Major differences in cardiovascular risk indicators by educational status. Results from a population based screening program

Hierarchical modelling of blood lipids' profile and 10-year (2002-2012) all cause mortality and incidence of cardiovascular disease: the ATTICA study

Background

The traditional view on the relationship between lipid biomarkers and CVD risk has changed during the last decade. However, it is not clear whether novel lipid biomarkers are able to confer a better predictability of CVD risk, compared to traditional ones.Under this perspective, the aim of the present work was to evaluate the predictive ability of blood lipids’ profile on all cause mortality as well as 10-year incidence of CVD, in a sample of apparently healthy adults of the ATTICA epidemiological study. 

Methods

From May 2001 to December 2002, 1514 men and 1528 women (>18 y) without any clinical evidence of any other chronic disease, at baseline, were enrolled. In 2011–12, the 10-year follow-up was performed in 2583 participants (85 % follow-up participation rate). Incidence of fatal or non-fatal CVD was defined according to WHO-ICD-10 criteria. Baseline serum blood lipids’ profile (Total-C, HDL-, non HDL-, LDL-cholesterol, triglycerides (TG), apolipoprotein (Apo)A1 and B, and lipoprotein–(a) levels were also measured.

Results

The 10-year all-cause mortality rate was 5.7 % for men and 2.0 % for women (p = 0.55). The, 10-year CVD incidence was 19.7 % in men and 11.7 % in women (p < 0.001). Multi-adjusted analysis revealed that TC, non-HDL-C, TG and TG/HDL-C ratio, were independent predictors of all cause mortality (RR per 1 mg/dL or unit (95 % CI): 1.006 (1.000–1.013), 1.006 (1.000–1.013), 1.002 (1.000–1.004), 1.038 (1.001–1.077), respectively). Moreover, TC, HDL-, LDL-, non-HDL-cholesterol, TG, apoA1, TC/HDL-C and TG/HDL-C were independently associated with CVD risk. Among all lipid indices the ratio of apoB/apoA1 demonstrated the best correct reclassification ability, followed by non-HDL-C and TC/HDL-C ratio (continuous Net Reclassification Index 26.1 and 21.2 %, respectively).

Conclusion

Elevated levels of lipid biomarkers are independently associated with all-cause mortality, as well as CVD risk. The ratio of apoB/apoA1, followed by non-HDL-C, demonstrated the best correct classification ability of the developed CVD risk models.

Screening for increased cardiometabolic risk in primary care: a systematic review

BACKGROUND

Many programmes to detect and prevent cardiovascular disease (CVD) have been performed, but the optimal strategy is not yet clear.

AIM

To present a systematic review of cardiometabolic screening programmes performed among apparently healthy people (not yet known to have CVD, diabetes, or cardiometabolic risk factors) and mixed populations (apparently healthy people and people diagnosed with risk factor or disease) to define the optimal screening strategy.

DESIGN AND SETTING

Systematic review of studies performed in primary care in Western countries.

METHOD

MEDLINE, Embase, and CINAHL databases were searched for studies screening for increased cardiometabolic risk. Exclusion criteria were studies designed to assess prevalence of risk factors without follow-up or treatment; without involving a GP; when fewer than two risk factors were considered as the primary outcome; and studies constrained to ethnic minorities.

RESULTS

The search strategy yielded 11 445 hits; 26 met the inclusion criteria. Five studies (1995-2012) were conducted in apparently healthy populations: three used a stepwise method. Response rates varied from 24% to 79%. Twenty-one studies (1967-2012) were performed in mixed populations; one used a stepwise method. Response rates varied from 50% to 75%. Prevalence rates could not be compared because of heterogeneity of used thresholds and eligible populations. Observed time trends were a shift from mixed to apparently healthy populations, increasing use of risk scores, and increasing use of stepwise screening methods.

CONCLUSION

The optimal screening strategy in primary care is likely stepwise, in apparently healthy people, with the use of risk scores. Increasing public awareness and actively involving GPs might facilitate screening efficiency and uptake.

