RESEARCH ARTICLE


Social Environment as a Precursor to Coronary Artery Disease in a Small, Resource-Limited Country



Mandreker Bahall1, *
1 Arthur Lok Jack Global School of Business, Mt. Hope, Trinidad, Trinidad and Tobago, Caribbean


Article Metrics

CrossRef Citations:
0
Total Statistics:

Full-Text HTML Views: 131
Abstract HTML Views: 51
PDF Downloads: 116
ePub Downloads: 40
Total Views/Downloads: 338
Unique Statistics:

Full-Text HTML Views: 84
Abstract HTML Views: 44
PDF Downloads: 88
ePub Downloads: 38
Total Views/Downloads: 254



Creative Commons License
© 2022 Mandreker Bahall.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

* Address correspondence to this author at the Arthur Lok Jack Global School of Business, Mt. Hope, Trinidad, Trinidad and Tobago Mc Bean, Couva, Trinidad and Tobago, Caribbean; Tel: 18687636608; Fax: 18686790816; E-mail: vmandrakes@hotmail.com


Abstract

Background:

Coronary artery disease has been the most prevalent chronic disease over the last two decades. In Trinidad and Tobago—a small, high-income, resource-limited country the median age of presentation of, and premature death from, acute myocardial infarction is more than 12 years earlier to that in high-income, developed countries. This may be attributed to the increased risk of coronary artery disease that stem from the presence of precursors in the social environment.

Objective:

We aimed to explore the association between “social environment” and coronary artery disease in Trinidad and Tobago.

Methods:

This is a descriptive ecological study that assessed secondary data. Data were collected from multiple search engines and websites. Data on Trinidad and Tobago’s social environment were also accessed from the World Databank and the Central Intelligence Agency fact book and analyzed.

Results:

Coronary artery disease was fueled by personal choices that were influenced by the social environment (“fast food” outlets, inadequate sporting facilities, increased use of activity-saving tools [vehicles, phones, and online activities], smoking and alcohol accessibility, and social stressors [murder, family disputes, divorce, child abuse, kidnapping, and rape]). Food imports, as a percentage of merchandise imports, were at 11.42% (2015); the level of physical activity was low (<600 MET-minutes per week; 38 in 2016), and social stressors were high.

Conclusion:

The social environment has encouraged a “cardiotoxic” or “atherogenic” environment influencing behavior, eventually resulting in a continued high risk of coronary artery disease, presenting at a younger age.

Keywords: Public health, Coronary artery disease, Cardiotoxic environment, Obesogenic environment, Atherogenic environment, Social environment.



1. INTRODUCTION

Coronary artery disease (CAD), like aging, is inevitable. However, CAD is accelerated by a multitude of risk factors, both modifiable and non-modifiable. Genetic engineering [1] that aims to minimize CAD risk is still in the early stages and is unlikely to achieve the desired targets. Much of the current research efforts have aimed to identify, modify, and treat cardiovascular (CV) risks [2] at an individual level. This was emphasized by Levenson et al., who reported that to reduce the impact of the global explosion in CV diseases (CVDs), it is important to understand and reduce the global increase in CVD risk [3]. CV risk development varies according to genetic transmission, individual behavior, and the social environment [4]. Trinidad and Tobago’s financial investment and health interventions have focused mainly on the individual’s responsibility to decrease the prevalence and improve or control CV risks. Interventions, such as the “Fight the Fat campaign,” “avoiding sweets,” and “exercising”, are commonly echoed in educational forums to change behaviors and decrease CV risk [5]. This practice of individual responsibility continues despite the recommendation of Trinidad and Tobago’s National Strategic Plan for non-communicable diseases [6], which requires that individuals take advantage of an enabling environment to control, improve, and maintain physical, mental, social, and spiritual well-being. Social determinants as a cause of CAD have been described by Kreatsoulas and Anand [2], Albus [7], and Bhatnagar [4]. These social determinants or environmental public health issues are the “root causes” that contribute to an atherogenic environment and the resultant increase in CAD risk and CAD [7] (Fig. 1).

In societies where geographic, environmental, and other socioeconomic problems are scarce [8], there is a lower chance of the early development of CAD; for example, in France, with its excellent public health system, there is a high life expectancy and low CVD mortality rate. In Trinidad and Tobago, with its high incidence of ischemic heart disease (IHD) and CAD, the main causes of death over the previous two decades (Fig. 2), the young age of presentation and premature death resulting from acute myocardial infarction (AMI) [9] have led to IHD being a major cause of concern. This study explores the social environment and its role in CAD development in a small, resource-limited country.

Fig. (1). Development of coronary artery disease.

