Original article 35
Prevalence of cardiovascular disease risk factors among Egyptian and Saudi medical students: a comparative study Alaa-El-Dine H. Mahmouda,b a Community Medicine Department, Ibn Sina National College for Medical Sciences, Jeddah, KSA and b Community Medicine Department, Faculty of Medicine, Beni Suef University, Beni Suef, Egypt
Correspondence to Alaa-El-Dine H. Mahmoud, MD, Faculty of Medicine, Beni Suef University, Beni Suef, Egypt Tel: + 20 111 269 8850; e-mail: [email protected]
Received 25 December 2014 Accepted 15 January 2015 Journal of the Egyptian Public Health Association 2015, 90:35–39
Background Results from recent reports suggest that the mortality and the morbidity from coronary heart disease (CHD) is leveling, especially in younger adults. Studies conducted in both Saudi Arabia and Egypt, aiming at the estimation of the prevalence of cardiovascular risk factors among the young population, demonstrated a high prevalence of risk factors. Objective The aim of this study was to compare the prevalence of cardiovascular risk factors among medical students aged 18–25 years in two Middle East countries (Egypt and Saudi Arabia). Participants and methods This was a cross-sectional comparative study involving a sample of 360 medical students of both sexes randomly selected from students enrolled into two medical colleges in Saudi Arabia and Egypt. Results The prevalence of risk factors for cardiovascular disease was relatively high among both Saudi and Egyptian medical students, particularly a sedentary life style, obesity, and abdominal obesity. Smoking was practiced by 29.7% of both populations. A significantly higher prevalence of obesity and a reported family history of premature CHD were observed among the Saudi students and a significantly higher prevalence of hypertension was found among male Egyptian students as compared with male Saudi students. A relatively high proportion of both populations (23.9% of Saudi students and 16.7% of the Egyptian students) was at an increased risk of developing fatal cardiovascular disease within 10 years. Conclusion Apart from the higher prevalence of obesity and reported family history of premature CHD among the Saudi students and the significantly higher prevalence of hypertension among the Egyptian students, there was no statistically significant difference between the risk profiles of both populations. Participatory behavior change programs in medical schools for the adoption of healthy lifestyles, particularly involvement in regular physical activity and smoking cessation are highly recommended. Keywords: cardiovascular disease, medical students, risk profile J Egypt Public Health Assoc 90:35–39 & 2015 Egyptian Public Health Association 0013-2446
Introduction Cardiovascular disease (CVD) disability-adjusted life years (DALYs) is expected to increase from a loss of 85 million DALYs in 1990 to a loss of 150 million DALYs globally in 2020, thereby remaining the leading somatic cause of loss of productivity [1]. Coronary heart disease (CHD) has also been recognized as the leading cause of death worldwide nowadays; it is on the rise and has become a true pandemic that respects no borders. [2]. In contrast to traditional beliefs, classifying CHD has reached enormous proportions, striking more and more at younger individuals. It will result in coming years in the greatest epidemic mankind has faced unless we are able to reverse the trend by concentrated research into its 0013-2446 & 2015 Egyptian Public Health Association
cause and prevention [3]. Results from recent reports suggest that the mortality and the morbidity from CHD is leveling, especially in younger adults [4,5]. CVD is strongly connected to lifestyle, especially the use of tobacco, unhealthy diet habits, physical inactivity, and psychosocial stress [6,7]. Prevention of CVD ideally starts during pregnancy and lasts until the end of life. Prevention efforts are typically targeted at middle-aged or older men and women with established CVD (i.e. secondary prevention) or those at a high risk of developing a first cardiovascular event [e.g. men and women with combinations of smoking, elevated blood pressure (BP), diabetes, or dyslipidemia (i.e. primary prevention)]. CVD prevention in the young, DOI: 10.1097/01.EPX.0000460969.93981.c2
Copyright © Journal of the Egyptian Public Health Association. Unauthorized reproduction of this article is prohibited.
36
Journal of the Egyptian Public Health Association
the very old, or those with just a moderate or mild risk is still limited, but can result in substantial benefit [8]. Studies conducted in Saudi Arabia aiming at the estimation of the prevalence of cardiovascular risk factors among the young population have been conducted and have demonstrated a high prevalence of risk factors, especially lifestyle-related factors including a sedentary life style, unhealthy eating habits, and overweight and obesity [9–11]. Despite the awareness about the risk factors of CVD among medical students, some factors showed a high prevalence among this population, in particular smoking [12]. A national survey conducted on a representative sample from 10 governorates in Egypt similarly revealed a high prevalence of CVD risk factors among the youth, aged 15–24 yeas [13]. Although Saudi Arabia and Egypt are two Middle Eastern countries with a close cultural background, yet with the percapita Gross Domestic Product and the Gross National Income in Saudi Arabia approaching nine times those in Egypt (2012), the standards of living might suggest a difference in the risk profile of the youth in both countries [14,15]. The objective of this study was to compare the prevalence of cardiovascular risk factors among medical students aged 18–25 years in two Middle East countries (Egypt and Saudi Arabia).
Participants and methods This cross-sectional comparative study was conducted in two medical colleges in Saudi Arabia and Egypt. The study population
The study population included students enrolled to the Ibn Sina National College for Medical Sciences, Jeddah, KSA, and students enrolled to the Faculty of Medicine, Beni Suef University, during the academic year 2013–2014, of either sex, aged 18–25 years, and willing to participate in the study as evidenced by signing the informed consent. Sample size
A sample size of 161 students in each group was required to detect a difference of 15% in the prevalence of risk factors at a power of 90% and a probability of type I error of 0.05 assuming the prevalence of cardiovascular risk factors among the Saudi population to be 15% [10]. Overall, 180 participants were recruited from each country to ensure an evaluable data for a minimum of 161 participants from each arm. Sampling method
A multistage stratified sample was selected; 15 male and 15 female participants were selected randomly from each of the 6-year students of both universities on the basis of the academic number using the random number generator of IBM SPSS (version 20) software [16]. The selected students were introduced to the study objectives and methodologies, and included in the study if
they met the inclusion criteria and signed the informed consent form.
