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11
International Heart
and Vascular Disease Journal • Volume 2, Number 3, June 2014 Journal of the Cardioprogress Foundation
LEADING ARTICLE
Prevalence of ideal cardiovascular
health in an adult Finnish population: the national FINRISK 2007 study
Peltonen M.*, Laatikainen T., Borodulin K., Wikström K., Jousilahti P., Jula A., Männistö S., Salomaa V., Vartiainen E., Puska P.
Department of Chronic Disease Prevention, National Institute for Health and Welfare (THL),
P.O. Box 30, FI-00271 Helsinki, Finland
Authors:
Markku Peltonen, PhD, Research Professor, National Institute for Health and Welfare Tiina Laatikainen, MD, Professor, National Institute for Health and Welfare; Institute of Public Health and Clinical Nutrition, Faculty of Health Sciences, University of Eastern Finland; Hospital District of North Karelia, Finland
Katja Borodulin, PhD, Adjunct Professor, National Institute for Health and Welfare Katja Wikström, MSc, Researcher, National Institute for Health and Welfare Pekka Jousilahti, MD, Research Professor, National Institute for Health and Welfare Antti Jula, MD, Research Professor, National Institute for Health and Welfare Satu Männistö, PhD, Adjunct Professor, National Institute for Health and Welfare Veikko Salomaa, MD, Research Professor, National Institute for Health and Welfare Erkki Vartiainen, MD, Research Professor, National Institute for Health and Welfare Pekka Puska, MD, Research Professor, National Institute for Health and Welfare
Summary Aim
Despite major reductions in cardiovascular disease (CVD) mortality rates during the past decades in Finland, the risk factor pattern of the population leaves much room for improvement. The aim of this study was to assess the prevalence of ideal cardiovascular (CV) health in Finnish men and women aged 25-74 years.
Material and methods
Cross-sectional population-based health examination survey was conducted in 2007 in Finland. Age and sex stratified random sample was drawn from the national population register. The total number of individuals in the analyses was 2,128 men and 2,613 women. Ideal CV health metrics were defined according to the recent guidelines of
* Corresponding author. Tel: +358 29524 8477. E-mail: [email protected]
the American Heart Association (AHA), considering behavioural factors (smoking, physical activity, diet, obesity), biological and physiological risk factors (blood pressure, total cholesterol, blood glucose).
Results
The prevalence of ideal CV health was the lowest for the physical activity, diet and blood pressure among the total of seven factors considered. Taken together, the prevalence of having 5 or more health metrics as ideal out of the 7 was just 8.8 % (95% CI: 7.7-10.0) in women and 3.0 % (95% CI: 2.3-3.8) in men. In contrast, the proportions of men and women with less than 3 of the metrics as ideal were 50.4 % (95% CI: 48.5-52.3) in women and 69.0 % (95% CI: 67.0-71.9) in men. Age was negatively associated with the number of ideal CV health factors.
Conclusion
The prevalence of ideal CVD related health behaviour and health factors is low in the Finnish adult population.
Keywords
Cardiovascular health, risk factors, health behaviour, health survey, Finland
Introduction
CVD is the leading cause of death in Finland and globally. In many Western countries the age specific rates are declining, but the disease rates are increasing in most developing countries [1]. The main traditional risk factors for CVD are hypertension, hypercholesterolemia and smoking [2]. Levels of blood pressure and total cholesterol can be modified by health behaviour including diet and physical activity [2-4].
In Finland, a marked decrease in CVD mortality has been observed since late 1960s. In working-aged men, the coronary heart disease (CHD) rates have declined by 80% [5]. This decrease has been parallel with a decrease in smoking prevalence and decline in blood pressure and total cholesterol levels [5]. Majority of the decline in CHD mortality can be explained by changes in risk factors, and a smaller part is explained by advancements in treatment and care [5].
Despite the favourable trend in both CVD mortality and risk factors, there is still much room for improvement in CV health in Finland. The prevalence of smoking in Finland is 19% in men and 13% in women in the age group of 15-64 years [6], and the average levels of serum total cholesterol are above the current recommendations [5]. In international comparison, blood pressure levels are still relatively high in Finland [7].
Recently, the AHA developed a set of 7 metrics to measure ideal CV health [8]. The proposed concept of ideal CV health puts more focus on health behaviours and risk factors leading to morbidity and mortality, instead of the disease itself. These measurable metrics will be used to monitor the AHA's Strategic
Impact Goal 2020, which aims to improve CV health and reduce deaths from CVD and stroke.
The aim of this study was to assess the prevalence of ideal CV health in a population-based study of adults in Finland.
