Human aging in contemporary industrialized populations focuses largely on chronic diseases of aging, including heart disease, diabetes and dementia. These three account for a third of all deaths in the US and UK, and are increasing throughout the rest of the world. To what extent do these characterize what aging might have looked like in our evolutionary past? For example, atherosclerosis has been identified in ancient mummies, leading some to claim that heart disease is a "serial killer that has been stalking mankind for thousands of years". Yet heart disease is commonly believed to be rare among people living active, subsistence lifestyles typical of our preindustrial past. Here, I evaluate evidence for heart disease and other “diseases of civilization” in subsistence populations, and consider the impacts of lifestyle change and infection, highlighting novel findings from a longitudinal study of Tsimane Amerindians. I will attempt to provide new perspectives to help facilitate comparative study, and to bridge more “ultimate” evolutionary accounts with more “proximate” biomarker-based epidemiological approaches.