Fig. (2). Deaths due to ischemic heart disease in Trinidad and Tobago in relation to GDP per capita.
IHD, ischemic heart disease; T&T, Trinidad and Tobago; GDP, gross domestic product; PPP, purchasing power parity.
Data retrieved from “The ministry of health. (2016). Healthgovtt. Retrieved 10 August, 2016, from http://www.health.gov.tt/downloads/DownloadItem.aspx?id=33” and “Healthdataorg. (2017). Healthdataorg. Retrieved 10 July, 2017, from http://www.healthdata.org/trinidad-and-tobago”

2. MATERIALS AND METHODS

This is a descriptive ecological study. This study analyzes secondary data from 1990 to 2021, comparing local data with two first-world countries, namely the USA and the UK. Data were obtained using various search engines: Google, PubMed, EBSCOHOST, and the websites of the Pan American and World Health Organizations. Data (published and unpublished) were also obtained from the Ministry of Health, World Databank, and the Central Intelligence Agency fact book websites. Local statistical data were obtained from the Ministry of Health and the Central Statistical Office of Trinidad and Tobago.

Search terms, such as “infrastructure,” “social determinants,” “CVD,” “CAD,” and “society”, were used. Local data included information on national health indicators, CAD risks, and environmental public health or social environment. CAD risks included diabetes mellitus, hypertension, hypercholesterolemia, smoking, alcohol use, and psychosocial factors. Environmental public health precursors [4], such as food outlets, sporting facilities, and social determinants, were identified in the local context. Research assistants assisted in data collection.

We analyzed CAD risks and the social environment to determine any links between them. The results are presented as graphs and tables. Due to limited resources and lack of funding, data collection was mainly confined to the local context. Nevertheless, the collected data were useful for understanding the associations likely existing between environmental public health issues and CAD risks.

3. RESULTS

The prevalence of abdominal obesity (48.1% in 2016) and diabetes mellitus (12.5% in 2016) in Trinidad and Tobago was much higher than that in the UK and the USA (Table 1). However, the prevalence of hypertension (45% in 2018) was higher in the USA than in Trinidad and Tobago. The prevalence of CV lifestyle risk factors (insufficient vegetable intake, sedentary activity) and psychological risks (stress) was higher in Trinidad and Tobago than in the USA and UK. Smoking prevalence (approximately 14% in 2019) in Trinidad and Tobago was similar to that in developed countries, like the USA and the UK.

3.1. Social Environment

The social environment influences our behavior: “Where to go? What to eat? Should I exercise? How to utilize spare time? How can social conflict be dealt with?” In this study, there was observed a remarkable increase in the social environmental factors (non-activity-related pastimes/sedentary activities, fast food outlets, smoking and alcohol outlets, and social stressors). Fast food outlets per million population have increased from 119 in 2012 to 142 in 2017, with the food import bill as a percentage of merchandise imports increasing from 8.31 in 2000 to 11.42 in 2015 [34]. The increase in the use of electronic devices (cell phones, vehicles) and the decrease in the number of playgrounds have also encouraged a sedentary lifestyle. Social stressors are high and are increasing. Generally, the rates of stress, depression, unemployment, murder, rape, divorce, suicide, traffic congestion, and road traffic deaths have fluctuated over the last decade; however, they remain high. The unemployment rate has also fluctuated (an average of 18.52% in 1991 and a decrease to 6.7% in 2020) [35]. Over the years, there has been a high level of murders (396, or 28.2 per 100 000, in 2020) [36] with low detection levels (lower than 26%). There has also been a high prevalence of teenage pregnancies, child marriage, divorce, abortions, incest, family conflicts, income discrepancies/inequity, major life events, and job losses (Table 2).

