Archives of Medicine

Keywords

Cardiovascular disease; Framingham risk score; Readiness for change

Introduction

Cardiovascular disease (CVD) includes conditions such as Hypertension (HTN), Coronary Heart Disease (CHD), myocardial infarction, angina pectoris, heart failure, and stroke [1]. Although incidence of and mortality from CVD has declined in recent decades [2], CVD remains the leading cause of death worldwide [3]; in 2008, CVD caused 7.3 million deaths (30% of all mortalities) [4]. According to the World Health Organization, the majority of mortalities in Saudi Arabia were due to non-communicable diseases which accounted for 73% of all deaths, 37% were due to CVDs [4]. According to the World Heart Federation, CVD is the most serious, neglected health problem affecting women worldwide [5]. Almost two-thirds (64%) of women who die suddenly of CHD have had no previous symptoms [6].

Modifiable risk factors clinically proven to influence cardiovascular health include diabetes, high blood pressure, hypercholesterolemia, overweight or obesity, insufficient physical activity, unhealthy diet, and smoking. Other non-modifiable risk factors include age, gender, family history, and race [7]. Previous studies have shown that tailoring messages on lifestyle counselling to an individual's readiness to change increases the likelihood of their success in adapting their modifiable risk factors for CVD. Therefore, this study aimed to evaluate cardiovascular disease risk among females ≥30 years and readiness to make lifestyle changes. The findings of this study could be used to support the development of an effective, community-based lifestyle modification program for women with moderate to high risk CVD in Saudi Arabia.

Research Methodology

The protocol of this study followed the principles of the Helsinki Declaration and was approved by King Abdullah International Medical Research Center (Institutional Review Board approval number: RJ13/039/J). Women received detailed information of the study and provided informed written consent before.

This study was conducted in the National Guard Residential City, Jeddah, which consists of 1229 villas from 5 geographical sections. Women aged ≥30 years were screened from January to April 2015 and their Framingham Risk Scores (FRS) were calculated. Accordingly, participants with moderate to high CVD risk were included in another interventional study. Women aged <30 years, aged ≥30 years with low risk of CVD, who were pregnant, or who were diagnosed with CVD were excluded.

All households in the residential city were visited and informed of the study by a group of trained research assistants. Eligible women were asked to participate in the research. By using the Coronary Risk Profile (CRP) questionnaire from Wellsource Inc. (Portland, OR, USA) [8], data on health history, smoking habits, physical activity, eating practices, social factors, and readiness for behavioural change to reduce CVD risk were collected.

Each participant’s weight, height, Body Mass Index (BMI), waist circumference, and blood pressure were measured. Fasting blood sample was obtained using the CardioChek PA System [Polymer Technology Systems, Inc. Indianapolis, IN, USA], to determine cholesterol, High-Density Lipoprotein (HDL), glucose, and triglyceride levels. The results met the accuracy guidelines established by the National Cholesterol Education Program of the National Institutes of Health [9]. FRS was calculated to estimate the 10-year risk of major cardiovascular events and was categorized into low (<10% FRS), moderate (10%-19% FRS), or high (≥20% FRS) risk. Those with moderate and high risk were evaluated for their Metabolic Syndrome (MS) status. They were classified as having MS if they satisfied 3 of the following 5 criteria (based on the criteria established by the National Heart, Lung, and Blood Institute for the diagnosis of MS): (1) abdominal obesity, determined by an increased waist circumference of >88 cm in women; (2) increased triglyceride levels of ≥1.7 mmol/L (150.6 mg/dL); (3) reduced HDL level of <1.3 mmol/L (50.2 mg/ dL); (4) elevated blood pressure of ≥ 130/≥ 85 mmHg; and (5) increased fasting glucose level of ≥6.1 mmol/L (109.8 mg/dL). Individuals who were screened as positive were referred to the primary health-care centre for further assessment. Nevertheless, these participants were enrolled in the study.

Statistical Analysis

Statistical analysis was performed using the Statistical Package for Social Sciences version 22 (IBM Corp., Armonk, NY, USA). Demographic and clinical data were analysed using descriptive statistics, including means, standard deviations, and frequencies as well as logistic regression analysis. This research used an alpha level of statistical significance of less than 0.05.

