- Email: [email protected]
Population-based study of cardiovascular health in Atahualpa, a rural village of coastal Ecuador
1618
Letters to the Editor
[4] Kavsak PA, MacRae AR, Yerna MJ, Jaffe AS. Analytic and clinical utility of a nextgeneration, highly sensitive cardiac troponin I assay for early detection of myocardial injury. Clin Chem 2009;55:573–7. [5] Mather AN, Fairbairn TA, Artis NJ, Greenwood JP, Plein S. Relationship of cardiac biomarkers and reversible and irreversible myocardial injury following acute myocardial
infarction as determined by cardiovascular magnetic resonance. Int J Cardiol 2013;166:458–64. [6] Lippi G. Biomarkers of myocardial ischemia in the emergency room: cardiospecific troponin and beyond. Eur J Intern Med 2013;24:97–9.
0167-5273/$ – see front matter © 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijcard.2013.01.018
Population-based study of cardiovascular health in Atahualpa, a rural village of coastal Ecuador☆ Oscar H. Del Brutto a,b,⁎, Milton Santamaría c, Elio Ochoa d, Ernesto Peñaherrera a,e, Rocío Santibáñez b,d, Freddy Pow-Chon-Long e, Mauricio Zambrano b, Victor J. Del Brutto b a
School of Medicine, Universidad de Especialidades Espíritu Santo, Ecuador Department of Neurological Sciences, Hospital-Clínica Kennedy, Guayaquil, Ecuador Health Center, Ministry of Public Health, Atahualpa, Ecuador d Hospital Teodoro Maldonado Carbo, National Institute of Social Security, Guayaquil, Ecuador e Department of Cardiology, Hospital Luis Vernaza, Guayaquil, Ecuador b c
a r t i c l e
i n f o
Article history: Received 6 December 2012 Accepted 18 January 2013 Available online 11 February 2013 Keywords: Cardiovascular health Epidemiology Prevalence Ecuador Atahualpa
The American Heart Association (AHA) recently defined the metrics needed to categorize cardiovascular health (CVH), to implement strategies directed to reduce vascular deaths among US populations [1]. The same could be applied to developing countries, where stroke and cardiovascular diseases will be the next health epidemics due to changes in lifestyle and increased life expectancy [2]. Indeed, the rate of vascular deaths in Latin America is higher than in the developed world; this excess mortality fraction could be related to modifiable factors, including: inadequate access to medical care, increasing obesity and diabetes mellitus, and uncontrolled arterial hypertension [3]. To optimize existing sanitary resources it is mandatory to know the CVH status of a given population using standardized metrics. Here, we present the CVH status of Atahualpa inhabitants, a village representative of rural coastal Ecuador. The methodology of this study has been detailed elsewhere [4]. After informed consent was obtained, field personnel performed a door-todoor survey to identify all Atahualpa residents, and to apply questionnaires designed to evaluate the CVH status of people aged ≥40 years who were free of stroke and ischemic heart disease. We used CVH metrics proposed by the AHA. Persons with stroke and ischemic heart disease were identified by the use of validated field questionnaires, and the diagnosis was further corroborated by a team of certified neurologists and cardiologists.
☆ External funding: This study was partially supported by an unrestricted grant from the Universidad Especialidades Espíritu Santo, Guayaquil, Ecuador. The sponsor had no role in the design of the study, nor in the collection, analysis, and interpretation of data. ⁎ Corresponding author at: Air Center 3542, PO Box 522970, Miami, Fl 33152-2970, USA. Tel.: + 1 593 42285790. E-mail address: [email protected] (O.H. Del Brutto).