Material and methods
A cross-sectional population-based survey, the National FINRISK Study, was carried out in 2007 in Finland among men and women aged 25-74 years to monitor national risk factor levels. The study was conducted in five geographical areas: the cities of Helsinki and Vantaa (the metropolitan area), the areas of Turku and Loimaa, and the provinces of Northern Savo, North Karelia, and Oulu. A random sample of people aged 25-74 years was drawn from the national population register stratified so that in each geographical area, 200 people of each sex and 10-year age group were chosen. The total sample size was thus 10,000 people, and the eligible study sample was 9,957 people after exclusion of those who died or moved out of the geographical area between the time of the sample selection and scheduled health examination date.
The overall participation rate in the study was 68% (N=6,733). Of these, 475 individuals who filled in the questionnaire but did not participate in the health examination of the study were excluded. The study sample was further restricted to those who participated in a substudy with fasting glucose measurement (N=5,024). In addition, 283 individuals with a history of CVD already at the time of the health examination were excluded. Thus, the analyses were done with data on 2,128 men and 2,613 women.
The survey was conducted according to the standardized protocol based on the Wortd Heath Organisation Multinational Monitoring of trends and determinants in CVD (WHO MONICA) Project protocol [9] and the later recommendations by the European Health Risk Monitoring Project [10]. The study protocol was approved by the Ethics Committee of the Hospital District of Helsinki and Uusimaa. All participants gave their written informed consent.
Study teams in each of the geographical regions, with five trained nurses in each, carried out the survey. The nurses were specially trained in survey methodology. Survey included a self-administered questionnaire and a health examination, where anthropometric measurements, blood pressure measurements and blood sampling were carried out. The questionnaire, together with the invitation letter to the health examination, was sent by mail to all the selected individuals. Physical measurements and blood sampling were carried out in local health centres or other study sites by specially trained nurses. Laboratory measurements were carried out centrally at the Disease Risk Unit at the National Institute for Health and Welfare, Helsinki. The testing laboratory of the Disease Risk Unit (No. T077) is accredited by the Finnish Accreditation Service, FINAS, and it fulfils the requirements of the standard SFS-EN ISO/IEC 17025:2005.
Ideal CV health was defined according to the recent guidelines of the AHA [8]. A set of 7 metrics to measure ideal CV health was developed, including health behavioural factors (smoking, physical activity, diet, obesity) and risk factors (blood pressure, total cholesterol, blood glucose). For physical activity and diet, adaptations to the original definition were made due to the lack of suitable data.
Blood pressure measurement
The nurses measuring blood pressure were circulated between the study areas to eliminate the possible observer bias in the between-areas comparisons. A standard mercury sphygmomanometer with a cuff bladder 14 cm wide and 40 cm long was used. The fifth phase of the Korotkoff sound was used as the diastolic blood pressure and the values were recorded to the nearest even numbers. Blood pressure was measured three times and the mean of the last two measurements was used in the present analyses.
Participants with systolic blood pressure <120 mmHg and diastolic blood pressure <80 mmHg without blood pressure lowering medication were categorized as having ideal CV health metric. Those
participants with systolic blood pressure s140 mmHg or diastolic blood pressure s90 were categorized as having poor CV health. All other participants were categorized in the intermediate category.
Blood sampling
Fasting venous blood samples were drawn from each participant to measure serum total cholesterol by an enzymatic method (Abbott Diagnostics Europe, Wiesbaden, Germany) using Abbott Architect c8000 clinical chemistry analyser. Cholesterol levels <5.18 mmol/l were defined as ideal cholesterol metric; &5.18 mmol/l up to 6.18 mmol/l as intermediate; and 6.19 mmol/l or more as poor.
Plasma glucose was determined with a hexokinase method (Abbott Laboratories, Abbott Park, IL). Plasma glucose levels <5.6 mmol/l without glucose lowering medication were defined as ideal; s5.6 mmol/l up to 7.0 mmol/l or <5.6 mmol/l with glucose lowering medication as intermediate; and s7.0 mmol/l as poor regarding CV health.
Obesity
Weight and height were measured with participants wearing light clothing and no shoes. Height was measured to the nearest 0.1cm, and weight to the nearest 100 grams. Body mass index (BMI) was calculated as weight (kg) divided by the square of height (m2).
BMI <25 kg/m2 was defined as ideal; 25-29.9 kg/m2 as intermediate; and 30 kg/m2 or more as poor metric for CV health.