Data collection
The necessary data on CVD risk factors as outlined by the Joint European Society of Cardiology Guidelines [7] were collected from selected students during an interview conducted by trained investigators. Smoking was defined as the current use of any form of tobacco (cigarettes, shisha, etc.) whether on an occasional or a daily basis. Demographic data were collected together with the measurement of anthropometric measurements and measurement of the BP using standardized mercury sphygmomanometers. All BP measurements were taken twice. Participants were categorized on the basis of the WHO international classification of adult underweight, overweight, and obesity according to the BMI [17]. Abdominal obesity was defined by a waist circumference more than 102 cm in men and more than 88 cm in women [18]. Hypertensive students were defined as those having a systolic BP of 140 mmHg or higher or a diastolic BP of 90 mmHg or more [7] or those who have been diagnosed by the treating physician as hypertensive and received an antihypertensive medication. Students were then given a reference letter to conduct a lipid profile including total cholesterol, HDL-cholesterol, LDL-cholesterol, and triglycerides in the serum in the Central Teaching Hospital Laboratory in Ibn Sina National College Hospital or a contracted private laboratory in Egypt. Dyslipidemia was defined by a total cholesterol level of 190 mg/dl or more, an LDL-cholesterol of 115 mg/dl or more, HDL-cholesterol less than 40 mg/dl in men or less than 46 mg/dl in women, or a triglyceride level of 150 mg/dl [7]. The 10-year risk of CVD was calculated separately for each study participant using the Heart Score, an open-source interactive tool for predicting and managing the risk of heart attack and stroke, available from the European Society of Cardiology website for download and works under Windows environment [19].
Ethical considerations
Approval of the ethics committees in both institutions was obtained and all students enrolled in the study were required to read and sign an informed consent form in Arabic language. Confidentiality and anonymity were guaranteed and maintained.
Data analysis
Data were fed to an IBM SPSS (version 20) data file by professional data entry specialists. Analysis was performed using the same software. Qualitative variables were summarized using percentages and 95% confidence limits. Quantitative variables were summarized using mean, SD, and SEM. Quantitative data were compared between the two subpopulations using the pooled Student t-test and qualitative data were compared using the w2-test. The significance level was set at 0.05.
Copyright © Journal of the Egyptian Public Health Association. Unauthorized reproduction of this article is prohibited.
Cardiovascular disease risk: KSA & Egypt Mahmoud 37
Table 1. The prevalence of cardiovascular risk factors among Saudi and Egyptian medical students Frequency (%)
Sedentary lifestyle Obesity Abdominal obesity Smoking Hypertension Family history of PCHD Dyslipidemia PCHD, premature coronary heart disease.
Saudi Arabia (n = 180) 114 107 102 52 26 26 12
Egypt (n = 180)
(63.3) (61.6) (56.7) (28.9) (14.4) (14.4) (6.7)
Results An overall of 360 participants were included in the current study, of whom 180 were from Saudi Arabia and 180 were from Egypt. The male-to-female ratio in both samples was 1 : 1. The ages of the participants ranged from 18 to 25 years as per the preset inclusion criteria, with a mean age of 21.43 years and a SD of 2.29 years. The mean age of Saudi students was 22.43 ± 2.26 years and the mean age of Egyptian students was 20.51 ± 2.09 years. Table 1 shows the prevalence of cardiovascular risk factors among Saudi and Egyptian medical students. The most frequently encountered risk factor among the studied students was a sedentary life style, the overall prevalence of which was 64.7%. The prevalence among Egyptian students was slightly higher than that among Saudi students (66.1 vs. 63.3%); yet the difference was not statistically significant (w2 = 0.1965, P = 0.657). The mean weight of the Saudi students (85.9 kg with a SD of 14.7 kg) was not significantly different from that of the Egyptian students (84.4 kg with a SD of 16.1 kg). The Saudi students had a mean height of 165.4 cm and a SD of 8.2 cm, which was not significantly different from the mean height of the Egyptian sample (166.4 cm). The BMI of the two groups of students, calculated according to the formula BMI = weight in kg/height in m2, did not differ significantly at the 0.05 level. Table 2 shows the mean, SD, and SEM weight, height, BMI, and systolic and diastolic BPs of the Saudi and the Egyptian samples. On the basis of the WHO international classification of adult underweight, overweight, and obesity according to the BMI [17], more than half (51.9%) of the students in both samples were obese. The prevalence of obesity was significantly higher among the Saudi students than among the Egyptian students (61.6 vs. 46.5%, w2 = 8.2, P = 0.04). Although the prevalence of obesity among Saudi women was significantly higher than among Egyptian women (70.1 vs. 54.0%, w2 = 7.8, P = 0.043), yet the higher prevalence of obesity observed among Saudi men (52.3%) as compared with Egyptian men (38.8%) was not statistically significant at the 0.05 level. Figure 1 shows the difference between the prevalence of obesity among Saudi and Egyptian male and female students. Abdominal obesity was also highly prevalent among both groups of students, with an overall prevalence of 51.9%. Although the prevalence among Saudi students (56.7%) was higher than that among Egyptian students (47.2%),
119 80 85 55 15 12 10
Total (n = 360)
(6.1) (46.5) (47.2) (30.6) (8.3) (6.7) (5.6)
233 187 187 107 41 38 22
(64.7) (51.9) (51.9) (29.7) (11.4) (10.6) (6.1)
Table 2. BMI, weight, height, and blood pressure measurements of Saudi and Egyptian students Saudi Arabia (n = 180) Measurements
Mean
SD
Egypt (n = 180) SE
Mean
SD
SE
Weight 85.94 14.71 1.10 84.43 16.08 1.20 Height 165.37 8.17 0.62 166.42 8.15 0.62 BMI 31.54 5.51 0.42 30.51 5.76 0.44 Systolic blood pressure 118.29 14.63 1.10 115.54 14.79 1.10 Diastolic blood pressure 58.74 7.86 0.59 58.28 7.31 0.54
Figure 1.