We assessed the number of Atahualpa residents aged ≥ 40 years (free of stroke or ischemic heart disease) with one to seven ideal CVH metrics. We also noted the number of intermediate and poor CVH metrics per person. CVH status was classified as ideal, intermediate and poor (Table 1). Statistical analysis was carried out using SPSS 18 software (SPSS Inc., Chicago, Illinois, USA). Significance was tested by the use of the χ2 test with Yates' correction when needed or the Fisher's exact test. Differences were considered significant if p b 0.05. Six-hundred forty-two (26%) of 2478 Atahualpa residents were aged ≥40 years. Twenty-six persons were excluded because of a stroke or ischemic heart disease. Therefore, CVH metrics and CVH status were evaluated in 616 persons (mean age 58.7±12.5 years, 59.4% women, and 64.4% with primary school instruction). CVH metrics of included individuals were stratified according to age, gender, and education (Table 2). Persons ≥60 years had higher rates of physical activity, blood pressure and fasting glucose in the poor range than those aged 40 to 59 years; in contrast, the rate of ideal BMI was higher for individuals aged ≥60 years. Men had lower rates of ideal smoking status, blood pressure and fasting glucose than women, but the latter had lower rates of ideal BMI, physical activity and total cholesterol than men. Physical activity, blood pressure and fasting glucose were the CVH metrics that showed lower ideal values in persons with up to primary school instruction. Overall, 13 (2%) persons had seven ideal CVH metrics (ideal CVH status), 211 (34%) had four to six ideal CVH metrics, and 392 (64%) had three or less ideal CVH metrics. Of the 603 persons with less than seven ideal CVH metrics, 173 (28%) had one or more intermediate CVH metrics but no poor metrics (intermediate CVH status), and 430 (70%) had at least one poor metric (poor CVH status). The odds for having a poor CVH status was most common in persons aged ≥60 years (OR=0.61, 95% C.I. 0.43–0.87, p=0.006). Among the 430 persons with poor CVH status, most have only one (51%) or two (35%) poor CVH metrics, 14% had three to four poor CVH metrics, and only one person had five poor CVH metrics. The poorest CVH metrics were blood pressure, fasting glucose, and BMI. In contrast, smoking status, diet, physical activity and total cholesterol were satisfactory, with values in the poor range found in less than 10% of persons (Table 2). A sizable proportion (70%) of Atahualpa residents aged ≥ 40 years had a poor CVH status. However, most of them (86%) had only one or two poor CVH metrics and 67% of the entire population had three or more ideal CVH metrics. Individuals scored better in the so-called “health behaviors” (smoking, BMI, physical activity and diet) than in the “health factors” (blood pressure, fasting glucose and total
Letters to the Editor
1619
Table 1 Cardiovascular health metrics and status according to the American Heart Association. Cardiovascular health metrics 1. Smoking: ideal (never or quit N1 year), intermediate (quit ≤ 1 year) and poor (current smoker). 2. Body mass index: ideal (b25 kg/m2), intermediate (25 to b30 kg/m2) and poor (≥ 30 kg/m2). 3. Physical activity: ideal (≥ 150 min/week moderate intensity or ≥75 min/week vigorous intensity or equivalent combination), intermediate (1–149 min/week moderate intensity or 1–74 min/week vigorous intensity or equivalent combination) and poor (no moderate and vigorous activity). 4. Diet: ideal (4–5 healthy components), intermediate (2–3 healthy components) and poor (0–1 healthy component); based on 5 health dietary components (≥4.5 cups fruits and vegetables/day, ≥two 3.5-oz servings fish/week, ≥three 1-oz equivalent servings fiber-rich whole grains/day, b1500 mg sodium/day, and ≤450 kcal sugar-sweetened beverages/week). 5. Total cholesterol: ideal (untreated and b 200 mg/dL), intermediate (treated to b 200 mg/dL or 200–239 mg/dL) and poor (≥240 mg/dL). 6. Blood pressure: ideal (untreated and b 120/b 80 mmHg), intermediate (treated to b 120/b 80 mmHg or 120–139/80–89 mmHg) and poor (≥140/90 mmHg). 7. Fasting glucose: ideal (untreated and b100 mg/dL), intermediate (treated to b 100 mg/dL or 100–125/mg/dL) and poor (≥126 mg/dL). Cardiovascular health status 1. Ideal CVH status: all seven CVH metrics in the ideal range. 2. Intermediate CVH status: at least one CVH metric in the intermediate range, but no poor metrics. 3. Poor CVH status: at least one CVH metric in the poor range.
cholesterol blood levels). Indeed, the only one health behavior that scored poor in our population was BMI. Of the three health factors, only total cholesterol scored well. In contrast, blood pressure and fasting glucose scored quite poor, with 38% and 32% of the population having such values in the poor range, respectively. The rather high rate of persons with arterial hypertension could be partly related to the high amount of salt in the diet, which was the individual healthy dietary factor that scored worst during the survey. The high percentage of persons with fasting glucose in the poor range could be associated with obesity and a diet that is rich in carbohydrates, but it is also possible that there is a yet unknown genetic susceptibility in Ecuadorian natives, a point that deserves further investigation.
