trends in lifestyle cardiovascular risk factors in women: analysis from the canadian national...

International Journal of Nursing Studies 39 (2002) 229–242

Trends in lifestyle cardiovascular risk factors in women:analysis from the Canadian National Population Health

Survey

Julia Wong*, Shirley Wong

School of Nursing, Dalhousie University, 5869 University Avenue, Halifax, NS, Canada B3H 3J5

Received 27 July 2000; received in revised form 11 December 2000; accepted 18 February 2001

Abstract

Cardiovascular disease (CVD) is the leading cause of death and disability among women. The present investigation

analyzed data from the National Population Health Survey to examine the prevalence trends of self-reported lifestyleCVD risk factors in adult women. Results indicated an upward prevalence trend in physical activity and high bloodpressure, and significant increased prevalence rates in obesity in the lower middle and middle income groups. Logisticregression analysis showed that increased physical activity and advancing age were significant predictors of CVD; age

confers more than a one-fold risk for developing heart disease and hypertension. Implications of the study results fornursing practice are discussed. # 2002 Elsevier Science Ltd. All rights reserved.

Keywords: Cardiovascular risk factors; Women; Prevalence trends

1. Introduction

Cardiovascular disease (CVD) is the leading cause ofdeath world wide, but rates vary considerably among

countries. Published studies clearly show that CVD is nolonger a ‘‘man disease’’; the Framingham Studyreported that two-thirds of sudden death occur amongwomen with no history of heart disease (Kannel, 1986).

In the mid-1990s, age-standardized cardiovascularmortality rates in women ranged from a high of 633deaths per 100,000 population in the Russian Federation

to a low of 139.9 per 100,000 population in France(WHO, 1998). Among the 22 selected countries,England and Wales ranked 4th and 8th in ischemic

heart disease (IHD) and CVD for women, respectively.The mortality rates were 117.9 and 238.4 per 100,000population for IHD and CVD. Comparatively, Canada

fared better, ranking 11th and 18th in mortality fromIHD and CVD for women (WHO, 1998), and ischemic

heart disease accounted for 49.7% among women

(Heart and Stroke Foundation of Canada, 2000a).Classic CVD risk factors such as hyperlipidemia,

hypertension, cigarette smoking, physical inactivity,

diabetes mellitus, certain lipoproteins and obesity applyto both sexes, but they affect women differently(Johansen et al., 1990). The strongest risk factors forwomen appear to be advancing age, low high-density

lipoprotein cholesterol (HDL-c) concentrations, tobaccouse and diabetes mellitus (Judelson, 1994).Frequently, women fail to recognize the personal

relevance of heart disease. They tend to focus onreproductive organ concerns rather than general healthissues and are generally more fearful of breast, ovarian

and uterine cancer than of heart disease (Walters, 1992;Pilote and Hlatky, 1995). Preventive health services tofemales during physician office visits are more likely

to focus on cancer screening than on coronaryheart disease (Horton, 1992). A recent Heart andStroke Foundation Survey of Canadian women age45–74 (Heart and Stroke Foundation of Canada, 2000b)

reported some unsettling results with respect to*Corresponding author. Tel.: +1-902-494-2535; fax: +1-

902-494-3487.

0020-7489/02/$ - see front matter # 2002 Elsevier Science Ltd. All rights reserved.

PII: S 0 0 2 0 - 7 4 8 9 ( 0 1 ) 0 0 0 1 3 - X

protecting their future heart health. Women with animmediate family history of CVD were no more likely to

take charge of their heart heath, in spite of the evidencethat a positive family history of heart disease can doublea woman’s own risk. Furthermore, awareness of the

cardiovascular benefits of hormone replacement therapy(HRT) for postmenopausal women was low (29% risingto 65% when they were prompted). This scenario istroubling for two reasons, (1) it suggests that women

appear to understand little or to deny their cardiac risks,and (2) despite an increasing attempt to educate the laypublic, women do not seem to recognize their ability to

control these risk factors. Based on Statistics Canadapopulation projections and current trends in age-specificmortality rates, projections to 2016 suggest that the

numbers of CVD for women will increase by 28%between 1995 and 2016 while the number of deathsattributed to CVD for men will not increase (LCDC,

Health Canada, 1999). The number of cardiovascular-related deaths in women will most likely surpass deathsin men in the near future. Thus far, there are nopublished reports that track the sex-specific trends in

CVD risk factors. Coronary heart disease (CHD) inwomen has not been studied as comprehensively as inmen. Results from studies of men have frequently been

generalized to women, which may not always beappropriate or even dangerous (Khan, 1993; Gurwitzet al., 1992). While there is considerable knowledge

about major risk factors of CHD, less is known aboutthe effects of altering these factors on reduction of CHDmortality and morbidity among women. A paucity ofdata on the sex-specific trends in CVD risk factors

warrants population-based investigations. The presentinvestigation set out to examine the prevalence trends ofself-reported lifestyle CVD risk factors (hypertension,

overweight, diabetes, inactivity, and current smoking) inadult women for the period 1994–1997 using data fromthe National Population Health Survey. Knowledge

about and recognition of these risk factors will enablenurses and other health professionals to design moreresponsive and targeted clinical interventions for this

vulnerable population.