Table 1. Risk factors for the prevalence of coronary artery disease in Trinidad and Tobago in comparison to those in the UK and the USA.
Risk Factor Measure of Risk Factor Prevalence by Year UK Values
%
USA Values
%
1990 2000 2005 2010 2015 2020 2016-2020 2016–2020
Cigarette smoking Smoking prevalence in the adult population (%) [10] n.a. 11.67 12.94 14.45 14.04 (2016) n.a. 14.1 (2019) [11] 14
(2019) [12]
Hypertension Hypertension (% adult population) n.a. n.a. 30.4 (2008) [13] 27 (2011) [14] 28 (2016) [15] n.a. 26.2
(2017) [16]
45
(2018) [17]
Diabetes (% of population aged 20–79 years) n.a. 12.7 (2001) [18] n.a. 11.7 [19] 12.5
(2016) [20]
11.0 (2019) [19] 7
(2020) [21]
5.2
(2020) [22]
Abdominal obesity Overweight/obesity (share of adults [%]) [23] 25.90 33.60 37.60 42.00 47.10 48.10 (2016) 28.0 (2019) [24] 42.4 (2017–2018) [25]
Lack of daily consumption of fruits and vegetables
and
fat consumption
Fruit consumption per capita (kg/year) [26] 57.15 64.81 73.63 75.68 111.85
(2013)
50.91
(2017)
89.60 (2017) 90.00 (2017)
Vegetable consumption per capita (kg/year) [27] 20.99 31.90 35.82 30.26 35.68 36.09 (2017) 82.91 (2017) 113.41
(2017)
Daily per capita dietary fat supply (grams per person per day) [28] n.a. n.a. 79.33 82.30 89.93 (2016) 88.93 (2017) 141.03 (2017) 167.21 (2017)
Lack of daily exercise Low level of physical activity (<600 MET-minutes per week) n.a. n.a. n.a. 45.4 (2011) [13] 38 (2016) [15] n.a. 25
(2017–2018) [29]
>15
(2020) [30]
Family history of IHD - n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a.
Excess use of alcohol Share of population with an alcohol disorder (%) [31] n.a. 1.57 1.65 1.73 1.73 1.72 (2017) 8.7 (2016) [32] 5.8%
(2020) [33]
IHD, ischemic heart disease; MET, metabolic equivalent.
Table 2. Selected social and psychosocial factors.
Social and Psychosocial Factors Year US UK
1990 2000 2005 2010 2015 2020 (2017–2021) (2017–2021)
Major fast food outlets (n) [37] (per million population) n.a. n.a. n.a. 118.6 (2012) n.a. 142 (2017) 599.8
(2021) [38]
>386.9 (2018) [39]
Food imports (% of merchandise imports) [40] 15.427 (1991) 8.313 9.02 11.19 11.42 n.a. 15
(2019) [41]
9.1549
(2019) [42]
Daily per capita dietary fat supply (grams per person per day) [43] 65.00 76.32 79.33 82.30 92.50 n.a. 167.21
(2017)
141.03 (2017)
Vehicles registered, per 1000 [44] n.a. n.a. 351.0 361.0 397.0 1016.26 (2017) [45] 838.7
(2019) [46], [47]
487.19 (2019) [48], [49]
Internet users (% of the population) [50] 0 7.721 28.977 48.5 69.198 77.326 (2017) (>85%) (2020) [51] 92.517% (2019) [52]
Mobile cellular subscriptions (per 100) [53] 0 12.774 71.276 142.623 154.954 155.109 (2019) 134.459 (2019) [54] 119.898 (2019) [55]
Unemployment rate (% of the working population) [56] 18.52 (1991) 12.1 7.9 5.9 3.4 6.7 5.9
(2021) [57]
4.8 (2021) [58]
Pupils attaining tertiary education (%) [59] 6.615 (1991) 6.061 11.951 (2004) n.a. n.a. n.a. 19.6 million (2019) [60] 2.38 million (2018/ 2019) [61]
Murder (per million people) [62] 102.1 (1994) 84.3 275.7 346.4 292.9 282.9 58.1 (2019) [63] 10.7 (2019/2020) [64]
Rape (per million people) [65] n.a. 186.4 238.6 155 128.6 65.7
(2019) [66]
98213 (2019) [67] 62200 (2019/2020) [68]
Kidnapping (per million people) [69] n.a. n.a. 41.4 [62] 80
(2013)
75.7 46.4 n.a. 85.1
(2020/2021) [70]
Sexual offences (per million people) [71] n.a. 202.9 288.6 343.6 495 (2014) >394.3
(2019) [66]
1393.9 (2019) (rape and sexual assault) [72] >2663.7 (2019/2020) [73]
Suicide rate per 100,000 [74] n.a. 16.3 12.7 11.3 10.2 8.7 (2019) 16.1 (2019) [75] 7.9 (2019) [75]
Depression (%) [76, 77] 2.97 3.38 3.49 3.56 3.57 3.57 (2017) 4.84%
(2017) [78]
3.96%
(2017) [79]
Underage marriages (per million people) [80] n.a. n.a. 49.3 (2006) 49.3 7.1 n.a. n.a. n.a.
Teenage pregnancies (per million people) [81] n.a. n.a. n.a. n.a. 532.1 269.3 (2018) n.a. 760.3 (2018) [82]
Divorces (per million people) [83] n.a. n.a. 1798.6 2087.1 2010 n.a 2267 (2020) [84] 1752 (2019) [85]
Road traffic deaths (per million people) [86] n.a. n.a. 134.3 (2006) 129.3 (2011) 146 96 36096 (2019)
[87]
1752 (2020) [88]

4. DISCUSSION

This study reveals the continued high prevalence of CV risk. The main thrust of the Ministry of Health was to change the individual’s effort/behavior (the “ability to change deeply entrenched habits and accept personal responsibility for our health status” [6]) and the presence of supportive public health regulations. The public health measures are as follows:

(i) The Tobacco Control Act (which banned smoking in public spaces and prohibited the promotion and sale of tobacco products to children)

(ii) The Tobacco Control Regulations, 2013

(iii) The National Policy on Alcohol

(iv) Breathalyzer legislation (to prevent drunk driving)

(v) Campaigns targeting healthy eating and active living (2008 to present)

(vi) The National School Health Policy

(vii) Health Promotion Policy for Public Sector Agencies in the Workplace

(viii) The Fight the Fat Campaign, 2012–2014 [6]

However, public health laws on smoking, alcohol use, and calorie documentation are seldom adhered to [89]. This also applies to many other regulations (littering, child protection, speeding, and seat belt regulations) [90]. This has created an environment where there is a lack of enforcement of public health regulations and a focus on individual’s efforts, thereby leading to a largely uncontrolled “social environment.” There has been observed a higher prevalence of diabetes mellitus and obesity in Trinidad and Tobago than in the USA and the UK, which may have resulted from the social environment with its abundance of fast food outlets, sedentary lifestyle activities/jobs, and social stressors. Apart from the increase in food consumption, our food content has revealed high levels of sugar, saturated fats, and carbohydrates, and there is a growing use of alcoholic beverages and low fruit and vegetable intake [91], encouraging the development of atherosclerosis [92].