Comparison of our results with other surveys [5–10] showed significantly better numbers for most CVH metrics and for the percentage of persons with ideal and intermediate CVH status. Such differences may be related to a more simple way of living in Atahualpa. On the light of these findings, the higher rate of vascular deaths in rural areas of Latin America could be explained by the counterbalance exerted by a lesser access to medical care and by the low income of the population that cannot afford costs related to chronic management of arterial hypertension and diabetes mellitus. In summary, this study shows—for the very first time—the CVH status of a rural population of Latin America. In general terms, the status is poor but it is much better than that reported from other populations. Further
Table 2 Cardiovascular health metrics in Atahualpa residents stratified by age, gender, education, and alcohol intake. Metrics
Total series (n=616)
Age
Gender
40≥ 59 years 60 years (n=339) (n=277)
p Value (age)
Women (n=366)
Education
Alcohol intake
Men (n=250)
p Value Up to (gender) primary school (n=397)
Secondary p Value school or (education) higher (n=219)
No alcohol or mild consumption (n=529)
Moderate to intense consumption (n=87)
p Value (alcohol intake)
92.8 2.8 4.4
b 0.001
97.2 1 1.8
96.8 1.4 1.8
0.919
98.7 0.9 0.4
87.4 2.3 10.3
b0.001
Smoking status, % Ideal 97.1 Intermediate 1.1 Poor 1.8
95.9 1.8 2.3
98.5 0.4 1.1
Body mass index, % Ideal 36 Intermediate 38 Poor 26
30.1 38.1 31.8
43.3 37.9 18.8
b 0.001
31.4 38.5 30.1
42.8 37.2 20
0.004
37.5 39.6 22.9
33.3 35.2 31.5
0.067
35.3 39.7 25
40.2 27.6 32.2
0.087
Physical activity, % Ideal 51.8 Intermediate 42.4 Poor 5.8
64 33.3 2.7
36.8 53.4 9.8
b 0.001
38.3 56 5.7
71.6 22.4 6
b 0.001
45.3 46.6 8.1
63.5 34.7 1.8
b 0.001
46.1 47.1 6.8
86.2 13.8 0
b0.001
Diet, % Ideal Intermediate Poor
19.8 77.4 2.8
19.8 78.4 1.8
19.9 76.2 3.9
0.249
21.3 76.5 2.2
17.6 78.8 3.6
0.331
17.9 78.8 3.3
23.3 74.9 1.8
0.179
21.2 76 2.8
11.5 86.2 2.3
b0.001
Total cholesterol, % Ideal 58.4 Intermediate 33 Poor 8.6
58.7 33.6 7.7
58.1 32.1 9.8
0.645
53.8 35.2 11
65.2 29.6 5.2
0.006
56.4 32.8 10.8
62.1 33.3 4.6
0.027
58.8 31.9 9.3
56.3 39.1 4.6
0.210
Blood pressure, % Ideal 22.2 Intermediate 40 Poor 37.8
29.8 42.8 27.4
13 36.5 50.5
b 0.001
25.7 38.3 36
17.2 42.4 40.4
0.045
19.1 38.6 42.3
27.8 42.5 29.7
0.003
24 38.8 37.2
11.5 47.1 41.4
0.032
Fasting glucose, % Ideal 30.8 Intermediate 37.5 Poor 31.7
36 36 28
24.5 39.4 36.1
0.007
34.4 38.3 27.3
25.6 36.4 38
0.01
27.2 37.5 35.3
37.4 37.4 25.2
0.009
30.8 37.8 31.4
31 35.6 33.4
0.911
0.124 100 0 0
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Letters to the Editor
large-scale studies are needed to implement cost-effective strategies directed to reduce the burden of stroke and cardiovascular diseases in the population at large. We appreciate the helpful suggestions and comments of Drs. Ralph L. Sacco and Clinton B. Wright from the University of Miami (Miami, FL) for the design of the study.
