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.     

Race disparities in cardiovascular disease risk factors within socioeconomic status strata

Purpose

Racial differences in socioeconomic status (SES) explain some, but not all, of racial disparities in cardiovascular disease (CVD) risk. To address this, race disparities among higher SES individuals need to be assessed. The purpose of this study was to assess whether racial disparities in CVD risk factors differ by SES levels.

767例离退休干部心脑血管疾病患病率及行为危险因素的调查

目的 研究心脑血管疾病在我省军队离退休干部中的患病率及相关行为危险因素，为制定医疗保健服务措施提供依据。方法 采用问卷访问和体格检查相结合的方法对我省军队部分离退休干部进行流行病学调查分析。结果 我省军队离退休干部中无躯体疾病的仅占8．47％，同时患两种以上疾病的人数占全部调查人数的72．36％，慢性非传染性疾病中患病率最高的是冠心病(65．32％)及高血压病(55．67％)，其次脑血管病的患病率在29．86％。调查显示：老年人心脑血管疾病与其年龄、居住状况、日常生活功能、心理卫生、膳食营养、生活满意度等紧密相关，其中烟酒嗜好、高脂高盐饮食、缺少娱乐及体力活动等是心脑血管疾病的主要行为危险因素。结论 进一步加强对心脑血管疾病的正确认识及健康知识的掌握，社会、家庭环境和人际交往，是行为改变的主要影响因素。     

767例离退休干部心脑血管疾病患病率及行为危险因素的调查

目的研究心脑血管疾病在我省军队离退休干部中的患病率及相关行为危险因素,为制定医疗保健服务措施提供依据.方法采用问卷访问和体格检查相结合的方法对我省军队部分离退休干部进行流行病学调查分析.结果我省军队离退休干部中无躯体疾病的仅占8.47%,同时患两种以上疾病的人数占全部调查人数的72.36%,慢性非传染性疾病中患病率最高的是冠心病(65.32%)及高血压病(55.67%),其次脑血管病的患病率在29.86%.调查显示:老年人心脑血管疾病与其年龄、居住状况、日常生活功能、心理卫生、膳食营养、生活满意度等紧密相关,其中烟酒嗜好、高脂高盐饮食、缺少娱乐及体力活动等是心脑血管疾病的主要行为危险因素.结论进一步加强对心脑血管疾病的正确认识及健康知识的掌握,社会、家庭环境和人际交往,是行为改变的主要影响因素.     

Racial/ethnic and socioeconomic disparities in multiple risk factors for heart disease and stroke--United States, 2003

Heart disease and stroke are the first and third leading causes of death, respectively, in the United States. Certain modifiable risk factors, including high blood pressure, high cholesterol, diabetes, tobacco use, obesity, and lack of exercise, are the main targets for primary and secondary prevention of heart disease and stroke. A substantial proportion of the population has multiple risk factors, increasing their likelihood of cardiovascular disease. To assess the prevalence of multiple risk factors for heart disease and stroke and to identify disparities in risk status among population subgroups, CDC analyzed data from the 2003 Behavioral Risk Factor Surveillance System (BRFSS) survey. This report summarizes the results of that analysis, which indicated that approximately 37% of the survey population had two or more risk factors for heart disease and stroke and that considerable disparities in risk factors existed among socioeconomic groups and racial/ethnic populations. To decrease morbidity and mortality from heart disease and stroke, public health programs should improve identification of persons with multiple risk factors and focus interventions on those populations disproportionately affected.     

Case-control study of coronary heart disease risk factors in the elderly

We undertook a case-control study utilizing a large coronary arteriography database to determine if traditional cardiovascular risk factors are as predictive of the presence of angiographically-proven coronary artery disease (CAD) in elderly patients as in younger patients. Among the patients aged 65 years or more, there were 2120 cases and 193 controls, while for the patients aged 35-49 years there were 1493 cases and 707 controls. Odds ratios obtained from logistic regression indicated that age, male sex, diabetes, cigarette smoking, hypertension, total cholesterol and left ventricular hypertrophy were all significant risk factors for CAD in both age groups, although the odds ratios tended to be somewhat lower in the elderly. Logistic regression analysis for gender subgroups generally revealed similar findings when compared with the combined (males + females) age groups, although power was limited for the subgroup of elderly males which had few controls. We conclude that most of the traditional cardiovascular risk factors which have been described as correlated with the presence of CAD in younger populations are also correlated with angiographically-proven CAD in older patients.     