The social environment with high traffic density, and the use of mobile phones and the internet, have encouraged a sedentary lifestyle. Vehicular traffic was high and ranked 41st in the world in 2007 [93]. The 2019 traffic survey results revealed that the citizens of Trinidad and Tobago spent at least 2-3 hours per day in traffic, resulting in lower work productivity levels, while stress affected family life [94] and increased the risk of CVDs [4]. The high incidence of crime and violence has further limited the use of the outdoor sporting facilities and leisure parks. Physically active people have an improved quality of life and a reduced risk of premature death [95]. Physical activities have shown improvements with the use of environmental designs in terms of modes of transportation (bicycles and cars) [96] and individuals’ choices to exercise [97].

The prevalence of social stressors in Trinidad and Tobago is high. However, the high levels of depression (3.57% in 2017) [98], suicide (8.7 per 100,000 population in 2019) [99], and divorce (2814 in 2015) [83] are not unique to this country. In the UK, the occurrence of depression (3.96% in 2017) [100], suicide (7.9 per 100,000 population in 2019) [101], and divorce (108,421 in 2019) [102] is comparable. Depression [103], anxiety, anger, hostility, acute and chronic life stressors [104], downward social mobility [105, 106], and lack of social capital [107, 108] are associated with risks of CVDs. Alcohol abuse as a social stressor also results in associated road traffic accidents, domestic violence, and medical problems [109]. With two-thirds of households consuming alcohol, the sequelae of psychological, physical, and social problems contribute to coronary artery plaque build-up [110].

This study has some limitations and “epistemic gaps” [111, 112]. It has used mainly secondary data, most of which could not be independently verified. Because of the limitations in time and resources, it did not include data on either socioeconomic status or the “exposome” (e.g., noise and chemical pollutants, [113, 114]), which are all implicated in the development of CAD.

CONCLUSION

The social environment (eating places, playing fields, and psychosocial stressors), a precursor to CAD, may be responsible for the continued high levels of CAD risk and CAD, young age of AMI presentation, and AMI death. Further studies are required to elucidate the type and degree of influence on behavior.

LIST OF ABBREVIATIONS

AMI = Acute Myocardial Infarction
CAD = Coronary Artery Disease
CV = Cardiovascular
CVD = Cardiovascular Disease
IHD = Ischemic Heart Disease

AUTHORS CONTRIBUTIONS

MB designed the study, collected and supervised the data collection, and wrote and edited the manuscript.

AUTHOR INFORMATION

MB is a specialist medical officer and part-time lecturer at the University of the West Indies (Mount Hope, Trinidad and Tobago).

ETHICS APPROVAL AND CONSENT TO PARTICIPATE

Not applicable.

HUMAN AND ANIMAL RIGHTS

Not applicable.

CONSENT FOR PUBLICATION

Not applicable.

AVAILABILITY OF DATA AND MATERIALS

The data supporting the findings of the article are available from the corresponding author [M.B] upon request.

FUNDING

None.

CONFLICT OF INTERESTS

The author declares that there are no competing interests.

ACKNOWLEDGEMENTS

The author would like to thank the premedical students Esther Ramlackhan and Alexia Mahadeo, who assisted in the data collection.