80.0% Male
70.1%
Female
70.0% 60.0%
52.3%
54.0%
50.0% Percent
Risk factors
38.8%
40.0% 30.0% 20.0% 10.0% 0.0%
Saudi Arabia
Egypt
The prevalence of obesity among Saudi and Egyptian male and female students.
yet the difference was not statistically significant (w2 = 2.90, P = 0.0884). The prevalence of abdominal obesity among Saudi women was 65.6% as compared with 52.2% among Egyptian women (w2 = 2.083, P = 0.148), whereas the prevalence of the risk factor among Saudi men was 47.8% compared with 42.2% among Egyptian men (w2 = 1.01, P = 0.314); neither of the differences was statistically significant at the 0.05 level. The prevalence of smoking among the two samples was 29.7%, being slightly higher among the Egyptian students (30.6%) than among the Saudi students (28.9%) (w2 = 0.095, P = 0.758). The prevalence of smoking among Egyptian and Saudi men was 48.9 and 50.0%, respectively (w2 = 0.04, P = 0.841), whereas among Egyptian and Saudi women, it was 7.8 and 12.2%, respectively (w2 = 2.301, P = 0.129). The differences were not statistically significant.
Copyright © Journal of the Egyptian Public Health Association. Unauthorized reproduction of this article is prohibited.
38
Journal of the Egyptian Public Health Association
Regarding the BP, the mean systolic BP of the Egyptian and the Saudi students did not differ significantly [115.54 mmHg (SD 14.79) and 118.29 mmHg (SD 14.63), respectively]; neither did the mean diastolic BP of the two samples [58.28 mmHg (SD 7.31) and 58.74 mmHg (SD 7.86), respectively]. Hypertensive students constituted 11.4% of the whole sample. The prevalence of hypertension was higher among Saudi students than among Egyptian students (14.4 vs. 8.3%, respectively); yet the difference was not statistically significant (w2 = 3.537, P = 0.060). However, the prevalence of hypertension among Egyptian men (18.9%) was significantly higher than that among Saudi men (6.7%) (w2 = 6.03, P = 0.014). In contrast, the prevalence of hypertension among Saudi and Egyptian women did not differ significantly (10.0 and 10.3%, respectively, w2 = 0.027, P = 0.869). A family history of premature CHD was reported by 10.6% of the study sample. Significantly more Saudi students reported a positive family history of premature CHD (14.4%) than Egyptian students (6.7%) (w2 = 5.77, P = 0.016). Stratifying by sex, there was no statistically significant difference between the prevalence of this particular risk factor among Saudi and Egyptian female students (13.3 and 5.6%, respectively, w2 = 2.660, P = 0.102), and similarly, the difference between the prevalence of this risk factor among Saudi and Egyptian male students (14.4 and 7.8%, respectively, w2 = 3.677, P = 0.055) was not statistically significant. Dyslipidemia was the least common risk factor among the study sample with an overall prevalence of 6.1%. The prevalence was higher among Saudi students than among Egyptian students (6.7 vs. 5.6%). The difference between the two samples was not statistically significant at the preset level (w2 = 0.384, P = 0.535). On the basis of the Heart Score software calculations, the 10-year risk of fatal CVD was 0% among healthy young women and 1% among healthy young men with no risk factors. Overall, 23.9% of the Saudi students had an increased risk of fatal CVD as against 16.7% of the Egyptian students. The difference between the two groups was not statistically significant at the 0.05 level. Regarding the Saudi female students, 18.9% were at an increased risk (1%) of fatal CVD compared with 12.2% of the Egyptian female students. As for the Saudi male students, 28.9% were at an increased risk of fatal CVD compared with 21.1% of the Egyptian male students.