Results

Data from 616 female subjects who met the inclusion criteria were analysed in this study. The mean age of participants was 42.0 ± 7.9 years. Most were married (93.2%), had university education (36.7%), were housewives (68.0%), and were employed (31.7%). Overall, 29.0% were overweight (BMI, 25-29.9 kg/m²), 54.2% were obese (BMI, ≥30 kg/m²), and 78.0% were abdominally obese (>88 cm). Some of the participants had one or more CVD risk factors, 4 including hypertension (11.0%), diabetes (15.7%), and hypercholesterolemia (18%). Family history of diabetes, hypertension, hypercholesterolemia, and heart diseases in firstdegree relatives were present in 65.6%, 52.8%, 25.3%, and 20.6% of the participants. Inactive lifestyle was commonly reported, with 54.0% having less than 30 min of exercise per day and 20% of women spending 2 hours daily in domestic work.

In the assessment of cardiovascular disease risk according to the Framingham 10-year CVD risk score, 86.0% (n=531) of the screened population showed low risk. Of the remaining participants, 10% were at moderate risk and 4% were in the highrisk category (n=85).

Statistically significant differences in CVD risk score were observed between the 2 groups in age (p=0.01), marital status (p=0.04), educational level (p=0.01), and income (p=0.01). Moderate- and high-risk groups were more likely to be older, illiterate, and have lower monthly income (Table 1).

Table 1 Socio-demographic characteristics of women according to cardiovascular disease risk score (n = 616) at the National Guard Residential City in Jeddah, Saudi Arabia, 2015.

Medical history was compared between the 2 groups, and a statistically significant difference in CVD risk score was found between the low-, moderate- and high-risk groups in diabetes (p=0.01), hypertension (p=0.01), and hypercholesterolemia (p=0.01). Overall, 58.0% in the moderate- and high-risk groups had diabetes, 48.0% had hypertension, and 52.0% had hypercholesterolemia.

There were statistically significant differences in CVD risk score between the low-risk group and moderate- and high-risk groups in family history of diabetes (p=0.01), heart diseases (p=0.01), and hypercholesterolemia (p=0.01). Moderate and high-risk groups were more likely to have family histories of diabetes, heart diseases, and hypercholesterolemia than the low-risk group. A statistically significant difference in CVD risk score was observed between the low-risk, moderate-risk, and high-risk groups in smoking status (p=0.03). The percentage of smokers in the moderate- and high-risk group (5.0%) was higher than in the low-risk group (0.5%). No statistically significant difference in CVD risk score in relation to passive smoking was observed between the 2 groups.

Table 2 shows that the moderate- and high-risk groups tended to be less active during the week. This difference was statistically significant (p=0.03).

Table 2 Physical activity according to cardiovascular risk score (n = 616) at the National Guard Residential City in Jeddah, Saudi Arabia, 2015.

As shown in Table 3, both groups tended to skip breakfast and eat less than one serving of fruits and vegetables, although the difference was not statistically significant. The moderate-and high-risk groups tended to consume more servings of bread; this difference was statistically significant (p=0.01).

Table 3 Nutritional habits according to cardiovascular disease risk score (n = 616) at the National Guard Residential City in Jeddah, Saudi Arabia, 2015.

Unhappiness, anger, and exhaustion were more prevalent in the low-risk group than in the moderate- and high-risk groups; the difference was statistically significant (p<0.05).

As shown in Table 4, metabolic syndrome was more common in moderate- and high-risk groups. This difference was statistically significant (p=0.01).

Table 4 Metabolic syndrome according to cardiovascular disease risk (n = 616) at the National Guard Residential City in Jeddah, Saudi Arabia, 2015.

The results of the logistic regression model indicated that medical history of hypercholesterolemia, hypertension, diabetes, family history of heart disease in a first-degree relative, and eating junk food were positive predictors (risk factors) of developing CVD. Thinking of changing lifestyle was a negative predictor (protective factor) of CVD (p<0.05).

CVD risk was seven-fold (95% CI, 3.6%-16.3%), six-fold (95% CI, 2.9%-13.9%) five-fold (95% CI, 2.3%-10.6%), two-fold (95% CI, 1.2%-5.1%), and almost three-fold (95% CI, 1.3%-5.3%) in women with diabetes, hypertension, family history of heart disease, hypercholesterolemia, and women who were junk food consumers, as shown in Figure 1.

Regarding readiness to make lifestyle changes, 61.0% of women were thinking of eating healthy meals daily and 46.0% were thinking of adopting 30 minutes or more of physical activity 3-4 days or more per week. Additionally, 51.0% were thinking of achieving a healthy weight (Figure 2).

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