REFERENCES

[1] Scheuner T. Genetic evaluation of coronary artery disease. Genet Med 2003; 5: 169-285.
[2] Kreatsoulas C, Anand SS. The impact of social determinants on cardiovascular disease. Can J Cardiol 2010; 26(Suppl. C): 8C-13C.
[3] Levenson JW, Skerrett PJ, Gaziano JM. Reducing the global burden of cardiovascular disease: The role of risk factors. Prev Cardiol 2002; 5(4): 188-99.
[4] Bhatnagar A. Environmental determinants of cardiovascular disease. Circ Res 2017; 121(2): 162-80.
[5] Mallika V, Goswami B, Rajappa M. Atherosclerosis pathophysiology and the role of novel risk factors: A clinicobiochemical perspective. Angiology 2007; 58(5): 513-22.
[6] https://health.gov.tt/services/ncd
[7] Albus C. Psychological and social factors in coronary heart disease 2010.
[8] Fuster V, Kelly BB. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health 2010.
[9] Bahall M. Epidemiology of acute myocardial infarction in South Trinidad. West Indian Med J 2016; 3(2): 1-6.https://www.mona.uwi.edu/wimjopen/sites/default/files/wimjopen/article_pdfs/WIMJOIss12016_1_6.pdf
[10] Our World in Data Prevalence of Daily Smoking in Populations Aged 10 Years and Older, 1990.https://ourworldindata.org/grapher/prevalence-of-daily-smoking-sdgs?tab=chart&country=TTO
[11] Office for National Statistics. Adult Smoking Habits in the UK 2019.https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandlifeexpectancies/bulletins/adultsmokinghabitsingreatbritain/2019#:~:text=In%20the%20UK%2C%20
[12] Centers for Disease Control and Prevention. Current Cigarette Smoking Among Adults in the United States 2021.https://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/index.htm
[13] Government of the Republic of Trinidad and Tobago Ministry of Health. National Strategic Plan for the Prevention and Control of Non-Communicable Diseases: Trinidad and Tobago 2017 2021.https://health.gov.tt/services/ncd
[14] World Health Organization. Trinidad and Tobago Hypertension Fact Sheet 2021.https://www.who.int/ncds/surveillance/steps/tto_en.pdf?ua=1
[15] World Health Organization. Noncommunicable Diseases (NCD) Country Profiles 2018.https://www.who.int/nmh/countries/tto_en.pdf
[16] Hughes A. Hypertension Prevalence Estimates in England, 2017: Estimated from the Health Survey for England 2020.https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/873605/Summary_of_hypertension_prevalence_estimates_in_England__1_.pdf
[17] Centers for Disease Control and Prevention. Facts About Hypertension 2021.https://www.cdc.gov/bloodpressure/facts.htm
[18] Hospedales JC. The Caribbean Chronic Disease Epidemic: What We Know…and What We Need to Know 2021.https://www.healthycaribbean.org/wp-content/uploads/2017/05/Hospedales_to_CHIRS_Oct_08_What_we_know_about_NCDs_in_Caribbean.pdf
[19] Trinidad and Tobago - Diabetes Prevalence as a Share of Population Aged 20-79 Years 2021.https://knoema.com/atlas/Trinidad-and-Tobago/topics/Health/Nutrition/Diabetes-prevalence
[20] World Health Organization. Diabetes Country Profiles 2016.https://www.who.int/diabetes/country-profiles/tto_en.pdf
[21] Whicher CA, O’Neill S, Holt RIG. Diabetes in the UK: 2019. Diabet Med 2020; 37(2): 242-7.
[22] Centers for Disease Control and Prevention. National Diabetes Statistics Report 2020.https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf
[23] Our World in Data. Share of Adults that are Overweight or Obese 1975.https://ourworldindata.org/grapher/share-of-adults-who-are-overweight?tab=chart&country=TTO
[24] Baker C. Obesity Statistics 2021.https://researchbriefings.files.parliament.uk/documents/SN03336/SN03336.pdf
[25] Centers for Disease Control and Prevention. Adult Obesity Facts 2021.https://www.cdc.gov/obesity/data/adult.html
[26] Our World in Data Fruit Consumption per Capita 1961.https://ourworldindata.org/grapher/fruit-consumption-per-capita?tab=chart&country=TTO~USA~GBR
[27] Our World in Data Vegetable Consumption per Capita 1961.https://ourworldindata.org/grapher/vegetable-consumption-per-capita?tab=chart&country=TTO~USA~GBR
[28] Our World in Data. Daily per Capita Fat Supply 1961.https://ourworldindata.org/grapher/daily-per-capita-fat-supply?tab=chart&country=TTO~USA~GBR
[29] GOV.UK. Ethnicity Facts and Figures: Physical Inactivity 2021.https://www.ethnicity-facts-figures.service.gov.uk/health/diet-and-exercise/physical-inactivity/latest#:~:text=data%20shows%20that%3A-,overall%2C%20
[30] Centers for Disease Control and Prevention. Adult Physical Inactivity Prevalence Maps by Race/Ethnicity 2021.https://www.cdc.gov/physicalactivity/data/inactivity-prevalence-maps/index.html
[31] Our World in Data. Share of Population With Alcohol Use Disorders 1990.https://ourworldindata.org/grapher/share-with-alcohol-use-disorders?tab=chart&country=TTO
[32] World Health Organization. Alcohol Consumption: United Kingdom of Great Britain and Northern Ireland 2021.https://www.who.int/substance_abuse/publications/global_alcohol_report/profiles/gbr.pdf
