ORIGINAL
PAPER
Association Between Low Education and Higher Global Cardiovascular Risk Tiziana Di Chiara, MD; Alessandra Scaglione, PhD; Salvatore Corrao, MD; Christiano Argano, MD; Antonio Pinto, MD; Rosario Scaglione, MD From the Dipartimento Biomedico di Medicina Interna e Specialistica, University of Palermo, Palermo, ltaly
This study was designed to evaluate the impact of educational status on global cardiovascular risk in a southern Italian urban population. The study population consisted of 488 consecutive outpatients aged 18 years and older. Educational status was categorized according to the number of years of formal education as follows: (1) low education group (.012) and inversely with educational status (P=.000). Education was independently (P=.000) associated with global cardiovascular risk. These data indicate a strong association between low education and cardiometabolic comorbidities suitable to influence the evolution of chronic degenerative diseases. Preventive strategies need to be more efficient and more effective in this patient population. J Clin Hypertens (Greenwich). 2015;17:332–337. ª 2015 Wiley Periodicals, Inc.
Socioeconomic factors have been reported to be associated with total mortality and cardiovascular (CV) disease (CVD) risk factors in life-course analysis using multiple measurements.1–6 This can be achieved by repeated measures of socioeconomic position from early childhood into adult life.5 Because CVD is a major cause of morbidity and mortality among older people,6 it is sensible that research seek out possible mechanisms that may explain the association between life-course socioeconomic inequalities and CVD. Education has been reported to be a valid and easily measurable marker of socioeconomic status and it has been used in studies on the relationship with adverse health effects.4,5 In this context, low education has been reported as an important predictor of CVD, hypertension, and total and CV mortality. Relative risk increases progressively from patients in the most educated class to those less educated, becoming significant from high school onwards.6 The present study was designed to evaluate the relationships between education and global CV risk in a southern Italian urban population. We have chosen to study this population since it was with the lowest number of individuals who continued their studies
beyond compulsory schooling.7 This is actually an important field of CV research, since CV risk factors are considered a major disease burden and account for a large contribution to global loss of healthy life caused by CVD worldwide.8 More recently, a prospective fixedcohort Italian study (the CUORE study) reported predictive equations with better accuracy to detect overall CV risk in Italian people.7 Accordingly, the prevalence of cardiometabolic comorbidities, global CV risk, microalbuminuria, and measurements of left ventricular geometry and function were evaluated in a southern Italian urban population subdivided according to educational status. The main goal of the study was to assess whether a low level of education was associated with cardiometabolic comorbidities and with a higher global CV risk.
Address for correspondence: Rosario Scaglione, MD, Associate Professor of Internal Medicine, Piazza delle Cliniche 2, 90127 Palermo, Italy. E-mail: [email protected] Manuscript received: October 9, 2014; revised: December 1, 2014; accepted: December 2, 2014 DOI: 10.1111/jch.12506
332
The Journal of Clinical Hypertension
Vol 17 | No 5 | May 2015
PATIENTS AND METHODS Patients In this cross-sectional study, 528 consecutive outpatients residing in a southern state of Italy (Palermo, Sicily) from January 2012 to December 2013 were evaluated. All patients were referred to our center of hypertension and metabolic disease at the Department of Internal Medicine (University of Palermo) for medical needs. Exclusion criteria included psychiatric problems or alcoholism. After the selection phase, 488 patients (240 men and 248 women) who aged 18 years and older were enrolled in the study.
Low Education and Global Cardiovascular Risk | Di Chiara et al.