Discussion The current study aimed at comparing the prevalence of CVD risk factors among Saudi and Egyptian medical students aged 18–25 years. The findings of the study revealed no significant differences between the two groups regarding the prevalence of the major risk factors. A sedentary lifestyle was the most prevalent risk factor among the two groups. This finding was in accordance with a recent study conducted among medical students in
Saudi Arabia (2014), wherein the prevalence of physical inactivity reached 57.9% [9]. An earlier survey conducted by the Population Council [20,] which studied a sample of 15 029 young people aged 10–29 years of both sexes from the major six administrative regions (metropolitan governorates, urban lower Egypt, rural lower Egypt, urban upper Egypt, rural upper Egypt, and the border governorates), revealed that young people were performing very little physical activity: only 28.3% of the surveyed young people reported performing no physical activities either for leisure or as part of their daily tasks. The higher prevalence of a sedentary lifestyle in the current sample can be explained by the high academic pressures imposed on medical students giving them no sufficient time to engage in physical activities for leisure. Abdominal obesity was the second most commonly prevalent risk factor among the two groups. The work conducted by Ibrahim et al. [9] in King Abdul Aziz University revealed that the prevalence of obesity and overweight among Saudi medical students was 31.2%, which is nearly half (61.6%) the figure obtained during the current study. This disparity may be partially attributed to the fact that the students enrolled in the current study represent private medical college students with probably higher socioeconomic standards and therefore having a different dietary style, with more frequent consumption of junk restaurant food. In contrast, the prevalence of obesity among Egyptian medical students (46.5%) was much higher than that reported in a community-based study on noncommunicable diseases in Egypt (2005) [13], which showed that only 11.6% of the surveyed population aged 15–24 years (an age group comparable to that of the participants in the current study) was obese. It is worth noting that the survey used the same working definitions of overweight and obesity, based on the WHO guidelines [17]. The difference is remarkable and goes far beyond the simple assumption that the sedentary lifestyle imposed on medical students by academic pressure hinders their involvement in physical activities. The prevalence of smoking among the Saudi students was 28.9% compared with 30.6% among the Egyptian students. The observed figures among Egyptian students are striking when compared with the figures given by the results reported in a community-based study on noncommunicable diseases in Egypt (2005) [13], which showed that the prevalence of all types of smoking among the youth aged 15–24 years to be 11.6%. This is alarming as it shows that the prevalence of smoking among medical students who are supposed to be knowledgeable about the hazards of smoking is markedly higher than that among the general population of similar age. In contrast, figures observed in the current study among the Saudi students were nearly 10 times those observed by Ibrahim et al. [9] among King Abdul Aziz medical students in Saudi Arabia (2.8%). This disparity could be explained by the strict regulations banning smoking in King Abdul Aziz University premises, which might have urged students to falsely report that they were nonsmokers.
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Cardiovascular disease risk: KSA & Egypt Mahmoud 39
The prevalence of hypertension among the Saudi student sample was 14.4%; this compares favorably with the work by Ibrahim et al. [9] in King Abdul Aziz University, who found that 9.3% of the students were hypertensive, and this could be attributed to the high prevalence of obesity, which has been identified by Koura et al. [10] in their study on prehypertension among young women in Dammam, Saudi Arabia, as the strongest predictor of prehypertension. The proportion of students at an increased risk of CVD within the upcoming 10 years was alarmingly, yet predictably, high among the two groups, given the high prevalence of the measured risk factors. It was interesting that a higher prevalence of a family history of premature CHD was reported by students among the Saudi sample compared the Egyptian students. One of the limitations of the current study is that it was conducted in only one medical college selected from each of the two countries (Saudi Arabia and Egypt). The study would have been much more representative if a larger sample was drawn from several randomly selected medical colleges from both countries.
Acknowledgements Conflicts of interest There are no conflicts of interest.
References 1 Scottish Intercollegiate Guidelines Network (SIGN). Risk estimation and the prevention of cardiovascular disease – a national clinical guideline. Edinburgh, Scotland: Scottish Intercollegiate Guidelines Network; 2012. Available at: http://www.sign.ac.uk/pdf/sign97.pdf. 2 Schu¨nemann HJ, Oxman AD, Brozek J, Glasziou P, Jaeschke R, Vist GE, et al. GRADE Working Group. Grading quality of evidence and strength of recommendations for diagnostic tests and strategies. BMJ 2008; 336:1106–1110. 3 World Health Organization (WHO). The prevention and control of major cardiovascular diseases, report no. Euro 8214. Geneva, Switzerland: WHO; 1973. 4 Ford ES, Capewell S. Coronary heart disease mortality among young adults in the U.S. from 1980 through 2002: concealed leveling of mortality rates. J Am Coll Cardiol 2007; 50:2128–2132. 5 Vander Stichele C, De Bacquer D, De Henauw S, Vannoote P, Gevaert S, Populier N, et al. Is the decline in coronary attack rates leveling off in Flanders? Eur J Cardiovasc Prev Rehabil 2008; 15:1–31. 6 World Health Organization (WHO). Joint WHO/FAO expert consultation on diet, nutrition and the prevention of chronic diseases, report no. 916. Geneva, Switzerland: WHO; 2002. 7 Perk J, De Backer G, Gohlke H, Graham I, Reiner Zˇ, Verschuren M, et al. European guidelines on cardiovascular disease prevention in clinical practice (version 2012). Eur Heart J 2012; 33:1635–1701. 8 Rose G. Sick individuals and sick populations. Int J Epidemiol 1985; 14:32–38.
Conclusion and recommendation The prevalence of risk factors for CVD was relatively high among both Saudi and Egyptian medical students, particularly a sedentary lifestyle, obesity, and abdominal obesity. Smoking was practiced by 29.7% of both samples, which is an alarming finding. Apart from a significantly higher prevalence of obesity, abdominal obesity, and a reported family history of premature CHD among the Saudi sample and a significantly higher prevalence of hypertension among Egyptian men as compared with Saudi men, the prevalence of risk factors among the two samples did not differ significantly. A relatively high percent of both samples (23.9% of the Saudi students and 16.7% of the Egyptian students) was at an increased risk of developing fatal CVD within 10 years. The high prevalence of cardiovascular risk factors among medical students from two Middle Eastern medical colleges implies that the knowledge acquired through medical curricula per se are not sufficient motivators for behavior change, which necessitates the establishment of participatory behavior change programs in medical schools to provide support for students for the adoption of healthy lifestyles, particularly involvement in regular physical activity and smoking cessation.