[33] Buddy T. Prevalence of Alcoholism in the United States 2021.https://www.verywellmind.com/prevalence-of-alcoholism-in-the-united-states-67876#citation-6
[34] IndexMundi. Trinidad and Tobago - Food Imports https://www.indexmundi.com/facts/trinidad-and-tobago/food-imports
[35] The World Bank. Unemployment, Total (% of Total Labor Force) (National Estimate) - Trinidad and Tobago https://data.worldbank.org/indicator/SL.UEM.TOTL.NE.ZS?locations=TT
[36] Crime TT. Crime Statistics 1994.https://www.ttcrime.com/crime-statistics/
[37] Gonzales O. Trinidad and Tobago Food Service Sector Report 2021.https://s3.amazonaws.com/ProductionContentBucket/pdf/20120513184838932.pdf
[38] IBISWorld. Fast Food Restaurants in the US - Number of Businesses 2002.https://www.ibisworld.com/industry-statistics/number-of-businesses/fast-food-restaurants-united-states/
[39] Statista. Number of Fast Food Restaurant Outlets in the United Kingdom (UK) in 2018.https://www.statista.com/statistics/712002/fast-food-outlets-united-kingdom-uk-by-type/
[40] IndexMundi. Trinidad and Tobago - Food Imports 2021.https://www.indexmundi.com/facts/trinidad-and-tobago/food-imports
[41] U.S. Food & Drug Administration. FDA Strategy for the Safety of Imported Food 2021.https://www.fda.gov/food/importing-food-products-united-states/fda-strategy-safety-imported-food
[42] Economics T. Trading Economics. United Kingdom - Food Imports (% of Merchandise Imports) 2021.https://tradingeconomics.com/united-kingdom/food-imports-percent-of-merchandise-imports-wb-data.html#:~:text=Food%20imports%20(%25%20of%20merchandise%20imports)%20
[43] Our World in Data. Daily per Capita Fat Supply 1961.https://ourworldindata.org/grapher/daily-per-capita-fat-supply?tab=chart&country=TTO~USA~GBR
[44] CEIC Data. Trinidad and Tobago Registered Motor Vehicles 2005.https://www.ceicdata.com/en/indicator/trinidad-and-tobago/motor-vehicle-registered
[45] TriniTuner. Over 1 Million Registered Vehicles on the Road in T&T in 2017.https://www.trinituner.com/v4/forums/viewtopic.php?t=717072
[46] Statista. Number of Motor Vehicles Registered in the United States from 2019.https://www.statista.com/statistics/183505/number-of-vehicles-in-the-united-states-since-1990/#:~:text=How%20many%20registered%20motor%20vehicles,12%20
[47] Worldometer. United States Population (Live) 2021.https://www.worldometers.info/world-population/us-population/
[48] Statista. Number of Licensed Cars in the United Kingdom (UK) from 2019.https://www.statista.com/statistics/299972/average-age-of-cars-on-the-road-in-the-united-kingdom/
[49] Worldometer.. UK Population (Live) 2019.https://www.worldometers.info/world-population/uk-population/
[50] The World Bank. Individuals Using the Internet (% of Population) - Trinidad and Tobago 2021.https://data.worldbank.org/indicator/IT.NET.USER.ZS?locations=TT
[51] Johnson J. Internet Usage in the United States - Statistics & Facts 2021.https://www.statista.com/topics/2237/internet-usage-in-the-united-states/#:~:text=As%20a%20global%20hub%20of,imagine%20a%20life%20without%20it
[52] The World Bank. Individuals Using the Internet (% of Population) - the United Kingdom 2021.https://data.worldbank.org/indicator/IT.NET.USER.ZS?locations=GB
[53] The World Bank. Mobile Cellular Subscriptions (per 100 People) - Trinidad and Tobago 2021.https://data.worldbank.org/indicator/IT.CEL.SETS.P2?locations=TT
[54] The World Bank. Mobile Cellular Subscriptions (per 100 People) - United States 2021.https://data.worldbank.org/indicator/IT.CEL.SETS.P2?locations=US
[55] The World Bank. Mobile Cellular Subscriptions (per 100 People) - United Kingdom 2021.https://data.worldbank.org/indicator/IT.CEL.SETS.P2?locations=GB
[56] The World Bank. World Development Indicators 2021.https://databank.worldbank.org/reports.aspx?source=2&country=TTO
[57] Economics T. Trading Economics. United States Unemployment Rate 2021.https://tradingeconomics.com/united-states/unemployment-rate
[58] King B. Unemployment Rate: How Many People are Out of Work? 2021.https://www.bbc.com/news/business-52660591#:~:text=How%20many%20people%20are%20unemployed,job%20can%27t%20find%20one
[59] The World Bank. School Enrollment, Tertiary (% Gross) - Trinidad and Tobago 2021.https://data.worldbank.org/indicator/SE.TER.ENRR?locations=TT
[60] Statista. College Enrollment in the United States from 1965 to 2019 and Projections up to 2029 for Public and Private Colleges 2021.https://www.statista.com/statistics/183995/us-college-enrollment-and-projections-in-public-and-private-institutions/
[61] Statista. Number of Students Enrolled in Higher Eduction in the United Kingdom from 2019/10.https://www.statista.com/statistics/875015/students-enrolled-in-higher-education-in-the-uk/#:~:text=In%202018%2F19%20there%20were,thousand%20enrolled%20