[5]
[6]
[7]
References [1] Lloyd-Jones D, Hong Y, Labarthe D, et al. Defining and setting national goals for cardiovascular health promotion. The American Heart Association's strategic impact goal through 2020 and beyond. Circulation 2010;121:586–613. [2] Legetic B, Campbell N. Reducing salt intake in the Americas: Pan American Health Organization actions. J Health Commun 2011;16:37–48. [3] Lavados PM, Hennis AJM, Fernandes JG, et al. Stroke epidemiology, prevention, and management strategies at a regional level: Latin America and the Caribbean. Lancet Neurol 2007;6:362–72. [4] Del Brutto OH, Peñaherrera E, Ochoa E, Santamaría M, Zambrano M, Del Brutto VJ. Door-to-door survey of cardiovascular health, stroke and ischemic heart disease in rural
[8]
[9]
[10]
coastal Ecuador—The Atahualpa Project: methodology and operational definitions. Int J Stroke 2013, http://dx.doi.org/10.111/ijs.12030. Folsom AR, Yatsuya H, Nettleton JA, Lutsey PL, Cushman M, Rosamond WD. Community prevalence of ideal cardiovascular health, by the American Heart Association definition, and relationship with cardiovascular disease incidence. J Am Coll Cardiol 2011;57:1690–6. Dong C, Rundek T, Wright CB, Anwar Z, Elkind MSV, Sacco RL. Ideal cardiovascular health predicts lower risks of myocardial infarction, stroke, and vascular deaths across Whites, Blacks and Hispanics: the Northern Manhattan Study. Circulation 2012;125:2975–84. Bambs C, Kip KE, Dinga A, Mulukutla SR, Aiyer AN, Reis SE. Low prevalence of “ideal cardiovascular health” in a community-based population: the heart strategies concentrating on risk evaluation (Heart SCORE) study. Circulation 2011;123:850–7. Yang Q, Coqswell ME, Flanders WD, et al. Trends in cardiovascular health metrics and associations with all-cause and CVD mortality among US adults. JAMA 2012;307:1273–83. Wu S, Huang Z, Yang X, et al. Prevalence of ideal cardiovascular health and its relationship with the 4-year cardiovascular events in a northern Chinese industrial city. Circ Cardiovasc Qual Outcomes 2012;5:487–93. Zeng Q, Dong S-Y, Song Z-Y, Zheng Y-S, Wu H-Y, Mao L-N. Ideal cardiovascular health in Chinese urban population. Int J Cardiol 2013;167:2311–7.
0167-5273/$ – see front matter © 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijcard.2013.01.017
Framingham risk score and ankle-brachial index in diabetic older adults Moatassem S. Amer a, Mohamed S. Khater a,⁎, Omar H. Omar b, Randa A. Mabrouk c, Wessam H. El-Kawaly a a b c
Geriatrics and Gerontology Department, Faculty of Medicine, Ain Shams University, Egypt Radiodiagnosis Department, Faculty of Medicine, Ain Shams University, Egypt Clinical Pathology Department, Faculty of Medicine, Ain Shams University, Egypt
a r t i c l e
i n f o
Article history: Received 9 December 2012 Accepted 18 January 2013 Available online 10 February 2013 Keywords: Framingham risk score Ankle-brachial index Type 2 diabetes Older adults
Type 2 diabetes is associated with atherosclerosis and increased risk of cardiovascular disease (CVD), therefore diabetic patients are three to four times more likely to develop CVD [1,2] and peripheral arterial disease (PAD) [3]. The ankle-brachial index (ABI) is considered to be the golden standard for the diagnosis of PAD, with 95% sensitivity and 99% specificity [4]. The Framingham risk score (FRS) is considered to be one of best validated tools to calculate the cardiovascular risk in the general population [5]. It also correlated with the presence and extent of subclinical atherosclerosis [6]. The aim of our study was to assess the association between FRS and ABI among diabetic older adults with asymptomatic PAD. A case control study was conducted on 90 individuals aged 60 years and older recruited from the Geriatrics and Gerontology Department and Outpatient Clinic at Ain Shams University Hospital, Cairo, Egypt. The participants were subdivided into three equal groups; (1) diabetic patients without PAD, (2) diabetic patients with asymptomatic PAD and (3) age and gender matched controls.
⁎ Corresponding author. Tel.: +20 1222138871; fax: +20 224192424. E-mail address: [email protected] (M.S. Khater).
