Prevalence of Cardiovascular Disease Risk-Factor Clustering Among Persons Aged greater than or equal to 45 Years -- Louisiana, 1991-19

Cardiovascular disease (CVD), including coronary heart disease, stroke, and hypertensive disease, is the leading cause of death in Louisiana and in the United States and, in 1994, accounted for 43.7% and 45.2% of all deaths among persons aged greater than or equal to 45 years in Louisiana and in the United States, respectively. The primary risk factors for CVD are hypertension, high cholesterol, diabetes, overweight, cigarette smoking, and physical inactivity. The first four of these risk factors may cluster in some persons and have been identified as components of a syndrome known as metabolic cardiovascular syndrome (1) or the "deadly quartet" (2). This syndrome is characterized by a persistent state of insulin resistance and compensatory hyperinsulinemia that may be etiologically related to the four risk factors. Persons with one of the four risk factors are at increased risk for having any of the other three (3). To determine the prevalence of risk-factor clustering among older residents of Louisiana, CDC analyzed data from the 1991, 1992, 1993, and 1995 Louisiana Behavioral Risk Factor Surveillance System (BRFSS). * This report summarizes the results of this analysis, which documented a prevalence of clustering of the four risk factors among 1.7% of the respondents aged greater than or equal to 45 years.

The BRFSS is a population-based, random-digit-dialed telephone survey of the civilian, noninstitutionalized U.S. population aged greater than or equal to 18 years. Respondents were asked their weight and height and whether they had ever been told by a health-care professional that they had high blood pressure, high cholesterol, or diabetes. Body mass index (BMI), defined as the ratio of weight in kilograms to height in meters squared, was used to determine overweight. Overweight was defined as a BMI of greater than 27.3 for women and greater than 27.8 for men. Presence of any of the other three risk factors was determined by a positive response to the other questions. Data were weighted, and prevalence estimates and standard errors were calculated using SUDAAN.

In Louisiana, complete data were available for 2068 (78%) of the 2646 respondents aged greater than or equal to 45 years during the 4 years. Data were incomplete for 578 (22%) respondents, including 532 (92%) who reported their cholesterol levels had never been checked.

Persons who reported their cholesterol level had been checked were more likely than those who did not to also report having high blood pressure (40.7% and 26.8%, respectively) and/or diabetes (12.3 % and 7.9%, respectively). Among the total respondent population of 2646 persons, the prevalence of high blood pressure and diabetes was 38.1% and 11.4%, respectively. This analysis is based on data from the 2068 respondents who had complete data and is generalizable to Louisiana residents aged greater than or equal to 45 years who have ever had their cholesterol level checked.

Overall prevalence estimates of the four risk factors ranged from 12.3% for diabetes to 40.2% for high blood pressure (Table_1). At least one of the four risk factors was reported by 73% of respondents, and 37% had two or more of the risk factors. Clustering of the four risk factors was estimated at 1.7% (Table_2). Although cell sizes were small, prevalence of clustering of the four risk factors ranged from 0.7% for white men to 4.8% for black women.

Reported by: R Meriwether, MD, M Kohn, MD, Office of Public Health, Louisiana Dept of Health and Hospitals. Div of Applied Public Health Training (proposed), Epidemiology Program Office, CDC.

Editorial Note

Editorial Note: From 1991 through 1994, the average annual age-adjusted CVD death rate among Louisiana women and men aged greater than or equal to 45 years (593.3 and 987.3 per 100,000 population, respectively) were the second and fourth highest, respectively, of the 50 states and the District of Columbia **. The findings in this report indicate that, during 1991-1995, 1.7% of Louisiana residents aged greater than or equal to 45 years self-reported risk factors compatible with metabolic cardiovascular syndrome and that prevalence of clustering of CVD risk factors varied substantially by sex and race. The race-specific prevalence of clustering of the four risk factors among black women was seven times that of white men and nearly three times that of white women, reflecting, in part, the higher prevalence of overweight among black women.

In this report, high blood pressure was the most prevalent CVD risk factor for both men and women aged greater than or equal to 45 years. In the United States, less than one fourth of persons with hypertension have their blood pressure under control (4). Because control of hypertension does not return CVD risk to that of normotensives, primary prevention of hypertension provides the best opportunity to reduce CVD risk associated with this risk factor. Strategies for the primary prevention of hypertension include attaining and maintaining optimal weight, engaging in moderate physical activity, and limiting intake of salt and alcohol (5).

Excessive caloric intake leading to overweight has been postulated as the event leading to the emergence of the other risk factors in metabolic cardiovascular syndrome (6). Therefore, reductions in the prevalence of overweight and individual weight loss may have the greatest impact on CVD risk and risk-factor clustering. Even small decreases in weight among persons who are overweight may decrease the prevalence of high blood pressure, elevated cholesterol levels, and diabetes (3). Comprehensive public health efforts to reduce the prevalence of overweight should include environmental interventions such as reducing the fat and caloric content of processed foods and changing food preparation methods in institutional settings (e.g., schools, worksites, restaurants, and hospitals). Efforts to improve eating and exercise behaviors should also continue to be encouraged through public health campaigns such as eating at least five servings of fruits and vegetables each day and initiatives to improve physical activity levels (7). The Office of Public Health, Louisiana Department of Health and Hospitals, is initiating programs to increase the proportion of residents who meet the Surgeon General's recommendations for moderate physical activity and who eat five servings of fruits and vegetables each day to reduce the burden of overweight, diabetes, and CVD.