[62] Crime TT. Crime Statistics 1994.https://www.ttcrime.com/crime-statistics/
[63] Centers for Disease Control and Prevention. Assault or Homicide 2021.https://www.cdc.gov/nchs/fastats/homicide.htm
[64] Statista. Number of Police Recorded Homicide Offences in England and Wales from 2002/03.https://www.statista.com/statistics/283093/homicides-in-the-uk/
[65] Seepersad R, Williams D. A report citizen security Trinidad And Tobago 2012 2012.https://www.undp.org/content/dam/trinidad_tobago/docs/DemocraticGovernance/Publications/UNDP_TandT_Citizen_Security_Survey_2012.pdf
[66] Khan R. Over 552 Sex Assault Cases were Reported Against Women in 2019.https://www.guardian.co.tt/news/over-552-sex-assault-cases-against-women-in-2019-6.2.997901.da21814c5f
[67] Statista. Number of Reported Forcible Rape Cases in the United States from 2019.https://www.statista.com/statistics/191137/reported-forcible-rape-cases-in-the-usa-since-1990/
[68] Elkin M. Crime In England And Wales: Year Ending September 2021 2022.https://www.ons.gov.uk/peoplepopulationandcommunity/crimeandjustice/bulletins/crimeinenglandandwales/yearendingseptember2021
[69] Trinidad & Tobago Police Service. Total Crime by Month Report 2022.https://www.ttps.gov.tt/Statistics/Crime-Totals-By-Month
[70] Statista. Number of Police Recorded Kidnapping Offences in England and Wales from 2020/21.https://www.statista.com/statistics/303548/kidnapping-in-england-and-wales-uk/#:~:text=Kidnapping%20offences%20
[71] Baboolal Y. Police service reveal worrying statistics- Rape cases on the decline, but more sexual offences 2021.https://www.guardian.co.tt/article-6.2.391660https://www.osac.gov/Country/TrinidadTobago/Content/Detail/Report/83007ec0-cd97-4dc2-95ac-15f4aecc2072
[72] Statista. Number of Rape or Sexual Assault Victims in the United States per Year from 2019.https://www.statista.com/statistics/642458/rape-and-sexual-assault-victims-in-the-us-by-gender/#:~:text=This%20statistic%20shows%20the%20annual,number%20for%20men%20was%2052%2C336
[73] Statista. Number of Police Recorded Sexual Offenses in England and Wales from 2020/21.https://www.statista.com/statistics/315500/sexual-offences-england-wales/
[74] The World Bank. Suicide Mortality Rate (per 100,000 Population) - Trinidad and Tobago 2021.https://data.worldbank.org/indicator/SH.STA.SUIC.P5?locations=TT&view=chart
[75] The World Bank. Suicide Mortality Rate (per 100,000 Population) - United Kingdom, United States 2021.https://data.worldbank.org/indicator/SH.STA.SUIC.P5?locations=GB-US
[76] Our World in Data. Number of People With Depression by Country 1990.https://ourworldindata.org/grapher/number-with-depression-by-country?tab=chart&country=TTO
[77] Worldometer. Trinidad and Tobago Population (Live) 2021.https://www.worldometers.info/world-population/trinidad-and-tobago-population/
[78] Our World in Data. Depression Prevalence Versus Self-Reported Life Satisfaction 2017.https://ourworldindata.org/grapher/depression-vs-self-reported-life-satisfaction?country=~USA
[79] Our World in Data. Depression Prevalence Versus Self-Reported Life Satisfaction 2017.https://ourworldindata.org/grapher/depression-vs-self-reported-life-satisfaction?country=~GBR
[80] UNICEF. Situation Analysis of Children in Trinidad and Tobago 2021.https://www.unicef.org/easterncaribbean/reports/situation-analysis-children-trinidad-and-tobago
[81] Tack CC. 3,777 Teen Pregnancies 2021.https://newsday.co.tt/2019/04/18/3777-teen-pregnancies/#:~:text=Of%20the%20pregnancies%20within%20this,and%2065%20pregnancies%20per%20month
[82] UNICEF. Situation Analysis of Children in Trinidad and Tobago 2018.https://www.statista.com/statistics/297625/uk-teenage-pregnancies/
[83] Julien J. Divorce Rate Down 2021.http://www.trinidadexpress.com/20150918/news/divorce-rate-down
[84] Centers for Disease Control and Prevention. Marriage and Divorce 2021.https://www.cdc.gov/nchs/fastats/marriage-divorce.htm#:~:text=Number%20of%20divorces%3A%20746%2C971%20(45,45%20reporting%20States%20and%20D.C.)
[85] Statista. Number of Divorces in the United Kingdom from 2019.https://www.statista.com/statistics/281565/number-of-divorces-in-the-united-kingdom-uk/
[86] Alive A. TTPS 2019 Traffic Safety Summary Review 2021.http://arrivealivett.com/statistics/
[87] National Highway Traffic Safety Administration(NHTSA). Fatality Data Show Continued Annual Decline in Traffic Deaths 2019.https://www.nhtsa.gov/press-releases/2019-fatality-data-show-continued-annual-decline-traffic-deaths
[88] Reported Road Casualties Great Britain GOVUK. Annual Report 2019.https://www.gov.uk/government/statistics/reported-road-casualties-great-britain-annual-report-2019
[89] Broome J. Workplace Drug Testing Policy http://trinidadandtobagolegalrights.blogspot.com/2019/12/workplace-drug-testing-policy.html
[90] Ministry of the Attorney General and Legal Affairs. Revised Laws https://agla.gov.tt/law-revision-commission/revised-laws/