9 Ibrahim NK, Mahnashi M, Al-Dhaheri A, Al-Zahrani B, Al-Wadie E, Aljabri M, et al. Risk factors of coronary heart disease among medical students in King Abdulaziz University, Jeddah, Saudi Arabia. BMC Public Health 2014; 14:411. 10 Koura MR, Al Dabal BK, Rasheed P, Al Sowielem LS, Makki SM. Prehypertension among young adult females in Dammam, Saudi Arabia. East Mediterr Health J 2012; 18:728–734. 11 Abdel-Megeid FY, Abdelkarem HM, El-Fetouh AM. Unhealthy nutritional habits in university students are a risk factor for cardiovascular diseases. Saudi Med J 2011; 32:621–627. 12 Han MY, Chen WQ, Chen X. Do smoking knowledge, attitudes and behaviors change with years of schooling? A comparison of medical with nonmedical students in China. J Community Health 2011; 36:966–974. 13 Egyptian Ministry of Health. Community based survey study on non-communicable diseases and their risk factors in Egypt 2005–2006. Cairo, Egypt: Ministry of Health; 2006. 14 World Bank. World development indicators. Washington, DC, USA: World Bank Publications; 2012. 15 World Bank. World data. Washington DC, USA: World Bank; 2014. Available at: http://data.worldbank.org/. 16 IBM Corporation. IBM SPSS statistics. Release 20. New York: IBM Corporation; 2011. 17 World Health Organization (WHO). Global database on body mass index. Geneva, Switzerland: WHO; 2012. Available at: http://apps.who.int/bmi/ index.jsp?introPage = intro_3.html. 18 World Health Organization (WHO). Waist circumference and waist–hip ratio: Report of a WHO Expert Consultation. Geneva, Switzerland: WHO; 2008. 19 European Society of Cardiology. Heart score. Sofia Antipolis, France: European Society of Cardiology; 2012. Available at: http://www.heartscore.org/Pages/ welcome.aspx. 20 Population Council. Survey of young people in Egypt. Cairo, Egypt: Population Council; 2011.
Copyright © Journal of the Egyptian Public Health Association. Unauthorized reproduction of this article is prohibited.
Prevalence of cardiovascular disease risk factors among Egyptian and Saudi medical students: a comparative study Alaa-El-Dine H. Mahmouda,b a Community Medicine Department, Ibn Sina National College for Medical Sciences, Jeddah, KSA and b Community Medicine Department, Faculty of Medicine, Beni Suef University, Beni Suef, Egypt
Correspondence to Alaa-El-Dine H. Mahmoud, MD, Faculty of Medicine, Beni Suef University, Beni Suef, Egypt Tel: + 20 111 269 8850; e-mail: [email protected]
Received 25 December 2014 Accepted 15 January 2015 Journal of the Egyptian Public Health Association 2015, 90:35–39
Background Results from recent reports suggest that the mortality and the morbidity from coronary heart disease (CHD) is leveling, especially in younger adults. Studies conducted in both Saudi Arabia and Egypt, aiming at the estimation of the prevalence of cardiovascular risk factors among the young population, demonstrated a high prevalence of risk factors. Objective The aim of this study was to compare the prevalence of cardiovascular risk factors among medical students aged 18–25 years in two Middle East countries (Egypt and Saudi Arabia). Participants and methods This was a cross-sectional comparative study involving a sample of 360 medical students of both sexes randomly selected from students enrolled into two medical colleges in Saudi Arabia and Egypt. Results The prevalence of risk factors for cardiovascular disease was relatively high among both Saudi and Egyptian medical students, particularly a sedentary life style, obesity, and abdominal obesity. Smoking was practiced by 29.7% of both populations. A significantly higher prevalence of obesity and a reported family history of premature CHD were observed among the Saudi students and a significantly higher prevalence of hypertension was found among male Egyptian students as compared with male Saudi students. A relatively high proportion of both populations (23.9% of Saudi students and 16.7% of the Egyptian students) was at an increased risk of developing fatal cardiovascular disease within 10 years. Conclusion Apart from the higher prevalence of obesity and reported family history of premature CHD among the Saudi students and the significantly higher prevalence of hypertension among the Egyptian students, there was no statistically significant difference between the risk profiles of both populations. Participatory behavior change programs in medical schools for the adoption of healthy lifestyles, particularly involvement in regular physical activity and smoking cessation are highly recommended. Keywords: cardiovascular disease, medical students, risk profile J Egypt Public Health Assoc 90:35–39 & 2015 Egyptian Public Health Association 0013-2446
Introduction Cardiovascular disease (CVD) disability-adjusted life years (DALYs) is expected to increase from a loss of 85 million DALYs in 1990 to a loss of 150 million DALYs globally in 2020, thereby remaining the leading somatic cause of loss of productivity [1]. Coronary heart disease (CHD) has also been recognized as the leading cause of death worldwide nowadays; it is on the rise and has become a true pandemic that respects no borders. [2]. In contrast to traditional beliefs, classifying CHD has reached enormous proportions, striking more and more at younger individuals. It will result in coming years in the greatest epidemic mankind has faced unless we are able to reverse the trend by concentrated research into its 0013-2446 & 2015 Egyptian Public Health Association
cause and prevention [3]. Results from recent reports suggest that the mortality and the morbidity from CHD is leveling, especially in younger adults [4,5]. CVD is strongly connected to lifestyle, especially the use of tobacco, unhealthy diet habits, physical inactivity, and psychosocial stress [6,7]. Prevention of CVD ideally starts during pregnancy and lasts until the end of life. Prevention efforts are typically targeted at middle-aged or older men and women with established CVD (i.e. secondary prevention) or those at a high risk of developing a first cardiovascular event [e.g. men and women with combinations of smoking, elevated blood pressure (BP), diabetes, or dyslipidemia (i.e. primary prevention)]. CVD prevention in the young, DOI: 10.1097/01.EPX.0000460969.93981.c2
Copyright © Journal of the Egyptian Public Health Association. Unauthorized reproduction of this article is prohibited.