Quantifying the dose-response of walking in reducing coronary heart disease risk: meta-analysis

The evidence for the efficacy of walking in reducing the risk of and preventing coronary heart disease (CHD) is not completely understood. This meta-analysis aimed to quantify the dose-response relationship between walking and CHD risk reduction for both men and women in the general population. Studies on walking and CHD primary prevention between 1954 and 2007 were identified through Medline, SportDiscus and the Cochrane Database of Systematic Reviews. Random-effect meta-regression models were used to pool the relative risks from individual studies. A total of 11 prospective cohort studies and one randomized control trial study met the inclusion criteria, with 295,177 participants free of CHD at baseline and 7,094 cases at follow-up. The meta-analysis indicated that an increment of approximately 30 min of normal walking a day for 5 days a week was associated with 19% CHD risk reduction (95% CI = 14–23%; P-heterogeneity = 0.56; I ² = 0%). We found no evidence of heterogeneity between subgroups of studies defined by gender (P = 0.67); age of the study population (P = 0.52); or follow-up duration (P = 0.77). The meta-analysis showed that the risk for developing CHD decreases as walking dose increases. Walking should be prescribed as an evidence-based effective exercise modality for CHD prevention in the general population.     

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.     

Earthquake and coronary heart disease risk factors: a longitudinal study.

The longitudinal association between a number of coronary heart disease risk factors and the experience of a natural disaster (earthquake) was analyzed in a group of workers participating in a longitudinal epidemiologic investigation. The 5-year follow-up examination was interrupted by a major earthquake, and examinations were resumed 2 weeks after the quake. Participants screened after the quake had, on average, higher heart rates, serum cholesterol, and triglycerides than participants examined before the quake; these differences were independent from the coronary heart disease risk factor values measured 5 years previously during the baseline examination. The data collected during the 12-year examination indicated that the observed short-term increase in serum lipids and heart rate was not present long-term (7 years after the quake). These longitudinal data indicate that exposure to a natural disaster can be associated with short-term increases in heart rate, serum cholesterol, and triglycerides but that there is no apparent long-term effect on these coronary heart disease risk factors.     

Dietary glycemic index in relation to metabolic risk factors and incidence of coronary heart disease: the Zutphen Elderly Study

OBJECTIVE: To examine whether a high dietary glycemic index is associated with hyperinsulinemia, hyperglycemia, dyslipidemia and coronary heart disease (CHD) risk in elderly men. DESIGN: Prospective study of incidence of major CHD (non-fatal myocardial infarction or death due to CHD) between 1985 and 1995 in 646 men, and a cross-sectional analysis of metabolic risk factors in 1990 in 394 men. SETTING: Population based study in the Dutch town Zutphen. SUBJECTS: Men aged 64-84 y in 1985 without a history of CHD or diabetes, whose diet was assessed with the cross-check dietary history method. RESULTS: The dietary glycemic index was positively correlated with consumption (g carbohydrate) of wheat bread (r=0.47) and sugar products (r=0.41) and inversely with fruit (r=-0.37) and milk (r=-0.40) consumption. During 4527 person-years of follow-up, 94 cases of CHD were documented. The risk ratio for CHD was 1.11 (95% CI, 0.66-1.87) for the highest as compared to the lowest tertile of glycemic index after correction for age, body mass index, physical activity, cigarette smoking, and dietary factors (P (trend)=0.70). Furthermore, the glycemic index was not appreciably associated with blood concentrations of total cholesterol, HDL-cholesterol, triacylglycerols or (fasting or postload) insulin or glucose. CONCLUSIONS: Our findings do not support the hypothesis that a high-glycemic-index diet unfavorably affects metabolic risk factors or increases risk for CHD in elderly men without a history of diabetes or CHD.     

Educational attainment and behavioral and biologic risk factors for coronary heart disease in middle-aged women