Participants in groups 1 and 2 were diabetic without symptoms suggestive of PAD, and without any diabetic complications, by history and clinical data. Exclusion criteria were: any patient with any other co-morbidity including ischemic heart disease, hypertension, renal or hepatic diseases and those with symptoms suggesting PAD. The Framingham risk score was calculated according to the adapted simplified model of Wilson et al. [7], using the weighted risk factors: age, gender, total cholesterol, HDL cholesterol, smoking history, blood pressure, and diabetes mellitus. The ABI was calculated separately for each leg by dividing the highest of the systolic pressure measurements in the posterior tibial and dorsalis pedis arteries by the highest systolic blood pressure measured in both brachial arteries. In the current study ABI was calculated separately for each leg, and we used the lower of the two ABI for the analysis [8]. Informed consent was obtained from each patient and the study protocol conforms to the ethical guidelines of the 1975 Declaration of Helsinki. Statistical analysis was performed by using the 16th version of Statistical Package of Social Science (SPSS; IBM Corporation, Somers, NY). Description of all data is in the form of mean and standard deviation (SD) for all quantitative variables. Frequency and percentage for all qualitative variables are provided. Comparison of qualitative variables was done using chi-square test. Comparison between quantitative variables was done using t-test to compare two groups and analysis of variance to compare more than two groups. Correlation coefficient was also done to find linear relation between different variables using r-test or Spearman correlation coefficient. Significant level measured according to P value: P N 0.05 insignificant, P b 0.05 significant, and P b 0.01 highly significant. In the current study the mean age of the participants was 69.6 years, 43 (47.8%) were male and 47 (52.2%) were females. Table 1 shows the clinical and laboratory characteristics of the studied three groups. There were no significant differences between the studied three groups as
Letters to the Editor
[4] Kavsak PA, MacRae AR, Yerna MJ, Jaffe AS. Analytic and clinical utility of a nextgeneration, highly sensitive cardiac troponin I assay for early detection of myocardial injury. Clin Chem 2009;55:573–7. [5] Mather AN, Fairbairn TA, Artis NJ, Greenwood JP, Plein S. Relationship of cardiac biomarkers and reversible and irreversible myocardial injury following acute myocardial
infarction as determined by cardiovascular magnetic resonance. Int J Cardiol 2013;166:458–64. [6] Lippi G. Biomarkers of myocardial ischemia in the emergency room: cardiospecific troponin and beyond. Eur J Intern Med 2013;24:97–9.
0167-5273/$ – see front matter © 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijcard.2013.01.018
Population-based study of cardiovascular health in Atahualpa, a rural village of coastal Ecuador☆ Oscar H. Del Brutto a,b,⁎, Milton Santamaría c, Elio Ochoa d, Ernesto Peñaherrera a,e, Rocío Santibáñez b,d, Freddy Pow-Chon-Long e, Mauricio Zambrano b, Victor J. Del Brutto b a
School of Medicine, Universidad de Especialidades Espíritu Santo, Ecuador Department of Neurological Sciences, Hospital-Clínica Kennedy, Guayaquil, Ecuador Health Center, Ministry of Public Health, Atahualpa, Ecuador d Hospital Teodoro Maldonado Carbo, National Institute of Social Security, Guayaquil, Ecuador e Department of Cardiology, Hospital Luis Vernaza, Guayaquil, Ecuador b c
a r t i c l e
i n f o
Article history: Received 6 December 2012 Accepted 18 January 2013 Available online 11 February 2013 Keywords: Cardiovascular health Epidemiology Prevalence Ecuador Atahualpa
The American Heart Association (AHA) recently defined the metrics needed to categorize cardiovascular health (CVH), to implement strategies directed to reduce vascular deaths among US populations [1]. The same could be applied to developing countries, where stroke and cardiovascular diseases will be the next health epidemics due to changes in lifestyle and increased life expectancy [2]. Indeed, the rate of vascular deaths in Latin America is higher than in the developed world; this excess mortality fraction could be related to modifiable factors, including: inadequate access to medical care, increasing obesity and diabetes mellitus, and uncontrolled arterial hypertension [3]. To optimize existing sanitary resources it is mandatory to know the CVH status of a given population using standardized metrics. Here, we present the CVH status of Atahualpa inhabitants, a village representative of rural coastal Ecuador. The methodology of this study has been detailed elsewhere [4]. After informed consent was obtained, field personnel performed a door-todoor survey to identify all Atahualpa residents, and to apply questionnaires designed to evaluate the CVH status of people aged ≥40 years who were free of stroke and ischemic heart disease. We used CVH metrics proposed by the AHA. Persons with stroke and ischemic heart disease were identified by the use of validated field questionnaires, and the diagnosis was further corroborated by a team of certified neurologists and cardiologists.