Physical activity
Physical activity was assessed in leisure time and during commuting using short self-administered questionnaires. Leisure time physical activity was divided into four categories, reflecting weekly amount and intensity of physical activity. The categories do not follow the current recommendations of physical activity for health, but are able to separate the inactive persons from moderately and vigorously active persons. The two-way commuting trip was assessed in minutes spent walking, biking or otherwise exercising and was further dichotomized into low-commuting physical activity (0-29 min daily) and high-commuting physical activity (more than 30 min daily).
Based on data on both leisure time and commuting physical activity, an index was derived so that those who were physically active both at leisure-time and commuting were classified as having ideal; those who were not active either at leisure-time or commuting were classified as having poor; and all others
(i.e. those being active either at leisure-time or commuting, but not both) were classified as having intermediate physical activity level regarding CV health.
Diet
Information on diet was collected with a self-administered food-frequency questionnaire. Four components were used to define healthy diet: eating either fruits or vegetables daily, eating fish two times or more per week, drinking low fat milk, and using vegetable oils in cooking at home.
From these data, a dietary index was derived so that those having healthy consumption of all the four components (fruits and vegetables, fish, milk and fat used for cooking) were classified as having ideal diet regarding CV health. Those who did not fulfil the healthy criteria for any of these diet components were defined as having poor diet. All the others (i.e. those fulfilling at least one but not all criteria) were defined as having an intermediate diet.
Smoking
Smoking was assessed by structured questions in the self-administered questionnaire. Based on their responses, the participants were classified into three categories: never smokers (ideal); ex-smokers (intermediate); and smokers (poor).
Statistical analyses
Mean values, standard deviations, and percentages were used to describe the characteristics of the study population. Prevalences of individual health metrics were calculated separately for men and women. Total number of ideal CV health factors was estimated by sex and age. Differences between groups were evaluated with t-tests for continuous variables and chi-squared and logistic regression models for di-chotomous variables. All P-values are two-sided, and
P-values less than 0.05 were considered statistically significant. The Stata statistical package, version 12.1, was used.
Results
Characteristics of the study population are shown in Table 1. The mean age was 52 years (range 25-74) and mean BMI 27 kg/m2. Men had higher blood pressure, triglycerides and glucose levels, and lower high density lipoprotein (HDL) cholesterol levels as compared to women.
All the individual health metrics except physical activity indicated lower CV health in men as compared to women (Table 2). One third of the participants had poor physical activity level, whereas just 15% were classified as having physical activity metric as ideal. Most of the participants achieved intermediate level for the metric on diet. In women, 66% were never-smokers as compared to 46% in men. More than 20% of both men and women were classified as obese (BMI s30 kg/m2) and therefore as having poor health in this metric.
For the CV risk factors, 32% of men and 45% of women were categorized as having poor health metric based on their blood pressure levels (Table 2). Total cholesterol levels were defined as ideal in 48% of women and 46% of men. Glucose levels were more favourable in women compared to men.
Taken together the 7 individual health metrics, the distribution of number of ideal CV health factors is shown in Figure 1. The prevalence of having 5 or more health factors as ideal out of the 7 was just 8.8% (95% CI: 7.7-10.0) in women and 3.0% (95% CI: 2.3-3.8) in men. In contrast, the proportions of men and women with less than 3 of the metrics as ideal were 50.4% (95% CI: 48.5-52.3) in women and 69.0% (95% CI: 67.0-71.9) in men.
Table 1. Characteristics of the study population
Women Men
mean SD mean SD P-value
N 2,613 2,128
Age, years 51.5 13.6 52.4 13.3 0.019
Body weight, kg 71.3 14.2 84.5 13.8 <0.001
Body mass index, kg/m2 26.9 LO 27.3 4.0 0.011
Systolic blood pressure, mmHg 131.2 20.3 136.4 18.3 <0.001
Diastolic blood pressure, mmHg 77.0 10.4 81.5 11.4 <0.001
Total serum cholesterol, mmol/l 5.31 0.98 5.30 0.99 0.636
HDL cholesterol, mmol/l 1.57 0.37 1.31 0.33 <0.001
Triglycerides, mmol/l 1.25 0.78 1.61 1.02 <0.001
Fasting plasma glucose, mmol/l 5.73 0.78 6.13 1.09 <0.001
Table 2. Individual metrics for ideal cardiovascular health
Women Men P-value
Prevalence,% Prevalence, %
Health behavior:
Smoking Ideal* 66.3 45.9 <0.001
Intermediate 19.1 32.7
Poor 14.6 21.4
Physical activity Ideal 13.8 15.5 0.276
Intermediate 48.8 48.1
Poor 37.4 36.4
Diet Ideal 12.6 24.1 <0.001
Intermediate 73.5 65.3
Poor 13.9 10.6
Body mass index Ideal 42.3 29.0 <0.001
Intermediate 34.1 50.4
Poor 23.5 20.6
Health factor:
Total cholesterol Ideal 47.5 45.9 0.049
Intermediate 33.5 36.7
Poor 19.0 17.4
Blood pressure Ideal 26.7 12.2 <0.001
Intermediate 41.2 42.4
Poor 32.2 45.4
Glucose Ideal 50.2 24.8 <0.001
Intermediate 46.3 66.2
Poor 3.5 9.1
* For definitions of ideal, intermediate and poor health metrics, see Methods.
