Teaching behavioral medicine using individual coronary heart disease risk factors

Two hundred twenty-one first-year medical students participated in a voluntary coronary heart disease risk factor self-change project designed to teach the principles of behavioral change. Blood pressure, serum lipids, percentage body fat, cardiovascular fitness, and smoking status were measured prior to the project. Students designed their own programs of behavior modification and, after 8 weeks, repeat measurements were obtained in students whose projects related to coronary heart disease risk (56% of entire group). Despite generally low initial coronary heart disease risk factors, most risk factor groups successfully altered the targeted risk factors. The subgroup attempting to lower serum cholesterol (n = 49) reduced total cholesterol 15 +/- 24 mg/dl (mean +/- SD) and low-density lipoprotein cholesterol 11 +/- 20 mg/dl (P less than 0.001 for both). The blood pressure group (n = 9) decreased systolic blood pressure 8 +/- 10 mm Hg (P less than 0.05), and the weight-loss group (n = 33) lost 3.0 +/- 2.9 kg (P less than 0.001), reducing estimated percentage body fat 1.7 +/- 1.8 (P less than 0.001). The self-change project was well received by the students and appears to be a useful technique for introducing the principles of behavioral medicine to first-year medical students.     

冠心病危险因子在女性冠心病心力衰竭中的研究

目的 探讨冠心病危险因子在女性冠心病患者发生心力衰竭中的影响。方法 选取328例冠心病患者,其中男196例（男性冠心病组）,女132例（女性冠心病组）,对两组患者各种冠心病危险因子包括年龄、高血压、糖尿病、血脂、血浆纤维蛋白原及血尿酸水平等进行比较;对所有患者随访1～3年,观察两组患者心力衰竭发生率,并对女性冠心病组发生心力衰竭者与未发生心力衰竭者的血尿酸水平进行比较。结果 女性冠心病组三酰甘油、血浆纤维蛋白原及血尿酸水平显著高于男性冠心病组(P＜0.05)。随访l～3年,女性冠心病组心力衰竭发生率显著高于男性冠心病组[27.27％(36/132)比16.84％( 33/196)],女性冠心病组发生心力衰竭者血尿酸水平为(368.85±78.60)μmol/L,未发生心力衰竭者血尿酸水平为(336.63±69.65)μmol/L,两者比较差异有统计学意义(P＜0.05)。结论 冠心病危险因子是女性冠心病患者心力衰竭的重要推动因素,而血尿酸是其发生心力衰竭的独立危险因素,可通过对血尿酸等进行早期监测并采取干预措施,减缓疾病的发展。     

Educational inequalities in the metabolic syndrome and coronary heart disease among middle-aged men and women

BACKGROUND: Previous studies have shown socioeconomic inequalities in the metabolic syndrome and coronary heart disease (CHD), but it is not known whether educational disparities in the metabolic syndrome explain educational inequalities in CHD. We investigated this question in a prospective study of middle-aged men and women. METHODS: Baseline data were collected in 1992 in Finland from 864 men and 1045 women aged 45-64 years without history of CHD. A total of 113 new CHD cases were identified by the end of 2001. Logistic and Cox regression models were used in data analysis. RESULTS: The metabolic syndrome defined by NCEP criteria was less prevalent in subjects with university education (21% in men and 14% in women) compared with basic level education (41% and 27%, respectively). Adjusting for health behavioural factors had only a slight effect on the educational gradient in the metabolic syndrome. An educational gradient in CHD incidence was clear [hazard ratio (HR) = 0.67 95% confidence interval (CI) 0.48-0.94, men and women combined]. Adjustment for the metabolic syndrome attenuated this gradient only slightly, but when individual components of the metabolic syndrome were included as covariates the attenuation was more substantial (HR = 0.73 95% CI 0.52-1.04). CONCLUSIONS: Educational differences in the metabolic syndrome and CHD incidence are clear. Metabolic risk factors explain the gradient in CHD incidence partly, but only when they are treated as independent risk factors. Screening for the metabolic syndrome alone is not sufficient to account for socioeconomic inequalities in cardiovascular disease.     