☆ External funding: This study was partially supported by an unrestricted grant from the Universidad Especialidades Espíritu Santo, Guayaquil, Ecuador. The sponsor had no role in the design of the study, nor in the collection, analysis, and interpretation of data. ⁎ Corresponding author at: Air Center 3542, PO Box 522970, Miami, Fl 33152-2970, USA. Tel.: + 1 593 42285790. E-mail address: [email protected] (O.H. Del Brutto).
We assessed the number of Atahualpa residents aged ≥ 40 years (free of stroke or ischemic heart disease) with one to seven ideal CVH metrics. We also noted the number of intermediate and poor CVH metrics per person. CVH status was classified as ideal, intermediate and poor (Table 1). Statistical analysis was carried out using SPSS 18 software (SPSS Inc., Chicago, Illinois, USA). Significance was tested by the use of the χ2 test with Yates' correction when needed or the Fisher's exact test. Differences were considered significant if p b 0.05. Six-hundred forty-two (26%) of 2478 Atahualpa residents were aged ≥40 years. Twenty-six persons were excluded because of a stroke or ischemic heart disease. Therefore, CVH metrics and CVH status were evaluated in 616 persons (mean age 58.7±12.5 years, 59.4% women, and 64.4% with primary school instruction). CVH metrics of included individuals were stratified according to age, gender, and education (Table 2). Persons ≥60 years had higher rates of physical activity, blood pressure and fasting glucose in the poor range than those aged 40 to 59 years; in contrast, the rate of ideal BMI was higher for individuals aged ≥60 years. Men had lower rates of ideal smoking status, blood pressure and fasting glucose than women, but the latter had lower rates of ideal BMI, physical activity and total cholesterol than men. Physical activity, blood pressure and fasting glucose were the CVH metrics that showed lower ideal values in persons with up to primary school instruction. Overall, 13 (2%) persons had seven ideal CVH metrics (ideal CVH status), 211 (34%) had four to six ideal CVH metrics, and 392 (64%) had three or less ideal CVH metrics. Of the 603 persons with less than seven ideal CVH metrics, 173 (28%) had one or more intermediate CVH metrics but no poor metrics (intermediate CVH status), and 430 (70%) had at least one poor metric (poor CVH status). The odds for having a poor CVH status was most common in persons aged ≥60 years (OR=0.61, 95% C.I. 0.43–0.87, p=0.006). Among the 430 persons with poor CVH status, most have only one (51%) or two (35%) poor CVH metrics, 14% had three to four poor CVH metrics, and only one person had five poor CVH metrics. The poorest CVH metrics were blood pressure, fasting glucose, and BMI. In contrast, smoking status, diet, physical activity and total cholesterol were satisfactory, with values in the poor range found in less than 10% of persons (Table 2). A sizable proportion (70%) of Atahualpa residents aged ≥ 40 years had a poor CVH status. However, most of them (86%) had only one or two poor CVH metrics and 67% of the entire population had three or more ideal CVH metrics. Individuals scored better in the so-called “health behaviors” (smoking, BMI, physical activity and diet) than in the “health factors” (blood pressure, fasting glucose and total
Letters to the Editor
1619
Table 1 Cardiovascular health metrics and status according to the American Heart Association. Cardiovascular health metrics 1. Smoking: ideal (never or quit N1 year), intermediate (quit ≤ 1 year) and poor (current smoker). 2. Body mass index: ideal (b25 kg/m2), intermediate (25 to b30 kg/m2) and poor (≥ 30 kg/m2). 3. Physical activity: ideal (≥ 150 min/week moderate intensity or ≥75 min/week vigorous intensity or equivalent combination), intermediate (1–149 min/week moderate intensity or 1–74 min/week vigorous intensity or equivalent combination) and poor (no moderate and vigorous activity). 4. Diet: ideal (4–5 healthy components), intermediate (2–3 healthy components) and poor (0–1 healthy component); based on 5 health dietary components (≥4.5 cups fruits and vegetables/day, ≥two 3.5-oz servings fish/week, ≥three 1-oz equivalent servings fiber-rich whole grains/day, b1500 mg sodium/day, and ≤450 kcal sugar-sweetened beverages/week). 5. Total cholesterol: ideal (untreated and b 200 mg/dL), intermediate (treated to b 200 mg/dL or 200–239 mg/dL) and poor (≥240 mg/dL). 6. Blood pressure: ideal (untreated and b 120/b 80 mmHg), intermediate (treated to b 120/b 80 mmHg or 120–139/80–89 mmHg) and poor (≥140/90 mmHg). 7. Fasting glucose: ideal (untreated and b100 mg/dL), intermediate (treated to b 100 mg/dL or 100–125/mg/dL) and poor (≥126 mg/dL). Cardiovascular health status 1. Ideal CVH status: all seven CVH metrics in the ideal range. 2. Intermediate CVH status: at least one CVH metric in the intermediate range, but no poor metrics. 3. Poor CVH status: at least one CVH metric in the poor range.