Women Men
Figure 1. Distribution of the number of ideal cardiovascular health factors by sex
As expected, age was inversely associated with the number of ideal CV health metrics (Figure 2). Still, already in the youngest age group 25-34 years, the proportions with 5 or more ideal metrics were as low as 23.9% (95% CI: 19.6-28.5) in women and 8.6% (95% CI: 5.5-12.8) in men.
Discussion
This study shows that the prevalence of ideal CV health is very low among adult men and women in Finland. The results demonstrate that in spite of major prog-
ress in Finland during the past decades, there is still considerable room for improvement and potential for reducing CVD burden at population level. It is noteworthy that the prevalence of ideal CV health is low already in the younger age groups. Low prevalence of ideal CV health has been observed also in other countries. Based on the AHA definition of ideal CV health, the prevalence was found to be extremely low in a community-based study of middle-aged individuals in the United States [11]. In Canada, based on the so called CANHEART health index, less than 10% of Canadian
Figure 2. Distribution of the number of ideal cardiovascular health factors by sex and age
adults were in ideal CV health [12]. These results are in good agreement with results from our study.
Ideal CV health is an instrument to assess the needs and potential for CVD prevention and CV health promotion in the population. It can also be used as a tool to monitor progress at the population level. Although this instrument is primarily a tool for CV health, the risk factors, especially the behavioural ones, are also strongly related to many other non-communicable diseases (NCDs). Thus, this instrument suits well for a more general monitoring of progress in NCD prevention and promotion of public health. The metrics in the instrument are the central targets and indicators in the new WHO Global Action Plan for the Non-communicable Diseases 2013-2020 [13].
The concept of ideal CV health considers both the traditional risk factors for CVD, as well as health behaviours related to these. Therefore, the instrument can be used as a motivational tool in preventive work. Further, the instrument emphasises the population risk, i.e. the public health needs, and the need to change the population levels or distributions of these factors. This calls for comprehensive interventions, including government policies, health promotion and intersectoral decisions, as described e.g. in the WHO Global Action Plan for the Non communicable Diseases 2013-2020 [13].
The number of ideal CV health metrics has been shown to be a strong predictor of both total and CVD specific mortality in the United States [14, 15]. A similar observation was recently reported from China [16]. Several earlier studies have utilised the concept of low risk factor profile and demonstrated its association with future onset of disease [17,18]. Thus, prospective studies using the concept of ideal CV health enable estimation of the potential for improvement in CVD burden in a population by looking at actual mortality and CVD morbidity rates.
There are some limitations, which need to be considered. Available data on physical activity and diet did not allow exactly the same definition as in the AHA metrics; adapted definitions, which take into account some aspects of healthy diet and physical activity, were used instead. The validity of these metrics to measure national recommendations and guidelines should be evaluated. Second, the non-participation rates in population surveys are considerable, especially in the younger age groups. It is difficult to point out exactly the effect of non-participation on our estimates of prevalence of ideal CV health. Historically, non-participation in population-based surveys in Finland has been associated with lower CV health
[19]. Thus, it is possible that our estimates of ideal CV health, while indicating a very low prevalence, are still too optimistic. Third, our estimates of ideal CV health were derived from the population without a history of CVD. Therefore, taken the population as a whole, the burden of CV risk factors and behaviours is even larger as those with a history of CVD cannot be regarded as having ideal CV health.
In the present study, we have used a cross-sectional population-based study to evaluate the prevalence of ideal CV health. In the future, this metric or adapted metric could be used to monitor changes in the population by looking at changes in ideal CV health and its components (both health factors and behaviours) over time. This type of monitoring could especially be beneficial for younger age groups where disease rates and total risk are still reasonably low.
Development of validated, culturally adapted indicators to be used in the definition of ideal CV health would increase the value of this tool. This could involve inclusion of other relevant health related behaviours in the definition. Evaluation of ideal CV health in subgroups of the population, e.g. in different socioeconomic groups, could be used to identify more targeted health promotion activities.