2. Existing knowledge

2.1. Physical inactivity and cardiovascular disease

Physical inactivity, an independent risk factor forcoronary artery disease (CAD) in women, is the mostprevalent coronary risk factor (Anda et al., 1990).

Exercise appears to have beneficial effects on cardiovas-cular risk factors for women. A study of an Australiancohort reported that previously sedentary women who

increased their fitness level over 4 years showedsignificant improvement in their blood lipid levels and

systolic blood pressure (Sedgwick et al., 1993). Blair et al.(1989) reported that women with the lowest fitness had a

relative risk of death nearly five times higher than thephysically fit women. Even in older age, a reduction inmyocardial infarction risk by 50% was evident with

modest leisure-time activities, equivalent to 30–45min ofwalking three times weekly (Lemaitre et al., 1995). Thisobservation is confirmed by Kushi et al. (1997) whodemonstrated a graded inverse association between

physical activity and all-cause mortality in postmeno-pausal women. Ashton et al. (2000) examined therelationship between reported physical activity and a

range of CHD risk factors in 1407 females aged 30–64years. Their results indicated that increasing activity wasassociated with lower systolic and diastolic blood

pressures, total triglycerides, cholesterol and body massindex.Emerging evidence suggests that cardiovascular health

benefits can also be realized in non-conventionalphysical activity programs. In a randomized clinicaltrial, Dunn et al. (1997) demonstrated that lifestylephysical activity counseling is as effective as a traditional

structured exercise program in reducing CVD riskfactors among healthy, sedentary, middle-aged menand women. After 6 months of intervention, 78% of

lifestyle participants and 85% of Structured participantswere engaging in 30min or more of moderate-intensityphysical activity on most days of the week. Both groups

had significant reductions in total cholesterol, totalcholesterol/high-density lipoprotein ratio, diastolicblood pressure, and percentage of body fat. Theseinvestigators concluded that these effective lifestyle

physical activity and counseling strategies could be usedin a wide variety of settings.

2.2. High blood pressure and cardiovascular disease

High blood pressure is an independent risk factor for

heart disease in women (Johansen et al., 1990; Judelson,1994). The incidence of hypertension increases with agein both sexes; but hypertension occurs significantly more

frequently in women (Heart and Stroke Foundation ofCanada, 1995). Isolated systolic hypertension with lossof arterial elasticity is more prevalent among older

women than their male counterparts. Published datashowed that these women have an elevated risk of deathfrom stroke or CHD (Fiebach et al., 1989). TheFramingham data showed that for coronary disease,

hypertensive women and men have almost identical riskratios: 2.2 for women versus 2.0 for men at 36 years’follow-up (Kannel, 1996).

Left ventricular hypertrophy (LVH) is a major sequelof chronic hypertension. Investigation of Levy et al.(1990) showed that for all cardiovascular deaths and

deaths from all causes, women with LVH had a greaterincrease in relative risk than men. In addition, these

J. Wong, S. Wong / International Journal of Nursing Studies 39 (2002) 229–242230

investigators also found that women with isolatedsystolic hypertension had more than twice the odds of

having LVH as did their male counterparts.Hypertension studies conducted in Europe and the

United States involving over 13,000 women aged 30–69

reported a decrease in all causes of mortality amongtreated versus control women (Medical Research Coun-cil, 1985; Hypertension and Detection Follow-upProgram, 1979). In general, trials that have included a

large number of women have shown favorable effects ofhypertensive therapy in terms of CAD events for olderwomen (SHEP, 1991; Dahlof et al., 1991).

2.3. Cigarette smoking and cardiovascular risk

Cigarette smoking is a powerful risk factor for CADwith the risk of cardiac events increases in relation to thenumber of cigarettes smoked daily. In the Systolic

Hypertension in the Elderly Program Study, both menand women over 60 years of age who smoked had 73%more CAD-related events than did non-smokers (Frostet al., 1996). The Nurses Health Study reported a

significant correlation among the number of cigarettessmoked and the risk of angina pectoris, non-fatalmyocardial infarction, and fatal CAD (Willett et al.,

1987). However, the risk declines rapidly after smokingcessation and approaches non-smokers’ level by 3–5years. In a longitudinal study, Prescott et al. (1998)

observed that cigarette use increases the risk of coronaryevents more for women than for men. One notableaspect of cigarette smoking is that it appears to alter

estrogen metabolism in premenopasual (Michnociczet al., 1986) and postmenopausal women (Baron et al.,1988).Cigarette smoking is also a risk factor for stroke

(Oparil, 1998). The risk of stroke for smokers was higherfor women than for men, and the risk for formersmokers has been found consistently to be lower than

that for current smokers (Wolf et al., 1992). Thus,smoking imparts the greatest risk for women already athigh risk due to older age, overweight, hypertension and

diabetes.

2.4. Diabetes and cardiovascular disease

Women with diabetes assume a risk for heart diseasethat closely approaches that of men (Barrett-Connoret al., 1991). Data from the Nurses Health Study showed

that maturity-onset diabetes mellitus confers a three- toseven-fold excess of cardiovascular events (Mansonet al., 1990). Diabetes is associated with less favorable

prognosis for women than for men compared with theirnon-diabetic counterparts (Fuller et al., 1980; Donahueet al., 1987).