Dietary habits mediate the relationship between socio-economic status and CVD factors among healthy adults: the ATTICA study

BACKGROUND

The aims of the present work were to investigate whether dietary habits are associated with socio-economic status (SES), and if they modify the relationship between SES and CVD risk factors, in a sample of men and women free from known CVD.

METHODS

This population-based study was carried out in the province of Attica, where Athens is a major metropolis. During 2001-2002, information from 1,528 men (18-87 years old) and 1,514 women (18-89 years old) was collected (75 % participation rate). Among several sociodemographic, clinical and biological factors, adherence to the Mediterranean diet was assessed by a special diet score (Mediterranean Diet Score, MDS) that incorporated the inherent characteristics of this traditional diet. CVD risk factors were examined across the participants' educational level and annual income that defined their SES.

RESULTS

Low SES groups exhibited higher prevalence of CVD risk factors, such as obesity, hypertension, diabetes mellitus and hypercholesterolaemia (all P < 0.001). Low SES groups also showed less adherence to the Mediterranean diet than high SES groups (MDS: 23.6 (sd 8.1) v. 25.6 (sd 5.6), P < 0.001). Higher SES index was associated with lower likelihood of having hypercholesterolaemia (OR = 0.91; 95 % CI 0.83, 1.00) and diabetes (OR = 0.83; 95 % CI 0.72, 0.95), after adjusting for various potential confounders. However, the previously mentioned inverse relationship observed between SES and prevalence of CVD risk factors was mainly explained by the dietary habits of the participants.

CONCLUSIONS

Low SES groups showed less adherence to the Mediterranean diet compared with high SES groups. This finding may, in part, explain the higher CVD risk factors profile observed among low SES participants.

Prevalence of self-reported hypercholesterolaemia and its relation to dietary habits, in Greek adults; a national nutrition & health survey

BACKGROUND

The strong causal role of hypercholesterolaemia on the progression of atherosclerosis and subsequently on the development of cardiovascular disease is well described. Main aim of this study was to evaluate the prevalence of self-reported hypercholesterolaemia and its relation to nutritional habits, in a representative nationwide sample of adult Greek population.

METHODS

Cross sectional survey. Based on a multistage sampling, 5003 adults (18-74 yr) were enrolled (men: 48.8%, women: 51.2%). All participants were interviewed by trained personnel who used a standard questionnaire. The questionnaire included demographic and socioeconomic characteristics, medical history, lifestyle habits and nutritional assessment.

RESULTS

The prevalence of self-reported hypercholesterolaemia was 16.4% in men and 21.8% in women (P < 0.001). Hypercholesterolaemic status was positively associated with the prevalence of hypertension, diabetes mellitus, renal failure, obesity and physical inactivity, and inversely with the prevalence of smoking. The analysis of reported food consumption patterns showed that consumption of fish, fruits and juices, cereals, and low fat milk and yogurt was significantly higher among hypercholesterolaemic participants while the opposite was observed for food items as red meat, pork, egg, full fat dairy products and desserts.

CONCLUSION

Hypercholesterolaemia seems to affect a large part of Greek population. It is hopeful that hypercholesterolaemics may have started adopting some more healthy nutritional behaviour compared to normocholesterolaemic ones.

Diet, lifestyle factors and hypercholesterolemia in elderly men and women from Cyprus

BACKGROUND

We sought to investigate the single and combined effect of Mediterranean diet, being physically active, moderate alcohol use, and non-smoking on clinical status of 150 elderly people from Cyprus.

METHODS

The study comprises individuals enrolled in surveys from Greece and Cyprus. This work includes 53 apparently men and 97 women, aged 65 to 100 years, from various areas of Cyprus. The cohort study was conducted between 2004 and 2005. A diet score that assesses the inherent characteristics of the Mediterranean diet was developed (range 0-55) and then a healthy index was calculated that evaluated four lifestyle habits (range 0-4), i.e. non-smoking, alcohol intake, physical activity and adherence to the Mediterranean diet (i.e. above the median of the score).