Conclusion
Despite major reductions in CVD rates during the past decades in Finland, the risk factor pattern of the population leaves much room for improvement. Strategies to increase healthy lifestyles at population level should be developed and implemented.
Conflict of interest: None declared
References
1. WHO. Global status report on noncommunicable diseases 2010. Geneva: World Health Organization; 2011. 176 p.
2. Perk J, De Backer G, Gohlke H, et al. European Guidelines on cardiovascular disease prevention in clinical practice (version 2012). The Fifth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of nine societies and by invited experts). Eur Heart J. 2012 Jul;33(13):1635-1701.
3. Eckel RH, Jakicic JM, Ard JD, et al. 2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2013 Nov 12. [Epub ahead of print].
4. Hsu S, Ton VK, Dominique Ashen M, et al. A clinician's guide to the ABCs of cardiovascular disease prevention: the Johns
Hopkins Ciccarone Center for the Prevention of Heart Disease and American College of Cardiology Cardiosource Approach to the Million Hearts Initiative. Clin Cardiol. 2013 Jul;36(7):383-393.
5. Vartiainen E, Laatikainen T, Peltonen M, et al. Thirty-five-year trends in cardiovascular risk factors in Finland. Int J Epidemiol. Apr 2010;39(2):504-518.
6. Helldan A, Helakorpi S, Virtanen S, Uutela A. Suomalaisen aikuisvaeston terveyskayttaytyminen ja terveys, kevat 2012. Health behaviour and health among the Finnish adult population, spring 2012. Terveyden ja hyvinvoinnin laitos (THL), Raportti 15/2013. Helsinki: National Institute for Health and Welfare (THL); 2013. 193 p.
7. Wolf-Maier K, Cooper RS, Banegas JR, et al. Hypertension prevalence and blood pressure levels in 6 European countries, Canada, and the United States. JAMA. 2003 May 14;289(18):2363-2369.
8. Lloyd-Jones DM, Hong Y, Labarthe D, et al. Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association's strategic Impact Goal through 2020 and beyond. Circulation. 2010 Feb 2;121(4):586-613.
9. The World Health Organization MONICA Project (monitoring trends and determinants in cardiovascular disease): a major international collaboration. WHO MONICA Project Principal Investigators. J Clin Epidemiol. 1988;41(2):105-114.
10. Tolonen H, Kuulasmaa K, Laatikainen T, Wolf H. European Health Risk Monitoring Project. Recommendation for indicators, international collaboration, protocol and manual of operations for chronic disease risk factor surveys. Helsinki (Finland): National Public Health Institute; 2002.
11. Bambs C, Kip KE, Dinga A, et al. Low prevalence of «ideal cardiovascular health» in a community-based population:
the heart strategies concentrating on risk evaluation (Heart SCORE) study. Circulation. 2011 Mar 1;123(8):850-857.
12. Maclagan LC, Park J, Sanmartin C, et al. The CANHEART health index: a tool for monitoring the cardiovascular health of the Canadian population. CMAJ. 2014 Feb 18;186(3):180-187.
13. WHO. Global action plan for the prevention and control of non-communicable diseases 2013-2020. Geneva: World Health Organization; 2013.
14. Ford ES, Greenlund KJ, Hong Y. Ideal cardiovascular health and mortality from all causes and diseases of the circulatory system among adults in the United States. Circulation. 2012 Feb 28;125(8):987-995.
15. Dong C, Rundek T, Wright CB, et al. Ideal cardiovascular health predicts lower risks of myocardial infarction, stroke, and vascular death across whites, blacks, and hispanics: the northern Manhattan study. Circulation. 2012 Jun 19;125(24):2975-2984.
16. Liu Y, Chi HJ, Cui LF, et al. The ideal cardiovascular health metrics associated inversely with mortality from all causes and from cardiovascular diseases among adults in a Northern Chinese industrial city. PLoS One. 2014 Feb 24;9(2):e89161.
17. Strandberg A, Strandberg TE, Salomaa VV, et al. A follow-up study found that cardiovascular risk in middle age predicted mortality and quality of life in old age. J Clin Epidemiol. 2004 Apr;57(4):415-421.
18. Akesson A, Weismayer C, Newby PK, Wolk A. Combined effect of low-risk dietary and lifestyle behaviors in primary prevention of myocardial infarction in women. Arch Intern Med. 2007 Oct 22;167(19):21 22-21 27.
19. Jousilahti P, Salomaa V, Kuulasmaa K, et al. Total and cause specific mortality among participants and non-participants of population based health surveys: a comprehensive follow up of 54 372 Finnish men and women. J Epidemiol Community Health. 2005 Apr;59(4):310-315.