Non-insulin dependent diabetes mellitus is associatedwith marked increase in the risk of CAD. Premenopausal

diabetic women experience a rate of CAD similar to thatof diabetic men, and a risk of CAD five times greater

than their age-matched non-diabetic peers (Barrette-Connor and Bush, 1991). The reasons for the relativelygreater impact of diabetes on CAD risk in women

remained undefined, but are likely related to athrogeniclipids and lipoprotein changes associated with insulinresistance (Walden et al., 1984).

2.5. Obesity and cardiovascular risk

Obesity in women is clearly linked to a worsening of

cardiovascular risk (Johansen et al., 1990; Reeder et al.,1992; Manson et al., 1990). The relationship of obesityto CAD risk in women may be due to body fat, estrogen

synthesis, and lipoprotein metabolism (Keys et al.,1984). Furthermore, the type of obesity is an indepen-dent risk for CAD in women. Upper body obesity

pattern is common among older women. A preponder-ance of abdominal fat has been shown to be a risk factorfor cardiovascular disease and diabetes, whereas pro-portionally more femoral fat is not statistically asso-

ciated with these diseases (Bjorntop, 1988).The Nurses Health Study (Manson et al., 1990) has

provided convincing evidence on the relationship of

obesity and changes in weight with the risk of coronaryevents. The risk of each type of coronary events(coronary death, myocardial infarction, angina with

stress test, angioplasty, or bypass surgery) increases withgreater body mass index (BMI). In the subsequentevaluation of women in ‘‘normal’’ weight ranges, Willett

and colleagues (1995) demonstrated a graded increase inthe risk of myocardial infarction or coronary death withhigher weight and BMI over 14 years of follow-up.

2.6. Socioeconomic status and cardiovascular disease

Socioeconomic status (SES) has been demonstrated to

be a strong and consistent determinant of health. Thereis substantial evidence for an inverse relationshipbetween socioeconomic status, CVD mortality and risk

factors. Lynch et al. (1996) observed that, comparedwith the highest income quintile, individuals in thelowest income quintile had age-adjusted relative hazards

of 2.66 and 4.33 for cardiovascular mortality and acutemyocardial infarction, respectively. Similarly, Escobedoet al. (1997) reported that indicators of low SES (familyincome, occupational status, and educational attain-

ment) account for most of the excess prematurecoronary heart disease among black Americans in theirstudy. The relationship between SES and cardiovascular

mortality extends to CVD risk factors where highlysignificant relationships have been documented betweenvarious indicators of SES and blood pressure, total

cholesterol, physical inactivity, smoking, and BMI(Winkleby et al., 1990; Shea et al., 1991; Luepker et al.,

J. Wong, S. Wong / International Journal of Nursing Studies 39 (2002) 229–242 231

1993). Winkleby and colleagues (1999) examined theassociation between education and income, two indica-

tors of SES and ethnicity with six risk factors }

smoking, hypertension, obesity, leisure-time inactivity,hypercholesterolemia, and diabetes. Both indicators of

SES and ethnicity were independently associated withCVD risk factors. This finding is consistent with Poduriand Grisso’s investigation (1998) in which they observeda substantial increase in the prevalence of CVD risk

factors among the low-income women.

3. Objectives of the study

The present investigation was designed to:

1. assess the impact of SES on lifestyle CVD risk factorsin adult Canadian women,

2. examine the prevalence trends of lifestyle cardiovas-

cular risk factors in this population, and3. explore the association between these risk factors andthe prevalence of cardiovascular disease (heartdisease and hypertension).

4. Methods

4.1. Study design

The present study analyzed the cross-sectional datafrom cycles 1 and 2 of the National Population Health

Survey (NPHS). The NPHS is the first national healthsurvey of its kind conducted in Canada. The purpose ofthis survey was to measure the health status ofCanadians in order to expand knowledge of the

determinants of health. The following is a briefdescription of the study design and data collectionprocedure of the Survey (Statistics Canada, 1998).

The initial wave of data collection (cycle 1) took placefrom June 1994 to June 1995. Data for cycle 2 werecollected from June 1996 to August 1997. The NPHS

covered household and institutional residents in allprovinces and territories, except persons living on IndianReserves, on Canadian Forces bases and some remote

areas. The Survey focused on behaviors or conditionsamenable to prevention, treatment, or intervention.Thus, data collected were factors related to good health,not just those related to illness.

The 1994–95 Survey sample was created by firstselecting households and then within each householdchoosing one member to be the longitudinal respondent.

For the second cycle, the distinction was made betweenthe sample selected for longitudinal purposes and thesample chosen for cross-sectional purposes. The core

sample selected was 20,095 and 17,276 for cycles 1 and 2,respectively. Cross-sectionally, the core target popula-

tion for cycle 2 Survey included all household membersliving with longitudinal respondents. The sample size in

the second cycle was slightly diminished from the firstcycle due to attrition of the sample, deaths, out-of-scopecase, untraceable cases and non-respondents. The

present study analyzed only data from the first andsecond cycles of the NPHS obtained from the femalerespondents aged 20 or older.

