THE popular view is that people in rural areas live much healthier lives and eat healthier food while living away from the pollution and stress of the urban environment. But are they really that healthier than those who face the daily grime and dust, and pressure of everyday living, in large towns and cities?
A study carried out by a team from the Faculty of Medicine, Universiti Kebangsaan Malaysia (UKM), headed by Prof Datuk Dr Khalid Yusoff, Professor of Medicine and Senior Consultant Cardiologist at UKM, together with Associate Prof Dr Hapizah Mohd Nawawi, who is also the Consultant Chemical Pathologist and Head of the Chemical Pathology Unit at UKM, has shattered this myth.
The research was carried out in the rural Malay population in Raub, Pahang, between 1993 and 1998. Over that period of five years, the team found significant changes in the trends of prevalence of heart disease risk factors in both males and females. The study discovered “a high-risk profile with two-thirds being at risk, and one-third being categorised in the high-risk group. Although rural communities were considered at low risk of developing CHD (coronary heart disease), this is changing fast, possibly due to the rapid socio-economic development, in addition to underlying genetic predisposition.”
The study, funded by the Science, Technology and Environment Ministry through the Intensification of Research in Priority Areas (IRPA) scheme has been published in the Journal of Cardiovascular Risk. Last year, Prof Khalid presented the study at medical conferences in Kuala Lumpur and Austria.
“We need to educate the public to separate myth from reality in terms of heart disease,” said Prof Khalid in a recent interview. “The myth is that heart disease is the disease of the rich and the urban dwellers. If we look at the way the disease spreads, it starts with the rich and the urban people. But as it spreads, as in any country, it starts to affect the lower-income group and the less urban group of people. We want to know where we are in Malaysia. Is the rural population still protected from coronary heart disease?”
CHD is the main cause of death in most developed countries, and has become the leading cause of death in Malaysia since 1980. Risk factors that could lead to CHD include high blood-cholesterol level, hypertension, diabetes, smoking and increased weight. Among the findings in the Raub study, in which 800 persons were included in 1993 and 627 in 1998, were that the prevalence of hypercholesterolaemia was high and that males compared with females had a more unfavourable lipid profile and were at higher risk of CHD.
The study also found that the prevalence of obesity had significantly increased in both males and females over the five-year period to about 30% using the usual criteria, and to over 50% using the International Obesity Task Force criteria.
The study concluded that “there is a high prevalence of the major coronary risk factors which had increased significantly over the five-year period among Malays in rural Malaysia.”
“Coronary heart disease in industrial nations has been cut down by 50% over 30 years,” said Prof Khalid. “But in developing countries like Malaysia, the incidence of coronary heart disease is on the rise. But developing countries like Malaysia also has to cope with traditional diseases, such as tuberculosis, malaria and dengue. At the same time, we also have to deal with new diseases such as stroke and heart attacks. The burden on us is so much more than on the developed countries.”
He added that they plan to go back to Raub to do a 10-year follow-up this year.
The study was also presented to the public at Raub recently, where Deputy Minister of Culture, Arts and Tourism Datuk Dr Ng Yen Yen, who is also Raub MP, was present. A seminar on Cholesterol Diet and Coronary Heart Disease was also held to create awareness among the people.
Prof Khalid answered other queries about the Raub Heart Study.
Why was Raub chosen and how does it represent the general rural Malay population?
If you could see the photos taken of the area, you would see how rural it is. We wanted a rural area, and we wanted a place that is accessible for us. (The Raub district is about 160km from Kuala Lumpur.) We had to bring lots of things with us, so we had to have accessibility. The third main reason is that one of our colleagues had been working there before us in Ulu Sungai, among the orang asli. Our colleague knew the penghulu (village head) there and that’s how it all came about.
Raub has developed a lot now. Previously it took us two-and-a-half hours to get there. And now it takes only an hour-and-a-half.
Why did you choose a period of five years?
Five years is probably adequate to see changes in the prevalence of coronary risk factors. I didn’t expect to see such a drastic difference. It shows that the changes in risk factors in rural Malaysia happened very, very fast. We are not talking about heart disease; we are talking about the risk factors that will lead to heart disease. You have to amass all those risk factors in your body, and the heart will take the brunt of this insult to it – the blood pressure, the glucose, the cholesterol. And 10 to 15 years later it will translate into heart attacks, heart failures, strokes.
Three-quarters of people walking around in Raub look healthy, but if you measure them ? So this is a very important health message for people to wake up and say “I better measure my body. I can’t wait until I feel the symptoms of the disease because it may be too late.”
The second point is that if we intervene early, we would be able to prevent this disease from coming up. So it is all the more important for us to do something positive about our own lives. This is very, very crucial. And the rate of change is very drastic. Five years is very short. And we’re talking about Raub.
Is the idea that rural people are generally healthier than urban folk just an assumption or has there been a study that shows this?
There has not been any study like this done before. But one would think that the rural folk lead an active lifestyle, doing physical work, and have healthy dietary habits.
Generally, there are two major areas to consider: one is genetics and the other is the environment. There must be change in the environment for these people. But more interestingly is how our bodies adapt to change when the change is drastic – the change in the environment and the economic opulence.
Coronary heart disease has always been thought to be the disease of Westerners. And that was true for so many decades. They have undergone a major economic change, but their change occurred over many more decades than the change we went through. We changed much more rapidly than the West. It could be that our bodies can’t cope with this. We don’t know. It could be something that we need to look into.
How much did the rural people of Raub understand what you presented to them and the health risks they face?
To make people understand is not easy. To actualise their understanding into their daily lives is not easy. Firstly is (the cultural factor). The people there were Malays – we hope to study the Chinese population in Raub soon.
Now the Malay word for illness is penyakit. It comes from the word sakit. So if you are not sakit, therefore in your mind you do not have penyakit. You may have hypertension but you don’t feel sakit, because it is something inside you and you feel quite well, despite harbouring an important disease, albeit asymptomatic. But you have to change your lifestyle because of it, and it may not be easy.
We are completing our study to look at intervention. We have a number of ways to intervene in their lifestyles and see which one would be most effective. I don’t have the results yet, we haven’t analysed them, but it would be interesting to find out.