ABC | Volume 110, Nº3, March 2018

Original Article Urbanization is Associated with Increased Trends in Cardiovascular Mortality Among Indigenous Populations: the PAI Study Anderson da Costa Armstrong, 1,3 Ana Marice Teixeira Ladeia, 2 Juracy Marques, 3 Dinani Matoso Fialho de Oliveira Armstrong, 1 Antonio Marconi Leandro da Silva, 1 Jeová Cordeiro de Morais Junior, 1 Aldina Barral, 4 Luis Claudio Lemos Correia, 2 Manoel Barral-Netto, 4 João A. C. Lima 5 Universidade Federal do Vale do São Francisco (UNIVASF), Petrolina, PE - Brazil 1 Escola Bahiana de Mediciana e Saúde Pública, Slvador, BA - Brazil 2 Universidade do Estado da Bahia (UNEB), Slvador, BA - Brazil 3 Centro de Pesquisas Gonçalo Moniz da Fundação Oswaldo Cruz (FIOCRUZ), Salvador, BA - Brazil 4 Johns Hopkins University, Baltimore – USA 5 Mailing Address: Anderson da Costa Armstrong • Avenida Jos de Sá Mani oba, s/n. COREME/Hospital Universitário da UNIVASF. Petrolina, PE – Brazil E-mail: armstrong_ac@cardiol.br Manuscript received May 11, 2017, revised manuscript July 31, 2017, accepted September 22, 2017 DOI: 10.5935/abc.20180026 Abstract Background: The cardiovascular risk burden among diverse indigenous populations is not totally known and may be influenced by lifestyle changes related to the urbanization process. Objectives: To investigate the cardiovascular (CV) mortality profile of indigenous populations during a rapid urbanization process largely influenced by governmental infrastructure interventions in Northeast Brazil. Methods: We assessed the mortality of indigenous populations (≥ 30 y/o) from 2007 to 2011 in Northeast Brazil (Bahia and Pernambuco states). Cardiovascular mortality was considered if the cause of death was in the ICD-10 CV disease group or if registered as sudden death. The indigenous populations were then divided into two groups according to the degree of urbanization based on anthropological criteria: 9, 10 Group 1 - less urbanized tribes (Funi-ô, Pankararu, Kiriri, and Pankararé); and Group 2 - more urbanized tribes (Tuxá, Truká, and Tumbalalá). Mortality rates of highly urbanized cities (Petrolina and Juazeiro) in the proximity of indigenous areas were also evaluated. The analysis explored trends in the percentage of CV mortality for each studied population. Statistical significance was established for p value < 0.05. Results: There were 1,333 indigenous deaths in tribes of Bahia and Pernambuco (2007-2011): 281 in Group 1 (1.8% of the 2012 group population) and 73 in Group 2 (3.7% of the 2012 group population), CV mortality of 24% and 37%, respectively (p = 0.02). In 2007-2009, there were 133 deaths in Group 1 and 44 in Group 2, CV mortality of 23% and 34%, respectively. In 2009-2010, there were 148 deaths in Group 1 and 29 in Group 2, CV mortality of 25% and 41%, respectively. Conclusions: Urbanization appears to influence increases in CV mortality of indigenous peoples living in traditional tribes. Lifestyle and environmental changes due to urbanization added to suboptimal health care may increase CV risk in this population. (Arq Bras Cardiol. 2018; 110(3):240-245) Keywords: Indigenous Population; Cardiovascular Diseases / mortality; Urbanization / trends; Social Change. Introduction The urbanization process is a concern in developing countries, as it influences the prevalence of cardiovascular (CV) risk factors and coronary disease. 1 In fact, an early process of lifestyle changes appears to lead to increases in CV risk when rural migrants settle in metropolitan areas. 2 Moreover, traditional indigenous populations are recognized as in greater risk of CV complications. 3 Diverse infectious diseases caused major health concerns when Europeans initially contacted Native American indigenous populations. Along the years, a shift in indigenous mortality rates has been shown toward chronic diseases affected by lifestyle changes, which varies highly across diverse native populations. 4-6 In recent years, isolated indigenous people in Brazil still showed low blood pressure that appears to be related to their traditional lifestyle. 7,8 Major infrastructural projects may rapidly influence populations in the surrounding areas, often affecting indigenous communities. More recently, the Sao Francisco Valley in Northeast Brazil has been experiencing major changes in infrastructure – particularly regarding construction of large dams and canals – that appear to affect traditional indigenous lifestyle in the area. 9,10 It is unclear, however, how the urbanization process has been affecting CV mortality in native indigenous communities over the years. The Project of Atherosclerosis Among Indigenous populations (PAI) was created to investigate the impact of urbanization on CV diseases among indigenous communities in the Sao Francisco Valley (Northeast Brazil). In this study, we 240