4.2. Data collection

The Survey used questions that were designed for

computer-assisted interviewing (CAI) to allow program-ming of the associated logical flow into and out ofthe questions. With CAI, the interview can be controlled

based on answers provided by the respondent. On-screen prompts are displayed to the respondent andinterviewer for correction of inconsistencies. Clarity

and quality of the questions were pre-tested beforethe main Survey was implemented in the field. Thiswas accomplished by using focus groups duringdevelopmental stages of the questionnaires to study

various aspects of their content. In addition, two fieldtests were carried out with the aim to observerespondent reaction to the Survey, to obtain estimates

of time for the various sections, and to study theresponse rates.The 1994–95 NPHS was collected primarily by

personal interview whereas the second cycle of theSurvey was collected primarily by telephone; respon-dents in the core sample were first contacted by

telephone. Personal visits were made only if therespondent did not have a telephone, if the interviewermade a personal visit in the course of tracing arespondent, or upon request by the respondent. Inter-

views were conducted by interviewers who were part-time employees hired and trained specifically to carryout the CAI interviewing method.

4.3. Measurements

For the purpose of the present study, the followinglifestyle CV risk factors were extracted from the NPHS(cycles 1 and 2) data set for analyses. Lifestyle risk

factors included in the study were obesity, physicalinactivity, cigarette smoking, high blood pressure, anddiabetes mellitus. Although serum cholesterol concen-trations is a well-documented CV risk factor in women,

however, no measurements were made in any of theSurvey cycles.(a) Obesity was defined as a BMI527. BMI was

calculated by dividing the weight in kilograms by theheight in meters squared (BMI=weight (kg)/height(m2)).

(b) Physical inactivity was reflected by the physicalactivity index, a derived variable based on the


respondent’s derived energy expenditure. Energy expen-diture is calculated by using the frequency and time

per session of the physical activity as well as its METvalue. MET is a value of metabolic energy costexpressed as a multiple of the resting metabolic rate.

NPHS did not ask the respondent to specify the intensitylevel of their activities, therefore, the MET valuesadopted correspond to the low-intensity value of eachactivity. Respondents who averaged 3.0+ kcal/kg/day

of energy expenditure were categorized as active. Anactive physical activity index is approximately theamount of exercise that is required for cardiovascular

health benefits. Individuals who averaged 1.5–2.9 kcal/kg/day were classified as moderately active; they mightexperience some health benefits but little cardiovascular

benefit. Those respondents with an energy expenditurebelow 1.5 kcal/kg/day were considered inactive (Statis-tics Canada, 1998).

(c) High blood pressure}respondents’ response to thequestion ‘‘Do you have high blood pressure diagnosedby a health professional?’’ was used to categorize themas being hypertensives or normotensives.

(d) Cigarette smoking}type of smoker was usedas a surrogate measurement of the frequency ofcigarette smoking. Similar to the physical activity

index, type of smoker is also a derived variablebased on the respondent’s response to the followingthree questions: ‘‘At the present time do you smoke

cigarettes daily, occasionally or not at all?’’, ‘‘Have youever smoked cigarettes at all?’’, and ‘‘Have you eversmoked cigarettes daily?’’ The respondent was categor-ized into daily smoker, occasional smoker but was

former smoker, always an occasional smoker, formerdaily smoker, former occasional smoker, and neversmoked.

(e) Diabetes}NPHS did not specify the type ofdiabetes. Respondents were asked to indicate if they hadbeen diagnosed with diabetes.

5. Data analysis

Data were grouped and analyzed using a StatisticalAnalysis Software (SAS) program package. Since the

Survey data are either nominal or ordinal measure-ments, descriptive statistics (frequency distributionand percentages) were used to assess the prevalencerates in lifestyle CV risk factors. Chi-squared test was

used to test significance of changes in prevalence.Logistic regression was employed to estimate therisk of developing heart disease and hypertension in

women with these risk factors. A p-value 50.05 wasconsidered statistically significant in single variablecomparisons. Bonferroni correction for multiple vari-

able analyses was used to determine the level ofsignificance (Polit, 1996).

6. Results

6.1. Demographic statistics

Responses from 8653 adult women (age 20–80 and

over) in the first cycle and 35701 women in the secondcycle of the Survey were analyzed. The majority of therespondents were married (56.7% in the 1994–95 cohort,and 56.3% in the 1996–97 cohort). Overall, the

prevalence rates of women in the low-income groups(no income to550,000) were significantly reduced in thesecond cycle of the Survey. Similarly, there was a

reduced number of women with a reported annualhousehold income 5$50,000; this reduction did notreach statistical significance (Fig. 1).

6.2. Association of SES and CV risk factors

We assessed the impact of SES (measured by theannual household income) on CV risk factors byexamining the distribution of CV risk factor prevalence

rates by income groups. In the present investigation,SES was arbitrarily divided into quintiles of annualhousehold income: the first quintile was 5$10,000; thesecond, $10,000–$29,999; the third, $30,000–$49,999; thefourth, $50,000–$79,999, and the fifth quintile5$80,000. Table 1 presents changes in the prevalenceof CV risk factors between two cycles of Survey

according to income quintiles.As shown in the Table 1, there was a downward

trend in the prevalence of physical inactivity across

Fig. 1. Frequency distribution of income of women aged 20

and older, 1994/95 and 1996/97.


all income quintiles. In other words, women in thisSurvey became more physically active in the second

cycle of the Survey, regardless of their income. However,the significant increase in physical activity level wasobserved only in the lowest, middle and highest income

groups. The prevalence rates in both obesity and highblood pressure were increased significantly in the secondand third income quintiles but was reduced significantly

in the fifth income quintile.Prevalence rates in diabetes remained unchanged over

the two Survey cycles. The significant increase insmoking was observed in the fourth and fifth income

quintiles.

