Hidden Heart Disease Toll Emerges in Indonesian Screening of Over-40s

A sweeping community screening campaign in North Sumatera, Indonesia, has uncovered a burden of cardiovascular risk factors so large that researchers say most people carrying them had no idea. In the ECARDIA-NS study, short for Early Detection of Cardiovascular Risk Factors as Primary Prevention amongst North Sumatera Adults, a team led by investigators at Universitas Sumatera Utara together with collaborators from the National Heart Centre Singapore and the Duke-NUS Global Health Institute recruited 1,208 adults aged 40 and older who had no apparent cardiovascular disease. Between March and December 2024, participants were screened at 15 sites across Kota Medan, Kota Tebing Tinggi and Kabupaten Langkat. What the team found was sobering: 56 percent had hypertension, 44 percent had dyslipidemia and 17 percent had diabetes, and the majority of these cases were newly diagnosed during the study itself, meaning they had gone undetected by the existing health system despite years of national survey infrastructure.

The study’s technical approach is what sets it apart from the questionnaire-based surveys that have dominated Indonesian national health surveillance. Rather than relying primarily on interviews, the researchers put every willing participant through a battery of objective measurements. Anthropometric assessments captured body mass index and waist circumference, blood pressure was measured with calibrated devices, and each subject received a single-lead electrocardiogram to probe for silent rhythm abnormalities. Crucially, blood was drawn for biochemical analysis, including glycated hemoglobin, or HbA1c, which reflects average blood glucose over roughly three months, and a full lipid panel measuring cholesterol fractions including low-density lipoprotein. This laboratory anchoring matters because prior nationwide efforts, such as the Indonesian Health Survey of 2023, largely depended on self-reported history and tested only a limited subset of respondents with oral glucose tolerance tests and biochemical lipid profiling, leaving substantial blind spots in prevalence estimates.

The metabolic findings were perhaps the most dramatic. Sixty-nine percent of participants met criteria for obesity, a further 15 percent were overweight, and 83 percent had elevated waist circumference, a marker of central adiposity that is increasingly recognized as an independent predictor of cardiometabolic risk. Central obesity, in which fat accumulates around the abdominal organs, is metabolically active tissue that promotes insulin resistance, raises blood pressure and dysregulates lipid metabolism. That more than eight in ten screened adults carried excess abdominal fat, in a population where 80 percent of participants were women, points to a profound nutritional and lifestyle transition in this semi-urban setting. Indonesia, like much of Southeast Asia, has seen rapid shifts in diet and physical activity patterns over recent decades, and these data offer one of the clearest snapshots yet of what that transition means for the cardiovascular health of a working-age and older population outside the major megacities.

The screening also caught a quieter danger. Using the single-lead electrocardiogram, the team identified atrial fibrillation in 1.3 percent of subjects. Atrial fibrillation is an irregular heart rhythm that dramatically increases the risk of ischemic stroke, often presenting with no symptoms at all until a clot-related catastrophe occurs. Detecting it in a community cohort of adults without known cardiovascular disease underscores the value of including simple, inexpensive rhythm screening in population health programs. A single-lead ECG takes minutes and requires modest equipment, yet it can flag individuals who would benefit from anticoagulation therapy and closer follow-up, potentially preventing disabling strokes before they happen.

To understand who was most at risk, the researchers turned to multivariable logistic regression, a statistical technique that estimates the independent association between each candidate factor and an outcome while holding the others constant. The analysis showed that the presence of cardiovascular risk factors was significantly associated with older age, obesity and elevated waist circumference. These associations align with the established pathophysiology of atherosclerosis and metabolic disease, in which adiposity drives hypertension, insulin resistance and dyslipidemia over decades of exposure. But the regression results also carry a public health message: the risk factor burden in this population concentrates in identifiable, measurable subgroups, meaning targeted screening and intervention programs could plausibly reach the people who need them most without screening everyone identically.