Public health burden of coronary heart disease risk factors among middle-aged and elderly men

BACKGROUND: An epidemiological evidence shows that smoking, high total cholesterol, hypertension, overweight, and a low level of physical activity are significant risk factors for coronary heart disease mortality. Therefore, by turning these risk factors in a healthier direction, presumably a substantial proportion of the deaths would be preventable. METHODS: The avoidable proportion of coronary heart disease deaths associated with smoking, a high level of total cholesterol, systolic hypertension, overweight, and a low level of leisure-time physical activity was assessed with the use of the population attributable risks for initially 30- to 63-year-old Finnish men (six studies with 1,340-7,928 subjects) who were followed up from 7 to 30 years. RESULTS: The theoretical estimates of population at tributable risks derived from published studies were as follows: smoking 10 to 33%; high total cholesterol 9 to 21%; hypertension 6 to 15%; overweight 3 to 6%; and low level of leisure-time physical activity 22 to 39%. CONCLUSIONS: These estimations, based on observed mortality rates and risk factor prevalences, suggest that, even if modest estimates are used, the burden from coronary heart disease deaths can be substantially reduced by converting the risk factors to more healthful levels. The results also suggest that efforts to increase physical activity deserve as much consideration as those aimed at influencing more traditional risk factors.     

Independent associations of educational attainment and ethnicity with behavioral risk factors for cardiovascular disease

The authors examined the independent associations of educational attainment and ethnicity with behavioral risk factors for cardiovascular disease using data from the 1989 baseline survey for the New York State Healthy Heart Program. This telephone survey used the Centers for Disease Control Behavioral Risk Factor Survey interview instrument and was conducted in eight communities (total population, approximately 1.24 million people) in New York State. The response rate was 65.5% (n = 4,179); 3,606 subjects aged 20-64 years with self-described ethnicity of white (n = 1,935), black (n = 1,035), or Hispanic (n = 636) and of known educational status were retained in the analysis. After adjustment for age, sex, and ethnicity, significant associations were found between educational attainment and smoking, lack of regular exercise, overweight, diet atherogenicity, and knowledge about blood pressure and cholesterol. After adjustment for age, sex, and educational attainment, associations were found between ethnicity and most of these same variables. Blacks and Hispanics generally had less favorable risk factor profiles. These data indicate that the differences in cardiovascular disease risk profiles between whites and blacks or Hispanics cannot be fully explained by underlying differences in educational attainment. The differing patterns of risk factor distribution by educational attainment within ethnic groups have implications for the segmentation of risk reduction programs.     

Employment status and heart disease risk factors in middle-aged women: the Rancho Bernardo Study.

BACKGROUND. In recent years, an increasing number of women have been entering the labor force. It is known that in men, employment is related to heart disease risk, but there are few studies examining this association among women. METHODS. The relation between employment status and heart disease risk factors including lipid and lipoprotein levels, systolic and diastolic blood pressure, fasting and postchallenge plasma glucose and insulin levels, was examined in 242 women aged 40 to 59 years, who were participants in the Rancho Bernardo Heart and Chronic Disease Survey. At the time of a follow-up clinic visit between 1984 and 1987, 46.7% were employed, primarily in managerial positions. RESULTS. Employed women smoked fewer cigarettes, drank less alcohol, and exercised more than unemployed women, but these differences were not statistically significant. After adjustment for covariates, employed women had significantly lower total cholesterol and fasting plasma glucose levels than unemployed women. Differences on other biological variables, although not statistically significant, also favored the employed women. CONCLUSIONS. Results of this study suggest that middle-aged women employed in managerial positions are healthier than unemployed women.     

Risk factors for coronary heart disease in middle-aged men in Crete in 1982

Risk factors for coronary heart disease were studied in healthy middle-aged Cretan men in order to compare them with the middle-aged men of a previous generation studied in 1960 as the Cretan cohort of the Seven Countries Study (1960). In the present cohort mean values for total cholesterol were 5.48 mmol/L, for HDL-cholesterol 1.26 mmol/L, for triglycerides 1.41 mmol/L, for systolic blood pressure 128 mmHg, and for diastolic blood pressure 77 mmHg. Serum cholesterol was higher and blood pressure slightly lower than the values observed in 1960. However, it is uncertain whether these changes were real or caused by changes in methodology. The mean body mass index has increased from 22.6 in 1960 to 26.9 kg/m2 in 1982, due to an increase in fatness. The percentage of smokers had increased from 57.4% to 74.1%. Upon multiple regression analysis the body mass index, the subscapular to triceps skinfold ratio and smoking were negatively and independently related with HDL-cholesterol. Body mass index correlated positively with serum triglycerides. Although the incidence of coronary heart disease is still low in Crete, it is concluded that there is nothing in the risk profile of these middle-aged men to suggest that they are at a low risk for coronary heart disease.     