RESULTS

65% participants had hypercholesterolemia (total serum cholesterol > 200 mg/dl or use of lipid lowering agents). Moreover, 32% of the participants reported physically active, 5% reported smoking habits and 4% that they have stopped smoking during the past decade, while 8% reported alcohol drinking. A positive association was observed between prevalence of hypercholesterolemia and smoking habits (odds ratio = 4.3, p = 0.03), while an inverse association was observed between hypercholesterolemia, alcohol drinking (odds ratio = 0.3, p = 0.04) and adherence to a Mediterranean diet (odds ratio = 0.77, p = 0.02), controlled for age, sex, and other factors.

CONCLUSION

Adherence to a Mediterranean diet and healthful lifestyle is associated with reduced odds of having hypercholesterolemia among elderly people.

The association between educational level and risk of cardiovascular disease fatality among women with cardiovascular disease

BACKGROUND

The inverse relation of socioeconomic status with incident cardiovascular diseases (CVDs) has been well established. However, few data are available describing this relation among ethnically diverse women with prevalent CVD. Using education as a proxy for socioeconomic status, we examined its relation to CVD mortality among women with established CVD.

SUBJECTS

Data from 2,157 women with CVD at baseline, who participated in nine long-term U.S. cohort studies, were pooled.

METHODS

Cox regression models adjusted for history of diabetes mellitus, total cholesterol, systolic and diastolic blood pressure, body mass index, smoking, race/ethnicity, and age at baseline were used to estimate hazard ratios for CVD mortality between non-high school graduates and high school graduates.

RESULTS

During a mean follow-up time of 11.5 years, 615 CVD deaths were observed. There was an age-dependent (p = .003) inverse association between education and CVD mortality among women with CVD. At age 60, the risk of dying due to CVD among non-high school graduates was more than twice greater than that of high school graduates (hazard ratio = 2.34; 95% CI 1.27-4.29). At age 65, the hazard ratio decreased to 1.31 (95% CI 1.00-1.71). By age 70, there was no difference in the hazard of dying between high school graduates and nongraduates (hazard ratio = 1.01; 95% CI .85-1.21).

CONCLUSIONS

Our results show that among women with CVD, educational level was a significant, and age-dependent, predictor of fatal CVD independent of other traditional risk factors. These women are an important high-risk population to target secondary prevention and educational efforts.

Status and management of blood lipids in Greek adults and their relation to socio-demographic, lifestyle and dietary factors: the ATTICA Study. Blood lipids distribution in Greece

OBJECTIVE

In this work, we assessed the status and management of blood lipids in a sample of cardiovascular disease free adult men and women from Greece. We also evaluated the effect of several socio-demographic, dietary and lifestyle habits on lipid levels.

METHODS

The ATTICA Study is a population-based cohort that has randomly enrolled 1128 men and 1154 women (aged >18 years old), stratified by age-gender, from the greater area of Athens, during 2001-2002. Adherence to Mediterranean diet was assessed through a diet score that was based on a validated food-frequency questionnaire.

RESULTS

Forty-six percent of men and 40% of women had total serum cholesterol levels >200mg/dl. Of them, 40% of men and 30% of women were unaware of their condition. Twenty-one percent of men and 7% of women had HDL-cholesterol levels <35 mg/dl. Twenty-eight percent of men and 13% of women had triglyceride levels >150 mg/dl. Fifteen percent of men and 12% of women had LDL-cholesterol levels >160 mg/dl and 52% of men and 48% of women had LDL >130 mg/dl. Of those who had known blood lipid abnormalities, 36% of men and 33% of women followed a dietary medication, 31% of men and 20% of women were receiving a pharmaceutical treatment (mainly statin) and the rest were untreated. Participants who adopted the Mediterranean diet and received statin, had on average 9% lower total cholesterol (P = 0.04), 19% lower LDL-cholesterol levels (P = 0.02) and 32% lower oxidized LDL-cholesterol levels (P < 0.001) compared to those who were untreated and adopted a Westernized diet.