Each patient gave written consent after receiving a detailed description of the study procedure. The study was approved by the ethics committee of our institution. All patients were subgrouped according to their educational status. In particular, educational status was categorized according to the number of years of formal education into two groups as follows: Less than 10 years of education (illiterate and less than secondary) was considered the “low education group.” This group consisted of 228 patients (100 men and 128 women) with a mean age of 52.38.0 years (range, 28 to 67 years); and 10 to 15 years of education (secondary to graduate) was considered the “medium-high education group.” This group consisted of 260 patients (140 men and 120 women) with a mean age of 48.55.6 years (range, 29 to 66 years). We chose this cutoff because until about 30 years ago in Italy, citizens were required by law to complete 8 years of compulsory education. Level of education was taken from the certificate of studies performed (graduated from elementary school, middle school, high school, and university). For all participants, the clinical visit included medical history, anthropometry, blood pressure (BP) measurements, resting electrocardiography, Doppler echocardiography, and a fasting collection of blood for determination of biochemical parameters. Body height, weight, and waist and hip circumferences were all taken in a standardized manner.9,10 Body mass index (BMI) was calculated as weight divided by squared height and expressed as kg/m2. Brachial BP was measured following the indications of the European Society of Hypertension/European Society of Cardiology (ESH/ESC) guidelines11 using a validated mercury-free digital sphygmomanometer with appropriate cuff size. The average of three consecutive measurements, spaced by an interval of 2 minutes with the patient in the sitting position for 5 minutes before the measurement, was used for the analysis. The following comorbidities were evaluated in both groups. Obesity and Visceral Obesity. Patients were defined as obese on the basis of sex-specific 85th percentile of BMI values, as reported in the Italian Consensus Conference on Obesity.10 Accordingly, men with BMI ≥30 kg/m2 and women with BMI ≥27.3 kg/m2 were considered obese. Visceral fat distribution was defined on the basis of sex-specific 85th percentile of waist-to-hip ratio (WHR). The cutoff values of visceral obesity were considered 0.81 for women and 0.92 for men.9,10 Hypertension. Patients taking antihypertensive treatment or with casual systolic BP (SBP) ≥140 mm Hg and/ or with casual diastolic BP (DBP) ≥90 mm Hg were considered to have hypertension. BP was measured with an appropriate large cuff in obese patients. SBP, DBP, and mean BP (MBP) were determined. MBP was
calculated by the sum of DBP plus one third of pulse pressure. Diabetes. According to guidelines from the American Diabetes Association, all patients with fasting glycemia ≥126 mg/dL or who were being treated with antidiabetic drugs or insulin were considered diabetics.12 Metabolic Syndrome. Patients with the metabolic syndrome (MetS) were recognized according to the Third Report of the Adult Treatment Panel National Cholesterol Education Program (NCEP-ATP III) criteria.13 In particular, any three of the five following criteria constitute a diagnosis of MetS: elevated BP, elevated waist circumference, elevated triglycerides, reduced high-density lipoprotein (HDL) cholesterol, and elevated fasting glucose. Dyslipidemia. Dyslipidemia was defined by the presence of high total cholesterol (≥200 mg/dL), high lowdensity lipoprotein (LDL) cholesterol (≥130 mg/dL), low HDL cholesterol (
PAPER
Association Between Low Education and Higher Global Cardiovascular Risk Tiziana Di Chiara, MD; Alessandra Scaglione, PhD; Salvatore Corrao, MD; Christiano Argano, MD; Antonio Pinto, MD; Rosario Scaglione, MD From the Dipartimento Biomedico di Medicina Interna e Specialistica, University of Palermo, Palermo, ltaly
This study was designed to evaluate the impact of educational status on global cardiovascular risk in a southern Italian urban population. The study population consisted of 488 consecutive outpatients aged 18 years and older. Educational status was categorized according to the number of years of formal education as follows: (1) low education group (.012) and inversely with educational status (P=.000). Education was independently (P=.000) associated with global cardiovascular risk. These data indicate a strong association between low education and cardiometabolic comorbidities suitable to influence the evolution of chronic degenerative diseases. Preventive strategies need to be more efficient and more effective in this patient population. J Clin Hypertens (Greenwich). 2015;17:332–337. ª 2015 Wiley Periodicals, Inc.
Socioeconomic factors have been reported to be associated with total mortality and cardiovascular (CV) disease (CVD) risk factors in life-course analysis using multiple measurements.1–6 This can be achieved by repeated measures of socioeconomic position from early childhood into adult life.5 Because CVD is a major cause of morbidity and mortality among older people,6 it is sensible that research seek out possible mechanisms that may explain the association between life-course socioeconomic inequalities and CVD. Education has been reported to be a valid and easily measurable marker of socioeconomic status and it has been used in studies on the relationship with adverse health effects.4,5 In this context, low education has been reported as an important predictor of CVD, hypertension, and total and CV mortality. Relative risk increases progressively from patients in the most educated class to those less educated, becoming significant from high school onwards.6 The present study was designed to evaluate the relationships between education and global CV risk in a southern Italian urban population. We have chosen to study this population since it was with the lowest number of individuals who continued their studies
beyond compulsory schooling.7 This is actually an important field of CV research, since CV risk factors are considered a major disease burden and account for a large contribution to global loss of healthy life caused by CVD worldwide.8 More recently, a prospective fixedcohort Italian study (the CUORE study) reported predictive equations with better accuracy to detect overall CV risk in Italian people.7 Accordingly, the prevalence of cardiometabolic comorbidities, global CV risk, microalbuminuria, and measurements of left ventricular geometry and function were evaluated in a southern Italian urban population subdivided according to educational status. The main goal of the study was to assess whether a low level of education was associated with cardiometabolic comorbidities and with a higher global CV risk.
