Coronary heart disease (CHD) is the leading cause of death in the United States.1 Factors associated with an increased risk of developing CHD that tend to cluster in individuals include older age, high blood pressure, a low level of high-density lipoprotein (HDL) cholesterol, a high triglyceride level, a high plasma glucose concentration, and obesity.2 These associated risk factors have been called syndrome X,3 the insulin resistance syndrome,4 or the metabolic syndrome.5

The mechanisms underlying the metabolic syndrome are not fully known; however, resistance to insulin-stimulated glucose uptake seems to modify biochemical responses in a way that predisposes to metabolic risk factors.3,6,7 Insulin resistance is thought to be primarily due to obesity or an inherited genetic defect.8 As the prevalence of obesity increases in the United States, the prevalence of the metabolic syndrome may be expected to increase markedly. Estimates of the prevalence of the metabolic syndrome have varied substantially in part because of the variability of evaluated populations and of diagnostic criteria.9

The recent Third Report of the National Cholesterol Education Program Adult Treatment Panel (ATP III) included clinical diagnosis guidelines for the metabolic syndrome.10 Compared with findings from earlier studies3-5 and World Health Organization guidelines, the new ATP III defines criteria readily measured in clinical practice. These consensus-generated guidelines provide the opportunity to assess the overall prevalence of the metabolic syndrome in the US population according to an accepted standard definition. In an initial study, Ford et al11 reported un-adjusted and age-adjusted metabolic syndrome prevalences of 21.8% and 23.7%, respectively, for the US population. The objectives of this study are to examine the prevalence of the metabolic syndrome by ethnicity, age, body mass index (BMI) (calculated as weight in kilograms divided by the square of height in meters), socioeconomic status, and lifestyle factors.

https://jamanetwork.com/journals/jamainternalmedicine/articlepdf/215123/ioi20116_427_436.pdf

The Metabolic Syndrome: Prevalence and Associated Risk Factor Findings in the US Population From the Third National Health and Nutrition Examination Survey, 1988-1994

Background: The metabolic syndrome is an importantclusterofcoronaryheartdiseaseriskfactorswithcommon insulin resistance. The extent to which the metabolic syndrome is associated with demographic and potentially modifiable lifestyle factors in the US population is unknown. Methods: Metabolic syndrome–associated factors and prevalence, as defined by Adult Treatment Panel III criteria,wereevaluatedinarepresentativeUSsampleof3305 black,3477MexicanAmerican,and5581whitemenand nonpregnantorlactatingwomenaged20yearsandolder who participated in the cross-sectional Third National Health and Nutrition Examination Survey. Results: The metabolic syndrome was present in 22.8% and 22.6% of US men and women, respectively (P=.86). The age-specific prevalence was highest in Mexican Americans and lowest in blacks of both sexes. Ethnic differences persisted even after adjusting for age, body mass index, and socioeconomic status. The metabolic syndrome was present in 4.6%, 22.4%, and 59.6% of normal-weight, overweight, and obese men, respectively, and a similar distribution was observed in women. Older age, postmenopausal status, Mexican American ethnicity, higher body mass index, current smoking, low household income, high carbohydrate intake, no alcohol consumption, and physical inactivity were associated with increased odds of the metabolic syndrome.

Prevalence and Associated Risk Factor Findings in the US Population From the Third National Health and Nutrition Examination Survey, 1988-1994

Using the concept of vulnerable populations, we examine how disparities in health may be exacerbated by populationapproach interventions. We show, from an etiologic perspective,howlife-course epidemiology, the concentration of risk factors, and the concept of fundamental causes of diseases may explain the differential capacity, throughout the risk-exposure distribution, to transform resources provided through population-approach interventions into health. From an intervention perspective, we argue that population-approach interventions may be compromised by inconsistencies between the social and cultural assumptions of public health practitioners and targeted groups. We propose some intervention principles to mitigate the health disparities associated with population-approach interventions.

Transcending the Known in Public Health Practice - The Inequality Paradox: The Population Approach and Vulnerable Populations

OBJECTIVE: Because women with systemic lupus erythematosus (SLE) are 5-8 times more likely to develop coronary heart disease (CHD) than are women in the general population, we assessed the prevalence of classic risk factors for CHD in women with SLE. METHODS: Consecutive female patients with SLE who were without evidence of CHD and were attending a large lupus clinic in Toronto were studied. The control population was recruited from among age-matched subjects attending a family practice unit for an annual physical examination. The prevalence of classic CHD risk factors and the 10-year risk of a CHD-related event were determined using the Framingham risk assessment formula. Lipid subfractions, other metabolic risk factors, lifestyle variables, and demographic characteristics were also compared between the 2 groups. RESULTS: We studied 250 SLE patients and 250 controls whose mean +/- SD age was 44.8 +/- 12 years and 44.3 +/- 15 years, respectively. Hypertension and diabetes were significantly more common among the SLE patients. Although the SLE patients had a higher mean number of CHD risk factors per patient, the 10-year risk of a CHD-related event, using the Framingham multiple risk factor assessment, was the same in SLE patients and controls (3.2%). Compared with controls, SLE patients had higher levels of very low-density lipoprotein cholesterol and total triglycerides, and had higher levels of homocysteine despite having higher folate levels. Premature menopause, sedentary lifestyle, and an at-risk body habitus were also more prevalent in SLE patients. CONCLUSION: Women with SLE have a range of detectable coronary risk factors that are not fully reflected in the Framingham risk factor formula. These factors are likely to contribute to the loss of protection from CHD that has been observed in SLE.

https://onlinelibrary.wiley.com/doi/pdf/10.1002/art.11296

Risk factors for coronary heart disease in women with systemic lupus erythematosus: The Toronto Risk Factor Study