cholesterol blood levels). Indeed, the only one health behavior that scored poor in our population was BMI. Of the three health factors, only total cholesterol scored well. In contrast, blood pressure and fasting glucose scored quite poor, with 38% and 32% of the population having such values in the poor range, respectively. The rather high rate of persons with arterial hypertension could be partly related to the high amount of salt in the diet, which was the individual healthy dietary factor that scored worst during the survey. The high percentage of persons with fasting glucose in the poor range could be associated with obesity and a diet that is rich in carbohydrates, but it is also possible that there is a yet unknown genetic susceptibility in Ecuadorian natives, a point that deserves further investigation.
Comparison of our results with other surveys [5–10] showed significantly better numbers for most CVH metrics and for the percentage of persons with ideal and intermediate CVH status. Such differences may be related to a more simple way of living in Atahualpa. On the light of these findings, the higher rate of vascular deaths in rural areas of Latin America could be explained by the counterbalance exerted by a lesser access to medical care and by the low income of the population that cannot afford costs related to chronic management of arterial hypertension and diabetes mellitus. In summary, this study shows—for the very first time—the CVH status of a rural population of Latin America. In general terms, the status is poor but it is much better than that reported from other populations. Further
Table 2 Cardiovascular health metrics in Atahualpa residents stratified by age, gender, education, and alcohol intake. Metrics
Total series (n=616)
Age
Gender
40≥ 59 years 60 years (n=339) (n=277)
p Value (age)
Women (n=366)
Education
Alcohol intake
Men (n=250)
p Value Up to (gender) primary school (n=397)
Secondary p Value school or (education) higher (n=219)
No alcohol or mild consumption (n=529)
Moderate to intense consumption (n=87)
p Value (alcohol intake)
92.8 2.8 4.4
b 0.001
97.2 1 1.8
96.8 1.4 1.8
0.919
98.7 0.9 0.4
87.4 2.3 10.3
b0.001
Smoking status, % Ideal 97.1 Intermediate 1.1 Poor 1.8
95.9 1.8 2.3
98.5 0.4 1.1
Body mass index, % Ideal 36 Intermediate 38 Poor 26
30.1 38.1 31.8
43.3 37.9 18.8
b 0.001
31.4 38.5 30.1
42.8 37.2 20
0.004
37.5 39.6 22.9
33.3 35.2 31.5
0.067
35.3 39.7 25
40.2 27.6 32.2
0.087
Physical activity, % Ideal 51.8 Intermediate 42.4 Poor 5.8
64 33.3 2.7
36.8 53.4 9.8
b 0.001
38.3 56 5.7
71.6 22.4 6
b 0.001
45.3 46.6 8.1
63.5 34.7 1.8
b 0.001
46.1 47.1 6.8
86.2 13.8 0
b0.001
Diet, % Ideal Intermediate Poor
19.8 77.4 2.8
19.8 78.4 1.8
19.9 76.2 3.9
0.249
21.3 76.5 2.2
17.6 78.8 3.6
0.331
17.9 78.8 3.3
23.3 74.9 1.8
0.179
21.2 76 2.8
11.5 86.2 2.3
b0.001
Total cholesterol, % Ideal 58.4 Intermediate 33 Poor 8.6
58.7 33.6 7.7
58.1 32.1 9.8
0.645
53.8 35.2 11
65.2 29.6 5.2
0.006
56.4 32.8 10.8
62.1 33.3 4.6
0.027
58.8 31.9 9.3
56.3 39.1 4.6
0.210
Blood pressure, % Ideal 22.2 Intermediate 40 Poor 37.8
29.8 42.8 27.4
13 36.5 50.5
b 0.001
25.7 38.3 36
17.2 42.4 40.4
0.045
19.1 38.6 42.3
27.8 42.5 29.7
0.003
24 38.8 37.2
11.5 47.1 41.4
0.032
Fasting glucose, % Ideal 30.8 Intermediate 37.5 Poor 31.7
36 36 28
24.5 39.4 36.1
0.007
34.4 38.3 27.3
25.6 36.4 38
0.01
27.2 37.5 35.3
37.4 37.4 25.2
0.009
30.8 37.8 31.4
31 35.6 33.4
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Letters to the Editor
large-scale studies are needed to implement cost-effective strategies directed to reduce the burden of stroke and cardiovascular diseases in the population at large. We appreciate the helpful suggestions and comments of Drs. Ralph L. Sacco and Clinton B. Wright from the University of Miami (Miami, FL) for the design of the study.