Epidemiologic investigations have shown that low socioeconomic status is related to ischemic coronary heart disease mortality in men and women as well as to major risk factors for coronary heart disease, predominantly in men. The present study investigated the associations between educational attainment and biologic and behavioral risk factors for coronary heart disease in a community sample of 2,138 middle-aged women residing in Allegheny County, Pennsylvania. The women were contacted between 1983 and 1985 to determine eligibility for a study of risk factor changes during the perimenopausal period. Eligibility criteria included age 42 to 50 years, premenopausal status, diastolic blood pressure less than 100 mmHg, and nonuse of medications known to influence risk factors. Among the 541 eligible participants, the less education the women reported, the more atherogenic was their risk factor profile, including higher systolic blood pressure, low density lipoprotein (LDL) cholesterol, apolipoprotein B, triglycerides, fasting and two-hour glucose values, two-hour insulin values, body mass indices, and lower high density lipoprotein (HDL) cholesterol and HDL/LDL ratio; the more often they reported being cigarette smokers, taking little physical exercise, and consuming alcohol less than one day a week; the more often they reported on standardized psychologic tests being Type B, angry, pessimistic, depressed, and dissatisfied with paid work, and having little social support and self-esteem (all p values less than 0.01). Similar associations were obtained between educational attainment and risk factors reported by the 1,588 nonparticipants during the telephone screening interview. These results suggest many biologic and behavioral factors by which women with little education are at elevated risk for coronary heart disease. To the extent that advanced education protects women against coronary heart disease, a potentially important public health intervention for women is education.     

Estimating the effect of cardiovascular risk factors on all-cause mortality and incidence of coronary heart disease using G-estimation: the atherosclerosis risk in communities study

Standard methods for analysis of cohort studies may give biased estimates of exposure effects in the presence of time-varying confounding. Such effects may instead be estimated by using G-estimation. This study aimed to examine the relations between important cardiovascular risk factors and all-cause mortality and risk of coronary heart disease (CHD), accounting for confounding between exposures over time using G-estimation. Results were compared with those from standard survival analyses (e.g., Weibull regression) with time-updated covariates. The dataset consisted of all participants in the Atherosclerosis Risk in Communities cohort study who had complete data on the first two of four visits, giving a sample of 13,898 people at baseline. Death and occurrence of CHD or stroke were recorded. G-estimated associations between several risk factors and mortality/CHD incidence differed from those estimated using standard survival analysis. The associations between mortality/CHD incidence and smoking, presence of diabetes, and use of antihypertensives were stronger than the standard survival estimates, while the G-estimated effect of low density lipoprotein and high density lipoprotein cholesterol on CHD incidence were more linear than the standard estimate. Complex relations between exposures over time may lead to biased exposure effect estimates in standard survival analyses. G-Estimation can be used to overcome such biases, and thus may have important implications for the analysis of observational studies.     

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.     

Neighborhood socioeconomic environment and incidence of coronary heart disease: a follow-up study of 25,319 women and men in Sweden

In this study, the authors examined whether neighborhood socioeconomic environment predicted incident coronary heart disease after adjustment for individual-level characteristics. A random sample of the Swedish population (25,319 women and men aged 35-74 years) was interviewed between 1986 and 1993 and was followed through December 1997 for incident coronary heart disease (1,189 events). Neighborhood socioeconomic environment was defined by small-area market statistics (6,145 neighborhoods) and measured by two indicators: neighborhood education (proportion of people with less than 10 years of education in the neighborhood) and neighborhood income (proportion of people with incomes in the lowest national income quartile). Separate multilevel Cox proportional hazards models showed that low neighborhood education and low neighborhood income each predicted incident coronary heart disease after adjustment for age, sex, and individual-level education and income (hazard ratios were 1.25 and 1.23, respectively). The authors conclude that neighborhood socioeconomic environment predicts incident coronary heart disease, having a significant effect on coronary heart disease risk beyond the individual effect.     

Adverse socioeconomic position across the lifecourse increases coronary heart disease risk cumulatively: findings from the British women's heart and health study

OBJECTIVE: To examine the associations of childhood and adult measurements of socioeconomic position with coronary heart disease (CHD) risk. METHODS: Cross sectional and prospective analysis of a cohort of 4286 British women who were aged 60-79 years at baseline. Among these women there were 694 prevalent cases of CHD and 182 new incident cases among 13 217 person years of follow up of women who were free of CHD at baseline. RESULTS: All measurements of socioeconomic position were associated with increased prevalent and incident CHD in simple age adjusted models. There was a cumulative effect, on prevalent and incident CHD, of socioeconomic position across the lifecourse. This effect was not fully explained by adult CHD risk factors. The adjusted odds ratio of prevalent CHD for each additional adverse (out of 10) lifecourse socioeconomic indicator was 1.11 (95% confidence interval: 1.06, 1.16). The magnitude of the effect of lifecourse socioeconomic position was the same in women who were lifelong non-smokers as in those who had been or were smokers. CONCLUSION: Adverse socioeconomic position across the lifecourse increases CHD risk cumulatively and this effect is not fully explained by adult risk factors. Specifically in this cohort of women cigarette smoking does not seem to explain the association between adverse lifecourse socioeconomic position and CHD risk.