References

1. Arnesen H. Introduction: the metabolic cardiovascular syndrome. J Cardiovasc Pharmacol 1992;20(suppl 8):S1-S4.

2. Kaplan N. The deadly quartet: upper-body obesity, glucose intolerance, hypertriglyceridemia, and hypertension. Arch Intern Med 1989;149:1514-20.

3. Pi-Sunyer FX. Medical hazards of obesity. Ann Intern Med 1993;119:655-60.

4. National High Blood Pressure Education Program, National Heart, Lung, and Blood Institute, National Institutes of Health. The fifth report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure, 1993; NIH publication no. 93-1088:1.

5. Anonymous. National High Blood Pressure Education Program Working Group report on primary prevention of hypertension. Arch Intern Med 1993;153:186-208.

6. DeFronzo RA, Ferrannini E. Insulin resistance: a multifaceted syndrome responsible for NIDDM, obesity, hypertension, dyslipidemia, and atherosclerotic cardiovascular disease. Diabetes Care 1991;14:173-94.

7. US Department of Health and Human Services. Physical activity and health: a report of the Surgeon General. Atlanta, Georgia: US Department of Health and Human Services, Public Health Service, CDC, National Center for Chronic Disease Prevention and Health Promotion, 1996.

* Data were not analyzed for 1994 and 1996 because blood pressure and cholesterol data were not collected. ** Data obtained from the Compressed Mortality File maintained by CDC.

TABLE 1. Percentage of respondents aged >=45 years self-reporting four cardiovascular disease risk factors, by sex and race * -- Louisiana, Behavioral Risk Factor Surveillance System, 1991-1993 and 1995
===============================================================================================================================================================================================================
                               White men (n=636)                     Black men (n=122)                   White women (n=1026)                   Black women (n=284)                   Total (n=2068)
                            ---------------------------          --------------------------           ----------------------------          ------------------------------      -------------------------------
Risk factor                   %             (95% CI +)            %              (95% CI)               %               (95% CI)              %               (95% CI)            %            (95% CI)
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Overweight &                40.2          (34.7%-45.7%)          27.8         (17.4%-38.2%)           31.6           (27.7%-35.5%)           63.1          (55.7%-70.6%)        38.1         (35.2%-41.0%)
High blood pressure         30.9          (26.2%-35.6%)          49.5         (37.5%-61.1%)           40.6           (36.5%-44.7%)           60.6          (53.2%-68.0%)        40.2         (37.4%-43.0%)
High cholesterol            33.1          (28.0%-38.2%)          19.1         (10.5%-27.7%)           38.8           (34.6%-43.0%)           36.1          (28.8%-43.4%)        34.5         (31.7%-37.3%)
Diabetes                    10.2          ( 7.2%-13.3%)          15.7         ( 6.9%-24.5%)           10.7           ( 8.1%-13.3%)           21.6          (15.2%-28.0%)        12.3         (10.4%-14.2%)
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
* Numbers for races other than black and white were too small for meaningful analysis.
+ Confidence interval.
& Body mass index (BMI) >27.8 for men and BMI >27.3 for women.
===============================================================================================================================================================================================================

TABLE 2. Percentage of respondents aged >=45 years at each level of cardiovascular disease risk factor * clustering, by sex and race + -- Louisiana, Behavioral Risk Factor Surveillance System, 1991-1993 and 1995
===================================================================================================================================================================================================================
                              White men (n=636)                   Black men (n=122)                   White women (n=1026)                   Black women (n=284)                    Total (n=2068)
                         ---------------------------          --------------------------         -------------------------------         ----------------------------       ------------------------------
No. risk factors           %             (95% CI &)            %              (95% CI)               %               (95% CI)              %               (95% CI)            %             (95% CI)
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
0                        28.8          (24.0%-33.6%)          28.3         (17.9%-38.7%)           29.2           (25.5%-32.9%)           10.7          ( 6.0%-15.4%)         26.8        (24.2%-29.4%)
1                        38.5          (33.2%-43.8%)          43.3         (31.5%-55.1%)           34.4           (30.4%-38.3%)           29.9          (22.8%-37.1%)         36.2        (33.4%-39.0%)
2                        22.7          (18.1%-27.3%)          16.3         ( 8.3%-24.3%)           24.1           (20.4%-27.8%)           31.4          (24.4%-38.4%)         23.7        (21.1%-26.3%)
3                         9.2          ( 6.0%-12.4%)          12.0         ( 4.0%-20.0%)           10.3           ( 7.8%-12.9%)           23.2          (16.2%-30.2%)         11.6        ( 9.7%-13.5%)
4                         0.7          ( 0.2%- 1.2%)           --                --                 2.0           ( 0.8%- 3.2%)            4.8          ( 1.9%- 7.7%)          1.7        ( 1.1%- 2.3%)
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
* Cardiovascular disease risk factors included are overweight (defined as body mass index {BMI} >27.8 for men and BMI 27.3 for women), high blood pressure, high cholesterol, and diabetes.
+ Numbers for races other than black and white were too small for meaningful analysis.
& Confidence interval.
===================================================================================================================================================================================================================

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