Trends in the coronary heart disease risk profile of middle-aged adults

PurposeTo examine recent trends in the coronary heart disease (CHD) risk profiles of the population aged 45 to 64 in the United States.MethodsData from the National Health and Nutrition Examination Surveys (NHANES) from 2 time periods (1988–1994 and 2005–2008) are used to estimate the CHD risk functions derived from the Framingham Heart Study. The risk functions take account of levels of blood pressure (systolic and diastolic), total and high-density lipoprotein serum cholesterol, diabetes (doctor diagnosed or based on fasting glucose), and smoking status to estimate the 10-year risk of myocardial infarction or coronary death. We estimate the risk functions by gender, race, and age group (45–54 and 55–64).ResultsThe CHD risk profile of middle-aged adults has improved over time. For example, the mean 10-year risk of heart attack or CHD death among persons 55 to 64 years has declined from 7.1% to 5.2%. Declines are seen among both men and women and among non-Hispanic Blacks and non-Hispanic whites.ConclusionsDespite increases in diabetes and obesity, the CHD risk profile of middle-aged adults improved during the period from 1988–1994 to 2005–2008.     

Characteristics of individuals with multiple behavioral risk factors for coronary heart disease: the Netherlands.

To test the hypothesis that risk factors are interrelated, the simultaneous occurrence of smoking, inadequate nutrition, obesity, and physical inactivity was studied in a random sample (n = 1,951) of the Dutch adult population. Although the results did not suggest systematic clustering, the assumption of independence of these risk factors could not be maintained. Sociodemographic and health-related characteristics of the group with three or four risk factors were assessed (n = 246). Comparison with a prudent life-style group (zero risk factors, n = 387) by means by discriminant analysis indicated that the target group included proportionally more men (odds ratio: OR = 3.3), of all ages, with low education and occupation (OR = 3.5 and 1.7). The two groups did not differ in awareness of cardiovascular risk factors, preventive orientation regarding cardiovascular risk, or disease in general, and the effectiveness of health education in modifying life-style. The target group exhibited a distorted perception of the healthfulness of its own life-style and unfavorable attitudes toward modifying existing smoking, eating habits, and physical activity.     

冠心病危险因素的临床评价

目的 探讨冠心病危险因素与冠状动脉病变的关系。方法 对341例冠状动脉造影患者可能伴有的危险因素进行询问和检测。结果 (1)冠状动脉造影显示有病变者214例,冠状动脉造影显示无病变者127例。两组的年龄、糖尿病病史、高脂血症史、冠心病家族史、吸烟史、高密度脂蛋白胆固醇(HDL-C)、低密度脂蛋白胆固醇(LDL-C)、总胆固醇／高密度脂蛋白胆固醇比率(TC／HDL-C)、脂蛋白(a)[Lp(a)]、纤维蛋白原(Fbg)、高敏C反应蛋白(hs-CRP)比较,差异均有显著性。(2)冠状动脉造影显示有病变者其病变积分与危险因素的相关性依次排列为hs-CRP、Lp(a)、TC／HDL-C、Fbg、高脂血症史、TC、LDL-C和甘油三酯(r=0．338、0．250、0．241、0．207、0．167、0．147、0．140和0．139)。(3)对冠状动脉造影患者与危险因素应用ROC曲线分析结果依次为hs-CRP、TC／HDL-C、Lp(a)、Fbg、LDL-C、高脂血症史,其ROC曲线下面积比分别是0．810、0．669、0．626、0．625、0．619和0．618。结论 高脂血症史是冠心病发生的预告信号,脂质检查项目中对冠心病的预测作用以TC／HDL-C和Lp(a)为优;提示当前冠状动脉炎性损伤以hs-CRP为优。     

冠心病危险因素在女性早发冠心病临床诊断中的价值

目的讨论冠心病危险因素在诊断女性早发冠心病中的价值。方法选择2010年4月—2013年4月间,选择因胸闷胸痛入院检查的女性患者332例,分析其病历资料,总结冠心病危险因素,包括既往病史、现病史、症状、生活习惯、家族史等相关因素,然后分别进行冠状动脉造影术,以诊断结果作为诊断依据,观察冠心病诊断符合率与危险因素的必然关系。结果冠心病的危险因素包括年龄,家族史,血糖、血脂、血压的三高史,吸烟史,肥胖史等多方面,临床诊断女性早发冠心与危险因素成反比关系,危险因素越多,临床诊断符合率越高,差异有统计学意义。结论仔细分析女性冠心病危险因素,对提高临床诊断准确率有重要价值。     

Risk factors for coronary heart disease in African American women.