Address for correspondence: Rosario Scaglione, MD, Associate Professor of Internal Medicine, Piazza delle Cliniche 2, 90127 Palermo, Italy. E-mail: [email protected] Manuscript received: October 9, 2014; revised: December 1, 2014; accepted: December 2, 2014 DOI: 10.1111/jch.12506
332
The Journal of Clinical Hypertension
Vol 17 | No 5 | May 2015
PATIENTS AND METHODS Patients In this cross-sectional study, 528 consecutive outpatients residing in a southern state of Italy (Palermo, Sicily) from January 2012 to December 2013 were evaluated. All patients were referred to our center of hypertension and metabolic disease at the Department of Internal Medicine (University of Palermo) for medical needs. Exclusion criteria included psychiatric problems or alcoholism. After the selection phase, 488 patients (240 men and 248 women) who aged 18 years and older were enrolled in the study.
Low Education and Global Cardiovascular Risk | Di Chiara et al.
Each patient gave written consent after receiving a detailed description of the study procedure. The study was approved by the ethics committee of our institution. All patients were subgrouped according to their educational status. In particular, educational status was categorized according to the number of years of formal education into two groups as follows: Less than 10 years of education (illiterate and less than secondary) was considered the “low education group.” This group consisted of 228 patients (100 men and 128 women) with a mean age of 52.38.0 years (range, 28 to 67 years); and 10 to 15 years of education (secondary to graduate) was considered the “medium-high education group.” This group consisted of 260 patients (140 men and 120 women) with a mean age of 48.55.6 years (range, 29 to 66 years). We chose this cutoff because until about 30 years ago in Italy, citizens were required by law to complete 8 years of compulsory education. Level of education was taken from the certificate of studies performed (graduated from elementary school, middle school, high school, and university). For all participants, the clinical visit included medical history, anthropometry, blood pressure (BP) measurements, resting electrocardiography, Doppler echocardiography, and a fasting collection of blood for determination of biochemical parameters. Body height, weight, and waist and hip circumferences were all taken in a standardized manner.9,10 Body mass index (BMI) was calculated as weight divided by squared height and expressed as kg/m2. Brachial BP was measured following the indications of the European Society of Hypertension/European Society of Cardiology (ESH/ESC) guidelines11 using a validated mercury-free digital sphygmomanometer with appropriate cuff size. The average of three consecutive measurements, spaced by an interval of 2 minutes with the patient in the sitting position for 5 minutes before the measurement, was used for the analysis. The following comorbidities were evaluated in both groups. Obesity and Visceral Obesity. Patients were defined as obese on the basis of sex-specific 85th percentile of BMI values, as reported in the Italian Consensus Conference on Obesity.10 Accordingly, men with BMI ≥30 kg/m2 and women with BMI ≥27.3 kg/m2 were considered obese. Visceral fat distribution was defined on the basis of sex-specific 85th percentile of waist-to-hip ratio (WHR). The cutoff values of visceral obesity were considered 0.81 for women and 0.92 for men.9,10 Hypertension. Patients taking antihypertensive treatment or with casual systolic BP (SBP) ≥140 mm Hg and/ or with casual diastolic BP (DBP) ≥90 mm Hg were considered to have hypertension. BP was measured with an appropriate large cuff in obese patients. SBP, DBP, and mean BP (MBP) were determined. MBP was
calculated by the sum of DBP plus one third of pulse pressure. Diabetes. According to guidelines from the American Diabetes Association, all patients with fasting glycemia ≥126 mg/dL or who were being treated with antidiabetic drugs or insulin were considered diabetics.12 Metabolic Syndrome. Patients with the metabolic syndrome (MetS) were recognized according to the Third Report of the Adult Treatment Panel National Cholesterol Education Program (NCEP-ATP III) criteria.13 In particular, any three of the five following criteria constitute a diagnosis of MetS: elevated BP, elevated waist circumference, elevated triglycerides, reduced high-density lipoprotein (HDL) cholesterol, and elevated fasting glucose. Dyslipidemia. Dyslipidemia was defined by the presence of high total cholesterol (≥200 mg/dL), high lowdensity lipoprotein (LDL) cholesterol (≥130 mg/dL), low HDL cholesterol (