36
Journal of the Egyptian Public Health Association
the very old, or those with just a moderate or mild risk is still limited, but can result in substantial benefit [8]. Studies conducted in Saudi Arabia aiming at the estimation of the prevalence of cardiovascular risk factors among the young population have been conducted and have demonstrated a high prevalence of risk factors, especially lifestyle-related factors including a sedentary life style, unhealthy eating habits, and overweight and obesity [9–11]. Despite the awareness about the risk factors of CVD among medical students, some factors showed a high prevalence among this population, in particular smoking [12]. A national survey conducted on a representative sample from 10 governorates in Egypt similarly revealed a high prevalence of CVD risk factors among the youth, aged 15–24 yeas [13]. Although Saudi Arabia and Egypt are two Middle Eastern countries with a close cultural background, yet with the percapita Gross Domestic Product and the Gross National Income in Saudi Arabia approaching nine times those in Egypt (2012), the standards of living might suggest a difference in the risk profile of the youth in both countries [14,15]. The objective of this study was to compare the prevalence of cardiovascular risk factors among medical students aged 18–25 years in two Middle East countries (Egypt and Saudi Arabia).
Participants and methods This cross-sectional comparative study was conducted in two medical colleges in Saudi Arabia and Egypt. The study population
The study population included students enrolled to the Ibn Sina National College for Medical Sciences, Jeddah, KSA, and students enrolled to the Faculty of Medicine, Beni Suef University, during the academic year 2013–2014, of either sex, aged 18–25 years, and willing to participate in the study as evidenced by signing the informed consent. Sample size
A sample size of 161 students in each group was required to detect a difference of 15% in the prevalence of risk factors at a power of 90% and a probability of type I error of 0.05 assuming the prevalence of cardiovascular risk factors among the Saudi population to be 15% [10]. Overall, 180 participants were recruited from each country to ensure an evaluable data for a minimum of 161 participants from each arm. Sampling method
A multistage stratified sample was selected; 15 male and 15 female participants were selected randomly from each of the 6-year students of both universities on the basis of the academic number using the random number generator of IBM SPSS (version 20) software [16]. The selected students were introduced to the study objectives and methodologies, and included in the study if
they met the inclusion criteria and signed the informed consent form.
Data collection
The necessary data on CVD risk factors as outlined by the Joint European Society of Cardiology Guidelines [7] were collected from selected students during an interview conducted by trained investigators. Smoking was defined as the current use of any form of tobacco (cigarettes, shisha, etc.) whether on an occasional or a daily basis. Demographic data were collected together with the measurement of anthropometric measurements and measurement of the BP using standardized mercury sphygmomanometers. All BP measurements were taken twice. Participants were categorized on the basis of the WHO international classification of adult underweight, overweight, and obesity according to the BMI [17]. Abdominal obesity was defined by a waist circumference more than 102 cm in men and more than 88 cm in women [18]. Hypertensive students were defined as those having a systolic BP of 140 mmHg or higher or a diastolic BP of 90 mmHg or more [7] or those who have been diagnosed by the treating physician as hypertensive and received an antihypertensive medication. Students were then given a reference letter to conduct a lipid profile including total cholesterol, HDL-cholesterol, LDL-cholesterol, and triglycerides in the serum in the Central Teaching Hospital Laboratory in Ibn Sina National College Hospital or a contracted private laboratory in Egypt. Dyslipidemia was defined by a total cholesterol level of 190 mg/dl or more, an LDL-cholesterol of 115 mg/dl or more, HDL-cholesterol less than 40 mg/dl in men or less than 46 mg/dl in women, or a triglyceride level of 150 mg/dl [7]. The 10-year risk of CVD was calculated separately for each study participant using the Heart Score, an open-source interactive tool for predicting and managing the risk of heart attack and stroke, available from the European Society of Cardiology website for download and works under Windows environment [19].
Ethical considerations
Approval of the ethics committees in both institutions was obtained and all students enrolled in the study were required to read and sign an informed consent form in Arabic language. Confidentiality and anonymity were guaranteed and maintained.
Data analysis
Data were fed to an IBM SPSS (version 20) data file by professional data entry specialists. Analysis was performed using the same software. Qualitative variables were summarized using percentages and 95% confidence limits. Quantitative variables were summarized using mean, SD, and SEM. Quantitative data were compared between the two subpopulations using the pooled Student t-test and qualitative data were compared using the w2-test. The significance level was set at 0.05.
Copyright © Journal of the Egyptian Public Health Association. Unauthorized reproduction of this article is prohibited.
Cardiovascular disease risk: KSA & Egypt Mahmoud 37
Table 1. The prevalence of cardiovascular risk factors among Saudi and Egyptian medical students Frequency (%)
Sedentary lifestyle Obesity Abdominal obesity Smoking Hypertension Family history of PCHD Dyslipidemia PCHD, premature coronary heart disease.