There have been few studies of risk factors for coronary heart disease in African American women. The authors investigated factors associated with prevalent coronary heart disease in data provided by participants in the Black Women's Health Study. In 1995, 64,530 US Black women aged 21-69 years completed postal health questionnaires. The 352 women who reported having had a heart attack (cases) were frequency matched 5:1 on age with 1,760 women who had not (controls); medical record review for 35 cases indicated that two-thirds had had a heart attack and the remainder had other coronary heart disease. Odds ratios, obtained from multiple logistic regression analyses, were significantly elevated for cigarette smoking, drug-treated hypertension, drug-treated diabetes mellitus, elevated cholesterol level, and history of heart attack in a parent. High body mass index (kg/m2) was associated with coronary heart disease in the absence of control for hypertension, diabetes mellitus, and elevated cholesterol but not when they were controlled, suggesting that obesity may influence risk as a result of its effects on blood pressure, glucose tolerance, and cholesterol levels. Odds ratios increased with increasing parity and with decreasing age at first birth. These data suggest that important risk factors for coronary heart disease are similar in Black women and White women.     

The relationship between education and risk factors for coronary heart disease

In nine samples of adult populations (2707 males and 2871 females, aged 20–59 years) we studied the relationship between educational level and several lifestyle factors at risk for coronary heart disease (CHD), (i.e., smoking, alcohol consumption, dietary fat intake, sedentary behaviour at work and leisure) and the association between education and certain CHD risk factors (i.e., total cholesterol, HDL-cholesterol, triglycerides, systolic and diastolic blood pressure, body mass index). The data were analyzed separately in samples from North, Central and Southern Italy. The results show that educational level is often associated to the lifestyle factors considered here. This association was positive for both men and women for physical activity at leisure and work stress and only for women with respect to smoking. It was negative for both men and women for alcohol consumption and physical activity at work and for men only for cigarette smoking. The age-adjusted mean levels of the CHD risk factors show some significant differences among subjects with different educational levels, which were not always the same for the three geographical areas. This was with the exception of BMI in females, which appears negatively associated to education in all areas. These differences decreased after adjustments were made for daily cigarette smoking, wine consumption and dietary fat intake. Education seems to play a determining role in lifestyle, however its direct and indirect effects on some major CHD risk factors are somewhat different in areas at different socio-economic conditions.     

Ischemic heart disease risk factors in middle-aged Seventh-day Adventist men and their neighbors

Seventh-day Adventists in California have much lower mortality from ischemic heart disease than do other Californians, but the risk factors have not been well documented previously for a representative sample. This study, conducted in 1982, chose a random sample of 160 Californian non-Hispanic white middle-aged Adventist men, 160 of their similar-aged male neighbors, and documented traditional ischemic heart disease risk factors. Results show major dietary differences between the two groups as expected, this being reflected in significant differences in consumption of total fat, saturated fat, dietary cholesterol, and crude fiber. Questionnaire data suggested that the Adventists also exercised 50% more, rarely smoked, but had identical Framingham Type A/B scores. There were no differences in obesity or blood pressure levels, but serum total cholesterol was significantly lower in the Adventists (190.1 vs. 203.5 mg/dl, p less than 0.001), as was low density lipoprotein cholesterol (125 vs. 134.0 mg/dl, p less than 0.03) and high density lipoprotein (HDL) cholesterol (42.3 vs. 46.0 mg/dl, p less than 0.005). Consequently, the ratio of total cholesterol/HDL cholesterol was virtually identical between the two groups. Possible explanations for some of these findings are discussed.     

Education and risk of coronary heart disease: assessment of mediation by behavioral risk factors using the additive hazards model

Educational-related gradients in coronary heart disease (CHD) and mediation by behavioral risk factors are plausible given previous research; however this has not been comprehensively addressed in absolute measures. Questionnaire data on health behavior of 69,513 participants, 52 % women, from seven Danish cohort studies were linked to registry data on education and incidence of CHD. Mediation by smoking, low physical activity, and body mass index (BMI) on the association between education and CHD were estimated by applying newly proposed methods for mediation based on the additive hazards model, and compared with results from the Cox proportional hazards model. Short (vs. long) education was associated with 277 (95 % CI: 219, 336) additional cases of CHD per 100,000 person-years at risk among women, and 461 (95 % CI: 368, 555) additional cases among men. Of these additional cases 17 (95 % CI: 12, 22) for women and 37 (95 % CI: 28, 46) for men could be ascribed to the pathway through smoking. Further, 39 (95 % CI: 30, 49) cases for women and 94 (95 % CI: 79, 110) cases for men could be ascribed to the pathway through BMI. The effects of low physical activity were negligible. Using contemporary methods, the additive hazards model, for mediation we indicated the absolute numbers of CHD cases prevented when modifying smoking and BMI. This study confirms previous claims based on the Cox proportional hazards model that behavioral risk factors partially mediates the effect of education on CHD, and the results seems not to be particularly model dependent.