6.3. Prevalence trends in cardiovascular risk factors inadult women

The factors included in this analysis were high bloodpressure, obesity, level of physical activity, history of

diabetes and cigarette smoking. Table 2 presents thesetrends.Results show significant upward prevalence trends

in high blood pressure, obesity, and physicalactivity, and significant downward trends in physicalinactivity and cigarette smoking. The decline in theprevalence of diabetes is small and statistically

non-significant.

Table 1

Changes in prevalence rates in CV risk factors between cycle 1 and 2 of the Survey. Values are expressed in percentage (%)a

Risk factor Overall Income quintile

1 2 3 4 5

High BP

Cycle 1 13.6 18.9 18.9 10.4 16.6 6.9

Cycle 2 14.6 18.8 21.3 11.9 7.4 5.9

D +1.0 �0.1 +2.4b +1.5b +0.8 �1.0b

Obesity (BMI>27)

Cycle 1 53.5 55.6 58.5 39.0 32.5 28.1

Cycle 2 53.0 50.2 59.8 41.0 34.4 26.0

D �0.5 �5.4b +1.3b +2.0b +1.9b �1.0b

Physical activity level

Active

Cycle 1 14.6 13.4 13.0 14.6 17.5 8.2

Cycle 2 15.6 16.0 13.7 17.3 17.7 20.8

D +1.0 +3.4b +0.7 +2.7b +0.2 +2.6b

Moderately active

Cycle 1 21.7 19.4 23.2 23.9 16.6 6.9

Cycle 2 22.2 20.5 23.5 25.5 7.4 5.9

D +0.5 +1.1b +0.3 +1.2b +0.8 �1.0b

Inactive

Cycle 1 63.6 66.3 67.6 62.2 58.6 55.9

Cycle 2 60.4 64.8 65.8 59.2 57.2 52.1

D �2.2b �1.5b �1.8b �3.0b �1.4b �3.8b

Diabetes

Cycle 1 4.0 6.4 6.0 2.4 2.0 1.6

Cycle 2 3.9 5.9 6.0 2.8 2.0 1.5

D �0.1 �0.5 0.0 +0.4 0.0 �0.1

Smoking

Cycle 1 25.4 33.8 28.2 26.3 19.6 14.7

Cycle 2 25.0 33.7 27.8 26.9 21.2 16.7

D �0.4 �0.1 �0.4 +0.6 +1.6b +2.0b

aCycle 1=1994/95 Survey; cycle 2=1996/97 Survey; BMI=body mass index; D=prevalence change between two Survey cycles.bp50:05.


6.4. Relationship of risk factors to cardiovascular disease

Logistic regression analysis was used to estimate theodds of developing heart disease and hypertension in

women with these CVD risk factors. In the regressionmodel, self-reported diagnosis of heart disease was thedependent variable, and high blood pressure, BMI,physical activity index, diagnosis of diabetes, smoking,

age group, and annual household income were the

dependent variables. A similar regression model was

used to estimate the odds ratio for developing hyperten-sion; in this model, hypertension was the dependentvariable, and BMI, physical activity level, diagnosis of

diabetes, smoking, age, and annual household incomewere the explanatory variables. Tables 3 and 4 presentthe analysis results.As shown in Table 3, age, physical activity, high

blood pressure, and household income were significant

Table 2

Prevalence trends in lifestyle CV risk factors in women aged 20 and older, 1994/95 and 1996/97a

Risk factor 1994/95 1996/97 p-value

n (%) n (%)

High blood pressure 1172 (13.6) 5198 (14.1) 50.001Obesity (BMI527) 4021 (48.1) 18029 (48.8) 50.001Physical activity level

active 347 (11.9) 5986 (16.2) 50.001moderately active 591 (20.4) 8260 (22.4) 50.001inactive 1966 (67.7) 22689 (61.5) 50.001

Diabetes 347 (4.0) 1403 (3.8) NS

Cigarette smoking 2526 (29.6) 9390 (25.4) 50.001

aNS=statistically nonsignificant.

Table 3

Logistic regression: prediction of the likelihood of developing heart disease in women, age 20 and older; (a) cycle 1 and (b) cycle 2 of

the Surveya

Predictor variable b Wald chi-square p-value Odds ratio

(a) 1994/95 Survey

Physical activity level 0.3103 12.2116 0.0005 1.364

Age 0.2931 90.7096 0.0001 1.341

Household income �0.1595 34.4134 0.0001 0.853

High blood pressure �0.8199 53.0062 0.0001 0.440

BMI �0.0010 0.1265 0.7221 0.999

Cigarette smoking �0.0526 3.2147 0.0730 0.949

Diabetes �0.4220 6.1007 0.0135 0.656

Intercept �3.1588�2Log likelihood 795.920 with 7 DF

p–value 0.0001

(b) 1996/97 Survey

Age 0.2973 483.5570 0.0001 1.346


High blood pressure �0.7508 202.4365 0.0001 0.472

Diabetes �0.6860 76.7987 0.0001 0.504


BMI 0.0018 2.4656 0.1164 1.002

Cigarette smoking �0.0024 0.5959 0.4401 0.998


p-value 0.0001

aBMI=body mass index.


predictors of heart disease in both Survey cycles(p50:007). However, age and level of physical activityemerged as the strongest risk factors and were directly

related to an increased probability for developing heartdisease. These findings imply that older women whowere physically active had a one-fold risk of developing

heart disease than the less active, younger women.With respect to hypertension, age, household income,

and history of diabetes were significant risk factors.