Saudi Arabia (n = 180) 114 107 102 52 26 26 12
Egypt (n = 180)
(63.3) (61.6) (56.7) (28.9) (14.4) (14.4) (6.7)
Results An overall of 360 participants were included in the current study, of whom 180 were from Saudi Arabia and 180 were from Egypt. The male-to-female ratio in both samples was 1 : 1. The ages of the participants ranged from 18 to 25 years as per the preset inclusion criteria, with a mean age of 21.43 years and a SD of 2.29 years. The mean age of Saudi students was 22.43 ± 2.26 years and the mean age of Egyptian students was 20.51 ± 2.09 years. Table 1 shows the prevalence of cardiovascular risk factors among Saudi and Egyptian medical students. The most frequently encountered risk factor among the studied students was a sedentary life style, the overall prevalence of which was 64.7%. The prevalence among Egyptian students was slightly higher than that among Saudi students (66.1 vs. 63.3%); yet the difference was not statistically significant (w2 = 0.1965, P = 0.657). The mean weight of the Saudi students (85.9 kg with a SD of 14.7 kg) was not significantly different from that of the Egyptian students (84.4 kg with a SD of 16.1 kg). The Saudi students had a mean height of 165.4 cm and a SD of 8.2 cm, which was not significantly different from the mean height of the Egyptian sample (166.4 cm). The BMI of the two groups of students, calculated according to the formula BMI = weight in kg/height in m2, did not differ significantly at the 0.05 level. Table 2 shows the mean, SD, and SEM weight, height, BMI, and systolic and diastolic BPs of the Saudi and the Egyptian samples. On the basis of the WHO international classification of adult underweight, overweight, and obesity according to the BMI [17], more than half (51.9%) of the students in both samples were obese. The prevalence of obesity was significantly higher among the Saudi students than among the Egyptian students (61.6 vs. 46.5%, w2 = 8.2, P = 0.04). Although the prevalence of obesity among Saudi women was significantly higher than among Egyptian women (70.1 vs. 54.0%, w2 = 7.8, P = 0.043), yet the higher prevalence of obesity observed among Saudi men (52.3%) as compared with Egyptian men (38.8%) was not statistically significant at the 0.05 level. Figure 1 shows the difference between the prevalence of obesity among Saudi and Egyptian male and female students. Abdominal obesity was also highly prevalent among both groups of students, with an overall prevalence of 51.9%. Although the prevalence among Saudi students (56.7%) was higher than that among Egyptian students (47.2%),
119 80 85 55 15 12 10
Total (n = 360)
(6.1) (46.5) (47.2) (30.6) (8.3) (6.7) (5.6)
233 187 187 107 41 38 22
(64.7) (51.9) (51.9) (29.7) (11.4) (10.6) (6.1)
Table 2. BMI, weight, height, and blood pressure measurements of Saudi and Egyptian students Saudi Arabia (n = 180) Measurements
Mean
SD
Egypt (n = 180) SE
Mean
SD
SE
Weight 85.94 14.71 1.10 84.43 16.08 1.20 Height 165.37 8.17 0.62 166.42 8.15 0.62 BMI 31.54 5.51 0.42 30.51 5.76 0.44 Systolic blood pressure 118.29 14.63 1.10 115.54 14.79 1.10 Diastolic blood pressure 58.74 7.86 0.59 58.28 7.31 0.54
Figure 1.
80.0% Male
70.1%
Female
70.0% 60.0%
52.3%
54.0%
50.0% Percent
Risk factors
38.8%
40.0% 30.0% 20.0% 10.0% 0.0%
Saudi Arabia
Egypt
The prevalence of obesity among Saudi and Egyptian male and female students.
yet the difference was not statistically significant (w2 = 2.90, P = 0.0884). The prevalence of abdominal obesity among Saudi women was 65.6% as compared with 52.2% among Egyptian women (w2 = 2.083, P = 0.148), whereas the prevalence of the risk factor among Saudi men was 47.8% compared with 42.2% among Egyptian men (w2 = 1.01, P = 0.314); neither of the differences was statistically significant at the 0.05 level. The prevalence of smoking among the two samples was 29.7%, being slightly higher among the Egyptian students (30.6%) than among the Saudi students (28.9%) (w2 = 0.095, P = 0.758). The prevalence of smoking among Egyptian and Saudi men was 48.9 and 50.0%, respectively (w2 = 0.04, P = 0.841), whereas among Egyptian and Saudi women, it was 7.8 and 12.2%, respectively (w2 = 2.301, P = 0.129). The differences were not statistically significant.
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Journal of the Egyptian Public Health Association
Regarding the BP, the mean systolic BP of the Egyptian and the Saudi students did not differ significantly [115.54 mmHg (SD 14.79) and 118.29 mmHg (SD 14.63), respectively]; neither did the mean diastolic BP of the two samples [58.28 mmHg (SD 7.31) and 58.74 mmHg (SD 7.86), respectively]. Hypertensive students constituted 11.4% of the whole sample. The prevalence of hypertension was higher among Saudi students than among Egyptian students (14.4 vs. 8.3%, respectively); yet the difference was not statistically significant (w2 = 3.537, P = 0.060). However, the prevalence of hypertension among Egyptian men (18.9%) was significantly higher than that among Saudi men (6.7%) (w2 = 6.03, P = 0.014). In contrast, the prevalence of hypertension among Saudi and Egyptian women did not differ significantly (10.0 and 10.3%, respectively, w2 = 0.027, P = 0.869). A family history of premature CHD was reported by 10.6% of the study sample. Significantly more Saudi students reported a positive family history of premature CHD (14.4%) than Egyptian students (6.7%) (w2 = 5.77, P = 0.016). Stratifying by sex, there was no statistically significant difference between the prevalence of this particular risk factor among Saudi and Egyptian female students (13.3 and 5.6%, respectively, w2 = 2.660, P = 0.102), and similarly, the difference between the prevalence of this risk factor among Saudi and Egyptian male students (14.4 and 7.8%, respectively, w2 = 3.677, P = 0.055) was not statistically significant. Dyslipidemia was the least common risk factor among the study sample with an overall prevalence of 6.1%. The prevalence was higher among Saudi students than among Egyptian students (6.7 vs. 5.6%). The difference between the two samples was not statistically significant at the preset level (w2 = 0.384, P = 0.535). On the basis of the Heart Score software calculations, the 10-year risk of fatal CVD was 0% among healthy young women and 1% among healthy young men with no risk factors. Overall, 23.9% of the Saudi students had an increased risk of fatal CVD as against 16.7% of the Egyptian students. The difference between the two groups was not statistically significant at the 0.05 level. Regarding the Saudi female students, 18.9% were at an increased risk (1%) of fatal CVD compared with 12.2% of the Egyptian female students. As for the Saudi male students, 28.9% were at an increased risk of fatal CVD compared with 21.1% of the Egyptian male students.