Objectives To examine tracking of body mass index (BMI) (weight in kilograms divided by the square of height in meters) from age 15 to 33 years, to examine the effect of adolescent and adult health-related behavior and parents' BMI and education on adult BMI; and to examine changes in lifestyle factors as predictors of adult overweight and obesity. Methods A longitudinal study with 18 to 20 years of follow-up in a cohort from Oslo, Norway (N = 485); mean age was 15 years at baseline. Weight, height, physical fitness, leisure time physical activity (LTPA), smoking, and education were assessed at baseline and follow-up. Parents' height, weight, and education were assessed at baseline. Results Tracking of BMI from age 15 to 33 years was high ( r = 0.54). Adolescent BMI, father's BMI, the subject's own LTPA, adult smoking, and sex explained 44.1% of the variation in adult BMI. The odds ratio (95% confidence interval) of having a BMI of 25 or more as an adult was 0.07 (0.03-0.14) for lowest vs highest quartile of adolescent BMI. The corresponding odds ratio of having a BMI of 30 or more was 0.02 (0.002-0.14). Those who increased their LTPA level between adolescence and adulthood had a lower risk of adult overweight than those with a stable low LTPA level. Conclusions Tracking of BMI from adolescence into adulthood was substantial. Changes in LTPA between adolescence and adulthood predicted the risk of adult overweight, suggesting that the foundation for adult body weight is laid during adolescence. Implications of this would be to emphasize physical activity among youths.

https://jamanetwork.com/journals/jamapediatrics/articlepdf/481501/poa30104_1212_1218.pdf

Predictors and Tracking of Body Mass Index From Adolescence Into Adulthood: Follow-up of 18 to 20 Years in the Oslo Youth Study

Background: We examined the ability of adult Canadians to recall cardiovascular disease risk factors to determine the associations between their ability to recall risk factors for cardiovascular disease and their socioeconomic status. Methods: This study used the database assembled by the Canadian Heart Health Surveys Research Group between 1986 and 1992 - a stratified representative sample comprising 23 129 Canadian residents aged 18 to 74. Nurses administered a standard questionnaire asking respondents to list the major risk factors for cardiovascular disease: fat in food, smoking, lack of exercise, excess weight, elevated blood cholesterol and high blood pressure. Six logistic regressions examined the multivariate associations between ability to recall each risk factor with education, income adequacy, occupation, sex, age, marital status and province of residence. Results: More people knew about the behaviour-related risk factors for cardiovascular disease than about the physiologic risk factors: 60% recalled fat in food, 52% smoking and 41% lack of exercise, but only 32% identified weight, 27% cholesterol and 22% high blood pressure. Education was the socioeconomic status indicator most strongly and consistently associated with the ability to recall risk factors for cardiovascular disease. The odds ratios of reporting an association of the risks between people with elementary education and those with university degrees varied between 0.16 (95% confidence interval 0.12 to 0.22) for lack of exercise to 0.55 (95% confidence interval 0.39 to 0.77) for smoking. Interpretation: People in categories at greater risk of cardiovascular disease, such as those aged 65 or more or those with only elementary education, are less able to recall important cardiovascular disease risk factors.

/pdf/knowledge-of-cardiovascular-disease-risk-factors-among-the-30p2vo9oho.pdf

Knowledge of cardiovascular disease risk factors among the Canadian population: relationships with indicators of socioeconomic status.

BACKGROUND: This study was designed to describe the distribution of risk factors for cardiovascular disease by socioeconomic status in adult men and women across Canada using the Canadian Heart Health Surveys Database. METHODS: The data were derived from provincial cross-sectional surveys done between 1986 and 1992. Data were obtained through a home interview and a clinic visit using a probability sample of 29,855 men and women aged 18-74 years of whom 23,129 (77%) agreed to participate. The following risk factors for cardiovascular disease were considered: elevated total plasma cholesterol (greater than 5.2 mmol/L), regular current cigarette smoking (one or more daily), elevated diastolic or systolic blood pressure (140/90 mm Hg), overweight (body mass index and lack of leisure-time physical activity [less than once a week in the last month]). Education and income adequacy were used as measures of socioeconomic status and mother tongue as a measure of cultural affiliation. RESULTS: For most of the risk factors examined, the prevalence of the risk factors was inversely related to socioeconomic status, but the relationship was stronger and more consistent for education than for income. The inverse relationship between socioeconomic status and the prevalence of the risk factors was particularly strong for smoking and overweight, where a gradient was observed: 46% (standard error [SE] 1.4) of men and 42% (SE 4.3) of women who had not completed secondary school were regular smokers, but only 12% (SE 1.0) of men and 13% (SE 0.9) of women with a university degree were regular smokers. Thirty-nine percent (SE 1.4) of men and 19% (SE 3.8) of women who had not completed secondary school were overweight, compared with 26% (SE 2.6) of male and 19% of female university graduates. The prevalence of leisure-time physical inactivity and elevated cholesterol was highest in both men and women in the lowest socioeconomic category, particularly by level of education. INTERPRETATION: The differences in the prevalence of risk factors for cardiovascular disease between socioeconomic groups are still important in Canada and should be considered in planning programs to reduce the morbidity and mortality from cardiovascular disease.

/pdf/distribution-of-cardiovascular-disease-risk-factors-by-2e1xahn4z2.pdf

Distribution of cardiovascular disease risk factors by socioeconomic status among Canadian adults

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Knowledge of cardiovascular disease risk factors among the Canadian population: relationships with indicators of socioeconomic status.

Distribution of cardiovascular disease risk factors by socioeconomic status among Canadian adults