However, age emerged as the most important predictorof hypertension in both Survey cycles (OR=1.4 in cycle1 and 1.39 in cycle 2); it confers more than a one-fold

risk for developing hypertension. Although diabetes andhousehold income were also significant predictors ofhypertension, they impart minimal risks (see Table 4).

7. Discussion

7.1. Socioeconomic status and lifestyle cardiovascularrisk factors

Socioeconomic factor may account for the increasedprevalence rates in high blood pressure and obesityobserved in our analysis. As shown in Fig. 1, a notice-

able proportion of women in the Survey (40% in the firstcycle and 28% in the second cycle) were in the lower

middle income group. Logistic regression analysisindicated that household income was a significantpredictor of cardiovascular disease, albeit not a major

one (Tables 3 and 4). Low SES has been reported to be arisk factor for CHD incidence and mortality in women.Poduri and Grisso’s investigation (1998) showed that

knowledge and understanding of CV risk factors issuboptimal among low-income women. In a prospectiveSwedish study, low socioeconomic status of the husband

was significantly associated with risk of MI in middle-aged women (Lapidus and Bengtsson, 1986). In theFramingham cohort, women with eight years of educa-

tion or less had almost four times the risk of developingcardiovascular disease than women with >12 years ofeducation (Eaker, 1989). Furthermore, obesity is mostprevalent among population with low income. Luepker

et al. (1993) documented a significant relationshipbetween several different indicators of socioeconomicstatus and body mass index. Obesity is an environmental

issue, and the primary determinants of obesity are highcalorie intake and low level of activity. The significantchange in the prevalence of obesity and diabetes in our

analysis may be best understood in light of emergingevidence that fasting hyperinsulinemia is typical ofpatients with non-insulin dependent diabetes mellitus,and is often associated with obesity (Nordt et al., 1995).

Weight loss (especially with reduction of visceral

Table 4

Logistic regression: prediction of the likelihood of developing hypertension in women, age 20 and older; (a) cycle 1 and (b) cycle 2 of

the Surveya

Predictor variable b Wald chi-square p-value Odds ratio

(a) 1994/95 Survey

Age 0.3382 326.1100 0.0001 1.402

Diabetes �1.1320 77.2067 0.0001 0.322

BMI �0.0052 9.3775 0.0022 0.995



Cigarette smoking 0.0171 0.7745 0.3788 1.017


p-value 0.0001

(b) 1996/97 Survey

Age 0.3295 1667.4237 0.0001 1.390


Diabetes �1.0719 302.1440 0.0001 0.342


BMI 0.0004 0.4213 0.5163 1.000

Cigarette smoking 0.0001 0.0039 0.9499 1.000


p-value 0.0001

aBMI=body mass index.


obesity) will improve insulin sensitivity and reduce therisk of the development of type 2 diabetes (Ashley and

Kannel, 1974).

7.2. Trends in cardiovascular risk factors in adult women

There is evidence to suggest that physical activity

reduced heart disease mortality and morbidity forwomen (Blair et al., 1989; Powell et al., 1987). Indeed,published data have clearly demonstrated that physicalactivity is associated with favorable levels of CVD risk

factors (Bijnen et al., 1996; Stender et al., 1993). Asteady decline in cardiovascular disease death rates inwomen since mid-1960s in Canada (Heart and Stroke

Foundation of Canada, 2000a) corroborates our findingof a significant increase in the prevalence of physicalactivity and a reduction in cigarette smoking. Our

finding of an upward prevalence trend in physicalactivity and high blood pressure is puzzling andunexpected. This observation is at odds with the

published data, which showed favorable effects ofincreased physical activity on CV risk factor reduction.However, a search of literature indicates that suchparadoxical trend indeed exists, and has been previously

reported. The finding of an increasing trend in physicalactivity and blood pressure in our study is compatiblewith that of the study by Pols et al. (1997) of 4575

women age 49–70 years in which they noted that bloodpressure (systolic and diastolic) was highest in womenwho performed heavy manual work, and was inversely

related to the time spent in leisure-time activities.Housework, walking and cycling were the three physicalactivities most frequently reported by the study subjects.Vaz de et al. (1999) also found that nearly three-quarters

of the population participants engaged in some type ofphysical activity, but more than one-third were over-weight (31%) or obese (10%). The significant associa-

tion between obesity and high blood pressure has beenreported in the literature (Ford and Cooper, 1991; Weir,1991), but the exact mechanism responsible for the

observation of a rise in physical activity with acorresponding increase in blood pressure remains to beelucidated.