Beyond physiology, the study probed the psychology of prevention. A subset of participants completed a 14-point questionnaire assessing knowledge, attitudes and practices, commonly abbreviated KAP in global health research. The median knowledge score was just 5 out of 10, and the median combined KAP score was 9 out of 14, revealing substantial gaps in what these adults understood about cardiovascular risk factors and how to control them. Further regression analysis suggested that KAP scores rose with education level but were unrelated to occupation, hinting that formal schooling, rather than workplace environment, shapes cardiovascular health literacy in this setting. Strikingly, the researchers found no significant relationship between KAP scores and the actual presence of cardiovascular risk factors. Knowing what is unhealthy, in other words, did not translate into measurably healthier risk profiles among those screened.

That disconnect between knowledge and behavior is a familiar puzzle in chronic disease prevention, but its scale here is notable. Health communication campaigns that simply inform people about the dangers of salt, sugar, tobacco and inactivity may be necessary but insufficient when the environments in which people eat, work and age make healthy choices difficult. In semi-urban North Sumatera, where community health infrastructure includes PUSKESMAS, the government community health centers, and POSBINDU, the integrated development posts designed for noncommunicable disease monitoring, the study’s findings suggest these channels exist but are not yet detecting or managing risk at the scale required. With more than half of screened adults hypertensive and most of those cases newly identified, the gap between the population’s need and the system’s reach is wide.

The study’s design deserves scrutiny as well as praise. Recruitment was opportunistic rather than a random population sample, meaning participants were people who came forward at screening sites, and four-fifths of them were women. Prevalence estimates drawn from such a cohort may not perfectly mirror the general adult population of North Sumatera, and the researchers are careful to frame the work as community-based screening rather than definitive epidemiology. Even so, the objective biochemical and instrumental measurements give the numbers a solidity that interview-based surveys cannot match, and the sheer proportion of newly diagnosed hypertension, diabetes and dyslipidemia among ostensibly healthy adults is unlikely to be an artifact. If anything, self-selection into a screening program would be expected to attract more health-conscious individuals, suggesting the true population burden could be still higher.

The ECARDIA-NS partnership between Universitas Sumatera Utara and the SingHealth Duke-National University of Singapore Global Health Institute, funded through pilot grants from both institutions, offers a model for how regional collaboration can generate locally actionable data. The authors conclude that the high burden of cardiometabolic disease, combined with the knowledge gaps the KAP survey exposed, indicates that considerably more work remains to be done in the region to address cardiovascular risk. Their findings arrive at a moment when low- and middle-income countries across Asia are confronting the collision of aging populations with rising obesity and diabetes, and when global health agencies are pressing for primary prevention strategies that identify risk before the first heart attack or stroke. In Medan and its surrounding districts, the message from this study is unambiguous: the risk factors are there, they are common, they are largely silent, and they are waiting to be found by anyone willing to measure a blood pressure, draw a blood sample and look.

Subject of Research: Prevalence and detection of cardiovascular risk factors among semi-urban adults in North Sumatera, Indonesia

Article Title: Prevalence of cardiovascular risk factors in a semi-urban population in Indonesia [Early detection of cardiovascular risk factors as primary prevention amongst North Sumatera adults (ECARDIA-NS) study]

Article References: Siregar, Y. F., Tern, P. J. W., Lei, J., Ilyas, K. K., Raynaldo, A. H., Sarastri, Y., Haykal, T. B., Andra, C. A., Habib, F., Hasan, R., Siregar, D. I. S., Koh, S. J. Q., Koh, A. S.-M., Tan, J. W. C., & Lubis, A. C. (2026). Prevalence of cardiovascular risk factors in a semi-urban population in Indonesia [Early detection of cardiovascular risk factors as primary prevention amongst North Sumatera adults (ECARDIA-NS) study]. BMC Public Health. https://doi.org/10.1186/s12889-026-29179-y

Image Credits: AI Generated

DOI: 10.1186/s12889-026-29179-y

Keywords: cardiovascular risk factors, hypertension, diabetes, dyslipidemia, obesity, Indonesia, North Sumatera, population screening, primary prevention, atrial fibrillation, public health, Prevalence