CONCLUSIONS

We could speculate that about 3 million Greek adults had high total cholesterol levels. Adverse findings were also observed regarding the other investigated blood lipids. Mediterranean diet could be a complimentary mean to pharmaceutical treatment in reducing blood lipids.

Multi-country comparison of plasma lipid relationship to years of schooling in men and women

BACKGROUND

The association between coronary heart disease (CHD) and social status has differed among societies in strength and direction. As years of schooling is a major determinant of socioeconomic status and dyslipidaemia a major CHD determinant, the purpose of this investigation is to estimate the association of years of schooling with plasma lipids and lipoproteins among samples from five countries representing different cultures, socio-political systems and stages of economic development.

METHODS

Men and women from Chinese, Polish, Russian, Israeli and US samples were studied. Years of schooling were analysed both as a multi-category ordinal variable and divided into two strata: less than the equivalent of high school and greater than or equal to high school equivalence. Fasting plasma cholesterol, low density lipoprotein (LDL) cholesterol, high density lipoprotein (HDL) cholesterol and triglycerides were compared across years of schooling strata within each country. Lipid levels were computed unadjusted and then adjusted for age and lipid risk factor variables.

RESULTS

Total cholesterol, LDL cholesterol, and triglycerides varied directly with years of schooling in Chinese, Polish and Russian men, and in contrast varied inversely with years of schooling among US white men. The HDL cholesterol varied inversely with years of schooling for Chinese, Polish, and Russian men, but varied directly with years of schooling among US white men. The lipid differences between men of high versus low years of schooling were not explained by age, body mass index, smoking, alcohol consumption or blood pressure medication use. Findings were less consistent for women and for Israelis and US blacks of both genders.

CONCLUSIONS

Lipid and lipoprotein levels consistent with atherogenicity varied directly with years of schooling in Chinese, Polish, and Russian samples. Opposite trends were present in US whites. These findings are consistent with a hypothesized influence of social status on CHD risk differing among populations in relation to stages in societal economic development.

Inequalities in life expectancy in Lithuania by level of education

The purpose of this study was to examine educational inequalities in life expectancy of the Lithuanian population. The life-tables by level of education were calculated on the basis of the individual records of the 1989 census, which were linked to the death records of males and females, aged 25-70 years. In comparison with the group with university education, the life expectancy of males with primary or lower education was 11.7 years shorter, and of females 4.3 years shorter. The greatest impact of educational differentials on life expectancy was the inequality found in the mortality of the population, aged 25-44 years. Sex differences in life expectancy were greatest among those with primary or lower education. External causes of death contributed most to educational differences in life expectancy of males, whereas cardiovascular diseases had a major impact to educational differences in females.

Potential explanations for the educational gradient in coronary heart disease: a population-based case-control study of Swedish women

OBJECTIVES

This study examined the association between educational attainment and coronary heart disease (CHD) and the factors that may explain this association.

METHODS

This population-based case-control study included 292 women with CHD who were 65 years or younger and 292 age-matched controls.

RESULTS

Compared with the adjusted odds ratio for CHD associated with college education, the age-adjusted odds ratio associated with mandatory education (< or = 9 years) was 1.87 (95% confidence interval [CI] = 1.23, 2.84) and the odds ratio for high school education was 1.35 (95% CI = 0.81, 2.25) (P for trend < .01). The odds ratio for mandatory education was reduced by 82%, to 1.16 (95% CI = 0.69, 2.09), after adjustment for psychosocial stress, unhealthy lifestyle patterns, hemostatic factors, hypertension, and lipids.

CONCLUSIONS

Much of the increased risk of CHD in women with low education appears to be linked to psychosocial stress and lifestyle factors. Hemostatic factors, lipids, and hypertension also contribute to a lesser extent. These factors may be considered in strategies geared to reducing socioeconomic inequalities in cardiovascular health.