Our finding of reduced prevalence in smoking andincreased prevalence in obesity is consistent with theobservation of Hu et al. (2000) of a substantial decline(40%) in the numbers of female participants who

smoked, but an increase (38%) in the prevalence ofoverweight, defined as a BMI525. The explanationoffered by Hu and co-workers is that the dietary

glycemic load in their subjects was increased due to ahigh intake of refined carbohydrates. In contrast,Rosengren et al. (2000) reported an upward trend in

obesity over a period of 30 years among smokers andformer smokers in their study. However, their study

involved men only, and it is possible that smoking mighthave differential effects on body weight in women.

In our study, prevalence of obesity and high bloodpressure increased significantly in the lower middleincome (group 2) and middle income (group 3) groups;

their level of physical activity increased minimally andnon-significantly in income group 2 (0.7%) but sub-stantially and significant in group 3 (2.7%). It is likelythat these two income groups engaged in activity such as

housework or some type of manual work, which maynot require much energy expenditure. In the presentinvestigation, we used self-reported data of physical

activity. Roberts (1995) challenged the accuracy of self-reported data as scientific measurement of the preva-lence of CV risk factors. Overestimation or under-

estimation of physical activity may account for theobserved upward prevalence trends in hypertension andobesity among women in the lower income groups,

despite an increase in physical activity levels.Our finding of a significant upward prevalence trend

in hypertension (0.5%) is in agreement with previouslypublished data (Fortmann et al., 1990; Puska et al.,

1983). Several explanations may account for thisobservation. First, an increased awareness of hyperten-sion as a major risk factor for CVD may motivate the

Survey participants to have their blood pressure checkedregularly. In fact, 58% and 59% of women in the NPHSreported having their blood pressure test less than 6

months in the first and second cycles of the Survey,respectively (data not shown). This increase in theproportion of women having regular blood pressuremonitoring, can translate into an increased percentage

of women diagnosed with high blood pressure. Sec-ondly, our analysis indicated that the rise in theprevalence of high blood pressure is associated with an

increase in obesity (Table 2). The close associationbetween hypertension and obesity has been firmlyestablished. Investigation by Ford and Cooper (1991)

demonstrated that BMI was positively related to theprobability of developing hypertension, independent ofage. The exact mechanism responsible for this relation-

ship remains unclear, but it is postulated that augmentedBMI requires both an increase in intravascular volumeand cardiac output to meet metabolic requirements.Such volume overload can result in elevated blood

pressure (Weir, 1991).

7.3. Relationship of risk factors to cardiovascular disease

The logistic regression analysis of heart disease andhigh blood pressure showed that physical activity and

age were significant predictors of CVD. The finding of adirect relationship between increased physical activityand cardiovascular disease is unexpected but is consis-

tent with that of the investigation by Pols et al. (1997) inwhich they observed an association between a higher


activity level of work or housework and a higher level ofcardiovascular disease risk indicators (blood pressure,

heart rate, BMI, waist/hip ratio, and waist circumfer-ence). The mechanism underlying this positive associa-tion is unknown, but one may surmise that older

participants in the NPHS might have subclinical heartdisease, hypertension or both, which might not havebeen diagnosed by the health professionals. If this werethe case, high level of physical activity could precipitate

a cardiovascular event in those whose cardiac functionmight have been compromised secondary to augmentedblood pressure. The inverse relation between heart

disease and high blood pressure noted in our analysis(Table 3) argues against the speculation that hyperten-sion contributes to an increased odds for developing

heart disease. The self-reported diagnosis of high bloodpressure may inflate or deflate its prevalence; this mightaccount for the inverse relationship between hyperten-

sion and heart disease. Nonetheless, the fact that agewas positively related to heart disease and high bloodpressure clearly suggests that older women are at highrisk for CVD.

8. Implications for nursing

Cardiovascular disease is primarily a lifestyle disease,and is amenable to changes. Research shows that CVD

can be slowed significantly or progression halted whenpreventive programs have been instituted at the begin-ning stages of the disease (Chesebro et al., 1982). Health

professionals have advocated primary prevention ofCVD for many years, but it seems that women in generalare not heeding the message. Despite increased physicalactivity, women participants in the NPHS demonstrated

an increase in the prevalence of obesity and high bloodpressure. In the last two decades, a number ofcommunity-based heart health programs have been

developed in the US and UK (Carleton et al., 1995;Brownson et al., 1996; Baxter et al., 1997; Tudor-Smithet al., 1998), but reports of these projects indicated

inconclusive and inconsistent results with respect toprogram efficacy. Hu et al. (2000) speculated that therecent lack of decline in the incidence of coronary heart

disease may be a reflection of stagnation of changesattributable to prevention. The issues of programrelevance and appropriateness perceived by participantswith varied needs and lifestyle may also contribute to a

lack of demonstrable program effectiveness.Primary prevention is directed towards reducing an

individual’s encounter with CV risk factors. Giardina

(1998) argued for early dialogue between the physicianand patient to foster preventive steps, and to identifythose women who are at high risk for CVD. However,

there is evidence indicating that a high proportion ofpatients’ visits to physician office does not include

counseling for prevention of CVD (Giardina, 1998;Centers for Disease Control and Prevention, 1998).