[91] Mumena WA. Food Security and Nutritional Health of School-Aged Children in Two Caribbean Countries 2016.https://www.proquest.com/openview/5d9b5884cceef41552ed8ab31719b873/1?pq-origsite=gscholar&cbl=18750&diss=y
[92] Otero-Losada ME, Mc Loughlin S, Rodríguez-Granillo G, et al. Metabolic disturbances and worsening of atherosclerotic lesions in ApoE-/- mice after cola beverages drinking. Cardiovasc Diabetol 2013.https://cardiab.biomedcentral.com/articles/10.1186/1475-2840-12-57
[93] NationMaster. Trinidad and Tobago Transport Stats 2021.http://www.nationmaster.com/country-info/profiles/Trinidad-and-Tobago/Transport
[94] Joint Select Committee on Land and Physical Infrastructure. Eighth report on an inquiry into the effectiveness of measures in place to reduce traffic congestion on the nation’s roads 2019.http://www.ttparliament.org/reports/p11-s5-J-20191206-LPI-R8.pdf
[95] Physical Activity Guidelines Advisory Committee. Physical Activity Guidelines Advisory Committee Report, 2008 2008.https://health.gov/our-work/nutrition-physical-activity/physical-activity-guidelines/previous-guidelines/2008-physical-activity-guidelines/advisory-report
[96] Oakes JM, Forsyth A, Schmitz KH. The effects of neighborhood density and street connectivity on walking behavior: The Twin Cities walking study Epidemiol Perspect Innov 2007.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2228289/
[97] Sallis JF, Bauman A, Pratt M. Environmental and policy interventions to promote physical activity. Am J Prev Med 1998; 15(4): 379-97.
[98] Our World in Data.. Number of People with Depression by Country 1990.https://ourworldindata.org/grapher/number-with-depression-by-country?tab=chart&country=TTO
[99] The World Bank. Suicide Mortality Rate (per 100,000 Population) - Trinidad and Tobago 2021.https://data.worldbank.org/indicator/SH.STA.SUIC.P5?locations=TT&view=chart
[100] Our World in Data. Depression Prevalence Versus Self-Reported Life Satisfaction 2021.https://ourworldindata.org/grapher/depression-vs-self-reported-life-satisfaction?country=~GBR
[101] The World Bank. Suicide Mortality Rate (per 100,000 Population) - United Kingdom, United States 2021.https://data.worldbank.org/indicator/SH.STA.SUIC.P5?locations=GB-US
[102] Statista. Number of Divorces in the United Kingdom from 2019.https://www.statista.com/statistics/281565/number-of-divorces-in-the-united-kingdom-uk/
[103] Khayyam-Nekouei Z, Neshatdoost H, Yousefy A, Sadeghi M, Manshaee G. Psychological factors and coronary heart disease. ARYA Atheroscler 2013; 9(1): 102-11.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3653260/
[104] Simandan D. On how much one can take: Relocating exploitation and exclusion within the broader framework of allostatic load theory. Health Place 2010; 16(6): 1291-3.
[105] Simandan D. Rethinking the health consequences of social class and social mobility. Soc Sci Med 2018; 200: 258-61.
[106] Simandan D. Being surprised and surprising ourselves: A geography of personal and social change. Prog Hum Geogr 2020; 44(1): 99-118.
[107] Lichtman JH, Bigger JT Jr, Blumenthal JA, et al. Depression and coronary heart disease: recommendations for screening, referral, and treatment: A science advisory from the American Heart Association Prevention Committee of the Council on Cardiovascular Nursing, Council on Clinical Cardiology, Council on Epidemiology and Prevention, and Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Psychiatric Association. Circulation, 2008; 118(17): 1768-75.https://pubmed.ncbi.nlm.nih.gov/18824640/
[108] Simandan D. Social capital, population health, and the gendered statistics of cardiovascular and all-cause mortality. SSM Popul Health 2021; 16100971
[109] Seepersad R. IDB series on crime and violence in the Caribbean 2016.https://publications.iadb.org/en/crime-and-violence-trinidad-and-tobago-idb-series-crime-and-violence-caribbean
[110] Maharaj RG, Motilal MS, Babwah T, et al. National Alcohol Survey of Households in Trinidad and Tobago (NASHTT): Alcohol use in households. BMC Public Health 2017; 17https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-017-4266-z
[111] Simandan D. Beyond Haraway? Addressing constructive criticisms to the ‘four epistemic gaps’ interpretation of positionality and situated knowledges. Dialogues Hum Geogr 2019; 9(2): 166-70.
[112] Simandan D. Revisiting positionality and the thesis of situated knowledge. Dialogues Hum Geogr 2019; 9(2): 129-49.
[113] Daiber A, Lelieveld J, Steven S, et al. The “exposome” concept - how environmental risk factors influence cardiovascular health. Acta Biochim Pol 2019; 66(3): 269-83.
[114] Daiber A, Kuntic M, Hahad O, et al. Effects of air pollution particles (ultrafine and fine particulate matter) on mitochondrial function and oxidative stress - Implications for cardiovascular and neurodegenerative diseases. Arch Biochem Biophys 2020; 696: 108662.