Discussion The current study aimed at comparing the prevalence of CVD risk factors among Saudi and Egyptian medical students aged 18–25 years. The findings of the study revealed no significant differences between the two groups regarding the prevalence of the major risk factors. A sedentary lifestyle was the most prevalent risk factor among the two groups. This finding was in accordance with a recent study conducted among medical students in
Saudi Arabia (2014), wherein the prevalence of physical inactivity reached 57.9% [9]. An earlier survey conducted by the Population Council [20,] which studied a sample of 15 029 young people aged 10–29 years of both sexes from the major six administrative regions (metropolitan governorates, urban lower Egypt, rural lower Egypt, urban upper Egypt, rural upper Egypt, and the border governorates), revealed that young people were performing very little physical activity: only 28.3% of the surveyed young people reported performing no physical activities either for leisure or as part of their daily tasks. The higher prevalence of a sedentary lifestyle in the current sample can be explained by the high academic pressures imposed on medical students giving them no sufficient time to engage in physical activities for leisure. Abdominal obesity was the second most commonly prevalent risk factor among the two groups. The work conducted by Ibrahim et al. [9] in King Abdul Aziz University revealed that the prevalence of obesity and overweight among Saudi medical students was 31.2%, which is nearly half (61.6%) the figure obtained during the current study. This disparity may be partially attributed to the fact that the students enrolled in the current study represent private medical college students with probably higher socioeconomic standards and therefore having a different dietary style, with more frequent consumption of junk restaurant food. In contrast, the prevalence of obesity among Egyptian medical students (46.5%) was much higher than that reported in a community-based study on noncommunicable diseases in Egypt (2005) [13], which showed that only 11.6% of the surveyed population aged 15–24 years (an age group comparable to that of the participants in the current study) was obese. It is worth noting that the survey used the same working definitions of overweight and obesity, based on the WHO guidelines [17]. The difference is remarkable and goes far beyond the simple assumption that the sedentary lifestyle imposed on medical students by academic pressure hinders their involvement in physical activities. The prevalence of smoking among the Saudi students was 28.9% compared with 30.6% among the Egyptian students. The observed figures among Egyptian students are striking when compared with the figures given by the results reported in a community-based study on noncommunicable diseases in Egypt (2005) [13], which showed that the prevalence of all types of smoking among the youth aged 15–24 years to be 11.6%. This is alarming as it shows that the prevalence of smoking among medical students who are supposed to be knowledgeable about the hazards of smoking is markedly higher than that among the general population of similar age. In contrast, figures observed in the current study among the Saudi students were nearly 10 times those observed by Ibrahim et al. [9] among King Abdul Aziz medical students in Saudi Arabia (2.8%). This disparity could be explained by the strict regulations banning smoking in King Abdul Aziz University premises, which might have urged students to falsely report that they were nonsmokers.
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Cardiovascular disease risk: KSA & Egypt Mahmoud 39
The prevalence of hypertension among the Saudi student sample was 14.4%; this compares favorably with the work by Ibrahim et al. [9] in King Abdul Aziz University, who found that 9.3% of the students were hypertensive, and this could be attributed to the high prevalence of obesity, which has been identified by Koura et al. [10] in their study on prehypertension among young women in Dammam, Saudi Arabia, as the strongest predictor of prehypertension. The proportion of students at an increased risk of CVD within the upcoming 10 years was alarmingly, yet predictably, high among the two groups, given the high prevalence of the measured risk factors. It was interesting that a higher prevalence of a family history of premature CHD was reported by students among the Saudi sample compared the Egyptian students. One of the limitations of the current study is that it was conducted in only one medical college selected from each of the two countries (Saudi Arabia and Egypt). The study would have been much more representative if a larger sample was drawn from several randomly selected medical colleges from both countries.
Acknowledgements Conflicts of interest There are no conflicts of interest.
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Conclusion and recommendation The prevalence of risk factors for CVD was relatively high among both Saudi and Egyptian medical students, particularly a sedentary lifestyle, obesity, and abdominal obesity. Smoking was practiced by 29.7% of both samples, which is an alarming finding. Apart from a significantly higher prevalence of obesity, abdominal obesity, and a reported family history of premature CHD among the Saudi sample and a significantly higher prevalence of hypertension among Egyptian men as compared with Saudi men, the prevalence of risk factors among the two samples did not differ significantly. A relatively high percent of both samples (23.9% of the Saudi students and 16.7% of the Egyptian students) was at an increased risk of developing fatal CVD within 10 years. The high prevalence of cardiovascular risk factors among medical students from two Middle Eastern medical colleges implies that the knowledge acquired through medical curricula per se are not sufficient motivators for behavior change, which necessitates the establishment of participatory behavior change programs in medical schools to provide support for students for the adoption of healthy lifestyles, particularly involvement in regular physical activity and smoking cessation.
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