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Framingham risk score and ankle-brachial index in diabetic older adults Moatassem S. Amer a, Mohamed S. Khater a,⁎, Omar H. Omar b, Randa A. Mabrouk c, Wessam H. El-Kawaly a a b c
Geriatrics and Gerontology Department, Faculty of Medicine, Ain Shams University, Egypt Radiodiagnosis Department, Faculty of Medicine, Ain Shams University, Egypt Clinical Pathology Department, Faculty of Medicine, Ain Shams University, Egypt
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Article history: Received 9 December 2012 Accepted 18 January 2013 Available online 10 February 2013 Keywords: Framingham risk score Ankle-brachial index Type 2 diabetes Older adults
Type 2 diabetes is associated with atherosclerosis and increased risk of cardiovascular disease (CVD), therefore diabetic patients are three to four times more likely to develop CVD [1,2] and peripheral arterial disease (PAD) [3]. The ankle-brachial index (ABI) is considered to be the golden standard for the diagnosis of PAD, with 95% sensitivity and 99% specificity [4]. The Framingham risk score (FRS) is considered to be one of best validated tools to calculate the cardiovascular risk in the general population [5]. It also correlated with the presence and extent of subclinical atherosclerosis [6]. The aim of our study was to assess the association between FRS and ABI among diabetic older adults with asymptomatic PAD. A case control study was conducted on 90 individuals aged 60 years and older recruited from the Geriatrics and Gerontology Department and Outpatient Clinic at Ain Shams University Hospital, Cairo, Egypt. The participants were subdivided into three equal groups; (1) diabetic patients without PAD, (2) diabetic patients with asymptomatic PAD and (3) age and gender matched controls.
⁎ Corresponding author. Tel.: +20 1222138871; fax: +20 224192424. E-mail address: [email protected] (M.S. Khater).
Participants in groups 1 and 2 were diabetic without symptoms suggestive of PAD, and without any diabetic complications, by history and clinical data. Exclusion criteria were: any patient with any other co-morbidity including ischemic heart disease, hypertension, renal or hepatic diseases and those with symptoms suggesting PAD. The Framingham risk score was calculated according to the adapted simplified model of Wilson et al. [7], using the weighted risk factors: age, gender, total cholesterol, HDL cholesterol, smoking history, blood pressure, and diabetes mellitus. The ABI was calculated separately for each leg by dividing the highest of the systolic pressure measurements in the posterior tibial and dorsalis pedis arteries by the highest systolic blood pressure measured in both brachial arteries. In the current study ABI was calculated separately for each leg, and we used the lower of the two ABI for the analysis [8]. Informed consent was obtained from each patient and the study protocol conforms to the ethical guidelines of the 1975 Declaration of Helsinki. Statistical analysis was performed by using the 16th version of Statistical Package of Social Science (SPSS; IBM Corporation, Somers, NY). Description of all data is in the form of mean and standard deviation (SD) for all quantitative variables. Frequency and percentage for all qualitative variables are provided. Comparison of qualitative variables was done using chi-square test. Comparison between quantitative variables was done using t-test to compare two groups and analysis of variance to compare more than two groups. Correlation coefficient was also done to find linear relation between different variables using r-test or Spearman correlation coefficient. Significant level measured according to P value: P N 0.05 insignificant, P b 0.05 significant, and P b 0.01 highly significant. In the current study the mean age of the participants was 69.6 years, 43 (47.8%) were male and 47 (52.2%) were females. Table 1 shows the clinical and laboratory characteristics of the studied three groups. There were no significant differences between the studied three groups as