CVD prevention interventions among young people can be challenging due to a combination of factors: lack of symptoms and low levels of perceived personal risk mean it may be hard to engage young people who feel healthy or do not present for routine clinical care (40). Interventions must be tailored to address these potential barriers to meet young people’s preferences for health services. This could include offering services in a community- or school-based environment, adapting counseling messages so that they are appropriate for young people’s developmental and health literacy levels, and targeting modifiable risk behaviors (e.g., high salt diet) with feasible strategies for behavior change (e.g., how to influence household meals). Providers need to be trained in youth-friendly approaches to CVD screening and prevention to ensure optimal, high-quality provision of services and increase retention of young people.

Strengths of this study include that it is the only population-based study design focused on CVD risk factors in the region. Further, our methods include the use of WHO and AHA blood pressure measurement procedures and inclusion of disaggregated data for young adults under the age of 30. Limitations include potential lack of generalizability to cohorts in rural settings and the lack of home-based or 24-hour ambulatory blood pressure measurements to confirm high BP. Other limitations include the cross-sectional study design precluding the ability to assess temporal relationships between time-varying independent variables and CVD risk factors, a sample size limited by age, given our focus on young adults within the larger population-based cohort which may limit generalizability to the general population in Haiti and other settings.

Conclusion

Young adults in Haiti have high rates of early-onset high BP and dyslipidemia underscoring the need for targeted lifestyle and developmentally appropriate behavioral interventions for CVD prevention and treatment.

Competing Interests

The authors have no competing interests to declare.

Author Contributions

Lindsey K. Reif contributed to the conceptualization and design of the study, data analysis, and manuscript drafting. She has reviewed and approved the final manuscript. Vanessa Rouzier contributed to the conceptualization and design of the study and data collection. She has reviewed and approved the final manuscript. Lily Yan contributed to the conceptualization and design of the study, data collection, data analysis and manuscript editing. She has reviewed and approved the final manuscript. Shalom Sabwa contributed to the conceptualization and design of the study, data collection, data analysis, data visualization, and manuscript drafting and editing. She has reviewed and approved the final manuscript. Genevieve Hilaire contributed to data collection and quality assurance and interpretation of results. She has reviewed and approved the final manuscript. Marie Jean Pierre contributed to data collection and quality assurance. She has reviewed and approved the final manuscript. Rose Cardelle Riche contributed to data collection and quality assurance. She has reviewed and approved the final manuscript. Robert Peck contributed to the conceptualization and design of the study, interpretation of results, and manuscript editing. He has reviewed and approved the final manuscript. Anju Ogyu contributed to data analysis, data visualization, and manuscript editing. She has reviewed and approved the final manuscript. Rodney Sufra contributed to data collection and interpretation of results. He has reviewed and approved the final manuscript. Jean W. Pape contributed to conceptualization and design of the study. He supervised the project and provided critical revisions to the manuscript. He has reviewed and approved the final manuscript. Daniel W. Fitzgerald contributed to conceptualization and design of the study. He supervised the project and provided critical revisions to the manuscript. He has reviewed and approved the final manuscript. Margaret L. McNairy contributed to conceptualization and design of the study. She supervised the project and contributed significantly to writing and drafting of the manuscript. She has reviewed and approved the final manuscript.