Furthermore, published data showed that women’sconfidence in their physicians is not optimal, citingcommunication problems as the leading reason of their

dissatisfaction (Taylor et al., 1993; Tobin et al., 1987).Health promotion and patient education historicallyfalls in the domain of nursing (Novak, 1988), a windowof opportunity now exists for nurses to lead the health

promotion movement. Lile (1990) maintained thatidentifying women who are at risk for CVD andinitiating programs to achieve an optimal risk profile

and to delay the progression of the disease is a challengeto the professional nurse. She proposed a plan to meetthis challenge; it consists of (a) providing health

information to maintain or strengthen the existingwomen’s health, (b) focusing on and supporting ofpositive behaviors and coping strategies, and (c)

desensitizing the existing or possible deleterious riskfactors. Although primary prevention efforts such as ahealthier diet, increased physical activity, and smokingcessation carry great promise in reducing CVD risk

factors, to our knowledge, few interventions aredesigned specifically for women, in particular olderwomen. Thus, prior to designing and implementing any

primary intervention strategies, it is imperative fornurses to obtain information about women’s healthbehavior profile, their readiness to change, as well as

their interest in dietary, physical activity, and smokingcessation interventions, either at the community orindividual level.It is well documented that socioeconomic status is

strongly associated with cardiovascular risk factors(Martinez et al., 1999; Margetts et al., 1999; Choiniereet al., 2000). This SES (income) gradient for CVD risk

factors is also borne out by our analysis. One reasonmight be that lower socioeconomic groups tend to beassociated with an unhealthy lifestyle including

consuming a more atherogenic diet, engaging in lessexercise, having higher blood pressure, and smokingmore. Hazuda et al. (1986) observed that employed

women ate a less atherogenic diet than full-time house-wives. In view of this evidence, nurses need to considerthe individuals’ SES to ascertain that strategies forreducing CVD risk factors are perceived as relevant and

realistic. The goal of nutrition teaching and counseling isto develop an enjoyable eating style that will result inbetter health and quality of life. Nurses and dietitians

focus their teaching on fat, cholesterol, sodium andcalorie information of food, including culturally specificfoods.

Recently, there is a better understanding of thecomplex relationship between physical activity and lifecircumstances in women. Scharff et al. (1999) noted that

women who have children performed less structured andless intense physical activities of daily living. Those in


the oldest age category cited health as the most commonmotivator for physical activity, but were also the least to

perform physical activity. Wilcox et al. (2000) alsoreported that older age, less education, and lack of socialsupport are the major barriers to leisure-time physical

activities among rural and urban women in their study.These findings imply unequivocally that community-based cardiovascular prevention programs need to bedeveloped specifically for the older, less educated

women. Furthermore, our finding of a significant andpositive association between level of physical activityand cardiovascular disease suggests that the intensity of

physical activity for this high-risk group needs to beprescribed and these women’s responses to increasedphysical activity must be monitored regularly by health

professionals.The objective of physical activity intervention is to

enhance the individuals’ quality of life when performed

on a regular basis. Hence, creative, flexible strategiesthat incorporate physical activity into the daily routineshould be used in CV risk reduction program to meet theunique needs of women at different stages of their life.

Nurses experienced in conducting behavior change teachwomen problem-solving approaches to learn cognitiveand behavioral skills appropriate for their level of

motivational readiness for physical activity adoptionand life circumstances (Dunn et al., 1997).Pearson (1999) maintained that efforts to control

CVD should invest strategically in research to under-stand the prevalence of, and risks associated with, CVDrisk factors, as well as in measures to prevent or modifyrisk. The discrepancy between increased physical activty,

high blood pressure, obesity and lower SES could not beexplained physiologically. Further nursing research iswarranted to examine the relationship between SES

status, employment status, and the prevalence of CVrisk factors. Different types of physical activity such asleisure-time, occupational, transportation and house-

hold activities should be evaluated with respect to theirimpact on CV risk in women across the life span. Inaddition, the impact of SES status and employment

status on various types of physical activity needs to beexplored. These qualitative and quantitative data wouldinvariably illuminate the diversity and socioculturalspecificity of women’s perspectives that may be im-

portant if healthy lifestyle and quality of life are to beachieved.

9. Conclusion

Cardiovascular disease is not only the leading cause ofdeath among women in developed countries, it is morelethal and less aggressively treated in women than in

men. Despite an intense education campaign aiming atimproving cardiovascular risk profile, discouraging

statistics on the status of women’s heart health emerge.To date, there are few heart health programs that target

exclusively on women. In addition, the misconceptionsabout women’s risk of cardiovascular disease shared byboth patients and physicians, may be partly responsible

for women being unaware of their risk for heart disease.The focus of contemporary nursing has shifted from

provision of care to patients in the acute care setting tohealth promotion and illness prevention. Nursing has a

responsibility to develop strategies to decrease the risk ofCVD and its often tragic consequences. The emphasis ofprimary prevention should be placed on increased

physical activity and weight reduction in overweightwomen, to reduce the chance in developing hypertensionand heart disease. This intervention must be relevant to

the women’ socioeconomic status and culture. Thepublic, particularly women, must be encouraged toparticipate in community-based or individual-based

programs directed at reducing the risk for heart disease,and improving the quality of life. Barrett-Connor (1994)maintained that prevention programs directed towardswomen would have a broader public health impact than

those directed towards men. Behavior modification by awoman often will result in better diet and behavior forher partner and children.

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